iI iiiii 'I 11111 IIi Illill' *EO 'll@ Hill! "IIII! 11 I l@(I 1 1 117 * J,bropriatlon on J ,ppro Fiscal year 1973 DEP OF LABOR, AND HEALTH, EDUCATION, AND WELFAPF,, AND RELATED POENCIES VOLUME I @TH SERVICES AND MINTAL HEALTH A=ISTRATION Mental Health @ugh Ijealth servioes Delivery U. S. DEPARTMENT OF HEALTH, EDU(ATIONAND WELFARE Nlti'J I IAL FIC@@ I @ m m m m m 0 m a m m n 0 M a n M M M DEPARTMENT OF HEALTH, EDUCATION, AND WELFARE HEALTH SERVICES AND MENTAL HEALTH ADMINISTRATION 1973 Appropriation .Appropriation Title - Estimate Page Pos. Amount Mental health .................. 2,178 $612,170,000 1 Saint Elizabeths Hospital ...... 4,132 28,271,000 78 Health services planning and development .............. 757 329,596,000 96 Health services delivery ....... 7,678 745,657,000 184 DEPARTMENT OF HEALTH, EDUCATION, AND WELFARE HEALTH SERVICES AND MENTAL HEALTH ADMINISTRATION Mental Health Page No. Appropriation language ....................................... 3 Amounts available for obligation ............................. 4 Obligations by activity ...................................... 5 Obligations by object ........................................ Summary of changes ........................................... 7 Authorizing legislation ...................................... 11 Explanation of Transfers ..................................... 17 Table of estimates and appropriations ........................ 18 Justification: A. 1. General statement ................................... 19 2. Activities: (1) Research: (a) Grants .................................... 20 (b) Direct operations ......................... 28 (2) Manpower development: (a) Training grants and fellowships ........... 31 (b) Direct operations ......................... 39 (3) State and community programs: (a@@ Community mental health centers: 1. Construction .......................... 42 2. Staffing .............................. 43 (b) Narcotic addiction ....... ................ 44 (c) Alcoholism 1. Project ............................... 48 2. Grants to states ...................... 51 (d) Mental health of children ................. 52 (e) Direct operations ......................... 53 (4) Rehabilitation of drug abusers ................. 54 (5) Program support activities: (a) Field activities ................. : ........ 56 (b) Scientific communication and public education ................................. 57 (c) Executive direction & management services. 59 3. Items of Special Concern: (a) Narcotic addiction ............................. 21, 30, 33, 44, 54, 57, 66, 71 (b) Alcoholism ..................................... 22, 24, 33, 48, 51, 58, 68 B. Program purpose and accomplishments ..................... 60 C. State tables ............................................ 73 D. New positions requested ................................. 77 3 Appropriation Estimate MENTAL HEALTH For carrying out the Public Health Service Act with respect to mental health and, except as otherwise provided, the Community Mental Health Centers Act (42 u.s.c. 2681, et seq.), the Comprehensive Alcohol Abuse and Alcoholism Prevention, Treatment, and Rehabilitation Act of 1970 (Public Law 91-616), and the Narcotic Addict Rehabilitation Act of 1966 (Public Law 89-793),[($612,201,000)](80 Stat. 1438), $612,170,000 of which [,$75,000,000] $141,491,000 shall remain available until June 30, [1973]1974 for grants pursuant to parts A, C, and D of the Community Mental Health Centers Act. DEPAR'n4EN-L OF HEALTH, EDUCATION, AND WELFARE HEALTH SERVICES AND MENTAL HEALTH ADMINISTRATION Mental Health Amounts Available for Obligation 1972 1973 Appropriation ........................ $612,201,000 $612,170,000 Real transfer to: "Operating expenses, Public Building, General Services Administration". -4,ooo --- Comparative transfer to: "Departmental management ............ -115,000 --- "Saint Elizabeths Hospital .......... -1,6oo,ooo --- Subtotal, budget authority ........... 61o,482,000 612,170,000 Receipts and reimbursements from: Non-Federal sources ................ 5,000 5,000 Other accounts ..................... 155,000 155,000 Unobligated balance, start of year ... 196,ooo 9,8oo,ooo Unobligated balance lapsing .......... -223,000 Unobligated balance, end of year..... -9,8oo,ooo --- Total, obligations .......... 6oo,815,000 622,130,000 5 Obligations by Activity 1972 1973 Increase or Page Estimate Estimate Decrease Ref. Pos. Amount Pos. Amount Pos. Amount Research: 20 Grants ............. --- $97,4oo,ooo $101,lioo,ooo --- +$4,000,000 28 Direct operations.. 1,170 41,699,ooo i,184 43,268,ooo +14 +1,569,ooo Manpower development: 31 Train 4ng grants and fellowships... --- 120,050,000 --- 105,050,000 --- -15,000,000 39 Direct operations.. 135 7,741,ooo 135 7,779,000 --- +38,ooo State & Community programs: Community mental health centers: 42 Construction ...... --- 5,200,000 --- 9,8oo,ooo --- +4,6oo,ooo 43 Staffing .......... --- 135,100,000 --- 135,100,000 --- 44 Narcotic addiction.. --- 76,390,000 --- 91,298,ooo +14,go8,ooo Alcoholism: 48 Project Grants.... --- 4o,297,000 --- 50,193,000 +9,896,ooo 51 Grants to states.. --- 30,000,000 --- 30,000,000 52 Mental health of children ........... --- 10,000,000 --- 10,000,000 --- --- 53 Direct operations ... 187 6,816,ooo 194 7,239,000 +7 +423,000 Rehabilitation of 54 drug abusers ........ 157 13,323,000 164 13,926,ooo +7 +603,000 Program support activities: 56 Field activities ... 152 3,71-9,000 152 4,ol5,ooo --- +276,ooo 57 Scientific communi- cation & Dublic ......... 90 7,29 000 go 7,293,000 --- -5,000 59 Executive direction & management services .......... 259 5,762,000 259 5,769,ooo --- +7,000 Total obligations .... 2,150 6oo,815,000 2,178 622,130,000 +28 +21,3"@5,000 Obligations by Object 1972 1973 Increase or Estimate Estimate Decrease Total number of permanent positions .................... 2,150 2,178 +28 Full-time equivalent of all other positions .............. 404 4o4 --- Average number of all employees .................... 2,485 2,538 +53 Personnel compensation: Permanent positions ......... $31,oo6,ooo $32,415,000 +$1,4ogiooo Positions other than permanent .................. 1,973,000 1,973,000 --- Other personnel compen- sation .................... 1,324,ooo 1,324,ooo --- Total personnel compensation ............. 34,303,000 35,712,000 +1,4og,ooo Personnel benefits ............ 3,o45,000 3,201,000 +156,ooo Travel and transportation of persons ...................... 1,954,ooo 1,981,ooo +27,000 Transportation of things ...... 255,000 255,000 --- Rent, communications and -utilities .................... -i,843,000 2,001,000 +158,000 Printing and reproduction ..... .,094",-)Oo i,o94,ooo --- Other services ................ 9,621,000 lo,471,000 +850,000 Project contracts ........... 31,436,ooo 31,436,ooo --- Supplies and materials ........ 1,946,ooo 1,958,ooo +12,000 Equipment .................... 893,000 1,192,000 +299,000 Gr-ar@ts, subsidies and contributions ................ 514,437,000 532,841,ooo +18,4o4,ooo Subtotal .................... 6oo,82-,,OOO 622,142,000 +21,315,000 Quarters & subsistence charges -12,000 -12,000 --- Total obligations by object ..................... 6oo,815,000 622,130,000 +21,315,000 7 Summary of Changes 1972 estimated obligations .......................... $6oo,815,000 1973 estimated obligations ...4 ...................... 622,130,000 Net change ............................ +21,315,000 Base Change from Base Pos. Amount Pos. Amount Increases: A. Built-in: 1. Within-grade increases ...... --- --- +850,000 2. Annualization of 1972 new positions .................. --- --- --- +1,021,000 3. Equipment replacements ...... --- --- +283,000 4. Annualization of 1972 in- crease of benefits for commissioned officers ...... --- --- --- +72,000 5. Increase in Federal Tele- communications service charges .................... --- --- +153,000 6. Holiday pay ................. --- +6,ooo 7. Increased payments to other accounts: a. NIH Management Fund ..... --- --- +676,ooo b. D.@ Working Capital Fund ................... --- --- --- +46,ooo c. HSbffIA Service and Supply Fund ............ --- --- --- +102,000 8. Payments to Bureau of Employees' Compensation.... . --- --- +17,000 Total, increases ....... --- --- +3,226,ooo B. Program: 1. Direct operations: a. Child mental health ..... --- 4 +4o,ooo b. Minority mental health.. 5 +50,000 c. Crime and delinquency... --- 5 +50,000 d. Alcoholism .............. --- --- 7 +70,000 e. Drug abuse .............. --- --- 7 +70,000 f. Upward mobility program. --- --- --- +i47,000 8 Base Change from Base Pos. ount Pos. Amount 2. Grants: a. Research ............... --- $97,4oo,ooo --- +4,ooo,ooo b. Community mental health centers construction ... 5,200,000 --- +4,6oo,ooo C. Narcotic addiction community assistance ... 76,390,000 --- +14,go8,ooo d. Alcoholism projects ..... --- 4o,297,000 --- +9,896,ooo Total, program increases --- --- +28 +33,831,000 Total, increases ...... --- --- +28 +37,057,000 Decreases: A. Built-ir@- 1. Two less days of pay ........ --- --- --- -169,ooo 2i Annualization of 1972 employment reductions ...... --- --- -573,000 Total built-in increases ............ --- --- --- -742,000 B. @ram: 1. Training grants ............. --- 120,050,000 --- -15,000,000 Total, decreases ...... --- --- --- -15,742,000 Total, net change ..................... --- --- + 28 +21,315,000 Explanation of Changes Increases: A. Built-in: 1. Within-grade increases: An increase of $859,030 will provide coverage for escalations in the cost of personal services resulting from normal periodic within-grade advances, to the extent that they are not offset by savings result- ing from employee turnover, 2. Annualization of FY 1972 New Positions: An increase of $1,021,000 will provide full year funding for 153 new positions established in 1972 to support the Institute's expanded narcotic addiction and alcoholism programs, 3. @@-n n@t R aceiltnts: Additional funding is required to cover the larger cost of research equipment items requiring replacement in 1973. 4. Annualization of FY 1972 Increase of Benefits for Commissioned Officers: An additional $72,000 will cover the full-year costs of continuation pay increases approved for Public Health Service officers in December of 1971. 5. Increase of Federal Telecommunications Service Charges: An increment of $153,033 is requested to cover increased costs of telephone services provided to the Institute. 6. Holiday Pay: Premium pay costs related to Inauguration Day, a legal holiday,' are estimated at $6,000. 7. Increased Payments to Other Accounts: A total increase of $824,000 is requested to provide for central service costs provided to the Institute by the Department ($46,000), Health Services and Mental Health Administration ($102,003), and National Institutes of Health ($676,000). 8. Bureau of EM21ovees' Compensation: Payments to the Bureau of Employees' Compensation will increase from $38,000 in 1972 to $55,000 in 1973. B. Lr _q& a@-,n: 1. Direct Operations: A total of $427,090 is requested for program increases in direct operations. Of this amount, $140,000 will provide first- year funding for 14 new positions in the research activity for programs in Child Mental Health (4), Minority Mental Health (5), and Crime and Delinquency (5). An additional 7 positions and $70,000 are requested to support the Institute's expanded alcoholism programs, and an equal number of positions and dollars is requested for support of narcotic addiction and drug abuse activities. An increase of $147,000 is requested to finance services provided to the Institute by HSMHA in connection with the Upward Mobility Program. 2. Grants: a. Research: The increase of $4,000,000 is requested for expanded research efforts in drug abuse ($500,000), child mental health ($1,500,000), alcoholism ($500,000), minority mental health problems ($1,000,000), and crime and delinquency ($500,000). b. Co,.nmunit)L Mental Health Centers Construction: Using funds carried over from 1972, obligations for construction of Community Mental Health Centers will increase by $4,600,000, to $9,800,000 in 1973. This will provide funds for 10 construction of approximately 24 new centers in 1973. No new appropriations are requested for centers construction in 1973. c. Narcotic Addiction Co@mnunity Assistance: An increase of $14,908,000 is requested for narcotic addiction and drug abuse community assistance projects. This will bring the 1973 funding level to a total of $91,298,000 for this budget activity. Priority will be given to funding programs serving metropolitan areas with a high incidence of drug addiction. d. Alcoholism P An increase of $9,896,000 is requested for alcoholism community assistance projects, bringing the total 1973 program level to $50,193,000. The increase will be used to support projects previously funded by the Office of Economic Opportunity. Decreases: A. Built-in: 1. Two Less Days @P@: A decrease of $169,UDU is included to reflect two less working days in FY 1973. 2. Annualization ot FY 1972 E-,np ovment Re uctions: A re uction of 52 filled positions in 1972, will result in a,.inaalized savings of $573,000 in 1973. B. Program: 1. Trai Grants: A total program decrease of $15,000,000 is proposed for mental health training programs in 1973, including $7,000,000 for the psychiatry residency program and $8,000,000 for other training programs. Authorizing Legislation 1973 Appropriation Legislation Authorized requested Public Health Service Act, Section 301: Research grants .......................... Indefinite $ioi,4oo,ooo Training grants .......................... Indefinite 105,050,000 Direct operations ........................ Indefinite 89,129,000 Community Mental Health Centers Act: Part A, Section 201--Construction of Community Mental Health Centers ......... $100,000,000 --- Part B, Section 224--Staffi.ng of Community Mental Health Centers: Initial grants ...... i .................. 6o,ooo,ooo 9,131,000 Continuation grants .................... Indefinite 125,969,ooo Parts C and D, Alcohol Abuse and Alcohol- ism, Narcotic Addiction, Drug Abuse, and Drug Dependence Prevention and Rehabiii- tation: Section 247--Grants and contracts for the prevention and treatment of alcohol abuse and alcoholism .......... 50,000,000 26,490,000 Section 253--Drug abuse education ...... 14,ooo,ooo 1,732,000 Section 256--Special projects for narcotic addicts and drug dependent persons ............................... 35,000,000 35,000,000 Section 261--Construction and staffing of alcoholism, narcotic addiction, and drug abuser rehabilitation facilities, training and evaluation, and direct grants for special projects: Initial grants ....................... 8o,ooo,ooo 24,616,ooo Continuations ........................ Indefinite 58,o43,000 Part E, Section 264--Grants for consults- tion services: Initial grants ......................... 5,000,000 100,000 Continuation grants .................... Indefinite --- Part F, Section 271--Construction and staffing of child mental health treat- ment facilities: Initial grants ......................... 30,000,000 1,515,000 Continuations .......................... Indefinite 8,485,000 Comprehensive Alcohol Abuse and Alcoholism Prevention, Treatment, and Rehabilitation Act of 1970: Title III, Part A, Section 301--Formula grants .................................. 8o,ooo,ooo 30,000,000 12 Authorizing Legislation for Grants I. The following Sections of the Public Health Service Act authorize grants under the activities "Research" and "Manpower Development." Sec. 301. The language of this Section will be found under the tab "Preamble Paragraph" in Volume II. Section. 302. (a) In carrying out the purposes of Section 301 with respect to narcotics, the studies and investigations shall include the use and misuse of narcotic drugs, the quantities of crude opium, coca leaves, and their salts, erivat ves, and preparations, together with reserves thereof, necessary to supply the normal and emergency medicinal and scientific requirements of the United States. The results of studies and investigations of the quantities of crude opium, coca leaves, or other narcotic drugs, together with such reserves thereof, as are necessary to supply the normal and emergency medicinal and scientific requirements of the United States, shall be reported not later than the lst day of September each year to the Secretary of the Treasury, to be used at his discretion in determining the amounts of crude opium and coca leaves to be imported under the Narcotic Drugs Import and Export Act, as amended. (b) The Surgeon General shall cooperate with States for the purpose of aiding them to solve their narcotic drug problems and shall give authorized representatives of the States the benefit of'his experience in the care, treatment, and rehabilitation of narcotic addicts to the end that each State may be encouraged to provide adequate facilities and methods for the care and treatment of its narcotic addicts. Sec. 303 (a) In carrying out the purposes of Section 301 with respect to mental health, the Surgeon General is authorized-- (1) to provide training and instruction and to establish and maintain traineeships, in accordance with the provisions of Section 433 (a); (2) to make grants to State or local agencies, laboratories, and other public or nonprofit agencies and institutions, and to individuals for investigations, experiments, demonstrations, studies, and research projects with respect to the development of improved methods of diagnosing mental illness, and of care, treatment, and rehabilitation of the mentally ill, including grants to State agencies responsible for 13 administration of State institutions for care, or care and treatment, of mentally ill persons for developing and establishing improved methods of operation and administration of such institutions. (b) Grants under paragraph (2) of subsection (a) may be made only upon recommendation of the National Advisory Mental Health Council. Such grants may be paid in advance or by way of reimbursement, as may be determined by the Surgeon General; and shall be made on such conditions as the Surgeon General finds necessary. Sec. 507. Appropriations to the Public Health Service avail- able for research, training, or demonstration project grants pursuant to this Act shall also be available on the same terms and conditions as applied to non-Federal institutions, for grants for the same purpose to hospitals of the Service, of the Veteran's Administration, or of the Bureau of Prisons of the Department of Justice, and the Saint Elizabeths Hospital. Community Mental Health Centers Act Part A--Construction of Community Mental Health Centers Authorization of Appropriations Sec. 201. There are authorized to be appropriated, for grants for construction of public and other nonprofit community mental health centers, $35,000,000 for the fiscal year ending June 30, i965, $50,000,000 for the fiscal year ending June 30, 1966, $65,000,000 for the fiscal year ending June 30, 1967, $50,000,000 for the fiscal year ending June 30, 1968, $60,000,000 for the fiscal year ending June 30, 1969, $70,000,000 for the fiscal year ending June 30, 1970, $80,000,000 for the fiscal year end4 ng June 30, i971, $90,000,000 for the fiscal year ending June 30, 1972, and $100,000,000 for the fiscal yeax ending June 30, 1973. Part B--Staffing of Community Mental Health Cent(-rs Authorization of Appropriations Sec' 224. There are hereby authorized to be appropriated $19,500,000 for the fiscal year ending June 30, 1966, $24,ooo,ooo for the fiscal year ending June 30, 1967, $30,000,000 for the fiscal year ending June 30, i968, $26,ooo,ooo for the fiscal year ending June 30, 1969, $32,000,000 for the fiscal year ending June 30, 1970, $45,000,000 for the fiscal year ending June 30, 1971, $50,000,000 for the fiscal year ending June 30, 1972, and $60,000,000 for the fiscal year ending June 30, 1973, to enable the Secretary to make initial grants to community mental health centers under the provisions of this part. For the fiscal year ending June 30, 1967, and for each of the thirteen succeeding years, there are hereby authorized to be appropriated 14 such sums as may be necessary to make grants to such centers which have previously received a grant under this part and are eligible for such a grant for the year for which sums are being appropriated under this sentence. Parts C and D--Alcohol Abuse and Alcoholism, Narcotic Addiction, Drug Abuse, and Drug Dependence Prevention and Rehabilitation ALCOHOL ABUSE AND ALCOHOLISM Authorization of Appropriations Sec. 247. (d) To carry out the purposes of this section, there are authorized to be appropriated $30,000,000 for the fiscal year ending June 30, 1971, $40,000,000 for the fisckl year ending June 30, 1972, and $50,000,000 for the fiscal year ending June 30, 1973. DRUG ABUSE EDUCATION Authorization of Appropriations Sec. 253. (d) To carry out the purposes of this section, there are authorized to be appropriated $3,000,000 for the fiscal year ending June 30, 1971, $12,000,000 for the fiscal year ending June 30, 1972, and $i4,ooo,ooo for the fiscal year ending June 30, 1973. SPECIAL PROJECTS FOR NARCOTIC ADDICTS AND DRUG DEPENDENT PERSONS Authorization of Appropriations Sec. 256. (e) There are authorized to be appropriated to carry out this section not to exceed $20,000,000 for the fiscal year ending June 30, 1971, $30,000,000 for the fiscal year ending June 30, 1972, and $35,000,000 for the fiscal year ending June 30, 1973. CONSTRUCTION AND STAFFING OF FACILITIES Authorization of Appropriations Sec. 26!. 'ka) There are authorized to be appropriated $15,000,000 for the fiscal year ending June 30, 1970, $40,000,000 for the f4 scal year ending June 30, 1971, $6o,ooo,ooo for the fiscal year g T endin une 30, 1972, and $80,000,000 for the fiscal year ending June 30, 1973, for project grants for construction and staffing of facilities for the prevention and treatment of alcoholism under Part C, or the prevention and treatment of narcotic addiction, drug abuse, and drug dependence, under Part D and for grants unl.er Section 252 and Section 246. Sums so appropriated for any fiscal year shall remain available for obligation until the close of the next fiscal year. (b) There are also authorized to be appropriated for the fiscal year ending June 30, 1971, and each of the next nine fiscal years such sums as may be necessary to continue to make grants for staffing with respect to any project under Part C or D for which a staffing grant was made from appropriations under subsection (a) of this section for any fiscal year ending before July 1, 1973. 15 Part E--Grant for Consultation Services Authorization of Appropriations Sec. 264. (c) For purposes of making initial grants under this section, there are authorized to be appropriated $5,000,000 for each of the fiscal years ending June 30, 1971, June 30, 1972, and June 30, 1973. There are also authorized to be appropriated for the fiscal year ending June 30, 1972, and for each of the. next eight fiscal years such sums as may be necessary to continue to make grants under this section for projects which received initial grants under this section from appropriations authorized for any fiscal year ending before July 1, 1973. Part F--Mental Health of Children Authorization of Appropriations See. 271. (d) (1) There are authorized to be appropriated $12,000,000 for the fiscal year ending June 30, 1971, $20,000,000 for the fiscal year end.ing June 30, 1972, and $30,000,000 for the fiscal year ending June 30, 1973, for grants under this part for construction and for initial grants under this part for compensation of professional and technical personnel, and for training and evaluation grants under section 272. @'(2) There are also authorized to be appropriated for the fiscal year ending June 30, 1972, and each of the next eight fiscal years such sums as may be necessary to continue to make grants with respect to any project under this part for which an initial staffing grant was made from appropriations under paragraph (1) for any fiscal year ending before July 1, 1973. III. The following sections of Public Law 91-616, the Comprehensive Alcohol Abuse and Alcoholism Prevention, Treatment and Rehabilitation Act of 1970, establish within,NIMH, the,National Institute of Alcohol Abuse End Alcoholism and authorize the award of formula grants to the States. P.L. 91-616 also amends the Community Mental Health Centers Act to authorize grants and contracts for the prevention and treatment of alcohol abuse and alcoholism. The amendatory language is set forth below. The dollar authorization appears in the appropriate section of the Community Mental Health Centers Act (Section 247). Title I - Natioiial Institute on Alcohol Abuse and Alcoholism Establishment of the Institute Sec. 101. (a) There is established in the National Institute of Mental Health, the National Institute on Alcohol Abuse and Alcohoiism (hereafter in this Act referred to as the "Institute") tc administer the progrpkmg and authorities assigned to the Secretary of Health, Education, and Welfare (hereafter in this Act refex-red to.as the "Secretary") by this Act and part C of the Comunity Mental Health Centers Act. The Secretary, acting through the Institute, shall, in carrying out the purposes of section 301 of the Public Health Service Act with respect to alcohol abuse and alcoholism, develop and conduct comprehensive health, education, training, research, and planning programs for the prevention and treatment of alcohol abuse and alcoholism and for the rehabilitation of alcohol abusers an alcoholics. 16 (b) The Institute shall be under the direction of a Director who shall be appointed by the Secretary. Title III - Federal Assistance for State and Local Programs Part A - Formula Grants Authorization of Appropriations Sec. 301. There are authorized to be appropriated $4o,ooo,ooo for the fiscal year ending June 30, 1971, $60,000,000 for the fiscal year ending June 30, 1972, $80,000,000 for the fiscal year ending June 30, 1973, for grants to States to assist them in planning, establishing, maintaining, coordinating, and evaluating projects for the development of more effective prevention, treatment, and rehabilitation progr-g to deal with alcohol abuse and alcoholism. For purposes of this part, the term "State" includes the District of Columbia, the Virgin Islands, the Commonwealth of Puerto Rico, Guam, American Samoa, and the Trust Territory of the Pacific Islands, in addition to the fifty States. 17 Explanation of Transfers 1972 Real Transfer to: Estimate Purpose "Operating expenses, Public - $4,ooo Rental of space, Seattle, Building, General Services Washington Regional Office. Administration" Comparative Transfer to: "Departmental Management" -115,000 For DHEW central service an support in the following axeas: 1. Upward Mobility Program (1 position, $13,000) 2. Model Cities Program (2 positions , $30,000) 3. Executive Secretariat (1 position, $16,000) 4. Public Affairs (2 positions, $55,000) 5. Central personnel office improvement ($1,000) "Saint Elizabeths Hospital" -1,6oo,ooo Transfer of resources which support clinically based training .and research activities at the hospital. 1. Training (35 positions, $1,250,000) 2. Research (17 positions, $350,000). 18 Mental Health Budget estimate to House Senate Appropria- Year Congress Allowance Allowance tion 1963 126,899,ooo 133,599,000 148,599,000 143,599,000 1964 igo,o96,ooo 177,288,ooo igo,o96,ooo 183,288,ooo 1965 224,o85,000 223,273,000 223,273,000 223,273,000 1966 278,669,ooo 278,669,ooo 283,169,ooo 283,169,ooo 1967 305,115,000 310,119,000 315,6ig,ooo 315,619,ooo 1968 346,gog,ooo 296,gog,ooo 346,gog,ooo 346,gog,ooo 1969 364,939,000 342,439,000 364,939,000 350,439,000 1970 357,go4,ooo 36o,302,000 385,000,000 36o,302,000 1971 346,656,ooo 371,738,000 456,738,ooo 389,238,ooo 1972 499,451,000 581,201,000 658,201,000 612,201,000 1973 612,170,000 9 General Statement The basic mission at the National Institute of Mental Health is to develop knowledge, manpower, and services to prevent mental illness, to treat and rehabilitate the mentally ill, and to promote and sustain mental health. Underlying the great diversity of studies and projects supported by the National Institute of Mental Health is a clear unity of purpose, which is to increase understanding of the forces within and around man Wllich affect or dictate his emotional and mental health, and to apply this knowledge in effective treatment and prevention services. A total approach to the problem of mental illness must also provide for focusing upon acute, critical problems. For this purpose, the Institute has established several centers which focus on specitic high-priority areas such as alcoholism and drug abuse. The organization of the Institute and the distribution of its resources, as reflected in this document, are intended to optimize support amo,.ig research, training, and service activities. Research is carried out by the Institute's intramural research program and is also supported by grants and contracts awarded to investigators in universi- ties, hospitals, and other institutions. Training programs to develop skilled manpo-4er in the mental health professions and allied fields are supported through training grants to institutions and through research fellowships. Financial and technical assistance to States and local com-.ninities aids the development of community mental health services. 20 1. Research a. Grants: Included in this subactivity are the Institute's research grant and hospital improvement programs, each of which is described below: RESEARCH GRANTS Increase or 1972 1973 Decrease Grants .................. $90,500,000 $94,500,000 +$4,ooo,ooo To find better ways to treat, control, and prevent mental illness, many types of research are supported. Besides the clinical research to study this illness in patients, basic research is conducted to discover how genetic factors, the environment, and our social systems affect thought and behavior. In services development, research investigators test new methods and concepts in care and prevention of mental illness which have been suggested by the results of basic research. Support is provided to individual investigators on a project basis for basic applied and clinical research, throughout the broad areas of mental illness as well as areas of special interest such as drug abuse, pshch6- pharmacology, alcoholism,child mental health, minority mental health, crime and delinquency, and services development research. Tables 1 and 2 show the distribution of research grant funds by type of grant and by program. Table 1. Distribution of Research Grants Increase or 1972 - -1973 Decrease No. Amount ',No. Amount No. Amount Continuations ........... 741 $49,851,ooo 655 $49,851,000 -86 --- Competing renewals ...... 153 9,943,000 171@ 11,927,000 +21 +$1,984,ooo New Projects ............ 628 6-o,So4,ooo 656 22,820,000 +28 +2,ol6,ooo Sup --- .plementals ............ (78) 1,500,000 (-78) 1,500,000 -- Total .............. 1,522 82,o98,ooo 1,485 86,o98,ooo -37 +4,ooo,ooo 21 Table 2. Research Grants Program Distribution Increase or 1972 1973 Decrease Narcotic Addiction & Drug Abuse .......... $10,549,000 $11,o4g,ooo +$500,000 Alcoholism ............................... 7,543,000 8,o43,000 +500,000 Crime and Delinquency .................... 3,643,000 4,143,000 +500,000 Minority Studies ......................... 1,135,000 2,135,000 +1,000,000 Suicide Prevention ....................... 1,744,ooo 1,744,ooo --- Early Child Care ......................... 2,000,000 2,000,000 --- Metropolitan Problems .................... 2,i83,000 2,183,000 Mental Health Services ................... 7,589,000 g,o8g,ooo +1,500,000 Psychopharmacolog3r ....................... 10,110,000 10,110,000 --- Behavioral Sciences ...................... 17,713,000 17,713,000 --- Applied Research ......................... 8,563,000 8,563,000 --- Epidemiology ............................. 1,120,000 1,120,000 --- Clinical Research ........................ 8,2o6,ooo 8,2o6,ooo --- 82,098,000 86,09b,000 +4,000,000 Scientific Evaluation .................... 375,000 375,000 --- General Research Support ................. 8,027,000 8,027,000 --- Total Regular Research ................... 90,500,000 94,500,000 +4,ooo,ooo Narcotic Addiction and Drug Abuse: The Institute requests an increase of $500,000 for research in narcotic addiction and drug abuse in 1973 to expand the intensified research program conducted in 1972. Among the areas of this broad and complex field requiring the development of new knowledge are: the mechanisms of drug action; the metabolism of abused drugs; the identifi- cation of drugs of abuse in body tissues and fluids; the development of narcotic substitutes and antagonists; the psychological and behavioral effects of drugs; and the genetic effects of abused drugs. One objective of the research program is to investigate the bio- chemical basis of drug tolerance and physical dependence to gain an understanding of the processes that underlie drug addiction in man. For example, one investigator has found that protein synthesis in the brain is altered biphasically by narcotics. This effect is now being explored in the rat brain using several avenues of research: (1) measur- ing the change in the rate of protein synthesis after a single injection of morphine using the in vivo amino acids into brain proteins; (2) by assaying tyrosine hy@oxlase, an enzyme, in six areas of the rat brain after morphine treatment; and (3) by studying the binding of morphine to nucleic acids. The cognitive effects of chronic marihuana and/or hallucinogenic drug usage on the intellectual and adaptive abilities of a young male undergraduate population are being studied on one campus, utilizing students who voluntarily report various levels of usage over a defined time period. Results of a variety of standardized tests will be compared with those made by students reporting no usage to determine if verbal intelligence, spatial orientation, concept formation and ability to abstract have been adversely affected. In another study, an investigator is attempting to determine the effect of marihuana on the cell nucleus and its relationship to gene transcrytion, metabolism of chromosomal protein, and energy metabolism. This study utilizes the in vivo study of rats injected with radio- actively labeled marihuana constituents, which are then traced in the 22 Brain after various time intervals. Important studies are being conducted to determine the potential of marihuana extract to produce damage to chromosomes in both human and animal systems following dosages of varying strength and over differing periods of time. Research is also being conducted in the area of amphetamine abuse. For example, the effects of methamphetamine on the cerebrovascular system in Rhesus monkeys is being studied. This may be of particular importance in view of the number of clinical reports describing cerebro- vascular changes in drug abusers who take amphetamines. Following intravenous dosage of varying periodicity, all animals will have arterial catheterization and arteriograms to determine the extent of changes in the arterial wall, arterial occlusions, and damaged arterioles. At the conclusion of test periods, or earlier if fatalities occur, the animals will be killed and both gross and microscopic histopathological examin- ations will be conducted to determine the form and extent of cerebro- vascular damage. One aspect of the work in progress on effective narcotic antagonists involves the development of a sustained release vehicle for their adminis- tration. To this end, several projects are being supported to dissolve or suspend narcotic antagonists in a variety of potential depots, inclu ing glycogen, cholesterol, polyvinyl alcohol and others. The investigators are also considering the possibility of administering the antagonists in tooth fillings or dental prosthetic devices. The acceptability and the effectiveness of methadone as a treatment agent is being studied under a grant to a large metropolitan multi- modality treatment facility. This study is examining (a) the client's initial concerns and feelings about methadone, (b) the impact of orientation on his attitudes, (c) the attitude of staff and patients undergoing other forms of treatment, and (d) the response of clients to the methadone maintenance program. Both behavioral and personality measures will be made, and follow-up data will be collected to show changes in functioning of clients in maintenance, abstinence, and other treatment programs. In view of the increasing use of methadone and the dearth of informa- tion on the fate of methadone in the pregnant state, a project is being supported to determine the distribution a-,id effects of methadone and its metabolites in pregnant rats and sheep, following acute and chronic administration of the drug, information about its nature, causes, treatment and prevention. Alcoholism: Since alcoholism is the product of a complex and as yet unexplained interaction of biological, psychological and sociological factors, researchers in a number of different fields seek answers to a broad range of questions about the nature of alcoholism and its antecedents. Only as knowledge in the field grows will the capability develop to apply these research findings to treatment and prevention programs. The 1973 budget request provides an increase of $500,000 for alcoholism related research. The material below provides examples of existing activities that will continue to receive support and, where necessary, be expanded. 1. Clinical research: This area continues to be an important part of the grant program, and ongoing projects are concerned with the effects of alcohol on the stomach, and the identification of different patterns of alcoholism. Research has also been conducted on hemodialysis, thb- rapid removal of alcohol from the bloodstream. Although this process is not currently practical, it has been accomplished without serious complications. More study on a practical means of channelling alcohol from the bloodstream is planned for 1973. 23 2. Prevention and education: Studies concerning the youth and young adult are needed. In a large scale study of high school youths it was demonstrated that parental rejection, deprivation and impulsivity are factors which can predict problem drinking in youth. Research is being planned to categorize and evaluate the major characteristics and effective- ness of existing preventive programs to develop theory-based programs of public education. Although primary emphasis will be on observing the develop- ment of problem drinking, the investigators will also study drug use, delinquency, and antisocial behavior in school. 3. Behavioral and psychological studies: Two studies have been done in an attempt to differentiate between subtypes of alcoholic patients to optimally match specific treatment modalities to particular patients. One of these has identified "essential" and reactive types of alcoholic persons and the other has describedfoursubtypes based on the relationship between social factors and drinking patterns. Studies such as these will provide information about the perceptual motivation of the alcoholic person, differences in personality characteristics of non-drinkers and drinkers, and other factors associated with the preference for alcohol. 4. Studies of alcohol and driving: The effect of alcohol on driving skills is another area requiring considerably more development. It is estimated that at least 50% of the 56,000 annual highway fatalities are alcohol-related. Experiments are being conducted to determine the effects of alcohol on attention in performing such tasks as driving a vehicle. These experiments suggest that attention is seriously impaired by relatively low doses of alcohol, in contrast to its effects on such functions as vision where relatively high doses are required to produce impairment. Under the effects of alcohol, subjects attempted to cope with the divided attention task by restricting their attention increasingly to one type of task. While the subjects maintained performance closer to normal on the preferred task, nearly all the performance impairment occurred on one of the two tasks. The subjects were generally unaware of any impairment in their own performance. Other aspects of the drinking-driving area in great need of research include the identification of population of of high risk drivers and the specification of its demographic characteristics in order to implement an effective program in driver education. 5. Evaluation o Grants which investigate the physiological effects of alcohol will continue to receive emphasis. Increasing the rate of metabolism of alcohol or preventing its absorption ir, the body may facilitate the care of acutely intoxicated persons by rapidly inducing sobriety or as a preventive measure against intoxi- cation. Further research needs to be conducted to determine the validity of these findings and to explore in greater depth the similarities and differences between the addictive processes of alcohol and other substances. Child Mental Health: Activities directed at improving the mental health of children carry the highest priority for NIMH. The foundation of the Institute's efforts in child mental health is research--an effort to understand both normal and abnormal behavior. The goals of the current program are to (1) develop and demonstrate new approaches to prevention of leaxning and behavioral disabilities in children through fanily-centered programs; (P) stimulate innovative approaches to the improvement of early child care services and education through existing community institutions, and (3) foster the development of a family and child advocacy system based on control by community organizations of parents rather than by professionals in order to improve and integrate family and child services. The 1973 budget request includes an increase of $1,500,000 for Child Mental Health research programs. This increase will be used to stimulate research in the following six priority areas. 24 --- Coordination of children's services with allied delivery systems: these projects will be concerned with services extended by community mental health facilities as they relate to welfare, medical, educational, correctional, and rehabilitation programs for the handicapped. --- Expansion and upgrading of preventive programs for children in community mental health centers contacts and other settings: research activities will include the development of models of children's services in centers and related facilities, with particular attention directed to consultation and education services among community agencies with parent groups. Developing methods of reducing hospitalization of children and youth: projects will test innovative approaches to alternative care programs as well as to such direct intervention techniques as family crisis intervention. Supporting models of mental health oriented day care, nursery, and kindergarten programs: special emphasis will be placed upon the role of mental health centers staff in providing technical assistance to partnership agencies providing programs for young children. --- Development of adequate services for minority children: aspects to be stressed are helping parents and referral sources utilize the availability of services in manners that are acceptable to them, the design of services to meet special needs of minority children, and intervention in community conditions which militate against the mental well-being of minority children. ... Developing special services for the adolescent who is likely to drop out of school or to resort to drugs: efforts will be made to develop subtle assistance that will not require labeling of the students to receive help--a factor that has been found to be a deterrent in referral of students for help. Mental Health of Minority GroUs: The Institute's Center for Minority Group Mental Health Programs focuses its attention on the special mental health problems of the almost 40 million minority group members in the United States. The general conditions of the life of many minorities are associated with high levels of schizophrenia, alcoholism, drug usage and other mental health problems and institutionalization in mental health facilities, though it is inaccurate to generalize for all minorities since there are inter-group and intra-group differences. Research is supported to understand the causes, results, and mechanisms of prejudice and discrimination, and to evaluate methods of correcting the attitudes and conditions which place minorities in a disadvantaged position. This is done with minority groups themselves playing a major role in design, administration, and conduct of the research. The 1 reques inc es $1,000,000 to expand research programs related to improving our under- standing of the mental health problems of minority groups. Areas of emphasis will include (1) continued study of causes and methods of combatting prejudice, discrimination, stereotypes and racism with emphasis on the aged and institutional change; (2) the relation of social class and minority mental health problems; (3) effective organization and delivery of mental health services for minorities; and (4) ways of building on the strengths of minority groups. The research program will also focus on the connection between residential segregation and assimilation; the factors that affect economic and occupational placement of minority group members as well as studies of minority group institutions and services such as churches and colleges. Crime and Delinquency: The risk of becoming a victim of a serious crime has more than doubled since 1960. Five million serious crimes were reported during 1960, representing 12 percent increase over 1968. Between 1960 and 25 1969, arrests of juveniles for serious crimes increased 90 percent, while the number of persons in the 10-17 year age group increased only 27 percent. Work in this field is based on the premise that effective prevention, treatment, and control of social deviance will depend largely upon a sound knowledge base. Some projects currently receiving support include improving the capabilities of the public schools to deal effectively with emotional, interpersonal and academic problems presented by adolescent boys; and studies on the effect of the "social climate" of correctional institutions on inmate behavior and on the relationship between the personal experiences of institutional inmates and the organizational structure and function of the total institution. In an effort to help determine and reduce the causes of crime and delinquency, the 1973 request provides an increase of $500,000 for the study of various forms of deviant and maladaptive behavior, including development of a sound understanding of its etiological factors; development of means and technology for prevention; and development of adequat6 methods of intervention. Other Research Programs: In addition to the fields of investigation just summarized, the Institute plans to continue the following programs in 1973 at their current-year funding level. --- Clinical research will emphasize studies leading to improved treatment methods, and the study of the complex of factors from which mental illness an emotional distress arise. --- Behavioral sciences research will cover a variety of subjects, encom- passing a range of biological and social sciences. Studies will be con e into the processes whereby the personality, motives, emotional and intellectual characteristics of children are shaped by the family and social environment. --- Psychopharmacology, one of the most successful of the Institute's research programs, will continue to support studies to assess the pharmacological properties of new compounds; to analyze the physiological and behavioral effects of drugs on animal and human subjects; and to evaluate the efficacy of new chemotherapeutic agents in the treatment of specific disorders such as schizo- phrenia, depression, drug abuse and alcoholism. --- Applied resea--ch will continue to pursue one of its primary aims: the prompt and effective application and evaluation of research findings. The program also seeks to test pioneering approaches and new concepts, such as the use of a mobile unit to provide mental health services to children and, their mothers in a deprived urban environment. --- Studies of metropolitan problems deal with the mental disorders and emotional distress that are most prevalent in the inner cities and decaying fringes of our urban areas. The Institute will continue to support studies that attempt to delineate the causes, determine why some are stricken while others are unaffected, and improve existing measures for prevention and treatment. 26 2. Hospital Improvement Grants Increase or 1972 1973 Decrease No. Amount No. ount No. Amo@t Continuations .......... 44 $4,loo,000 57 $5,4oo,ooo +13 +$1,300,000 Competing renewals ..... 17 1,500,000 8 701,000 -9 -799,000 Hew projects ........... 15 1,300,000 9 799,000 -6 -501,000 Total ............. 7@ 6,900,000 74 6,-goo,ooo -2 --- The major emphasis of the Hospital Improvement Program is directed toward improving the treatment, care, and rehabilitation of the mentally ill in the 302 eligible state-supported mental hospitals throughout the Nation. The program specifically focuses on the use of latest techniques and knowledge in demon- strating improved services for patients. Programs are planned in response to the hospitals' highest priority needs, and directed to the long-range goal of improving patient care throughout the Institution. In 1972 the Institute decentralized the administration of the Hospital improvement Program to the Department of Health, Education, and Welfare Regional Offices. As a result of the close proximity of the Regional Offices to the State hospitals it is felt that they can be more responsive to the needs of the hospitals and can provide improved monitoring of those institutions which have received grants. As part of the program, hospitals are encouraged to move toward,the develop- ment of cooperative relationships with comprehensive community mental health programs and by the close of 1971, 162 State hospitals reported the start or growth of cooperative relationships with local groups and agencies. Within this number 134 are directly affiliated with community mental health centers and have demonstrated the crucial value of State hospitals as back-up or special resources to newly developing mental health centers. They have assisted in prov ding a range of services not available in mental health centers and provide component parts of center programs such as inpatient care, emergency care, aftercare, outpatient care, diagnostic services, rehabilitation, consultation and education. As a result of improved delivery of services achieved through a Hospital Improvement award, six state hospitals have received staffing support through the Community Mental Health Centers program. At the end of 1971 a total of 2 9 Hospital Improve- ment grants had been awarded to 179 of the 302 eligible State mental hospitals. There are a number of noteworthy examples of progress in the Hospital Improve- ment program that illustrate its success in improving patient care. In one typical program, the project was designed to bring together approximately 7 back ward chronic schizophrenic patients into a single ward for resocialization and rehabilitation in preparation for community placement, gainful employment, and to provide them with opportunity to assume the major responsibility for their own conduct and activities. The protocol involved a five step operant conditioning program with each higher step representing an increase of income (the range of income was from $3 to $12 per week) and a commensurate degree of increased responsibility and privilege. In the final stages the patient was permitted to spend his own money and assume almost full responsibility for his activity and actions of others in the group. After a period of time patients were moved in small groups to a rented furnished home in the community under supervision of a community coordinator. During this period, appropriate job placements were made and the income used to help pay for rent, food and other items. About 165 patients have been discharged through this project with a return rate of only 10% as compared to 30% in most hospitals. Another program was developed in response to the rapidly growing number of admissions in the 12 to 18 year old age group. During the first years of operation of this program admissions more than doubled. Educational recreational and occupational programs were extensively used and individual attention and psychotherapy was provided. Of the 272 patients admitted to the program about 84% have been released. The average stay of patients in the program vas reduced from 26 months to 13 months., 28 b. Direct Operations Increase or 1972 1973 Decrease Pos. Amount Pos. Amount Pos. Amount Personnel compensation and benefits ......... 1,170 $18,903,000 1,184 $19,169,ooo +14 +$266,000 Other expenses ........ --- 22,796,ooo --- 24,o99,000 --- +1,303,000 Total ............ 1,170 41,699,ooo 1,184 439268,000 +14 +1,569,ooo This activity supports 1) staff who are responsible for the planning, develop- ment and administration of the research grant and contract program; 2) funding for the intramural research program which is conducted in the Institute's awn laboratories and clinics; 3) the Clinical Research Center at Lexington, Kentucky; and 4) a limited amount of research performed on a contract basis. The Division of Extramural Research Programs plans and administers research programs in the areas of behavioral science, clinical research, applied research, psychopharmacology and epidemiologic studies. Included in this Division is the Center for Studies of Schizophrenia which serves as a coordinating unit to analyze current research to avoid unjustified duplication of effort and to stimulate promising new avenues of scientific investigation. The Division of Special Mental Health Programs administers programs directed toward problems of special significance such as crime and -delinquency, metro- politan problems, mental health of children and families, and minority group mental health problems. These highly responsive centers were established to coordinate and focus grant and contract funds on specific problem areas. Intramural Research: The NIMH Intramural Research Program conducts basic and clinical research on the problems of mental illness and related pathologies. Strategically located on the campus of the National Institutes of Health where opportunities for fruitful exchange abound, its scientists pursue the new knowl- edge without which we cannot hope to alleviate the scourge of mental illness for millions of Americans or to reduce the enormous economic toll it exacts. These scientists are members of a research cadre whose excellence is esteemed throughout the scientific world, a fact evidenced by the honors which continue to be bestowed m them in this country and abroad. Dr. Julius Axelrod, 1970 Nobel Prize winner, together with a team o collab- orators, is currently engaged in a search for enzymes involved in biogenic amine biosynthesis and metabolism in the blood. The measurement of these enzymes makes it possible to determine the activity of the sympathetic nervous system in stress and in a number of diseases, (e.g., manic depression and familial dysautonomia) and after drug treatment. Other members of the research team.are working on development of the adrenergic neurones in the fetal brain. Their findings have given considerable insight into the development of these important nerves as e brain grows to maturity. Still another team is engaged in clinical studies of drugs which are frequently abused, e.g., amphetamine and tetrahydrocannabinol (THC), the active ingredient in marihuana. They have found that although tetrahydrocannabinol is partly metabolized, a considerable residue is stored in the tissues and is released so slowly that it can be detected in the blood for several days after its administration. Chronic users of marihuana metabolize it more rapidly than controls who had never used the drug. Another aspect of the THC story concerns the role of an enzyme which induces metabolism of the drug in the lung but which is not present in the liver. Data from another Intramural study suggest that since marihuana is usually smoked, this lung enzyme may play a significant role in determining biochemical patterns of drug distribution in abusers of cannabinols. 29 A team of intramural scientists is now reporting their findings from data collected over the past several years on early family development. The sequence begins with the newly wedded couple, examines their adjustment to marriage, the birth of their first child, the newborn infant in the first few hours of life, mather-infant interaction, the same infant when he becomes 2 112 years old and attends nursery school, the pre-school period and later, the early school period. The findings clearly demonstrate relationships between newborn and later behavior, and between pre-school behavior and that of the school-age period. For example, vigorous and goal-oriented behavior (assertiveness) in the pre-school period has proved to be related to later verbal intelligence and use of imagination in the early Behool-age period, as well as to social ease, lack of fearfulness and more adequate coping with strange new situations. These findings are important for parents, educators and others concerned with fostering the development of learning capability in the young child. Thirteen years of planning, designing and building became a reality this past year when the Institutes' Laboratory of Brain Evolution and Behavior was dedicated at the National Institutes of Health Animal Center in Poolesville, Maryland. The new facility will help Institute scientists conduct brain function and behavior studies on animals living in semi-natural habitats thus eliminating some of the obvious difficulties inherent in behavioral studies of animals con- fined in laborat cry cages and living under largely artificial conditions. In an engrossing study of overcrowding in caged mice, one scientist has witnessed what he terms "the dissolution of social organization", the end result of which is an incapacity on the part of the subjects to replace themselves through reproduction. Even when some of the mice were removed to less crowded quarters, their capacities for carrying out the complex behaviors (social relating, courtship, mating and motherhood) which are requisite for survival of the species, were impaired. Although these studies were conducted with mice, the findings may have application for other species, including man. In other studies of the brain, investigators have shown that cerebral vessels are remarkably sensitive to oxygen and that concentrations no higher then those commonly used therapeutically for premature and newborn infants with cardiac or respiratory diseases cause as much as 35% reduction in blood flow in most parts of the brain. These findings suggest that oxygen inhalation therapy should be used cautiously during the peri-natal period lest it lead to retarded brain development and other deleterious effects in the nervous system. Alcoholism: The Intramural research portion of the National Institute of Alcoholism and Alcohol Abuse, carried out in special research facilities at Saint Elizabeths Hospital in Washington, D. C., is particularly concerned with the nature of the addictive process in alcoholism. The research model that,is used allows the investigators to study both the behavior and bio- chemistry of alcoholic individuals in all phases of experimentally-induced intoxication. An important reason for studies of the drinking pattern and behavior of chronic alcoholics is the need to examine the many untested assumptions about how and why an alcoholic drinks. These assumptions are 40 based on retrospective reports of alcoholic individuals made during periods of sobriety and their validity may be affected both by deliberate and unintentional distortions or by the patient's inability to recall and adequately state his attitudes toward alcohol. The program uses experimental animals to test hypothesis developed from intensive study of the alcoholic individual. For more than a decade, much effort has been expended to produce alcoholism in an animal in order to facilitate the study of the development sequence and the actions of possible neurechemical, neurophysiological and metabolic factors which are concomitants of alcohol addiction. Data obtained from analyzing the development of such addiction will ultimately help to clarify the biological mechanisms of alcohol addiction and suggest ways to stop or reverse the disease process. 30 The Narcotic Addiction Research Center, ts the intramural research arm of the Division of Narcotic Addiction and Drug Abuse, carries out the continuing responsibility for producing laboratory and clinical data on the effects of drugs. This includes studies which assess the psychic dependence producing properties of new non-narcatic drugs prior to their entry into the commercial market, the continued research into new methodologies for improved research on drugs and diagnosis of drug usage, and pharmacological studies of drugs and their action on the nervous system. The center is the only facility which can be called upon to do human assessment of narcotic and non-narcotic drugs. With positions and funds provided in the 1972 budget amendment the Addiction Research Center will expand its existing efforts to assess the dependence pro- ducing properties of narcotic analgesics to include studies of non-narcotic drugs to determine their abuse potential prior to their entry into the commercial market. Clinical pharmacological research on new non-narcotic drugs often reveals the presence of addictive properties which had not been.discovered in animal testing. Moreover manipulation of dose range in clinical testing brings about variances in subjective reactions which are invaluable in understanding the nature and assessing the danger of drugs. This determination is necessary so that the Secretary can carry out his responsibilities under the Comprehensive Drug Abuse Prevention and Control Act of 1970 (P.L. 91-513), which requires that he make recommendations to the Attorney General on the control classification of a drug. Efforts are continuing in order to develop, assess and validate methods for the determination of narcotics in the urine. One method which shows great promise as a practical means for the diagnosis of drug abuse uses thin layer chromatography applied to the urine. This detects the presence of certain drugs and differentiates them from one another. .ClLnical Research Center: In recognition of its primary research orienta- tion, funding for the Institute's Clinical Research Center at Lexington, Kentucky has been transferred to this activity from the "Rehabilitation of Drug Abusers" account. The Center will continue to provide services to addicts committed to the care of the Federal Government under the Narcotic Addict Rehabilitat4 on Act of 1966, by the courts, from cities that do not have adequate facilities sustained either by local funds or with Federal grant or contract support. Research at the Lexington Clinical Research Center focuses on the followup of the discharged patient. Post hospital services are provided in collaboration with community agencies, and a controlled evaluation of these activities is being completed. Directed Research: Included in this activity is $6,000,000 in 1973 for research contracts. Although a large majority of the drug abuse research is supported under grants to independent scientists, some promising fields of research are not represented by sufficient numbers of investigators to achieve an acceptable rate of progress through the normal grant procedure. These funds will be used to carry out extensive controlled clinical tests with presently available antagonists such as naloxone and cyclazocine; begin a research and development program to develop substitutes for opium derivatives; study the receptivity of prescribers to adopt non-opiate drugs in their medical practice; develop educational programs to assist physicians in making the switch to synthetics as soon as they become available; and to fill gaps in knowledge identified through surveys and assessment of progress during 1972. Funds are also included to continue the marihuana research contract study which is designed to determine the effects on humans of the prolonged use of marihuana. A total of 14 new positions is requested under this activity in 1973. Four of these positions will provide additional staff support for programs related to the mental health of children. Five positions will be directed toward studies of minority group mental health problems, and the five remain- iiigpositi ons will support research in the field of crime and delinquency. 31 2. Manpower Development a) Training grants and fellowships Increase or 1972 1973 Decrease Training grants and fellowships ............... $120,050,000 $105,050,000 -$15,000,000 An adequate supply of trained manpower is essential to sustain the Nation's efforts to increase mental health services, to obtain new knowledge through research, and to develop and improve methods of organizing and delivering mental health services. Training Grants Institute efforts related to the training of mental health manpower are supported through a variety of programs including: (1),Professional Training: Grants are awarded to training centers and educational organizations for support of training programs in psychiatry, psycho- logy, social work, and psychiatric nursing. This support covers teaching costs and enables institutions to offer financial assistance to students, including stipends, tuition, and dependency allowances. (2) Experimental and Special Training Projects: Grants are made to eligible institutions and agencies for innovative, experimental training projects. These may include the development of training programs for new types of mental health personnel, programs for persons whose roles or functions may be related to mental health, or the development of new and experimental methods of training. Support is provided for teaching costs and for full-time training, for student support as well. (3) Continuing Education in Mental Health: Grants are awarded to eligible institutions which develop strong continuing education divisions within profes- sional schools and training centers for the mental health professions, make continuing education an integral component in implementing community and State mental health planning and programs, or provide for program development directed to the needs of a specific group of potential trainees, as opposed to offering isolated courses for whomever can be recruited. Programs are supported at both the professional and nonprofessional levels and are primarily for support of teaching costs only. Although the NIIIH supported programs have contributed to the growth in t e supply of manpower providing mental health services to the public, the demand for such services has also grown at a rapid rate. The following table summrizes. the unmet need for mental health personnel, by comparing budgeted positions in public mental health facilities (Manpower Demand) with filled positions (Manpower supply): 32 Discipline Manpower Demand Manpower Supply Unmet Needs, Psychiatry .................. 20,612 18,588 29024 Psychology .................. 13,190 11,350 1,840 Psychiatric social work ..... 21,153 18,133 3,020 Nonprofessionals ............ 17,039 16,241 798 Total ..................... 71,994 64,312 7,682 Within this data, Community Mental Health Centers and State and county mental health hospitals show the greatest need for increased professional and nonprofessional workers to meet the increasing demand for services. Tables 1 and 2 below show the distribution of training grant fun a by type of grant and by functional program respectively. The narrative material following the tables describes the training grants structure on a programmatic basis. Table 1. Distribution of Training Grants by Type of Grant Increase or 1972 1973 Decrease Noncompeting No. Amount No. Amount No. Amount continuation ...... 1,670 $90,500,000 1,334 $73,000,000 -336 -$17,500,000 Competing continu- atibno ............ 179 11,734,000 216 15,314,000 +37 +3, 80,000 New Projects ....... 155 8,080,000 134 7,000,000 -21 -1,080,000 Supplemental Awards (27) 700,000 (27) 700,000 --- --- Scientific Evalu- ation ............. 16 336,000 16 336,000 Total .......... 2,020 111,350,000 1,700 96,350,000 -320 -15,000,000 Table 2. Training Grants Program Distribution Increase or 1972 1973 Decrease Narcotic addiction and drug abuse ... $1,700,000 $1,700,000 ... Alcoholism .......................... 4,013,000 4,013,000 --- Minority Training ................... 1,300,000 1,300,000 --- Psychiatry .......................... 32,433,000 20,473,000 -11,960,000 General Practitioner ................ 5,533,000 5,533,000 --- Behavioral Sciences ............e .... 24,279,eOO 24,279,000 --- Psychiatric Nursing ................. 10,299,000 7,259,000 -3,040,000 Social Work ......................... 12,678,000 12,678,000 --- Experimental and-Special ............ 7,743,000 7,743,000 --- Continuing Education ................ 4,264,000 4,26 000 --- Hospital Staff Development .......... 3,800,000 3,800,000 --- Crime and Delinquency .............. 2,204,000 2,204,000 --- Metropolitan Problems ............... 374,000 374,000 --- Suicide Prevention .................. 394,000 394,000 --- Scientific Evaluation ............... 336,000 336,000 --- Total ........................... 111,350,000 96,350,000 -15,00,0,000 33 Narcotic Addiction and Drug Abuse: The purpose of these programs is to assure an increased supply of trained professional and paraprofessional manpower to provide treatment and rehabilitation services and to obtain now knowledge through research. Some new awards planned in this area include grants providing students in health fields with training in the drug abuse area. A grant funded jointly with the National Institute on Alcohol Abuse and Alcoholism provides support to medical schools to develop courses of instructions on drug and alcohol abuse and a career teacher award intended to train medical school faculty members in the field of drug addiction. Alcoholism: Currently the Institute is emphasizing the development of training programs which concentrate on the training of individuals who will work with alcoholic employees, drinking drivers, American Indiana, public intoxi- dents and other identified target groups. In 1973 the Institute will continue these programs and support programs to provide manpower for after-treatment care of the alcoholic persons. Finally, efforts will be intensified to develop a cadre of well trained individuals who can develop alcoholism training programs which will increase the number of persons receiving training and at the same time re uce t e perio of training, with no exppnse to the quality of the students graduated. Disciplines in which such efforts should be successful are sociology, psychiatry, social work, psychology, nursing, and rehabilitation counseling. Minority Training: Support will focus on the development of techniques for the recruitment and training of minority students in graduate, post-graduate, and baccalaureate programs and in community college human services associate mental health worker programs. Additionally, the Institute will maintain and expand its interest in, and recruitment of minority members in teaching as a career. it will also foster training researchers, as well as programs designed to enable trained minority group members to enter Federal and private decision land policy-=king positions in mental health and health related agencies. Further, there will be a concerted effort in training professionals to work in the area of psychosomatic illness prevention, especial y in those most preva- lent among minority group members. Psychiatry TrainiM Program: Support is provided for the training of physicians and medical students in the broad concepts of mental health and in the delivery of mental health services. Every medical school and school of osteopathy and almost all accredited psychiatric training programs in the country receive support through one or more of the ten types of grants administered and funded under this program. Highest priority for support is given to applications in the areas of child mental health and minority mental health services, drug abuse prevention and treatment, and health manpower deficiencies. Support provided by this program may be grouped into two different grant categories: Pre M.D. Psychiatry Training, and Graduate Psychiatry Training. 1. Pre M.D. Programs - Medical school training in psychiatry not only serves to increase the number of persons entering the mental health field, but also enhances the knowledge and skills of persons who may be involved, direct y or indirectly with the care and treatment of mental health problems. These grants provide faculty support and student support in order to introduce the principles of psychiatry and mental health into the curriculum of the medical student early in his training. This program will be reduced by $4,960,000 in 1973. It is intended that financial assistance be funded in the future through the student assistance programs administered by other Federal agencies. 