i i@ i i 1 i@l, 1 1 i 1 , Fiji All I 'D@GIONAL MEDICAL PROGRAMS - OVERSIGHT House Committee on @Interstate and Foreign Comm.erce Hearings May 8, 1973 CREGIONAL MEDICAL PROGRAMS-4VERSIGHT HEARING BEFORE THE SUBCO.)I.)IITTEE ON PUBLIC HEALTH A'-\-D E'@\-A@'IRO.@-@)JE,)-T OF THE COMMITTEE ON I-NTERSTATE AND FOREIG ,@- COII.,)IERCE HOTJSE OF REPRESENTATIVES NINETY-THIRD CONGRESS FIRST SESSION ON' OVERSIGHT OVER PROGRA'.NIS AUTHORIZED BY TITLE IN' OF THE PUBLIC HEALTH SERVICE ACT, CO'.\I-ilO-NLY K-NOW-NZ AS REGIO.N.A,L'\IEDICAL PROGRA.NIS .%IAY 8, 1973 Serial No. 93-27 Printed for the use of the Committee,oii Interstate and Foreign Comnierce U.S. GOVER.NNIEN'T PRI4TING OFFICE @s-,2 0 WASHI@'IGTON : 1973 CO-II.IIITTEE ON INTERSTATE A-ND FOREIG.N CO.NI.IIERCE HAITLEY O..@TA(.GERS. %rest A'irglula. I'OIiBERTH..NIACDO.NAI.D.'.%Izi!,,;t(-Iiiis,@tis S.KNIL'EL L. DI-VI.NL. )Iiio JOHN JAR.NIAN, Oklahonia NFI,SEN, 3iiiiiie.,oti E, Californi@i JA.NIE.@ T. BIZOYIIII.L, Nortli ('.irolina I- (I JA)IFS Nlit-hi,;tii Cklt'I'Ell. l@piitii(-ky LIONEL A'A.N DEERLIN. California "I,AltE.NCE J. BITOWN. Olilo J. J. PICI@LE. Texas D.@N l@UYliE.ND.kl,l,, Teiiii--ssee FRED B. ROONEY. 1'enn.,3-1%-,iiiia .101@ 1,KI'IiITZ. JOHN 31. 31URPIIY, New York J.%IIE.@ l@. II.% STI.XGS. Ne%k- York I)Al']D E. SATTERFIEID 111. N'irgiiii:i -NI. Texas BROCK ADA31S, IA'a.,Iiingtoii Fit]-'.Y. Tit.. Fl,,ridi W. S. (BILI.) STUCKEY, JR., Georgi:l 1'eiiit,.viviiiiia IIETER N. KN'ROS. JOHN Y. .11(,COI.LISTI.R, Nel)raskzi BOB ECKHARI)I'. Texas I)ICI@ SIfOuIl, .11,.ilit;ill:i RICHARDSON IIRL@YER, Nortli Caroliiizt BARRY.%I. GOLDIA'.ITElt. JR., C;iliforiii@i BERTRA'.%l L. PODELL, Y@,r@ NoR'%IAN F. LE.NT..\eiv Y4,rk HENRY BELSI'OSKI. New Jer@e3- H. JOHN HI@INZ 111. .iA'.%IUEI, 11. YOT'N(;, Illitit,i., HALIIH H. '%IETCALFE, Illinois GOODLOE E. BYRON'..%I,,iryland WILLI.k3f R. ROY, Kansas JOHN BRECKI.XRIDGE, Kentti(,k)- X\'. E. WILLI.1%ISO.\, ('Ic@-k l@EN.NETIJ J. PAI.\TER. Assistatit Clerk WILLIA-11 J. Dlxo\ ('IIARLE,@ P.. ('['ItTI., ROBEITT F. GI'TFIRIF I,I:i; S. IIYI,F. SUBCO.Nf',IITTEE O-, PL7BLIc HE.ILLTII A.\D EN-VrRON.NIE'\T Nortli Ciir,,Iit@;i 1'4,rk 11, IiiIIN lll:INZ Ill. 11. lll'I)NI'T Ill. m CONTENTS of- Page i'arter. Dr. Robert E., dean of of Luediciiie, University of Iliii- tit,@i)ta ------------------------------------------------------- 1 6,-', 1 C),- lf;ig,wd. Dr. William J.. Jr., speaker, flouse of I)t@legate.@, the -'%ledic:il .Society of N'irginia ------------------------------------------- I(;2. 165 ll:tiuliton. Dr. H. llliillil). cliairiii:iii of ttie I)oar(l, FI-)ri(ll regional wedical program --------------------------------------------- 173. 17.5 Dr. R. F., executive director. Likt-.s Ar@i regi4)iiil medical I)rogr.,ini - ----------------------------------------------------- 173 @.NicBt!@ith, Dr. Williim H.. director, Oliif) A':illt@y regional nit@(lical I)ro- ;:r:im ------------------------------------------------------- 173. 214 >.Nlzirgtilies. Dr. Harold. Director. R(@-,,i,inal Nlt-(Iif-zkl Ilrogrinis Iieri-ice. lfi@alth Services and Nleiital Health A@Iiiiiiiistritioii. Department of health. Education, and '"'elf:ir( ---------------------------------- I Dr. Faxon. cliiirniiti. Area At]%-isor3-, @IN'. Keiitticlly for Ten- liq@.@see-'.Nlidsoutli R31P --- -------------------------------------- 162 >IN'nrd, Paul D., executive director, California committee on regional iiie(ii(-al programs --------------------------------------------- 173, 21T Z:Illl). Dr. John Deputy A!4.@i@t;lllt @ecrt-t:iry for I.egisl:itit)ii illealth), Department of Ht@.iltli. E(Iiic,,itioiti, iji(I -------- 1 material supplied for the rt,(-or(i lii - .%tiierican O.;4teopatliie A%.@)(-Iatinii. Aiii(,ric.,iii Ostei)l):itliic llnspittl As- ,%'t)ciatinii. and the Anieri(-;iii (of ('ollegt@.,z of Osteopathic .Nfedicine. letter dated -%lay 4, 1973, to Chairman Rogers --------- 248 li:lliil)t4)n. Dr. H. Pbillil). chairman of the I)i,arfl. Ylciri(lq RIIP. mei3t to the Journal of the Florida 3fedical Association entitled, "Florida Regional 3ledical Pro,-rani ------------------------------- 17S II,-.'iltb, Education. an(] Welfare D(-I),,irtniejit: 19-11 -State Certificati(-)n-of-need legisl,,ition-siirver report: Amer- ican Hospital Aqsociition -------------------------- I -------- 40 "Certification of need-The bridge betxveen health care planning ,ind implementation:" "Certificate of Sep(l the CI.'e for in(I Againszt." I)y John F. O'l.eary, J.D.. pamphlet piil)li.'Zlie(I br Health Insurance Council ------------------------------- 32 ('Our." registrations In R.%IP-.,;I)onsored education activities hqcal Year 1972 (listed hr type of training received and discipline of recipient) ------------------------------------------------- 140 Nlenior,indiim dated February 22. 1973, from Dr. Hirold 31,ir- culie.,z. director. Reginiiil '.Nlpdic,,il Progrini.,z q. Prvice. to till RNIP coordinators and grantee offici,,ilz to refinp ind rlnrify point.,z In the telegram dated February 1 re pbaqing out of the program--- 149 Pr,,Ilor(ld termination dateq of regional medical progr,,tm.,z In clironolr)gical order ----------------------------------------- 15() R'%Ip qllpport to the University of Kt-ntil(-ky and Vandpri)ilt T'ni- ,rerqity ---------------------------------------------------- 10 Rp.@irlii,il authorities.; Aynilnhlp for R.%IP-trpp netirities ---------- 142@. Review criteria and rating system-regional medical progrfimq-- 23 Telegram dated Fel)ruarr 1. 19-i3. from Dr. Harold 31qrgtilieq to '111 RN .IP.R coordinators adriqing them of termination of the pro gram aq of June 30. 19T3 ----------------------------------- 145 lnz,lll. Dr. R. P.. executive director, Liilp Arpi R.NIP: T)at.q on R'.NIP nppronriqtinn,: and R'.%fP ,npnfliiif.,. ---- 240 Letter dated May 22, 1973 from Dr. Ingill to Ch',Iirman Rogers; re ippropriatinnq and expenditures for R'%ITI ------------------- - 241. (rri I A-k Additional iuaterial supplied for the record by-Continued Page 3lcBe,itli. Dr. William H., director, Ohio Valley R.IIP: Participating agencies (affiliated Institutions and contract or- ganizations) ----------------------------------------------- 127 Regional geograpliv-map ------------------------------------- 216 Selected healtli resources-map -------------------------------- 216 @ervice nctivities-Ohio N'allev R31P -------------------------- 238 'kledical @ ociet3- of Virginia, Dr. AVilliaiii J. Hagood, Jr. Letter dated April 9. 1973. from Rotiert G. Btisboozii, Nl@D.. presi- dent, medical staff Waynesboro Community Hospital, to Eu- gene Perez, II.I). N'irginia Regional Ilrogriiii re viitatioli bv Dr. Frank %IcCiie ---------------------------------------------- 166 Letter dated April 12, 1973. from Frank C. lIcCue. '.%I.D., to Dr. Ed. E. Perry, Virginia Regional Nledical Program re report of his visit to Waynesboro Communitv Hospital ----------------- 167 Ward. Paul D.. executive director. California Committee on R31P's. special progress report on R.NIP's ------------------------------- 221 IIEGIONAL 31EDICAL PROGRA)IS-OVERSIGHT TUESDAY, XAY 8, 1973 HousE OF REPREZENTkTll'ES. @L'BCO.)I--Nll-rrEE ON PT7BLIc HE.ILLTII zt-, D E -, @-iRoN T. C031.)IIrrEE O@ I-%TER'-ZT.%TE A-,I) FOREI(;-, CO'-Nl'-NIERCE. 11'a-3hiligtoii. I.i le subcommittee met at 10 a.m.. pursuant to notice. In room House Office Building,. I4-on. Paul G. Rooei-s (chairman) @ii-. Rt-)GER@,. The subcommittee -,vill come to order. morning the subcommittee is coiidtictilio, over---iglit lieal7iii(,,s on ZP 1.r,)gr;iiiis authorized by title IX of the Public Heal@h Service Act. oll;liloiilv klioNvn as regional medical programs. These programs. the pri),Itiet ;f legislat developed by this subcommittee. were fi@-t au- I'@orized iii 1963. @ h law has siii@e been amended on two occasions. T:@ @e atilount appropriated for regional medical programs has quadi-u- P!f.-cl since 1966. A,-; vou kno-,N-. the fiscal year 1974 budget submitted to the Conai-ess @ontaiiis the recommendation for termination of the reoloiial medical Programs at the en E! d of fiscal year 1973. '.,\-o new procrams are offered to replace the role of R-IIP's iii communities. 