34 2. Graduate Psychiatry Training - Support is provided to medical schools, hospitals, and clinics for programs of residency training at the graduate level in psychiatry, including child psychiatry, and for training in special areas such as community psychiatry, student mental health, and others. In community psychiatry training, interdisciplinary programs have been encouraged which involve jurists, attorneys, penologists, and other law enforce- ment officials, in addition to professionals and lay personnel involved in problems of drug abuse, suicide prevention and alcoholism. The 1973 President's Budget contains a decrease of $7,000,000 for psychiatry residency training. Substituted for the present system will be an expanded institutional support grant program. Behavioral Sciences Traininx Programs: Support of training in the behaviors sciences include grants to institutions for the training of psychologists, for the training of biological and social scientists for research in mental health, and for the training of mental health specialists in the biological or social sciences. In each instance, grants include funds for both institutional costs and for a limited number of stipends. Psychiatric Nursing: This program produces the manpower for training addition- al graduate, undergraduate and non-professional nursing personnel to meet the increasing demands for psychiatric nurses in community mental health centers, hospitals and their service agencies, as well as in teaching roles. The graduate and undergraduate components of this program are discussed be ow. 1. Undergraduate training: This program provides an opportunity to strengthen the teaching of community mental health and behavioral sciences content through- out the curriculum in baccalaureate and associate degree nursing programs. In addition, it serves to increase the number of graduate nurses continuing their education in the mental health field and provides a sound basis for advanced training and specialization at the graduate level. This program will be reduced by $3,040,000 in 1973. It is intended that financial assistance be funded in the future through the student assistance programs administered by other Federal agencies. 2. Graduate training: This program produces the highly qualified manpower for training additional graduate, undergraduate And non-professional nursing personnel to meet the increasing demands for psychiatric nurses in community mental health centers, hospitals and their service agencies, as well as in teaching and consultation roles. All programs are heavily focused upon training for the delivery of community mental health services, with program content in the areas of community crisis and systems theory, community organization and planning with supervised field training. This training takes place in a variety of community agencies And institutions including mental health centers, in-patient services, outpatient clinics, schools, churches, courts, prisons, nursing homes and housing developments. 35 Social Work Training: Training support in the field of social work is designed to augment the supply of social workers trained in mental health and to improve the quality of social work training relevant to mental health. With these objectives, grants are made to graduate schools of social work and other training centers or institutions for support of graduate training programs in any area of social work relevant to mental health. These grants provide both institutional support and to a lesser degree, student support. High priority in 1973 will be given to projects with the general objectives of improving and extending training capabilities to produce more manpower in community mental health, in minority group development, in innovative educational efforts and in child mental health. Continuing Education Training,: This program supports efforts to improve and increase the skills of mental health specialists so that they can keep abreast of the most recent advances in theory, practice and technology. In addition, the program assists training institutions by increasing their capacity to make established mental health personnel more effective and supports con- tinuing education courses for general practitioners. The continuing education training program will be used extensively during 1973 as part of a multi-faceted approach throughout the training programs to stimulate paraprofessional training activities. In addition to upgrading the skills of the existing cadre of mental health workers and to provide them more meaningful roles on a total health service team, continuing education will also focus on training professional mental health personnel in the effective use of mental health workers, and on a restructuring of roles and service functions to capitalize on the Potential contributions of these workers. Emphasis in the training will be placed upon providing specific mental health skills in response to expressed needs of individuals and service agencies. Hospital Staff Development: The Hospital Staff Development Program is designed to improve the quality of patient care in public mental health hospitals included in state systems of care through inservice training of staff personnel. It encourages hospitals to provide staff development programs at the subprofessional and professional levels through a variety of courses, such as orientation, refresher and continuation training, as well as through special courses for those who conduct the training. The difficulties encountered in securing and retaining adequate mental health personnel in state mental hospitals has long been recognized. The Hospital Staff Development Program is directed toward alleviating these difficulties by providing a source of funds for some 300 eligible state- supported mental hospitals to initiate or expand new training programs. Of these eligible hospitals, 214 have received staff development grants providing training to an estimated 60,000 persons. Crime and Delinquency: A major emphasis in this area is placed on the development of training models and programs for both professional and non-pro- fessional service personnel, and behavioral and social science researchers. In addition to the development of innovative training models for professional service manpower, the Institute is devoting more effort to the expansion of work opportunities in this field for various non-professionals--including ex-otfenders--as probation officer case aides in the supervision of criminal offenders. Results of this program are quite promising and are expected to shed light on the future role of indigenous non-professionals in the community treatment of offenders. 36 Metropolitan Problems: Training is supported for professionals and non- professionals which will enable them to contribute substantially to metropolitan mental health problems. This training has been interdisciplinary, combining facets of urban planning, systems analysis, and social and behavioral sciences. An example of this approach is a training program sponsored jointly with the Bureau of Camunity and Environmental Management which will train students in the areas of community development and leadership in.the solution of social and environmental problems. Fellowships The Research Fellowship Program: This program provides advanced research training relevant to mental health at three levels, (1) predoctoral, for graduate training toward the doctoral degree; (2) postdoctoral, for advanced training and; (3) special fellowships, usually for individuals in mid-career who have contributed effectively to behavioral research. The fellowship program provides basic scientific training as well as advanced and specialized training in a variety of mental health research areas. These include the psychiatric and psychological study of mental development and mental illness; the biological, psychosocial, and cultural correlates of behavior; and research in basic psycho- logical processes. Awards are made for research training in any area of behavioral science, clinical or non-clinical, in which the applicant's proposed program shows rele- vance to the understanding of normal or abnormal behavior. These include the general categories of biological and physiological correlates of behavior; psychiatric and psychological study of mental development and mental illness; psychosodial and cultural correlates of behavior, and basic psychological processes. There is great benefit in improving the capacity of individual scientists to increase our knowledge of mental health and mental disease problems. Espe- cially in newly emerging fields, such as community mental health, it is important for outstanding research-oriented behavioral scientists to have the brief period of training necessary to enable them to acquire such specialized knowledge. other areas of special interest are those concerned with drug,addiction, anti- social behavior, brain damage, alcoholism, child mental health, and problems of living in overcrowded,or underprivileged communities. Research Development Program: The Research Development Program is designed for the support of research, as well as research training, of mental health problems. Its function is to insure continuity of effort in research programs. There is a conspicuous deficiency of both scientific knowledge for mental health services, and non-Federal funds for the support of scientists in research positions in centers for the treatment of the mentally ill. More than half of the awards in the Research Development Program support scientists in psychiatric centers, mainly psychiatric departments in medical schools. Programs of both basic and applied research on problems relevant to mental health and mental illness are supported, including research on personality and on human development in relation to mental health, studies of social factors in mental health, studies of physiological and biochemical substrates in relation to behavior, and investigations to clarify mental disorders and illness, with reference to etiology, diagnosis, treatment or prevention. Research on Child Mental Health: Of the current awardees, about 35% are studying various aspects of problems related to the growth and development of infants and children. These investigators represent a variety of fieldsi such As psychiatry, animal behavior, neuropsychology, psychophysi6logy, medicine, biology, endocrinology, and social, experimental, and developmental psychology. 37 The following are examples of the many problem areas under study: the nature of the early infant@mother bond; the effects of early "tutoring" to counteract the effects of deprived environments; treatment methods for pre- delinqu6nt children;'carefully controlled drug studies with hyperactive children; factors contributing to the strengths of black children and families; and longi- tudina,l studies of the effects of preventive interventions in the early school years. Research on Minority Groups: About 15 awardees are working on problems directli related to minority and disadvantaged groups, while the research findings of many others can be considered to be of potential relevance (e.g., studies of learning, thought processes, language, memory an d attention). Of more immediate import are the current studies of the development of racial attitudes and how they can be influenced; the approach of Puerto Rican children to new learning situations; the incidence and epidemiological trends for mental illness, suicide and alcoholism among Blacks, Indians, and other cultural groupings; and longitu- dinal studies of the school adjustment and mental health status of children in ghetto areas. Research oh Service-Delivery: A variety of investigations are relevant to the improvement of delivery of mental health services, ranging, in the medical area, from problems relating to the treatment of Parkinson's disease, depression, schizophrenia, hyperactive children and children with learning disorders, to attempts at understanding the emotional impact of kidney transplants. The previous examples of Research Development Program awards in the areas of children, minority groups, and aspects of service-delivory represent but a small fraction of the diversity of the program in terms of disciplines represented, and the continuum of approaches from basic to clinical and applied research. Research on Narcotic Addiction and Alcoholism: In the area of research on drugs and alcoholism, at least 25 awardees are investigating the mechanism of action of various hallucinogens and drugs, psychological reactions to the use of drugs or alcohol, as well as epidemiological data on incidence and social corre- lates of addictions. 38 As shown'in the following tables, the request for 1973 reflects a program level identical to 1972. Distribution of Fellowshi UR Awards by type Increase or 1972 1973 Decrease Noncompeting No. Amount No. AmounF No. Amount continuations ............. 399 $5,182,000 418 $5,428,000 +19 +246 Competing renewals ......... 185 1,310,000 150 1,064,000 -35 -246 Supplemental awards ........ 89 208,000 89 208,000 --- --- New Projects ............ O.. 192 2,000,000 192 2,000,000 --- Total ................. 673 8,700,000 657 8,700,000 -16 --- Distribution of Fellowship Awards by Program Increase or 1972 1973 Decrease No. Amount No. Amount No. Amount Predoctoral ................ 400 $2,624,000 370 $2,528,000 -30 - 96,000 Postdoctoral ............... 58 480,000 75 624,000 +17 +144,000 Special ............... i .... 43 566,500 39 518,500 -4 -48,000 Research career ............ 18 534,500 16 472,500 -2 -62,000 Research scientist ......... 62 1,645,000 70 1,857,000 +8 +212,000 Research scientist develop- ment ...................... 92 2,850,000 87 2,700,000 -5 -150,000 Total ................. 673 8,700,000 657 8,700,000 -16 --- 39 b. Direct Operations Increase or 1972 1973 Decrease Pos. Amo n@t Pos. amount Pos. Amount Personnel compensation and benefits ........... 135 $3,004,000 135 $3,042,000 --- +$38,000 other expenses .......... ... 4,737,000 --- 4,737,000 --- --- Total .............. 135 7,741,000 135 7,779,000 --- +38,000 This activity supports Institute staff who are responsible for planning and administering the National Mental Health Manpower program, including mental health manpower studies and the training of paraprofessionals and includes funds for contract support of training centers. The Division of Manpower and Trainin ro iL m@s administers most of the Insti- tute's training grant and fellowship programs. A high priority is placed upon developing programs which emphasize community mental health concepts and prac- tices; interdisciplinary awareness and cooperation; the care and treatment of children; the provision of services to minority communities, and the recruitment and effective utilization of minority group members into the mental health man- power pool; and the development and training of new types of mental health workers for responsible roles in the delivery of mental health services. In relation to research training, stress is given to programs that prepare biological, psycho- logical and sociological scientists to undertake studies relevant to: (a) the understanding of mental illness and social problems and (b) the delivery of mental health services. Staff of this Division also perform continuing analyses and evaluations of the Nation's mental health manpower requirements, periodic assessment of available and projected manpower resources, and appraisal of the contribution of NIMH- supported training programs toward meeting the Nation's needs. Am.Dng studies currently in process are a jointly funded NIH/NIMH survey of the sources of fund- ing of graduate research training throughout the Nation, including an assessment of the consequences of possible cnanges in current patterns of funding; and a project to develop a design for evaluating training programs for new careerists in mental health roles. An additional study explores staffing patterns and training requirements of Community Mental Health Centers, and assesses the rela- tionship of current NDM programs of training support to the staffing needs of the Centers. Included in the Division of Manpower and Training is the Mental Health Career Development Program, which is designed to supply the Public Health Service, -L including the National Institute of Mental Health, with professional personnel trained in mental health related disciplines. The training programs focus on the development of psychiatrists and mental health nurses who are planning on a Federal professional career. The persons currently being trained are working in a wide variety of health-related settings, including patient care facilities, mental health research units, demonstration projects and mental health administra- tion. Contract support will continue in 1973 for specialized training programs designed to improve the ability of physicians, mental health and educational professionals to identify, treat and counsel drug abusers. Three of the training institutes located in Oklahoma City, New Haven, and Hayward, California will continue to train a broad range of professional and paraprofessional personnel whose vocational activities relate to drug abuse. The fourth training institute established in 1972 will continue to be devoted exclusively to clinica training. 40 3. Support of State and Community Programs a. Community Mental Health Centers Program: The objective of the Community Mental Health Centers (CMHC) Program is to facilitate the organization and delivery of mental health services so that all Americans will have access to quality mental health care. Through this program, resources are utilized so that greater progress can be made in the treatment and prevention of mental illness. It is essential that the Nation continue its efforts in establishing a basic network of mental health services at the community level. Through the grant mechanism, Federal monies are being expended to assist in the construction and staffing of community mental health centers. Each center must provide five basic treatment and prevention services to a specific catch- ment or service area to insure that the community will be the front line of defense against mental illness. To achieve this capability, each center must provide as a minimum inpatient care, outpatient care, 24-hour emergency service, partial hospitalization, and consultation and education. In addition to these five essential services, centers are encouraged to develop rehabilitation services, training activities, research and evaluation programs, and an administrative organization which will achieve the intent of the program. A total of $478.9 million awarded since the CNHC program began in 1965 has assisted communities to develop 452 community mental health centers. When fully operational, these centers will serve geographic areas with an estimated 61 million people. Types of areas served by these centers differ markedly. They range from the poverty of Appalachia to the urban-suburban affluence of our major cities. Seventy-two of the centers serve catchment areas in cities with a population of 500,000 or more; 221 will serve smaller cities; 157 are located in small towns and communities and will serve large rural areas through use of outreach teams and satellite facilities where mental health services have not been available in the past. In its short history, the CMHC program has demonstrated one aspect of its effectiveness by providing mental health services to people who previously had no access to them. As of June 30, 1971, 300 community mental health centers were operational. During the calendar year 1970, there were 399,000 individuals admitted to community mental health centers case load. Of the 452 funded centers, 168 have received construction grants, 1011 have received staffing grants, and 181 have received both staffing and construction grants. In a number of inner-city areas, community mental health centers demonstrate imaginative and innovative programming which involve a wide variety of professional and paraprofessional staff and volunteers. Inspired by the leadership developed in the community mental health center movement, many educational institutions have initiated formal educational programs for training new careers personnel. Community mental health centers also provide an opportunity for demon- stration and application of exciting new therapeutic concepts and techniques. These include the provision of crisis intervention, alternatives to 24-hour care, consultation to community care-takers and outreach to previously under- served groups. Among the alternatives to 24-hour inpatient care are daycare, which engages the patient in therapeutic activity during the day, and permits him to return to his family at night and on week-ends, and night care which assists those who are able to function in a job or at home but who require more intensive supervision than can be provided on an outpatient basis. 41 Beginning in 1969, the program increased its evaluation activities in- cluding a major effort to measure the effectiveness of the community mental health center model is a service delivery system and to monitor its impact on existing mental health ptograme. 42 (1) Construction of Community Mental Health Centers Increase or Decrease 1972 1973 Construction grants ........ $5,200,000 $9,800,000 $+4,600,000 (Budget authority) ......... (15,000,000) --- (-15,000,000) The purpose of this program is to improve the organization and allocation of mental health services and their effectiveness so that the highest possible quality of modern treatment and care will be available and accessible to all who need it. GrAnts are authorized for the construction of public and other nonprofit community mental health centers. Projects may consist of the con- struction of completely new facilities or the acquisition, remodeling, alter- ation or expansion of dxisting facilities. The center program may be based in one or more facilities in the community under central administration which assures continuity of patient care. Community program objectives include the provision of those essential elements of service that make it possible for the resources to serve the community as a first line of defense against mental illness; the linking of service elements to assure continuity of care; the provision of services to the population of a specifically defined catchment area; the affiliation of treatment and service facilities into a network of comprehensive services; and the establishment and maintenance of preventive services, The funds available in 1973 represent a carryover of unobligated funds from the 1972 appropriation. No new obligational authority is requested for this program since Community Mental Health Centers are eligible for Hill-Burton funds under the outpatient and rehabilitation categories funding through the Hill-Burton mechanism will ensure conformity with local facility needs. 43 (2) Staffing of Community Mental Health Centers. Increase or 1972 1973 Decrease Staffing grants ........... $135,100,000 $135,100,000 --- Staffing grants support a portion of the initial salary costs for pro- fessional and technical staff in community mental health centers. Federal participation in staffing costs enables the community to initiate new or im- proved services and makes them available while longer term sources of finan- cial support are being developed. Under current legislation, higher funding rates are available for centers serving designated poverty areas. Because of the emphasis on new services, Federal staffing grants have their greatest impact on creation of improved delivery systems for community mental health care. To meet the basic requirements, a 'center must provide at least the five essential services outlined in the introduction to this activity, and provide mental health care to those living in the catchment or service Area. To do this, it is necessary in most cases for an applicant to obtain the cooperation and help of a number of organizations who then affil- iate with the center. As of June 30, 1970, 80% of the centers had more than 2 affiliates. Centers created through the joint planning and development of a number of service providers and community leaders maximize the potential of community resources and provide a coordinated network of services to consumers. Federal funds thus serve as a stimulus in developing innovative programs and in obtaining local private and public funds as well as state support. The Westside Community Mental Health Center in San Francisco, California, organized by four private General Hospitals and twelve other community agencies is an excellent example of cooperative planning. This group has designed a ccm=nity mental health center for its catchment area which makes maximal use of existing services and which includes community representatives in its de- cision and policy making. A number of centers - particularly those which serve metropo tan areas with unusual concentrations of special needs - have used a series of phased staffing grants to put together comprehensive community programs. Bernalillo County Mental Health Center, Albuquerque, New Mexico, has received five staff- ing grants and a construction grant. Nine services are presently provided by the center as well as a specialized children's program, a geriatric program and services for those with alcoholism and drug abuse problems. The CMC program has made a great effort toward providing mental health care to the poor - those who most need treatment but are least able to provide it. As of June 30, 1971, 57.47. of the centers receiving staffing support were serving .designated proverty areas. Special emphasis in 1973 will be given to those applicants who have pre- viously received a construction grant, and are ready to begin operation, as well as applications from centers serving poverty and minority areas. The request will provide continuation support for 479 staffing grants and the awarding of 22 new staffing grants. In addition, one percent of the amounts appropriated will be available for program evaluation activities. 44 b. Narcotic addiction Increase or 1972 Estimate 1973 Estimate Decrease Obligations ............. $76,390,000 $91,298,000 +$14,go8 Budget authority ........ 76,298,ooo 91,298,ooo +15,000 This activity supports the Institute's program to develop and conduct comprehensive health, education, training and planning programs for the pre- vention and treatment of drug abuse. The program was initially authorized on October 15, 1968 when the Congress enacted the Alcoholic and Narcotic Addict Amendments (PL 91-574) to the Community Mental Health Centers Act. Additiona legislation was enacted during 1971 which revised existing authorizations and established some new programs. It has been estimated that in 1970 as many as 250,000 Americans were heroin addicts, and that drug addiction and abuse in general had risen sharply over the previous year. The President demonstrated the importance he has placed on combatting narcotic addiction and drug abuse by submitting a budget amendment in 1972 of $67 million for the Institute's drug abuse.programs with the intent of developing resources within the Federal Government to combat the problem which he has characterized a "National Emergency." Simultaneously, he established a Special Action Office for Drug Abuse Prevention to coordinate the efforts of the Federal Government in this area. In 1971, $21,252,000 was obligated in the community assistance activity for drug abuse programs. This included a $6.5 million supplemental appropriation enacted to implement the provisions of the Comprehensive Drug Act (P.L. 91-513). At the close of 1971, there were 9,574 drug abuse patients receiving treatment and rehabilitation in 23 operational community based programs supported by the NIMH. This represents a threefold patient load increase over 1970. In terms of patients seen there were 13,228 new admissions to these operational programs. The 1973 request for community assistance programs is $91,928,000, an increase of $14,908,000 over the 1972 level of support. This increase will allow the Institute to continue to develop and conduct comprehensive health, education, training, and planning programs for the prevention and treatment of narcotic addiction and drug abuse. The following table sets forth the 1972 and 1973 funding levels -oy program area. All of the programs funded in this budget activity are authorized under Part D of the Community Mental Health Centers Act (CMC), as amended. Funds are provided to assist communities in establishing programs to treat and control narcotic addiction and drug abuse through awards for planning and development of a broad range,of treatment facilities, consultation services, training and education activities and evaluation projects. A description of each of the specific programs is provided in the material which follows. Staffing Grants - These grants are authorized under Section 251 of the CMHC Act and provide for a portion of the initial salary costs for professional and technical personnel hired by the Center to provide treatment and rehabilitation services to an addict or drug abuser. Federal support for the program enables the community to initiate new and improved services and makes them available while longer term sources of financial support are being developed. Under current legislation, higher funding rates are available for Centers serving designated poverty areas. 45 The programs supported will provide a variety of treatment modalities including inpatient, outpatient, emergency, and partial hospitalization services. Methadone maintenance treatment and therapeutic communities can also be offered by these centers. In addition, centers provide extensive community education and consultation services and could conduct professional training, rehabilitation, and aftercare services. By the close of 1972, 31 programs will have received staffing grant support, providing services to an estimated 26,600 addicts or drug abusers. Many of these programs will be incorporated in or have strong linkage to existing community mental health centers, thus providing additional professional and technical resources for the treatment and prevention program. The request for 1973 will provide continued support for the existing 31 programs and $2,100,000 in new funds for 2 additional programs. Special Projects - These grants are, authorized under Section 252 of the CMHC Act and provide for treatment and rehabilitation programs of narcotic addicts and other persons with drug abuse and drug dependence problems which have special significance because they demonstrate new or relatively effective or efficient methods of delivery of health services to the narcotic addict or drug abuser. These grants are awarded on a project basis and do not require any matching funds on the part of the grantee. With the funds available in 1972, an estimated 47 projects will receive funding under this authority. When fully operational these programs will provide services to an estimated 33,100 addicts or drug abusers. The request for 1973 will provide continued support for these 47 programs and $6,581,000 in.new funds for 15 new programs. Service Grants - These grants are authorized under Section 256 of the CMHC Act and provide partial Federal support for programs of treatment and rehabilitation to narcotic addicts and drug abusers which include one or more of the following: (1) Detoxification services or (2) insti- tutional services (including medical, psychological, educational, or counseling services) or (3) community based aftercare services. The criteria by which service grants are made are designed to provide priority to areas having higher percentages of the population who are narcotic addicts or drug dependent persons. Federal participation in funding service grants enables the community to initiate new and improved services and makes them available while longer term sources of financial support are being developed. The detoxification units that, are supported under this program are designed to help addicts withdraw from drugs, principally heroin and barbiturates, and to prepare them for treatment by other means. With the funds available in 1972, an estimated 81 projects will receive funding under this authority, including continuation support for 16 projects funded initially in 1971 and 65 new projects. The request for 1973 will provide continuation funding for these 81 projects and $6,367,000 for support of 16 new projects. The total request of $35,000,000 for this program represents the full amount authorized in the legislation. Training Grants - These grants are also authorized under Sections 252.of the CNHC Act and provide for specialized training programs or materials for the prevention and treatment of narcotic addiction, drug abuse, and drug dependence or developing in-service training or short term or refresher courses with respect to the provision of such services. Some of the programs supported include training for persons in the "helping professions," who may come in contact with narcotic addicts or drug abusers; programs for new types of treatment, rehabilitation, and prevention 46 personnel; evaluation of teaching methods and development of new training methods; and training of health professionals in the field of narcotic addiction and drug abuse. With the funds available in 1972, an estimated 45 projects will receive funding under this authority, including continuation support for 4 projects funded initially in prior fiscal years and $6,110,000 for 41 new projects. The request for 1973 will provide continuation funding for these 45 projects and $2,641,ooo for support of 11 new projects. Education Projects - These projects are authorized under Section 253 of the CMHC Act and provides for the awarding of grants and contracts on a project basis for the collection, preparation, and dissemination of educational materials dealing with the use and abuse of drugs and the prevention of drug abuse. These programs are directed at the general public, school-age children, and special high risk groups. In 1972, $1,604,000 was obligated for the support of approximately 20 education projects. The 1973 request will provide for the continued support of the program at approximately the same level. Planning and Initiation - Section 261 of the CMHC Act authorizes projects for assessing loctl needs for treatment and rehabilitation program,;. The $2,200,000 available for the program in 1972 and re- quested for 1973 will provide planning grants to states, metropolitan areas, cities and small towns to stimulate coordinated, adequately focused programs at the state and local levels. Summary AZ noted in the above material the Institute's community assistance program provides support for d variety of programs aimed at reducing the incidence of narcotic addiction and drug abuse. In 1973 priority will be given to the continued targeting of new service and special projects in areas with high incidence of drug addiction relative to treatment capability. Emphasis will also be placed on making available to the addict a choice of treatment modalities either through the estab- lishment of multi-modality treatment facilities or the development of linkages among drug treatment facilities in a given area insuring referral among modalities. 47 Narcotic Addiction Community Assistance (In Thousands) Increase or 1972 1973 Decrease Staffing: No. Amount No. IAmount No. Amount Continuations ....... 29 $13,368,ooo 31 $15,145,000 +2 $+1,777,000 New ................. 2 2,100,000 2 2,100,000 -- --Z. Total ............. 31 15,468,000 33 17,245,000 +2 +1,777,000 Special Projects: Cmtinuat ons ....... -- --- 47 18,559,000 +47 +18,559,000 New ................. 47 19,536,ooo 15 6,581,ooo -32 -12,955-,OOO Total ............. -T7 19,536,000 62 25,14o,ooo +15 +5,6o4,ooo Service Projects: Continuations ....... 16 4,059,000 8.1 28,633,000 +65 +24,574,ooo New ................. -65 25,941,ooo 16 6,367,00o -49 -19,574,ooo Total ............. 81 30,000,000 97 35,000,000 +16 +5,000,000 Training Projects: Continuations ....... 4 6o4,ooo 45 6,359,000 +41 +5,755,000 New ................. 41 6,ilo.ooo 11 2,641,ooo 30 -3,469,ooo Total ............. -75 6,714,000 56 9,000,000 +11 +2,286,ooo Education Projects .... 20 1,6o4,ooo 20 1,700,000 -- +96,ooo I & D................. 44 2,200,000 44 2,200,000 -- --- Evaluation ............ 3 768,ooo 4 913,000 +1 +145,000 Consultation .......... 1 100,000 1 100,000 -- --- Total ............ 272 76,390,000 317 91,298,000 +45 +14,go8,ooo 48 C. Alcoholism: (1) Project Grants: Increase or 1972 1973 Decrease Obligations ........... .. $40,297,000 $50,193,000 +$9,896,000 Budget authority ........ (40,193,000) (50,193,000) (+10,000,000) Alcoholism or problem drinking today affects an estimated 9 million Americans and directly or indirectly affects some 36 million persons in the United States. Alcohol related problems are the cause of more than 85,000 deaths in the United States each year, including half of the more than 50,000 individuals killed annually in highway accidents. There are approximately 2 1/2 million arrests related to alcohol each year. Alcoholism shortens life expectancy 10-12 years and the total economic loss to the Nation from alcohol problems is an estimated $15 billion annually. To these statistics must be added immeasurable human costs and suffering - br6l,.en homes, deserted families, and psychological problems - resulting from alcohol abuse and alcoholism. This activity supports the program efforts of the National Institute on Alcohol Abuse and Alcoholism (NLAAA) to develop and conduct comprehensive health, training and planning programs for the treatment of alcohol abuse. The program was initially authorized on October 15, 1968 when the Congress en- acted the Alcoholic and Narcotic Addiction Amendments (PL 90-574) to the Community Mental Health Centers Act. Additional legislation was enacted in December 1970, which revised existing authorizations and established some new programs including grants to states allocated on a formula basis. The goal of the alcohol community assistance program is to reduce the seriousness, prevalence and incidence of alcoholism and alcohol problems in the Nation. This is done through a variety of programs which are described in the material which follows. All these programs are authorized under Part C of the Community Mental Health Centers Act (CEEC), as amended. Funds are provided to assist communities in establishing programs to treat and control alcoholism through awards for planning and development of a broad range of treatment facilities, consultation services, training, and evaluation projects A description of each of the specific programs is provided in the material which follows. ,Staffing Grants: These grants are authorized under Section 242 of the CMHC Act and support a portion of the initial salary costs for professional and technical staff in facilities for the prevention and treatment of alcoholism. Federal participation in staffing costs enables the community to initiate new or improved services and makes them available while longer term sources of financial support are being developed. Under current legislation, higher Federal funding rates are available for centers serving designated poverty areas. All program funded under this activity must be community based and provide a comprehensive range of services, including emergency, inpatient, outpatient'intermediate care services and consultation and education. Identi- fication and referral services should also be included as well as mechanism for ensuring continuity of care. 49 In 1972, a total of 68 staffing projects were funded and, when fully opera- tional, will provide treatment to 109,000 alcoholic persons and alcoholic abusers. At the end of 1973, a total of 88 centers will be funded and will pro- vide services to a total of 141,000 alcoholic persons. These programs represent a variety of approaches to treatment and care of alcoholics. One program, located in a medium size city, serves three catchment areas, and includes affiliation arrangements with one Community Mental Health Center and two hos- pitals in the area. Another, located in a rural area of a Midwestern state, is an example of a largely non-medical approach to the treatment and care of alcoholics. Special Projects: These grants are authorized under Section 246 of the CMHC Act and provide support for: (1) Developing specialized training programs or materials relating to the pro- vision of public health services for the prevention and treatment of alcoholism. (2) Training personnel to operate, supervise and administer such services. (3) Conducting surveys and field trials to evaluate the adequacy of the program for the prevention and treatment of alcoholism with the several states. (4) Programs for treatment and rehabilitation which demonstrate new or relatively efficient methods of delivery of services to such alcoholics. In his 1972 Health Message, the President increased the budget request by $7,OOOiOOO for alcohol programs to support field trials and demonstrations to develop innovative ways to treat alcoholic persons. These projects are designed to find the best way to influence medical and other helping Pro- fessinnals to utilize the information available on alcoholism therapy, as well as to assess the most effective organization and delivery of care in community treatment and rehabilitation programs. The funds available in 1972 will support an estimated 29 projects and provide treatment services to approximately 17,000 alcoholics. The request for 1973 will support an add- itinnal 13 projects. These projects will provide services to an additional 7,800 alcoholic personsi Grants and Contracts: These awards are authorized by Section 247 of the CIIHC Kct and may be used to: (1) conduct demonstrations, services and evaluation projects, (2) provide education and training, (3) provide programs and services in cooperation with schools, courts, penal institutions and other public agencies, and (4) provide counseling and education activities on an individual or community basis. One of the major efforts conducted by the Institute is this provision of services to the American Indian population. Because of poverty, dislocation and failure of this population to be acclimated into the mainstream of American society, the Indians have developed many serious social problems, including alcoholism. To help meet these needs, the Institute provided $750,000 for educational programs and treatment and rehabilitation services according to guidelines established by the Indians themselves. Another group of special concern is the chronic drunkenness offender. Although -only about 5% of all alcoholic persons are the homeless and socially isolated individuals known as "skid row drunks", they account for 40% of all annual arrests for non-traffic offensers. The NIAAA is working with other agencies of the Federal Government to find more practical and effective alternatives for handling and rehabilitating these individuals. The Institute will also initiate a series of occupational alcoholism programs at the State and Community level as well as private industry. The funds available in 1972 will support approximately 70 projects and will provide treatment services to approximately 4,200 alcoholics. The request for 1973 includes a $10,000,000 increase for treatment projects previously supported by the Community Action Program of the OBO. 50 Initiation and Development: These grants are authorized under Section 224 of the C14HC Act and provide one year planning grants to local public or non-profit private agencies to plan and develop alcoholism servicesin a particular area. The purpose of these awards is to assess local needs, design alcoholism treat- ment programs and obtain local financial and professional assistance, and foster community involvement in developing local treatment services. A summary of the alcoholism project grant program appears in the following table: Distribution of Alcohol Project Grants Alcohol Comunit)r Assistance 1972 Estimate 1973 Estimate Change No. Amount No. Amount No. Amount Staffing: Continuations ........... 32 $6,098,000 68 $15,510,000 +36 +$9,412,000 New ..................... 36 10,904,000 4 1,100,000 -32 -9,804,000 Subtotal .............. 68 17,002,000 72 16,610,000 44 -392,000 Special Projects: Continuations ........... 1 150,000 29 5,410,000 +28 +5,260,000 New ..................... 28 5,773,000 3 581,000 -25 -5,192,000 Subtotal .............. 29 5,923,000 32 5,991,000 +3 +68,000 Grants and Contracts: Continuations ........... -- --- 70 14,490,000 +70 +14,490,000 New ..................... 70 15,970,000 259 12,000,000 +189 -3,970,000 Subtotal .............. 70 15,970,000 329 26,490,000 +259 +10,520,000 Initiation & Development.. 20 1,000,000 12 600,000 -8 -400,000 Evaluation ................ 402,000 502,000 +100,000 Total ............... 40,297,000 50,193,000 +9,896,000 51 (2) Grants to States Increase or 1972 1973 Decrease Obligations/Budget authority ........ $30,000,000 $30,000,000 --- Part A, Title III of the Comprehensive Alcohol Abuse and Alcoholism Act of 1970 (Public Law 91-616) authorizes formula grants to states for the planning, establishment, maintenance, coordination and evaluation of projects for the development of alcoholism prevention, treatment and rehabilitation programs. The $30,000,000 included in the President's budget request will be allotted to the States on the basis of their relative population, financial need and the need for more effective prevention, treatment and rehabilitation programs. The min- imum allotment for each state is $200,000. At the request of any State, a portion of any allotment shall be available to pay for a portion of the admin- istration of the state alcoholism program. In addition the plans submitted by the states must set forth a survey of need for the prevention and treatment of alcohol abuse and alcoholism, in- cluding an assessment of the health facilities needed to provide services. 52 d. Child Mental Health Program Increase or 1972 1973 Decrease Child mental health (obliga- tions/Budget Authority) ...... $10,000,000 $10,000,000 --- Up to now the mental health of children, contrary to general belief, has been neglected. In 1968, approximately 437,000 children were seen in out-patient psychiatric clinics, 33,000 were patients in public and private mental hospitals, 26,000 were in residential treatment centers, and 52,000 were patients in community mental health centers. Almost ten percent of our young people will have had at least one psychiatric contact by the time they are 25. Statistics such as these, and the realization that adult mental illness often has its roots in childhood, has led the National Institute of Mental Health to designate child mental health as its number one priority. In developing improved services for children, the extensive network of community mental health centers provide a base for local services. In 1972 fund- ing for the Child Mental Health program authorized by Part F of the Community Mental Health Centers Act, was initiated to stimulate innovative approaches toward expanding the range of services for children. This is done by awarding staffing grants to applicants which are already a part of or affiliated with a community mental health center and who are establishing or expanding services directed primarily at children. These grants support a portion of the initial salary costs for professional and technical staff employed by the center. If there is no center serving the community, a grant may be awarded to a public or non-profit agency which can provide an adequate range of prevention and treatment services for all children within their area. In 1972, priority for support will be given to programs which emphasize: (1) the prevention and early treatment of mental health problems in children with emphasis on consultation and education to improve and increase service to children in their normal life settings; (2) have impact on children early in life at the preschool and elementary school levels and particularly on children who are Ilikely to be at high risk later in life such as those from poverty-stricken areas; (3) aim for the total integration of children's services in the community, creat- ing partnerships between mental health staff and others who work wit-n children in setting such as the schools and day care centers to increase their expertise in the prevention, identification and management of mental health problems; (4) utilize existing resources to their maximum extent and combine resources and funding from a variety of health and human services sources to develop new services and expertise; (5) develop innovative uses of new types of personnel; and (6) show promise of transferability to other community settings. The 1973 request will provide continued funding for 28 grants initially awarded in 1972, and 4 new awards. Childrens Grants by Type of Grant Increase or 1972 19 7 3 Decrease No. Amount No. Amount No. Amount Continuations ........ -- 28 $8,485,000 +28 +$8,485,000 New Projects ......... 28 $10,000,000 4 1,515,000 -24 -8,485,000 Total ........... 28 10,000,000 32 10,000,000 +4 53 e. Direct operations Increase or 1972 1973 Decrease Pos. Amount Pos. Amount Pos. Amount Personnel Compensations & other Benefits ...... 187 $3,289,000 194 $3,695,000 +7 +$406,000 Other Expenses 3,527,000 --- 3,544,000 -- + 17,000 Total .... 187 6,816,000 194 7,239,000 +7 + 423,000 The funds in this activity provide staff support for the Division of Mental Health Service Programs, and the National Institute on Alcohol Abuse and Alcoholism. The Division of Mental Health Service Programs provides program plann ng at the National level for Parts A, B and F of the Community Mental Health Centers programs which are administered on a project basis in the HEW Regional Offices. The Division also operates the Mental Health Study Center located in Adelphi, L@laryland which plans and administers a community laboratory for the development, innovation and evaluation of approved service delivery methods in a community con- text. In 1973, the primary areas of emphasis will be on the provision of services to young children, adolescents and the aged. In May 1971, the National Institute on Alcohol Abuse and Alcoholism (NIAAA) was established within the National Institute of 'rental Health, by Public Law 91- 616. This legislation provided, for the first time, some of the resources neces- sary to build an innovative and outreaching alcoholism program for the nation. The NIAAA has adopted two principal goals to guide its program development (1) to mobil.ize all existing treatment and rehabilitation resources at the Federal, State, and local levels to provide care for the alcoholic individual and (2) to develop and begin viable and comprehensive programs of prevention of alcohol abuse and alcoholism. The organization of the NIAAA includes four divisions, each repre- senting a significant Program emphasis in the Institute. These are the Division of Research, State and Community Assistance, Special. Treatment and Rehabilitation programs, and Prevention. To make maximum use of all available Federal res ources, the NIAAA is also cooperating in various areas with other agencies such as, the Office of Economic Opportunity, the Department of Transportation and the Department of Labor. The NIAAA has been working with the Civil Service Commission to develop guidelines for the implementation of alcohol programs in all Federal agencies. The Institute has also been consulting actively with State and local governments and industry to help them develop alcoholism treatment programs for their employees. There are 7 new positions requested for the Institute to administer t e ex- panded alcohol programs and to meet the demands for consultation and technical assistance. 54 Rehabilitation of Drug Abusers Increase or 1972 1973 or Personnel Compensation Pos. Amount Pos. Amount Pos. Amount & Benefits ............. 157 $3,227,000 164 $3,795,000 +7 +$568,000 Other Expenses .......... --- 10,096,000 --- 10,131,000 -- + 35,000 Total .............. 157 13,323,000 164 13,926,000 +7 + 603,000 This activity provides support for the NIMH staff who administer the Institute's narcotic addiction and drug abuse program and funding for the treat- ment and rehabilitation of narcotic addicts under contract arrangements with community agencies. The staff operates within the Institute's Division of Narcotic Addiction and Drug Abuse. The Division of Narcotic Addiction and Drug Abuse (1) plans and develops programs of research, training, community services, and public education for prevention and control of narcotic addiction and drug abuse; (2) conducts and supports research on the biological, environmental, and social causes of addic- tion and drug abuse; (3) supports the training of professional and paraprofes- sional personnel in drug abuse prevention and control; (4) supports the development of community facilities and services for addicts and other drug abusers; (5) collaborates with other Federal agencies, national, state, and local organizations, and voluntary groups to facilitate and extend programs for the prevention of drug abuse and for the care, treatment, and rehabilitation of addicts; (6) coordinates and stimulates statistical and biometric programs nec- essary for epidemiologic and longitudinal studies of drug addiction and abuse; (7) stimulates the communication of appropriate information and educational material through the development of conferences, committees, publications, and use of public media; (8) administers the Institute's program for rehabilitation of narcotic addicts authorized under the Narcotic Addict Rehabilitation Act through (a) operation of a Clinical Research Center (funded under "Research - Direct Operation"), and (b) contract support of patient care activities in the community. The Narcotic Addict Rehabilitation Program, authorized by the Narcotic Addict Rehabilitation Act of 1.966, provides an opportunity for individuals addicted to narcotic drugs to volunteer for civil commitment for treatment (Title III) and allows addicted individuals charged with violating certain Federal criminal laws to apply for civil commitment in lieu of prosecution (Title 1). At the present time the program is utilizing the Clinical Research Center at Lexington, Kentucky, and under contract arrangements, local community agencies to provide the examination and evaluation and inpatient phases of the program. Following initial treatment at the Lexington Center or by a contract agency, the patient is conditionally released to his home community and provided with supervised treatment and rehabilitative services for up to an additional 36 months. Again these Aftercare services are provided by local mental health, family service, vocational rehabilitation, and other agencies under contract with the National Institute of Mental Health. The community agency provides the patient supervision, treatment, and rehabilitation services which are tailored to his individual needs. The agency must also facilitate and coordinate the use of existing community services for continuing psychotherapy, education, vocation- al training, job placement, medical care, and welfare. By the end of 1971 approximately 165 contracts were awarded to local agencies for the treatment of narcotic addicts committed to the care of the Surgeon General. These contracts provided a wide range of service in 153 cities and 44 states. on June 30, 1971, there were 2,078 patients remaining in the program, which represents an increase of 420 over the previous year. Efforts during the year to redirect services from the Clinical Research Centers to local facilities in the addicts' home communities resulted in the extension of 42 aftercare contracts to provide examination and evaluation, and 19 contracts to provide inpatient treatment, During the year 629 examinations, representing twice the previous year, were conducted in 29 community agencies, and 106 patients, representing five times the previous year, received inpatient treatment in 9 community agencies. in 1973, a major emphasis will be placed on reducing the level of direct patient care provided under the NARA Act commensurate with the development of community-based grant programs under State and local management. To initiate this plan, $2,131,000 has been redirected to the community assistance grant program for narcotic addiction treatment and rehabilitation programs. In recognition of its primary research orientation, the Clinical Research Center at Lexington, Kentucky, formerly funded under this actiIvity, appears in the budget under Research - Direct Operations activity. However, the Center will continue to provide services to addicts under the NARA program from cities that do not have adequate facilities sustained either by local funds, or with Federal grant or contract support. Included in the 1973 request are 7 new positions to provide continued improvement of the administration of the Institute's drug abuse programs. 56 5. Program Support Activities a. Field Activities Increase or 1972 1973 Decrease Pos. Amount Pos. Amount Pos. Amount Personnel Compensation and Benefits ........... 162 $3,181,000 162 $3,457,000 --- +$276,000 Other Expenses .......... ... --- 558,000 --- --- Total .............. 162 3,739,000 162 4,015,000 --- + 276,000 This activitv includes funds for NIMII staff located In the HEW Regional. Offices to carry out programs of assistance to the state$ and serve as field units providing technical assistance on mental health programs to state and utions. The regional offices have responsibility for the admini- community instit stration, on a project basis, of the community mental health centers program, the Hospital Improvement Program, and the Hospital Staff Development Program. Funds are also included in this activity for the Office of Program Coordi- nation which is responsible for coordinating Institute activities with other DHEW components, Federal agencies, international groups, and with regional, state and local mental health agencies and-citi.7en frotips. It also acts as liaison between the Institute's regional organization and other Institute program areas. 57 b. Scientific communication and public education Increase or 1972 1973 Decrease Pos. Amount Pos. Amount Pos. AmouiFt Personnel Compensation and Benefits ......... 80 $1,485,000 80 $1,480,000 -$5,000 Other Expenses ......... -- 5,813,000 -- 5,813,000 --- Total ............. 80 7,298,000 80 7,293,000 5,000 This activity supports the Office of Communications which operates the National Clearinghouse for Mental Health Information (NCTIHI) in conjunction with its scientific communications program, and in collaboration with respective pro- gram areas of the Institute is responsible for the Institute's public information activities, as well as the National Clearinghouse for Drug Abuse Information. The NCMHI is the Institute's resource for collecting, analyzing and dissemi- nating scientific and technical information. It has basically three functions: first, it provides scientific information both upon individtlal request and in the form of recurring and single issue publications; second, it provides scientific analyses and compilations which present an overview and synthesis of current re- search activities; and third, it attempts to develop net,? solutions to scientific information problems and devises improvements in its storage and retrieval system. The National Clearinghouse for Drug Abuse Information (NCI).kl) provides the public with a central office within the Federal Government to contact for informa- tion and assistance concerning this critical social problem. The NCDAI collects and disseminates materials and data taken not only from Federal programs, but from appropriate private, state, and local community projects. The Clearinghouse will continue to improve and expand its computerized information system. The drug abuse information resources and materials file, which contains abstracts and de- scriptions of drug abuse literature and audiovisual materials, will be evaluated and improved to provide better and more information. The file on drug abuse programs, which includes information on treatment, education, information, and law enforcement programs across the country, i-ii.11 be made current and kept up to date. In addition to filling individual requests for information, the Clearinghouse will produce a number of publications derived from its data base, including an annotated bibliography, directories of voluntary action and religious programs, a guide to speakers bureaus, a listing of treatment and rehabilitation resources, topical bibliographies, and a current awareness system. The pilot operation of 8 to 10 cooperating state and regional information centers will initiate the decentralized information network of tile NCDAI. At the direction of the Special Action Office on Drug Abuse Prevention, the Clearing- house will develop national statistical and descriptive information to make up a National Inventory of Drug Abuse Programs. The Inventory will make it possible to store and retrieve information about all the known drug abuse programs in the United States, supported by statistical information and tabulations. ])rug abuse public information activities will include production of printed and other materials directed at four points of emphasis in the mass media cam- paign against drug abuse being conducted by the Federal agencies in cooperation with the Advertising Council: warnings to traveling Americans against violating foreign drug laws; added activities relating to the national observance of Drug 58 Abuse Prevention Week; a separate minority-oriented drug abuse campaign, and alternatives to drug abuse. Increased public information activities concerning the first two categories will utilize primarily the print and electronic mass media -- posters, pamphlets, and radio/television exposure. For example, to meet President Nixon's mandate for a Drug Abuse Prevention Week, the Institute produced a broad range of materials for distribution to local and national press, radio, and 'fV outlets. A key to preventing alcohol abuse and alcoholism lies in the broadscale edu- cation of the public on the dangers of alcohol use and abuse. The Institute's education and prevention program has several objectives: (1) to develop public recognition of alcoholism as an illness for which the afflicted individual needs help, and can be helped; (2) to encourage the health system to accept alcoholism as a medical-social-behavioral problem and to treat the alcoholic person with the same attention and consideration as any other patient; (3) to develop public aware- ness of the properties of alcohol, its effects on the body and behavior, and its potential for harm; and (4) to produce a new national environment concerning the use and misuse of alcoholic beverages in the United States to bring about an even- tual reduction in the rate of drunkenness, problem drinking, and alcoholism. The NI@IH information and education programs in this health area begun in 1971 and expanded in 1972, will be continued at approximately the same level in 1973. The first year of the information/education program, devoted in large part to "tooling up" for a long-range effort, and to building a foundation of awareness of the nature and scope of alcoliol-related problems in the IJ.S., included such activities as a public service advertising program, surveys of existing printed materials and films on alcohol and alcoholism, development of general and.scienti- fic publications, and production of a brief film for junior high and high school use. Based on findings in surveys, further publication and film presentations, the Institute has prepared a nationwide advertising campaign to build a foundation of awareness of the nature and scope of alcohol-related problems in the Nation. Ad- ditional and intensified efforts, including a major effort in curriculum develop- ment and teacher training, will be needed to reach young people, and to encourage and assist community groups, churches, industries, schools, and other groups in initiating local information and education activities. One of the major mechanisms for implementing these programs is the new National Clearinghouse on Alcohol Infor- mation, established in 1972. 59 c. Executive direction and management services Increase or 1972 1973 Decrease Tos. Amount Pos. Amount Pos. Amount Personnel Compensation '& Other Benefits ..... o 259 $4,302,000 259 $4,162,000 --- -$140,000 Other Expenses .......... ... 1,460,000 --- 1,607,000 + 147,000 Total ............. 259 5,762,000 259 5,769,000 + 7,000 The funds in this activity support Institute staff in the Immediate Office of the Director, the Offices of Program Planning and Evaluation, and Administrative Management. The Immediate Office of the Director provides for the overall planning, di- rection and administration of the Tnstitute's programs. The Office of Administra- tive Management is responsible for centralized services in inanc a management, management and administrative services. It has broad responsibility for the design, issuance, and implementation of administrative operating procedures for the conduct of Institute operations. The Office of Program Planning and Evaluation is responsible for the stimu- lation, development, and coordination of the Institute's planning, program analysis, data collection analysis, and evaluation activities. Of highest priority is the development of the Institute evaluation program which is directed at evaluating the responsiveness of community mental health services to the needs of the community and the individual, the effectiveness of the Institute's training programs, and the impact of NIMB supported research on the treatment and prevention of mental illness. The approach is not only to evaluate the input of individual programs, but also to assess interrelationships among them. Examples of new studies planned for FY 1973 include: (1) evaluation of the new careers training program; (2) evaluation of the impact of increased Federal matching rates for community mental health centers serving designated poverty areas; and (3) analysis and evaluation of NIMH research, training, and services activities related to the aged for purposes of determining future program direction. The other priority activity of this office is the coordination of overall mental health strategy, developed for the period 1973 through 1977. This compre- hensive planning approach involves the development of a strategy integrating future financing of mental health programs, delivery system development, manpower development, and research priorities. GO HEALTH SERVICES AND MENTAL HEALTH ADMINISTRATION Mental Health Program Purpose and Accomplishments Activity: Research-(a) Grants (Public Health Service Act, Sections 301, 302, 303). 1973 1972 Budget Available 1973 Estimate Pos. Amount Authorization Pos. Amount --- $97,400,000 Indefinite --- $101,400,000 Purpose: Sections 301, 302, and 303 of the Public Health Service Act authorizes a grant-supported program of research, experimentation, and demonstration relat- ing to the causes, diagnosis, treatment, and prevention of mental diseases. Two major grant programs are included in this subactivity. First, the regular research grants program provides support on a project basis for behavioral, clinical, psychopharmacology and applied research as well as clinical research centers and areas of special interest such as alcoholism, drug abuse, violence, early child care, minority studies and services development research. Secondly, the hospital improvement program provides grants to state mental hospitals for projects which provide immediate improvement in the care, treatment, and rehabili- tation of patients. Explanation: The grants go to investigators affiliated with hospitals, academic and research institutions, and other nonprofit organizations in the United States. Under very special circumstances, grants may be awarded to foreign institutions for research in areas of top priority. The grants may provide support for large- scale, broad-based research, usually on a long-term basis. Such research, usually interdisciplinary, consists of several projects with a common focus or target. Small grants limited to a maximum of $6,000 including indirect costs, may be awarded for a period of I year for pilot studies or for exploration of an unusual research opportunity. Accomplishments: In Fiscal Year 1972, a total of 1,522 regular research grants, 200 small grants and 76 hospital improvement grants were supported with special emphasis given to research into the causes and prevention of alcoholism, narcotic addiction and drug abuse. In addition, the Institute undertook a reprogramming of the research grant funds to establish a minority studies research program and to provide resources for an expanded services development research program. Objectives: The increase provided in 1973 will allow expanded support of the high priority research programs in drug abuse, alcoholism, child mental health, minority mental health, and crime and delinquency will receive new emphasis. HEALTH SERVICES AND MENTAL HEALTH ADMINISTRATION Mental Health Program Purpose and Accomplishments Activity: Research-(b) Direct Operations (Public Health Service Act, Sections 301, 302, and 303). 1973 1972 Budget Available 1973 Estimate Pos.- Amount Authorization Pos. Amount 1,170 $41,639,000 Indefinite 1,184 $43,208,000 Purpose: This activity supports (1) intramural laboratory and clinical research in the behavioral and biological sciences, and (2) the planning, development and administration of most of the Institute's grant and contract research programs. Explanation: This is a program of direct research support for NIMH staff in The Institute's own laboratories and clinics. Funds are also provided for research activities supported on a contract basis and for support of the Clinical Research Center at Lexington, Kentucky. Accomplishment : It has now been clearly demonstrated in animals that certain s Themicals which occur naturally in the brain play a crucial role in its function and that certain drugs influence their activity. This work with its promising implications for future treatment of mental disorders, particularly schizophrenia and depression, earned a Nobel Prize for a pharmacologist working for the NIMH Intramural research program. Basic research continues to discover physiological and neurological phenomena which lead to the production of new drugs which bio- chemically reduce or remove behavioral defects. The addiction research center expanded its existing efforts to assess the dependence producing properties of narcotic analgesics to include non-narcotic drugs. The Institute also began a contract research program on drug abuse to investigate promising fields of research which at present are not represented by sufficient numbers of investigators to achieve an acceptable rate of progress through the normal grant procedure. Objectives: The Institute plans to continue research on psychiatric disorders as well as on the basic biological and psychosocial processes which determine normal and abnormal behavior. The additional positions requested will provide much needed staff support for the child mental health, crime and delinquency and minority group mental health programs. G2 HEALTH SERVICE.9 AKID MENTAL IIEAT,Tll ADIFINISTRATION Mental Health Program Purpose and Accomplishments Activitv: Manpower Development (a) Training Grants and Fellowships (Publl-c @t, SCLL'.:-@ and 303). 1972 1973 Available 1973 Budget Estimate Pos. Amount Authorization Pos. Amount $120,050,000 Indefinite --- $105,050,000 Purpose: Sections 301 and 303 of the Public Health Service Act authorize training grants and fellowships to meet the mental health needs of the nation. Grants are made to institutions for training in psychiatry, behavioral sciences, psychiatric nursing, and social work, and other mental health disciplines. Ex- perimental and special programs and continuing education in the mental health field are supported, as well as special training in such areas as alcoholism, drug abuse, suicide prevention, and minority studies. Fellowships are made on the basis of excellence to individuals involved in mental health research. Explanation: (,rants are awarded to training centers and organizations for professional training in mental health to enable them to offer financial assist- ance to students and for partial support of teaching costs. Funds to support continuing education programs are awarded to public or private non-profit insti- tutions, professional organizations, or State or community agencies. Grants are also made to eligible institutions and agencies for innovative, experimental training projects. Research Fellowships are awarded to qualified persons in mental health and related disciplines for research training. Accomplishments: Within the funds available for new grants in 1972 the Institute gave priority consideration to training programs which stressed: (1) training professional and paraprofessional personnel in the area of child mental health; (2) developing models and training programs for crime and delinquency; (3) training of individuals who work with alcoholics and drinking drivers; (4) training for professionals and non-professionals directly involved In the treat- ment and rehabilitation of drug addicts and drug abusers; and (5) the recruitment and training of minority group mental health personnel. Objectives: In 1973, continued emphasis will be given to initiating training programs in the areas of child mental health, crime and delinquency, alcoholism and narcotic addiction treatment. and rehabilitation, and minority group mental health. The psychiatric residency program is being reduced by $7,000,000. An expanded institutional support grant program will be substituted. Undergraduate programs have been reduced by $8,000,000. It is intended that financial assist- ance be funded in the future through the student assistance programs administered by other Federal agencies. 