'I'!, L, purpose of today's hearings is to explore the adiiiiiiiz-tration's at;onale for termination of these programs and to explore the effec- t,,vt"less of regional medical programs during the past 3 yeai-Q-. AVe will receive testimony from re v - preseiitati es of the Dei),,ti-tmelit of i'[,,altli. Fducation, aid IVelf are; secoiid,.a panel of physicians that file become involved with regional medical T)rogranis .through the I)rnc't ice of medicine or through academic niedicin@, and fiiiillv. f roni I I)Iliiel of coordinators of regional medical prozi,ains. oll" fil--zt witiiess this moriiinz is Dr. John IV Deputy Secretary for Legislation. accompai told gulies. Director of Region-al ',Nledical Prograi HS'-NIHA. ,z -e your state- N@'(, welcome -vou gentlemen and will be pleased to i-eceii flit-'It at this ti@e. STATEMENT OF DR. JOHN S. ZAPP, DEP'UTY ASSISTANT SECRE- TARY FOR LEGISLATION (HEALTH), DEPARTMENT OF HEALTH, EDIJCATION, AND WELFARF,, ACCOMPANIED BY DR. HAROLD MARGULIES, DIRECTOR, REGIONAL MEDICAL PROGRAMS SERV- ICE, HEALTH SERVICES ANI) MENTAL HEALTH ADMINIS- TRATION Tliaiik- voti,.\Ii -. Chiii-iii,,iii, ,iiid members of tli(, committee. Rl)l)ezii-iii(,r iii response to voiii- request to present the I)o.@itioii of tile Department witll 1. L ecr,,ii-d to'tlie medical pi-o(,ri-aiiis ciir- i-entlv authorized I)v tit](, TX of tlic, Public Health Service Act. I ' 1)(@i-iiiitted to exl)il.e ;it tile I!)7:)) is it doe-z ,,,,(Iowa. the (,iii-i-eiit st,,Ittlte fol. tile ll(,xt fiqc;tl N.eai-. Witli lio fill)(], '.X'1'10'\ S to t(,,,Illiliiitioii of the .e(,ioiial medical I)i,o- -;illi must fii-st I)t@ (.oi)izi(lei-ed iii li,,Iit of the oN-ei-,ill health stiite,@ ot tile ;I(Illllllistl.;Itloli. III tile of the I!)74 lieiltli I)iid(,et f)otli IIEIA' @Iiii(I otliei- i-(@sl)oiisil)le ;t,,t@ii(-ies focused upon several ilill)ortll)t ,tit([ iiiiiiiistakeil)](@ I)t-ol)](@iiis had bevii eitlici- 1)z,eiiiattireiv d'l;z. iiii@sed oi- (I(-;tlt N%-itli iii the past. In Iccoi-dalice %viii, tile '.iiiiii:iiioii that the idnii ])I.esi(lelit's (let(,l liisti-,Itioli's Avotild iioz ex(,ee(I reasoiiil)le I)roje(-tioiis of Federal fiiii(Iiii,,, tl)ility without in- creased taxation. these issues had to be i-net head on. IVe had to make realistic i,-sessiiieiit., of the programs' efl'e(,ti@-eiiess iii terms of the Federal funds iiix-este(I iii them. He could not condone fiiiidiiiu iiiereIN- foi- tile sike of keel)iii(,, a 1)ro@yi-aiii some fol- -.1110tilei- %-earn. Fiii@thei@- more. Av(@ had to :issess the potential for s'liiftiii,, financial i,espoiisibil- iti- to iioii-Fe(lei-al soiii-(@es. )Iic and I)j-ii-ate. Ivi@ seen tl);It the iliftisioii of billioiir, of Federal (Iollqi,s iritc, the -kiiit-i-icaii lieiltli kiitei-l)t-ise liqs failed to solve some of the I)rob- ](,iiis that liqve I)Iigiie(I tliai svsteiii foi- decades ,iiid iii some cases iiiade matters woi-se tliail before. ' 11'e believe the path out of this dilei-niiia is not sinil)lv more spend- iiir,,. but i,,,itliei- more iiitelli(,eiit use of Federal lieiltli .dollqrs. It is. iii oiii- iiid(.Yiiieiit. tili)(@ to insist tliit tli(, I)eol)](, of this cotintrv ],P(Ieix-e ;i I)ett(@i- i-Ettii-ii oil. tile iiix-estiiieiit iii li(@;iltli I)I-ogi-allis of ,I Saint equal to I() of tll(@ entire Fedei-al I)iidc,,et. ,i return that van I)e measured in iiiil)i-oN-e(i health, not just fiirtliez- inflation. Al'it], that ol)jeetiN-t@ in iiiiii(l, we liaN-e 1)ro])oqe(l to terminate i niim- 1)(@l. of Fe(l(,I.;Il I)1.0,(-rl,aiiiF. that eitliel, ( I ) li,,ix-e served tl)eir I)II"1) ()S(l ;Ill(l now Should I,(- fiiiiii(,(-d bv otli(@i- permanent source;-:. or (2) jl:ix-e li:itt )to :iiid e-sejitiil I)lii,l)ose to sei-A-e. -@t the s,,illlEl tillie. NA-P have proposed in other health ,ic- tivities that Ipl)e@ll- to offei, significant opportunities foi- improving the health of the Aiiiei-ioiii people. Some of these ii,e iiiil)ol)iil,,ii- earth tho' ze se(,riiieiits of the health eiitei,l)i,is(, treat I)eeoiiie qc(,iistoiii(,(l to ste,,idv iiiereasez in Federal support. T@',N-eii before the President submitted his budget to the Colici-es-, oil -2() of this @-e@ii,: strenuous 1)i,ote5:ts began to be heard front iii(Iii-idiiils iiid organization:, iiitereited in the con- tilili,,itioli and expansion of one 01- ',Illotliei- Federal health ictivitv. These protests Call I)e eXI)ette(I to l@e,,icli i crescendo I)efoi-e.tlie end of this fis(,al veii, Everett iiiiiiv of the ,ifl'ecte(I iiitlioritiE- expire. We ire not iii@littei-eiit to these protests. nor do -,ve exl)ect tile COII(,'I.O,;s to ic@el)t-tile ])I-ol)Ositioll that oiii- oiilv choice is to clin(y to tile I)attei,ji.,z of lie I),.Ist. Iiistei(l. AN-e must cleai-].N- dpfiiie the proper Federal role in lieiltli all(] tlieii I)egiii to literature i-,Ii-iotis traditional proposals foi- Federal interrelation against tlli definition. Olllv then 3 I)i-iorities biQe(I oil a(,ttiil i)e(,(]-z iii(i I,e,,ilisticallv meac- lirt- lit,iicri,es.,; iii iiieetiiig these iiee(Is. I.,.[ II)(, tlefijie for -%.oti bi-iefli- oiii- I)t,i-eel)tioii of the I)epirtiiieiit's iii t lie I)i-ol)ej- Fe d(@i-al role iii: I)i,ioi-itv should be oil i-e(Iticiiiir fiii,,iiiei;tl barriers that I:iiilr to needed health cii-e. Tlii@ iz ,iceoiiil)li@-lied iiow the iiie(licat-c qii(i nie(li(,;ii(I it %A-ill 1)(@ fill-tliei,ed v of I solill(I iiiti,)Il;ll lio:iltli iil4ztii,:tii(,e ])I-Ogl,:Illl Oil N'%'Iiicli iii;tk' I -ezs. 111(r 0111, to the Coiizi Sliould also be Federal support foi- health qii(i medical i-e- .41:kf,.,Il. ']'Ill, I)ellefits of this IctiN-it%- iiitioll:ll ill 4zcol)e. :111(l Iii.all ill- co@ts iiiake oii(Toiiig Stil)l.)Oil fi-olli tll(' I)I.iN-,Ite sectoi- ol. froiii t- lieiltli iii(i ,oiistiiiit,i- I)i-(-)ti,(-tioll I(Itll,ltl(ls ql,e Ilzo I I-e(lei-,il coii.-ei-ii '@ iii tlik, -ollet-tiN-e ii;itloli,-i i tel t. 1.1 )II i 11 rilie hazards ilill(,I.ellr ill ilik, li@(@ of I)i-ex-eiitiii-a .111(l fc)o(l -,tiid coQnieti(,@ ;iiliiltei-.it'i)ii. all(] (,Iie(,kil)z the spread ,If.-Iiilliiiiiiii(-:ible disease.cle:ii-lx- .1 Fetlel-.il 1-esi)olisil)ilitv.-Tra- liealtli -iltifill:il I)iil)lit coii(,ei,ii :t@ el)i,leiiiics ic -os.@ State Iiiies :11111 ilil:ti-;iiitiiie i-eqiiii-emeiits fill iiito tlil..z clasz. titliotiffli Ni-e think tilt, liix-e:i iii:ijoi- i-esl)oiiizil)ilitN- ]let'(, IS %"ell. r- Iiiiiite(I Foilel-al-i-ole i-elliiic(, oil the cal)al)il- lo(.,II I)III)Iie ',Illd I)i-ii-,ite :.ectot-s -.ti-e ijidic-;ite(I iii the followinfr til@) ftiiidiiia for deiiioii,-zti-,itioii of new facilities or Services ](I incorporate fi-oiii the lioiii(I be tiiiie-Iiiiiite(I -,and IN%-Ili(.Ii short t f(@:tsll)let:ike-oN-ei-fiii:iiiriii,-, fi-oiii i)et-iii;liieli altei-iiitil-e Qotil-ce;z (iii-ect provision of licaltli cai't, to se(,Tiiieiits of the pollination I-jt,llt. to sticli care is i-eco-iiize(I lit oi- i%-Ilose need is espe- 1)(@c;iiise of tlic, fiiiiii-t- of iiiore traditional means of pro- lieiltli services. (lit(-atioii of health ni:iiil)owei- which cannot be Iccomplislied the basic student tssist..iiiet, I)z,o-raiiis offered bv th- Office I:illl,-,itioii Nvliieli arL,. essential to iii(@(,t esi)(,ciilli- diKeult siipplv ivitli respect to certain professions. for example. i)hvsician.s :11,11 cli-iiticts. oi- to assure I)j-op(,i- distribt;tiol'i'oi heiltli ()I- demonstrate the role of lie%%- tvl)es of health worlers. It is ill the context. Cliaii-iiiaii -,iiid ni'einl)ers of the siibcommit- If@". f)f this iiioi-P Iiiiiited Fe(l(-i-al role that the decision -%,was iiiade. to tli(, ;tiitlioi-itv -foi- i-c,,ioiial i)iedical I)rorrriiiis to expire 'It the p- p- "14)st' of fis(-ii] io,-3 .is it (lot,.q iiiidt-i- the current statute. R31P WEAKNESSES F"Olll tlte oiitqet. regional iii(,(Iie:il 1)i-o,-ri,ailis )its had great diffl- (I(@fijiiiig a cleat- role foi- its(-If in (.'Ojiceiiti-ating its efforts and oil a fenv. well-select(@(I t-.ii-g(,t areas. It has been unsuccess- the coiiflictiiia and eiii basis between cate- Activities and .0 enis. As C'l I 0 iiioi-(, thin S.500 iiiillloi is exl)eiid in nTiiri@tN pes of ,(.tivitv i,atlici- than icliiei-iii@l, t direct apl)roa'eh'to the Of ),' -obl(,iiis ill selected iiiajoi- areas. Even iig emphasis on rep-ionalization,- there is with its original stro little evidence-an(I oiilv witfi regard to kid@ey disease-that the R'.