63 HEALTH SERVICES AND MENTAL HEALTH ADIENISTRATION Mental Health Program Purpose and Accomplishments Activity: Manpower Development-(b) Direct Operations (Public Health Service Act, Section 301 and 303). 1973 1972 Budget Available 1973 Estimate Pos. Amount authorization Pos. Amount 135 $7,741,ooo Indefinite 135 $7,779,000 Purpose: Analytic studies of manpower are undertaken in this activity with emphasis given to the full range of manpower requirements in the field of mental health including the disciplines of psychiatry, behavioral sciences, psychiatric nursing, and social work. Also, d direct training program is supported for mental health professionals who are interested in a wide variety of career possibilities in the Public Health Service. E*planation: The funds requested support the salary and related costs for employees who administer most of the Institute's grant and contract training programs. Accomplishments: Resources were directed toward the coordination of gra s an contract support functions to plan and administer the National Mental Health Manpower Program, collection and evaluation of data on mental health manpower, and conducting the intramural training program of the Institute. Support was also given to direct training programs for mental health professionals and sub-professionals who are presently or potentially engaged in the treatment and rehabilitation of narcotic cts an a users. Objectives: In addition to continuing programs begun in 1972, emphasis will be continued on programs emphasizing community mental health concepts and practices, the care and treatment of chiJ.dren, and the provision of service to the minority community. 64 HEALTH SERVICES AND MENTAL HEALTH ADIENISTRATION Mental Health Program Purpose and Accomplishments Activity: State and Community Programs: (a) Community Mental Health Centers (1) Construction (Community Mental Health Centers Act, Section 201, as amended). 1973 1972 Budget Available 1973 Estimate Pos. Amount Authorization Pos. Amount --- $15,000,000 $100,000,000 --- --- --- (5,200,000) (Obligations) --- ($9,800,000) Purpose: For grants for construction of public and other non-profit community mental health centers. Construction grants assist communities in establishing appropriate facilities for the delivery of comprehensive community mental health services by supplementing state, local, and private financial resources. Explanation: Funds appropriated for.this program are allocated to the States on a formula basis taking into account such factors as population and per capita income. Grants are awarded on a matching basis with the percent of Federal support varying depending on whether or not the catchment area served has been designated by the Secretary as a "poverty area." Accomplishments: It is expected that 24 new centers will be established with the $5.2 million available for obligation in 1972. This will bring the total number of centers receiving construction support to 385. Objectives: The $9.8 million available for obligation in 1973 will provide support for approximately 24 additional centers. No new budget authority is requested for FY 1973. Community Mental Health Centers can be funded under the Hill-Burton program. G5 HEALTH SERVICES AND MENTAL HEALTH ADMINI8TRATION Mental Health Program Purpose and Accomplishments Activity: State and Community Programs: (a) Community Mental Health Centers (2) Staffing (Community Mental Health Centers Act, Section 224, as amended). 1973 1972 Budget Available 1973 Estimate Pos. Amount Authorization Pos. Amount 44,200,000 new 60,000,000 new 9,131 new --- 90,900,000 continu- --- continu- 125,969 contin- atims ations uations Purpose: For grants to assist in the establishment and operation of community mental health centers in areas designated by State Mental Health Authorities as "Catchment Areas" (geographical areas containing between 75,000 and 200,000 people among whom there is to be a coordinated, comprehensive system for providing mental health care). Grants axe awarded on a project basis to eligible centers for partial support of staffing costs of professional and technical personnel. Explanation: This assistance enables the community to initiate new or improved mental health services and make them available while longer term sources of financial support are being developed. Grants are awarded on a matching basis with the percent of Federal support varying, depending on whether the catchment area served has been designated by the Secretary as a "poverty" area. Accomplishments: An estimated 119 new awards will be made in 1972, raising the number of funded centers to 529. Of these, 389 will be operational by the end of the year. Primary emphasis in awarding new grants was given to applications approved but unfunded from prior fiscal years. High priority was also given to applicants for initial staffing support from centers which had received prior construction awards. Objectives: The request for 1973 will provide continuation support of the 529 centers funded through 197r'- and support 22 new awards. This will raise the number of funded centers to 562, of which 422 will be operational. by the close of FY 1973. HEALTH SERVICES AND MENTAL HEALTH ADMINISTRATION Mental Health Program Purpose and Accomplishments Activity: State and Community Programs: @b) Narcotic Addiction (Community Mental Health Centers Act, as amended: Sections 261 and 256) 1973 1972 Budget Available 1973 Estimate POS. Amount Authorization Pos. Amount $76,390,000 $134,ooo,ooo 91,298,ooo Authorization includes the following section of the Community Mental Health Center Act: Section De Authorization 253: Drug abuse education .............. $14,000,000 A/ 256: Special projects .................. 35,000,000 A/ 261: Construction, staffing, training, evaluation, special projects ..... 80,000,000 B/ C/ 264: Consultation services ............. 5,000,000 B/ D/ A/ Includes continuation costs. Excludes continuation costs, which are authorized as "sums necessary." Authorization is shared with alcoholism. Authorization is shared with alcoholism and Centers staffing. Purpose: This activity supports Institute efforts to develop and conduct compre- hensive health, ed-ace@ion, training and planning programs for the prevention and treatment of drug abuse. Explanation,; This activity provides funding for all the programs authorized under Part D of the Community Mental Health Centers Act, including: Staffing grants which provide for a portion of the salary costs of professional and technical personnel to staff comprehensive community centers for the treatment of narcotic addiction and drug abuse. Special Projects finance treatment and rehabilitation programs which demonstrate new or relatively effective or efficient methods of delivery of health services. Service grants provide partial Federal support for programs of treatment and rehabilitation which include detoxification services, institutional services, or community based aftercare services. Training grants support specialized training programs or materials for the prevention and treatment of narcotic addiction and drug abuse. Education projects provide for the collection, preparation, and dissemination of educational materials dealing with the use and abuse of drugs and the prevention of drug abuse. Planning and Initiation Grants are awarded to plan or develop narcotic addiction I I n-rpn- 67 Accmplishments: In the area of narcotic addiction and drug, abuse, funds have been allocated in the following areas in 1972: 1. Treatment Programs: Funds were used for a broad variety of narcotic addiction and drug abuse treatment services to meet the general and particular needs of the communities across the Nation. Emphasis in this fiscal year was Dr ta-,geti@a 4',ln(iq qn qs to extend the opportunities for treatment and rehabili- tation to t ose drug abusers and narcotic addicts who have a strong motivation for recovery, but for whom community services were not available. By the close of 1972 approximately 162 treatment programs will be supported which, when fully operational, will provide treatment services to 33,600 individuals. 2. Training: Funds were utilized for specialized training programs for prevention and treatment of narcotic addicts and drug abusers. These programs train physicians, social workers, psychologists, other professionals, and sub- professionals to cope with expanded narcotic addiction and drug abuse prevention, treatment and rehabilitation programs throughout the Nation. In 1972, an estimated 45 training projects will be supported under this program. 3. Planning: Funds will be provided for planning grants to states, metro- politan areas, cities and small towns to stimulate coordinated, adequately focused programs at the state and local levels. An estimated 44 grants will be supported in 1972. : Efforts in this area will continue to be directed towards developing treatment and rehabilitation services at the community level. A major portion of the increased funds will be used to support the continued development of compre- hensive treatment centers. r t.)8 HEALTH SERVICES AND MENTAL HEALTH ADMINISTRATION Mental Health Program Purpose and Accomplishments Activity: State and Community Programs: (c) Alcoholism Projects and Grants to States (Community Mental Health Centers Act, as amended, Section 261 and the Comprehensive Alcohol Abuse and Alcoholism Prevention Treatment and Rehabili- tation Act of 1970 - PL 91-616). 1973 1972 Budget Available 1973 Estimate Pos. Amount Authorization Pos. Amount --- $70,173,000 $215,000,000 --- $8o,193,000 Authorization includes the following: Community Mental Health Centers Act Section Description Authorization 247 Prevention and treatment ........... $50,000,000 A/ 261 Construction, staffing, training and evaluation, special projects.. 8o,ooo,ooo c/ 264 Consultation services .............. 5,000,000 TT/ Comprehensive Alcohol Abuse and Alcoholism Prevention, Treatment, and Rehabilitation Act of 1970 Section Description Authorization 301 Formula grants ..................... $80,000,000 A/ Includes continuation costs. B/ Excludes continuation costs which are authorized as 11-ums necessary." @/ Authorization shared with narcotic addiction. D/ Authorization shared with narcotic addiction and centers staffing. Purpose: Communities are assisted in establishing "centers" to help prevent and control alcoholism through awards for the support of construction and/or staffing of facilities, development of new services in poverty areas, and special projects. Public Law 91-616 authorizes formula grants to states for the planning, establishment, maintenance, coordination and evaluation of projects for the development of alcoholism prevention, treatment and rehabilitation programs. Explanation: The project grant program included in this activity is authorized under Part C of the CMHC Act, as amended. These programs include: Staffing grants which support a portion of the initial salary costs for professional and technical staff to enable communities to initiate facilities for the prevention and treatment of alcoholism while longer term sources of financial support are being developed. Special projects provide support for training programs or materials for the pre- vention and treatment of alcoholism and treatment and rehabilitation programs which demonstrate new or relatively effective or efficient methods of delivery of health services. Grants and contracts for the prevention and treatment of alcokol abuse and alcoholism. Includes support for demonstration, service, education and training programs in cooperation with schools, courts, penal institutions and other community-based public agencies. Planning and Initiation grants are awarded to plan or develop alcoholism treatment and prevention services in a particular area. Accomplishments: In 1972, an estimated 75 staffing projects were funded which, when fully operational, will provide services to 109,000 individuals. In addition the Institute funded a series of projects to provide treatment services for the Indian population as well as a number of special projects to develop innovative ways to deliver services to alcoholics. Objectives 1973: The 1973 request will provide continued support of the treatment and rehabilitation programs established in 1972. A major portion of the increase in 1973 will provide continued support for alcoholism projects transferred from OEO. Funds provided for the formula grant program will permit the states to plan, establish and maintain projects for the development of alcoholism prevention, treatment and rehabilitation programs. These funds will be allotted to states on the basis of relative population and financial need. 70 HEALTH SERVICES AND MENTAL HEALTH ADIENISTRATION Mental Health Program Purpose and Accomplishments Activity: State and Community Programs: (d) Mental Health of Children (Community Mental Health Centers Act, Part F). 1973 1972 Budget Available 1973 Estimate Pos. Amount Authorization Pos. Amount --- $10,000,000 $35,000,000 (new) --- $1,515,000 --- --- Indefinite (continu- --- 8,485,000 ation) Purpose: This activity supports grants which will improve the quality and quantity of services to children through staffing and training grants. ation: Funds will provide staffing support to existing community mental health centers for establishment or expansion of mental health services to children. Accomplishments: This program received its initial funding in FY 1972 and provides partial support of professional and technical staff in community mental health centers providing initial or expanded mental health services to children. The funds were used to stimulate innovative approaches toward expanding the range of services for children with an emphasis on prevention and early treatment. A total of 28 new awards were made in 1972. Objectives: In 1973 the Institute will continue to utilize existing resources for staffing grants to initiate or expand children's services in community mental health centers. It is anticipated that the funds requested will provide continu- atioii support for the 28 grants initially awarded in 1972 and provide support for 4 new awards. 71 HEALTH SERVICES AND MENTAL HEALTH ADMINISTRATION Mental Health Program Purpose and Accomplishments Activity: Rehabilitation of Drug Abusers (Public Health Service Act, as amended: Narcotic Addict Rehabilitation Act). 1973 1972 Budget Available 1973 Estimate Pos. Amount Authorization Pos. Amount 157 $13,323,000 Indefinite 164 $13,926,ooo Purpose: This activity supports the administration of the Narcotic Addict Rehabil- itation Program, authorized by the Narcotic Addict Rehabilitation Act of 1966, which provides for the rehabilitation of narcotic addicts through contract arrange- ments with community agencies and in the Clinical Research Center located at Lexington, Kentucky. Under this program individuals addicted to narcotic drugs may volunteer for civil commitment for treatment (Title III), or those addicted individuals charged with violating certain Federal criminal laws may apply for civil conEnitment in lieu of prosecution (Title I). The staff supported under this activity also administer the marihuana research contract program and the community narcotic addiction treatment and rehabilitation grant program, both of which are funded under a different activity. Explanation: This program provides (1) contract funds for the community "aftercare" of addicts upon their release from inpatient treatment at the Clinical Research Center and (2) salary and related support for the staff who administer the Institute's over-all drug abuse program. Accomplishments: The development and administration of the civil commitment pro- gram has continued to be a major activity in response to increasing numbers of commitments by the U. S. Courts. In 1972 the Institute transferred the Fort Worth Center to the Bureau of Prisons, Department of Justice, who'will operate it as a medium security general medical facility for narcotic addicts. The services which had been provided at Ft. Worth are now provided by local health agencies in the addicts community under contracts with NIMH. Objectives: In 1973 the community assistance program is being expanded to provide community based treatment to addicts formerly treated under the aftercare contract program. This action will reduce the Federal Govei-nment's involvement in direct care programs and is in keeping with our goal of supporting the development of State and local capabilities to deal with narcotic addiction and drug abuse. 72 IMLTH SIOVICES AND MENTAL @TH ADNANISTRATION Mental Health Program Purpose and Accomplishments Activity: Program Support Activities (Public Health Service Act, as amended). 1973 1972 Budget Available 1973 Estimate Pos. Amount Authorization Pos. Amount 501 $16,699,ooo Indefinite 501 $16,977,000 Purpose: There are three Institute programs included under the Program Support Tkctivity. These are: (1) Field Activities - which provide central office coordi- nation of regional programs and maintain Institute relationships with other Federal agencies and State and community organizations. (2) Scientific Comuni- cation and Public Education Activity-which supports the National Clearinghouse for Mental Health Information, a public education program on the dangers of drug abuse and alcoholism and the National Clearinghouse for Drug Abuse Information. (3) Executive Direction and Program Management Services--which supports the program planning and evaluation, biometric and legislative services, and adminis- trative management of the Institute. Explanation: The funds requested support salary and related costs of employees who work in the activities described above. Accomplishments: The Institute's drug abuse information and education program has been expanded with development of the National Clearinghouse for Drug Abuse Infor- mation to full operational status. An alcoholism public information program was expanded in 1972 to include an information and education campaign in the public media, including television and radio spot announcements, newspaper and magazine advertisements, posters and other materials. Also, the National Clearinghouse for Alcohol Information was established to provide support for programs of educa- tion, prevention, treatment, rehabilitation, reseexch and training n e areas of alcohol abuse and alcoholism. Objectives: As a result of increases in the size and number of decentralized pro- grgms, the Institute will increase coordination and collaboration between head- quarters and regional offices. Collaboration with other Federal and state agencies and citizens groups will be increased. The Information programs of the Institute will continue its efforts to disse n e information on mental health as well as its public information programs to educate the public on the dangers of drug abuse and alcoholism. 73 Allocation of Funds for Construction Grants of Community Mental Health Centers 1971 1972 1973 Actual Allocations Allocations Alabama ...................... 617,582 291,445 --- Alaska ....................... 89,040 100,000 Arizona ...................... --- 125,829 --- Arkansas ..................... 195,984 163,258 California.i ................. 1,846,971 1,222,364 --- Colorado ..................... 105,816 15l,lo4 --- Connecticut .................. 424,655 179,172 --- Delaware ..................... --- 100,000 --- District of Columbia ......... 100,000 100,000 Florida ...................... 535,021 48o,427 --- Georgia ...................... 728,123 34o,564 Hawaii ....................... 255,742 100,000 --- Idaho ........................ 124,286 100,000 --- Illinois ..................... 1,349,474 675,977 Indiana ...................... --- 352,254 --- Iowa ......................... 383,725 196,013 Kansas ....................... 322,488 152,031 --- Kentucky ..................... 542,6o8 254,.479 --- Louisiana .................... 6o8,795 288,161 Maine ........................ 217,933 100,000 --- Maryland ..................... 483,89o 248,865 --- Massachusetts ................ 6go,826 355,o6i Michigan ..................... 295,500 567,915 --- Minnesota .................... 510,5i8 258,226 --- Mississippi .................. 470,16o 2o6,300 --- Missouri ..................... 652,870 322,783 --- Montana ...................... 175,343 100,000 --- Nebraska ..................... 335,523 101,5o8 --- Nevada ....................... 75,320 100,000 New Hampshire ................ 100,365 100,000 --- New Jersey ................... 1,141,141 432,711 --- New Mexico ................... 68,520 100,000 --- New York ..................... 1,024,251 i,o68,452 North Carolina ............... 842,ol6 392,012 --- North Dakota ................. 88,500 100,000 --- Ohio ......................... 1,430,990 699,835 --- Oklahoma ..................... 392,420 191,803 Oregon ....................... --- 142,684 --- Pennsylvania ................. 1,598,712 789,652 --- Rhode Island ................. 54,867 100,000 74 1971 1972 1973 Actual Allocations Allocations South Carolina ................ 472,334 2-,l 914 --- South.Dakota .................. --- ioo,ooc --- Tennessee ..................... 184,6o8 311,555 --- Texas ......................... 1,751,o86 8o6,493 Uth .......................... 161,544 100,000 --- Vermont ....................... 100,000 100,000 --- Virginia ...................... 717,744 329,8oo --- Washington .................... lo6,568 219,394 West Virginia ................. 314,971 141,281 Wisconsin ..................... 86,o87 305,001 --- Wyoming ....................... 98,405 100,000 Guam .......................... --- 7,48o --- Puerto Rico ................... 548,446 249,342 --- Virgin Islands..i ............. --- 5,150 --- American Samoa ................ --- 2,344 --- Trust Territories ............. --- 9,361 --- Total ..................... 23,421,768 14,850,000 -O- Allocation of Funds for Alcohol Formula Grants 1971 1972 1973 Actual Allocations Allocations Alabama ......................... --- 589,488 589,488 Alaska .......................... 200,000 200,000 Arizona ......................... --- 254,507 254,507 Arkansas ........................ --- 330,212 330,212 California ...................... --- 2,472,403 2,472,403 Colorado ........................ --- 305,630 305,630 Connecticut ..................... --- 362,402 362,402 Delaware ........................ --- 200,000 200,000 District of Columbia ............ 200,000 200,000 Florida ......................... --- 971,731 971,731 Georgia ......................... --- 688,838 688,838 Hawaii .......................... --- 200,000 200,000 Idaho ........................... --- 200,000 200,000 Illinois ........................ --- 1,367,259 1,367,259 Indiana ......................... --- 712,484 712,484 Iowa ............................ --- 396,464 396,464 Kansas .......................... --- 307,503 307,503 Kentucky ........................ --- 514,720 514,720 Louisiana ....................... 582,846 582,846 Maine ........................... --- 200,000 200,000 Maryland ........................ --- 503,365 503,365 Massachusetts ................... --- 718,161 718,161 Michigan ........................ --- 1,148,688 1,148,688 Minnesota ....................... --- 522,299 522,299 Mississippi ..................... --- kl7,271 417,271 Missouri ........................ 652,873 652,873 Montana ......................... --- 200,000 200,000 Nebraska ........................ 205,314 205,314 Nevada .......................... 200,000 200,000 New Hampshire ................... 200,000 200,000 New Jersey ...................... --- 875,219 875,219 New Mexico ...................... 200,000 200,000 New York ........................ --- 2,i6i,o96 2,161,o96 North Carolina .................. 792,901 792,901 North Dakota .................... --- 200,000 200,000 Ohio ............................ 1,415,515 1,415,515 Oklahoma ........................ --- 387,949 387,949 Oregon .......................... --- 288,598 288,598 Pennsylvania .................... --- 1,597,184 1,597,184 Rhode Island .................... 200,000 200,000 76 1971 1972 1973 Actual Al-locations Allocations South Carolina .................. --- 428,626 428,626 South Dakota .................... --- 200,000 200,000 Tennessee ....................... --- 630,165 630,165 Texas ........................... --- 1,631,247 1,631,247 Utah ............................ --- 200,000 200,000 Vermont ......................... --- 200,000 200,000 Virginia ........................ 667,o66 667,066 Washington ...................... --- 443,755 443,755 West Virginia ................... --- 285,76o 285,76o Wisconsin ....................... --- 616,gog 616,gog Wyoming ......................... --- 200,000 200,000 Guam ............................ --- 15,130 15,130 Puerto Rico ..................... --- 5o4,331 504,331 Virgin Islands .................. --- lo,418 lo,418 American Samoa .................. 4,74o 4,74o Trust Territory ................. --- 18,933 18,933 Total ....................... -0- 30,000,000 30,000,000 77 New Positions Requested Fiscal Year 1973 Annual Grade Number Salary Research Psychologist .......................... GS-15 1 $24,251 Anthropologist ........................ GS-14 1 20,815 Child Psychologist .................... Gs-14 1 20,815 Sociologist ........................... GS-14 2 41,630 Psychologist .......................... GS-14 1 20,815 Anthropologist ........................ GS-13 1 17,761 Economist ............................. GS-13 1 17,761 Political Scientist ................... GS-13 1 17,761 Ecologist ............................. GS-12 1 15,o4o Public Health Analyst ................. GS-11 1 12,615 Public Health Analyst ................. GS- 9 1 lo,470 Secretary ............................. GS- 5 2 13,876 14 233,61o State and Community Programs Public Health Advisor ................. GS-14 2 41,630 Public Health Advisor ................. GS-13 2 35,522 Public Health Advisor ................. GS-12 1 15,o4o Secretary ............................. GS- 5 2 13,876 7 lo6,o68 Rehabilitation of Drug Abusers Public Health Advisor ............ GS-13 1 17,761 Public Health Advisor ................. r;.S-12 1 15,o4c) Program Analyst ................. GS- 9 1 lo,470 Secretary ............................. GS- 6 1 7,727 Clerk-typist .......................... GS- 5 1 6,938 Clerk-typist .......................... G,9- 4 2 7 70,3 0 Total new positions, all activities 28 41o,ol8 m n a m n a m m a m m 0 m m m m a m DEPAR OF BMTH, EDucATioN, AND WELFARE SA32[T ELV"TM HOSPITAL Page Noe Appropriation language ................ ............ 79 A ts available for obligation ...... ......... * ..... 8o obligations by activity ............................... 8o obligations by object ............... * ....0..... 00 ..... 81 S of c@es ... ..........0 ...... ........ 82 Exp@tion of transfers .* ...*.... ..*.o #."*.* ... 6. 83 Table of estimates and appropriations .............. 85 justification: A. General statement 86 1. Hospital pTowams ........ * ......... 86 2. Re sement detail ........ *.*.o ...... *..*. 93 3. Statement of average daily patient population 94 B. Program jrarpose and accoWlisbments ............ 95 Appropriation Estimate SAINT ELIZABETHS HOSPITAL For expenses necessary for the maintenance and operation of the hospital, including clothing for patients, and cooperation with organizations or individuals in the scientific research into the nature, causes, prevention, and treatment of mental illness, [$23,144,000] $28,271,'ooo or such amount as may be necessary to provide a total appropriation equal to the difference between the amount of the reimbursements received during the current fiscal year on account of patient care provided by the hospital during such year and [$49,709,0001 $55, 860, 000 (Department of Health, Education, and Welfare Appropria;, on Act, 1972). 80 DEPARTMNT OF @TH, EDUCATION, AND WELFARE ELIZABETHS HOSPITAL Am@s Available for-obligation 1972 1973 Appropriation ................... $24,936,ooo $28,271,000 Comparative transfer to: 'IDepartToenta.1 Management'l -13,000 --- Comparative transfer from: "Mental Health .. ............... i.6oo.ooo --- Subtotal, budget authority 26,523,000 28,271,000 Receipts and Reimbursements from: Federal ftmdo ....... 0.... *..a. 721,000 807,000 Trust funds ....... *.*. 300,000 300,000 Non-Federal sources ........ *.* 23,826,ooo 26,482,000 Total obligations ........ 51,370,000 55,86o,ooo Obligations by Activity 19-12 1973 Increase or Page Estimate Estimate Decrease Ref. Pos. Pmount POSO Amoimt Fos. Amount- 86 Clinical & Com- munity Services: Total obliga- tions 4,132 $51,370,ooo 4,132 $55,86o,ooo --- +$4,490,000 obligations by ObJect Increase 1972 1973 or Estimate Estimate Decrease Total n@er of penment positions ..i .... &*.Oooo.*Ooo 4,132 4,132 --- Full-time equivalent of all other positions 195 220 +25 Average number of all employees 4,ol6 4,2o4 +188 Personnel compensation: Permanent positions ......... $36,451,000 $38,921,000 +$2,470,000 Positions other than permanent 1,388,000 1,657,000 +269,ooo other persormel compensation 2.s277,000 2,395,000 +118,ooo Special personal service payments ................... 41,ooo 41,ooo --- Total personnel coMensation 4o,157,000 43,ol4,ooo +2,857,000 Persomel benefits .. ....0... 000 3,472,ooo 3,709,000 +237,000 Travel and transportation of persons ...................... 151,000 165,000 +14,ooo Transportation of things ....... 107,000 107,000 --- Rent, c ications and utilities 658,ooo 734,000 +76,ooo Printing and re@uction ...... 35,000 35,000 --- Other services ..... 4.......... * 1,195,000 1,899,ooo +7o4,ooo Supplies and materials ......... 4,751,000 5,114,ooo +363,000 Equipment ...................... 764,ooo 937,000 +173,000 Lands and structures ... ...... 0. 110,000 i76,ooo +66,ooo Insurance claims and indemities 2,000 2,000 Subtotal .. ................ 51,402,000 55,892,000 +4,490,000 Deduct charges for quarters -32,000 -32,000 Total obligations by object 51,370,000 55,86o,ooo +4,49o,ooo 82 Suuwy of Changes 1972 estimated obligations .........* ...................... $51,370,000 1973 estimated obligations ... .......0 .... 55,86o.ooo Net change .. ................................ +4j,4909000 Base Change from Base Poo.. Amount Pos. Amount- Increases: A. Built-in: 1. Annualization of employment and related support to effect unit- ization oo* ..... *I .....0 .....0--- --- --- 1,8o4,ooo 2. Average s@ and wage grade adjustments plus additional holiday ............ o ......... --- --- --- 1,236,ooo 3. other (including M, DHEW working capital Fund) ........ --- --- --- 4oo,ooo B. Program: 1. Equipment replacements ......... --- 874,000 --- 239,000 2. Restoration of Interas and Residents staffing ........... --- --- --- 280,000 3. Scheduled supp=t for Upward Yiobility Program ............. --- --- --- 523,000 4. Scheduled support for WOW Program ......... *.** ......... --- --- --- 107,000 Total, increases ........... --- --- --- 4,589.,Ooo Decreases: A. Built-in: 1, one less day of pay ..* ........ --- --- --- -gg.ooo Total, net change ........ --- --- 4,49o,ooo 83 E=@tim of Changes Increases: A. @t-in: 1. Full year funding of 300 @ti@ positions (291 man years) authorized in 1972 for necessary programmatic changes including the initial implementation of the unit system of organization which has been widely adopted by other progressive, psychiatric hospitals. Funds are also needed to make necessary alterations to patient care facilities and to support req:uired c ty related activities required for unitization and other service improvements. 2. Increases in the pay costs for within grade increases, quarters allowances for PHS officers, wage grade reclassifications and adjustments, and holiday pav for the Presidential D2auguration. 3. Additional funds are required for increased telephone costs, wor@ capital fund assessments, increased electricity for air conditioning and supplies for patients. Be Program: 1. Additional funds to cover the larger cost of equipment items r@ring replacement in 1973. 2. Restoration of @ng support for Intern and Resident positions to be transferred at the beginning of 1973 to NIM's Division of Man- power and Training. These participants in the Hospital's clinical training program provide a valuable s@ce of recruitmerr for scarce- category medical officers and other related professional staff. 3. Fu3-l year costs with increased enrollment in the Upward Mobilit,v College, which was established for the purpose of providing educati=U opportunities and career development to primarily dis- advantaged minority employees. Requested funds will also support required Hospital participation in other Upward Mobility Program efforts. 4. @@ds to cover 10 additional trainees and increased costs for 26 trainees completing program requirements under the Washington opportunity for Women program, a social se.-vice for sub-professional indigenous workers. Decreases: A. Built-in: 1. one less day of pay below 1972 base. 34 pmumtim of Transfers 1972 Eatimte Purpose Comexative transfer to: Departmental Management -$13,000 Central services pro- vided to Saint Elizabeths Hospital for administration of Upward Mobility Program. comparative transfer from: Mental Health 1,600,000 Transfer would align fiscal responsibility with organizational changes re- sulting from the disestab- lishment of National Center f'= Mental Health Services, Training and Research. As a result of these changes, research and training pro- grams integrally related to clinical operation of Hospital were transferred to Saint Elizabeths. SAINT ELV"THS HOSPITAL Budget Estimate House Senate Year to Congress Allowance Allowance Appropriation 1963 $5,974,000 $6,332,000 $6,332,000 $6,332,000 1964 lo,178,ooo 7,816,ooo 7,816,ooo 7,852,000 1965 9,429,ooo 9,P-16,000 9,216,ooo 9,620,OC)O 1966 lo,o84,ooo 10,217,000 10,217,000 10,290,000 1967 9,073,OC)O 9,906,000 g,go6,000 10,171,000 1968 9,044,000 9,028,000 91,028,000 10,749,ooo 1969 11,077,000 32,077,000 11,077,000 13,380,000 1970 lo,405,ODO 10,405,000 10,405,000 16,883,000 19 71 14,823,000 14,823,000 14,823,000 23,796,ooo 1972 23,144,ooo 23,144.,ooo 23,i44,ooo 24,936, ooo 1973 28,271,000 Difference between estimated appropriation and House and Senate allowances is d-ae to changes in estimated patient load. justification ELIZABETH9 HOSPITAL 1972 1973 Increase or Estimate Estimate Decrease Po$. Amount pos. Amount Pos. Am3un-t Personnel compensation and benefits .....*..4,132 $43,,629,ooo 4,132 $46,723,000 +$3,o94,ooo other Expenses .... 7,773,000 991699000 +1,396,000 Deduct charges for quaxters .* ......... -32,000 -- -32,000,-- Total ........... *4,132 $51,370,ooo 4,132 $55,86o,ooo -- +$4,49o,ooo General Statement This appropriation supports the operation of the Saint Elizabeths Hospital - Division of Clinical and C ity Services. Saint Elizabeths provides treatment and rehabilitation for approximately 3,300 inpatients and 2,650 outpatients and operates a c ity mental health center which serves District of Columbia residents in the southeast quadrant of the city, south of the Anacostia River, commonly referred to in this context as "Area D". The 1973 budget request of $55,86o,ooo includes $1,600,000 to support Saint Elizabeths' clinical research and training programs which, in previous years, were budgeted under the "Mental Health" Appropriation. Saint Elizabeths Hospital. - Division of Clinical and Co itv Services The Hospital provides treatment, care,and rehabilitation services for a variety of patient categories including District of Columbia residents, persons charged with or convicted of crimes in the United States or District of' Columbia courts, U.S. Nationals who ecome mentallv ill while abroad, residents of the Virgin Islands and U.S. Soldiers' Home, and other categories of Federal beneficiaries. Facilities of the Division include a forensic psychiatry and security unit for the examination, treatment and rehabilitation of patients referred by the courts under various types of criminal procee ngs, and a comprehensive c ity mental health center. The Hospital conducts a clinical- research program for the purpose of obtaining a better understanding of the causes of mental disorders, and the factors bearing upon their development, treatment and possible 87 prevention. Saint Elizabeths also provides multidisciplinary clinical training for professional and ancillary personnel engaged in or interest- ed in mental health activities. It also provides administrative and logistical support to NIMH activities located at the Hospital. MaJor Accomplishments Since its organizational placement within NDE, the Hospital has given its highest priority of effort to the reduction of its inpatient resident population. This has been accomplished by careful screening of the patient population to ascertain sound alternatives to hospital- ization. Patients no longer in need of hospital psychiatric care and who are not dangerous to themselves or others are being returned to normal community living. Since this intensive program has been in operation, the inpatient population has been reduced by almost 2,000. This accomplishment has materially assisted with upgrading of patient care by elimination of much of the dehumanizing aspects of residing in obsolete and substandard Hospital areas. Success in reducing the necessity,for inpatient hospitalization is evidenced by the average daily outpatient load increasing by approximately 500 to an average of 2,650 in 19172, primarily due to the Community Mental Health Center. over 10,000 patients were treated at Saint Elizabeths last year, with admissions rising from 3,650 in 1970 to 4,012 in 1971. In its continuing effort to provide better services to its patients, the Hospital made the following programmatic improvements: (a) Unitization. With the additional staffing authorized in 1972, the Hospital began the initial implementation of unitization of services to patients. Actions were taken to begin reorganizing the Hospital into a nwber of semi-autan@ patient services, each having treat- meat teams with the necessary staffing to provide a full range of mental health services and continuity of care for patients within its own geographic catcbment area. Selected patient services were reorganized internally into units and teams, and some organizational components within the Hospital are being consolidated to reflect proper alignment with the health area served. Decentralization was initiated in medical service functions such as nursing, psychology and social service with related pers@iel@ now being directly assigned to clinical directors. (b) special Programs. The narcotic addiction program, a drug-free therapeutic community known as Last Renaissance, was expanded to serve approximately thirty patients. There have been 105 admissions into this program in nineteen months, with a current waiting list of seven- teen addicts. Sixteen patients have graduated, with seven graduates now employed in drug rehabilitation centers throughout the country. The program also provides a variety of consultative and educational services to neighborhood drug programs, schools and medical societies. A mental health program for the deaf was established, including inpat- ients @tient, @ita.Uzatim and full emergency services. This pioneering effort integrates s@ces, training, research and combined 0 ation wthods to yrovide c=Xehensive mental health services to dftf people. It also provides cmaultaticu, educatim and rebab- i3ltative services, and serves as a resatwce in training and research. Thor* is an average of 47 patients recei@ treatment vmder this prqWm,, of whom an average of 24 are outpatients. A special alcohol Vrmgzm vas also e4&lisbed for wmm. (c) Services to en. Another ward, with a capacity of 30 patients,, was to serve a selected group of children. (d) Medical and swgical Support. intewive care units are being "nlopg to etrwohen these s@ces which are seriously wwburdened. (e) Now Aft"aicn Semice. A new admission service for nonresident MA no-fixed-address patients of all ages was established in the Oeriatries Di@icu, This is in keeping with the modern practice of @ttiM patients to age-integrated vards. (f) @amic s@ces. This program, under which the number of cases to determine c@ @ to stand trial has rapidly increased, was reorganized to separate pretrial from tre@ent patients, and o=Um seavr:ity frm asevrity i@, (g) @s@e train The Hospital reassessed its in-serv:Lce tro,4"lnit ed staff d@vol@ efforts in order to increase st PrMwtivity., The Wwd @ility College, which currently has 150 stud@nts,, w" established In collaboration with Federal City College I'ar the "*one of lpr@aM educational opportunities wA career dov@ to pri=krily disadvantaged minority ozoployees. A collab- orative effort was LU* @taken with Washington Opportunities for Womn for training @genoiig social work aides. laimi rrotul Continusid efforts to improve treatment. sopeci@ for new pationtag and to speed the rati=n of patients to the commmity have aumt#Uod the a@ reduction in the average length of hospitalization @Ooriwwod in recent y*eLro., The median time spent = the Hospital roLU by patients @ were discharged during 1971 was slightly more than three mmthaj in contrast to a comparable stay period of near2,v eleven mmthe only six years ago, The median time since admission for those patients = the end of yousr rolls has dropped during the last six years from nearly 9.5 years to 5.3 years at the end of 1971. A concentrated effort has also been made to place patients in the com=ity after hospitalization is no longer necessary. The unproced @ ed reduction in the resident patient census during recent years reflects the accelerated return to the commmity of those patients who c=ld most readily make the transition back to the C! ty environment. The residual patients having an outplacement potential include those presenting medic@ related (not psychiatric) problems and those whose long period of institutionalization make such action more difficult. The lack of suitable, alternative living arrangements and adequate financial support for the indigent patient will also have an inhibiting influence on further outplacements. Because efforts must now be directed toward the movement of the more chronic patients, of whom fifty-eight percent are over 54 years of age, it is anticipated that the markedly slower outplacement rate currently being experienced will continue and result in an average daily load of 3,150 during 1973. Area D C ity Mental Health Center A major step in the conversion of Saint Elizabeths Hospital into a modern c ity-based mental health facility was the establishment of the Area D Commmity Mental Health Center (CMHC) in 1969. The CNHC serves approximately 175,000 residents of that southeast portion of the District of Columbia designated as Area D, and which has the massive social problems associated with uxban localities. The Center offers all the elements of a model community center including con- timlity of care, a c=Tlete range of children's services, consultation activities and c ty involvement. Specialized programs are offered in alcoholism, drug addiction, and suicidology, including the clinical and c ty media for a psychiatric residency program. In addition, five satellites have been developed in Area D to service immediate neighborhoods. Through close involvement with the residents of the c ity, mental illness can be detected earlier, thus reducing the probability of inpatient hospitalization. The policy has also been established to treat the patient in his community environment until such time that the degree of illness passes the threshold whereby inpatient hospitalization becomes essential. The Area D CMHC now has on its rolls an average of' 1,400 patients, -if which 1,160 are out- patients. From its inception, 5,267 patients have been admitted for treatment in the Center. C la Relations Saint Blizabeths continues to expand its participation in co ity activities, such as the vocational rehabilitation program which is operated jointly with the D.C. Department of Vocational Rehabilitation. During the past year, the Hospital accepted 600 referrals with 191 patients being successfully rehabilitated (i.e. the patients were working and no longer needed the group's services). The District also cooperates with the Hospital in the operation of a transitional work- shop for patients. The Hospital also supplies the clinical base for the provision of accredited co=se work for students from local schools and universities in the fields of medicine, social work, psychology, hospital administrat- ion, vocational rehabilitation, chaplaincy and nursing. Saint Elizabeths also provides formal orientation in mental health concepts to such c ty groups as police officers, probation officers, Secret Service and FBI agents, and the clergy. In addition, the Hospital has oriented over 25,000 college and high sbhool student visitors to its operations during the past eight years. Members of the professional staff, both officially and individ- ually, provide consultative and educational services on request to D.C. commmity agencies and personnel. The Hospital also cooperates with local mental health associations in finding jobs for former patients. Patient Population The average daily outpatient load will increase to approximately 2,65o in i972, and to 2,750 in 1973, primarily due to the operation of the Area D C ty Mental Health Center, and will offset the gradual decrease in the average daily inpatient load. Consequently, the average daily load for all patients is expected to remain relatively stable, going from 5,950 in 1972 to 5,900 in 1973. With a planned average daily inpatient load of 3,300 in 1972, it is estimated that an average of 3,150 will be experienced in 1973. The number of patients treated wi" approximate the 1971 level of 10,100. Since the Hospitalls growing outpatient population is requiring the diversion of increasing amomts of scarce time for services to outpatients, the total number of patients is considered in determining staffing levels. Based on the projected level of employment and the average daily load of all patients, the staffing ratio would be sixty-eight employees per one-hundred patients in 1973. Clinical Research and Training The 1973 request includes $1,600,000 to support clinical research and training programs which, in previcriz years, were budgeted under the "Mental Health" Appropriation. This change in f-unding is proposed for the purpose of aligning fiscal responsibility with the organizational changes effected in May, 1971, wherein the National Center for Mental Health Services, Training, and Research was disestablished. In the deactivation of the National Center, those research and training pr @ ams which were integrally related to the clinical operation of the Hospital were transferred to Saint Elizabe s. The goal of the Hospitalls research activities, which are intimately linked with related programs of clinical care and training, is to better -understand the causes of mental disorders and the factors bearing upon their development, treatment, and prevention. Research studies in 1973 will be conducted primarily in the areas of operant behavior, criminal behavior, clinical psychology and psychiatric sociol- ogy. The principal objective of the training program is to increase the number and improve the skills of persons serving medical, nvrsing and allied medical and mental health disciplines concerned with the treatment and rehabilitation of the mentally ill. In 1973, the Hospital wi" provide: training to 120 medical students; graduate and postgraduate programs in mental health such as those for intern- ships and psychiatric residency training; training for mental health professionals, counselors and technicians; and special workshops for Community Mental Health and other community groups. The training program serves as a valuable source of recruitment for scarce- category medical- officers and other.related professional staff. Unitization During 1973 the highest priority of the Hospital will be to proceed towards the full implementation of the unitization of services to patients. Unitization is considered the most essential step in the conversion of S'aint Elizabeths Hospital into a modern community- oriented facility. Under the planned unitization of the Hospital, the clinical services will be decentralized into smaller treatment units within which a basic unit team will provide patient-centered treatment and continuity care to an individual patient. Each unit will provide comprehensive care and treatment services to all patients within its catcbment area including diagnosis, inpatient treatment, rehabilitation, evaulation, outpatient and outplacement services. Training will be provided to aid many employees whose work activity will be shifting from primarily a custodial orientation to that of a community-oriented active treatment effort. The Unit system will stimulate extensive interchangeability and jointness of fuctions among staff members in a constructive team approach. This should produce better staff and patient morale and will improve communication between staff, the patient, the patient's family, and the c ty. The morale of the ward staff should also improve because, ' after becoming more therapeutically oriented, their feeling Of contribution to the effectiveness of the total program should be enhanced. More c ty involvement can be expected with the added participation by the staff in consUl-tiLtion activities with local;-health, welfare and other institutions. The Hospital will also continue to make such needed improvements in medical and surgical support services, services to geriatric patients, forensic services and improved services to children. Continuing efforts will be made to reduce the necessity for inpatient hospital- ization, and to speed the return of patients to normal c ty life. The requested increase of $4,49o,ooo includes $1,8o4,ooo to cover additional costs to continue with the implementation of the unit system of services to patients, including full year costs of additional employ- ment authorized during 1972. An additional $1,776,ooo is required to cover built-in salary and wage adjustments, increased operational support costs such as Working Capital Fund assessments, plus necessary equipment replacements. nM year cost with increased enrollment in the @d Mobility College, together with scheduled support for the Washington Opportunities for Women program, will require an additional $630,000. The remaining amaLmt of $280,000 is requested for the restoration of Intern and Resident trainee positions. 93 Reimbursement Detail 1972 1973 Increase or Estimate Estimate Decrease Reimbursewnts for services perf (patient care): Veterans Administration ..... $15,000 $17,100 +$2,100 U.S Soldiers How ...... # ... 90,200 85,900 -4,300 Public Health Service (Indians) .00 ...... 30,100 34,300 +4,200 U.S. Nationals . 450,200 515,300 +65,loo U.S. Prisoners ...... 135,500 154,4oo +i8,goo Soco Sec. (Medicare p@nts) 300,000 300,000 --- Subtotal . ........... #.... o 1,021,000 1,107,000 +86,ooo Payment received from Non- Federal sm=ces: Patient care: District of Columbia ..o .... 23,667,ooo 26,372,000 +2,705,000 Cafeteria sales .. .......... 82,000 68,ooo -14,ooo Sale of scrap .... ...0.....0 3,000 2,000 -1,000 Washington opportunity for Women oo.#.# ... o.... 74,ooo 4o.ooo -34.ooo Subtotal ... o ..... oo ...... 23,826,000 26,482,ooo +2,656,ooo Total reimbursements .. ....... 24,847,000 27,589,000 +2,742,000 Per them rate: im m Change District of Columbia ....... $22o84. t26-38 +$3o54 o ........ o o o..... 0. lli.cg 47-10 +6.ol 94 statement of Average Daily Patient PoPulatiOn 1971 1972 1973 Actual Estimate Estimate Reimbursable public Health Service (Indians) 2 2 2 D.C. (Residents) .............. 2,376 2,173 2,078 D.C. (Vol. and Non-Protesting). 361 366 370 D C. (Prisoners) .............. 303 290 285 D:C. (Jury Trial) ............. 41 38 37 U.S. Soldiers Home ...... 6 6 5 Veteram Administration ** 2 1 1 U,S. ffati o..oo .... *..* ... 32 30 30 U.S. Prisoners o ........ 10 9 9 Reimbursable Totals 3,133 2,915 2,817 Nmweimbursable Military ........ 92 85 70 D.C. N=-residents .@ .......... 205 Igo 165 Pub:Lic Health Service 6 5 5 Virgin Islands ................ 85 80 72 Misce ow 26 25 21 monreimbursable Totals 414 385 333 Total In Hospital Patients 3,547 3,300 3,150 SAINT ELIZABETIM HOSPITAL Clinical and Commmity Services Program Purpose and Accomplishments Activity: Clinical and C ty Services 1973 Budget 1972 Estimate POS. Amomt Authorization Pos. Amoimt ,523,000 Indefinite 4,132 2 271,000 DMse: Saint Elizabetbs Hospital provides treatment, care, and rehab- itation services for apprcocimately 3,300 inpatients and 2,650 outpatients. The Hospital operates a security treatment facility and a comprehensive mental health center whidh services District of Columbia residents in the smAheast quadrant of the city. Saint Elizabeths also conducts a clinical research program and provides multidisciplinary clinical training for professional and related personnel. Ex-planation: The Hospital operates with an indefinite appropriation, which fixes a total operating ceiling and provides that direct Federal appropriations will make up the difference between the total authorized ceiling and the amount of reimbursements received during the year. Virtua3ly all reimbursements received are for inpatient care. The principal reimbursing agency is the District of Columbia. Prior to 1973, the clinical research and training programs were funded from the Mental Health appropriation. Acc2M3.ishments in 1272: The Hospital began the initial implementation of unitization of services to patients, with initial actions being taken to reorganize the Hospital into a nwber of semi-autonomous patient services. Medical and Surgical intensive care units are being set up. Special pcograms in narcotic addiction, alcohol and services to children were expanded. over 10,000 patients were treated and, due to the emphasis placed on the early return of patients to productive community life, the average daily patient load was reduced by 247. The Upward @jobil.ity College, with 150 students, was established to provide career development opportunities to primarily disadvantaged minority employees. objectives for 1973: To cmtinue further implementation of the unit plan, including closer working relations with co=mnity agencies, active treatment with early return to the c ty and effective fo3.low-up, and provision of treatment efforts to avert the need for inpatient care. To be able to offer comprehensive care and treatment services within a catcbment area, including the acute and chronic patients, the non- psychiatric special care patients, and special groups such as children,, drug abusers, alcoholics and geriatric patients. orther needed improve- ments are the strengthening of medical and surgical support services, i3mproved services to geriatric patients, strengthening of forensic services and improved services to children. It is hoped that the unitization of patient services will enable the Hospital to further reduce the inpatient population. -I. - -- . ,-. . . m M M M m M m m m m m m 0 m m m m m m DEPARTMENT OF HEALTH, EDUCATION, AND 14ELFARE HEALTH SERVICES AND MENTAL HEALTH ADMINISTRATION Health Services Planning and Development Page No. Appropriation language ........................................ 98 Explanation of language changes ............................... 101 Amounts available for obligation .............................. 102 Obligations by activity ....................................... 103 Obligations by object ......................................... 104 Summary of changes ............................................ 105 Significant items in House and Senate Appropriations Committee Reports ........................................... 109 Authorizing legislation ....................................... ill Explanation of transfers ....................................... 118 Table on estimates and appropriations ......................... 119 Justification: A. General Statement ....................................... 120 1. Health services research and development: (a) Grants and contracts ........................... 123 (b) Direct operations .............................. 135 2. CompreLiensive health planning: (a) Planning grants ................................ 136 (b) Direct operations ............................... 140 3. Regional medical programs: (a) Grants and contracts ........................... 142 (b) Direct operations .............................. 147 4. Medical facilities construction: (a) Construction grants ............................ 149 (b) Interest subsidies ............ ......... 149 ..... ;'es (c) District of Columbia medical facili i ........ 149 (d) Direct operations .............................. 150 5. Program direction and management services ........... 151 B. Items of special concern: 1. Regional medical programs ........................... 109, 120, 142, 159 2. Nursing home improvement ............................ 130 DEPARTMENT OF HEALTH, EDUCATION, AND WELFARE HEALTH SERVICES AND MENTAL HEALTH ADMINISTRATION Health Services Planning and Development Page No. C. Program purpose and accomplishments ................... 152 D. State tables .......................................... 169 E. New positions requested ............................... 182 98 Appropriation Estimate HEALTH SERVICES PLANNING AND DEVELOPMENT To cwLAy out @e,6 VI and IX, section,6 314 (a) ttiAough 314(c), and except " otheqivize ptovide4 6ection,6 301, 304, 311, 402 (g), 403 (a) (1), and 433(a) o4 the Pubtic Heatth SeAt,ice Act; $329,596,000, o4 which $85,000,000 slwtt be avaitabte until June 30, 1975 6ot g)Lant,6 puuuant to .6ection 601 o6 the Pubtic Heatth SeAvice Act 6ot the construction 6'L mod- eanization o6 medical @a e,6, and $2,500,000 5hatt temain avaitabte without 6i,6cat yea& @itation 6o4 payment oA inteAest on guaranteed toan6 a,6 authorized by .6ection 626 oi the Act.1 [HEALTH SERVICES RESEARCH AND DEVELOP@IENT] 2 [To carry out, except as otherwise provided, sections 301 and 304 of the Public Health Service Act, with respect to health services research and development, $62,070,0001 [REGIONAL MEDICAL PROGRAMS]2 [To carry out title IX, sections L02(g), 403(a)(1), 433(a@ and, to the extent not otherwise provided, 301 and 311 of the Public Health Service Act, $102,771,000.1 [MEDICAL FACILITIES CONSTRUCTION]2 [To carry out title VI of the Public Health Service Act, and, except as otherwise provided, section 304 of the Act for administrative and tech- nical services under parts B and C of the Developmental Disabilities Services and Facilities Construction Act (42 U.S.C. 2661-2677), the District of Columbia Medical Facilities Construction Act of 1968 (Publjc Law 90-457), and the Community Mental Health Centers Act (42 U.S.C. 2681-2687), $306,704,000; of which $197,200,000 shall be available until June 30, 1974 99 for grants pursuant to section 601 of the Public Health Service Act for the construction or modernization of medical facilities, of which $41,400,000 shall be available only for grants for the construction of pub- lic of other nonprofit hospitals and public health centers; $8,300,000 for grants and $6,700,000 for loans shall remain available until expended for hospital experimentation projects pursuant to section 304 and section 643A of the Public Health Service Act; $50,300,000 shall be for deposit in the fund established under section 626, and shall be available without fiscal year limitation for the purposes of that section of the Act of which $30,000,000 shall be available for direct loans pursuant to section 627 of the Act; $24,052,000 shall be for grants and $16,575,000 shall be for loans for nonprofit private facilities pursuant to the District of Colum- bia Medical Facilities Construction Act of 1968 (Public Law 90-457); P,tovided, That there are authorized to be deposited in the fund established under section 626(a)(1) of the Act amounts received by the Secretary and derived by him from his operations under part B of title VI of the Act which shall be available for the purposed of section 626(a)(1): Ptovi-ded 6wUheA, That sums received by the Secretary from the sale of loans made pursuant to section 627 of the Act shall be available to him for the pur- poses of that section] [For an additional amount for "Medical facilities construction", $1,500,000, to remain available until expended: Ptovided, That these funds shall be avail@ole only for loans for nonprofit private facilities pur- suant to the District of Columbia Medical Facilities Construction Act of 1968 (Public Law 90-457): Ptovided 6uAtheA, That the funds appropriated to carry out that Act in the Departments of Labor, and Health, Education, and Welfare, and Related Agencies Appropriation Act, 1972 (Public Law 92- 80) shall remain available until expended) 100 Appropriation Estimate MEDICAL FACILITIES GUARANTEE AND LOAN FUND TheAe aAe heAeby authorized to be deposited in the "Medicat 6a e,6 guarantee and toan 6und" amounts teceived by the Sec- tetaAy 64om op@6nz undeA paAt B o4 tWe VI o6 the Pubtic Heatth Setvice Act and such amounts 61tatt be avaitabte to the SecAetaAy without 6i6cat yeoA P-imitation 6ot cwftying out his 6unction6 undeA 6ection 626 (a) (1) o6 the Act: Ptovided, That 4um6 teceived 6,tom the sate o6 loans made puAsuant to sec;tion 627 o6 the Act zhatt be avaitabte to ca4Ay out the poApo6ez o6 that section. 101 Explanation of Language Changes HEALTH SERVICES PLANNING AND DEVELOPMENT 1. A new account is proposed as a result of the consolidation of three HSMHA appropriations, "Health Services Research and Development", "Regional Medical Programs", and "Medical Facilities Construction". This consolidation creates a new appropriation which not only reflects a functional grouping of the accounts, but also provides for better admin- istration by making the appropriation structure consistent with the current HSMHA organization structure. 2. Language formerly used for the three consolidated accounts is deleted. MEDICAL FACILITIES GUARANTEE AND LOAN FUND 1. The proposed language provides authorization for the Secretary to use monies received from the sale of direct Hill-Burton loans to make additional loans. 102 DEPARTMENT OF HEALTH, EDUCATION, AND WELFARE HEALTH SERVICES AND MENTAL HEALTH ADMINISTRATION Health Services Planning and Development Amounts Available for Obligation 197 2 1 97 3 Appropriation ...................... $473,045,000 $329,596,000 Real transfers to: "Operating expenses," Public Buildings Service, GSA ........ -3,000 --- "Medical facilities guarantee and loan fund .................. -30,000,000 --- Real transfer from: "Nursing home improvement ......... 1,000,000 --- Comparative transfers to: "Departmental management .......... -27,000 --- "Preventive health services" ..... -2,189,000 --- "Office of the Administrator ..... -55,000 --- Comparative transfers from: "Health services delivery ......... 25,935,000 --- "Office of the Administrator".... 27,000 --- Subtotal, budget authority ......... 467,733,000 329,596,000 Unobligated balance, start of year. 500,000 --- Unobligated balance, lapsing ....... -109,000 --- Total, obligations ........ 512,124,000 329,596,000 103 Obligations by Activity.L/ 1972 1973 Increase or Page Estimate Estimate Decrease Ref. Pos. Amo n@t Pos. Amount Pos. Amount 122 Health services research and development: 123 (a) Grants and contracts... --- $56,118,000 --- $58,018,000 --- +$1,900,000 135 (b) Direct operations.. 218 5,898,000 230 6,325,000 +12 +427,000 Subtotal ... 218 62,016,000 230 64,343,000 4-12 +2,327,000 136 Comprehensive health planning: 136 (a) Planning grants ...... --- 25,000,000 --- 39,800,000 --- +14,800,000 140 (b) Direct operations 24 935,000 49 1,833,000 +25 +898,000 Subtotal ... 24 25,935,000 49 41,633,000 +25 +15,698,000 141 Regional medical programs: 142 (a) Grants and contracts... --- 139,300,000 --- 125,100,000 --- -14,200,000 147 (b) Direct operations.. 169 4,602,000 194 5,051,000 +25 +449,000 Subtotal... 169 143,902,000 194 130,151,000 +25 -13,751,000 148 Medical facilities construction: 149 (a) Construction grants ...... --- 197,200,000 --- 85,000,000 -112,200,000 149 (b) Interest subsidies... 20,300,000 --- 2,500,000 -17,800,000 149 (c) District of Columbia medical facilities.. 42,127,000 --- --- -42,127,000 150 (d) Hospital exper- imentation project ..... --- 15,000,000 --- --- -15,000,000 150 (e) Direct operations 135 3,058,QOO' 135 3,259,000 --- +201,000 Subtotal... 135 277,685,000 135 90,759,000 --- -186,926,000 151 Program direction and management services ........ 149 2,586,000 149 2,710,000 --- +124,000 Total obligations. 695 512,124,000 757 329,596,000 +62 -182,528,000 .lj Amounts included for Medical facilities construction activity are budget authority. 1.04 Obligations by ObjectL/ 1972 1973 Increase or Estimate Estimate Decrease Total number of permanent positions .................. 695 757 +62 Full-time equivalent of all other positions ............ 90 96 +6 Average number of all employees .................. 710 797 +58 Personnel compensation: Permanent positions ........ $10,045,000 $10,915,000 +$870,000 Positions other than permanent ................ 654,000 728,000 +7 , 0 Other personnel compen- sation ................... 72,000 72,000 --- Subtotal, personnel compensation ........ 10,771,000 11,715,000 +944,000 Personnel benefits ........... 1,069,000 1,209,000 +140,000 Travel and transportation of persons .................... 1,126,000 1,271,000 +145,000 Transportation of things ..... 99,000 114,000 +15,000 Rent, communications and utilities .................. 688,000 810,000 +122,000 Printing and reproduction.... 293,000 333,000 +40,000 Other services ............... 2,544,000 2,961,000 +417,000 Project contracts .......... 27,888,000 28,133,000 +245,000 Supplies and materials ....... 127,000 145,000 +18,000 Equipment .................... 130,000 143,000 +13,000 Investments and loans ........ 24,775,000 --- -24,775,000 Grants, subsidies and contributions .............. 442,614,000 282,762,000 -159,852,000 Total obligations by object 512,124,000 329,596,000 -182,528,000 1/ Amounts included for Medical facilities construction activity are budget authority. 105 Summary of Changes 1/ 1972 estimated obligations ................................. $512,124,000 1973 estimated obligations ................................. 329,596,000 Net change .................................. -182,528,000 Base Change from Base Pos. Amount Pos. Amount Increases: A. Built-in: 1. Tnnualization of positions new in 1972 ............... --- --- +330,000 2. Within grade and longevity increases ....... i ......... --- --- --- +32-5,ooo 3. Annualization of uniformed services pay increase (PL 92-129) ............... --- --- --- +19,000 4. Increases for DHEW Working Capital Fund, HSMHA Service and Supply Fund, and FTS charges ................... --- --- --- +1689000 5. Increase in continuation costs for area-wide plan- ning grants ............... --- +2,900,000 B. Program: 1. Health services research and development'. a. Grants and contracts .... --- 56,118,000 --- +1,900,000 b. Direct operations ....... 218 5,898,000 +12 +251,000 2. Comprehensive health planning. a. Formula grants to States for health planning ... --- 7,675,000 --- +2,325,000 b. Project grants for area- wide planning ......... --- 13,200,000 --- +9,000,000 c. Project grants for train- ing, studies, and demo- strations ............. --- 4,125,000 --- +575,000 d. Direct operations ....... 24 935,000 + 25 + 890,000 3. ser3Zices. ............. --- --- 25 .350,000 4. Program direction and management services ....... 149 2,65 Total, increases ........ +62 +19,101,000 1/ Amounts included.for Medical facilities construction activity are budget authority. 106 Base Change from Base Pos. Amount Pos. Amount Decreases: A. Built-in: 1- Two less days of pav ...................... --- --- --- -$74,000 2. Decrease resulting from employment cut-back during 1972 ....................... --- --- -204,000 3. Non-recurring equipment and change of station costs.... --- --- -24,000 B. Program: 1. Regional medical programs: io .... 139,300,000 --- 2. Medical facilities construc- tion : a. Construction grants ...... --- 197,200,000 -112,200,000 b. D.C. medical facilities construction ............ --- 42,127,000 -42,127,000 c. Hospital experimentation project ................ --- 15,000,000 -15,000,000 d. Interest subsidies of guaranteed loans........ --- 20,300,000 -17,800,000 Total, decreases ......... --- -201,629,000 Total, net change ..................... +62 -182,528,000 Explanation of Changes Increases: A. Built-in: An increase of $3,742,000 is for mandatory items. Of this $330,000 is for full-year costs of positions new in 1972, $325,000 is for net additional costs of within grade and longevity increases, $168,000 is for DHEW Working Capital Fund, HSMHA Service and Supply Fund, and FTS charges, ani,$2,900,000 is for an incro!ase in continuation costs for area"wide planning gratLts. B. Program: Grants and contracts--The increase of $1,900,000 will support an expanded R&D effort in the development of a cooperative Federal-State-local health services data system. This system is the tool by which the Federal Govern- ment can measure progress in reaching its health goals. Direct operations--An increase of 12 positions and $251,000 is requested in 1973, The increased program effort in the development of health services data systems requires personnel with capability to develop health status sur- veys, monitor data systems for ambulatory care, and to collect and analyze the national data resulting from this program. Explanation of Chinges--continued Formula grants to States for comprehensive health planning--The increase of $2,325,000 would allow State agencies to increase professional staffs by Z5% and in addition provide for an increase in special studies and consulta- tion to support effective planning at the areawide level; a crucial under- taking in FY 1973 due to the substantial increase in the number of new area- wide agencies. Project grants for areawide comprehensive health planning--The increase of $9,000,000 includes $5,100,000 to establish approximately 100 new area- wide agencies and 20 new State assisted local councils and $3,900,000 to increase the average Federal share to avoid financial dependence upon organizations whose activities must be reviewed and commented upon by 314(b) agencies. Project grants for training, studies and demonstrations--An increase of $575,000 is requested for 1973. This amount would enable the graduate pro- grams to increase the level of technical assistance to be provided to the operating Agencies and would be directed in part to further emphasis on the development of Planning for innovative systems for the delivery of health care. Direct operations--An increase of 25 positions and $890,000 is requested for 1973. Twenty (20) of the additional positions and equivalent funds will be placed in the Regional Offices to enable the staff to be more responsive to both the State and Areawide agencies in providing technical assistance and consultation. Emergency medical services--25 positions and $350,000 are included for the new Emergency Medical Ser@ices Program. These resources will be used to provide planning and evaluation, professional and technical assistance, standard setting, project review, project grants and contracts management and data system development. Program direction and management services--Includes $68,000 to support the Upward Mobility Program. Decreases: A. Built-in: The decrease of $74,000 represents non-recurring salary costs resulting from a reduction of two days of pay in 1973. The decrease of $204,000 results from position reductions in line with the Administration's economic policy. The decrease of $24,000 is due to non-recurring equipment items and change-of-station costs associated with positions new in 1972. B. Program: $14 - Regional medical grogramIrants and contract"rthe decrease of ,200,uvu in iy/j reLiecus aajustment@o@two non-recurring items in 1972 of $21,000,000 and an increase of $7,000,000 for a new program of grants and contracts for emergency medical services. These funds will be used to support 5 projects in addition to the 5 funded in 1972. 