\IPs have in many area.s roducecf the regionalized svstems of health care that the law envisioned There is no siL7iiificant. evidence that the R.\IPs have achieved their goal of gettiiig-researcli advances into regular. large-scale practice. The training programs undertaken are tv@icallv of limited scope and duration. and the-re is no substantiating evidence that these have had a significant impact on actual medical practice or in demonstrating improved qualit.@ care. A major problem with respect to R.\IP has been the high cost of maintaining the program. or'core. staffs in each of the 56 regions. A significant part of the overall R,\IP effort and funds have gone to pay @ogram staff and the activities performed bv them. including admin- p I istration. consultation. project development and management, and evaluation. Last vear. fiscal vear 1972. 40 percent of R'.\IP grant funds were for this pu@pose. And'Nvliile reasonable men mav disagree, \fr. Chairman, exactiv how much of that reflects administrative costs. or overhead. strict]-v' defined. it is clear that a verv significant fraction of R.\IP grant funds have been and are being used t@support apyroxi- matelv 1.400-full-time eq.uivalents-staff of the 56 regions who are invol@d in the effort of trving to produce directlv certain results. rather than in merelv administrative support of specific operational ro,iects and activities which are themselves designed to produce the @esi'red results. R.\IP grant funds are allocated for both operational projects. -,vhich -,ire tli@se activities conducted bv outside institutions and organizations. and for Nvbat are called program activities. -which are those carried out bv the salaried R.\IP staffs themselves. Another contiiiiiiii(, problem has been the relationship of regional r- i-nedie,,i] procyrnnis to coin reliensive health planning. In some areas. p R'@\IP's and CHPs have Nvorked closelv together in,,i beneficial -,vnv. but often tli(,ii- individual i,oles have been lili'rd to differentiate. It is' diffi- (-tilt to i CIIP ageiiev Nvitli i-es@onsipbilitv for the health anni@117 P' -iii area .vliile aiiotliei- N slip 0 -ogram for . federal rt@d pi .an R \IP. is iiiil)leiiiezitiii.L,: .ictivities in that same area based oi.i its own planning and pi-iol-iti- setting. IV]i,,it frequently happens, since the @'.\IP ha the fiiids to cai,rv out operational activities. is that its p@an- inner in eff(-et i)e(-oi-n(@s the deciding force of what is done in i given area. (iin-eii the iiai-roi\-er providei- base of R.\IP. this is not always consistent with I)z,oiidet- community ,iiid consumer health needs and interests. It is expected that the compr@.liensiN-e health planniilc,, agencies Nvill be sti-elirtlieiied during fiscal veqr 19T4. both bv increased funding Find i niijor technical tissistaiiee effort to be carried out across the country. The budget request for supporting the planning acreiici?s in 19T4 is @39 million. I'Iii@ is $3 million more than in fiscal yeir 191'3. and S12 million more than in fiscal ve-,ir 19T2. and is in keeping with our efforts to coiifer more i-esponsibiliiv on these organizations. IVitli i strengthened CHP pi,o(rram. it is expected that the CHP agencies could c,,irrv out a v,,irietv of pl-,innin,, ,iiid (IRTR svstem efforts. sog,e 1)revio6slv supported by R.IIP. at both Stite and areawide levels. 11-4 lvvll iis joiiiin in re ion@l interstate activities where indicated. It if 11 g :s also expected t at t e planning done by the consumer-oi-iented CHP azeiicie-c -will be more i-epresezitatin-e of ox-er,,ill community health ALTERN-ATB-E SOURCES OF SUPPORT FOR R31P ACNN-ITIES -Nloreover. in our assessment of the variety of other health programs @,,ipportedbvtheDepartmeiit.itbec,iniecle,irtliatai-arieti.o ongoing R.@fP activities are'similar to the activities being carried out undei, other programs or authorities in the Department. A major R'-NIP ac- t;i-itv has been the funding of demonstration project-. but many otliei- HEI@' pro reiit Federal.'