108 Explanation of Changes--continued Medical facilities construction: Construction grants--A decrease of $112,200,000 in construction and modernization of hospitals and long-term care facilities is a result of the continued redirection of Hill-Burton activities from a grant program to a program of loan guarantees with interest subsidies for inpatient health facilities. Ambulatory care facilities do not have the same revenue pro- ducing potential as do general and long-term hospital beds and therefore the capital costs of construction for these facilities will continue to be supported through Federal grants. District of Columbia medical facilities--A decrease of $42,127,000 occurs in the construction or modernization of medical facilities in the District of Columbia because the full amount authorized by the Statute has been appropriated. The statute expires on June 30, 1972. Hospital experimentation projects--A decrease of $15,000,000 occurs in the construction of hospital experimentation projects because appropriated funds are sufficient for currently authorized projects. Interest subsidies--A decrease of $17,800,000 is due to the avail- ability of $20,300,000 brought forward from prior appropriations. log Significant Items in House and Senate Appropriations Committee Reports Item Action taken or to be taken 1972 House Report Research and demonstration grants Committee directed that the Eight Pediatric Pulmonary proj- Pediatric Pulmonary Program be con- ects were funded at a 1,000,000 tinued in 1972 at not less than the level in 1971. It is anticipated 1971 level. (page 16 of the report). that the 1972 and 1973 levels will be approximately the same. 1972 Senate Report Research and demonstration grants 1. Committee expressed keen 1. Recent studies have begun to interest in a long-range plan to develop long-range plans for combat- develop interrelated kidney pro- ing end-stage kidney disease. There grams aimed at providing therapy will be much greater emphasis on for the 8,000 to 10,000 Americans placing each project in the context who fell victim to kidney disease of both regional and national needs. annually. (page 25 of the report). In keeping with expanded plans, . funds invested in these activities will increase from $4,800,000 in 1971 to an estimated $8,500,000 in 1972. 2. Committee directed that a 2. Up to $16,200,000 will be used portion of RMP increases be used to to fund the planning and development prove out HMO programs. (page 25 of HMO's in 1972. of the report). 3. Committee concurred with the 3. All projects ongoing in 1971 House and further directed that all which have been included in their pediatric pulmonary projects ongoing applications by the RMP's affected in 1971 were to be funded in 1972. have been approved for 1972. At the (page 26 of the report). same time, final funding decisions have been left to the 'individual regions within their own systems of priorities. Significant Items in House and Senate Appropriations Committee Reports - (Conttd) Item Action taken or to be taken 1972 Senate Report (Cont'd) 4. Committee directed HSMHA and 4. Over the past year specific cri- the National Advisory Council to teria and policy have been developed c-idress themselves to questions and issued to the RMP'S. There has arrounding the flexibility and been a marked increase in efforts of individuality allowed RMP's which staff to meet with Regional Advisory could impair their effectiveness. Groups. In January, 1972, a National (page 25 of the report). Coordinators Conference was held. It brought together all coordinators, RAG members from every region and Council members to discuss with staff issues, policy, etc. 5. Committee directed that 5. A new survey of cardiovascular increased funds be targeted to a surgery facilities in the District review of the availability of and of Columbia is currently in progress access to special surgical teams in iinder the auspices of the Metropoli- open-heart and coronary artery tan Washington RMP. A report will surgery, especially in the District be available before 6/30/72. In of Columbia. (page 25 of the report). addition, Regional Medical Programs Service, in order to carry out Sec. 907 of the Public Health Service Act, contracted with the Joint Commission on Accreditation of Hospitals to develop the Secretary's Lists. One of the criteria which will be used in identifying eligible institutions for those lists will be their par-. ticipation in a regional plan for the optimal development and utiliza- tion of specialized facilities and services. 1972 Conference Report Research and demonstration grants Committee agreed that no exist- All RMP's will, where consis- ing regional medical program is to tent with National Advisory Council receive a lesser amount in FY 1972 approved funding levels, be funded than it received in 1971. (page 6 at or above the FY lq7l level. of the report). Authorizing Legislation 1973 Appropriation Legislation Authorization requested Public Health Service Act Section 301 Indefinite $22,726,000 Section 304 $94,000,000 41,617,000 Public Health Service Act Research, Research Training, and Fellowships Section 301 of the Act provides legislative authority for the award of grants for research, research training, and fellowships. Research and Demonstrations Relating to Health Facilities and Services Section 304. (a) (1) The Secretary is authorized-- (A) to make grants to States, political subdivisions, universities, hospitals, and other public or nonprofit private agencies, institutions, or organizations for projects for the conduct of research, experiments, or demonstrations (and related training), and (B) to make contracts with public or private agencies, institutions, or organizations for the conduct of research, experiments, or demonstrations (and related training), relating to the development, utilization, quality, organization, and financing o services, facilities and resources of hospitals, facilities for long-term care, or other medical facilities (including, for purposes of this section, facilities for the mentally retarded, as defined in the Mental Retardation Facilities and Commu- nity Mental Health Centers Construction Act of 1963), agencies, institutions, or organizations or to development of new methods or improvement of existing methods of organization, delivery, or financing of health services, including among others -- (iv) projects for research, experiments, and demonstrations dealing with the effective combination or coordination of public, private, or combined public- private methods or systems for the delivery of health services at regional, State, or local levels. "(c) (1) There are authorized to be appropriated for payment of grants or under contracts under subsection (a), and for purposes of carrying out the provi- sions of subsection (b), $71,000,000 for the fiscal year ending June 30, 1971 (of which not less than $2,000,000 shall be available only for purposes of carrying out the provisions of subsection (b)), $82,000,000 for the fiscal year ending June 30, 1972, and $94,000,000 for the fiscal year ending June 30, 1973. "(2) In addition to the funds authorized to be appropriated under para- graph (1) to carry out the provisions of subsection (b) there are hereby authorized to be appropriated to carry out such provisions for each fiscal year such sums as may be necessary." 112 Authorizing Legislation 1973 Appropriation Legislation Authorized requested Public Health Service Act Section 314(a)--Grants to States for Comprehensive State Health Planning ..... i................ $20,000,000 $10,000,000 Section 314(b)--Project Grants for Areawide Health Planning ............... 40,000,000 25,100,000 Section 314(c)--Project Grants for Training, Studies, and Demonstrations ............................. 12,000,000 4,700,000 PUBLIC HEALTH SERVICE Title III--General Powers and Duties of Public Health Service Part B - Federal-State Cooperation "GrAnts to States for Comprehensive State Health Planning "Sec. 314. (a) (1) AUTHORIZATION.--In order to assist the States in comprehen- sive and continuing planning for their current and future health needs, the Secretary is authorized during the period beginning July 1, 1966, and ending June 30, 1973, to make grants to States which have submitted, and had approved by the Secretary, State plans for comprehensive State health planning. For the purposes of carrying out this subsection, there are hereby authorized to be appro- priated $2,500,000 for the fiscal year ending June 30, 1967, 7,000,000 for the fiscal year ending June 30, 1968, $10,000,000 for the fiscal year ending June 30, 1969, $15,000,000 for the fiscal year ending June 30, 1970, $15,000,000 for the fiscal year ending June 30, 1971, $17,000,000 for the fiscal year ending June 30, 1972, and $20,000,000 for the fiscal year ending June 30, 1-973. "Project Grants for Areawide Health Planning "(b) (1) (A) The Secretary is authorized, during the period beginning July 1, 1966, and ending June 30, 1973, to make, with the approval of the State agency administering or supervising the administration of the State plan approved under subsection (a), project grants to any other public or nonprofit private agency or organization (but with appropriate representation of the interests of local Govern- ment where the recipient of the grant is not a local Government or combination thereof or an agency of such Government or combination) to cover not to exceed 75 per centum of the costs of projects for developing (and from time to time revising) comprehensive regional, metropolitan area, or other local area plans for coordina- tion of existing and planned health services, including the facilities and persons required for provision of such services and including the provision of such services through home health care; except that in the case of project grants made in any State prior to July 1, 1968, approval of such State agency shall be required only if such State has such a State plan in effect at the time of such grants. For the purposes of carrying out this subsection, there are hereby authorized to be appropriated $5,000,000 for the fiscal year ending June 30, 1967, $7,500,000 for the fiscal year ending June 30, 1968, $10,000,000 for the fiscal year ending June 30, 1969, $15,000,000 for the fiscal year ending June 30, 1970, $20,000,000 for the fiscal year ending June 30, 1971, $30,000,000 for the fiscal year ending June 30, 1972, and $40,000,000 for the fiscal year ending June 30, 1973. 1.13 "Project Grants for Training, Studies, and Demonstrations "(c) The Secretary is also authorized, during the period beginning July 1, 1966, and ending June 30, 1973, to make grants to any public or nonprofit private agency, institution, or other organization to cover all or any part of the cost of projects for training, studies, or demonstrations looking toward the development of improved or more effective comprehensive health planning throughout the Nation. For the purposes of carrying out this subsection, there are hereby authorized to be appropriated $1,500,000 for the fiscal year ending June 30, 1967, $2,500,000 for the fiscal year ending June 30, 1968, $5,000,000 for the fiscal year ending June 30, 1969, $7,500,000 for the fiscal year ending June 30, 1970, $8,000,000 for the fiscal year ending June 30, 1971, $10,000,000 for the fiscal year ending June 30, 1972, and $12,000,000 for the fiscal year ending June 30, 1973." 11.4 Authorizing Legislation 1973 Appropriation Legislation Authorized requested Public Health Service Act: Section 601 -- Construction grants ........ $417,500,000 $85,000,000 Section 626(a)(1) Interest subsidies ...... Indefinite 2,500,000 PUBLIC HEALTH SERVICE ACT Title VI--Assistance for Construction and Modernization of Hospitals and Other Medical Facilities Part A--Grants for Construction and Modernization of Hospitals and Other Medical Facilities Appropriation "Sec. 601, In order to assist the States in carrying out the purpose of section 600, there are authorized to be appropriated-- "(a) for the fiscal year ending June 30, 1965, and each of the next eight fiscal years-- "(I) $85,000,000 for grants for the construction of public or other nonprofit facilities for long-term care; "(2) $70,000,000 for grants for the construction of public or other nonprofit diagnostic or treatment centers; '1(3) $15,000,COO for grants for the construction of public or other nonprofit rehabilitation facilities (b) for grants for the construction of public or other nonprofit hospitals and public health centers and for grants for modernization of such facilities and the facilities referred to in paragraph a , $150,000,000 for the fiscal year ending June 30, 1965, $160,000,000 for the fiscal year ending June 30, 1966, $170,000,000 for the fiscal year ending June 30, 1967, $180,000,000 each for the next two fiscal years, $195,000,000 for the fiscal year ending June 30, 1970, $147,500,000 for the fiscal year ending June 30, 1971, $152,500,000 for the fiscal year ending June 30, 1972, and $157,500,000 for the fiscal year ending June 30, 1973. 11(c) for grants for modernization of the facilities referred to in paragraphs (a) and (b), $65,000,000 for the fiscal year ending June 30, 1971, $80,000,000 for the fiscal year ending June 30, 1972, and $90,000,000 for the fiscal year ending June 30, 1973. Title VI--Assistance for Construction and Modernization of Hospitals and Other Health Facilitips Part B--Loan Guarantees and Loans for Modernization and Construction of Hospitals and Other Medical Facilities Appropriation "Sec. 626. (a)(1) There is hereby established in the Treasury a loan guarantee and loan fund (Hereinafter in this section referred to as the 'fund') which shall be available to the Secretary without fiscal year limitation, in such amounts as may be specified from time to time in appropriations Acts, (i) to enable him to discharge his responsibilities under guarantees issued by him under this part, (ii) for payment of interest on the loans to nonprofit agencies which are guaranteed, (iii) for direct loans to public agencies which are sold and guaranteed, (iv) for payment of interest with.respect to such loans, and (v) for repurchase by him of direct loans to public agencies which have been sold and guaranteed. There are authorized to be appropriated to the fund from time to time such amounts as may be necessary to provide capital required for the fund. To the extent authorized from time to time in appropriations Acts, there shall be deposited in the fund amounts received by the Secretary as interest payments or repaymentsce prinicpal on loans and any other moneys, property, or assets derived by him from his operations under this part, including any moneys derived from the sale of assets. i I 116 Authorizing Legislation 1973 Appropriation lation Authorized requested Public Health Service Act Title IX -- Education, Research, Training, and Demonstrations in the Fields of Heart Disease, Cancer, Stroke, Kidney Disease, and other Related Diseases ..... $250,000,000 $120,800,000 PUBLIC HEALTH SERVICE ACT The Public Health Service Act, Title IX, Education, Research, Training and Demonstrations in the Fields of Heart Disease, Cancer, Stroke, Kidney Disease, and other Related Diseases. "Sec. 900. The purposes of this title are-- 11(a) through grants and contracts, to encourage and assist in the establish- ment of regional cooperative arrangements among medical schools, research insti- tutions, and hospitals for research and training (including continuing education), for medical data exchange, and for demonstrations of patient care in the fields of heart disease, dancer, stroke, and kidney disease, and other relate iseases; "(b) to afford to the medical profession and the medical institutions of the Nation through such cooperative arrangements, the opportunity of making available to their patients the latest advances in the prevention, diagnosis, and treatment and rehabilitation of persons suffering from these diseases; "(c) to promote and foster regional linkages among health care institutions and providers so as to strengthen and improve primary care and the relationship between specialized and primary care; and "(d) by these means, to improve generally the quality and enhance the capacity of the health manpower and facilities available to the Nation and to improve health services for persons residing in areas with limited health services, and to accomplish these ends without interfering with the patterns, or the methods of financing, of patient care or professional practice, or with the administration of hospitals, and in cooperation with practicing physicians, medical center officials, hospital administrators, and representatives from appropriate voluntary health agencies." Sec. 901(a) There are authorized to be appropriated $50,000,000 for the fiscal year ending June 30, 1966, $90,000,000 for the fiscal year ending June 30, 1967, $200,000,000 for the fiscal year ending June 30, 1968, $65,000,000 for the fiscal year ending June 30, 1969, $120,000,000 for the next fiscal year, $125,000,000 for the fiscal year ending June 30, 19710 $150,000,000 for the fiscal year ending June 30, 1972, and $250,000,000 for the fiscal year ending June 30, 1973, for grants to assist public or nonprofit private universities, medical schools, research institutions, and other public-or nonprofit private institutions and agencies in planning, in conducting feasibility studies, and in operating pilot projects for the establishment of regional medical programs of 11.7 research, training and demonstration activities for carrying out the purposes of this title and for contracts to carry out the purposes of this title. Of the sums appropriated under this section for the fiscal year ending June 30, 1971, not more than $15,000,000 shall be available for activities in the field of kidney disease. Of the sums appropriated under this section for any fiscal year ending after June 30, 1970, not more than $5,000,000 may be made available in any such fiscal year for grants for new construction. For any fiscal year ending after June 30, 1969, such portions of the appropriations pursuant to this section as the Secretary may determine, but not exceeding 1 per centum thereof, shall be available to the Secretary for evaluation (directly or by grants or contracts) of the program authorized by this title." "MULTIPROGRAM SERVICES "Sec. 910. (a)To facilitate interregional cooperation, and develop improved national capability for delivery of health services, the Secretary is authorized to utilize funds appropriated under this title to make grants to public or non- profit private agencies or institutions or combinations thereof and to contract for-- "(1) programs, services, and activities of substantial use to two or more regional medical programs; "(2) development, trial, or demonstration of methods for control of heart disease, cancer, stroke, kidney disease, or other related diseases; "(3) the collection and study of epidemiologic data related to any of the diseases referred to in paragraph (2); "(4) development of training specifically related to the prevention, diagnosis, or treatment of any of the diseases referred to in paragraph (2), or to the rehabilitation of persons suffering from any of such diseases; and for continuing programs of such training where shortage of trained personnel would otherwise limit application of knowledge and skills important to the control of any of such diseases; and "(5) the conduct of cooperative clinical field trials. 11(b) The Secretary is authorized to assist in meeting the costs of special projects for improving or developing new means for the delivery of health services concerned with the diseases with which this title is concerned. (c) The Secretary is authorized to support research, studies, investigat ons, training, and demonstrations designed to maximize the utilization of manpower in the delivery of health services." Explanation of Transfers 1972 Estimate Purpose Real transfers to: Operating expenses Public Building Service, GSA ....... -$3,000 Transfer to GSA for rental of space. Medical facilities guar- To establish the "Medical antee and loan fund ......... -30,000,000 facilities guarantee and loan fund" to provide funds for direct loans to public agencies for the construction of health care facilities. Real transfer from: Nursing home improvement ..... 1,000,000 Transfer to the research and development elements of the nursing home improvement program (National Center for Health Services Research and Development). Funds for a Department-wide r-ursing home initiative were appropriated in the Supplemental Approprid- tions Act, 1972. Subse- quently, the entire appropria- tion was transferred to the appropriate agencies for implementation. Comparative transfers to: Departmental Management ..... -27,000 Transfer to support the departmental public affairs activities. Preventive health services.. -2,189,000 Transfer of National Clearing house for Smoking and Health. office of the Administrator. -55,000 Transfer of 3 positions to the Office of Financial Management to establish a Comparative transfers from: loan accounting section. Health Services Delivery .... 25,935,000 Transfer of planning grants and related direct operations due to reorgani- zation of HSMRA. Office of the Administrator. 27,000 Transfer of Deputy and staff due to reorganization of HSMRA. 119 Health Services Planning and Development Budget Estimate House Senate Year to Congress Allowance Allowance Appropriation 1963 $176,220,000 $188,672,000 $226,220,000 $226,220,000 1964 184,589,000 182,981,000 233,281,000 231,287,000 1965 247,057,000 44,407,000 267,057,000 266,907,000 1966 328,304,000 259,089,000 I/ 328,304,000 328,304,000 1967 358,568,000 358,529,000 358,529,000 358,529,000 1968 372,671,000 347,671,000 357,671,000 342,171,000 1969 327,290,000 273,368,000 1/ 388,489,000 335,275,000 1970 319,548,000 327,748,000 351,748,000 351,748,000 1971 266,029,000 358,229,000 400,430,000 393,717,000 1972 249,653,000 437,480,000 542,480,000 498,980,000 1973 329,596,000 1/ The Regional Medical Programs activity was not considered bv the House. 120 Justification Health Services Planning and Development Increase or 1972 estimate 1973 estimate Decrease Pos. Amount Pos. Amount Pos. Amount Personnel compensa- tion and benefits. 695 $11,840,000 757 $12,924,000 +62 +$1,084,000 Other expenses ...... --- 500,284,000 --- 316,672,000 --- -183,612,000 Total ........... 695 512,124,000 757 329,596,000 +62 -182,582,000 General Statement This budget proposes a consolidated appropriation, Health Services Planning and Development, for HSMHA's health services planning and develop- ment programs which were supported previously by four separate appropriations: Health services research and development, Comprehensive health planning and services, Regional medical programs, and Medical facilities construction. The proposed appropriation is consistent with the recent internal reorganization of the Health Services and Mental Health Administration. It@ reflects a functional grouping of the health services planning and develop- ment programs and as such provides for improved coordination and administra- tion of these activities. Research and Development The National Center for Health Services Research and Development will continue major studies designed to improve the way in which health care is delivered in this country. Special emphasis will be placed on cost, dis- tribution and quality of health care. The budget includes $64,343,000, an increase of $2,327,000 over 1972. The increase will support the continued development of a cooperative Federal-State-local health sta- tistics system. This project is designed to produce the most compre- hensive data base yet developed for assessing the Nation's health. Comprehensive Health Planning For Comprehensive health planning, $41,633,000 is requested. The in- crease of $15,698,000 over the 1972 appropriation would permit the funding of 100 new areawide health planning agencies and 20 new State assisted councils in rural areas for a total of 272 and 28 respectively. This in- crease is a further significant step towards the development of a compre- hensive, Nationwide health planning system. Regional Medical Programs The 1973 estimate for the Regional medical programs includes $130,191,000 a not decrease of $13,751,000 below the 1972 obligations (but an increase of $30'681,000 in actual appropriations), consisting of increases of $7,449,000 offset by decreases totalling $21,200,000 for non-recurring construction and 1.21 transfer of planning projects for the health maintenance organization effort to that activity. The additional funds, together with the substantial increase in 1972, will provide for a special initiative in emergency medical services and will strengthen the 56 RMP's and will permit new and increased efforts associated with (1) manpower development and utilization programs, such as Area Health Education Centers, (2) emergency medical service and rural health care systems aimed at improving the accessibility, efficiency, and quality of health care for all Americans, (3) a systematic approach to the treatment of end-stage kidney disease patients through the sharing of facilities, manpower and other resources, (4) the development, demonstration and application of the latest advances in biomedical and management tech- nology as they relate to the delivery of health care. Medical Facilities Construction The 1973 estimate for Medical facilities construction reflects a balanced program of loans, guaranteed loans and grants. Over $600,000,000 in loans will be made or guaranteed in 1973, adding over 12,000 new or mo- dernized hospital beds to the health care system. In addition to the loan program, $85,000,000 in grants is included for construction of outpatient and rehabilitation facilities, $2,500,000 for interest subsidies and $486,000 for direct operations. Health Services Research and Development 22 Increase or 1972 1973 Decrease Pos. Amount Pos. Amount Pos. -Amount Personnel compensation and benefits ........... 218 $3,675,000 230 $3,968,000 +12 +$293,000 Other expenses ........... -- 58,341,000 -- 60,375,000 -- +2,034,000 Total .............. 218 62,016,000 230 64,343,000 +12 +29327,000 Introduction The primary national health goal is the provision of the highest level of health attainable for the entire population of this country. In keeping with this goal, special attention must be directed to the persisting inability of the health care system to meet the demand for high quality health services, the continuing disproportionate rise in medical care costs and the unequal distribution and uti- lization of health services. As the health services delivery arm of HEW, the Health Service and Mental Health Administration has concentrated most of its R&D effort in the National Center for Health Services Research and Development. The National Center stimulates, supports and manages research, research and develop- IB ment, demonstration, and related training activities which will lead to increased efficiency and effectiveness in the organization, delivery and financing of health services in the United States. B The National Center's role, working with both the public and private health sectors, is to develop And test innovations to determine their effectiveness, acceptability, and applicability on a large scale. The collective impact of the R&D program should be increased efficiency in the public and private delivery of health services and increased effectiveness of publicly funded service programs in meeting national health goals and in responding to the public's needs. Priority has been given to innovations which appear to offer the greatest potential for improving access, moderating cost increases and assuring quality. These include: 1. new types of health manpower, especially development and evaluation of physician-extenders like physicians' assistants, including MEDEX and their civilian counterparts, pediatric and family nurse practitioners, and mid-level dental workers; 2. evaluating the effectiveness of various HMO models and monitoring their fiscal impact; 3. cost containment in health care institutions through all-inclusive rate reimbursement and common claims forms, mergers and shared services; 4. methods for objectively assessing health care needs and adequacy of manpower, facilities and services for communities and states; 5. experimental medical care review organizations to provide operating B prototypes for Professional Standards Review Organizations; 6. cost-effective health care technology; 7. Experimental Health Services Delivery Systems to optimize the use of Federal, State and private dollars in bringing comprehensive health care for the total population of communities or entire states. 123 Health Services Research and Development Increase or (a) Grants and Contracts 1972 Estimate 1973 Estimate Decrease Pos. Amount Pos. Amount, Pos. Amount Other expenses ............ $56,118,000 $58,018,000 +$I,900,000 Subactivities: Research and develop- ment grants and contracts ............. 51,118,000 53,018,000 +1,900,000 Research and develop- ment training ......... 5,000,000 5,000,000 Total .............. 56,118,000 58,018,000 +1,900,000 (1) Research and Development Grants and Contracts: 1972 1973 Increase or Estimate Estimate Decrease No. Amount No. Amount No. Amount Research, Development and Demonstration Grants: Non-competing continuations. 90 $18,559,000 103 $22,045,000 +13 +$3,486,000 New and renewal grants ...... 40 9,291,000 33 7,705,000 -7 -1,586,000 Supplementals ............... (15) 2OOiOOO (15) 200,000 -- --- Subtotal ............... 130 28,050,000 136 29,950,000 +6 +1,900,000 Contracts: Continuations ............... 61 16,150,000 61 16,150,000 -- Yew contracts ............... -38 6,918,000 38 6,918,000 Subtotal ............... -99 23,068,000 99 23,068,000 Total ....................... 229 51,118,000 235 53,018,000 +6 +1,900,000 Distribution by Program Increase or 1972 Estimate 1973 Estimate Decrease Research and Development: Health services manpower ............. $5,000,000 $5,000,000 --- Health maintenance organizations - evaluation ......... 2,000,000 2,000,000 --- Health care institutions, costs, and financing ...................... 9,518,000 9,518,000 --- Federal-State-local health services data system ............... 1,600,000 3,500,000 +$1,900,000 Performance accounting ............... 11,000,000 11,000,000 --- Health care technology ............... 7,000,000 7,000,000 --- Health care systems .................. 15,000,000 15,000,000 --- Total ........................... 51,118,000 53,018,000 +1,900,000 124 Building on previous health services research, the National Center has estab- lished a research and development program directed to creating, introducing, testing and evaluating the essential components of comprehensive community health care delivery systems that will increase the supply, improve the distribution, and moderate the cost of health services. The problems and approaches of the R&D program are developed through consul- tation with private and public health care providers, both institutional and indi- vidual, third-party payers, consumers, and university-based specialists and re- searchers in health care organization, delivery or financing. The Center also maintains working liaison with other programs of HSMRA, DHEW, and other federal agencies concerned with health services. By these means, program areas, major projects, and other principal aspects of the program are defined, focused, and kept under continuous critical review and appraisal. The National Center's strategy for carrying out its R&D program consists of the development of prototype community health services systems. The systems approach calls for identification and examination of the inter-related components which constitute community health care and modification of these components in order to maximize their individual and joint contributions. The major components which have been identified for special attention are new types of health manpower; evaluation of health care financing mechanisms; cost containment through innova- tive institutional arrangements and insuring quality of care; the development of a cooperative Federal-State-local health statistics system; cost effective tech- nology; and community health services R&D. In addition, in 1973 the Center will begin to develop its second generation R&D programs. Building upon its current R&D program and the commitment of HSMHA to integrate its service and development programs, this will lead to the HSMRA R&D strategy for systematically introducing at State and regional levels the tested organizational, manpower and technological innovations that predictably will bring about constructive reform in health services delivery. This national implemen- tation strategy will provide the mechanisms needed to assure the attainment of the intended purposes of financial entitlement legislation. lk Data from the various studies will be combined in designs for R&D projects, which will put into effect and test the new planning and development methods. It is expected that several alternative patterns of planning and development will be offered for evaluation to States, regions, and localities. Both the planning studies and the implementation studi@es will emphasize the development of cost/ effective preventive health services through the creation of Mlos and similar health services organizations. Planning and implementation studies will be carried out with involvement of CHP and RMP agencies and personnel, and the Regional offices. The National Center will design.and guide studies and provide technical assistance and financial support for key R&D projects. To support the R&D effort, the National Center is requesting a budget of $53,018,000 for grants and contracts in 1973, An increase of $1,900,000 over the 1972 level. The increase will support the continued development of the coopera- tive Federal-state-local health Statistics system. Specifically, the following high priority R&D programs will be supported in 1973. 1. Health Services Manpower It is estimated that some 200 physician's assistant programs of the widest possible range of types may now be in existence or in some stage of development. The proliferation of many different and uncoordinated programs may cause great confusion and be disruptive to the attempts to use these new types of health manpower effectively. Moreover, few of the current physician's assistant programs address themselves to anything but the numerical shortage f physicians. It is not clear that physician's assistants, who must functi*n under the supervision of licensed practitioners, will be able to relieve the shortage. This cannot occur if requirements for supervision cause them to distribute themselves in accordance with the existing pattern of physician distribution, which re- flects over-concentration in certain medical specialties and in affluent population centers. In addition, the kind of training now being given to physician's assis- tants tends to assume that established patterns of medical practice and organization will remain unchanged. Little attention is given to coming technological developments and new forms of health care organization, which will undoubtedly have a pronounced influence on the duties to be performed and the skills required by the physician's assistant. A climate of accept- ance of the physician's assistant unquestionably now exists. But answers to these basic questions must be found before we can move effectively to develop the potential which the physician's assistant appears to offer. Several projects currently supported by the National Center are devel- oping and evaluating physician-extender manpower which can be used in normal practice settings, group practice clinics or remote health care centers linked to medical supervision by radio, television, or special telephonic connections. These demonstrations are being evaluated by use of procedure which will permit direct comparisons of results. The Uniform National Evaluation Protocol includes the effects of introducing physician's assis- tants in various sized medical practices on the costs and quality of care, patient and physician satisfaction, delegation of tasks, and relationships with other health professionals. Recruitment, selection and curriculum are also being studied. This evaluation is now under way with six MEDEX projects as well as with the Center-sponsored demonstrations of the family nurse practitioner, schoo nurse practitioner, the pediatric nurse practitioner, the nurse midwife, and the dental auxiliary. Data is being gathered in 25 states from 200 coop- erating medical practices which range in size from solo-general practices to large-scale urban group clinics. Ways in which physicians productivity is being increased is being documented: Preliminary findings, based on a random sample of 3,000 cases from 20 solo family practices show a potential savings of approximately 20% of physician time through assignment of patients in certain diagnostic categories to primary contact with only the nurse. In 1973, demonstrations and uniform evaluation of mid-level medical workers will be extended to a total of 35 states. Comparable data will be available in sufficient quantity to permit assessment of the cost effec- tiveness of mid-level workers. By the end of 1973, the licensure and cre- dentialing issues will be sufficiently analyzed to suggest guidelines for national policy, which will supplement and expand those transmitted to the Congress by the Secretary in June 1971. (Report on Licensure and Related Health Personnel Credentia@n In 1973, R&D emphasis will shift to problems of multiple alternative staffing patterns in regionalized delivery programs and in group practices, including HMOs. An estimated $5,000,000 will be used to support manpower studies in 1973. 1.26 II. Health Maintenance Organizations - Evaluation The National Center is supporting a variety of projects related to research, development and evaluation of Health Maintenance Organizations (HMOs). M40s will be studied with respect to such factors as enrolled pop- ulation, benefit structures, utilization patterns, monitoring of services, costs and quality of care and financing mechanisms. A provisional HMO data monitoring plan is being developed in 1972 and will be ready for installation and evaluation in 1973. The uniform national evaluation protocol under development can be used by Federal and private agencies to evaluate the benefits of the HMO form of health services delivery. The protocol will bring together in one techn que the several different types of measurements needed to assess the net effects of HMOs, such as the breadth and continuity of services delivered to people, the quality of the services, the resources required by the HMO, and the costs to individuals and families and to supporting public and private programs. This will make possible a comparison of HMO costs and efficiency wit ot er forms of medical practice organization. In 1973 an estimated $2,000,000 will be used to support the evaluation of Health Maintenance Organizations. III. Health Care Institutions, Costs and Financing A. Costs and Financing The cost of medical care continues to increase at a fast pace; by the end of fiscal 1971 the bill for the Nation's health care had risen to 75.0 billion, 7.4 percent of the Gross National Product. On the average, each man, woman and child in the United States was paying $358.00 annually for medical care, an increase of $31.00 per person over the previous year alone. As a result, consumers have difficulty purchasing comprehensive health care coverage, or even worse, they are completely denied medical care because of its costs. It is obvious that costs must be effectively controlled if significant progress is to be made in the improvement of the delivery of health services to the population. An ongoing study of Title XIX in the State of California is comparing the quality, use and costs of care among six different forms of physician organization. The use and costs patterns differ depending upon the degree of physician responsibility actually exerted in maintaining surveillance over the appropriateness and quality of care. The provision and utilization of medical services often requires sub- stantial costs to patients which are not reflected in dollar expenditures, e.g. waiting times, travel times and costs, and time and effort involved in patient participation. These costs are likely to increase in the event of a substantial increase in insurance coverage, resulting in little net change in access to many population groups. Research and development is being under- taken in these non-monetary costs including the magnitude of such costs, their effect on patient behavior, and possibilities for reducing the level of these costs. The National Center is supporting a major study of the efficiency of alternative organizational forms for the delivery of ambulatory care, in- cluding prepayment plans, fee-for-service group practices, and traditional solo practice. The study focuses on economic aspects and implications of medical organizations, use of non-physician personnel in new ambulatory care systems, and problems in the definition of price and productivity indices for such systems. It is expected that preliminary data will be available in the summer of 1972. These analyses will serve as a basis for fundamental deci- sions affecting government support of various modes of practice, including the 1. @@ 7 development and implementation of HMOs. B. Institutions The costs of hospital care continue to rise more rapidly than the costs of any other component of the health care industry and twice as fast as the overall cost of living. The National Center is deeply involved in research and development directed to cost containment projects which are intended to produce nationally applicable results. It is the nationwide installation of the new procedures that will moderate cost increases, improve interinstitu- tional relationships and reduce unnecessary hospitalization. The R&D pro- jects encompass hospitals and other care institutions. Simplifying administrative procedures in hospitals has great potential for reducing costs of health care. Two approaches to simplification, each of which is being evaluated on a national basis, are: I 1. Implementation of an all-inclusive rate charging and reimbursement procedure in hospitals. Instead of charging for each specific item, hospitals will establish average costs in typical patient categories and then bill each carrier or agency or patient the appropriate standard daily rate. 2. Establishment of a nationally accepted uniform hospital discharge abstract and common insurance claim data. This project, currently being tested in five communities, will facilitate analysis of hospital costs in relation to the number and types of patients served and to the size and type of hospital. This will for the first time permit nation- wide comparisons of hospitalization experience by length of stay, diagnosis, medical procedures, age, sey,, size of hospital, and other variables. In time, it will provide useful data for determining community needs for additional hospital beds and for other types of services, such as nursing home beds and outpatient facilities. Previous studies of both approaches to cost moderation, indicated potential savings of hundreds of millions of dollars annually if the pro- cedures were adopted by all hospitals and accepted by third-party payers. Savings can also be realized by reducing management overhead, better utilization of skilled manpower in short supply, avoiding the duplication of facilities, equipment, or services through shared services among similar or diverse types of facilities; mergers of facilities into one common corporate identity; agreements among different types of facilities to insure appro- priate placement of patients relative to their needs; and formal relation- ships between ambulatory care facilities and hospitals. 1. A major national study of hospital mergers and shared services is being made by the Health Services Research Center jointly sponsored by the American Hospital Association and Northwestern University. The Center is supporting an evaluation of the integrated health care facil- ities established by the Samaritan Health Service, Phoenix, Arizona. Special attention is given to the efficiencies resulting from common management of groups of hospitals and sharing of medical services such as obstetrics, pediatrics, radiation therapy and the like. Economies resulting from centralized purchasing, laundry, food services, computer services, billing, laboratory testing and maintenance are being demon- strated. The potential impact on quality of care resulting from sharing of clinical services will also be evaluated. In addition, insights gained in the Samaritan study have been incorporated in two publications dealing with hospital mergers and shared services which have been made available to the hospital community on a national basis. i 'LI 8 Although studies of the different forms of arrangements have been com- pleted or are in progress, available reports do not permit a precise estimate on a national scale of the magnitude of potential cost reduction. The evi- dence is clear, however, that cost savings will be achieved. The results of these analyses will be published in the form of R&D guide- lines for communities, systems or institutions who wish to test these methods of implementing interinstitutional arrangements. In 1973, an estimated $9,518,000 will be used to support studies in the area of health care institutions, costs and financing. IV. Federal-State-Local Health Statistics System Rational decision making for any substantial investment requires reliable baseline and trend data. This is particularly true of the health care system, which has been undergoing tremendous expansion in recent years without atten- dant refinement of its data-gathering and handling mechanisms. In an era when the health care system has investments from all sectors, and, particu- larly, when there appears to be great merit and emphasis upon decentralization of as much decision making as possible, a cooperative Federal-State-local health data system is imperative. Lead responsibility within the Health Services and Mental Health Admini- stration for the research and development phase of the program is located in the National Center for Health Services Research and Development. This pro- ject is being developed jointly with the National Center for Health Statis- tics which has responsibility for the implementation of the system. Consistent with current national priorities, the cooperative system gives priority attention to data needed for the planning, operation, manage- ment, and evaluation of health services delivery. If individual access to health services is to be improved, while maintaining quality and containing costs, the health care system cannot continue to operate without adequate knowledge of its effects upon the health of the population. The Cooperative Federal-State-Local Health Services Data System must serve to coordinate data-collection activities at various levels, from individual patient care to local, State, and national decision making. Emphasis, therefore, is placed on developing an intimate working relationship between the data system, health services delivery systems, and local, State, and Federal governments. The system will be developed through the use of standard definitions) standard measurements for quality of performance, and standard procedures or the collection, processing, and analysis of health data. The system should provide data which will accurately and adequately reflect (1) the physical and mental health of the people, (2) the use of ambulatory, hospital, and long- term care services, including preventive, diagnostic, curative and rehabili- tative services, (3) the cost of these services, (4) the available health resources--facilities, manpower, and services, (5) the character and quality of the environment as it relates to health, (6) the basic demographic characteristics of the population, including patterns of family growth, births, deaths, etc., and (7) the knowledge, practices, and attitudes toward health and health care. In 1073, an estimated $3,500,000 will be used to support the R&D phase of this cooperative project, an increase of $1,900,000 over the 1972 level. 129 V. Performance Accounting A. Quality Assurance and Review The National Center, working in cooperation with the regional !Icdical Program, has supported basic research and development on the quality of medical care and on improving methods of measuring and monitoring quality. In 1971, the National Center began support of experimental medical care review organizations (EMCROS) by eight State and county medical societies to review the quality of health services delivered by all providers in specified geographic areas. In 1972, these experimental organizations are being ex- tended to 10-12 sites. The purpose of the EMCRO is to develop and test alternative methods for conducting objective peer review of the content, appropriateness and quality of medical care. Those which prove successful will be prototypes for implementation of Professional Standards Review Organizations legislation. Review mechanisms will encompass office and hos- pital care, nursing home drug use, drug utilization review, criteria for admission to hospitals and long-term care facilities. Health professions other than medicine are to participate and establish review mechanisms. The public is to be appropriately represented in the review process at a suitable level. The elimination of medical care and pro- cedures which are unnecessary, without compromising quality of care is a necessary objective in the effort to contain costs. The quality assurance program seeks to achieve this effect while also impacting on the delivery of care to insure an acceptable level of quality. In 1973, the Center will expand research and development in two parts of the future quality assurance system which have as yet received little at- tention. These are measures of outcome of medical care, and methods for developing and installing in office practice and hospitals the patterns of medical practice which reasonably assure high quality outcomes. The results of the basic research previously supported and of these new studies will provide the methods for quality assurance in HMOs, as well as in all other forms of provider organizations. B. Health Services Data System Developmental projects have been initiated and will continue in selected communities with the goal of establishing continuing and flexible systems for making available and using health services data in the planning, operation and evaluation of health services delivery programs. In the short-run, these efforts will be focused on providing information for evaluating Experimental Health Services Delivery Systems and Health Maintenance Organizations. Data collection activities within the experi- mental community systems and the HMOs bc(!ur concurrently with the planning and development of these new organizations and will relate specifically to their activities. Comparison and evaluation of the various data efforts produced during the development of these activities will be carried out with a view to determining the most useful and least costly means of gathering and evaluating health care data. Initial attention is being given to developing a community profile from census and other data. The first components of the data system are the household survey, hospital discharge abstract data and methods for obtaining information on cash flow. At a later time, attention will be given to de- signing an encounter form for ambulatory care data and for methods of col- lecting data for quality assessment. The basic data elements will include descriptive information such as demographic information, community surveys and data on manpower and facilities; ambulatory care data; hospital discharge data; quality assessment data; and financial data. The hospital discharge Abstracts and ambulatory care surveys, together with other utilization data, are being developed for further implementation and evaluation within the context of the Federal-State-local health services data system, which is being jointly developed with the National Center for Health Statistics. 130 These prototype health services data systems are being developed and evaluated in four locations. Two, Rhode Island and Colorado are statewide; two others are local efforts at Livingston and San Joaquin in California. Timetables for component development, implementation, evaluation and modifica- tion have been established at all four locations and the expectation is that health services data systems, including survey, ambulatory, funds flow and uniform hospital discharge components will be in operation by May 1973. Tech- niques for demographic analysis of existing census data will be available by December 1972. A similar data collection effort will be undertaken in order to monitor and evaluate the performance of Health Maintenance Organizations. Standard- ized data systems will be installed in experimental HMOs and HMO-like instal- lations. These.will be more formal management information systems, for inter- nal mana iding for effective .gement and control within the HMO as well as prov and objective review by outside authorities. The data collected will provide for the continuous monitoring and periodic evaluation of performance within individual HMOs and for comparison between HMOs. C. Nursing Home Improvements In 1972 the DHEW received a supplemental appropriation to implement the President's request that new initiatives be taken to improve the general con- ditions of the Nation's nursing homes and extended care.facilities. The National Center received $900,000 to support a new R&D effort with respect to nursing home standards and quality. The R&D approach will: (1) improve the techniques of quality performance assessment of nursing homes to enable inspectors to detect deficits in patient care and environmental hazards; (2) introduce new types of mid-level manpower such as nurse clinicians and physician extender personnel to augment the phy- sicianis care and provide medical management supervision; and (3) design a data system that would provide a systematic inter-agency data/report sharing and implementation plan. The latter would achieve a uniform minimum core data set compatible with data used by other agencies. In 1973, an estimated $11,000,000 will be used to support studies re- lating to quality assurance and review, EMCROS, data systems development, and other evaluation activities. IV. Health Care Technology The projects undertaken by the National Center's Technology Division are directed to the issues of cost-containment, efficiency and productivity in the delivery of health services. These projects employ state of the art computer techniques to: Automate certain service functions; process data to improve the clinical management of patients; and provide management information to im- prove the operation of health care facilities. Health care technology research and development is directed to four areas: 1. Medical information technology includes work in hospital information systems and medical signal processing. The current strategy is to sup port two approaches to the development of hospital information systems. One capitalizes on the sizeable public and private monies already inves- ted in achieving a workable total hospital information system (HIS). 'This evaluation assesses the impact of HIS on manpower requirements, -level of skills, length of stay, quality of care, cash flow, inventory and fiscal controls. The second is based on time shared computers which make feasible a shared, modular hospital information system. This ap- proach supports a group of cooperating hospitals to implement modules of the system and share cost based on computer time utilization. Both of these approaches are currentl@ undergoing the test of demonstration and 131 objective evaluation in operational settings. The hospital information system at the Massachusetts General Hos- pital utilizes in a modular fashion small computers and the MUMPS lan- guage (a high-lev6l language interpreter). Several examples of economies achieved with individual modules are available. For example, the Census and Bed Control Module at Framingham Union Hospital in Massachusetts, re- quiring daily physician updating of estimated length of stay, resulted in a 14% increase in bed utilization for the 150 medical/surgical beds of this 288 bed hospital. With daily charges at $75 per day, this module thus resulted in an increased cash flow of $1,500 per day, which calcu- lated on a yearly basis, produced $500,000 of income to offset fixed operating costs. Other modules, such as radiology and pharmacy, may achieve cost savings through rationalizing information flow within these departments and thus facilitate optimal resource allocation. 2. Automated health maintenance systems R&D include projects in labors- tory automation and screening and disease detection and screening. Two projects are currently being supported which successfully demonstrate the use of computers in improving the operation of the clinical laboratory. The new activity planned in this area is to explore the feasibility of extending automation techniques into the microbiological laboratory. Developmental work on mass screening devices will continue for white cell differential counts, sputum cytology and ECG analysis. These are clini- cally important, high volume activities that are labor intensive. Auto- mation of these tests would result in significant cost reduction and con- servation of skilled manpower. Private enterprise has moved in to further development and expansion of many of the Technology Division's projects. For example, the automa- ted ECG program developed by the Division is the focus of an ECG Data Pool supported by more than one hundred members, largely from the private sector. The studies show that a 75% savings in physician manpower may be achieved by using a computer assisted ECG analysis program. On a national scale, this would free an estimated 1,300 cardiologists for direct patient care. Equally important, this system improves patient care by providing rapid access to a correct ECG interpretation in medi- cally underserved areas. This project has progressed to the point where it is providing a valuable service to a community of hospitals within the city and the outlying regions surrounding Denver. This activity which was initially funded for three years as a demonstration will be complete- .1y self supporting in 1973. 3. Technology for Logistics and Data §y t@e@s. Data System activities are directed toward the design and development of computer systems for handling medical transactions and claims data. One such contract is a pilot study for the On-Line Medicaid Claims Processing for the entire State of Alabama. In the area of medical logistics, the delivery of health services to remote areas has been identified as a problem of significant scope in which existing technology offers possible solutions. One such possible solution is the use of picture-phones and closed circuit television to 19 extend medical support to health services personnel and facilities oper- ating in remote or isolated locations. An activity to explore these possibilities has been initiated. a a 132 4. Ambulatory Servi ces. Priority is given to increasing productivity and efficiency of the physician in the individual office, group practice, or clinic settings, where in fact the majority of health care in this country is delivered. Significant gains in ambulatory care management can be made through automating medical record systems, medical history acquisition, and providing physician consultative support. Major pro- jects in these categories will be subjected to a nationally-based assess- ment in order to concentrate R&D on those approaches which promise the best pay-offs in savings of physician time and increasing productivity. The automated history is considered the most probable cost-effective vehicle for bringing the time-shared computer terminal into the physi- cian's office. This versatile communication device will permit such innovations'in the office as computer aided diagnosis; drug interaction warnings; educational materials and treatment plans; special instructions in diets; patient scheduling to hospitals, clinics, and laboratories; communication with hospital information systems that will allow entering of preadmit data, review of patient charts, and entering of medical orders; and record, billing, and accounting functions. In 1973, an estimated $7,000,000 will be used to support health care technology research and development. VII. Health Care @stems The National Center for Health Services Research and Development supports the implementation of model health care delivery community systems which stress preventive measures, ambulatory care, improved financing methods, and improved use of manpower and technology. A. Experimental Health Service Delivery Systems. The "health care delivery syst em!' in the United States consists of practitioners, administrators, financers, consumers, and private and public agencies at all levels and fre- quently having overlapping jurisdictions. It is often impossible for a comnu- nity to allocate resources for maximum community benefit because conflicting or competing programs may provide multiple sponsorship for some services ol beneficiary groups, while other desirable services and needy beneficiaries are not covered by any program. In response to this situation, the Health Services and Mental Health Administration, through the National Center for Health Services Research and Development, is supporting the creation of experimental health services delivery systems for entire communities. In 1971, the Center served as lead agency for the cooperative initiation of Experimental Health Services Delivery Systems (EHSDS), in 12 urban and rural communities across the United States, including the States of Vermont and Arkansas. Up to eight new EHSDS will be started in 1972. These are voluntarily established projects covering entire communities or states whose purposes are to: 1. Establish a voluntary management capability reflecting a balance of control between the providers, third-party payors, political ele- ments, and the public. 2. Assure access to the system by all inhabitants of the area. 3. Assure the quality of care in the component organizations. 4. Evaluate performance of the system in terms of community needs. 5. Combine public and private funds to increase access, moderate cost increase, and insure adequate quality of care. The NCHSRD is evaluating the EHSDS program and assisting EHSDS colmmuni- I ties in developing a@uniform health services data system. Innovations, 13 developed through research and development elsewhere, will be installed and tested in EHSDS. Examples are new manpower types, financing arrangements, quality assurance techniques, and cooperative arrangements among health care facilities. The EHSDS program reflects, at the national level, a common effort by all HSMRA programs. It includes the development of joint funding of these large-scale projects to improve community health care delivery. The EHSDS program also involves coordination with other HEW agencies and with other Federal departments. At the community level, the EHSDS projects first establish and then determine whether a management structure can improve performance of the health services delivery system in improving access to care for the entire community at reasonable cost and of assured quality. Major consideration is given to redirecting private and public (Federal, regional, State and local) sources of funds more ef@"@04 --ntly, and tc) ',,LgLdLiLIr, UUWWULlity services. The R&D will be supported for a limited period only. Mote efficient use of existing dollar flow will enable each system to support the necessary staff and special activities. The service money flowing through the community in- cludes medicare, medicaid or private insurance as well as HEW funds. B. Community health services research and development. Community health services R&D projects are carefully selected laboratories within which the separate manpower, institutional, financing and other R&D programs of the National Center are given final test of effectiveness. Each such laboratory analyzes the health care requirements of the population.in relation to existing resources. On the basis of this, R&D is conducted in installing new kinds of manpower, financing, ambulatory care services, interinstitutional agreements and the like. Their effect will be evaluated in terms of increased access to, and utilization of, health services, costs, and patient and pro- vider satisfaction. One of the first prototypes to emerge under this strategy is Rhode Island Health Services Research, Inc., a non-profit corporation which in- eludes in its membership the major health provider, payer, and organizations in the State. The development of this health services corporation is the first step In the creation of a statewide comprehensive health services system which will -incorporate results of the Center-supported research and development. The Corporation is presently considering revised programs of ambulatory care in the community, establishing a health services information system, and experimenting with hospital reimbursement mechanisms in which all hospitals will participate. Each of these changes, if instituted, will be scientifi- cally evaluated. Several other innovations are under discussion. The cor- poration has completed an analysis of its needs and is now studying its health services resources. The survey of health care needs will be refined and re- applied periodically. In 1973, an estimated $15,000,000 will be spent on 1) the development of experimental health services deliverv systems; and 2) community health service research and development. In summary, the National Center is requesting $53,018,000 for support of its research and development activities in 1973, an increase of $1,900,000 over the 1972 level. The additional $1,900,000 is requested to support the continued devel- opment of a cooperative Federal-State-local health services data system. 3 4 (2)@Res'earch and Development Training 1972 1973 Increase or Estimate Estimate Decrease No. Amount No. Amount No. Amount Training grants: Non-competing contin- uations .............. 43 $3,771,000 43 $3,771,000 New and renewal grants.. 1 67,000 1 67,000 Supplementals ........... (&) 150,000 (8) 150,000 Subtotal ........... 44 3,988,000 44 3,988,000 Fellowships: Non-competing contin- uations .............. 62 574,500 62 574,500 New grants .............. 5 71,500 5 71,500 Supplemental ............ (8) 30@000 (8) 30,000 Subtotal ........... 7@- -676,000 67 676,000 Contracts: Continuations ........... 2 166,000 2 166,000 New contracts ........... 2 170,000 2 170, 00 Subtotal ........... 336,000 4 -336,000 Total ...................... 115 5,000,000 115 5,000,000 As the development of new systems for the organization, delivery and financing of personal health services evolves, the focus of training activities within the National Center is shifting in anticipation of the research an management capa- bilities which will be required. In 1972-1973, a major emphasis of the training program will be the develop- ment of training in health services management and evaluation. Implementation of the innovations in health services delivery systems resulting from the Center's R&D program will require training of new types of managers and administrators. These new types, including physicians, hospital administrators and others from non-health backgrounds, must be prepared to pi-an, implement, operate and evaluate evolving systems. Experience in health services R&D is essential in training programs geared to produce these skills. This training, while it may be conducted in an academic setting, will not be entirely degree-oriented. It will emphasize the development of quantitative, analytical skills for existing health services administrators to provide in- creased managerial and executive capabilities. It is not intended solely to develop independent health services research personnel, but will focus on mid- career experience designed to produce improved capacity for planning, more tational allocation of scarce resources, and knowledge of processes for syste- matic, objective evaluation of the impact of innovation on the health care delivery system. The 1973 level of $5,000,000 will support 48 awards to institutional programs and 67 individual fellowships. This is the same level as in 1972. 135 Health Services Research and Development Increase or 1972 1973 Decrease (b) Direct Operations Pos. Amo n@t Fos-. Amount Pos. Amount Personnel compensation and benefits ............... 218 $3,675,000 230 $3,968,000 +12 +$293,000 Other expenses ............... .. 2,223,000 -- 2,357,000 -- +134,000 Total .................. 218 5,898,000 230 6,325,000 +12 +427,000 The National Center for Health Services Research and Development is responsi- ble for the appraisal and evaluation of the effectiveness of health services opera- tions and for developing a research and development program that is geared to im- proving health care nationally. The staff of the National Center devoted major effort to designing and direct- ing the strategic program of research and development. The staff obtains high- level evaluation of all proposals, closely monitors contracts, reviews results, in- forms the professional community of significant progress and identifies the next steps in research and development. Considerable time and effort is devoted to close collaboration with the investigators, providers, payors and major national organizations. The staff of the Center is organized into three major programs: 1. Special Projects R&D, addressing highest priority problems through short-term research and development. 2. Social and Economic Analysis with programs in the social sciences, economics, epidemiology, and legal medicine; addressing fundamental long-term issues in health care. 3. Health Care Technology which encourages applications of advanced instrumentation and automation to Improving the delivery of health services. The National Center is requesting a program increase of 12 positions and $251,000 in 1973. The increase is essential for the National Center to further de- velop the managerial and technical capability to carry out its large-scale R&D efforts. The increased program effort in the development of community-wide health services data Systems requires additional personnel with statistical and computer capability to develop health status surveys, to monitor data systems for ambulatory care, and to collect and analyze the national data resulting from this program. The additional increase of $256,000 provides for built-in changes, which is partially offset by a decrease of $80,000 due to non-recurring program costs. Comprehensive Health Planning ncrease or 1972 estimate 1973 estimate Decrease Personnel compensation Pos. Amount Pos. Amount Pos. Amount and benefits ............ 24 $546,000 49 $8729000 +25 +$326,000 Other expenses ............ .. 25,389,000 -- 40.761.000 -- +15,372,000 Total 24 25,935,000 49 41,633,000 +25 +15,698,000 Planning Grants Personnel compensation and benefits ............ .. 38,000 -- 38,000 -- Other expenses ............ .. 24,962,000 39,762,000 +14,800,000 Total ............. .. 25,000,000 39,800,000 +14,800,000 Subactivities: (a) Formula grants to States for comprehen- +2,325,000 sive health planning.. 7,675,000 10,000,000 (b) Project grants for areawide comprehensive health planning ....... 13,200,000 25,100,000 +11,900,000 (c) Project grants for training, studies and demonstrations ........ 4,125,000 4,700,000 +575,000 Total ............ 25,000,000 39,800,000 +14,800,000 (a) Formula Grants for State Comprehensive Health Planning Agencies The Partnership for Health Program introduced the concept of comprehensive health planning as a mechanism through which the planning activities of health and related elements can be linked together within the States. Formula grant funds are awarded to the 50 States, District of Columbia, and 5 Territories based on population and per capita income. The funds support up to 75% of the costs associated with conducting State comprehensive health planning. The 1970 amendments to Title III of the Public Health Service Act contained in P.L. 91-515 have led to expansion of State advisory councils to include repre- sentatives of the Veterans Administration facilities and Regional Medical Programs operating in the State. State agencies have continued to be involved in planning, priority setting, and special studies that in many cases have led to recommenda- tions to improve provisions of health services. For example, two State agencies recently accomplished studies that led to recommendations for expanded and improved services to crippled children. Both of these recommendations led to legislation expanding and improving these services. Other State agencies have recommended environmental programs such as solid waste disposal, emergency medical care pro- grams, certificate of need programs to assure effective review of proposed health facilities, and a variety of other programs. Many have been implemented. 