@t,,ite, ai;d local ams and many other diffe gr ager,cieq- similarly fund demonstration projects,. thus adding to the proliferation of separate categorical projects. Some of these can be rLed up by the @@ational Ce-nter for-Health Ser-.-ices Research and Vecil-elopment, disease control programs in hear-t disease and cancer by .@IH and emergency medical service system demonstrations under tl;e autlioritn- of section. 304 of the PHS 'act. '-Nlucli of the R.\IP effort in the area' of developing national capability for transplantation and diaIN-sis is expected to be integrated into the' financing system provided through the additional medicare coverage for kidney disease -provided bv the Social Security Amendments of 19T2. I A further example of activities formerly assigned to R'-\IP which ar(- beipF supported by other components @f the Department is in the area of improving th@ quality of care. Under authority provided by the Social Securftv Amendments of 1972, the Departinent is in the process of implementing the section on professional standards review organizations. These O@ganizations will be set up in local areas to assume responsibility for comprehensive and ongoing review of serv- ices covered under the medicare and medic,,iid programs. The PSRO 'will be responsible for assuring that services are medically necessary and provided in accordance wit7h professional standards. Other quality of care programs, Particularly in the area of disease control. 'will be developed as pa'rt of the s@ecial '-\-IH cancer and heart' disease initiatives. @IF ACHIENE31E'\T@ ORTLOOK would not wish to leave you. ;Nlr. Chairman and other members of the sub(!Ommittee,,with the, impression that regional medical programs had no achievements and accomplishments. @lthough they have- been very unei-eii in their quality and performance. some R.\IP's have,. for example. Fos-tered development of a local decisionmaking and implementin- mechanism that constitutes a framework or forum for a broad spec- tr']Pl of provider interests. institutions and -ai-oul)s to cooperatively :ddress problems. This legacy will. I believe. be helpful to our PSRO fTort and very possiblv-ot@er quality assessment endeavors in the future. .@(,rved as i modest force for institutional reform in the health ,,r,,iia. R-IIP may htve helped. foi- example. to reduce in some regions tli,, gap between'the rese,,ir-ch-educ,,itioiial focus of medical schools and the 1),Itieiit sei,i-icc, needs of colilillill'itl hospitals and practicing physicians. !Found coiitiiiiiatioii support. :Ill)eit usually ,it ,i reduced level, for I I)I-Oi(@(.ts initiated wit], R.NIP grants. about one-half of the ol)ei-atioiia Contributed to the I-,iiiiicliiiia -of 6t]le" Federal health initiatives such as the ciiiei-gejici- niedicil.'ei-vice tlffol'ts. s Oil balance. liowev'ei@. we do not believe 1-e(rioilal medical programs has ,icliieved the I)roiiiise it held wile,, first eiiact(@(I nearly 8 years ago, nor in our considered judgment liaN-e its iccoiii )Iislinienst been com- iii(@iistii,at(@ Nvitli the totalled itioi,t, trial ,.-)oo ]Julian. Fiiialli-.,%ve feel that those tN.I)es of activities funded by R.NIP which .-ipl eir to have @ii stice(,,;sf .ill. sti(,Ii -is eii rzeiicy medical services activities iiid some kidiien. disease I)i@oai-aiiis. wilf be carried on by other iieiv and existiii(,, 1) .i,ogi-aiiis in tii(, I)epartnieiit more sharply fociisedoiij),,trticiilai-ol)jectives. .Nfr. Cliiirniaii. Ave ,il)l)i,eciate the opportunity to present our views cr 'I wot 1)(@ I)Ieased to t' and my colleaties and II(] i-v to qiiswer aiii ques- tions V-Oii or otlivi- iii(@iiibei-s of the subcommittee may have. .Nfi-:ROGFR.@. Thank Nloti very much. I yield to T)i-. Cartel,. .%fr. Ro(;T.Rs. IV]i don't Nvt, just go down and you can reserve your y time? Al] i-i(rlit. RorT-Rs..\Ii. i-evei p ? \[I'. PRFYER. Thank 'oii.