137 States will be continuing to place emphasis upon the setting of priorities for health within their jurisdictions and making recommendations for the imple- mentation of these priorities within the State. Comprehensive Health Planning is a continuous process which requires not only the participation of both providers and consumers, but also is equally dependent upon close cooperation of State and local planning bodies. Thus, in 1973, many State agencies will become increasingly involved in coordinating the efforts of areawide health planning agencies within their jurisdiction and working with them toward a joint accomplishment of mutual objectives. The continuing close ties of the State comprehensive health planning programs to the State political, economic and social systems will, in 1973, facilitate the adoption by the States of recommended planning priorities and recommended alternatives for the solution of their problems. More and more of the States will be drawing together the categorical programs in health for the purpose of attacking health problems through joint efforts. As they accumulate more know-!edge and experience, States will be in a better position to modify or realign health resources in order to more effectively combat problems. State comprehensive health planning organizations will review and comment on a wider range and variety of health projects. The increase of $2,325,000 will allow State agencies to increase professional staffs by 25%, from just over 300 persons to over 400. In addition, there will be an increase in consultation and special studies to support effective planning. These increases will enable agencies to increase not only their manpower but also their breadth and scope of skills. A primary emphasis will be for State agencies to become substantially more involved in assisting the development of new area- wide planning agencies. (b) Project Grants for Areawide Comprehensive Health Planning It is essential to the health planning process that every area identify its health needs, inventory resources, establish priorities and goals, and recommend courses of action. To assist public or nonprofit private agencies in this vital effort, project grants will be awarded in 1973 which will comprise about 60% of the total amount spent for the purpose. The remaining funds will be obtained from a broad range of community or local sources. The Federal share may reach as high as 75% if the area has been designated as a poverty area. During 1970 and 1971, the number of areawide agencies increased from 93 to 158 agencies. The number of these agencies which have finished organizing and have launched active planning programs has increased to 110 and is expected to reach 125 by the end of 1972. Recommendations from areawide health planning agencies have had important consequences. For example: Hospital mergers have been effected with more efficient services at lower cost resulting, unnecessary facility construction has been avoided, modernized facilities have been developed, neighborhood health centers have been introduced into communities, immunization and screening programs have been started, lea poisoning prevention programs have been designed, ambulance and other emergency care programs have been operationalited, city water and sewage systems have been improved, and a vast array of other services have been improved. As these examples suggest, comprehensive health planning agencies work across the whole range of health concerns with attention paid to personal health, mental health and environmental health, as well as health facilities. Emphasis is placed on the cost, availability, and accessibility of health care. While each agency defines its own agenda in relation to the needs of its own communities, there are 138 commonalities. For example, more than half of the operational areawide agencies were active in drug abuse and alchoholism in 1972, and similar percentages would be true of other health problems of current concern. In 1973 there will be increased emphasis on review and comment of ropose health programs and facilities. Such review and comment is now required by law for Hill-Burton, RMP, and 314(e). In addition, there are administrative require- ments for review and comment by 314(b) agencies on local applications under 314(d) and migrant health applications, and various States have laws requiring additional review and comment, certification of need, or even approval of some applications by the areawide comprehensive health planning agencies. The increase of $11,900,000 will provide $2,900,000 for continuation costs of the 172 agencies expected to be receiving grants by the end of 1972. Of the balance, $5,100 '000 is included to establish approximately 100 new areawide Agencies and 20 new State assisted local councils. In addition $3,900,000 is included to increase the average Federal share to avoid financial dependence upon organizations whose activities must be reviewed and commented upon by 314(b) agencies. The following table reflects the actual/estimated number of 314(b) agencies: AREAWIDE COMPREHENSIVE HEALTH PLANNING UNDER SECTION 314(b) 1. Number of Areawide 1969 1970 1971 1972 1973 Planning Agencies 93 127 158 172 272 (a) Planning 7 36 90 127 158 (b) Organizational 86 91 68 45 114 2. Number of State Assisted Local Councils -- -- 8 28 % of Population covered by- Not Areawide Agencies Available 55 65 67 80+ (c) Project Grants for Training, Studies and Demonstrations for Comprehensive Health Planning Effective health planning is dependent on skilled health planners - a resource in short supply. To help remedy this situation, about 400 graduate students were trained in the principles, concepts, and techniques of comprehensive health plan- ning through grants to 22 graduate institutions. Further, about 400 local elected officials, health professionals, administrators, planners, consultants and policy level personnel were trained through ten continuing education programs aimed at foupgrading" individuals already involved or connected with health planning in 1972. The improved ability of consumers to participate in comprehensive health plan- ning is extremely important to its success and to foster that objective about 1,500 consumers were trained in thirteen consumer education programs during 1972. The 1973 request will continue support of the graduate programs with about 240 expected to graduate with advanced degrees in the spring of 1973. It will also support about ten continuing education programs which will reach about 600 individuals already involved or connected with health planning. Consumer educa- tion programs will be continued and will reach approximately 1,750 people. The success of State and areavide planning will depend to a large extent upon the availability of personnel skilled in health planning and on constructive con- sumer participation in health planning. The increase of $575,000 for project grants for training, studies and demon- strations will enable the university programs to provide an increased leve o technical assistance to the planning agencies. It will also a ow greater emphasis on the development of health planning methodology. 140 Direct Operations increase or 1972 estimate 1973 estimate Decrease 'FOS. Amount Pos. Amount Pos. Amount Personnel compensation and benefits ............. 24 $508,000 49 $834,000 +25 +$326,000 Other expenses ............. .. 427,000 -- 999,000 -- +572,000 Total .............. 24 $935,000 49 $1,833,000 +25 +$898,000 The efforts of Federal, State, and local governments and the private sector to improve significantly the health status of the individual have fallen below expectations, in part due to the lack of a planning process which links health needs to health resources at the various levels of community health organization. This lack results in an inability to identify such organizational problems as gaps in health coverage, deficiencies in financing, and rational alternative arrangements for patient care as opposed to our presently fragmented health system and subsystem. The development of comprehensive health planning agencies at the State and areawide levels provides a focus where planning and analysis can be undertaken and those interested, both as providers and consumers of health services, can participate in reaching mutually satisfactory decisions. Through the operation of this planning process, more systematic attention can be given to problems, community health goals, relationships, the development of alternative solutions, and evaluation. One possible outcome will be a more integrated use of Federal, State and local resources to improve the health of the people. The Comprehensive Health Planning Program develops national policies and criteria for use by the Regional Offices and provides guidance and technical assistance to 56 State and territorial Comprehensive Health Planning Agencies as well as the 172 areawide agencies expected to be in operation by the end of 1972. Section 314(a) formula grants are supporting 56 State and Territorial Comprehensive Health Planning agencies. In 1973, Section 314(b) project grants will support 272 areawide comprehensive health planning agencies, 100 of which will be new with about 28 special grants made to States to help provide planning assistance to sparsely populated areas. In addition, the Program develops and provides assistance to projects, supported under Section 314(c), which train participants in the comprehensive health planning process. Program emphasis in 1973 is on the provision of developmental assistance to aid the large number of new 314(b) agencies to achieve successful operations, and to meet the increasing demand from both 314(a) and 314(b) agencies for Federal help and guidance. 1973 Increases A net increase of $898,000 is requested for these activities. It includes 25 positions and $495,000 to increase staff capability to respond to State and areawide agencieslrequests for technical assistance and consultation. In addition, $395,000 is included for project contracts aimed at determining various patterns of effective on-going comprehensive health planning and making information about them available to all 314(a) and 314(b) agencies. The total also includes $10,000 for built-in items, partially offset by a decrease of $2,000 for two less days of pay. Regional Medical Programs Increase or 1972 Estimate 1973 Estimate Decrease Personnel compensation Pos. Amount Pos. Amount Pos. Amount and benefits ........ 169 $3,157,000 194 $3,523,000 +25 + 366,000 Other expenses ........ -- 140,745,000 -- 126,628,000 -- -14,117,000 Total ............. 169 143,902,000 194 130,151,000 +25 -13,751,000 Introduction The Regional Medical Programs Service provides a major mechanism and supports activities required to enhance the capacity of the health care system to furnish services of satisfactory quality to all Americans. Regional Medical Programs Service: (1) supports grants and contracts which on a regional basis bring together in a common effort the local medical centers, hospitals, and other health care facilities, health care providers and other resources to systematically identify health problems, commitments, and undertake the solutions; (2) furnishes professional and technical assistance and advice to the Regional Medical Programs, States, local communities and other relevant health agencies: (3) conducts programs through voluntary commitment of regional resources to bring about an increased, effective use of medical knowledge, make more efficient use of physical and human medical care resources and help remove barriers which impede entry of patients into the health care system, maintaining major focus on those diseases which are the greatest causes of morbidity, disa- bility, and death in the United States and (4) facilitates and provides professional guidance at the regional level to other governmental and private efforts aimed at improving the organization and delivery of health care. 142 Regional Medical Programs: Increase or 1972 Estimate 1973 Estimate Decrease (a) Grants & Contracts.. $139,300,000 $125,100,000 -$14,200,000 The Administration's proposed national health strategy is as follows: 1. There must be assurance of equal access to our health care system. 2. Supply and demand for health and medical services must be brought into balance. 3. A purposeful organization of our efforts to improve efficiency must be implemented: first,.by emphasizing preventative services and health maintenance on a prospective and systematic basis; second, by maintaining a reasonable and understood relationship between expenditure and care rendered. Cost conscious- ness and economy need to be introduced by direct incentives. 4. Finally we must build upon our present strengths in the Nation's pluralistic health enterprise. it is specifically these goals that Regional Medical Programs have been organized and geared to accomplish. Regional Medical Programs have been organized as functional consortiums of health care providers, each with special and specific resources which can be made responsive to health needs. They are also structures deliberately designed to take into account local resources, patterns of practice and referrals, and needs. As such they have been important forces for bringing about institutional reform through changes in the provision of personal health service and care. This merger of providers has already produced systematic approaches to the major diseases of the heart as well as cancer, stroke and kidney disease. Several regions have accomplished the pooling of training resources to more effectively meet the manpower needs of each region. In some areas, healthmaintenance projects are being supported in a variety of ways. For example, a prepaid health care insurance program for the residents of Milwaukee's inner city has been developed with the assistance of the Wisconsin Regional Medical Program. The Cream City Community Health Center has been established by nine physicians who organized into a group practice to provide medical services for the health center clientele. Technical and financial assist- ance were provided by the Wisconsin Regional Medical Program for early planning of the Center. Grants funds were obtained from the Office of Economic Opportunity, with Wisconsin Regional Medical Program assistance, to help support the first year of operation. The Center is working with Medicaid, Blue Cross-Blue Shield and the Milwaukee County Medical Society to develop a completely self-supporting experi- mental health maintenance organization. During 1971 and 1972 the affiliated health providers with the aid of the Regional Medical Program mechanism, have promoted and demonstrated at the local levels, new techniques and innovative delivery patterns that lead to improved accessibility, efficiency and effectiveness of health care. For instance, five community hospitals on the north shore of Massachusetts have begun home care programs through the efforts of the Tri-State Regional Medical Program and the Massachusetts Hospital Association. Such programs will provide continuity of care for hospitalized patients after discharge, as well as reduce the length of stay in the hospital. To date, one hospital has achieved a fully coordinated 143 home care program with excellent multi-disciplinary input. Three hospitals are planning to hire full-time nurse coordinators and have opened a much improved information interchange with the local Visiting Nurse Association. One hospital moved the Visiting Nurse Association right into the hospital building and also appointed a full-time qualified nurse as coordinator. In the rural and inner city areas and in concert with related Federal, local State, regional officials and programs, specific efforts have been directed to encourage the providers of health care to make care available and accessible to those areas where there is a distinct scarcity of resources. As an example, in the State of Washington, because of a physician manpower shortage, the isolated community of South Bend and surrounding areas were about to lose their hospital until the Washington/Alaska Regional Medical Program stepped in to organize community, State, and Federal interest and resources to save it. Not only are new physicians locating in South Bend but additional services beyond those formerly offered are now available. In 1972 a grant has been made for a regional cancer center in Seattle, Washington. Health Maintenance Organizations - Assuming that authorizing legislation has been approved, there are likely to be about 350 Health Maintenance Organizations in either planning or operational stages by June 30, 1974. Nearly every Regional Medical Program already has been involved in the development of professional activities at the local level. Because of their provider linkages, Regional Medical Programs, act as catalytic agents to bring together the various elements of the health care system, provide an environment conducive to planning, and give staff support and professional guidance, when necessary. In this way, Regional Medical Programs support professional organizations which have the potential for becoming Health Maintenance Organizations. In addition, subsequent to the establishment of Health Maintenance Organizations, Regional Medical Programs have actively engaged in the professional aspects of planning for manpower programs, mechanisms for monitoring the quality of care, ambulatory and emergency medical care services, centralization of laboratory facilities, data systems, etc. Regional Medical Programs is, within present legislative authority, also pro- viding funding through grants and contracts to support the planning and develop- ment of Health Maintenance Organizations in 1972. Experimental Health Service Delivery Systems - Regional Medical Programs are playing the same catalytic role with respect to Experimental Health Service Delivery Systems. Some are providing staff support even after an Experimental Health Service Delivery System contract has been signed. For instance, the interim director of the project in Boise, Idaho also is an area coordinator for the Mountain States Regional Medical Program. Program for 1972-73 Although Regional Medical Programs have been moving away from the narrow categorical disease approach and the emphasis on continuing education projects, the substantial increase in funds in 1972 has provided the impetus to substan- tially speed up that redirection. Goals 1. Manpower Development and Utilization - Programs aimed at enabling exist- ing health manpower to provide more and better care and training and more effec- tive utilization of new kinds of health manpower. New funds will be used to plan and develop Area Health Education Centers. These programs which focus on improved patient care services, depend on affiliations of hospitals and other treatment 144 facilities, nursing homes, junior colleges, etc., usually linked with a university health science center, to improve manpower distribution and to provide the missing link between manpower education and patterns of delivery. Area Health Education Centers will be a source of manpower for Health Maintenance Organizations, Experimental Health Service Delivery Systems and other comprehensive health care systems. Area Health Education Centers and other Regional Medical Program funded projects will emphasize improved utilization of new kinds of health manpower, particularly physician extenders, who can take over many of the traditional functions of the physician-enabling him to see more patients while, at the same time, lowering the cost of 6are. Another important aspect of Regional Medical Program efforts will be to encourage the expansion of existing familv practice programs and the establishment of new ones. One important specific contribution will be to assist in identify- ing intern and residency training sites (e.g., preceptorships, group practices) and setting up such graduate training programs at the community level. In addition, Regional Medical Programs will seek to favorably influence the distribu- tion of family practitioners -- that is, to get them to locate in areas of greater need -- by strengthening the professional linkages between family and speciality practice, between small community hospitals and larger hospitals and medical centers. They will attempt to minimize or remove the sense of isolation and enhance the professional growth of these individuals through such efforts as the partial support of dircuit-riding Directors of Medical Education serving several small hospitals and the outreach programs of medical centers providing speciality consultation to family practitioners. 2. New Techniques and Innovative Delivery Patterns - Activities aimed at improving the accessibility 'efficiency, and quality of health care. They provide opportunities to increase the rate of implementation of systems innovations, new technologies including automation, and changes in delivery patterns, particularly those developed through the efforts of the National Center for Health Services Research and Development. Rural Health Care Systems New techniques and innovative delivery patterns have allowed Regional Medical Programs to improve access to quality health care and provide emergency services to Americans in urban and suburban areas. Thus far. however, no one has found a way to adapt the same techniques and patterns of care to rural areas. Geography has been the stumbling block. For example, a rural area of South Georgia and Northern Florida which has a staggering number of serious auto accidents has round-the-clock emergency service for the first time under a Georgia Regional Medical Program Project. In a typical year, December 1, 1968 to December 31, 1969, there were 1,618 motor vehicle accidents on the section of Highway I-75 which passes through this Florida resort area. At that time, all hospitals in the area were relying on practicing physicians to be called on a rotating basis for emergencies. Virtually the only ambulances available were those from local funeral homes, which, in most cases, did not meet medical standards. The population of 200,000 in land area of 3,800 square miles is served by 96 physicians (the national average is 141 physicians per 100,000 population) and ten hospitals with a capacity of 838 beds. The project staffs and equips round-the-clock emergency rooms in two of the larger hospitals and provides emergency ambulances with intensive care capabilities. In addition, Moody Air Force Base has agreed to provide helicopter ambulance service in dire emergencies. 145 Although projects like this are worthy, they are not comprehensive nor do they begin either to provide adequate emergency services or to touch the majority of the residents of rural and remote areas. For the first time, rural health care systems will be developed which will have as their long-range goals: a. The same quality of care enjoyed by those Americans fortunate enough to reside in areas where favorable distributions of health care resources exist. b. Primary and emergency care within a reasonable travel time even under the poorest of weather conditions. c. Care that is not only available and accessible but also care which is provided in such a way as not to encroach on the dignity of the consumer. Comprehensive rural health care systems will include (1) health education for the consumer, (2) primary/preventive care, (3) emergency care, (4) secondary/ tertiary care, (5) rehabilitation services, (6) extended care, and (7) home care. Emergency Health Services Systems Today more Americans require hospitalization for accidents than for any other diseases except cancer and heart disease. In the last decade the mortality rate for males has been rising with increasing changes in younger age groups primarily due to external causes including accidental death. Yet we spend less than 1% of the amount spent on cancer or heart disease in alleviating this problem. It is not surprising, then, that adequate emergency care systems are sadly lacking. What is needed are systems which bring together better transportation services, communication which would tie hospitals, transportation facilities and other emergency organizations into rapid response systems, and emergency medical centers with specially trained doctors and nurses. This will require a very carefully designed plan of coordination which includes firemen, police, highway safety officials, mayors, governors, as well as those who must provide the professional and technical services. There is also an urgent need for effective public education. Emergency Medical Systems at a cost of $8,000,000 will be funded in 1972. An additional $7,000,000 is requested to allow the funding of additional projects totaling $15,000,000 in 1973. These will be implemented in major cities, medium size cities, combinations of cities and adjacent areas, rural areas, and entire States. In all@ cases they will be linked to adjacent systems and will address the larger question of ambulatory services for those who do not requ'@re emergency care. Demonstration projects should clearly show the improvement in health which can be obtained by such systems. An improvement of only 10 percent in emergency care would save 15,000 lives and more than 3,000,000 hospitalizations and would return $3 billion to the economy. 3. Regionalization Activities - Provider-initiated activities leading to greater sharing of health facilities, manpower, and other resources. End stage kidney disease is one area in which the development of integrated regional systems could prevent the duplication which has characterized certain other specialized resources. These regional systems provide the opportunity to show how scarce resources can be linked together efficiently. 4. Development and Implementation of Quality of Care Guidelines and Performance Review Mechanisms - Such guidelines and mechanisms are necessary to the development of the new and more effective comprehensive systems of health services such as Health Maintenance Organizations, rural health delivery systems, and emergency health systems. The development of these guidelines and mechanisms is carried out in conjunction with the efforts of the National Center for Health Services Research and Development. 146 5. Development, Demonstration, and Application of Biomedical and Management Techniques - Activities aimed at increasing productivity of providers and extend- ing specialized services to areas not currently covered. 6. Strengthening Regional Medical Programs - Thus far, this discussion has emphasized the direction of resources toward meeting new national objectives. One must not lose sight, however, of the overriding purpose for Regional Medical Pro- gram organizations which purpose is to bring together local resources in such a fashion as to create efficient and effective solutions to local health problems. While the new initiatives will contribute significantly to those solutions, they do not constitute a panacea. It is equally true that some Regional Medical Programs have not well served that overriding purpose. Accordingly, the selective funding policy has sought to reward the effective regions and to provide a sufficient base from which new initiatives could be launched. At the same time, concerted efforts are being made to improve the ability of the lesser Regional Medical Programs to attack the problems in their regions. Some have already made good progress. At some stage in their improvement, new funds must and will be made available to these Regional Medical Programs for new project activity. In exercising the current authority to use funds for the purpose of program planning and evaluation, in addition to exercising this authority through grants and contracts, these funds will also be used to finance consultative and other services required to prepare, monitor, and review various forms of evaluation. Such consultative services would be performed under contract or through the use of part-time or intermittent consultants. 147 Regional Medical Programs: Increase or (b) Direct operations 1972 Estimate 1973 Estimate Decrease Pos. Amount Pos. Amount Pos. Amount Personnel compensation and benefits ........ 169 3,157,000 194 3,523,000 +25 +$366,000 Other expenses ........ -- 1,445,000 -- 1,528,000 -- +83,000 Total ............. 169 4,602,000 194 5,051,000 +25 +449,000 This activity supports staff for reviewing, processing, awarding and adminis- tration of grants; provides health data required by the 56 local Regional Medical Programs in the implementation of their activities; develops and maintains appro- priate relationships with government and private agencies concerned with improving the organization and delivery of health services. This activity also provides technical assistance to the regions in the plan- ning, development and implementation of their programs. Three of the many areas of,assistance have been (1) development of professional concensus on regional programming for long-term control of hypertension, (2) development of regional information services to promulgate each region's experiences to the other regions, and (3) a study of the cooperation in trials and observation of experimental services such as "Physician Assistant" programs. The rapid expansion of Regional Medical Program activity and the movement into new areas of emphasis carrv with them additional requirements for development of policy guidance and criteria for project development. More finished products relating to specific professional issues of critical importance will be needed. Thev will range from technical problems to health delivery methods. The most outstanding example of this is the new emergency health services program. The 1973 increase includes 25 positions and $350,000 to develop and carry out this important health initiative. It also includes a $99,000 net increase partially offset by both program and mandatory decreases. 148 Medical Facilities Construction Increase or 1972 1973 Decrease Pos. Amount Pos. Amount Pos. Amount Personnel compensation and benefits ........ 135 $2,223,000 135 $2,300,000 --- $77,000 Other expenses ........ --- 275,462,000 --- 88,459,000 -187,003,000 Budget Authority Total ........... 135 277,685,000 135 90,759,000 -186,926,000 Obligations 135 134,091,000 135 201,280,000 --- +67,189,000 Introduction A request for $90,759,000 is submitted for 1973. This amount provides $85,000,000 for construction grants, $2,500,000 for interest subsidies on guar- anteed oans and direct loans for construction and modernization of hospitals and other health care facilities, and $3,259,000 for direct operations. The 1973 budget for medical facilities construction reflects a shift in the Federal role in financing hospital construction from a purely grant basis to a balanced program of direct loans, guaranteed loans and grants. With the recog- nition of depreciation as an integral part of hospital costs by Medicare, Medicaid and private insurance carriers, financing of hospital construction can be put on the same basis as other capital investment. In effect, the purchaser of the medical service bears the cost of the capital investment. With this change in concept, medical facilities are now able to compete in the mortgage market and do not have to rely upon grants and contributions for capital investment. The 1973 budget reflects this shift in emphasis away from outright grants as a financing mechanism to direct Federal loans and guarantees with interest subsidies on loans made by the private money market. Maximum flexibility in the use of construction support funds will be further encouraged by applying them to projects which will serve other HSMRA and Depart- ment programs. Hill-Burton grants will be used to construct community mental health centers, for facilities to house health maintenance organizations and for comprehensive health care centers which include programs in maternal and child health, family planning, drug abuse prevention and care, and alcoholic rehabili- tation. The administrative barriers between these several programs and the de- finition of those areas in planning and structural requirements which might re- quire waivers of policy or regulations is already being explored at the staff level between a number of HSMU programs. 1.49 Construction under Title VI, the Public Health Service Act (Hill-Burton) 1972 1973 Increase or Estimate Estimate Decrease Other expenses (B.A.)...,$217,500,000 $87,500,000 -$130,000,000 other expenses (oblig.). 92,192,000 198,021,000 + 105,829,000 The $87,500,000 requested for 1973 under Title VI of the Public Health Ser- vice Act will provide $70,000,000 for grants for outpatient facilities, $15,000,000 for grants for rehabilitation facilities, and $2,500,000 for interest subsidies on guaranteed loans to private nonprofit organizations and direct loans to public agencies for construction and modernization of hospitals and other health care facilities. 1. Construction grants --- The construction of health care facilities for ambulatory patients would be supported with the $85,000,000 requested for con- strudtion grants. The $70,000,000 requested for Outpatient Facilities would assist in the construction of an estimated 194 projects. The 15,0 , re- quested for Rehabilitation Facilities would assist in the construction of an estimated 49 projects. 2. Direct loans --- Construction of health care facilities owned by public agencies (States, cities, counties, hospital districts, etc.). which are pre- cluded by local laws from borrowing mortgage funds from commercial lenders, is supported by a program of direct loans. Loans would be made by HEW and the resulting debt obligation sold to the Federal National Mortgage Association and other investors, Proceeds from these sales would be used to provide capital for additional direct loans. 3. Interest subsidies --- Under the redirected Hill-Burton program, Federal support for construction of inpatient health facilities such as hospitals and long-term care centers would be available through guaranteed loans with interest subsidies for private, nonprofit hospitals and direct loans for facilities owned by public agencies. These types of facilities generate the income from fees for services and third-party payments necessary for repayment of mortgage loans, The $2,500,000 requested for 1973 would, when added to $20,300,000 carried forward form previous appropriations. subsidize over $600,000,000 worth of guaranteed and direct loans. District of Columbia medical facilities 1972 1973 Increase or Estimate Estimate Decrease Other expenses (B.A.) ...... $42,127,000 ---- -$42'127,000 Other expenses (Oblig.) .... 38,967,000 ---- - 38:967,000 $40,052,000 has been appropriated for grants and $40,575,000 for loans to assist in meeting the cost of projects in the District of Columbia for the moderni- zation of public or nonprofit hospitals and in meeting the cost of projects for the construction or modernization of public health centers, long-term care facilities, including extended care facilities, outpatient facilities, rehabilitation facili- ties, facilities for the mentally retarded, and community mental health centers. Legislation for this pvagver expires on June 30,1972. 150 Hospital experimentation projects 1972 1973 Increase or Estimate Estimate Decrease Other expenses (B.A.) ......... $15,000,000 -$15,000,000 Other expenses (Oblig.) ....... ---- ---- ---- Grants and loans are authorized to provide for construction of medical facilities.vhich involve experimental designs or methods of construction to serve as demonstrations relating to delivery of health services, No funds are being requested for this activity in 1973, Direct operations 1972 1973 Increase or Estimate Estimate Decrease Pos, Amount Pos. Amount Pos. Amount Personnel compensation and benefits ................ 135 $2,223,000 135 $2,300,000 --- $+77,000 Other expenses ............ --- 835,000 --- 959,000 +124,000 Total..(B.A.) ....... 135 3,058,000 135 3,259,005' +201,000 (oblig.) ..... --- 2,932,000 --- 3i2-99!1 IOOO +327,000 The estimate of'$3,259,000 and 135 positions requested for 1973 are neces- sary to continue the Federal Goverrments' role of providing national leadership in the planning, programing, design and functioning of all types of medical facilities. The funds requested will support the staff necessary to provide technical assistance and consultation to project sponsors and State agencies regarding all aspects of program administration; to develop and revise guidelines for the design,,- construction, and equipping of health care facilities; to develop regu- lations, procedures, and policies for operation of the program; to review and approve basic documents, such as State plans and project applications: to compile and analyze data pertinent to health care facilities: and to assist health facility construction programs with the above activities. The operation of this program requires a variety of specialized and highly technical skills relating to the planning, design, equipping, functional layout and construction of all types of health care facilities as well as the prereq- uisite talent necessary for administration of a significant Federal program of national scope. The professional staff includes deciplines such as medicine, nursing, hospital administration, architecture, engineering and public adminis- tration. Program direction and management services Increase or 1972 estimate 1973 estimate Decrease Pos. Amount Pos. Amount Fos-. Amount Pers onnel compensation and benefits ........ 149 $2,239,000 149 $2,261,000 +$22,000 Other expenses ........ --- 347,000 --- 449,000 +102,000 Total ............ 149 2,586,000 149 2,710,000 +124,000 This activity includes program leadership and direction and staff services including administrative management, program planning and evaluation. The immediate office of the Director is responsible for planning, directing, coordinating, and administering the Health services planning and development programs. Administrative management is responsible for the development, coordination, direction, and assessment of management activities. It directs such services as financial, personnel, and contract management. Planning activities focus-on annual work plans, the longer-range goa - oriented planning system and encompasses efforts in program analysis and evaluation, as well. The increase of $124,000 includes a program increase of $68,000 for the Upward Mobility program and a net increase of $56,000 for built-in items. 152 HEALTH SERVICES AND MENTAL HEALTH ADMINISTRATION Health Services Planning and Development Program Purpose and Accomplishments Activity: Health services research and development - Grants and contracts. (PHS Act: Sec. 301 and 304) 1973 Budget Pos. 1972 Amount Authorization Pos. Estimate Amo n@t $56,118,000 Sec. 301 - indefinite $58,018,000 Sec. 304 $94,000,000 Purpose: The National Center focuses on national priority problems in health services such as rising costs of medical care, unequal distribution and utilization of health services, inadequate methods for health services planning and decision- making at local and national levels and shortages of professional health personnel. Explanation: The scientific programs of the National Center are carried out through research, development, demonstrations and related training. Research grants are awarded to organizations and individuals to perform studies and to con- duct and evaluate demonstrations. Contracts are used to support research and development projects. Under the training program, grants are awarded on a competi- tive basis to institutions and to qualified scholars for research and managerial training programs in the health services field. Accomplishments in 1972: In 1972 the National Center made progress in primary com- ponents essential to involving and increasing comprehensive and effective health services for total communities. Major projects involved new types of manpower, ambulatory care, automation of hospital services, methods for assessing and main- taining quality of care, methods for limiting hospital costs, and the launching of community-wide health services systems. For example: 1. To pave the way for using much larger numbers of physician's assistants and nurse practitioners in physician-extender roles, the Center designed a method for determining how and where these new types of manpower should be used. This method will provide data for future national health manpower policy and-is being applied at first to the evaluation of the M-edex type of physician's assistants and now to nurses such as pediatric nurse practitioners, nurse midwives, and family nurse practitioners. 2. The Center is supporting the first automated hospital patient care management-system in the United States. This computer-based system controls the admission of patients, the scheduling of medical, nursing, and auxiliary services according to highly sophisticated patient care plans; reports and records services actually performed; measures patient changes in response to services, and feedback data essential to up ate the system as a whole. other projects played major roles in creation of automated clinical hospital laboratories capable of producing the thou- sands of quality-controlled tests required daily in the operation o a large hospitals. 3. The 1972 budget is supporting research, development and evaluation of HH09 which were funded by HSMHA in 1971 and are now in the planning and organizational phase of development. The HMOs will be studied with respect to such factors as enrolled populations, benefit structures, utilization patterns, monitoring of services, and legal and market factors. 153 4. R&D is being carried out, in close cooperation with the National Center for Health Statistics, on the Cooperative Federal-State-local Health Statistics System. This work will begin in 4-6 communities, States and regions. The cooperative system will provide information about the health of the nation, its health resources, and the utilization of these resources. It will furnish the data needed to make rational de- cisions at all levels about health care delivery problems and ways of meeting these problems. 5. In 1971, the Center initiated and supported the development of Experimental Medical Care Review Organizations (EMCROS) by 8 States and county medical societies. In 1972, these experimental review organizations which are intended to be prototype Professional Standard Review Organizations (PSROS) will be extended to 10 to 12 sites. Objectives for 1973: In 1973 the National Center will continue and expand its priority R&D in new types of manpower, HMOs, health care institutions, cost effec- tive technology, experimental medical care review organizations, and health service delivery systems. The 1973 budget includes an increase of $1,900,000 for the con- tinued development of the cooperative Federal-State-local health statistics system. Out of this project will come the most comprehensive data base yet developed for assessing the Natibn's health. 154 HEALTH SERVICES AND MENTAL HEALTH ADMINISTRATION Health Services Planning and Development Program Purpose and Accomplishments Act Health services research and development - Direct operations. (PHS Act, Sec. 301 and 304) 1973 Budget 1972 Estimate Pos. Amount Authorization Pos. 'Amount 218 $5,898,000 Indefinite 230 $6,325,000 Purpose and Explanation: The National Center for Health Services Research and Development is responsible for the appraisal and evaluation of the effectiveness of health services operations and for developing a research and development pro- gram that is geared to improving health care nationally. Accomplishments in 1972: The staff of the National Center devotes major effort to designing and directing the strategic program of research and development. The staff obtains high-level evaluation of all proposals, closely monitors contracts, reviews results, informs the professional community of significant progress and identifies the next steps in research and development. Considerable time and effort is devoted to close collaboration with the investigators, providers, payors and major national organizations. The 1972 budget provides additional specialized staff which are essential for the National Center to further develop its capability for mounting large-scale R&D projects. The increased program effort in the development of cooperative Federal- State-local statistics systems requires personnel with statistical and computer capability to develop health status surveys, to monitor data systems for ambulatory care, and to collect and analyze the national data resulting from this program. Objectives, 1973: An increase of $251,000 and 12 positions is necessary to support the expanded R&D strategy. Nine of the positions would be used to support the con- tinued development of the cooperative Federal-State-local health statistics system. Parallel to the R&D studies and projects, a number of internal studies by staff would move ahead. These studies would identify political, legal, and organi- zational barriers to large-scale adoption of new policies, and program formats suggested by the R&D. An additional increase of $176,000 will provide for mandatory increases. HEALTH SERVICES AND MENTAL HEALTH ADMINISTRATION Health services planning and development Program Purpose and Accomplishments Activity: Comprehensive health planning - Project grants for training, studies, and demonstrations for comprehensive health planning (PIIS Act, Section 314(c)) 1973 Budget 1972 Estimate Pos. Amount Authorization Pos. Amount $4,125,000 $12,000,000 -- $4,700,000 Purpose: To train people in health planning skills. To improve the art and skills of comprehensive health planning. Explanation: Grants are awarded to public and nonprofit private agencies, institutions, or organizations to support graduate education, continuing education, and training of consumers to participate in comprehensive health planning. Accomplishments in 1972: In 22 graduate programs, over 400 students were trained in the principles, concepts, and techniques used by State and areawide compre- hensive health planning agencies, preparing them to practice effectively in this field. Ten continuing education programs aimed at upgrading individuals already involved or connected with health planning reached approximately 400 local elected officials, health professionals, administrators, planners, con- sultants and policy level personnel. Consumer education programs reached approximately 1,500 persons. Objectives for 1973: To increase the level of technical assistance provided by university programs to the planning agencies. To increase emphasis on the development of health planning methodology. To support short-term training for about 1,750 health professionals and consumers and long-term training for over 400 graduate students. 156 HEALTH SERVICES AND MENTAL HEALTH ADMINISTRATION Health services planning and development Program Purpose and Accomplishments Activity: Comprehensive health planning - Project grants for areawide compre- hensive health planning (PHS Act, Section 314(b)) 1973 Budget 1972 Estimate os. Amoun- Pos. Amount Authorization t $13,200,000 $40,000,000 $25,100,000 Purpose: To provide a mechanism for the development and coordination of a strengthened planning capacity for solving the health needs of our citizens at the community level. Explanation: It is essential to the health planning process that every area identify its health needs, inventory resources, establish priorities and goals, and recommend courses of action. To assist public or nonprofit private agencies in this vital areawide comprehensive health planning, project grants are awarded according to a matching fund formula. Federal funds will average 60% of the project with the additional remaining funds coming from a broad range of community groups and local governmental funds. The Federal share may reach as high as 75% if the area is all or partially designated'as one of poverty by the Department of Commerce or if the Agency supports projects for poverty areas. Accomplishments in 1972: The number of agencies which have finished organizing and have launched active planning programs is expected to reach 125 (of 172 total agencies) by the end of 1972. Agencies in the planning phase help set priorities for their communities and establish a framework of comprehensive health planning. Against that framework, they review and comment, as required by law and policy, upon a variety of proposals for health services and facilities. A broad range of health problems are addressed in these efforts; in 1971 and 72, for example, a majority of all agencies in the planning phase were involved in drug and alcohol abuse issues. Building cooperative relationships with other federal health programs is an essential element in 314(b) work. For instance, assistance may be provided in the development of health maintenance organizations, OEO Health Centers and Experimental Health Delivery Systems. Objectiies for 1973: Improve the effectiveness of the 172 agencies and 8 State assisted local councils expected to be in operation at that time. Increase Federal share of individual agency budgets to avoid financial dependence upon organizations whose activities must be reviewed and commented upon by 314(b) agencies. Establish approximately 100 new agencies and 20 new State assisted comprehensive health planning councils in rural areas. Agencies will be located in areas in which approximately 80% of the population reside. 1,5 7 HEALTH SERVICES AND MENTAL HEALTH ADMINISTRATION Health services planning and development Program Purpose and Accomplishments Activity: Comprehensive health planning - Formula grants to states (PHS Act, Section 314(a)) 1973 Budget 1972 Estimate Pos. Amount Authorization Pos. Amount $7,675,000 $20,000,000 -- $10,000,000 Purpose: To assist the States in comprehensive and continuing planning for their current and future health needs. Explanation: Formula grants are awarded to States, the District of Columbia, and five Territories, according to a formula based on population and per capita income. Federal financial participation cannot exceed 75% of the costs. Accomplishments in 1972: Formula grants were awarded to the States, the District of Columbia, and five Territories and supported up to 75% of the costs of their programs. New Federal legislation led to expansion of State advisory councils to include representatives of the Veterans Administration facilities and Regional Medical Programs operating in the State. State agencies were involved in planning, priority setting, and special studies that in many cases led to recommendations to improve provision of health services. For example, two State agencies accomplished studies that led to recommendations for expanded and improved services to crippled children. Both of these recommendations led to legislation expanding and improving these services. Objectives for 1973: To increase professional staffs of State agencies by 25%, from just over 300 persons to over 400. To upgrade capability of State agencies through increased consultation and special studies. HEALTH SERVICES AND MENTAL HEALTH ADMINISTRATION 158 Health services planning and development Program Purpose and Accomplishments Activity: Comprehensive health planning - Direct operations 1973 Budget 1972 Estimate Pos. Amo n@t Authorization Pos. Amount 24 $935,000 Indefinite 49 $1,833,000 Purpose: This activity supports the comprehensive health planning staff that provides national leadership in the development and operation of programs to provide grants to States and local agencies for the conduct and improvement of comprehensive State and areawide health planning. In addition, the program develops and provides assistance to projects which train participants in the comprehensive health planning process. @l nation: This activity provides consultation and technical assistance to States, communities, providers of health services, medical and health services, medical and health organizations and other Federal units. Also, develops national policies and criteria for use by the regional offices and provides leadership in the health planning field. Accomplishments in 1972: Guidance and technical assistance were given to State planning agencies in each of the 50 States, the District of Columbia and 5 Territories, 172 areawide health planning agencies, and training institutions for health planning. Objectives for 1973: To improve staff capability to respond to State and areawide agencies'needs for technical assistance and consultation. To devise ways to help State and areawide ag6nc4@es to learn from each other's successes. HEALTH SERVICES AND MENTAL HEALTH ADMINISTRATION Health services planning and development Program Purpose and Accomplishments Activity: Regional medical programs - Grants and contracts (PHS Act, Title IX, Secs. 301, 311, 402(g), 403(a)(1), 433(a)) 1973 Budget -1972 - Estimate Pos. Amount Authorization Pos. Amount Budget Authority -- $94,800YO00 $250,000,000 $125,100,000 Obligations -- $139,300,000 $125,100,000 Purpose: Funds are used for grants and contracts which on a regional basis encourage common efforts of health providers at all levels to systematically identify health problems, and develop programs which provide solutions to these problems. Explanation: Applications for grants are submitted by each regional medical pro- gram. Applications are received in Review Committee and by Council for approval of funding. Contracts are reviewed by a Contracts Committee and approved by the Director. The final contract is negotiated, in accordance with prescribed regula- tions, by Health Services and Mental Health Administration contract officers. Accomplishments in 1972: Regional Medical Programs have been organized as func- tional consort@Lums of heall7b care providers, each with special and specific resources which can be made responsive to health needs. The merger of providers has produced systematic approaches to the major di.seases of the heart as well as cancer and kidney disease. In 1972, the affiliated health providers with the aid of the Regional Medical Program mechanism, are promoting and demonstrating at the local levels, new techniques and innovative delivery patterns that lead to improved accessibility, efficiency and effectiveness of health care. Efforts at both regional and national levels are being directed to encourage providers of health care to make care available and accessible to areas where there is a distinct scarcity of resources, particularly in the rural and inner city areas. In 1972, a construction grant has been made for a regional cancer center in Seattle, Washington. Objectives for 1973: Funds will be provided for programs to enable existing health manpower to provide more and better care and training and more effective utilization of new kinds of health manpower. New funds will be used to plan and develop Area@Health Education Centers, which will be major sources of manpower for Health Maintenance Organizations, Experimental Health Service Delivery Systems and other comprehensive health care systems. 160 Activities aimed at improving the accessibility, efficiency, and quality of health care will provide opportunities to increase the rate of implementation of systems, innovations and new technology. Rural health care systems will be developed that are comparable with needs of rural areas; development of emergency health care systems and development of integrated regional systems which will prevent duplications of specialized resources. The provider-initiated activities leading to a greater sharing of health facilities, manpower, and other resources will provide the opportunity to show how scarce resources can be linked together efficiently. HEALTH SERVICES AND MENTAL HEALTH ADMINISTRATION Health services planning and development Program Purpose and Accomplishments Activity: Regional medical programs - Direct operations (PHS Act, Sec. 301) 1973 Budget 1972 Estimate Pos. Amount Authorization Pos. Amount 169 $4,602,000 --- 194 $5,051,000 Purpose: Evaluates, processes and awards grants; provides the principal point of contact between the service and the individual Regions for assisting in the development and implementation of cooperative program arrangements. Develops and maintains appropriate relationships with government and private agencies concerned with improving the organization and delivery of health services. Explanation: Applications from Regional Medical Programs are reviewed by special consultants, other Federal agencies and Service staff and are then analyzed and integrated for presentation to Review Committee. A written Summary of Committee review is provided for presentation to the Council. Technical assistance is provided in the development and coordination of programs aimed at improving the availability and quality of hea t care. Accomplishments in 1972: The Anniversary Review process has been refined and the review and award process is being accomplished through a triennial review by the National Advisory Council. Additionally, this activity continues to provide Health Services data,to the 56 Regional Medical Programs as required for their planning and operational programs. This activity provides technical assistance to the regions. In 1972 the primary emphasis will be on local health requirements and needs. Some major studies associated with the coordination and execution of continuing education are those associated with the coordination and training programs such as: (1) development of professional consensus on regional programming for long-term control. of hypertension; (2) development of regional operational information services to promulgate each regions experiences to the other regions and (3) a study of the cooperation in trials and observation of experimental services such as "Physician Assistant" plans. Each of these programs and studies are designed to develop criteria for evaluation and to assist in the development of effective regional systems of health. Objectives for 1973: To provide the strong leadership to the Regional Medical Programs, particularly the weaker ones, required by the expansion and redirection of Regional Medical Program activities. The rapid expansion of Regional Medical Program activity and the movement into new areas of emphasis will require additional development of policy guidance and criteria for project development. Increased technical assistance will be needed for new projects in areas involving new techniques and innovative delivery patterns, more effective use of new kinds of health manpower, and the quality of care guidelines. 162 HEALTH SERVICES AND MENTAL HEALTH ADMINISTRATION Health services planning and development Program Purpose and Accomplishments Activity: Medical facilities construction--Construction grants,(Public Health Service Act,Sec,601) 1973 Budget 1972 Estimate Pos. Amount Authorization Pos. Amount Budget Authority --- $197,200,000 $417,500,000 --- $85,000,000 Obligations --- 87,192,00 --- 175,221,000 Purpose: Formula grants, matched by local funds, are used for construction of new buildings, for expansion or remodeling of existing buildings, for moderni- zation of obsolete facilities, for replacement of obsolete equipment, and for the purchase of initial equipment for new, expanded or modernized facilities. Explanation:, Applications for grants are submitted by public bodies or private nonprofit organizations to the designated state agency and selected for funding based on points established in the State plan. Applications are reviewed and approved by the DHEW Regional Offices. Accomplishments in 1972: In 1972, the $197,200,000 appropriated for construc- tion grants will assist in the construction of an estimated 445 health facility projects. Of those, 232 will be outpatient facility projects, 47 will be re- habilitation facility projects, 42 will be long-term care facility projects, 57 will be hospital projects and 67 will be modernization projects. Objectives for 1973: Tie Health Care Facilities Service will encourage max- im= flexibility iW-the use of construction support funds by applying them to projects which will serve other HSMU and Department programs. Hill-Burton grants will, be used to construct community mental health centers, for facilities to house health maintenance organizations and for comprehensive health care centers which include programs in maternal and child health, family planning, drug abuse prevention and care' and alcoholic rehabilitation. of the $85,000,000 requested for construction grants in 1913, $70,000,000 will be invested in 194 outpatient facility projects and $15,000,000 will be used to support 49 rehabilitation facility projects. IG3 HEALTH SERVICES AND MENTAL HEALTH ADMINISTRATION Health services planning and development Program Purpose and Accomplishments Activity: Medical facilities construction--Direct loans, (Public Health Service Act, Sec. 620) 1973 Budget 1972 Estimate Pos. Amount Authorization Pos. Amount $30,000,000 ------------- ------ PuERose: Construction of health facilities owned by public agencies (states, cities, counties, hospital districts, etc.), which are precluded by local laws from borrowing mortgage funds from commercial lenders, is supported by a program of direct loans. Explanation: This mechanism of assistance enables public agencies to partici- pate in the loan guarantee and interest subsidy program. Loans would be made from a revolving fund capitalized with a $30,000,000 appropriation in 1972. The debt obligations, usually in the form of bonds, received for the loans would be sold by HEW to the Federal National Mortgage Association and other investors. Proceeds from t--hese sales by HEW would be used to provide capital for additional direct loans. Accgmplishments in 1972: Program regulations ha-ve been published and agreements with the Federal Nati n@l Mortgage Association and private bond investment con- cerns regarding procedures for committing and transferring bond obligations are being negotiated. Approximately $30,000,000 in direct loans will be com- mitted in 1972. objectives for 1973: Additional experience and streamlining of procedures will permit extensive Ut-ilization of the program in 1973. Depending on the volume of loan applications, it is anticipated that conmittmeuts to use revolving fund capital several times will be made. C) 4 HEALTH SERVICES AND MENTAL HEALTH ADMINISTRATION Health services planning and development Program Purpose and Accomplishments Activity: Medical facilities construction--Interest subsidies (Sec. 626 (a) (1) of the Public Health Service Act) 1973 Budget 1972 Estimate Pos. Amount Authorization Pos. Amount Budget Authority Such amounts as --- $20,300,000 necessary --- $2,500,000 Obligations --- 5,000,000 --- 22,000,000 ose.- Loan guarantees with interest subsidies provide another form of Federal assistance to private nonprofit and public agencies for hospital construction. Federal participation in debt service costs is authorized to reduce the rate of interest paid on approved projects by 3 percent. Explanation- Interest subsidies are paid on guaranteed loans made to private nonprofit anct publicly-owned hospitals. The subsidy serves to reduce the rate of interest paid by the borrowing institution by three percent. In the cage of private non-profit hospitals, subsidies are paid only on loans guaranteed by Hill-Burton. Hospitals owned by public agencies are eligible for direct Hill-Burton loans paid out of a revolving fund. The fund is replenished by selling the obligations received for the loans to the Federal National Mortgage Association and other investors at a higher, taxable interest rate. Interest subsidy appropriations are used to supplement the higher interest rate. Accomplishments in 1972: Approximately $170 million worth of loans will be ranteed or directly made in 1972, requiring $5,000,000 in interest sub- sidies. Twenty-three projects, building or modernizing facilities for 3,300 inpatient beds, will be supported. objectives for 1973: $605,000,000 worth of loans will be guaranteed in 1973 resulting in 83 projects adding or modernizing over 12,000 beds. The program will require $17,900,000 to subsidize current loan guarantees and $4,900,000 to subsidize prior loan guarantees for a total of $22,800,000. of this amount $2,500,000 is requested in 1973 with the remainder carried-forward from previous appropriations. 165 HEALTH SERVICES AND MENTAL HEALTH ADMINISTRATION Health services planning and development Program Purpose and Accomplishments Activity: Medical facilities construction--District of Columbia medical facilities (Sections 2 and 3 of the District of Columbia Medical Facilities Construction Act of 1968) 1973 Budget 1972 Estimate Pos. Amount Authorization Pos. Amount Budget Authority --- $42,127,000 Expired Obligations --- 38,967,000 --- ----- Purpose: Funds for grants or loans are for the construction and modernization of hospitals and other medical facilities in the District of Columbia. Explanation: Grants and loans are awarded on a project basis. Federal payment made under this Act for the construction of long-term care facilities, including extended care facilities, outpatient facilities, or rehabilitation facilities, may not exceed 66-2/37. of cost of such project. In the case of any other pro- ject (including a modernization project), the Federal payment may not exceed 507. of the cost of such project. Loans shall bear interest at the rate of 2-1/27. per annum and shall be repaid over a period not to exceed 50 years. Accomplishments in 1972: In 1972, 5 loans totaling $16,575,000 and 4 grants totaling $22,167,000 will be awarded to the following hospitals: Loans Grants Rogers mem rial Hospital Georgetown University Hospital Childrens Hospital Washington Hospital Center George Washington University Hospital Childrens Hospital Georgttown University Hospital Rogers Memorial Hospital Washington Hospital Center Legislation for this program expires on June 30,1972 HEALTH SERVICES AND MENTAL HEALTH ADMINISTRATION Health services planning and development Program Purpose and Accomplishments Activi@. Medical facilities construction--Hospital expermentation projects (Public Health Service Act, section 304 and 643A) 1973 Budget 1972 Estimate Pos. Amount Authorization Pos. Amount --- $15,000,000 --- ------ Purpose: Funds for grants or loans are for the construction of hospitals or otrer ;;dical facilities which demnstrate experimental hospital design. Explanation: Grants and loans are awarded on a project basis. Grants are awarded to provide construction of hospitals, facilities for long-tern care, or other utedical facilities which involve experimental designs or methods of construction to serve as demonstrations relating to delivery of health services. Loans are awarded to provide up to 66 2/37. of the increased cost of projects for the construction of demonstration of experimental hospitals. Loans shall bear interest at the rate of 2 1/27. per annum and shall be repaid over a period not to exceed 50 yearso Accomplishments in 1972: The $15,000,000 appropriated in 1972 will be placed in reserve in order to reduce Federal outlays. objectives for 1973: No funds are being requested for 1973. 167 HEALTH SERVICES AND MENTAL HEALTH ADMINISTRATION Health services planning and development Program Purpose and Accomplishments Activity: Medical fa cilitice construction--Direct operations 1973 Budget 1972 Estimate Too-. Amount Authorization Pos. Amount Budget Authority 135 $31058,000 ----------- 135 $3,259,000 Obligations 135 2,932,000 135 3,259,000 Purpose: To provide national leadership in the planning, programming, design anT functioning of all types of medical facilities, and to provide,State agencies with technical assistance in determining additional facilities re- quited and developing programs to meet the indicated needs. Explanation: State plans are reviewed for conformance with planning criteria and guidelines. Assistance is provided to the States and communities in the planning, programming, designing and functioning of hospitals and other health facilities, and proposed projects are reviewed to determine eligibility and compliance with the law and regulations. Accomplishments in 1972: Technical assistance and consultation to project sponsors and State agencies regarding all aspects of program administration were provided; guidelines, regulations, procedures and policies were developed and revised; basic documents, such as State plans, project applications and as- sign drawings were reviewed and approved: surveillance over bid awards and construction of facilities was maintained; statistical data regarding health facility planning was compiled and analyzed; and several other facility con- struction programs were assisted with the above activities. in addition, implementation in 1972 of the loan guarantee and direct loan program was undertaken. objectives for 1973: The staff will update and revise regulations and gui a- lines as changes occur in the planning, design, equipping, functional layout and construction of all types of health facilities and will continue to pro- vide national leadership in all aspects of health facility construction. Considerable emphasis will.be placed on completing implementation of the loan guarantee and direct loan program begun in 1972. l@G8 HEALTH SERVICES AND MENTAL HEALTH ADMINISTRATION Health services planning and development Program Purpose and Adcomplishments Activity: Program direction and management services 1973 Budget 1972 Estimate Pos. Amount Authorization Pos. Amount 149 $2,586,000 Indefinite 149 $2,710,000 PurRose: This activity provides for the overall planning, direction and administration of the broad scope of programs of the Health services planning and development appropriation. Ealanation: It includes program planning and evaluation activities which focus on program, operational, and legislative planning. Administrative management is responsible for the development, coordination, direction, and assessment of management activities. It directs such services as financial, personnel, and conttact,management. Health Services Planning and Development Allocations of Grants to States for Comprehensive State Health nin 1971 1972 1973 Actual Allocation Estimate Alabama ......................... $151,600 $143,500 $180,000 Alaska .......................... 76,800 76,800 100,000 Arizona ......................... 76,800 76,800 100,000 Arkansas ........................ 86,200 83,200 102,800 California ...............I ....... 491,500 500,500 674,500 Colorado ........................ 76,800 76,800 100,000 Connecticut ................. i ... 76,800 76,800 100,000 Delaware ........................ 76,800 76,800 100,000 District of Columbia ............ 76,800 76,800 ioo,ooo Florida .......................... 199,700 207,300 285,400 Georgia .... ..................... 167,400 160,800 206,600 Hawaii ........................... 76,800 76,800 100,000 Idaho ... i....................... 76,800 76,800 100,000 Illinois .............. .......... 278,400 279,000 367,100 Indiana ......................... 150,500 151,600 205,900 Iowa.... 85,400 85,700 114, 0 76,800 76,800 100,000 Kentucky ........................ 122,600 l2li7OO 157,600 Louisiana ....................... 142,600 141,000 178,200 Maine ........................... 76,800 76,800 100,000 Maryland ........................ 100,900 103,600 138,800 Massachusetts ................... 143,000 147,300 194,900 Michigan ........................ 239,300 239,100 327,200 Minnesota ....................... 111,100 112,600 149,800 Mississippi ..................... 113,800 107,500 127,600 Missouri ........................ 143,300 145,500 189,300 Montana ......................... 76,800 76,800 100,000 Nebraska ........................ 76,800 76,800 100,000 Nevada .......................... 76,800 76,800 100,000 New Hampshire ................... 76,800 76,800 100,000 New Jersey ...................... 181,300 181,900 234,400 New Mexico ...................... 76,800 76,800 100,000 New York ......................... 442,800 440,700 569,200 North Carolina .................. 196,000 189,300 236,900 North Dakota ............ I ........ 76,800 76,800 100,000 170 Health Services Planning and Development Allocations of Grants to States for Comprehensive State Health Planning (cont'd) 1971 1972 1973 Actual Allocation Estimate Ohio ............................ $307,000 $306,600 $400,600 Oklahoma ........................ 89,400 90,400 116,300 Oregon .......................... 76,800 76,800 100,000 Pennsylvania ............... ... 346,300 346,800 446,500 Rhode Island ............... :: ... 76,800 76,800 100,000 South Carolina .................. 113,500 106,900 132 10 South Dakota .................... 76,800 76,800 10 , Tennessee ............. 155,000 150,400 190,900 Texas ....................... 370,500 369,700 479,100 Utah ............................ 76,800 76,800 100,000 Vermont ......................... 76,800 76,800 100,000 Virginia ............... I ......... 152,700 151,200 192,900 Washington ..... 92,500 95,300 127,500 West Virginia..: ....................... 76,800 76,800 100,000 Wisconsin ....................... 126,300 130,900 178,900 Wyoming ......................... 