\fi,. Chairman. y I)i-. Zapp. I think we all Nvitli voiii- statement at the otits(-t that money doesn't )iecessarilv solve oili, II(' iltli ,iiiv more than it does ;iiaiiv other problems. I)iit T think we ll,(IN-e to "Igr@ there can@t 1)(, any sol;ltiolis without I iiiiiik wliqt %\'(@ "III(, lookii'),--, ;it is wlietliei- it is justified oi- not. In I.,Itionaliziliff N"-Ilqt -,-oil :ii-e seekiii- to (lo. I (earlier ' rationalize p-- I . is Out -e , P- . medical e:ii I voii ,N-ei-P v,,lviii(-r discoiitiiiiiiii(' this l)l,Oaraiii -%-oii (loti@t tl)iiik will i-(@@l'llv vaii.,(@ it,,- tf)'Io'@e much I)ecatl-e tll(, clip's N\-Ill ta@-e oN-(,i,. i sti-eii--,tlieiie(i (IIIP will ti@-e ox-ei- ,i lot of tll(. fill)(.tiolis of tile I )-totally utility I-- fai Z.\I,I,. I think- unit is @i- the depart- 11)(@lit is it is :I olit]:IN. oili- exi)(@lls(.s ill- -,3 million. IN'(@ tliiiik in -,ozi i(@ tli(@ ('111) NA-ill I)i(-k up some of tile rxlll) I)Iqllllill",. Tile ])Iallllill(.r has (Ilti,el.e(I from olle 1)(Il't of tli(@ (Country to another. IVe think in the ki(iii(@v (IiiilN-si, iiilell(lllltllt to Ptil)lie l,aw ()2-(io3 will pick 111) SOI)I(' of tile 11'e tliiiik tli(@ iild heart diseise ])ill I)v tlii@ (-Ollllll'ittee will I)i(-Ii 111) some of the -ictiN-ities. IVe think the authorities of tliiscoiiiiiiitte(@ will :il]oNN- all appropriate II(Isel-i-oil. to fund little 'N- of the 1)(@ttt,i- AN'(- find fi-t)iii oiii- stand- T)oiiit that we (-all no ]oil"(,], ]]lake (-roo(I tis(@ of the Fe,lei-,il.(Iollii,s. Where we ]life iiiiiltil)lt, 1)i-otri-,iiiis A\-itli ovel-lill)])ili(,r ',Ill(] (Illl)liclt- iii,-r we _ro tlii-oti-ii qoiii(@tliiii.- like this Nvitli -,In e-xl)ei)(litiii-e o@ iill'oli. He c:tii't t(@(I in oil :I national basis ZZIV lia\-e t;il-(,re in solving any IVe doii t feel tIjiS is (roo(I use of Federal dollars. 7 I'RFYEI?. On the streiigtlieiiiii(,r of CHP'S. icttiqlli- -,-oiii- budzet vear 1974 proposes million iiid that is (Io,lx-ll. isn't it. fr-,!ti tlit, @42.5 million -original]% I)i-opose(I foi- fiscal 1973? That is I!Ilt 1!111(1]i strengthening, is it? ' I)i-. Z.11,1,. It ITS ilicretqe(I bN- @3 million foi- 11)74. 1 woiilcl like to 1--i::r otit section -221 of Piil)fi(, I,:iNi- ()2-(io:') coiifei,s -,tittllol.iti- oil ol.(-ritllizitioiis as (-;oi-ei-iioi-. II, :IIIA- Case. it woii](I i-eqtiiz(, (-otiii)leiitz I)N- NN-liere in e c ;z of @ks far is coiiiiiieiit4-; oil cal)it,,i] O.Ni) 11(litill -xces- foi- those activities tlien- :ii-(@ to ))e i-eiiiil)tii,s(,(l the @o(,ial i-i t i- 'I'i-i ist Fund. -tl.%- Al-ilit tl)is iilloillit Avill 1)(, it tliiz tiiiie. k-iioii-. I)iit it certainly NN-ill I)t@ :I IllloiiilT oil ;Iillf)llt)t of construction tli:it ill Illl ]),I?-ti( I iz a soiirce of wllqt N\-(@ I)e I t t IP's a \-el- it .,-,i\-es the Cl N !;[Ti-tl to its workload aside front the 1)i-oje(,t (Frantz tli(@ :314 e (7N to theme I)Ity)-Fi?. Oil the siil)ject of fiii,,iiiciii,-r this. -ziiice i\-(@ (le,,iliiic-r billion illdtlstl@v. it doesn't se(@iii that 01' it iiil--,Iit be, in tliit (renez-.il is oiit of line ot- is .1 program in invsejise of the i%-oi-(I. line] question oil th'at. and then I want to leave it. concerns the I I (lo tliev cover the entire coiiiiti-N- ? '-\-'o. 1'3 percent of t)ie couiiti- - is covered I)i- CHP B aaeii- (,olilltl,l- is coi,ei,e(l b\- ;k :t!zpiicies I'IYl-Fr,. Oil PI,@e 10 of votir 'Statement voii give some credit to ]late accomplished. You do saN- tliei- ire uneven iii the of I)('I.fol.lll.,In CL@. @iid I suppose that i's ti-iii. I i,iiess tli:tt is true ,;Iztte. at least I tliiiik tliei- ]i:ii-e 1)ei-foi-iiiecl i-ei-v \x-ell. In(] t 1,4 (-onsidei,able concern aboiit'desti-oi-in@ ill of the 'momentum I)et,it built up in the R-IIP's. Out- medical schools sp(.@lit of %-(@,11-s jioiv working Avith t)ie Cancer Association. the Heirt S@ foi-tli. btiildinz relatioiishi s and there is gi-eit concern ;ill ,,oinz'doivii the di-aiii. p in North Carolina there has been ,i verv substantial Ictivftv. mani, doctors liai-e i-oluiiteered tliei@ time. I am tile next time tfiev are isked to volunteei- foi- some sort of itv tlie@- are ]list c,,oiiig to sav. "Are]]. no. thank voii. ali@ faitli in the C-,-overnmejit' commitment. You ,et Of thi ilt of it.!