76,800 76,800 100,000 Guam ............................ 76,800 76,800 100,000 Puerto Rico ............. i ....... 224,000 234,600 294,800 Virgin Islands .................. 76,800 76,800 100,000 American Samoa .................. 76,800 76,800 100,000 Trust Territory of the Pacific Islands ....................... 76,800 76,800 100,000 TOTAL ................... ... 7,598,200 7,598,200 9,900,000 Evaluation Amount.Z/ ..... : ... 76,800 76,800 100,000 Grand Total ................. 7,675,000 7,675,000 10,000,000 I/ Allocation a are awarded to States based on population weig te y per capita income, and a requirement that each State receive a minimum of one percent of the amount available for allotment. 2/ A-utborized by P.L. 91-29 1 71 Health Services Planning and Development ALLOCATIONS TO STATES For Construction and Modernization of Hospitals and Related Health Facilities Fiscal Year 1971 1972 1973 Totals $111,720,000 $194,900,000 $85, 00,000 Alabama 3,583,851 4,188,571 2,280,880 Alaska 1,200,000 1,200,000 300,000 Arizona 1,750 396 1,819,715 869,221 Arkansas 2,310:311 2,521,617 1,305,875 California 8,715,388 10,969,161 5,381,676 Colorado 1,966,225 2,149,437 927,368 Connecticut 1,967,408 1,967,424 650,977 Delaware 1,200,000 1,200,000 300,000 District of Columbia 1,200,000 1,200,000 300,000 Florida 5,042,959 6,013,391 3,062,420 Georgia 4,124,611 4,723,773 2,485,192 Hawaii 1,233,723 1,227,026 329,177 Idaho 1,317,315 1,334,854 438,668 Tlltnois 6,005,622 7,226,850 2,965,145 Indiana. 3,906,922 4,639,957 2,024,093 Iowa 2,608,846 2,927,735 1,170,640 Kansas 2,345,838 2,463,324 947,392 Kentucky 3,201,234 3,669,239 1,910,800 Louisiana 3,857,231 4,400,140 2,143,059 Maine 1,454,903 1,475,010 541,781 Maryland 2,295,896 2,573,699 1,246,392 Massachusetts 4,351,125 4,794,952 1,667,528 Michigan 5,248,395 6,367,206 2,922,847 Minnesota 3,153,688 3,580,635 1,548,980 Mississippi 2,785,582 3,078,736 1,667,695 Missouri 3,940,580 4,536,710 2,013,164 Montana 1,278,915 1,294,566 396,023 Nebraska 1,492,746 1,523,755 626,199 Nevada 1,200,000 1,200,000 300,000 New Hampshire 1,254,586 1,262,946 367,454 New Jersey 4,527,306 5,150,828 1,986,719 New Mexico 1,466,199 1,489,209 588,587 New York 10,344,755 11,642,494 4,435,453 North Carolina 5,128,165 5 907,674 2,950,461 North Dakota 1,281,757 1:288,394 387,355 Ohio 6,538,653 8,067,855 4,010,144 Oklahoma 2,567,115 2,870,251 1,370,029 Oregon 1,838,826 1,967,281 872,141 Pennsylvania 9,538,650 11,341,528 4,599,219 Rhode Island 1,273,925 1,276,467 375,220 ALLOCATIONS TO STATES - Continued J.72 For Construction and Modernization of Hospitals and Related Health Facilities Fiscal Year 1971 1972 1973 South Carolina 2,996,889 3,342,108 1,703,903 South Dakota 1,298,046 1,299,489 396,855 Tennessee 4,233,766 4,886,243 2,370,731 Texas 9,504,132 11,333,449 5,512,489 Utah 1,454,762 1,478,323 589,072 Vermont 1,200,000 1,200,000 300,000 Virginia 4,125,804 4i7O2,248 2,210,385 Washington 2,461,557 2,747,025 1,156,791 West Virginia 2,450,982 2,627,584 1,108,238 Wisconsin 3,265,948 3,879,886 1,765,555 Wyoming 1,200,000 1,200,000 300,000 American Samoa 750,000 750,000 150,000 Guam 750,000 750,000 150,000 Puerto Rico 4,028,467 4,671,235 2,320,007 Trust Territory 750,000 750,000 150,000 Virgin Islands 750,000 750,000 150,000 ALLOCATIONS TO STATES FOR CONSTRUCTION AND MODEMZATTON OF HOSPITAL AND HEALTH REIATED FACILITIES 7OR FISCAL YKAR 1971 AS OF JULY 1, 1971 Hospitals and Long-Term Rehabili- Moderni- Public Health Care Outpatient I tation State Total zation Centers Facilities Facilities Facilities Total $171,720,000 $57,609,575 $19,252,623 $18,583,846 $62,179,197 $14,094,059 Alabama 3,583,851 1,286,706 600,000 581,445 818,645 297,055 Alaska 1,200,000 1,000,000 - - 100,000 100,000 Arizona 1,750,396 300,000 300,000 300,000 707,061 143,335 Arkansas 2,310,311 498,327 790,000 110,000 780,816 131 168 California 8,715,388 2,325,744 300,000 867,725 4,341,761 880:158 Colorado 1,966,225 526,417 300,000 300,000 69 141,550 Connecticut 1,967,408 874,739 83,000 - 900,000 109,669 Delaware 1,200,000 300,000 300,000 300,000 200,000 100,000 Dist. of Col. 1,200,000 300,000 300,000 300,000 200,000 100,000 Florida 5,042,959 1,210,984 300,000 503,278 2,518,208 510,489 Georgia 4,124,611 1,020,000 326,492 434,998 1,976,564 3 5 Hawaii i,233,723 220,325 379,675 300,000 233,723 100,000 Idaho 1,317,315 300,000 300,000 300,000 317,315 100,000 Illinois 6,005,622 2,431,.171 300,000 466,568 2,334,529 473,254 Indiana 3,906,922 1,392,815 300,000 315,492 1,578,602 320,013 Iowa 2,608,846 920,196 313,921 300,000 905,157 169,572 Kansas 2,345,838 150,096 I,,148,333 738,200 209,400 99,809 Kentucky j,201,234 630,159 300,000 323,609 1,619,219 328,247 Louisiana 3,857,231 1,012,706 216,960 410,000 1,843,793 373,772 Maine 1,454,903 300,000 300,000 328,282 426,621 100,000 Maryland 2,295,896 477,365 300,000 300,000 1,013,147 205,384 Massachusetts 4,351,125 2,075,926 300,000 300,000 1,392,843 282,356 Michigan 5,248,395 1,676,086 300,000 466,277 2,333,073 472,959 Minnesota 3,153,688 925,870 1,653,914 - 320,451 253,453 Mississippi 2,785,582 364,414 900,000 2,249 1,312,339 206,580 Missouri 3,940,580 1,319,049 300,000 330,799 1,655,193 335,539 Montana 1,278,915 378,477 194,091 300,000 278,915 127,432 Nebraska 1,492,746 300,000 307,018 300,000 492,746 92,982 Nevada 1,200,000 1,184,265 - - - 15,735 New Hampshire 1,254,586 300,000 300,000 300,000 254,586 100,000 New Jersey 4,527,306 1,980,923 300,000 320,091 11601,614 324,678 New Mexico 1,466,199 771,764 155,000 36,800 404,500 98,135 New York 10,344,755 4,563 297 300,000 781,063 3,908 140 792,255 North Carolina 5,128,165 3,500:781 300,000 516,811 386'356 North Dakota 1,281,757 300,000 300,000 300,000 281,757 100,000 Ohio 6,538,653 1,638,075 300,000 655,545 3,260,095 664,938 Oklahoma 2,567,115 1,029,364 175,000 - I,,133,058 229,693 'Oregon 1,838,826 423,943 300,000 300,000 677v534 137,349 Pennsylvania 9,538,650 3,929,849 300,000 756,461 3,785,040 767,300 Rhode island 1,273,925 300,000 300,000 300,000 273,925 @100,000 South Carolina 2,996,889 594,310 300,000 300,000@ 1,498,753 303,826 South Dakota 1,298 046 300,000 300,000 300,000 298,046 100,000 Tennessee 4,233:766 2,327,741 977. 277 241,01@6 380,012 307,720 Texas 9,504,132 2,656,156 300,000 1,418,733 4,277,059 852,184 Utah 1,454,762 900,000 - @200,000 254,762 100,000 Vermont 1,200,000 300,000 600,000 - 200,000 100,00 Virginia 4,125,804 1,174,806 300,000 377,746 1,890,094 383,1@8 Washington 2,461,557 766,321 300,000 300,000 910,633 184,603 West Virginia 2,450,982 717,316 300,000 300,000 942,586 191,080 Wisconsin 3,265,948 1,010,923 300,000 300,000 1,376,0619 278,956 Wy-ing 1,200,000 705,397 31,942 200,000 252,161 10,500 American Samoa 750,000 200,000 200,000 200,000 ioo,ooo 50,000 Guam 750,000 200,000 200,000 200,000 100,000 50,000 Puerto Rico 4,028,467 916,672 300,000 400,658 2,004,738 406,399 Trust Territory 750,000 200,000 200,000 200,000 100,000 50,000 Virgin islands 750,000 200,000 200,000 200,000 ioo,ooo 50,000 FISCAL YEAR 1972 GRANT ALLOCATIONS TO STATES FOR CONSTRUCTION AND MODERNIZATION OF ROSPITAIS AND OTHER HEALTH FACILITIES Hospitals and Long-Term Rehabili- Public Health Care Outpatient tation States Total modernization Centers Facilities Facilities Facilities Total $194,900,000 @50,000,000 $40,250,000 $19,650,000 $70,000,000 $15,000,000 Alab-.q 4,188,571 526,566 1,014,369 3559837 1,904,969 386,830 Alaska 1,200,000 300,000 300,000 300,000 200,000 100,000 Arizona 1,819,715 300,000 374,222 300,000 702,783 142,710 Arkansas 2,521,617 330,126 580,330 300,000 1,089,852 221,309 California .10,969,161 2,357,609 2,385,384 836,785 4,479,716 909i667 Colorado 2,149,437 536,814 402,727 300,000 756,316 153,580 Connecticut 1,967,424 717,225 300,000 300,000 540,453 109,746 Delaware 1,200,000 300,000 300,000 300,000 200,000 100,000 Dist. of Columbia 1,200,000 300,000 300,000 300,000 200,000 100,000 Florida 6,013,391 1,224,471 1,326,522 465,340 2,491,189 505,869 Georgia 4,723,773 757,180 1,098,739 385,434 2,063,416 419,004 Hawaii 1,227,0@-6 300,000 300,000 300,000 227,026 100,000 Idaho 1,334,854 300,000 300,000 300,000 334,854 100,000 Illinois 7,226,850 2,453,126 1,322,313 463,863 2,483,284 504,264 Indiana 4,639,957 1,407,044 895,511 314,142 1,681,757 341,503 Iowa 2,927,735 929,882 520,920 300,000 978,280 198,653 Kansas 2,463,324 781,623 423,921 300,000 796,118 161,662 Kentucky 3,669,239 625,092 841,934 300,000 1,581,141 321,072 Louisiana 4,400,lzC 960,342 952,820 334,245 1,789,376 363,357 Maine 1,475,010 330,596 300,000 300,000 444,414 100,000 Maryland 2,573,699 484,261 549,019 300,000 1,031,050 209,369 Massachusetts 4,794,952 2,082,480 740,173 300,000 1,390,034 282,265 Michigan 6,367,206 1,691,057 1,295,2.85 454,382 2,432,525 493,957 Minnesota 3,580,635 1,056,987 682,240 300,000 1,281,236 260,172 Mississippi 3,078,736 346,767 746,155 300,000 1,4019268 284,546 Missouri 4,536,710 1,321,257 890,675 312,446 1,672,673 339,659 Montana 1,294,566 300,000 300,000 300,000 294,566 100,000 Nebraska 1,523,755 300,000 300,000 300,000 518,472 105i2 3 Nevada 1,200,000 300,000 300,000 300,000 200,000 100,000 New Hampshire 1,262,946 300,000 300,000 300,000 262,946 100,000 New Jersey 5,150,828 1,986,963 876,385 307,433 1,645,838 334,ZO9 New Mexico 1,489,209 300,000 300,000 489,209 100,000 New York 11,642,494 4,527,098 1;970,952 691,403 3,701,418 751,623 North Carolina 5,907,674 1,182,071 1,308,984 459,187 2,458,251 499,181 North Dakota 1,288,394 300,000 300,000 300,000 288,394 100,000 Ohio 8,061-,855 1,640,149 1,780,463 624,581 3,343,682 678,980 Oklahoma 2,870,251 603,422 603,445 300,000 1,133,260 230,124 Oreg*n 1,967,281 429,874 379,650 300,000 712,977 144,780 Pennsylvania 11,341,528 3,935,804 2,051,372 719,615 3,852,446 782,291 Rhode Island 1,276,4,67 300,000 300,000 300,000 276,467 100' 000 South Carolina 3,342,108 581,376 754,980 300,000 1,417,840 287,912 South Dakota 1,299,489 300,000 300,000 300,000 299,489 100,000 Tennessee 4,886,243 1,104,934 1,047,416 367,430 1,967,031 399,432 Texas 11,333,449 2,598,329 2,419,612 848,793 4,543,996 922,719 Utah 1,478,323 300,000 300,000 300,000 478,323 100,000 Vermont 1,200,000 300,000 300,000 300,000 200,000 100,000 Virginia 4,702,248 1,167,546 979,105 343,467 1,838,748 373,382 Washington 2,747,025 772,880 513,646 300,000 964,620 195,879 West Virginia 2,627r584 712,289 495,591 300,000 930,711 188,993 Wisconisn 3,879,886 1,028,172 782,894 300,000 1,470,263 298,557 ,WY-ing 1,200,000 300,000 300,000 300,000 200,000 100,000 American Samoa 750,000 200,000 200,000 200,000 100,000 50,000 Guam 750,000 200,000 200,000 200,000 100,000 50,000 Puerto Rico 4,671,235 908,588 1,042,246 365,617 1,957,323 397,461 Trust Territory 750,000 200,000 200,000 200,000 100,000 50,000 Virgin Islands 750,000 200,000 200,000 200,000 100,000 50,000 --j 'I 77 TENTATIVE ALLOCATIONS TO STATES FOR CONSTRUCTION AND MDERNIZATION OF HOSPITALS AND OTHER HEALTH FACILITIES For Fiscal Year 1973 Rehabili- Outpatient tation State Total Facilities Facilities $85,000,000 870.000.00 0 $15,000,000 Alabama 2,280,880 1,895,822 385,058 Alaska 300,000 200,000 100,000 Arizona 869,221 722,479 146,742 Arkansas 1,305,875 1,085,417 220,458 California 5,381,676 4,473,142 908,534 Colorado 927,368 770,810 156,558 Connecticut 650,977 541,079 109,898 Delaware 300,000 200,000 100,000 Dist. of Col. 300,000 200,000 100,000 Florida 3,062,420 2,545,422 516,998 Georgia 2,485,192 2,065,642 419,550 Hawaii 329,177 229,177 100,000 Idaho 438,668 338,668 100,000 Illinois 2,965,145 2,464,569 500,576 Indiana 2,024,093 1,682,386 341,707 Iowa 1,170,640 973,013 197,627 Kansas 947,392 787,453 159,939 Kentucky 1,910,800 1,588,219 322,581 Louisiana 2,143,059 1,781,268 361,791 Maine 541,781 441,781 100,000 Maryland 1,246,392 1,035,976 210,416 Massachusetts 1,667,528 1,386,016 281,512 Michigan 2,922,847 2,429,412 493,435 Minnesota 1,548,980 1,287,481 261,499 Mississippi 1,667,695 1,386,155 281,540 Missouri 2,013,164 1,673,302 339,862 Montana 396,023 296,023 100,000 Nebraska 626,199 520,484 105,715 Nevada 300,000 200,000 100,000 New Hampshire 367,454 267,454 100,000 New Jersey 1,986,719 1,651,321 335,398 New Mexico 588,587 488,587 100,000 Ne,# York 4,435,453 3,686,560 748,793 North Carolina 2,950,461 2,452,364 498,097 North Dakota 387@355 287,355 ioo,o Ohio 4,010,144 3,333,152 676,992 Oklahoma 1,370,029 1,138,741 231,288 Oregon 872,141 724,906 147,235 Pennsylvania 4,599,219 3,822,779 776,440 Rhode Island 375,220 275,220 100,000 South Carolina 1,703,903 1,416,250 287,653 South Dakota 396,855 296,855 100,000 Tennessee 2,370,731 1,970,504 400,227 Texas 5,512,489 4,581,871 930,618 utah 589,072 489,072 100,000 178 TENTATIVE ALLOCATIONS TO STATES FOR CONSTRUCTION AND MDENIZATION OF HOSPITALS AND OTHER HEALTH FACILITIES (Continued) Rehabili- Outpatient tation State Total Facilities Facilities Vermont 300,000 200,000 100,000 Virginia 2,210,385 1,837,228 373,157 Washington 1,156,791 961,502 195,289 West Virginia 1,108,238 921,145 187,093 Wisconsin 1,765,555 1,467,494 298,061 Wyoming 300,000 200,000 100,000 American Samoa 150,000 100,000 50,000 Guam 150,000 100,000 50,000 Puerto Rico 2,320,007 1,928,344 391,663 Trust Territory 150,000 100,000 50,000 Virgin Islands 150,000 100,000 50,000 i. -$19 FY 1971 Loan and Loan Guarantee Allocations to States for Modernization and Construction of Hospitals and other Health Facilities TOTAL $500,000,000 Alabama 8,236,500 New Jersey 18,222,500 Alaska 456,500 New Mexico 2,151,000 Arizona 3,247,500 New York 42,450,500 Arkansas 4,992,000 North Carolina 14,544,000 California 26,721,000 North Dakota Colorado 5,432,500 Ohio 19,301,000 Connecticut 6,509,500 Oklahoma 6,954,000 Delaware 1,659,500 Oregon 4,624,500 Dist. of Columbia 1,355,000 Pennsylvania 37,465,500 Florida 14,470,500 Rhode Island li6l3,500 Georgia 10,460,000 South Carolina 7,670,500 Hawaii 1,323,000 South Dakota 2,496,500 Idaho 1,888,500 Tennessee l2s642,500 Illinois 23,163,000 Texas 29,653,500 Indiana 13,792,000 Utah 2,509,000 Iowa 8,813,500 Vemont 1,098,500 Kansas 7,577,000 Virginia 12,842,000 Kentucky 8,198,000 Washington 7,679,000 Louisiana 11,224,500 West Virginia 7,383,500 Maine 3,369,000 Wisconsin 10,508,500 Wyoming 759,500 Maryland 5,748,500 Massachusetts 18,478,000 American Samoa 79,500 Michigan 17,534,500 Guam 435,500 11,167,000 Minnesota 10,527,000 Puerto Rico Mississippi 5,987,,500 Trust Territories 235,500 Virgin Islands 309,000 Missouri 13,408,000 Montana 2,703,000 Nebraska 3,202,500 Nevada 912,000 New Hampshire 1,894,500 11,10 an and Loan Guarantee Allocations to States for Modernization FY 1972 Lo and Construction of Hospitals and other Health Facilities TORAL $500,000,000 Alabama 8,041,500 New Jersey 18,354,500 Alaska 460,000 New Mexico 2,221,500 Arizona 3,255,000 New York 41,715,000 Arkansas 4,815,500 North Carolina 14,119,000 California 27,244,500 North Dakota 1,938,500 Colorado 5,633,000 Ohio 19,445,000 Connecticut 61509,500 Oklahoma 6,944,500 Delaware 1,720,000 Oregon 4,743,000 Dist. of Columbia 1,353,500 Pennsylvania 37,638,500 Florida i4,5O6,000 Rhode Island 1,629,500 Georgia 10,101,500 South Carolina 7,396,000 Hawaii 1,294,000 South Dakota 2,501,500 Idaho 1,936,000 Tennessee 12 482,000 Illinois 23,637,500 Texas 29:176,000 Indiana 14*114,500 Utah 2,579,000 Iowa 9,039i5OO Vermont 1,102,500 Kansas 7,542,000 Virginia 12,671,000 Kentucky 8,075,000 Washington 7,841,000 Louisiana 11,021,000 West Virginia 7,317,000 Maine 3,423,000 Wisconsin 10,836,000 Wyoming 794,500 Maryland 5,836,000 Massachusetts 18,512,500 American Samoa 68,000 Michigan 17,853,000 Guam 389,000 Minnesota 10,641,500 Puerto Rico 10,999,000 Mississippi 5,613,000 Trust Territory 244,500 Virgin Islands 325,5 Missouri 13,456,500 Montana 2,746,500 Nebraska 3,286,000 Nevada 937,000 New Hampshire 1,924,000 131 Tentative FY 1973 Loan and Loan Guarantee Allocations to States for Modernization and Construction of Hospitals and other Health Facilities TOTAL $500,000,000 Alabam 8,009,500 New Jersey 18,377,500 Alaska 466,000 New Mexico 2,219 500 Arizona 3,329,000 New York 41,650:500 Arkansas 4,800,000 North Carolina 14PO98,000 California 27,216,500 North Dakota 1,934,000 Colorado 5,689,000 Ohio 19,403,500 Connecticut 6,512,000 Oklahoma 6,964,500 Dalawre 1,722,000 Oregon 4,789,000 Dist. Of Columbia 1,333,000 Pennsylvania 37,523,500 Florida 14,711,500 Rhode island 1,624,500 Georgia 10,109,500 South Carolina 7,390,000 Hawaii 1,303,000 South Dakota 2,491,000 Idaho 1,949,500 Tennessee 12,4945500 Illinois 23,5571,500 Texas 29o3l7,000 Indiana 14,117,000 Utah 2,618,500 Iowa 9,020,000 Vermont 1,112,000 Kansas 7,509,000 Virginia 12,665,000 Kentucky 8,100,000 Washington 7,829,000 Louisiana 10,992p5OO West Virginia 7,283,000 Maine 3,413,000 Wisconsin 10,825,000 Maryland 5,856,500 Wyoming 798,500 Massachusetts 18,496,000 American Samoa 67,500 Michigan 17,840,500 Guam '385,000 Minnesota 10,665,500 Puerto Rico 10,903,000 Mississippi 5,561,500 Trust Territory 240,500 Virgin Islands 323 500 Missouri 13,458,500 Montana 2,752,500 Ne6reake 3,294,000 Nevada 947,000 New Hampshire 1,941,000 182 New Positions Requested Fiscal Year 1973 Annual Grade Number Salary Health services research and development Direct @erations Public Health Analyst .................. GS-14 1 $20,815 Health Science Administrator ........... GS-14 1 20,815 Social Science Analyst ................. GS-12 1 15,040 Public Health Analyst .................. GS-12 1 15,040 Program Analyst .............I........... GS-11 1 12,615 Health Statistician .................... GS-11 1 12,615 Statistician..* ........................ GS-9 1 10,470 Staff Assistant ................... i .... GS-7 1 8,582 Secretary .............................. GS-6 2 15,454 Clerical Assistant ..................... GS-5 -2 13,876 12 145,322 Comprehensive health planning fi Direct operations Public Health Advisor .................. GS-15 1 25,583 Health Planner ......................... GS-14 1 21,960 Public Health Program Specialist ............................. GS-14 2 43,920 Health Planner GS-13 1 18,737 Public Health @ro'gr,am ................... Specialist... ......................... GS-13 3 56t2ll Public Health Advisor .................. GS-12 2 31,732 Public Health Program Specialist ............................ GS-12 1 15,866 Program Management Officer ............................... GS-12 1 15,866 Administrative Assistant ............... GS-.ll. 1 13,309 Clerical Assistant ..................... GS-6 3 24,459 Clerical Assistant ..................... GS-5 3 21,957 Clerical Assistant ..................... GS-4 2 13,088 Commissioned Officers: Director Grade ....................... 2 46,048 Full Grade ........................... 2 26,964 25 375,700 Regional medical programs Direct operations Supervisory Public Health Analyst ...... GS-15 1 24,251 Supervisory Systems Analyst ............ GS-14 1 20,815 Public Health Analysts ................. GS-13 3 53,283 Systems Analyst ........................ GS-13 1 17,761 Public Health Advisors.. GS-12 7 105,280 Systems Analyst ......... GS-12 1 15,040i@: Administrative Assistant ............... OS-9 1 10,470 Secretary ............................... GS-6 1 7,727 183 Secretary/Clerk-Typist .............. GS-5 4 27,752 'Clerk-Typist ................ 0 0. GS-4 5 31,010 25 313,389 Total, new positions, all activities 62 .834,411 mm a m m m n m n a 0 a a n n m 0 0 0 a 134 DEPARTMENT OF HEALTH, EDUCATION, AND WELFARE HEALTH SERVICES AND @IENTAL HEALTH ADMINISTRATION Health Services Delivery Page No. Appropriation language ............................................. 186 Explanation of language changes .................................... 189 Amounts available for obligation ................................... 190 Obligations by activity ............................................ 191 Obligations by object .............................................. 193 Summary of changes ................................................. 195 Authorizing legislation ............................................ 199 Explanation of tranfera ............................................ 206 Table on estimates and appropriations .............................. 208 Justification: A. General Statement ............................................ 209 1. Comprehensive health services: (a) Grants to States .................................... 212 (b) Health services grants .............................. 214 (c) Migrant health grants ............................... 215 (d) Direct operations ................................... 217 2. Maternal and child health: (a) Grants to States .................................... 224 (b) Project grants ...................................... 227 (c) Research and training ............................... 231 (d) Direct operations ................................... 233 3. Family planning: (a) Project grants and contracts ........................ 235 (b) Direct operations ................................... 242 4. National health service corps ............................ 244 5. Patient care and special health services: (a) Inpatient and outpatient care ....................... 248 (b) Coast Guard medical services ........................ 249 (c) Federal Employees ................................... 250 (d) Payment to Hawaii ................................... 251 6. Regional office central staff ............................ 252 7. Program direction and management services ................ 253 1.85 DEPARTMENT OF HEALTH, EDUCATION, AND WELFARE HEALTH SERVICES AND MENTAL HEALTH ADMINISTRATION Health Services Delivery Page No. B. Items of special concern: 1. Family vlanning ................................. 210, 234, 264 2. Nursing home improvement ........................ 218, 257 3. Migrant health .................................. 209, 215, 256 4. Status of conversion of PHS hospitals ..................................... 210, 248, 268 5. National health service corps ................... 210, 244, 267 C. Program purposes and accomplishments ................ 254 D. State tables ........................................ 274 E. New positions requested ............................. 280 186 Appropriation Estimate HEALTH SERVICES DEL-T@Y For cary-ging cut, except as otherwise provid ed, sections 301, 310, 311, 314(d), 314(e), 32.1, 322, 324, 326, 328, 329, 33.1, 332, 502, 504, tile X the Public Health Service Act, the Act of August 8, 1946. (5 U.S.C. 7.901), section 1010 of the Act of July 1, 1944 (33 U.S.C. @763c) qcction 1 of the Act of July 19, 1963 (42 U.S.C. 263a), and title V of the Sccial Security Act, $745,657,000, of which $1,200,000 shall be available only for payments to the State of Hawaii for &are and treat- ment of persons afflicted with leprosy: Provided, That any allotment to d State.purstiant to section 503(2) or 504(2) of the Social Security Act shall not be included in computing for the purposes of subsections (a) and (b) of section 506 of such Act an amount expended or estimated to be expended by the State: Provided further, That when the Health Services and Mental Health Administration operates an employee health pro- gram for any Federal department or agency, payment for the estimated cost shall be made by way of reimbursement or in advance to this apprg- p@ation: Provided further, That in addition, $4,719,000 may be trans- ferred to this rop@ation as authorized by section 201(g)(1) of the' app Social Security Act, from any one or all the trust funds referred to 2 @therein: Provided further, That =ounts received for services rendered under section 329 of such Act shall be credited to this appropriation'.. [COMPREHENSIVE HEALTH PLANNING AND SERVI.CES).3 [To carry out sections 310, 314(a) through 314(e), 317, and 329 of the Public Health Service Act, and except as otherwise provided, gections 301 and 311 of the Act, $320,703,000: Provided, That $4,519,000 may be transferred to this appropriation, as authorized by section 2Ql(g)(1) of the Social Security Act, as amended, from 187. any one or all of the trust funds referred to therein, and may be ex- pended for functions delegated to the Administrator of the Health Services and Mental Health Administration under title XVIII of the Social Security Act] [MATERNAL AND CHILD HEALTH]3 [For carrying out, except as otherwise provided, sections 301, 311, and title X of the Public Health Service Act and title V of the Social Security Act, $330,151,000: Provided, That any allotment to a State pursuant to section 503(2) or 504(2) of such Act shall not be included in computing for the purposes of subsections (a) and (b) of section 506 of such Act an amount expended or estimated to be ex- pended by the State.] [Grants made during the current fiscal year for any project under section 508, 509, or 510 of the Social Security Act may be for periods ending prior to July 1, 1973] [PATIENT CARE AND SPECIAL HEALTH SERVICES]3 [For carrying out, except as otherwise provided, the Act of August 8, 1946 (5,U.S.C. 7901), and under sections 301, 311, 321, 322, 324, 326, 328, 331, 332, 502, and 504 of the Public Health Service Actt section 1010 of the Act of July 1, 1944 (33 U.S.C 763c) and section 1 of the'Act of July 19, 1963 (42 U.S.C. 253a), $85,700,000, of which $1,200,000 shall be available only for payments,to the State of Hawaii for care and treatment of persons afflicted with leprosy: Provided, That when the Health Services and Mental Health Administration establishes or operates a health service program for 188 any department or Rgeiicyt payment for the estimated cost shall be made by way of reimbursement or in advance for deposit to the credit of this appropriations] 189 Explanation of Language Changes 3. New lingu.,ige is proposed is a result of the consolidation of three approl)rllLiotlq, "Cc)nipreliensive Ilea.Ith Planiilng and Services", "Maternal and. Child Health", iiii(i "Patient Care and Speci.al Health ServicL-.". This consolida- tioti not only rcflL@cLg a functional grouping of the accounts, but also provides for-betler administration of the I)rbgramg by niaking'the appropriation structure consistent with the current organization of IISMIA. .2.. Language has been added for the National Health Service Corps which would allow funds collected for services to be returned to this appropriation. Under existing authority, any amounts received for services would be deposited in miscellaneous receipts of the Treasury. This proviso is requested in order that fees from third-party payers and individuals who are able to pay may be collected and "re-used" by the program. Also crediting reimbursements to this appropriation'would reduce the amount of direct appropriations requited. 3. Language formerly used for the three consolidated accounts is deleted. DEPARTMENT OF HEALTH, EDUCATION, AND WELFARE HEALTH SERVICES AND MENTAL HEALTH ADMINISTRATION Health Services Delivery Amounts Available for Obligation 1972 1973 Appropriation ..................... $736,554,000 $745,657,000 Proposed supplemental ............. 5,610,000 --- Subtotal, appropriations .......... 742,164,000 --- Real transfers to: "Operating expenses, Public Buildings Service," General Services Administration ...... -31,000 "Salaries and expenses," Economic Stabilization Activities ..... -1,300,000 --- Real transfer from: "Nursing home improvement ........ 4,300,000 Comparative transfers to: "Departmental management ......... -125,000 --- "Health services planning and development ................... -25,935,000 --- "Preventive health services".... -54,300,000 "Office of the Administrator" ... -20,000 --- Comparative transfer from: "Office of the Administrator"... 136,000 --- Subtotal, budget authority ........ 664,889,000 745,657,000 Receipts and reimbursements from: "Federal funds" ................. 16,665,000 16,559,000 "Trust fundsit ................... 4,719,000 4,719,000 "Non-Federal sources ............. 558,000 6,940,000 ,,nobligated balance, start of year 9,000,000 --- v Unobligated balance, lapsing ...... -459.00 --- Total, obligations .......... 695,372,000 773,875,000 191 ob li a ations bV A -,,I ,4 1972 1973 Increase or Page Estimate Estimate Decrease Ref. Pos. Awount Pos. Amount FOS. Amount 211 Comprehensive Health services: 212 (a) Grants to --- $90,000,000 --- --- States ....... --- $90,000,000 214 (b) Health services --- 116,200,000 --- +$12,287,000 grants ....... --- 103,913,000 215 (c) Migrant health grants ....... --- 17,950,000 --- 23,750,000 --- +5,800,000 217 (d) Direct 445 18,862,00 +881,000 operations.-- 445 17,981,000 0 --- Subtotal .... 445 229,844,000 445 248,812,000 --- +18,968,000 223 Maternal and child health: 224 (a) Grants to States ....... --- 121,522,000 --- 125,678,000 +4,156,000 227 (b) Project grants. --- 92,008,000 --- 101,330,000 +9,322,000 231 (c) Research and training ..... --- 21,106,000 --- 21.,392,000 --- +286,000 233 (d) Direct operations ... 133 4.078.000 133 4,148.000 --- +70-000 Subtotal .... 133 238,714,000 133 252,548,000 +13,834,000 234 Family planning- 235 (a) Project grants and contracts --- 94,815,000 --- 137,024,000 +42,209,000 242 (b) Direct operations ... 70 1.438.000 A7 1.187.000 +17 +549,000 Subtotal .... 70 96,253,000 87 139,011.,OOO +17 +42,758,000 244 National health service corps ...... 637 14,117,000 637 14,803,000 --- +686,000 246 Patient care and special health services: 248 (a) Inpatient and outpatient care ......... 5,479 95,237,000 5,479 96,303,000 +1,066,000 249 (b) Coast Guard medical services ..... 151 4,802,000 151 5,105,000 +303,000 250 (c) Federal employees .... 260 4,487,000 260 4,498,000 --- +11,000 251 (d) Payment to Hawaii ....... --- 1.200,000 --- 1, --- subtotal .... 5,890 105,726,000 5,890 107,106,000 --- +1,380,000 252 Regional office central staff ...... 250 5,287,000 250 5,281,000 --- -6,000 1.92 253 Program direction and management services ........... 233 5,431,000 236 6,314,000 +3 +883,000 Total obligations..7,658 695,372,000 7,678 773,875,000 +20 +78,503,000 193 Obligations by Object 1972 1973 Increase or Estimate Estimate Decrease Total number of permanent positions ................ 7,658 7,678 +20 Full-time equivalent of all other positions .......... 401 422 +21 Average number of all employees ................ 7,387 7,886 +499 Personnel compensation: Permanent positions ....... $80,918,000 $84,029,000 +$3,111,000 Positions other than permanent ............. 3,956,000 3,918,000 -38,000 Special personal services, 375,000 375,000 --- Other personnel compen- 4,529,000 4,527,000 -2,000 sation ................. Subtotal, personnel compensation ....... 89,778,000 92,849,000 +3,071,000 Personnel benefits ........ 12,338,000 13,951,000 +1,613,000 Travel and transportation of persons .................. 4,785,000 4,627,000 -158,000 Transportation of things ... 2,716,000 2,169,000 -547,000 Rent, communications and 3,117,000 3.333,000 +216,000 utilities ............... Printing and reproduction 537,000 489,000 -48,000 other services ........... 15,109,000 1.5,782,000 +673,000 Project contracts ...... 15,383,000 15,048,000 -335,000 Supplies and materials .... 11,694,000 12,074,000 +380,000 Equipment ................ 4,143,000 3,930,000 -213,000 Grants, subsidies and contributions .......... 536,071,000 609,922,000 +73,851,000 Subtotal ............. 695,671,000 774,174,000 +78,503,000 194 obligation bv 1972 1973 Increase or Estimate Estimate Decrease Deduct quarters and subsis- -299,000 -299,000 --- tence(-) ................. Total obligations by object ................ 695,372,000 773,875,000 +78,503,000 195 Summary of Changes 1972 estimated obligations ..................I....................... $695,372,000 1973 estimated obligations ......................................... 773,875,000 Net change .......................................... +78,503,000 Base Change from Base' Pos. Amount. Pos. Amount Increases: A. Built-in: 1. Annualization of positions new in 1972 ............... --- --- --- 755,000 2. Within grade and longevity increases ................. --- --- --- 2,511,000 3. Continuation pay costs for commissioned officers (medical) ................. --- --- --- 547,000 4. Annualization of uniformed services pay increase (PL 92-129) ............... --- --- --- 664,000 5. Increases for DHEW Working Capital Fund, HSMHA Service and Supply Fund, and FTS charges ........... --- --- --- 249,000 6. Increase in continuation costs for migrant health projects..* ............... --- --- --- 2,800,000 7. Social Security contri- butions .................. --- --- 36,000 8. Contract medical care and supply price increases ... ... --- 358,000 B. Program: 1. Comprehensive health services: a. Health service grants: (1) Comprehensive health centers ... --- 88,618,000 --- 9,287,000 (2) Family health centers .......... --- 13,000,000 --- 3,000,000 b. Migrant health grants ... --- 17,950,000 --- 3,000,000 c. Direct operations ....... 445 18,811,000 --- 120,000 2. Maternal and child health a. Grants to States for: (1) Maternal and child health services.. 59,250,000 --- 1,528,000 (2) Crippled children's services ......... --- 62,272,000 --- 2,628,000 b. Project grants for: (1) Maternity and infant care ............. --- 43,428,000 --- 3,804,000 (2) Comprehensive health care for children and youth ........ 47,400,000 --- 5,442,000 Base Change from Base Pos. Amount Pos. Amount Program (continued) (3) Dental health of --- 1,180,000 --- 76,000 children ........ --- 15,071,000 --- 286,000 C. Training ............... 133 4,078,000 46,000 d. Direct operations ...... 3. Family planning: a. Project grants and contracts: --- 88,500,000 42,000,000 (1) Service projects.. (2) Education and --- 700,000 209,000 information ..... 70 1,438,000 17 233,000 b. Direct operations ...... 4. Program direction and man- S3 2.133.000 000 agement services ......... Total, increases ... 4 ... 80,273,000 Decreases: A. Built-in: 1. Two less days --- --- -233,000 of pay .................. 2. Decrease resulting from employment Cut-back --- --- -1,514,000 during 1972 .............. --- B. ram: 1. Decrease in reimbursable --- --- -23,000 programs ................. Total, decreases ....... ooo +78.503 000 Total. net change .1,9 7 Explanation of Changes Increases: A. Built-in: An increase of $7,920,000 is for mandatory items. Of this $755,000 is for full-year costs of positions new in 1972, $2,511,000 is for net addi- tional costs of within grade and longevity increases, $547,000 continuation pay costs for medical officers, $664,000 for annualization of uniformed services pay increases, $249,000 DHEW Working Capital Fund, HSMHA Service and Supply Fund, and FTS charges, $2,800,000 increase in continuation costs for migrant health projects, $36,000 increase in Social Security contri- butions, $358,000 contract medical care and supply price increases. B. Program: Health service grants--An increase of $12,287,000 is requested for this activity. These increases would provide support for additional neighborhood health centers previously funded by the Office of Economic Opportunity and the conversion of several Family Bealth Centers from planning to operational status. Migrant health grants--The requested increase of $3000,000 would be used for upgrading existing projects strategically located along the migrant streams to maximize their quality and utilization. Direct tions--An increase of $120,000 is requested for project contracts to initiate a reporting system to collect information on the extent.of health services obtained by migrants and seasonal farmworkers and their families. Maternal and child health services--The $1,528,000 increase will help States maintain the current level of medical care services and partially offset the rising costs of medical care. Crippled children's services--The increase of $2,628,000 will help States in meeting the increased costs of providing the more effective but technically more complex treatment of handicapped children. Maternity and infant care--The increase of $3,804,000 will support expansion of the 56 existing maternity and infant care projects and extend services to an additional 12,000 mothers and infants, for a total of 205,000, in 1973. It will also assure continuation of intensive care to infants in ongoing projects and new projects becoming operational in 1972. Children and youth--The increase of $5,422,000 will assure comprehensive health services to an estimated 547,000 children. This compares with a total of 504,000 expected to be served in 1972. Dental health of children--The increase of $76iOOO will support contin- uation of an estimated 17 dental projects planned to be in operation in 1972. It is expected that these projects will provide comprehensive dental health care to an estimated 22,000 children in 1973. 198 Explanation of changes (continued) Training--The increase of $286,000 will provide the continued support of 19 university-affiliated mental retardation centers and for training personnel in health care and related services for mothers and children. Direct operations--The increase of $46,000 provides for added costs of central services. Family planning services-- The increase of $42,000,000 in obligations for family planning project grants includes $10,000,000 to fund established family planning projects presently funded by the Office of Economic Opportunity. The remaining $32,000,000 will support new or expanded family planning projects with State and local health departments, hospitals, universities, and other public and/or nonprofit organizations. Priority will be given to funding projects serving rural areas, migrants, Appalachia, Spanish-speaking Americans and other hard-to-reach areas and groups. The increase will extend services to approximately 700,000 additional women by the time the funds are totally expended. The total program level for 1973 will provide services to approximately 2,200,000 women when the projects are fully operational. Education--The increase of $209,000 will be used to develop improved educational materials and promote the use of educational methods which have proven their usefulness. Direct operations--The increase of $233,000 will support 17 new positions in the regions and central office to administer the expanded grants and contracts program. P.rogram direction and management services--The increase of $694,000 includes $649,000 to expand the upward mobility program and $45,000 for added costs of central services to administer an expanded family planning grants and contracts program. Decreases: A. Buil.t-in: The decrease of $233,000 represents nonrecurring salary costs result- ing from a reduction of two days of pay in 1973. The decrease of $1,514,000 results from position reductions in line with the Administration's economic policy. B., Program: Inpatient and outpatient care--The decrease of $23,000 represents a -declin6 in reimbursable program. Authorizing Legislation 139 1973 Appropriation Legislation Authorized requested Public Health Service Act Section 310--Grants for Health Services for Domestic Agricultural Migrants .................................... $30,000,000 $23,750,000 Section 314(d)--Grants for Comprehensive Public Health Services .................................... 165,000,000 90,000,000 Section 314(e)--Project Grants for Health Services Development ............. 157,000,000 116,200,000 Section 329--Assignment of Medical and Other Health Personnel to Critical Meed Areas ......................... 30,000,000 8,418,000 PUBLIC HEALTH SERVICE "Health Services for Domestic Agricultural Migrants "Section 310. There ate hereby authorized to be appropriated not to exceed $7,000,000 for the fiscal year ending June 30, 1966, $8,000,000 for the fiscal year ending June 30, 1967, $9,000,000 each for the fiscal year ending June 30, 1968, and the next fiscal year, $15,000,000 for the fiscal year ending June 30, 1970, $20,000,000 for the fiscal year ending June 30, 1971, $25,000,000 for the fiscal year ending June 30, 1972, and $30,000,000 for the fiscal year ending June 30, 1973, to enable the Secretary (1) to make grants to public and other nonprofit agencies, institutions, and organizations for paying part of the cost of (i) estab- lishing and operating family health service clinics for domestic agricultural migratory workers and their families, including training persons (including allied health professions personnel) to provide services in the establishing and operating of such clinics, and (ii) special projects to improve and provide a continuity in health services for and to improve the health conditions of domestic agricultural migratory workers and their families, including necessary hospital care, and including training persons (including allied health professions personnel) to pro- vide health services for or otherwise improve the health conditions of such migra- tory workers and their families, and (2) to encourage and cooperate in programs for the purpose of improving health services for or otherwise improving the health conditions of domestic agricultural migratory workers and their families. The Secretary may also use funds appropriated under this section to provide health services to persons (and their families) who perform seasonal agricultural services similar to the services performed by domestic,agricultural migratory workers if the Secreta@'finds that the provision of health services under this sentence will contribute to the improvement of the health conditions of such migratory workers and their families. For the purposes of assessing and meeting domestic migratory agricultural workers' health needs, developing necessary resources, and involving local citizens in the development and implementation of health care programs authorized by this section, the Secretary must be satisfied, upon the basis of evidence supplied by each applicant, that persons broadly representative of all elements of the population to be served and others in the community knowledgeable I about such needs fiave been given an opportunity to participate in the development of such programs, and will be given an opportunity to participate in the imple.- I mentation of such programs. 200 "Grants for Comprehensive Public Health Services "Section 314. (d) (1) AUTHORIZATION OF APPROPRIATIONS.--There are authorized to be Appropriated $70,000,000 for the fiscal year ending June 30, 1968 ' $90,000,000 for the fiscal year ending June 30, 1969, $100,000,000 for the fiscal year ending June 30, 1970, $130,000,000 for the fiscal year ending June 30, 1971, $145,000,000 for the fiscal year ending June 30, 1972, and $165,000,000 for the fiscal year ending June 30, 1973, to enable the Secretary to make grants to State health or mental health authorities to assist the States in establishing and main- taining adequate public health services, including the training of personnel for State and local health work. The sums so appropriated shall be used for making payments to States which have submitted, and had approved by the Secretary, State plans for provision of public health services. "Project Grants for Health Services Development "(e) There are authorized to be appropriated $90,000,000 for the fiscal year ending June 30, 1968, $95,000,000 for the fiscal year ending June 30, 1969, $80,000,000 for the fiscal year ending June 30, 1970, $109,500,000 for the fiscal year ending June 30, 1571, $135,000,000 for the fiscal year ending June 30, 1972, and $151,000,000 for the fiscal year ending June 30, 1973, for grants to any public or nonprofit private agency, institution, or organization to cover part of the cost (including equity requirements and amortization of loans on facilities acquired from the Office of Economic Opportunity or construction in connection with any program or project transferred from the Office of Economic Opportunity) of (1) providing services (including related training) to meet health needs of limited geographic scope or of specialized regional or national significance, or (2) devel- oping a supporting for an initial period new programs of health services (includ- ing related training). Any grant made under this subsection may be made only if the application for such grant has been referred for review and comment to the appropriate areawide health planning agency or agencies (or, if there is no such agency in the.area, then to such other public or nonprofit private agency or organization (if any) which performs similar functions) and only if the services assisted under such grant will be provided in accordance with such plans as have been developed pursuant to subsection (a). "Assignment of Medical and Other Health Personnel to Critical Need Areas t'Section 329. (a) It shall be the function of an identifiable administrative unit within the Service to improve the delivery of health services to persons living in communities and areas of the United States where health personnel and services are inadequate to meet the health needs of the residents of such communi- ties and areas. 11(g) To carry out the purposes of this section, there are authorized to be appropriated $10,000,000 for the fiscal year ending June 30, 1971; $20,000,000 for the fiscal year ending June 30, 1972; and $30,000,000 for the fiscal year ending June 30, 1973." @oriziug Legislation 201 1973 Appropriation Legislation AuthorizedQ requested Pablic Health Service Act Section 331--Lepers ................. Indefinite $1,200,000 PUBLIC HEALTH SERVICE ACT Title III--General Powers and Duties of Public Health Serwice Part D--Ioapers Appropriation Section 331. "xxx when so provided in appropriations available for any fiscal year for the mintenance of hospitals of the Service, the Surgeon General is authorized and directed to make paymnts to the Board of Health of Hawaii for the care and treatment in its facilities of persons a M icted with leprosy at a per them rate, determined from time to time by the Surgeon General, which s@ subject to the availability of appropriations, be approximately e@ to the per them operating cost per patient of such facilities, except that such per them ra;e s a not be greater than the comparable per them operating cost per patient at the National Leprosarium, Caryi-Ile, Louisiana." 202 Authorizing Legislation 1973 Appropriati-on Legislation Authorized Requested Public Health Service Act: Section 1001 - Grants and contracts for family planning services $90,000,000 $111,500,000!L/ Section 1003 - Training grants and contracts . . . . . . . . . 4,000,000 3,000,000 Section 1004 - Research grants and contracts . . . . . . . . . 65,000,000 2,615,000 Section 1005 - Informational and educational materials . . . . . 1,250,000 909,000 Project Grants and Contracts for Family Planning Services Sec. 1001. (a) The Secretary is authorized to make grants to and enter into contracts with public or nonprofit private entities to assist in the establishment and operation of voluntary family planning projects. (b) In making grants and contracts under this section the Secretary shall take into account the number of patients to be served, the extent to which family planning services are needed locally, the relative need of the applicant, and its capacity to make rapid and effective use of such assistance. (c) For the purpose of making grants and contracts under this section, there are authorized to be appropriated $30,000,000 for the fiscal year ending June 30, 1971; $60,000,000 for the fiscal year ending June 30, 1972; and $90,000,000 for the fiscal year ending June 30, 1973. Training Grants and Contracts Sec. 1003. (a) The Secretary is authorized to make grants to public or nonprofit private entities and to enter into contracts with public or private entities and individuals to provide the training for personnel to carry out family planning service programs described in section 1001 or 1002. (b) For the purpose of making payments pursuant to grants and contracts under this section, there are authorized to be appropriated $2,000,000 for the fiscal year ending June 30, 1971; $3,000,000 for the fiscal year ending June 30, 1972; and $4,000,000 for the fiscal year ending June 30, 1973. Research Grants and Contracts Sec. 1004. (a) In order to promote research in the biomedical, contra- ceptive development, behavioral, and program implementation fields related to family planning and population, the Secretary is authorized to make grants to public or nonprofit private entities and to enter into contracts with public or private entities and individuals for projects for research and research training in such fields. (b) For the purpose of making payments pursuant to grants and contracts under this section, there are authorized to be appropriated $30,000,000 for the fiscal year ending June 30, 1971; $50,000,000 for the fiscal year ending June 30, 203 1972; and $65,000,000 for the fiscal year ending June 30, 1973. Informational and Educational Materials Sec. 1005. (a) The Secretary is authorized to make grants to public or nonprofit private entities and to enter into contracts with public or private entities and individuals to assist in developing and making available family planning and population growth information (including educational materials) to all persons desiring such information (or materials). (b) For the purpose of making payments pursuant to grants and contracts under this section, there are authorized to be appropriated $750,000 for the fiscal year ending June 30, 1971; $1,000,000 for the fiscal year ending June 30, 1972; and $1,250,000 for the fiscal year ending June 30, 1973. 1/ Additional authorizing legislation to be submitted Authorizing Legislation 204 1973 Appropriation Legislation Authorized requested Social Security Act Section 501--Maternal and Child Health and Crippled Children's Services ........... $350,000,000 $267,400,000 SOCIAL SECURITY ACT Title V--Maternal and Child Health and Crippled Children's Services Authorization of Appropriations Section 501. For the purpose of enabling each State to extend and improve (especially in rural areas and in areas suffering from severe economic distress), as far as practicable under the conditions in such State, (1) services for reducing infant mortality and otherwise promoting the health of mothers and children; and (2) services for locating, and for medical, surgical, corrective, and other services and care for and facilities for diagnosis, hospitalization, and aftercare for, children who are crippled or who are suffering from conditions leading to crippling, there are authorized to be appropriated $250,000,000 for the fiscal year ending June 30, 1969, $275,000,000 for the fiscal year ending June 30, 1970, $300,000,000 for the fiscal year ending June 30, 1971, $325,000,000 for the fiscal year ending June 30, 1972, and $350,000,000 for the fiscal year ending June 30, 1973, and each fiscal year thereafter. Purposes for which Funds are Available Section 502. Appropriations pursuant to section 501 shall be available for the following purposes in the following proportions: (1) in the case of the fiscal year ending June 30, 1969, and each of the next 3 fiscal years, (A) 50 percent of the appropriation for such year shall be for allotments pursuant to sections 50'j and 504; (B) 40 percent thereof shall be for grants pursuant to sections 508, 509, and 510; and (C) 10 percent thereof shall be for grants, contracts, or other arrange- ments pursuant to sections 511 and 512. (2) In the case of the fiscal year ending June 30, 1973, and each fiscal year thereafter, (A) 90 percent of the appropriation for such years shall be for allotments pursuant to sections 503 and 504, and (B) 10 percent thereof shall be for grants, contracts, or other arrangements pursuant to sections 511 and 512. Not to exceed 5 percent of the appropriation for any fiscal year under this section shall be transferred, at the request of the Secretary, from one of the purposes specified in paragraph (1) or (2) to another purpose or purposes so specified. For each fiscal year, the Secretary shall determine the portion of the appropriation, within the percentage determined above to be available for I/ Includes $19,000,000 for family planning projects. 205 sections 503 and 504, which shall be available for allotment pursuant to section 503 and the portion thereof which shall be available for allotment pursuant to section 504. Notwithstanding the preceding provisions of this section, of the amount appropriated for any fiscal year pursuant to section 501, not less than 6 percent of the amount appropriated shall be available for family planning services from allotments under section 503 and for family planning services under projects under sections 508 and 512. Administration Section 513. (b) Such portion of the appropriations for grants under section 501 as the Secretary may determine, but not exceeding one-half of I percent thereof, shall be available for evaluation by the Secretary (directly or by grants or contracts) of the programs for which such appropriations are made and, in the case of allotments from any such appropriation, the amount available for allotments shall be reduced accordingly. 206 Explanation of Transfers 1972 Estimate Real transfers to: operating expenses, Public $31,000 Transfer to the General Buildings Service, GSA ....... Services Administration for rental of space. Salaries and expenses, Economic Stabilization Act ... -1,300,000 Reflects a transfer of funds to the Executive Office of the President, as autho- rized bv the Economic Stabi- lization Act. Funds would be used for administrative expenses associated with carrying out provisions of the act. ReaII transfer from: Nursing home improvement ..... 4,300,000 Transfer to the research and development elements of nursing home improvement program from the Office of the National Center for Health Services Research and Development. Comparative transfers to: Preventive health services... -54,300,000 Transfer of project grants resulting from the reorganization of HSMHA. Health planning and development..; ..... ......... -25,935,000 Transfer of planning grants and related direct operations due to the reor- ganization of HSMHA. Departmental management ...... -125,000 Reflects transfers to support the departmental intergovernmental coordina- tion functions, coordinated field personnel management, Upward Mobility, and the adverse action and employee grievance examining staff. Office of the Administrator.. -20,000 Transfer of a budget analyst position to HSMHA Financial Management. 1 207 1 Comparative transfer from: 11 "Office of the Administrator.. 136,000 Transfer of Deputy and staff due to the reorgani- zation of H-SMHA. 11 I I I I I I I I I I I I a I 208 Health Services Delivery Budget Estimate House Senate Year to Congress Allowance Allowance Appropriation 1963 $101,514,000 $101,477,000 $98,820,000 $98,820,000 1964 116,538,000 116,462,00 0 116,462,000 116,462,000 1965 142,536,000 142,436,000 143,064,000 143,064,000 1966 196,616,000 197,480,000 183,480,000 197,980,000 1967 242,521,000 242,271,000 242,271,000 242,271,000 1968 410,599,000 383,406,000 384,209,000 383,806,000 1969 513,476,000 454,847,000 457,847,000 456,347,000 1970 453,507,000 461,297,000 463,207,000 463,207,000 Trust fund transfers 4,320,000 4,320,000 4,320,000 4,320,000 1971 519,798,000 519,798,000 525,940,000 521,248,000 Trust fund transfers 4,320,000 4,320,000 4,320,000 4,320,000 1972 640,851,000 644,869,000 685,750,000 656,319,000 Trust fund transfers 4,519,000 4,519,000 4,519,000 4,519,000 Proposed supplemental 5,610,000 1973 745,657.000 Trust fund transfers 4,719,000 209 Justification Health Services Delivery Increase or 1972 1973 Decrease Amount Pos. Amount Pos. Amount Pos. Personnel compensa- tion and benefits ... 7,658 $102,116,000 7,678 $106,800,000 +20 +$4,684,000 Other expenses ..... 4 --- 593,256,000 --- 667,075,000 --- +738,000 Total ........... 7,658 695,372,000 7,678 773,875,000 +20 +78,503,000 General Statement This budget proposes a consolidated appropriation, Health Services De- livery, for HSMRA's health services programs which were supported previously by three separate appropriations: Comprehensive health planning and services, Maternal and child health, and Patient care and Special health services. The proposed appropriation is consistent with the recent internal re- organization of the Health Services and Mental Health Administration. It reflects a functional grouping of the health services delivery programs and as such provides for improved coordination and administration. Not included in this grouping of health devlivery programs is the Indian health service appropriation which is presented to the Subcommittee on Department of Interior and Related Agencies and the Emergency health service appro- priatibn which is heard by the Subcommittee on the Department of Treasury, Postal Service and General Government. Comprehensive Health Services The budget includes $90,000,000 for the States under the Partnership for Health formula grant program and $116,200,000 for 65 neighborhood health centers and 23 family health center projects. The Federal funding of these centers supports the development of primary and ambulatory health services for inner city and rural areas lacking adequate services. Efforts will be continued to assist these centers to collect third party health insurance payments so that they can become self- sufficient. The migrant health activity includes $23,750,000 for Health care for migrant and seasonal farmworkers, an increase of $5,800,000 over 1972. The 1973 program will focus on up-grading at least 50 existing projects strategically located along the migrant streams to improve quality of dare and utilization. Maternal and Child Health In 1973, the budget includes $252,548,000 for Maternal and Child Health Services,.an increase of $13,834,000 over 1972. Grants to States for mater- nal And child health services are being increased by $1,528,000 and for the care of crippled children by $2,628,000 to reduce infant mortality and to 210 continue and expand services for crippled children. These funds will pro- vide for physicians' services to more than 500 thousand crippled children, prenatal and postpartum care to more than 400 thousand women, and family planning services to 850 thousand women. The projects grants program of $101,330,000 an increase of $9,322,000 over 1972, will provide comprehensive care services to 152,000 mothers, 53,000 infants and 546,000 children and youth in disadvantaged urban and rural areas. .Family Planning Services The 1973 budget includes $139,011,000 for the National Center for Fam- ily Planning Services, an increase of $42,758,000 over 1972. This request will continue progress toward the President's goal of providing family planning services to women who need but cannot afford them. Project grants to State and local health departments and other public or nonprofit organizations will provide services to an estimated 2.2 million women in 1973 as compared to 1.5 million in 1972 and 700,000 in 1971. Current estimates are that approximately 2.3 million additional women may be receiving services from other providers in 1973, including private physicians and voluntary organizations. When combined with the 2.2 million women to be served by projects funded by the National Center, a total of 4,5 million will be receiving services. This significant national effort will help reduce the dependency of many families presently burdened with the consequences of unwanted childbirth. Patient Care and Special Health Services The 1973 estimate for the PHS hospitals and clinics will maintain the same level of operation as in 1972. The number of primary PHS benefi- ciaries in the hospitals has continued its decline. In 1973 we estimate that 59 percent of the total patient load will represent primary bene- ficiaries as compared to 61 percent in 1971. During 1973 efforts will continue toward converting some of these facilities to community control in line with local health care needs and resources. National Health Service Corps In 1973, the Corps will accelerate placements of health personnel in Nation'6 health manpower shortage areas. Almost 600 physicians, dentists, nurses and other health professionals will be providing direct health care in these locations. These health personnel will provide support for a total of 175-225 communities with a total population of approximately 700,000 to 900,000 people. 211 Comprehensive Health Services Increase or 1972 1973 Decrease Personnel compensation Pos. Amount Pos. Amount pos. Amount and benefits ............ 445 $8,327,000 445 $8,970,000 +$643,000 Other expenses ............ --- 221,517,000 --- 239,842,000 +18,325,000 Total .............. 445 229,844,000 445 248,812,000 +18,968,000 Introduction This activity encompasses a number of unique and interrelated programs designed to improve the delivery of health care to the American people. Comprehen- sive health services development, Migrant health, and support of Medicare pro- i grams - all move toward the improvement in the delivery of health care that we are seeking. One of the highest priorities is the support of 55 comprehensive health care centers and 118 migrant health projects. The centers and projects provide family-oriented primary care to population groups long without basic health services. The comprehensive health care centers provide basic health care primarily to the urban poor. The Migrant health program provides access to health services to migrant and seasonal fal,@iworkers and their families. Emphasis is now on the improvement of the quality of those services. The quality of services provided through Medicare is aided through medical care standard development pro- grams and through counseling and participation in the application of Medicare standards. States and communities are he ped in maintaining quality of care in their health institutions through programs of training for their license inspectors and Medicare and Medicaid surveyors through the Nursing Home Improvement program. 212 Grants to States Increase or 1972 1973 Decrease Personnel compensation Pos. Amount Pos. Amount Pos. Amount and benefits .............. .. $1,306,000 $1,306,000 Other expenses .............. 88,694iOOO 88,694,000 Total .............. .. 90,000,000 90,000,000 The formula grant authorized by Section 314(d) enables the States to provide more direct support to a broad range of public health programs at the State and local levels. The authority provides for flexibility in the use of these Federal funds in response to State needs. The States are using these funds to support communicable disease control programs such as venereal disease, tuberculosis and immunization activities (particularly rubella); chronic disease programs directed toward such major causes of death and disability as heart disease, canceri diabetes, and stroke; environmental health services, including food and drug, industrial health, radiological health, sanitary engineering, Air and water pollu- tion; laboratory services; home health and public health nursing services, com- munity mental health, including treatment of alcoholism, drug abuse, and suicide prevention. A number of States-use a portion of their allocation in developmental health activity. California has for some years provided State project support to com- munities for the organization, development, and operation of new and innovative health services, particularly community health services in urban or rural ghettoes and model cities areas. The Missouri Division of Mental Health supports a crisis intervention program in Joplin serving two counties. A 24-hour-a-day program patterned after suicide prevention programs, serves a broader need to assist people with personal and emotional problems in addition to seeking to forestall suicide. The mental health program of Kansas allocated all of its formula and matching funds to support new and innovative programs within the State, such as a thera- peutic day school project, an adolescent walk-in clinic, a juvenile court cooperative group care program, and a family life education program. Arizona is supporting the establishment and utilization of a pediatric nurse practitioner program in one county as a method of broadening its maternal and child health effort. In mental health, one of their programs in which State formula grant funds are used is in the prevention of mental illness through the early identification of high risk persons and the application of preventive psychotherapy. one use of formula grant funds in American Samoa has been to extend dental health services into the elementary schools. Another has been to start a post- graduate course in public health nursing--a first in the medical history of American Samoa. The State of Nebraska used some of its allotment to support health pro- fessionals.assigned to local communities to carry out communicable disease and environmental health programs. Pennsylvania uses formula funds to assist in aerrying out a student intern project providing services to mental health, mental retardation, an related agencies. Undergraduate college students are placed in an agency for a year. They earn college credit through their universities and are paid a modest stipend for their services. 213 Expanded environmental health services is one of Maryland's uses of.the grant. A sanitation inspection unit for nursing home facilities and expanded sanitary survey section of shellfish waters receive support from this use of the monies. Virginia uses all its funds to assist in the operation of its local health departments for services rendered on the basis of the need of the individual locality. In the District of Columbia these funds have enabled their community health services administration to further the concept of Neighborhood Health Centers which provide comprehensive health services to families within a short distance of their homes. In 1972, funds authorized for evaluation are being used to continue to support a contract with the Association of State and Territorial Health Officers to develop and activate a uniform program reporting system for State health depart- ments. This project will assist the State and Federal governments in planning and evaluation as a result of increased information which will lend itself to evaluation. In 1973 we anticipate that the States will continue to support a broad range of health programs at the local level. No increase is requested in this activity in 1973. 214 Health Services Grants Increase or 1972 1973 Decrease Pos. Amount Pos. Amount Pos. Amount other expenses .... .. $103,913,000 -- $116,200,000 -- +$12,287,000 Project grants authorized under Section 314(e) of the Partnership for Health Legislation provide means to help upgrade the delivery of health services. First priority for awarding these grants is given to comprehensive health service pro- grams providing primary care and a broad range of ambulatory services to medically underserved urban and rural neighborhoods. In 1973 these programs will provide comprehensive health services for about 1,280,000 persons, an increase of 330,000 over 1972. Comprehensive Health Centers The comprehensive health service program supported 55 comprehensive health centers, including nine neighborhood health centers transferred from OEO, and a limited number of developmental and supportive projects in 1972. These health care programs covered an eligible population of approximately 2,700,000 persons and provided services to an estimated 850,000 persons at a cost of $88,618,000. The centers are organized to deliver all ambulatory health care services and have arrangements to secure most needed specialty treatment. Improved management capability in the 55 comprehensive health centers in 1972 was encouraged through the support of ambulatory health care information systems an account ng systems. In addition, support was furnished to the centers to enable them to develop pro- grams to increase their ability to obtain third party funding. In 1973, $100,200,000 is requested to continue funding the existing compre- hensive health programs, with $20,000,000 of this amount to be available for supporting 10 to 14 additional health centers previously funded by OEO. In total we expect these centers to provide services to over 1,000,000 people. We are assisting health centers to improve their management capability and develop financial plans so they can recover increasing amounts of their cost of operation through third party payments. Where possibletemphasis is given on conversions to prepaid capitation and increasing the c6uter's potential for be- coming an HMO or an componen . Family Health Centers The Family Health Center Program, initiated in 1972 with $13,000,000, will continue our efforts to increase ambulatory health care resources in medically underserved urban neighborhoods and remote rural areas. These ce nters provide a basic package of health services on a prepaid capitation basis. Family health centers actively coordinate with other Federal planning and direct service pro- grams at the national, regional and State levels to maximize the.effects of plan- ning, community relationships, funding allocations and staff competencies in a given geographic area. In 1973, an increase of $3,000,000 will provide for funding three new centers and for activating the operational phase of at least 10 developmental projects initiated in 1972. These new centers plus the 10 centers which began operating in 1972 will bring the total to 23 operating centers serving an estimated 230,000 persons. Emphasis will continue to be placed upon efficient and effective methods of managing, organizing and financing health care services. Through these methods the family health center will become an integral part of the community medical care pattern and federal grant support can be released for resource building in other areas of critical health need. 215 Migrant Health Grants ncrease or 1972 1973 Decrease Pos. Amount Pos. Amount Pos. Amount other expenses ......... $17,950,000 -- $23,750,000 -- +$5,800,000 Projects supported under this activity provide health care services to migrant agricultural laborers and seasonal farmworkers and their families. The purpose of this program is to raise the level of migrants' health to that of the general population, and to assure that migrants have access to ongoing community health services. The problem of providing adequate health services to migrants and seasonal farmworkers and their families is closely related to the problem of insufficient health resources available to all rural residents. As more resources and financing mechanisms become available to support health care services for the general population, one aim of the Migrant Health Program will be to develop adequate services in migrant impact areas to meet the increased demand. In 1972 the program initiated efforts to convert existing projects from their present grant method of financing services to a prepaid capitation system. An additional effort was made to assist projects in substantially upgrading the quality of their services and increasing their scope of service as well as increasing the numbers of persons served. It is estimated that there will'be 460,000 patient visits in 1972, an increase of approximately 101,000 over 1971. During 1972, 64 of the 118 projects reported the establishment of consumer boards. The remaining projects while having less formal mechanisms at this time are making efforts toward meeting the 1970 legislative mandate to show evidence of consumer participation in project activities. In an effort to extend the concept of using indigenous personnel in the administration and delivery at health services in migrant projects, 90% of the projects have employed migrants or Comer migrants as paraprofessional staff members to assist in the delivery of services. In addition, four of the seven comprehensive projects have Max can Amer 8 as project directors. 1973 Increases In 1973, the program will maintain its efforts toward increasing the capacity and utilization of health services in the areas of major migrant populations. An increase of $2,800,000 is requested to cover increased continuatioit,costs. A program increase of $3,000,000 is requested to accomplish the followiu g purposes: --- An effort will be designed to provide 1,000 families, from one or more different areas, an appropriate health services benefit packa$e through a prepaio capitation system capitalizing on existing migrant health projects as providers.-of service. 216 ---This effort will provide an experience base with respect to the ability of established migrant health projects to cost out a service package and to collect third party payments. In addition, the effort would provide specific experience on the ability of migrants to effectively utilize available services provided under a prepaid delivery system spanning the migrants' work areas. --- A Uniform Cost Reporting and Accounting System will be implemented in 15 projects which have developed the potential capability to utilize third party reimbursement payment mechanisms. This effort will be needed in order to provide the framework to begin conversion from grant support to other funding approaches. --- In addition, the increase will be used to assist the remaining projects to become capable of converting from a grant method of financing to A prepaid capitation plan for delivering an acceptable benefit package, or to assist them to become a provider component of a prepaid health plan. It will also allow the projects to focus on improving the quality and utilization of services available. At least 50 existing projects strategically located along the migrant streams will be up-graded. This increase will also provide approximately 148,000 addi- tional patient visits by migrants and seasonal farmworkers and their families bringing the total of patient visits in 1973 to more than 600,000. The patient visit increase will be accomplished through the support of primary health care projects located in areas of high migrant impact, interrelated with other health services in rural areas. In areas where provider organizations exist, the pro- gram will provide funds which can be used in a third party payment arrangement to assure that the migrants would receive care. In those rural areas where resources and/or services are not accessible to the migrants ' the program will direct funds to develop programs that can provide an acceptable benefit package and attract resources to provide services through a variety of arrangements and payment mechanisms. In order to have access to timely and more accurate program information on existing migrant health program activities to enable the program to judge more accurately the extent to which individual projects and the program as a whole are meeting their goals, emphasis will be placed on extending the information system designed and implemented on a limited basis in 1972 to a majority of projects funded in 1973. The projects will also be encouraged to support efforts directed at training migrants for use as paraprofessional staff in ongoing projects and to enhance the training of policy board members in effectively fulfilling their roles. 217 Direct Operations Increase or 1972 1973 Decrease Pos. Amount Pos. Amount Pos. Amount Personnel compensation and benefits ........ 445 $7,021,000 445 $7,664,000 +$643,000 Other expenses ........ .. 10,960,000 -- 11,1§8,000 +238,000 Total ............. 445 17,981,000 445 18,862,000 +881,000 The direct operations under this activity provide professional and technical assistance to States, communities, providers of health services, medical and health organizations and other Federal units. This activity supports the staff that provides: (1) guidance on health care services essential to promote the utilization of improved methods of health services organization, delivery and financing at the community level in both urban and rural settings; (2) technical assistance and consultation to migrant health projects and other organizations which can contribute to the improvement of health services for the migrants and seasonal farmworkers and their families; and (3) the continuing responsibility of the Community Health Service to serve as the professional health resource of the Social Security Administration in the Medicare program. This latter responsibility provides the mechanism for defining and applying standards of quality for providers of service under Title XVIII of the Social Security Act. These standards are coordinated with those of the Title XIX (Medicaid) program to assure that the programs are consistent and do not adversely influence quality of tare or the administration of these two programs. To a large extent, the success of the Federal role in comprehensive health services is dependent upon the quality and responsiveness of staff in meeting State and community requests for assistance and for taking the initiative in coordinated actions leading to delivery of health services. The role of staff in the administration of comprehensive health centers goes far beyond just administration of individual grant programs. An extremely important aspect of this role is aimed at providing the positive kind of help required to make our health system more responsive and efficient. The following are examples of staff activities: Assisting health centers to develop a strong management capability; developing component program activities; providing assistance in integrating and coordinating health center services with other services in the community; developing and applying techniques to assist the centers in becoming more self-sufficient; and evaluating project activities. Comprehensive Health Services Policy guidance, professional advice and technical assistance are rendered to comprehensive health center projects with emphasis on the development of organized primary care programs for those regions, communities, and population groups which do not have access to adequate primary health care. A substantial proportion of staff and contract effort is devoted to providing expert back-up for HSHHA regional staff activity in improving the management capability and operational aspects of these comprehensive health centers as they become operational. Once such projects are established, extensive staff effort is required to assure an effective operation of health centers. The programs of these centers are so complex they require technical assistance from many different operational levels and on a wide variety of complex iisues. I 218 The staff assigned to the migrant health program provided consultation on health matters in health care, nursing, health education, hospital administration, nutrition, pharmacy and sanitation. Staff members also provide consultation on statistical reporting, project evaluation, general project administration, consumer participation and community organization. In conformance with the new and comprehensive series of guidelines concerning the quality of medical care, the participation of consumers, and other aspects of the Migrant Health Program, 64 of the 118 projects reported the establishment of consumer boards. In 1972, the new Family Health Center Program devoted considerable time and effort in the areas of staff recruitment, organization, business management design and implementation of prepayment schemes, and evaluation. technical and program assistance to potential and funded projects was provided. Continuing emphasis was placed on improving management of the comprehensive health centers through expansion of the site assessment activities and the provision of technical services in the administrative, financial and professional service areas. It is estimated that 12 comprehensive health centers will receive a complete site assessment followed by the development and implementation of corrective action plans to improve the efficiency of the centers and the quality of care furnished. Emphasis is being placed on moving positively toward improving management capacity to secure medicare, medicaid, private insurance, and other forms of reimbursement for services delivered through the centers. In 1973, program emphasis will continue to be directed toward aiding the health centers in achieving a significant degree of financial independence through the garnering of additional third party reimbursements and other State and local support. Technical assistance will be provided to communities to aid them in developing community oriented health care programs. Considerable staff time will be required in connection with the transfer of OEO neighborhood health centers. Nursing Home Improvement Substantial efforts continued to be concentrated on the improvement of the quality of care in nursing homes as a major component of the implementation of the 1971 nursing home initiatives. This has included training health facility surveyors, short-term training of nursing home personnel, the initiation of demonstrations of consumer services programs, and pr ovision of technical assistance to State and local programs. Health facility surveyors or inspectors have the key responsibility for determining whether nursing homes comply with required standards for provision of care. These State inspectors are usually health professionals, well-prepared in their profession, but often lack specific training in the most effective techniques of surveying health facilities, recording and documenting findings, consultation, programming for facility improvements, and the changing requirements and standards of Federal health care programs. A curriculum for university-based training was developed to provide full understanding of health facility components and the health care facility requirements and standards which have been established to protect and maintain the health of patients served by these facilities. The capacity of three tmiversity-based programs was increased in 1972 together with the establishment of additional training programs in three new universities, to provide intensive, professionally-directed training for an additional 950 inspectors. 219 Surveyors often need an in-depth knowledge in manv specialty areas, other than the one in which they were trained, to make a comprehensive, objective, and accurate evaluation of the compliance of a facility with Federal require- ments under Titles XVIII and XIX and to assist the facility administrator in making needed improvements. In 1972, in-depth specialty courses were conducted at State and local levels for over 2,000 personnel concerned with inspection, in such areas as physical environment, physician services, nursing, medical records and social services. This in-depth training experience has generated more interest in the overall program among the States. New prepackaged in-depth courses will be added during 1973 including social services, dietary services, administrative management and diagnostic services. It is expected that, with increased interest among States and the expanded subject material, the participation for 1973 will approximately double that of the 1972 activity. An expanded and accelerated overall surveyor training effort will provide training for 1,050 inspectors in 1973 which, added to the 950 trained in 1972, will achieve our objective of upgrading the capacity of 2,000 nursing home inspectors employed by the States4 During 1972, a nationwide effort was initiated to improve the capabilities of the health personnel serving nursing home patients. Staff efforts are currently underway for working with States and other multi-professional organizations as well as with physician, nurse and other individual disciplines in training efforts aimed at people who have day to day responsibilities for nursing home patients. Special efforts will also be made to develop activities which will bring about a better understanding of mental health problems on the part of nursing home personnel. The short-term training programs for 1973 will give highest priority to rapid and effective achievement of objectives in fulfillment of the President's and the Department's commitments to the improvement of nursing homes in this country. As part of the dynamics of program development, efforts will be directed to closely coordinated activities of State governments, State affiliates of professional societies, and organizations related to the facilities themselves, with the educational systems and institutions which can assist in the actual staging of short-term training programs. These resources will be utilized to develop short-term training models that transmit principles and methods of gerontology and mental health practices to achieve a meaningful impact, as well as effective and viable long-term programs for the improved health, welfare, and mental health of nursing home patients. Fiscal year 1973 funds will support short-term and in-service training to enhance the competence of thousands of professional and ancillary health personnel providing care and service to patients who utilize a nursing home for a part of their requirements for long-term care. This estimate will continue the support for demonstration projects funded in 1972 to assist the States in establishing consumer service or investigative units which will respond in a responsible and constructive way to complaints made by or on behalf of individual patients. The individual who is confined to an institution and dependent upon it is often powerless to make his voice heard. These demonstrations are designed to show how governmental and voluntary organizations at both State and local levels can function to protect the nursing home patient's personal and property rights and improve the quality of his life while in a care facility. Activities will continue to su .pport responsibilities in professional and technical assistance to States, communities, providers of health services, medical and health organizations, and other Federal units and to further promote the Federal-State partnership for health. Coordinators will be placed in all ten Regional Offices to work directly with Federal-State programs to assure effectiveness in the development, coordination, and implementation of short-term and in-service educations programs or ong-term care personnel and survey improvement activities. In addition to the primary concern for nursing home improvement, emphasis will be made on continuation of activities directed toward correcting deficiencies in facilities which receive Medicare and Medicaid reimbursements. Projects will be supported in five States to correct the most serious provider deficiencies through programs of concerted action, developed through the collabo- ration of State health agencies (planning, licensure, certification, and construc- tion) and related patient care provider organizations. Medical Care Standards and Consultation The Community Health Service supplies, in partnership with the Social Security Administration's Bureau of Health Insurance, the professional health expertise necessary for carrying out the Federal Government's responsibility for establish- ing, implementing, and evaluating Medicare standards and related policies. In 1972, as a result of review and assessment of all Me icare requirements for providers of service and independent laboratories, the updating of regulations for hospitals, extended care facilities, home health agencies, and independent laboratories was completed. This major accomplishment was part of a general effort to clarify, on the basis of five years of Medicare program experience, provider requirements subject to misinterpretation and uneven enforcement and to standardize and improve the overall survey process. Survey report forms and surveyor guidelines for uniform application of the new and revised standards were prepared during 1972 and staffs of all regional offices and State agencies were oriented in the application of the new requirements. During 1973, the revised Medicare provider standards will have had the test of application by the State agencies, and areas in need of further clarification will be identified and appro- priate revisions prepared. To help insure effective application of Medicare quality standards, physicians, nurses, and other health services specialists assigned to regional offices provide continuing assistance and consultation to State Medicare agencies and regional Social Security staff. The resulting upgrading of facilities and services, in which the States are partners has benefited persons of all ages, has strengthened State licensure statutes and Regulations for health facilities, has had a positive effect on voluntary accrediting programs, and will provide the base for assurance of quality care in any national health program the Congress may enact. Program review has become a major continuing process for evaluating the effectiveness of the application of the Medicare provider standards by State agencies. During 1972 and 1973, review teams composed of representatives of the Bureau of Health Insurance and the Community Health Service central and regional offices will conduct extensive reviews in each of the States, providing an in-depth evaluation of each State's Medicare certification operations. Yeat- 221 round evaluation of State agencies by regional office staff will be enhanced through quarterly visits and sample surveys of providers in each of the States. In 1973, the methodology for conducting program reviews will be modified to be more selective and responsive to the needs of regional offices and the State agencies they serve. Consultation is provided to Social Security Administration on a continuous basis on questions concerning covered services under Medicare, professional ethics, appropriateness of fees, termination of provider status, emergency hospital claims, and the development of policy and procedures not related specifically to standards for providers or independent laboratories, but having an effect on quality or delivery of service. The second administration of an examination for physical therapists not meeting Medicare's formal professional qualifications was conducted during 1972. The 1972 Social Security amendments will require the Secretary to provide a similar route to qualification for other health professionals and subprofessionals and in 1972 staff initiated a number of activities related to this: 1) review of related programs, both governmental and otherwise, which the Medicare program could benefit from; 2) development of intra-government agreements for use of existing examinations;and 3) contracting for an examination which would qualify waivered licensed Practical nurses. In 1973, this program will be intensified to initiate action related to all appropriate personnel categories, and will include mechanisms to identify training needs of the examinees, in order that they may upgrade their skills. Staff work will continue from 1972 into 1973 on a number of special activities, such as: (1) anticipated new authority to bar from Medicare parti- cipation any provider or supplier who abuses the program; (2) alternative approaches to the development of standards relating physicians' qualifications to the nature of services provided under the Medicare program; (3) consideration of alternative approaches to the problem of small, substandard rural hospitals; (4) the relationship between the two financing programs and grant-supported projects; (5) an evaluation of the impact of present nursing home standards on patient outcome and cost of care; and (6) anticipated new authority for advance Medicare approval of extended or home health care. In 1973, emphasis will continue on Medicare quality control mechanisms of several kinds. Under a contract co-funded with BHI, we will have completed special training of State staff in clinical laboratory quality control, and the new regulations related to this will be in effect. Another 1972 contract provided for development of a prototype medical school curriculum on medical care appraisal. Seminars and other training in utilization review, as a follow-up on a series of training institutes in 1972, will be made available for providers, intermediaries, and physicians, and State staff will receive intensified training in this area. Direct assistance and advice will continue to be provided to the Medical Services Administration, Social and Rehabilitation Service, on the development and implementation of regulations for skilled nursing homes, intermediate care facilities, utilization review, and medical review under the Title XIX (Medicaid) program. During 1972, Community Health Service regional offices worked closely with the Medical Services Administration in connection with the Nursing Home Improvement Program. 1973 Increases In 1973, an increase of $988,000 is requested. This amount, partially offset by decreases of $38,000 for two less days of pay and $69,000 annualization of DHEW 1972 employment cutback, would provide $120,000 for program increase and $868,000 for mandatory items. The prog ram increase would be used to initiate a 2 2 reporting system to collect information on the extent of health services obtained by migrants and seasonal farmworkers and their families. The mandatory items would cover annualization of 1972 new positions $443,000, annualization of the uniformed services pay increase, Public Law 92-129, dated September 29, 1971, $25,000, net costs of within grade and longevity increases $179,000 and increases for DHEW Working Capital Fund $95,000, HSMHA Service and Supply Fund $18,000 and FTS charges $108,000. 223 Maternal and Child Health Increase or 1972 1973 Decrease Pos. Amount Pos. Amount Pos. Amount Personnel compensation and benefits ........ 133 $2,633,000 133 $2,658,000 --- +$25,000 Other expenses ........ --- 236,081,000 --- 249,890,000 +13,809,000 Total ........... 133 238,714,000 133 252,548,000 +13,834,000 Introduction The programs authorized under Title V of the Social Security Act are a major national resource for providing basic preventive maternal and child health services and for the location, diagnosis, treatment, and follow-up care of children with crippling or potentially crippling conditions, especially in rural areas and areas which are economically depressed. They respond to the serious deficiencies that exist in the amount and quality of care received by poor children as compared with middle class children which result in an excess of preventable deaths, illnesses and handicapping conditions among the poor. The dual approach to services which the legislation provides--grants to States to strengthen and improve basic services especially in rural areas, and project grants targeted on low-income areas where there is heavy concentration of need-- recognizes today's needs and permits some of the flexibility necessary to reapon to them. The research and training programs, concentrating on finding new and improved ways to improve the delivery of services and on filling the manpower gap, round out the comprehensive approach provided by Title V legislation. Section 513(b) provides that not exceeding one half of one percent of funds appropriated under the authority of Title V shall be available for evaluation by the Secretary of programs authorized under this title. In addition to grants and contracts, funds available for evaluation may also be used to finance consultative and other services related to evaluation purposes. Such consultative Bervices would be performed under contract or through the use of experts and consultants. 224 Grants to States Increase 1972 1973 or Other expenses Amount Amount Decrease Maternal and child health services .................. $59,250,000 $60,778,000 +$I,528,000 Crippled children's services 62,272,000 64,900,000 +2,628,000 Total ................. 121,522,000 125,678,000 +4,156,000 The basic purposes of the maternal and child health and crippled children a services programs of grants to States are to (1) reduce infant mortality and otherwise promote the health of mothers and children, and (2) locate, diagnose, treat and provide follow-up care for children who are suffering from crippling or handicapping illnesses. In addition to providing grants to States on a formula basis, these programs also fund special projects of regional or national signifi- cance which contribute to improvement of the programs. Specialized program efforts are described in more detail under the appropriate activities. Program Accomplishments ,Training: In both the maternal and child health and crippled children's programs, States provide for training and use of paid subprofessional staff, with special emphasis given to employing low-income persons. Duties are tailored to the needs of the several programs and include work in casefinding, as nutrition aides, dental aides, home health advisors, and community services aides. As employment of such workers increases, new career opportunities will become avail- able to persons who lack professional training. Training of professional personnel under the maternal and child health and crippled children's special project grants is also continuing. In 1971, more than 660 health-related professional personnel received training through institutions of higher education and State agencies. During 1972 and 1973 the numbers of professionals trained are expected to rise to 700 and 830 respectively. Mentally retarded children: The maternal and child health and crippled children's programs currently support in whole or in part 150 mental retardation clinics in which 57,000 children and their families received diagnostic and counselling services; 20 cytogenetic diagnostic and counselling programs; and 15 special clinics for children with multiple handicaps. The services include diagnosis, evaluation of a child's capacity for growth, the development of a treatment and management plan, interpretation to parents and follow-up care and supervision. A major effort in the prevention of mental retardation continues to be in relation to phenylketonuria (PKU). MCHS continues to work with State health departments in developing the necessary laboratory facilities to detect families with the condition and assisting States to provide special diets and follow-up programs. During 1970 approximately 90 percent of the newborns in the 50 States and District of Columbia were screened. This screening effort by the States, supported through MCHS, turned up approximately one confirmed case for every 16,000 live registered births. ,Nutrition services: As an integral part of the maternal and child health and crippled thildren's programs, nutrition services are provided through well-child clinics, pediatric clinics, group care facilities and school health programs. Currently over 500 nutrition personnel are employed by State and local agencies. 225 These personnel play a major role in assisting low-income families to develop a better understanding of normal as well as therapeutic diets. Their activities are contributing to the prevention or elimination of malnutrition in many families. 1. Maternal and child health services States use Federal funds, together with State and local funds, for prenatal and postpartum care in rural areas where mothers may receive clinical services including family planning services and home visits by public health nurses; for well-child clinics where mothers can bring children for examination, immunizations, and competent advice. Such measures have been instrumental in the reduction of maternal and infant mortality, Funds are used to provide medical, dental and nursing services for school health examinations and immunizations. These projects are primarily located in rural areas. Major support for dental services for children through State health departments continues to be from maternal and child health funds. For many basic maternal and child health programs the development and extension of family planning services continue to be a priority in 1972 with special emphasis on the provision of services to pregnant adolescents. Among the more significant services provided through the maternal and child health services program are the following: 1971 1972 1973 Provisional Estimate Estimate Mothers receiving prenatal and postpartum care in maternity clinics ....................... 334,000 400,000 400,000 Women receiving family planning services ...................... 752,000 752,000 752,000 Public health nursing visits made on behalf of: Mothers ..................... 566,000 566,000 566,000 Children .................... 3,290,000 3,290,000 3,290,000 Children attending well child clinics ....................... 1,500,000 1,500,000 1,500,000 Children receiving screening tests for: Vision ...................... 8,977,000 10,000,000 10,000,000 Hearing ..................... 5,677,000 6,250,000 6,250,000 .1973 Program: Funding proposed for 1973, which includes an increase of $1,528,000 over 1972, is expected to continue support of essential services provided through this program and maintain the high level of excellence in quality of such services. 2. Crippled children's services State crippled children's agencies use their funds especially in rural areas, to locate handicapped children, to provide diagnostic services, and then to see that each child gets the medical care, hospitalization, and continuing care by a variety of professional people that he needs. Fewer than half of the children served have orthopedic handicaps. The rest include epilepsy, hearing impairment, cerebral palsy, cystic fibrosis, heart disease, and many congenital defects. Clinics are held periodically by State crippled children's agencies. Some clinics are mobile and travel from place to place; others are held in permanent locations. Any parent may take his child to a crippled children's clinic for diagnosis. Within the last two decades, the number of children using the crippled children's program has more than doubled. In 1950, there were 214,405 children served, while in 1971 the number served was approximately 485,000. More than a third of the children served were new admissions to the crippled children's program. The number of children who received physicians' services in clinics increased (2.1 percent) as did the number who received other physician s services (7.2 percent). The number of children requiring hospital inpatient care decreased (3.8 percent) as did the number of children who received convalescent home care (14.0 percent). Among the specific services provided through this program are the following: 1971 1972 1973 Number of Children Provisional Estimate Estimate Receiving physicians' services ..... 485,000 500,000 500,000 Receiving hospital inpatient care.. 82,000 82,000 82,000 With multiple handicaps ............ 90,000 90,000 90,000 With congenital heart disease ...... 33,000 331000 33,000 1973 Program: The additional $2,628,000 proposed for 1973 will help States meet the rising costs of providing care for crippled children. Increased costs in the crippled children's program are due not only to the average annual increase in medical care costs but also to the fact that the more effective treatment methods are now more complicated technically and more costly. 2 o@c. 7 Project Grants Increase or 1972 1973 Decrease Other expenses No. Amount No. Amount No. Amount Maternity and infant care: Comprehensive centers 56 $42,675,000 56 $46,332,000 +$3,657,000 Intensive care of infants ............ 8 753,000 8 900,000 +147,000 Children and youth .... 59 47,400,000 59 52,842,000 +5,442,000 Dental health of children ............. 17 1,180,000 17 1,256,000 +76,000 Total ............ 140 92,008,000 140 101,330,000 +9,322,000 These programs provide comprehensive medical care to poor and near-poor mothers and children who might otherwise not receive such services. Efforts are particularly focused on those who live in urban slums. The comprehensive maternity and infant care (M&I), and children and youth (C&Y) projects together with related neighborhood health centers are making it possible for community health organizations to develop new and imaginative methods of reaching out to the people in slum areas, decentralizing services into neighbor- hoods, reducing crowding in tax-supported hospitals by paying for care in voluntary hospitals, and establishing well-organized systems of providing compre- hensive health programs for casefinding, prevention, health supervision, and treatment. These programs, for the most part, are being carried out in areas where there are few physicians in private practice and where existing clinics are grossly overcrowded. In these areas they are creating new resources and changing existing methods of delivering health services in order to be responsive to the needs of the people. Of the 115 comprehensive M&I and C&Y projects now in operation almost one-third are involved in cooperative efforts with other Federal programs. Two-thirds are located in city slum areas. Over 1,600 community aides are employed through these projects. In 1973 and future years, emphasis will be on coordination of existing maternal and child health programs with other Federal-State-local sponsored service and financing mechanisms. The M&I and C&Y projects are Health Maintenance Organization prototypes incorporating several of the basic characteristics of Health Maintenance Organizations. They are a form of group practice, but broader than the usual group practice model in that they include the services o nutr - tionists, social workers, public health nurses, and aides. Prevention is a major emphasis and patients are enrolled in a system of continuing health supervision rather than one which responds only to episodic illnesses. The services are prepaid through tax funds and the staff is salaried. The additional resources available for FY 1973 will help to expand and broaden the existing centers and to facilitate their collaboration with other health providers and financing systems. -e 2 Comp infant care spring o Ihis program, begun in the and in r cts in operation in large and middle-sized cities -olumbia cts are located in 35 States, the Dictrict of more than 60 percent of the maternity and care pro C),OOO inhabitants or more, infant projects are also Located in rural and urban-rural populations in such States as Alabama, Georgia, 71orida, Arkansas, Idaho and others. All the projects serve localities which in :he past showed much higher infant and maternal mortality rates than the Nation as a whole. 1971 1973 timate Estimate -admissions for services: Mothers ........................ 141,000 144,000 152,000 Cumulative since start of program ...................... 877,000 1,021,000 1,173,000 Infants ........................ 47,000 49,000 53,000 ;omen receiving family planning services ....................... 134,000 134,000 134,000 Approximately 60 percent of all women admitted for maternity care in the ::ojects during fiscal year 1971 (the most recent vear for which complete data is i,.,ailable) were black, 20 percent were white, and the rest were of other origin. @e large proportion of black women reflects the central-city, metropolitan -:cation of the projects as well as the predominance of blacks in the medically .@digent segment of the urban population. T irty-nine percent of all women admitted for maternity care in fiscal year .-@71 had become pregnant out-of-wedlock, This figure varied from 87 percent in @-.ase under 15 years of age to 25 percent in those 35 years and older. The large ;-oportion of out-of-wedlock pregnancies in part comes from the greater reported ---cidence of such pregnancies in low-income populations and from emphasis on the ;art of projects in reaching this particular high-risk group either through zeighborhood canvassing or through referral agreements with schools and other c-@unity agencies. Significant contributions to recent reductions in the Nation's infant ncztality rate have been made through the maternal and child health program and t-@- comprehensive maternity and infant care projects. For the Nation as a whole, t--@ant mortality decreased almost 24 percent during the period 1960-70. Almost tE t!ree-fourths of that decrease occurred during the four-vear period 1966-70. Reports submitted by specific projects show these reductions in infant W-tality rates per 1,000 live births in these maj or cities: 24')- From To Decrease Year Rate Year Rate % National rate .................... 1965 24.7 1970 19.8 19.8% Cities with major maternity and infant care projects: Baltimore, Md . ................ 1965 26.8 1970 25.1 6.3 Houston, Texas ................ 1965 28.0 1970 20.0 28.6 St. Louis, Mo . ................ 1965 44.4 1970 31.1 30.0 Chicago, III . ................. 1965 33.6 1970 27.7 17.6 The impact of the maternity and infant care projects on infant mortality can be measured in many ways, among them: a. The increased number of women who request help early in pregnancy so that they get the most benefit from prenatal care. This trend is shown by the fact that for M&I projects as a whole, the percentage of new maternity patients seen during the first trimester of pregnancy was 23.0 in 1971 as compared with 18.8 in 1970, an increase of 4.2 percent in one year. b. Some projects are making marked reductions in the number of mothers being delivered without any prenatal care. In Greenville, S. C., the proportion dropped from 25 percent in 1967 to 5.9 percent in 1970. 1973 Program: The request of $46,332,000, an increase of $3,657,000 provides for increased support of 56 ongoing projects. About one-fourth of the expenditures under this program represent hospital costs and one-half, salaries and services of medical and other staff. Intensive care projects for higii-risk infants: Specialized care for infants born at high risk (prematurely born or with other conditions detrimental to their normal growth and development) provides another means of combating high infant mortality rates. Such infants usually require both intensive care during their hospital stay and follow-up attention during the first year. A large number of studies in this country and others have shown that a considerable degree of effectiveness in reducing the mortality rate among high-risk infants can be achieved through the use of special intensive care units,or centers. These provide increased medical and nursing supervision, care by personnel specially trained in such fields as treatment of cardiopulmonary failure and respiratory distress in newborns, and use of special equipment as needed. In 1973, the $900,000 requested, an increase of $147,000 over the 1972 level, will continue support of the five ongoing projects initiated in 1970 and three new projects initiated in 1972. 2. Children and youth The "Children and Youth" project grants support comprehensive health care for children in areas where low-income families are concentrated. Projects provide screening, diagnosis, preventive services, correction of defects and after-care (both medical and dental). Services are coordinated with the programs of the State or local health, welfare and education departments and with related programs 230 of the Office of Economic Opportunity and other programs in HSMHA. The treatment services available under the program are provided only to children from poor families who would not otherwise receive such care. There were 59 operating children and youth project units as of June 30, 1971, serving areas in which approximately 3,653,000 children and youth under age 21 live. Sixty-seven percent of the projects and 87 percent of the registrants are from cental city areas. The grantees are about equally divided between health departments and medical schools with their affiliated teaching hospitals. A breakdown by race shows that 64 percent of registrants are black, 32 percent are white, 4 percent are of other races. Girls outnumber boys in each of the ethnic categories. Median age for registration was about 5 years. The age group 5 to 9 has the highest percentage of registered children, followed by the 1 to 4 age group. Most projects focus their efforts on children between the ages of 0-14. At least one-fourth of the new registrants has had an acute medical care episode before initial health assessment. The number of registrants with acute episodes of care decreases dramatically after provision of comprehensive health care services has begun. Since the beginning of the program there has been a marked decrease in the percentage of registrants needing hospitalization. Figures comparing 1968, 1969 and 1970 are: No. of No. of % of Average Hospital Hospital Registrants Length Year Admissions Days Hospitalized of Stay 1968 ............. 15)100 113,100 7.73 7.48 1969 ...... ....... 15,400 111,800 4.50 7.27 1970 ............. 15,238 97,500 4.09 6,40 Accompanying the decrease in hospitalization rates is a decrease in annual average per capita costs: Average Annual Cost per Child 1968 .... $201.26 1969 162.47 1970 ....................................... 149.82 This demonstrates that child health services which emphasize prevention pay off among the poor as well as among private patients. There is a consistent decrease in illness and in the need for hospital care. Screening for correctable defects is one important program objective. For the year ending June 30, 1971, of the 65,000 children screened for visual impairments 14,404 failed the test. Of the 63,500 children who had hearing tests in this same year, 5,800 failed. Projects also offer special screening programs to detect diseases that are more common in their particular community, such as lead poisoning and sickle cell disease. In a cooperative effort between the Chicago Board of Health, the State Health Department, OEO, and the children and youth program, 116,261 children were screened for lead poisoning over a 3-year period in the Chicago area, and of these over 10,000 had abnormally high lead levels indicative of excessive exposure. 230A In order to more effectively serve their communities, the projects have involved parents in the overall planning and implementation of Services. Forty- three percent of the projects have developed community advisorv boards, although this is not mandated by law. Some of the projects are able to utilize the services of medical personnel such as interns and residents, who are in a rotational program from educational institutions such as medical schools and teaching hospitals. Thirty-nine projects report a total of 1,641 persons working in this capacity, either full- or part-time. 1973 Program: The request of $52,842,000 for 1973, an increase of $5,442,000 over 1972, provides for the effect of rising medical care costs and for expansion of the 59 operating projects. It also provides funds to study the feasibility of converting children and youth projects to Health Maintenance Organizations on a prepaid capitation basis. 3. Dental health of children The Child Health Act of 1967 authorized a program of special project grants to promote the dental health of children. Up to 75 percent of the cost may be paid from comprehensive projects serving school and preschool children from low-income families. These are located particularly in areas with concentrations of low-income families. These projects can employ dental personnel without professional training, as well as dental hygienists. Dental disease in children is common; however, the plight of the rural or disadvantaged child is most serious. While approximately one-half of all children under 15 in the country have never been to a dentist, this percentage is higher for children in rural areas. It rises to 75 percent of the children living in families with incomes under $2,000. Sixty-six percent of the children in families with incomes under $4,000 have never been to a dentist, compared to 40 percent in families with an income of $4,000 or more. The 1971 appropriation provided for initiation of this program to provide comprehensive dental care to 10,000 children. Coverage included first grade children only as the first increment in a program aimed at full coverage of all eligible children in grades 1 through 12. Each year services will be continued for these children and a new group of 5 and 6 year olds will be added. The advantage of the incremental approach is that less professional time is required to carry out preventive and corrective measures than to correct neglected and advanced dental. problems. Children become familiar with dental procedures at an early age, thus are less likely to avoid such procedures as they grow older. This approach emphasizes preventive and continuing dental health supervision. It is expected that 21,000 children will receive treatment under this program with funds appropriated in 1972. 1973 Program: The total request of $1,256,000, an increase of $76,000 over the 1972 amount, is expected to provide dental care for 22,000 children in 1973. 231 Research and Training Increase or 1972 1973 Decrease Other expenses No. Amount No. Amount No. Amount Training ............. 33 $15,071,000 33 $15,357,000 +$286,000 Research ............. 68 6,035,000 68 6,035,000 Total .......... 101 21,106,000 101 21,392,000 +286,000 1. Training The major purpose of this program has been to support training in University- Affiliated Centers for the Mentally Retarded in an effort to improve and expand the supply and competence of personnel working with children with multiple handi- caps and their families. The primary objective of these centers is to carry the concept of a coordinated multidisciplinary multiservice approach to the problem of mental retardation forward into a training program. This training program is charged with turning out professionals who not only have the clinical competency in their own discipline but who, as a result of their training, have an apprecia- ti6n of the roles and contributions of an array of other disciplines and can fit their own skills and function into such a coordinated group approach. The centers offer a complete range of services for mentally retarded and multiply handicapped children. During fiscal year 1971, the 19 University-Affiliated Centers (4 new in 1971) which had training support from this program provided long-term training for over 300 professional health personnel and short-term training for 3,600 graduate and undergraduate trainees. The major impact of the 19 centers during 1971 continued to be in raising levels of teaching and service and influencing a variety of basic curriculum changes in the affiliated degr ee-grantirig departments, colleges and universities. Colleges for example, are using the centers to train their students and give degree recognition for the training the centers provide. Over 16,000 children and their families were evaluated to select the appropriate teaching situations for students enrolled in the program. Excellent quality health dare was provided to the children selected for this program. In 1972 a new program under S6ction 511 is being initiated to train obstetrical and pediatric health manpower. This is a new training program not Associated with the training efforts of the 19 centers previously described. It is expected that approximately 150 nurse midwives, pediatric nurses and other physicians' assistants will be trained in 1972. 1973 Program: The 1973 amount requested, $15,357,000, will support improved staffing levels for the existing university-affiliated centers and also support continuation of the new training programs initiated in 1972. 2. Research The basic purpose of this research grant program is to contribute to improving the health of mothers and children of the Nation. In consonance with that objec- tive, it aims to improve the operation, functioning, and general usefulness and effectiveness of maternal and child health and crippled children a services. The concern is with mothers and children in all classes of our society with high 232 priority given to special problems for those segments of the population not receiving adequate health care. Some examples of areas being or to be investigated are: health status of and health services for mothers and children in urban and rural communities; new approaches to providing maternity health services; methods of increasing the effectiveness of child health programs, especially services for school-aged children and for mentally retarded children; prevalence of handicapping conditions; cost of services; evaluation of the effectiveness of programs; nutrition; and programs and services for teenage parents. Special emphasis is being given to studies of the need for and feasibility and effectiveness of comprehensive health care programs in which maximum use is made of health personnel with varying levels of training. The purpose of the research project entitled "Allied Health Worker Utilization in Maternity Care," for example, was to determine how physicians who specialize in obstetrics-gynecology use allied health workers in maternity service. About half the respondents endorsed the concept of greater use of maternity nurses and agreed in general on the tasks to be delegated, while about one-fourth were negative or opposed and the remaining fourth were uncommitted or neutral. Obstacles to such delegation were an increase in physician's liability and the lack of well-qualified maternity nurses. 1973 Program: The 1973 request of $6,035,000 would continue support of 68 ongoing research efforts in the broad field of maternal and child health and crippled children's services. 233 Direct Operations Increase or 1972 1973 Decrease - Pos. Amount Pos. Amount Pos. Amount Personnel compensation and henefits...4 .... 133 $2,633,000 133 $2,658,000 --- +$25,000 Other expenses ........ --- 1,445,000 --- 1,490,000 --- +45,000 Total ........... 133 4,078,000 133 4,148,000 --- +70,000 The Maternal and Child Health Service staff are concerned with (1) administra- tion of grants for medical care services, research and training grants; (2) tech- nical assistance and consultation to States, localities and organizations; (3) development and issuance of standards and guidelines for services to mothers and children; and (4) evaluation and analysis of program performance and potentia . The special emphasis placed in 1971 on providing consultation an a v ce to tate and local agencies is being continued in 1972. Special effort is also being directed to assisting States in meeting the legislative requirements to provide family planning services Statewide by 1975. ation efforts 1973 Program: MCHS staff will continue consultation and evalu and will continue to concentrate on monitoring of grant activities, improved management of services, and provision of technical assistance and guidance to States and communities. Mandatory costs associated with within-grades, reclassi- fications, and central services charges account for the total increase of $70,000 in 1973. The staff will continue its current high rate of productivity in providing technical assistance and consultation to grantees, States and localities, and in implementing policies related to capitation and third party payments. 234 Family Planning Increase or 1972 1973 Decrease Pos. Amount Pos. Amount Pos. Amount Personnel compensation and benefits. . . . . 70 $1,024,000 87 $1,407,000 +17 +$383,000 Other expenses . . . . . .. 95,229,000 -- 137,604,000 -- +42,375,000 Total 70 96,253,000 87 139,011,000 +17 +42,758,000 Introduction Family planning services are defined as those educational, comprehensive medical and social services necessary to enable individuals to determine freely the number and spacing of their children. An estimated 20 percent of all births in the United States are unwanted by either the husband or wife or both. The proportion of unwanted births is significantly higher among the poor for whom contraceptive information and services are less available than for others. This lack of information and services causes unwanted pregnancies which result in numerous health, social and economic problems, and deny individuals the right to control their own fertility. To remedy the situation, the President has declared it a national goal that family planning services should be available by 1975 to all who want, but cannot afford them. The Federal responsibility is to provide leadership in meeting this goal. About 2.9 million individuals were receiving services by the end of 1971, through all public and private means. The major responsibility to more than double the nationwide capacity to deliver family planning services by 1975 rests with the Department of Health Education and Welfare, primari y w t t e at ona Center for Family Planning Services. The National Center for Family Planning Services, as the lead agency within the Health Services and Mental Health Administration for the delivery of family planning services, administers a program of project grants and contracts for the support of family planning clinics, the training of family planning workers, the development and distribution of family planning educational materials, and for research and technical assistance to improve the delivery of family planning services. These programs are designed to accomplish the President's goal by focusing and coordinating efforts to reach the maximum number of people with quality services as rapidly as possible. 235 Project Grants and Contracts 1972 1973 Increase or Amount Amount Decrease other expenses . . . . . . . . . . .$94,815,000 $137,024,000 +$42,209,000 Included in this subactivity are project grants and contracts for the delivery of family planning services; project grants and contracts for the training of allied and other health personnel for work in family planning clinics; and project contracts for education, research, technical assistance and planning and evaluation as described below: (1) Family planning services 1972 1973 Increase or Amount Amount Decrease Project grants and contracts for family planning services: Project grants . . . . . . . . . . .$87,875,000 $129,875,000 +$42,000,000 Project contracts . . . . . . . . 625,000 625,000 -- Total $88,500,000 $130,500,000 + 42,000,000 Support for the delivery of family planning services is provided through project grants authorized under Title V of the Social Security Act and Title X of the Public Health Service Act. These grants, which are administered by regional office staff, are made to State and local health departments, hospitals, universities, community agencies and other public or nonprofit groups. Family planning services include comprehensive medical services composed of physical examiniations, medical history, laboratory tests, contraceptive supplies and referral for other health service needs. In addition to those medical services directly relevant to family plan- ning and contraception, clinics provide services for the detection, diagnosis and referral of other major health problems, such as breast and cervical cancers venereal disease, and among black patients only, sickle cell disease. Other services include patient education and counseling and social services, such as transportation and babysitting to facilitate patients' use of family planning services. The mandate of the National Center is to provide comprehensive family planning services to the millions of individuals who, for many reasons, are denied access to these services, with priority on services for persons from low income families. The acceptance of these services is purely voluntary, and does not affect the recipient's eligibility for other services. Prior ty is placed on locating services in areas with high concentrations of persons in need of family planning services and high rates of maternal and infant sickness and death. In addition, consideration is given to integrating family planning projects within existing health systems. Many projects supplement programs of State and local health departments or other Federal programs to avoid duplication of effort and provide a base for more compre- hensive services. 236 During FY 1972, grants totalling $87,875,000 will support about 325 projects whose total capacity for services will be about 1.5 million people, more than doubling the service capacity funded through 1971. To guide program development and funding during FY 1972, the Center has established several priorities. The priorities are based on a concern for the timely development of programs against the five-year goal, utilizing the project grant which is particularly suited to support the creation and initial expansion of a capacity to provide family planning services into which other sources of continuing financial support can be channeled. This is particularly true for specific groups and areas for which the traditional means of health care delivery are not generally available. Specifically, these priorities are: 1. To ensure geographic and administrative coverage of the entire United States by developing plans and identifying service providers and kull-time administrators for areas such as states or metro- politan areas. 2. To establish and enforce minimum program standards for medical services, administration and staffing; 3. To maximize the extent to which financial resources other than those available through the National Center are utilized; and 4. To increase the availability of services to rural residents, low-income whites, people who have achieved their desired family size, adolescents, and those with no children. During 1972,75 OEO projects were transferred to the National Center. Liaison with OEO, the Maternal and Child Health Service and other providers of services was maintained to ensure the most effective utilization of all family planning resources. The Center will continue to support project contracts totalling $625,000 in both 1972 and 1973 for the delivery of family planning services to American Indians. Of the total 1973 program level of $129,875,000 for family planning project grants, Approximately $114,875,000 will be for the continuation and expansion of 325 prior-year awards, including $27,000,000 for program expansion. Ten million dollars is included for the transfer of approximately 75 additional on--going projects from OEO and $5,000,000 is included to initiate about 25 new projects. In 1973, the estimated 425 projects will provide service capacity for approximately 2.2 million women. At least one project will be operating in each state, as well as Puerto Rico, The Virgin Islands and Guam. Priority will be given to the expansion of existing programs including the development of services in additional locations within the service area, such as Additional cities and counties within a statewide project. It is crucial that the basic capacity to deliver services be established through- out the country in 1973 so that the national goal can be achieved. Efforts will be made to involve all elements of the health services delivery system in the provision of family planning services, and to make family planning a basic component of all comprehensive health programs. This will include providing family planning services in public and private hospitals, comprehensive health centers and neighborhood health centers. It is estimated that 90 percent of the services needed for family planning can be provided by existing health facilities. All projects will be encouraged to seek other sources of financial support, particularly for the support of 237 continuing care through third-party reimbursements, including private insurance and public programs such as Medicaid. The $10,000,000 for the funding of an estimated 75 OEO family planning projects throughout the nation reflects the Administration's policy of having successful OEO projects transferred to operating agencies once they are established. Although all of the projects to be transferred have not yet been identified, priority will be given to transferring programs which are jointly funded by OEO and the National Center for Family Planning Services and projects which have accomplished their development and demonstration purposes. The National Center is currently working with the OEO to facilitate this second round of transfers so that program continuity will be ensured. The following table shows the estimated number of projects, women served, and funding of family planning project grants to be supported by the National Center in 1972 and 1973: 1972 1973 Increase or Prol@ct giants funded Estimate Estimate Decrease iii the Fiscal Year No. Amount No. Amount ..No. Amount Continuation projects 265 $75,875,000 325 $114,875,000 +60 +$39,000,000 OEO projects to be transferred 75 10,000,000 +75 +10,000,000 New project grants 60 12,000,000 25 5,000,000 -35 -7,000,000 Total 325 87,875,000 425 129,875,000 +100 +42,000,000 Number of women served* 1,500,000 2,200,000 +700,000 *Estimated oh the basis of $60 per woman per year Current estimates indicate that approximately 2.3 million additional women may be receiving services from other providers of services in 1973, including private physicians and voluntary organizations. When combined with the 2.2 million women to be served by projects funded by the National Center, a total of 4.5 million women ii need of subsidized services will be receiving them. Thusi at the end of the third year of the five-year effort, well over two-thirds of the total estimated need for subsidized family planning services will have been met. This significant national effort will greatly help reduce the dependency of many families presently burdened with the consequences of unwanted childbirth. 238 (2) Training and Education 1972 1973 Increase or Amount Amount Decrease Project grants and contracts for training and education Training grants . . . . . . $2,000,000 $2,000,000 Training contracts . . . . 1,000,000 1,000,000 Education contracts . . . . 700,000 909,000 $+209,000 Total . . . . . . . . . 3,700,000 3,909,000 +209,000 The rapid establishment of a network of family planning service programs requires the availability of trained manpower, the absence of which is a major impediment to the development of many health programs. The crucial efforts to remove this as a constraint include training additional family planning workers, creating new categories of health workers, and special efforts to demonstrate the most effective utilization of manpower resources. Project grants and contracts totalling $3,000,000 in 1972 will be used for the development of a short-term training capacity to train approximately 2,200 personnel who will assist in the delivery of family planning services. Priority will be given to the development of training capacity at regional and state levels to provide training for all categories of service delivery personnel. Emphasis will be on training administrators for improved management and program development, and training selected individuals from fami y planning projects to assume the role of trainers within their own projects. In an effort to improve the delivery of services in rural areas and promote effective man- power utilization, special training programs will develop the clinical service delivery skills of physicians' assistants, nurse clinicians, public health nurses, and nurse midwives. Special studies to improve the tools available for family planning training programs will be further developed in 1972. it has become crucial that all materials currently used in family planning training be reviewed to determine their effectiveness, to make the best materials more widely available and to determine where new materials should be developed. In addition, new methods for evaluating the effectiveness of various training approaches will be developed as a tool for administrators responsible for implementing training programs. Models for training will be developed to assist new projects in initiating training efforts and established projects to improve programs. During 1973, the $3,000,000 training grants and contracts program will concentrate upon the improvement and strengthening of the regional and state training capacities developed during the preceding year. A major training objective will be to continue to gain a high multiplier effect by training selected project level personnel to provide family planning service delivery training at the local level. The development of a minimum training capability within each project will thereby be achieved. Program areas to receive the greatest attention will include program and project management, with emphasis upon skills in personnel, office management, record keeping, budgeting and accounting, planning and evaluation, clinic management, community relations 239 and education, and staff training. The training program will also continue to develop new manpower categories such as family planning assistants and nurse clinicians to assume increasing responsibility for the delivery of services previously accomplished by physicians and nurses alone. Continued emphasis will be placed on the effective utilization of existing categories of manpower such as nurse-midwives, nurse clinicians and physicians' assistants so that they might assume responsibility for many of the more routine medical procedures. Education - The broad objectives of the education program of the Center range from providing information to a variety of family planning personnel at all levels to increase their awareness of the family planning field, to assisting in the implementation of effective education components of operating family planning programs. These efforts are intended to give direct support to NCFPS service projects in the development of provider and patient oriented education programs, and to extend and improve the understanding, knowledge and commitment of the total community to the potential benefits of effective family planning services. In 1972 a variety of activities will be supported to improve awareness and knowledge of family planning at all levels. Special efforts will be made, through studies, surveys and workshops to extend and improve knowledge about special patient groups such as adolescents and minorities, in order to develop improved education programs responsive to their needs. Further studies are needed to learn more about the specific barriers which may prevent people from controlling their own fertility. For example, in-depth studies are needed of the attitudes of individuals of varying characteristics toward specific methods of family planning and toward various sources of service in order that education, medical and-social services might take such attitudes into consideration in planning the actual services to be offered. Projects will be initiated in 1972 to disseminate educational materials to selected audiences including potential deliverers of medical, educational, referral and other supportive services. New educational materials will be developed and evaluated for use in multiple settings, such as hospitals and private doctor waiting rooms as well as family planning clinics. The increase of $209,000 in 1973 will enable the Center to develop and evaluate new education materials and promote the use of education methods which have proven their usefulness. A major objective in 1973 will be to utilize the information derived from studies to develop and introduce educational programs for hard-to-reach groups based on a sound understanding of their levels of knowledge and attitudes toward family planning services. 21f 0 (3) Services Delivery Improvement 1972 1973 Increase or Amount Amount Decrease Project contracts for services delivery improvement . . . . .$2,615,000 $2,615,000 Special studies and programs are being supported by the Center to develop and improve its ability to mount a coordinated program responsive to national priorities and to significant regional and local variations. These programs, supported under project contracts, are in the areas of operational research, planning, evaluation and technical assistance. Operational Research - This program seeks to develop the most effective methods for the delivery of family planning services, and to apply the most modern research techniques to the solution of operational problems. In 1972, the operational research program is directed toward the exploration of new techniques for serving the "hard-to-reach" segments of the population in need of services. Extension of services into rural areas will be explored in several studies. These studies will document existing rural delivery approaches, identify major barriers to services, design alternative models for delivery of services and, in a controlled situation, evaluate various delivery mechanisms such as mobile clinics, private physician programs, and free-standing clinics. Studies also will be supported which will use and compare a wide variety of program designs responsive to the needs of the adolescent. Other studies will seek ways to improve the accessibility of services through establishment of alternative delivery settings. One project, for instance, will test the feasibility of providing services at work sites to reach the many low income workers who cannot, because of both job and family responsibilities, easily avail themselves of services provided elsewhere. Planning - Activities are supported at the national, regional, state and local level to provide program managers with the demographic, analytical and procedural tools for designing future program efforts. During 1972, the Center will continue its efforts in defining the scope, strategies, policy requirements, resources and needs of a nationwide services delivery program. The need to plan alternative levels of program implementa- tion led to the development in 1972 of separate regional profiles which itemize for each of the ten DHEW regions detailed data and strategy implications. A detailed update and assessment of program progress will be initiated in the Spring of 1972, the first point at which significant new data and program information will be available. This will form the basis for the more detailed analysis and update of the five year plan in January of 1973, the midpoint in the five year mandate for the nationwide delivery of family planning services. Evaluation - The development of methods and data for determining progress and identifying problems in implementing program objectives is crucial. At all levels of program implementation effective decisions depend directly on the availability and analysis of current information on program status and impact and on the effectiveness of various operating techniques and strategies. 241 A joint OEO/HEW evaluation project identifying and comparing detailed data from selected projects on utilization of services, patient characteristics and clinic operations, will be completed in the Spring of 1972. On January 1, 1972, the National Center for Health Statistics began the final phase of implementation of the National Reporting System for Family Planning Services, which includes all DHEW funded projects among others. This will form one of the core elements of the evaluation effort, by providing continuing data on the number and characteristics of all family planning patients. A high priority in 1972 will be the development of an evaluation process built upon project monitoring concepts. Projected phases include assessment of evaluation needs at all levels of program management; identification of existing evaluation activities; development of program specific evaluation concepts; definition of project performance criteria; field-testing of the resulting evaluation process; preparation of technical assistance manuals for application of this process at various operating levels; and installation of the evaluation system in selected areas. This process is being designed to provide a common framework within which project evaluation will become an ongoing Activity at the national, regional and the project levels. Technical Assistance -- Special efforts are supported to provide outside consultation to directly assist local communities in the development and implementation of specific aspects of effective delivery of family planning services. These cover a range of activities, including: development of mechanisms for area-wide coordination of delivery programs; implementation of effective consumer participation activities; the improvement of project management skills; the development of effective coordination with other Federal agencies providing family planning services; and the improvement of communica- tion skills and attitudes in providing services to ethnic groups. These activities, initiated in 1971, will be expanded to assist additional projects in 1972. In 1973, studies will be continued to improve the delivery of services to people with problems of access to health services such as adolescents and rural people in general. Planning and evaluation data will be used to meet the immediate requirements of family planning administrators primarily at the regional, State and local levels. The project evaluation process will be further refined and fully implemented across all levels of program administra- tion. The Center's technical assistance efforts in 1973 will concentrate on improving project management and assisting in the orderly expansion of services in given geographic areas. 242 Direct operations Increase or 1972 1973 Decrease k'OS. Amount Pos. Amount Pos. Amount Personnel compensation and benefits . . . . . . 70 $1,024,000 87 $1,407,000 +17 +$383,000 Other expenses . . . . . . -- 414,000 -- 580,000 -- +166,000 Total . . . . . . . . 70 1,438,000 87 1,987,000 +17 +549,000 The direct operations subactivity provides staff and operating funds necessary for program development and administration of the programs of the National Center for Family Planning Services. During 1972, 60 new project grants totalling $12,000,000 million were awarded, 75 OEO projects totalling $10,000,000 were transferred to the National Center and project grants and contracts totalling $6,315,000 for training, education, and services delivery improvement related to family planning were awarded. Priority in 1972 was given to staffing regional and central office programs in line with their increased responsibilities for program development and monitoring. By the end of 1972, the regional office staff will have awarded pro- ject grants totalling almost $88,000,000 to about 325 grantees serving approxi- mately 1.5 million women. Efforts were also focused on the improvement of the organizational and management structure of the Center. Special training and orientation was provided to the many new staff members who were assuming major responsibilities for the achievement of program goals. A major step forward was begun in 1972 toward measuring the accomplishment of program objectives through project evaluation. The Five-Year Plan was updated to reflect the latest analyses of census data and information from the National Center for Health Statistics Patient Reporting System. The 17 additional positions requested in 1973 will be used to strengthen both regional and central office program management capabilities and to provide increased technical assistance to grantees. In the regions, priority will be given to providing the basic program and management staff necessary to develop and evaluate family planning projects on a decentralized basis including the development of alternative funding sources. A total of ten positions are requested to strengthen the regional offices in these areas. The remaining seven positions will be used in the central office to strengthen program management, especially in relation to assisting grantees and regional office staff in the areas of training, education, and technical assistance. An increase of $549,000 is requested for direct operations in 1973. Of this amount, $233,000 is for the first year costs of the 17 new positions, $267,000 is to annualize the costs of the new 1972 positions, $28,000 for the cost of within grade increases; $28,000 for the increased cost of ETS and the HSMHA Service.and Supply Fund; and $2,000 is to annualize the costs of the 1971 Commissioned Officer pay increase. These increases are partially offset by.a built-in decrease of $9,000 for two days less pay in 1973. National Health Service Corps 244 Increase or 1972 1973 Decrease Pos. Amount Pos. Amount Pos. Amouni' Personnel compensation and benefits ................... 637 $6,994,000 637 $9,518,000 +$2,524,000 Other expenses ............... -- 7,123,000 -- 5,285,000 -1,838,000 Total .................... 637 14,117,000 637 14,803,000 +686,000 Budget authority ......... 11,200,000 8,418,000 Reimbursements ........... --- 6,385,000 The National Health Service Corps represents a new approach in the Federal effort to improve the health care of people residing in medically underserved areas of this country. For the first time, Public Health Service physicians, dentists, nurses and other health professionals will be providing direct health care to persons living in an area where existing health manpower resources are inadequate to provide this care. The Administration has stated, "It is a matter for public concern that too many of you live in areas where there are critical shortages of health person- nel." The Corps was formed to help alleviate this situation. "In over 120 counties, comprising over eight percent of our land area, there are no private doctors -- and the number of such counties is growing." "A similar problem exists in our inner cities. In some areas of New York, for example, there is one private doctor for every 200 persons but in other areas the ratio is one to 12,000. Chicago's inner city neighborhoods have some 1,700 fewer physicians today than they had ten years ago." In the preamble of the law, there is explicitly identified a major goal of the whole program -- to get Corps assignees to stay in the areas to which they are assigned after the completion of their service with the Corps. If we are to have any success at all with this goal, we must develop community patterns which are natural and cooperative. Our assignees must be a real part of community life. They must, however, have the administrative and professional backup which they need to remain as fully effective health professionals. We will supply this, partly through the Corps' own resources and partly through the resources of the community and the region itself. If we are to build systems which will be self-sustaining and which will outlast the need for the Corps, then the community must develop its own complete system. One small aspect of this system is the building of an economic base for an independent, post-Corps medical or dental practice. Thus the provision for collection of fees, from individuals or third-party payers as necessary, is an important part of the general effort at effective system-building. Only in this way can the Corps achieve loni term success in overcoming the "emergencies" which led to its creation. The 1973 request is based on anticipated reimbursements of $6,385,000. During the course of 1972, the following significant steps were accomplished: --Appointment of the National Advisory Council on Health Manpower Shortage Areas and convening of its first meeting December 4-5, 1971. Support for the Council for 1973 is covered in this request. 245 --- Regulations governing the policies and procedures of all aspects of the program, e.g., criteria for community participation, conversion of assignees to status of private practitioners, and the collection of fees for services have been prepared and published. --- Advice and assistance to communities, and processing of their requests for assignees. Of the first 122 requests received and processed, 18 were evaluated, the sites visited and finally selected for manpower assistance. As of December 31, 1971, 494 requests have been received and are in various steps of processing and development. It is incumbent on staff working with community groups to encourage them to set realistic goals and to assure that assignees are effectively linked to other provider units in a way that fosters the development of effective and efficient systems for care. In some cases, a physician will not be warranted in light of the overall need. In such cases, the community will be assisted in determining the most appropriate type of health personnel and arrangements. A major goal of the program, in addition to the assignment of health professionals to such areas, is the encouragement of National Health Service Corps assignees to stay in the areas to which they were assigned after completion of service. To this end, a careful program of matching by the assignees and the communities is being developed, as well as the development of educational linkages to maximize the chances of retention of such persons in the communities. --- A total of approximately 240 health professionals, including doctors, dentists' nurses and other allied health personnel will have been recruited, oriented and assigned to communities in critical need of health services. Teams vary in size from two to seven health professionals. It is estimated that approximately 60 communities serving approximately 600,000 people will be reached. --- To ensure that program goals and objectives are being met, an evaluation component utilizing 1/2% funds has been approved; it will evaluate consumer acceptance, effectiveness of the matching process, attitudinal changes in assignees and communities and the factors related to establishment and growth of medical practices in medically underserved areas. 1973 Program This request would allow for recruitment of an additional 337 health pro- fessionals for a total of 577. This number would provide support for a total of 175-225 communities with a total population of approximately 700,000 - 900,000 people. No program increase is requested for this activity. Howeverwe are re- questing a net increase of $686,000 to cover mandatory items. The mandatory items include $547,000 for continuation pay costs for commissioned officer medical positions, $148,000 for net costs of within grade increases and $139,000 for annualization of the uniformed services pay increase, Public Law 92-129, dated September 29, 1971. These increases are partially offset by decreases of $23,000 for two less days of pay and $125,000 annualization of DHEW 1972 employment cutback. 246 Patient Care and @cial Health Services increase or 1972 1973 Decrease Pos. Amount Pos. Amount Pos. Amount Personnel compensation and benefits, ..... * ... 5,8W $74,603,000 5,8W $75,628,ooo --- 41,025,000 other expowes, .... 00 ... --- 31,422,000 --- 312777,000 --- +355,000 &ftotal ..... 5,8W 106,025,000 5,890 107,405,000 --- +1,38o,ooo @ers and o@istence charges... --- -299,000 --- -299,000 --- --- Total .......... 5)890 105,726,000 5,890 lo7,lo6,ooo +1,380,000 Re able obligations -17,223,000 -17,114,ooo +iog.ooo Direct obliga- tions ........ 88,503,000 89,992,000 +i,@1000 Introduction 7his program @o health care to the legal beneficiaries of the Public Health Service. Major beneficiary groups are American seamen, Coast and PHS Comissioned Co@ personnel, and persons afflicted with leprosy. on a re- @sable basis, medical care is also provided to Federal employees in PHS health units. In addition, Coast Guard personnel are provided medical and dental services at various Coast OwLrd locations. 1. D4iont and outpatient cars. - The primary purpose of this activity is to provide for the eM ve alth care of its beneficiaries. The budget for 1973 VM @t operation of the eight PHS general hospitals, 30 out- patient clWco and the National Leprosarium at Carvi.Ue, La. It win also fund contracts with about 250 private physicians wA with other Federal and non-Federal facilities to @sh health care to the legal beneficiaries of the Pkxblic Health Service. 2. CO"t Guard medical services. - MU activity provides PHS personnel to staff Coast GwLrd ies, dispensaries and sick bays at shore stations, air stations, and on board vessels* Contract care is also provided in civilian or Federal facilities. Coast Ouard medical services bas also develoW program in industrial, @rvmter and aviation mdicine, and in al sanitation. The nt enpbasis is on establishing programs to UUct and rehabilitate drug abusers and to set up treatment centers at Cape NW, New Jersey and da, California to rehabilitate persons with minor poe@gical disorders. 247 3. Federal emloyme. - 7his activity provides cometation to and Ye of Federal agencies, upm request, on the conduct of Federal wWloyeest occupational health programs. Federal employee health programs are operated for Federal @ies on a reiW=sable basis, on request. In 1973, it is expected th&t 95 health units operating under this activity vi3l provide ocaVational health services to an estimated 160,000 Federal eMloyees. 4. Paymnt to Havaii. - Grmts are made to Hawaii to defray the cost of I of persons afflicted with leprosy. The average daily patient load is expected to be 158 in 1973, as compared with 164 in 1972 and 3j% in 1971. 248 Inpatient and outpatient Care Increase or 1972 1973 Decrease Pos. Amo=t Poo. unt Po's. Personnel compensation and benefits ....... 0 ........ 5,479 $68,975,000 5,479 $69,W8,000 4913,000 Otber @nses ............ --- 26,%l,OOC) --- 26,714,000 +153,000 satotal .............. 5,479 95,536,COO 5,479 96,602,000 +1,o66,ooo Deduct quarters and @- sisteme charges ........ --- -299,000 --- -299,000 Total ... 0....... O...*. 5,479 95,237,000 5,479 96,303,000 +1,066,000 Be able obligations.. -13,223,000 -13,110,000 +113,000 Direct obligations.... 82,014,000 83,193,000 +1,179,000 fte pr@ mission of this program is to provide comprehensive health care to PHS beneficiaries. fte mjor boneficimT groups are American seamen, Coast and PES Cm"sioned Cor" personnel, and persons witb leprosy. The largest 4na3a category of beneficiary is the Amrican seamen, comprising approximtely ;Ofof the inpatient load in PHS general hospitals. on a reimbursable basis, bealt3i care is also provided to foreign seamn and beneficiaries of other Federal apneies in Pus hospitals. In addition to providing direct health care services, the hospitals are ac- tively "fticipating In the lVrovemnt of health services in the local a ties. Over 6W professional and sab-professi@ employee and 2,400 individuals from the ties receive clinical training both in theme facilities and thr@ affiliations and &=iliary training programs. EMbasis is given to t@- ing of dise groups. C ty involvement has increased throu& mbaring available medical c@ilities and health care resources where re saments or recip services are received from the c ties. ft M hospit&U have been experiencing a cont decline in inpati@ workloada and are now aWating at less Um maxim= capacity. The facilities has, r, becom iVortant conamity health resources. Recognizing the potential of further increasing the value of these facilities to the a ties and to aamm max@ ut:LUzation, we are conducting @dies to dete@ the feasibility of converting them from Federal to local control. During l9T3 is will be plwed on converting as @ of these facilities as possible, in order to permit cc=amit:Les mro latitude in utilizing the excess capacity to met local needs. fte net increase of $1,179,000 in coWrined of an increase of $2,283,000 for built-in costs of oont the 1972 level of hospital and clinic operations, offset by a decrease of $1,104,000 vhich reflects this program's share of an M@de personnel reduction. 249 Coast Guard Medical Serv-ices Increase or 1972 1973 Decrease Pos. Amount Fos. Amount Pos. Amount Personnel c sation and benefits .............. 151 $2,490,000 151 $2,591,000 +$ioi,ooo Other expenses .............. --- 2,312,000 --- 2,5i4,ooo +202,000 Total ............... 151 4,802,000 151 5,105,000 +303,000 The budget estimate provides for medical services to Coast Guard personnel aboard their vessels and at their air and other shore stations. It also provides for care in contract medical facilities,- hospitalization in Federal facilities other than those operated by the Public Health Service, and emergency medical treatment in non-contract facilities as authorized by law. Not included are costs funded by the Coast Guard such as space, utilities, medical and dental eqaipmt, mobile dental units, furniture, office &Mliances, and pay and travel allowances of Coast Guard personnel aesigkied to the program. Medical facilities at Coast Guard units are classified as infirmwies, dis- pensaries, or sick bays. The larger shore units have infirmaries staffed with medical and dental officers of the Public Health Serv-ice. Dispensaries are facilities at intermediate size shore units at which either or both medical and dental officers are assigned to duty. Sick bays are facilities aboard vessels and at maller shore units. Sick bays are usually manned by hospital corpamen, but vessels may have a medical officer assigned. The Coast Guard operates one accredited hospital, located at the Coast Guard Academy, New London, Connecticut. Full-time medical, dental, and ancillary staff are assigned where sufficient concentration of personnel wdet to make operation of such facilities economical to the t. 8=11 concentrations of personnel are provided medical and dental care by local contract @icians and dentists. Mobi dental units ed with Pablic Health Service dental officers are also used to provide dental ser- vices to personnel in remote areas. The major problem of the Coast G?aard program is provision of adequate medical and dental care to personnel widely dispersed in numerous mal units, many of vbich are geographically and medically isolated. The budget increase for medical eery-ices for the Coast Guard in the amount of $303,000 provides for built-in items of expmse: statutory salary increases price increases for contract medical care, and increased cost of medical supplies. 250 Federal Employees Increase or 1972 1973 Decrease Pos. Amount Pos. Amount Pos. Amount Personnel compensation and benefits ................... 260 $3,138,000 260 $3,149,000 --- tsii,ooo Other expenses ............... --- 1,349,000 --- 1,349@000 --- --- Total ..................... 260 4,487,000 260 4,498,000 --- +11,000 Reimbursable obligations.. -4,000,000 -4,004,000 .74,000 Direct obligations ........ 487,000 494,000 +7,000 Responsibility for Federal employee health is assigned to the Public Health Service under P.L. 79-658, August 8, 1946 (5-USC-7901), and the Bureau of the Budget Executive Circular No. A-72, June 18, 1965. The services authorized include emergency diagnosis and treatment of injury or illness occurring during working hours; pre-employment examina- tions; inservice examinations determined necessary by the Department or agency head; administration of treatments and medications under certain circumstances; preventive services to appraise and report work environment health hazards; health education, and specific disease screening examina- tions and immunizations; and referral to private physicians, dentists, and other community health resources. The specified goal is the provision of these services for all Federal employees who work in groups of 300 or more. The Division of Federal Employee Health has established the following objectives: a. To provide consultation on the organization and establishment of employee health services to any Federal agency requesting advice; to proNide standards and criteria for the furnishing of such employee health services; and, when requested, to assist agencies of the Goverrunent in the evaluation of such services. b. To organize, administer, and operate Federal employee health services for participating Federal agencies on a reimbursable basis. The requested increase of $7,000 in appropriated funds and $4,000 in reimbursable funds are for built-in items of expense. In 1973, it is expected that 95 health units operating under this activity will provide occupational health services to-an estimated 160,000 Federal employees. 251 Payment to Hawaii Increase or Decreue Otbor sea, total ..... $i,200,000 $i,200,000 In accordance with 42 U.S.C. 255, funds under this activity are to be u@ for p to to the State of @i for care and treatment of persons afflicted with leprosy. For the past several years, $1,200,000 has been appropriated each yew to assist @i in defraying the expenses relating to this care mA treatment. We we rwpesting no change in the ==t for 1973. It dmld be noted that reimbursement is ba@ on actual enenses so that the requested =at will not be paid unless it is actually needed. ex- penses the $1,200,000 are borne by the State of @i. The table below shows the estimated average daily patient load, patient daVe, per diem cost, and appropriation requests for 1972 and 1973. 1972 Average daily patient load ... 164 158 Patient days ................. 59,936 57,758 Per diem cost .............. $32-37 $32.47 Total cost and net require- ...................... $1,940,000 $1,875,ooo iation request ...... 1 200 000 1.200. 252 Regional office central staff Increase or 1972 1973 Decrease Pos. Amount Pos. Amount Pos. Amount Personnel compensa- -$6,000 tion and benefits - 250 $4,549,000 250 $4,543,000 other expenses ...... -- 738,000 -- 738,000 Total ........... 250 5,287,000 250 5,281,000 -$6,000 This staff is located in the 10 Regional Offices. These are direct operational arms of HSMHA and serve as focal points for the packaging of multiple program efforts to meet community needs. Such needs encompass, but are not limited to, comprehensive health planning, resource development, disease control and collaborative endeavors for the improvement of health service in States and communities. Regional Office functions fall into the following broad categories: 1. Operational planning. 2. Technical assistance and consultation to: a. Plan and evaluate comprehensive health services in the States and communities within the Region. b. Aid State and community organizations in the provision of high quality health services. c. Fill gaps in existing community health services (including provision of grant funds for start-up costs)., d. Assist State and local agencies to effect HSMHA goals in the delivery of health services. 3. Manage Federal grant funds as outlined in the authorities delegated to the Regional Offices. To carry out these HSMHA Regional Office responsibilities, the Regional Healt'n Director has a Central or "core" staff of capable individuals unin- cumbered by categorical loyalties reporting directly to him. Such a "core" staff gives the Regional Health Director the flexibility to react effectively to the needs of the Region's citizens and the objectives of a decentralized health delivery system. In 1973 a net decrease of $6,000 occurs. This is composed of $11,000 for annualization of the uniformed services pay increase, Public Lau, 92-129, dated September 29, 1971, and $116,000 net costs of within grade increases, offset by decreases of $12,000 for ti-io less days of pay and $121,000 annualization of DHEW 1972 employment cutback. 253 Program direction and management services Increase or 1972 -1973 Decrease Po S. Amount Pos. Amount Pos. Amount Personnel compensation and benefits ........ 233 $3,986,000 236 $4,076,000 +3 +$90,000 Other expenses ......... --- 1,445,000 --- 2,238,000 --- .+793,000 Total ............ 233 5,431,000 236 6,314,000 +3 4883,000 This activity includes program leadership and direction and staff services including administrative management, program planning, and evaluation. The immediate office of the Director is responsible for planning, directing, coordinating,and administering the Health services delivery programs. Administrative management is responsible for the development, coordination, direction, and assessment of management activities. It directs such services as financial, personnel, and contract management. Planning activities focus on annual work plans, the longer-range goal- oriented planning system and encompases efforts in program analysis and evalu- ation, as well. A net increase of $883,000 is requested for 1973. This amount includes program increases of $649,000 for the Upward Mobility Program, $45,000 and three positions to administer the expanded family planning program and several built-in increases amounting to $189,000.. 254 HEALTH SERVICES AND MENTAL HEALTH ADMINISTRATION Health services delivery Program Purpose and Accomplishments Activity: Comprehensive health services - Grants to states (PHS Act, Section 314(d)) 1973 Budget 1972 Estimate Pos. Amount Authorization Pos. Amount -- $90,000,000 $165,000,000 -- $90,000P.000 @r ose: Formula grants are awarded to State health and mental health authorities to assist the States in providing and maintaining adequate public health services in accord with priorities and goals established by the States. Explanation: A plan for the provision of public health and mental health services is required from each State. Grant allocations are based on a State's population and per capita income, with the restriction that States make available at least 15% of the funds for the support of mental health activities, and at least 70% for the provision of health services at the local level. The Federal share ranges from 33 1/3% to 66 2/3% based on population and per capita income. Accomplishments in 1972: State health and mental health agencies have utilized their funds to assist in the support of a broad range of basic health programs provided at the State and local level. Among these ongoing activities that provide health services to both the general population of the States and to high risk groups within the States are communicable disease control, environmental health programs (including food and drugs, radiological health, sanitary engi- neering, and vector control), laboratory services, vital statistics, nursing services, and a variety of community mental health services. Some States have used the flexibility of these funds to support new approaches to the delivery of these health programs, and others have expanded into new areas of services for their State health agencies, such as family planning, dental and medical care clinics. Objectives for 1973: The 1973 budget request would allow the States to continue the same level of support for their State plan programs as in 1972. A large number of States distribute the grant funds through systems of formula or project grants to local health jurisdictions. 255 HEALTH SERVICES AND MENTAL HEALTH ADMINISTRATION Health services delivery Program Purposes and Accomplishments Activity: Comprehensive health services - health services grants (PHS Act, Section 314(e)) 1973 Budget 1972 Estimate Pos. Amount Authorization Pos. Amount -- $103,913,000 $157,000,000 -- $116,200,000 Purpose: This program provides an effective means for upgrading and expanding the capacity of the ambulatory health services delivery system, and permits the Federal Government to be more responsive to health needs of limited geographic scope or of special regional or national significance, and for developing and initially supporting new health service programs and related training. Explanation: Grants are awarded to support comprehensive health service programs which provide primary care and a broad range of ambulatory services. Accomplishments in 1972: In 1972, 55 comprehensive health centers (including nine health centers transferred from OEO) and component projects provided primary care and ambulatory services to an estimated 850,000 persons. These projects covered an eligible population of approximately 2,700,000 persons. It is estimated that the new Family Health Centers programs established in 19,72 will have 20 centers in the planning stage and 10 operational centers serving about 100,000 persons. Each center will have an agreed upon package of health benefits for each enrollee under prepaid capitation arrangements. The location of centers will be con- sistent with the development of health maintenance organizations on a short- or long-range basis. The experience with this unique type of health center will provide models by which previously existing health centers developed under different criteria and conditions may be converted to prepayment and health maintenance organization status. Objectives for 1973: Emphasis in 1973 will be placed on continued improvement in the management of existing comprehensive health centers, the quality of health care provided, operation of uniform accounting systems, development of financial plans by the centers to aid them in developing a broad base financial support and eventual self-sufficiency, and the utilization of medical audits. The program of shifting mature OEO health center projects into this activity will also be carried on in 1973. Continued priority will be placed on assisting health centers to convert to prepaid capitation arrangements and increase collections from third party payers. It is expected that these actions will result in reduced Federal grant require- ments and in opportunities for enhancing the use of project grant funds in improving or expanding health services. The increase of $3,000,000 for Family Health Centers would allow 10 develop- mental projects initiated in 1972 to become operational and fund three new centers. These new operational projects will serve an additional 130,000 persons for a total of 23 centers serving approximately 230,000 persons. 256 HEALTH SERVICES AND MENTAL HEALTH ADMINISTRATION Health services delivery Program Purpose and Accomplishments Activity: Comprehensive health services - Migrant health grants (PHS Act, Section 310) Budget 1972 Estimate Pos. Amount Authorization Pos. Amount -- $17,950,000 $30,000,000 -- $23,750,000 Purpose: To provide health care services to migrant agricultural laborers and seasonal farmworkers and their families in order to raise the level of their health to that of the general population. Explanation: Project grants are made to finance part of the costs (no specific matching requirement) of establishing family health services clinics and to improve the health services and health condition of agricultural migrant workers and their families by providing primary health care services organized to maintain their health as well as to treat their illnesses. Accomplishments in 1972: Emphasis was placed on existing projects in initiating activities designed to convert their current grant method of financing to a prepaid capitation system. Existing projects were encouraged to expand their scope of services. It is estimated that there will be 460,000 patient visits in 1972, an increase of 101,000 over 1971. Objectives for 1973: Continuing emphasis will be placed on: (1) converting existing projects from grant support to other funding mechanisms; (2) improving the quality of services provided to migrants and seasonal farmworkers and increasing the number of persons served; and (3) methods to integrate migrants into a comprehensive system of care in rural areas which are responsive to their unique needs. 257 HEALTH SERVICES AND MENTAL HEALTH ADMINISTRATION Health services delivery Program Purpose and Accomplishments Activity: Comprehensive health services - Direct operations 1973 Budget 1972 Estimate Pos. Amount Authorization Pos. Amount 44@5 $17,981,000 Indefinite 445 $18,862,000 Purpose: This activity provides continuing professional and technical assistance to States, communities, providers of health services, medical and health organizations and other Federal units for the development of specialized programs in comprehensive health and resources improvement. Explanation: The direct operating programs under this activity provide services to the regional and specialized program staff for support of the comprehensive health services grant programs. This activity also provides for the development of specialized programs related to medical care administration, including the professional health aspects of Title XVIII of the Social Security Act. Accomplishments in 1972: Major emphasis was placed on initiating the new Family Health Centers program. A continuing objective has been improving management of the comprehensive health centers and migrant health projects through the provision of technical services in the administrative, financial and professional service areas. Emphasis is also being placed on moving pbs- itively toward improving management capacity to secure medicare, medicaid, private insurance, and other forms of reimbursement for services delivered through the centers. A major new initiative has been the President's program for improving general conditions of the Nation's nursing homes and extended care facilities. The health facility survey improvement program provided training for 275 State sur- veyors andutilizing an accelerated program of university-based training courses, an additional 950 surveyors/inspectors will be trained. The goal is 2,000 trained surveyors by February 1973. A second element in the President's program is short-term training for those health personnel who are furnishing services to patients in nursing -nomes. Thousands of health personnel actually working in nursing homes are being reached through this initial effort. A third priority is on demonstrations in five States to assist in developing consumer investigative units designed to provide a mechanism for nursing home patients to have an advocate to protect their basic rights. Substantial staff assistance was given to the Social and Rehabilitation Service in the enforcement of Medicaid requirements for nursing homes. As a result of review and assessment of all Medicare requirements for providers of service and independent laboratories,the updating of regulations for hospitals,extended care facilities, home health agencies and independent laboratories was completed. Survey report forms and surveyor guidelines for uniform application of the new and revised standards were prepared and staffs of all regional offices and State agencies were oriented in the application of the new requirements. Objectives for 1973: Program emphasis will continue to be directed toward aiding health centers in achieving a significant degree of financial independence through the garnering of additional third party reimbursements and other State and local support and moving toward prepayment systems wherever feasible. 258 Technical assistance will be provided to cities and neighborhoods to aid them in developing community oriented health care programs. The health facility surveyor improvement program, utilizing the university-based training program will train 775 State surveyors. This number, plus those trained in 1972, would apchieve the President's overall objective of training a total of 2,000 surveyors in an eighteen-month period. Short-term training program will continue to be emphasized and will support training for professional and ancillary health personnel providing services for patients in nursing homes. Continued support will be provided to State-sponsored consumer investigative units. These demonstrations will be supported in both governmental and vo untary settings and will attempt to demonstrate activities on both State and local levels. Program review has become a major continuing process for evaluating the effectiveness of the application of the Medicare provider standards by State agencies. In 1973, the methodology for conducting program reviews will be modified to be more selective and responsive to the needs of regional offices and the State agencies they serve. The program increase of $120,000 would be used to initiate a migrant health service reporting system. The information collected would be used to evaluate the adequacy and effectiveness of health services offered migrant workers. 259 HEALTH SERVICES AND MENTAL HEALTH ADMINISTRATION Health services delivery Program Purpose and Accomplishments Activity: Maternal and child health--Grants to states (Social Security Act as amended through 1967, Sections 503 and 504) 1973 Budget 1972 Estimate Pos. Amount Authorization Pos. Amount --- $121,522,000 Indefinite 1/ --- $125,678,000 by activity- Purpose: The basic purposes of these grants to States are to (1) reduce infant mortality and otherwise promote the health of mothers and children, (2) locate, diagnose, and treat children who are suffering from crippling or other handi- capping illnesses. Explanation: Grants are made to States on a formula basis and to State agencies and public or non-profit agencies of higher learning for special projects of regional or national significance which contribute to the health of mothers and children, including crippled and mentally retarded children. In both the maternal and child health services and crippled children's services formu a grant programs one-half of the amount appropriated in each case is apportioned among the States on a population-related formula basis and must be matched dollar for dollar. From the remaining half of the appropriation, specified amounts are reserved for special project grants and the balance is then apportioned by formula (in inverse population and per capita income ratio) among the States. Matching is not required for funds awarded from the second half of the appropriation. Accomplishments in 1972: The 1972 program continues to provide a variety of health services to mothers and children, including the following: Estimate Mothers receiving prenatal and postpartum care in maternity clinics ...................................... 400,000 Women receiving family planning services ................. 752,000 Children attending well-child conferences ................ 1,500,000 Crippled children receiving physicians' services ......... 500,000 Clinics for the mentally retarded ........................ 150 Objectives for 1973: Additional funds proposed for 1973 will help meet the rising costs of locating, diagnosing, treating and providing follow-up care for crippled children. Approximately 500,000 children will receive physicians' services under the crippled children's program. Maternal and Child Health Services grants will continue to provide care in maternity clinics to about 400,000 women, family planning services to about 752,000 women, and dental services to 1,300,000 children. I/ Authorization for all programs under Title V, Social Security Act, is $350,000,000. 260 HEALTH SERVICES AND MENTAL HEALTH ADMINISTRATION Health services delivery Program Purpose and Accomplishments Activity: Maternal and child health--Project grants (Social Security Act as amended through 1967, Sections 508, 509, and 510) 1973 Budget 1972 Estimate Pos. Amount Authorization Pos. Amount $92,008,000 Indefinite . --- $101,330,000 by activity.L/ .Purpose: The basic purpose of this program is to provide comprehensive health care to poor and near-poor mothers and children who might otherwise not receive such services. ExplanAtion: Project grants are awarded on a 75% Federal, 25% matching basis in the following areas: (1) to State and local health agencies and to other public or non-profit private agencies, for comprehensive maternity care and specialized care of infants born at high risk (Sec. 508); (2) to State and local agencies, medical schools, and teaching hospitals for comprehensive health care of children and youth (Sec. 509); and (3) to State and local health agencies and other public or non-profit private agencies, institutions, or organizations for comprehensive dental services for children and youth (Sec. 510). Accomplishmen ts in 1972: The 1972 program has been designed to provide a variety of services to poor and near-poor mothers and children in order to improve their health status. The following are some of the services provided and estimates of number of individuals reached: Estimate Admissions for comprehensive services: Mothers ...................................................... 144,000 Infants ...................................................... 49,000 Women receiving family planning services ....................... 134,000 Children registered fok comprehensive health care .............. 504,000 Children cared for in dental projects .......................... 21,000 Health aides employed by projects .............................. 1,600 Number of comprehensive projects funded (Maternity and infant tare and children and youth projects).. 115 Objectives for 1973: The 1973 program is planned to increase the level of services anticipated for 1972 in the maternity and infant care and children and youth projects, and to expand services in the dental cake program. It will also provide for studying the feasibility of converting children and youth projects to Health Maintenance Organizations on a prepaid capitation basis. Estimated numbers to receive services are as follows: 1/ Authorization for all programs under Title V, Social Security Act, is $350,000,000. 2Gl Admissions for comprehensive services: Estimate Mothers ...................................................... 152,000 Infants ...................................................... 53,000 Women receiving family planning services ....................... 134,000 Children registered for comprehensive health care .............. 547,000 Children cared for in dental projects .......................... 22,000 Health aides employed by projects .............................. 1,600 Number of comprehensive projects funded (Maternity and infant care and children and youth projects).. 115 The maternity and infant care projects are continuing to exert influence on decreasing infant mortality rates in cities where large projects are located. For example, in Houston, Texas, the infant mortality rate dropped from 28.0 in 1965 to 20.0 in 1970; in Chicago, Illinois, from 33.6 to 27.7; and in St. Louis, Missouri, from 44.4 to 31.1. All these cities have large projects. 2G2 HEALTH SERVICES AND MENTAL HEALTH ADMINISTRATION Health services delivery Program Purpose and Accompli hments Activity: Maternal and child health--Research and training (Social Security Act as amended through 1967, Sections 511 and 512) 1973 Budget 1972 Estimate Pos. Amount Authorization Pos. Amount --- $21,106,000 Indefinite , --- $21,392,000 by activity.L/ Purpose: These programs are designed to improve health and medical services to mothers and children through applied research and through training of personnel involved in providing health care and related services for mothers and children, particularly mentally retarded and multiply-handicapped children. ation: Primary effort has been given to support of training in university- affiliated centers for the mentally retarded. These centers provide specialized clinical training in a multidisciplinary setting for physicians and other health personnel who focus their activity on the multiply-handicapped child. Grants to public or non-profit institutions of higher learning provide support for faculty, traineeships, services, clinical facilities and short-term institutes and workshops. Research grants and contracts are made with public or other nonprofit institutions of higher learning and public or non-profit private agencies and appropriate research organizations. The research effort is concerned with mothers and children in all classes of our society, with high priority given to special problems for those segments of the population not receiving adequate health care. Accomplishments in 1972: The program provides staffing support for a total of 19 university-affiliated mental retardation centers in geographically dispersed areas. The primary effort of these centers has been to support advanced training of professionals in maternal and child health fields. In addition to supporting training for over 300 individuals in 1971 these centers offer a complete range of services for mentally retarded and multiply-handicapped children. The 1972 program also provides for training of up to 150 nurse midwives, pediatric nurses and other physicians' assistants. This newly initiated program is separate from the training efforts of the university-affiliated centers. The research program, through its 68 projects, is focusing on improving health and medical services to mothers and children. Two of its major undertakings concentrate on evaluation and assessment of the comprehensive medical care projects. objectives for 1973: The 1973 budget continues support of the 19 university- affiliated centers for the mentally retarded and sustains the annual level of long-term training at about 450 individuals. I/ Authorization for all programs under Title V, Social Security Act, is $350,000,000. 2G3 HEALTH SERVICES AND MENTAL HEALTH ADMINISTRATION Health services delivery Program Purpose and Accomplishments Activity: Maternal and child health--Direct operations 1973 Budget 1972 Estimate Pos. Amount Authorization Pos. Amount 133 $4,078,000 Indefinite 133 $4,148,000 Purpose: This activity provides staffing resources and operating funds essential to implementing program requirements of the Maternal and Child Health Service. Explanation: The Maternal and Child Health Service staff are concerned with (1) administration of grants for medical care service, research and training grants; (2) provision of technical assistance and consultation to States, localities and organizations; (3) development and issuance of standards and 'dolines for health services to mothers and children; and (4) evaluation and gul analysis of program performance and potential. Accomplishments in 1972: In 1972 MCHS staff will continue consultation and evaluation efforts undertaken in 1970 and will concentrate on monitoring of grant activities, provision of technical Assistance and guidance to States (with special emphasis on simplified State Plans) and communities and to improved management resources. Program monitoring and analysis includes overview of 450 service, research and training projects in addition to supervision of the two discrete State grant programs. Obiectives for 1973: Mandatory costs associated with within-grades, reclassifi- cations, and central services charges amount for the total increase of $70,000 in 1973. Staff will continue its current high rate of productivity in providing technical assistance and consultation to grantees, States and localities, and in implementing policies now proposed relative to capitation and third party payments. 264 HEALTH SERVICES AND MENTAL HEALTH ADMINISTRATION Health services delivery Program Purpose and Accomplishments Activity: Family planning - Project grants and contracts. (Social Security Act as amended, Title V. Sections 508 and 512, and Public Health Service Act as amended, Title X. 1973 Budget 1972 Estimate Pos. Amount Authorization Pos. Amount $94,815,000 1/ -- $137,024,000 Total authorization for All programs under Title V, Social Security Act in 1973 is $350,000,000. The authorization is indefinite by activity with the specification that not less than 6 percent of the funds shall be for family planning services. The National Center is requesting $19,000,000 for family planning project grants under this authorization in 1973. See earlier section on authorizing legislation for discussion of amounts authorized and requested under Title X, Public Health Service Act. Purpose: The primary mission of the family planning service program is to insure that individuals are free to choose the number and spacing of their children and thereby improve maternal and child health. The goal is to provide, by 1975, a full range of high quality family planning services to all women who might want such services but cannot obtain them. Explanation: Project grants are made under Title V, Social Security Act and Title X, Public Health Service Act to State and local health departments and other public or non-profit private organizations to provide family planning services. Project grants under Title V of the Social Security Act are for up to 75 percent of the cost of the project, while those under Title X of the Public Health Service Act have no specified matching requirements. Title X of the Public Health Service Act also authorizes project grants and contracts for the training of family planning workers, studies of new and improved methods of delivering family planning services, and the development and distribution of family planning education materials. Accomplishments in 1972: Approximately 60 new grants totalling almost $121000,000 will be awarded and 75 OEO projects totalling $10,000,000 will be transferred to the National Center in 1972, bringing the total number of active projects to 325. The number of women who will receive family planning.services from all projects funded through 1972 will total approximately 1,500,000 when the projects are fully operational. Project grants and contracts totalling $6,315,000 will be awarded for the development of training programs, the development and distribution of educational materials related to family planning and for operational research and technical assistance to improve the delivery of family planning services. Objectives for 1973: The family planning project grants program for 1973 is designed to increase the number of people receiving family planning services to approximately 2,200,000 persons when all projects are operational. This will be accomplished through expansion of existing projects and development of new 2G5 projects. Included in the total are an estimated additional 75 OEO projects totalling $10,000,000 and serving about 200,000 persons. Project grants and contracts will be awarded to train allied health and other personnel for service in family planning clinics, to educate and inform families about voluntary family planning, to develop improved family planning educational materials, and to carry out studies designed to improve the delivery of family planning services. 266 HEALTH SERVICES AND MENTAL HEALTH ADMINISTRATION Health Services delivery Program Purpose and Accomp isiments Activity: Family planning-Direct operations 1973 Budget 1972 Estimate Pos. Amount Authorization Pos. Amount 1/ 70 $1,438,000 Indefinite 87 $1,987,000 1/ Section 301, Public Health Service Act Purpose: The direct operations activity provides staff and operating funds necessary for program deve opment and administration of t e programs o t e National Center for Family Planning Services, including the administration of the decentralized service project grant program in the ten DHEW regions. Explanation:, Staff of the National Center administer project grants and contracts for the provision of family planning services, the training of family planning workers, operational research, and for family planning education activities. In addition, central office staff provide technical assistance to the regional offices, as well as current and potential grantees, in administering the service delivery grant program, and developing and implementing policies and program plans for the areas of training, education, operational research and technical assistance. Accomplishments in 1972: Efforts in 1972 were concentrated on the development of improved policies and guidelines, improving program management and the recruitment and training of new staff. The first Five-Year Plan for Family Planning Services was updated, 60 new project grants totalling approximately $12,000,000 were awarded, $10,000,000 in OEO projects were transferred to the Center, and a $6,315,000 project grants and contracts program for training,education, and services delivery improvement related to family planning was implemented. Objectives for 1973: The seventeen new positions for the central and regional office staff are requested to provide the program development and management capacity to program'the additional service grant funds. Continued priority will be given to staffing the regional offices which assist local communities in the development and expansion of family planning services and in developing support staff in central office for the services, training, research and education programs. 2G7 HEALTH SERVICES AND MENTAL HEALTH ADMINISTRATION Health services delivery Program Purpose and Accomplishments Activity: National health service corps (PHS Act, Section 329) 1973 Budget 1972 Estimate Pos. Amount Authorization Pos. Amount 637 $14,117,000 $30,000,000 637 $14,803,000 Purpose: The assignment of personnel to areas with critical medical manpower shortages and to encourage health personnel to practice in areas where shortages of such personnel exist. Explanation: This activity provides for the direct assignment of health personnel to areas with critical health manpower shortages. Where practical, the team approach will be utilized in the assignment of health personnel. Accomplishments in 1972: Initial emphasis was placed on appointment of the National Advisory Council on Health Manpower Shortage Areas; development of regulations, policies and procedures, criteria for community participation and fee collection and submission to Treasury; and the provision of technical assistance to community groups to encourage them to set realistic goals to assure that assignees were effectively linked to other provider units in a way that fostered the development of effective and efficient systems for care. In cases where a physician was not warranted, the community was assisted in 4eter- mining the most appropriate type of health personnel for the community. A mere compilation of a list of candidates and random selection was not sufficient. In an effort to assure success, assignees were "matched" with the communities to which they were assigned. A total of approximately 240 health professionals (including doctors, dentists, nurses and other allied health personnel) were recruited, oriented and assigned to approximately 60 communities in critical need of health services. Two to seven health professionals were assigned to communities with an average team size of four. Objectives for 1973: This request would allow for recruitment of an additional 337 health professionals for a total of 577. This number would provide support for a total of 175-225 communities with a total population of approximately 700,000 - 900,000 people. 2G8 @CES M MOM EMUI ADXMB@ON Health services delivery Program @ose and Acc@sbmnts Activity: Patient care and special health services -- Inpatient and outpatient ea" (pHs Act, Sectio@ 301, -n-l- 321, 322, 324, 326, 328, 331, 332, 502, 504, 33 U.;.C. 763c @@2 @.B.C. 2534) 1973 1972 Estimate Pos. Anthorization Pox. Amotmt @t ity 5@479 ft$2,0.14,000 Indefinite 5,479 $83,193,000 ticus 5,479 @ 237,000 5,479 $96,303,000 @ns: The p purpose of this program is to provide for the ccmwrebexwive health care of American scamn, Coast and PHS Counissioned Corps personnel, and persons with leprosy. on a reimbursable basis, health care is also provided to foreign seamen @ beneficiaries of other Federal agencies in PHS hospitals. @tion: To cwry out this mission, funds have been appropriated to operate Health cc hospitals @ clinics and where necess@, to provide for care of pr@ beneficiaries thrm& contractual arr@ewnts with other Federal and non-Federal hospitals, and with private p@iciam. Yiedical care is easo provided to beneficiaries of other Federal agencies on a reimbursable basis. Acccowlishments in 1972: Health owe was @ a"nable to an estimated 492,ooo beneficiaries with an estimated 1,800 average daily inpatient load and a total of 1,758,000 outpatient TUits to PHO facilities. Contract care in other Federal and -- deral facilities averaged 100 inpatients per @; in "ation, 63,000 out- patient visits were made to @ivate physicians. Direct fun@ supported ap- proximtely 92 clinical and 56 heaJLth serwice research projects with 40 other rexearch projects by @ts and reimbursements. C ty inv-olvemnt was y throu& affiliations, and local OZO and Dep nt of TAbor p for the umwloyed. PHS health care resources were integrated er @ c ties sharing &"Uable madi@ capabilities where reimburse- =mto or reciprocal services were received from the co=mmity. Objectives for 1973: @es bave indicated that the most effective alternative for ass@ e@ient =ea of the PHS facilities within the a ties my in- volve converting these facilities to c ty control. If, after further revievs and re a of c ty proposals, this is found to be so, comprehensive health care for p beneficiaries would be provided through service Mm with these c ty controlled facilities and other health resources, as necessary. In 1973, we hope to conrert as of these facilities as possible. !be CarrMe leprosarium will continue to provide for treatment of leprosy. HMTH BMCES MD MOM @M S'IRATION 269 Health serv-ices delivery Program Purpose and Accompliebments Acti@ity: Patient care and special health sery-icas -- Coast Guard mdi@ serv-ices (M Act, Section 326 as amended) 1973 Budget 1972 Estimate Pos. Authorization Fos. Amount 151 $4,802,000 Indeftate 151 $5,105,000 ftnose: The Coast mdical program, under the direction of the Chief Medical Officer, U. S. Coast , provides for the delivery of direct health care to personnel aboard its vessels and at its shore and air Stations. Coast personnel are also provided @tient, outpatient and emrgency medical care and services on a contractual basis in areas without PHS facilities or in cases needing special care. Explanation: Appropriated funds are used to finance a system or medical facili- ties classified as infirmarits, dispensaries, and sick b@. Where sufficient concentrations of personal exist, large infirmaries with fmU-time medical, , and anci@ staff provide comprehensive care to authorized benefi- ciaries. er concentrations of personnel are serwed by dispensaries and sick bVs which my have @ical and dental officers assigned or my be starfed by Coast G@ hospital corp In =W instances, 9-11 concentrations of pera are provided health care by local contract physicians, dentists, and hospitals, as vel3. as through utilization of Federal mdi@ facilities vbere &@able. The coast operates one accredited hospital, located at the Coast Ouard Ac@. Ae llsbruta in 1972: In 1972, care is being made available to appr tely @,2w Coast Guard personal (active duty and retired), and 81,300 dependents. Outpatient =edical and dental visits by all bonefici@ c.Lassirications will be in excess or 500,000 for the ymw. A total of approximtely i4,000 inpatient @ are anticipated in Coast medical facilities. Program are being established to prmlde both detection and rehabilitation of personnel with problems related to drug abue. Facilities to deal with the rehabilitation of persormel with nlnor p Qgical disorders are being established at the two major recruit centers located at Cape My, Now Jersey and Alameda, California. Contracts for inpatient care in nm-PHS @itals will account ror an additional 84 average daily patient load; and agreements with local pbysicUm will accomt ror an additiomi 18,750 visits. Ojectiven for lff3: Objectives in 1973 @ be to met the needs of an in@ased bamriciary population of approximtely 139,000. IVograns started in prior years viU be contimad and d to the extent possible. lacluded am program related to aviation medicine, @rwater mdicine, indutrial Medicare, and sanitation. Efrorts to lMrova the effectiveness of health care doUver7 in pursuit or the above stated objectives will continue. 270 HEALTH SERVICES AND MENTAL HEALTH ADMINISTRATION Health services delivery Program Purpose and Accomplishments Activity: Patient care and special health services -- Federal employees (P.L. 79-658, August 8, 1946, 5 USC 7901) 1973 Budget 1972 Estimate Pos. Amount Authorization Pos. Amount Budget Auth 260 $ 487,000 Indefinite 260 $ 494,000 Obligations 260 $4,487,000 260 $4,498,000 Purpose: This activity provides upon request consultation to and su rveys of Federal agencies on the conduct of Federal employees occupational health programs, and operates selected programs for Federal agencies on a reim- bursable basis. .Explanation: Prior to establishing a Federal employee health program all Federal agencies must, by law, consult with the Public Health Service regarding standards. The appropriated funds provide for consultation services to any Federal agency, on request, on the establishment or eval- uation of Federal employee occupational health programs. The Public Health Service also provides, under reimbursable authority, direct clinical health services to other Federal agencies on request. Accomplishments in 1972: In 1972 over 100 consultations to Federal agencies, executive boards, and associations were provided on the evaluation and estab- lishment of Federal employee health activities. By the end of 1972, health care services will have been provided to 160,000 Federal employees in 95 facilities. Objectiv6s for 1973: This activity will permit maintenance of employee health activities at the same level reached by 1972, providing approximately 100 consultations to Federal agencies and operating 95 health units providing services to 160,000 Federal employees. 271 U"ni CBS AM HMni ADMMSTRATION Health services delivery Program @as and AcccMlisbments Activity: Patient care and special health services -- t to Hawaii (PM Act, Section 331) 1973 Budget 1972 Entir4ate Poo. Amount Authorization Pon. AmoAmt --- $1,200,000 Indefinite --- $1,2001000 @se: a are =-de to the State of Hawaii for care and treatmnt of persons afflicted with leprosy. Bmlmtion: @ appropriated are paid as a reimbursement of actmi expeme to the nt of Health of Hawaii to assist in that care and treat- in its facilities. Any experAes above the appropriated funds are borne by the $Uto of Ha@. Acccmplisbmatx In 1972: @ will have been provided to an- eatimted daily average of 164 t ntx. Ibis is a continuation of the decreasim inpatient load of recent years. Of the total program costs eatimted to be $1,940,000, the xbare borne by Havaii is $7409000. Obj@ives for 1973: The average daily patient load is expected to be 158 in 1973. Om total program re ntx are estimated to be $1,875,000, of which the Federal govermmnt will pay $1,200.,000. HEALTH SERVICES AND MENTAL HEALTH ADMINISTRATION 272 Health services delivery Program Purpose and Accomplishments Activity: Regional office central staff 1973 Budget 1972 Estimate Pos. Amount Authorization Pos. Amount 250 $5,287,000 Indefinite 250 $5,281,000 Purpose: This activity supports the Regional Health Directors and their central staffs which are concerned with the coordination and interrelation of the various program activities of HSMRA and the implementation of those programs in the regional offices. Explanation: The regional office central staff includes: (1) a comprehensive health planning unit that provides leadership in the development and operation of programs for the conduct and improvement of comprehensive State and areawide health planning; 2) a grants management unit which provides centralized support for all HSMRA grants that have been decentralized to the regions; and (3) a special proj6cts unit which manages an information system providing data on areas of special interest to each particular region. 273 HEALTH SERVICES AND MENTAL HEALTH ADMINISTRATION Health services delivery Program Purpose and Accomplishments Activity: Program direction and-management services 1973 Budget 1972 Estimate Pos. Amount Authorization Pos. Amount 233 $5,431,000 Indefinite 236 $6,314,000 Purpose: This activity provides for the overall planning, direction and administration of the broad scope of programs of the Health service delivery appropriation. Explanation: It includes program planning and evaluation Activities which focus on program, operational, and legislative planning. Administrative management is responsible for the development, coordi- nation, direction, and assessment of management activities. It directs such services as financial, personnel, and contract management. 274 Health Services Delivery Allocations of Grants for Comprehensive Public Health Services 1971 1972 1973 Actual Allocation Estimate Alabama .......................... $1,787,800 $1,723,400 $1,689,500 Alaska ........................... 388,100 394,100 397,600 Arizona .......................... 918,600 933,600 952,200 Arkansas ......................... 1,143,500 1,111,900 1,085,900 California ....................... 6,539,900 6,662,100 6,753,800 Colorado ......................... 1,030,300 1,063,300 1,081,200 Connecticut ...................... 1,233,000 1,237,600 1,242i9OO Delaware ......................... 476,200 477,700 479,400 District of Columbia ............. 543,600 530,700 516,600 Florida .......................... 2,561,700 2,675,100 2,767,600 Georgia .......................... 2,074,400 2,023,400 2,011,200 Hawaii ........................... 569,000 555,100 548,600 Idaho ............................ 580,200 572,900 572,000 Illinois ......................... 3,839,900 3,845,300 3,845,200 Indiana .......................... 2,062,300 2,077,000 2,113,800 Iowa ............................. 1,278,200 1,284,600 1,292,800 Kansas ........................... 1,111,700 1,090,500 1,072,000 Kentucky ......................... 1,569,700 1,559,200 1,557,500 Louisiana ........................ 1,774,700 1,743i8OO 1,716,600 Maine ............................ 670,400 673,700 672,000 Maryland ......................... 1,540,500 1,580,100 1,599,400 Massachusetts .................... 2,081,400 2,139,800 2,149,800 Michigan ......................... 3,213,600 3,223,600 3,289,500 Minnesota ........................ 1,587,000 1,610,800 1,627,100 Mississippi ...................... 1,.365,200 1,302,400 1,243,200 Missouri ......................... 1,938,500 1,951,800 1,950,100 Montana .......................... 557,000 557,600 557,300 Nebraska ......................... 811,400 812,600 821,600 Nevada ........................... 446,200 452,600 459,000 New Hampshire .................... 551,900 559,500 568,400 New Jersey ....................... 2,597,300 2,597,100 2,589,400 New Mexico ....................... 689,600 693,200 690,200 New York ......................... 6,063,300 6,011,200 5,976,200 North Carolina ................... 2,337,200 2,272,700 2,227,000 North Dakota ..................... 536,900 533,900 542,400 275 Health Services Delivery 1/ Allocations of Grants for Comprehensive Public Health Services (cont'd)- 1971 1972 1973 Actual Allocation Estimate Ohio ............................. $3,949,000 $3,921,000 $3,919,000 Oklahoma ........................ 1,263,400 1,264,800 1,260,400 Oregon .......................... 1,009,000 1,026,300 1,049,400 Pennsylvania .................... 4,360,800 4,351,000 4,310,800 Rhode Island .................... 607,300 617,500 624,500 South Carolina .................. 1,422,200 1,364,500 1,332,200 South Dakota .................... 546,900 551,600 552,100 Tennessee ....................... 1,887,800 1,846,800 1,825,700 Texas ........................... 4,389,800 4,376,200 4,380,500 Utah ............................ 698,300 702,500 710,600 Vermont ......................... 458,700 461,600 465,600 Virginia ........................ 1,995,300 1,979,200 1,960,000 Washington ...................... 1,428,500 1,442,500 1,454,700 West Virginia ................... 1,042,200 1,017,200 977,400 Wisconsin ....................... 1,767,800 1,822,700 1,857,500 Wyoming ......................... 413,300 418,700 420,000 Guam ............................ 351,500 307,700 304,000 Puerto Rico ..................... 2,063,300 2,109,500 2,058,500 Virgin Islands .................. 265 700 265,700 265,700 American Samoa .................. 265:700 265,700 265,700 Trust Territory of the Pacific Islands ....................... 443,300 453,400 446,700 TOTAL ....................... 89,100,000 89,100,000 89,100,000 Evaluation Amount2-/ ......... 900,000 900,000 900,000 Grand Total ................. 90,000,000 90,000,000 90,000,000 1/ Allocations are awarded to States based on population and ],)er capita income with a minimum program requirement. 2/ Authorized by P.L. 91-296 276 HEALTH SERVICES DELIVERY Allocations of Grants fOT Mate @ I and Child Health Services Actual and Estimated Awards 1/ Fiscal Years 1971-73 1971 1972 1973 State Actual Estimate Estimate Alabama ................ $1,247,908 $1,238,285 $1,273,000 Alaska ........... 195,461 186,495 187,900 Arizona .......... 425,974 434,434 434,100 Arkansas.* ............. 673,478 694,603 712,400 California ............. 2,834,834 2,828,154 2,917,600 Colorado ............... 494,248 469,248 490,100 Connecticut ............ 475,448 494,721 505,200 Delaware ............... 201,995 211,196 213,300 District of Columbia... 247,008 247,944 251,100 Florida ................ 1,604,726 1,659,093 1,650,400 Georgia ................ 1,654,810 1,635,785 1,654,500 Guam ................... 158,028 158,164 158,700 Havaii ................. 245,422 245,080 248 200 Idaho .................. 234,870 234,870 246,200 Illinois ............... 1,668,815 1,624,459 1,728,700 Indiana ................ 1,089,353 1,258,011 1,323,700 Iova .................... 680,398 691,122 730,600 Kansas ................. 483,732 479,770 500,300 Kentucky ............... 1,133,396 1,149,085 1,173,700 Louisiana .............. 1,3 1,208 33 337 1,37 , 00 Maine .................. 356,076 330,076 342,800 Maryland ............... 1,098,384 1,063,730 1,084,900 Massachusetts .......... 838,403 847,061 848,100 Michigan ............... 1,926' 890 1,884,356 1,967,000 Minnesota .............. 905,063 910,103 934,900 Mississippi ............ 1,085,847 1,052,599 1,077,700 Missouri ............... 1,020,062 ].,074,037 1,107,700 Montana ................ 222,453 226,685 229,200 Nebraska ............... 346,591 346,379 360,700 Nevada ................. 200,211 202,707 204,600 New Hampshire .......... 262,881 229,881 232,500 Nev Jersey ............. 1,046,999 1,061,487 1,106,900 New Mexico ............. 340,026 325,026 338,600 Nev York ............... 2,649,381 2,651,940 2,650,400 North Carolina ......... 1,908,325 1,887,202 1,922,500 277 HEALTH SERVICES DELIVERY Allocations of Grants for Maternal and Child Health Services (cont'd.) 1971 1972 1973 State Actual Estimate Estimate North Dakota ........... 216,561 216,561 218,800 Ohio ................... 2,201,112 2,260,887 2,358 700 Oklahoma ............... 602,965 606,840 625:400 Oregon ................. 536,415 534,555 554,900 Pennsylvania ........... 2,522,102 2,522,102 2,617,900 Puerto Rico ............ 1,638,916 1,646,229 1,694,800 Rhode Island ........... 273,072 250,431 253,700 South Carolina ......... 1,142,005 1,127,632 1,153,500 South Dakota ........... 182,917 223,592 229,400 Tennessee .............. 1,236,805 1,214,192 1,245,800 Texas .................. 2,577,513 2,584,320 2,604,700 Utah ................... 435,724 404,862 423,300 Vermont ................ 230,921 195,331 197,000 Virgin Islands ......... 157,002 157,002 157,500 Virginia ............... 1,371,581 1,325,581 1,350,100 Washington ............. 791,559 794,386 836,700 West Virginia .......... 761,498 624,050 649,600 Wisconsin ............. 1,004,099 997,099 1,037,400 Wyoming ................ 204,043 181,723 183,000 Total distribution by formula 1/ ......... 49,405,514 49,237,500 50,574,500 Special projects for mentally retarded children ............. 4,749,325 4,750,000 4,750,000 Other special projects. 5,0331872 5,262,500 5,453,500 - Total .............. 59,188,711 59,250,000 60,778,000 1/ (a) one-half of the amount appropriated for each year is apportioned among States on the basis of a uniform grant of $70,000 and an additional grant in proportion to the number of live births in the State. Amounts awarded must be matched dollar for dollar. (b) The remaining half, after being reduced by the amounts reserved for the two categories of special projects, is apportioned by formula. Each State receives an amount which varies directly with the number of urban and rural births in the State and inversely with State per capita income. No State receives less than $70,000 and rural live births are given twice the weight of urban births. (c) The 1972 and 1973 figures represent tentative apportionment of the amount requested. 278 HEALTH SERVICES DELIVERY Allocations of G @ ta far Crippled Children's Services Actual and Estimated Awards Fiscal Years 1971-73 1971 1972 1973 State Actual Estimate Estimate Alabama ................ $1,233,750 $1,270,900 $1,334,500 Alaska ................. 190,886 183,600 187,400 Arizona ................ 453,155 460,400 489,900 Arkansas ............... 764,797 766,700 802 000 California ............. 2,525,849 2,702,900 2,820:100 Colorado ............... 447,187 524,900 556,900 Connecticut ............ 506,134 531,000 550 300 Delaware ............... 218,463 215,600 219:300 District of Columbia ... 220,.212 227,900 231,300 Florida ................ 1,412,687 1,485,100 1,566,300 Georgia ................ 1,532,393 1,570,200 1,647,100 Guam ................... 273,999 229,200 154 900 Hawaii ................. 320,945 341,600 248:500 Idaho ............... 276,339 276,300 292,800 Illinois ............ 1,528,560 1,721,700 1,797,800 Indiana ................ 1,241,567 1,393,500 1,461,800 Iowa ................... 754,187 854,300 894,100 Kansas .................. 559,493 586,300 611,300 Kentucky ............... 1,183,600 1,235,600 1,306,100 Louisiana .............. 1,256,709 1,256,900 1,316,900 Maine .................. 336,140 339,000 356,100 Maryland ............... 723,483 802,400 843,400 Massachusetts .......... 789,336 871,400 912,300 Michigan ............... 1,737,632 1,925,700 2,013,700 Minnesota .............. 956,268 1,072,700 1,127,800 Mississippi ............ 1,079,784 1,066,600 1,115,700 Missouri ............... 1,065,628 1,162,600 1,219,900 Montana ................ 289,988 246,300 261,000 'Nebraska ............... 399,551 436,300 460,400 Nevada ................. 266,705 253,900 208,100 New Hampshire .......... 243,654 239,600 245,300 New Jersey ............. 981,662 1,047,100 1,094,700 New Mexico ............. 330,493 378,000 364,000 New York ............... 2,245,364 2,393,200 2,505,200 North Carolina ......... 1,974,387 2,028,000 2,133,000 279 HF-KLTH SERVICES DELIVERY Allocations of Grants for Crippled Children's Services (cont'd.) 1971 1972 1973 State Actual Estimate Estimate North Dakota 242,699 258,700 274,500 Ohio ................... 2,206,790 2,397,400 2,510,000 Oklahoma ............... 666,832 721,000 759,000 Oregon ................. 533,302 559,500 591,700 Pennsylvania ........... 2,368,601 2,598,500 2,717,100 Puerto Rico ............ 1,465,042 1,599,500 1,581,400 Rhode Island ........... 250,764 256,900 262,100 South Carolina ......... 1,115,709 1,132,400 1,185,600 South Dakota ........... 248,501 265,600 2789800 Tennessee .............. 1,285,940 1,370,400 1,439,500 Texas ................... 2,56lo876 2,765,400 2,904,500 Utah ................... 297,465 322,100 343,100 Vermont ................. 207,827 202,300 206,000 Virgin Islands ......... 148,560 151,100 150,700 Virginia ............... 1,424,748 1,417,200 1,487,700 Washington ............. 689,782 779,600 05,000 West Virginia .......... 717,319 708,400 740,200 Wisconsin ........... 4.. 1,049,513 1,203,600 i,262,300 Wyoming ................ 171,983 186iOOO 188,400 Total distribution by formula 1/ ......... 47,974,240 50,993,000 53,037,500 Special projects for mentally retarded children ............. 4,998,967 5,000,000 5,000,000 other special projects. 5,624,412 6,27 000 6,862,500 Total .............. 58,597,619 62,272,000 64,900,000 .I/ (a) one-half of the amount appropriated for each year is apportioned -mong States on the basis of a uniform grant of @70,000 and an additional grant in proportion to the number of children under 21 years in the State. Amounts awarded must be matched dollar for dollar. (b) The remaining half, after being reduced by the amounts reserved for the two categories of special projects, is apportioned by formula. Each State receives an amount which varies directly with the number of children under 21 years in urban and rural areas in the State and varies inversely with State per capita income. No State receives less than a specific minimum amount and children in rura areas are given twice the weight of those in urban areas. (c) The 1972 and 1973 figures represent tentative apportionment of the amount requested. 280 New Positions Requested Fiscal Year 1973 Annual Family Planning Grade Nuraber Salary Direct Operations Health Educator . . . . . . . . . . . . GS-14 1 .$21,960 Grantee Training Specialist . . . . . . GS-13 1 18,737 Program Analyst . . . . . . . . . . . . GS-12 1 15,866 Operations Analyst . . . . . . . . . . GS-11 1 13,309 Program Analyst . . . . . . . . . . . . GS-11 4 53,236 Program Analyst . . . . . . . . . . . . GS- 9 2 22,092 Clerk Typist . . . . . . . . . . . . . GS- 5 2 14,638 Clerk Typist . . . . . . . . . . . . . GS- 4 4 26,175 Clerk Typist . . . . . . . . . . . . . GS- 3 1 5,828 17 191,841 Program Direction and Management Services Program Analyst . . . . . . . . . . . GS-11 1 15,866 Clerk Typist . . . . . . . . . . . . . GS- 4 1 @6,545 Clerk Typist . . . . . . . . . . . . . GS- 3 1 5,828 3 28,239 Total new positions, all activities 20 220,080