@ s sort and then vou back right o health plaiiiiing'P . E- rocrram. ivill that be anv sub "fitlitt- fol- PNIP in this respect because the CHP does not deal with of health seriice. does it. like RI[P does? it deals iy-itli,l)roi-iders -.iii(i (-oiistiiiiei-s. It is ;I more com- fililltit@' representative group. ivhere,,is. I think is I pointed out in mN- St are more provider-oi,iented. In both cases I thin!- til"r" is oi-ei-lap. %vf)lil(l tell(] to think, Ifr. Pi-evei-. in cases ,vliere. especia]]N- in the (';'I-Oliiia R-IIP You mentioned. there h,.ii-e been a lai,ce number, of physicians volunteering their time, and they Nvere not doing this because of Federal dollars but because thev believed in the project there, that this would continue. I am not intimately familiar with the individual activities of each of the R.NIP's oil ,t national basis. but depending on what the.@, were on a large reservoir of residual doing, those programs can compete auth-oritiesthat t@iis committee and Congress as a whole has conferred u on the Department for similar purposes. @ll'. I-RFYFR. I won't take ziiiv more time on questions at the moment. I think we all agree that there'are some shortcomings in the programs. The purpose of'-aii oversight hearing is to find out what they are anct trN to correct them. It mtv be we should have some chaii(,,es in the program ,ind in its relati-onshii) with CHP and other health agencies. I am concerned that -,ve might. because of some elements that are not working well, be throwing out the baby Nvitli the bathwater and are destroying a good and bealthv ongoing relationship in areas where it has worked. I tl)iiik it li-,is'wot-@-ed i-ii otii- ai@ea. I am afraid if ,ve destrov it. it will be to ii-i-iitioiialize health services rather than rationalize it'. I think this hearing will help us get a bettei- line oil where thev are working. iN-li3- tliev are N@-oi-kiiig and where tliev are not workiii and why aren't tliev. 9 I)i-. Z.xpp. 'We -,voiild hope the reverse would be true. that tliev Nvould build oil the relationships fostei,ed rather than destrov tlieni'because. the Federal dollar in that particular area is no loii,,-,ei-.aviilable. @\lr. PNFYFR. Think i-oii. ROGERS. Di-. Caiter? C.@RTI'E. Til-,iiik voti,.\Ir. ('Iiairniaii. Howdoi-oiidefiiieaiiR'.\IP,Di-.Za 1)? Dr. ZAP@. I %N-ill give a broad definition. Di-. -Ilii-giilies could giN@@ a bettei- One. @ii R.III" in this case is one of ;)6 regional @roiips %v icli ]lad been formed with Federal funds for a x-ai,ietN- of p@rposes. These purposes I)eiiiu to translate research iiifoi-iii@itioi@ and finiliii(rs to the practice of medicine in heart. caiieei-. and sti-oke. qiiieiidiii(@iit@ them I)roa(lei, iiitlioi-itN- and tliev leave in different pii-t,@ of the coiliiti-N become iiivo]N-e(I wit]) utilization of man- ])Owei' development. e(iii(-,it'ioii iii(I iioNN- in actual (I(@li\-erv of services. That is soiiietiiiii(, I tliiiik we would not leave I)ei-ceive(fto have been all initial piii-I)ost, of l@IIP. -Ill-. his that ill the bill oi-igiiizillN.. de]iN-erN. of services. except ill :ill ex )Cllilllelitil nature ? I Di-. Z.\i,i,. it is in ill(- experimental liittii-e-tllei-e is a great fle-xi- bilitv in tli(@ ]@.Alt)'s s(,Ie(-tiii(, 1)i-oj(@(@ts foi. tl)eii- o@N-ii I)articiilir area 11'e often tii)i(,s disagree. ;tiid I ,iiii sure we will in the future. as to Nvli,it particular joint ill tiliie.it should 1)(, demonstrated. de\-eloped, and turned on-ei, to tli(, community. In soiji(@ (-,,ises 111) to '11) t of their tiiii(@ is iiii-olx-e(l- in services -,iiid I iiii siii-(@ tlie@ feel they ,ii-e deiiioiisti,,itiii(., soziietl)lii.- in that area. liaN-e Di-. Z.ki,i-. That is correct. Air. Ali R.IIP could be a medical ceiit(@i-. ,i medical school or ,t pi te. nonprofit Corporation Di-. Z.ki,i,. That is correct. 9 ('.Nit,rEit. Tlip purpose of tliit ,,.ztitlitioll xvis not onIN. to dis- 1 - kiiowle(Ige,btit was to conduct is that true ? Z.%t,i,. I .votild have to till-II to Dr. Nlzii-,,rtilies. I think we depend -eseii-eli. -II ai@ea . - .,I litt, tiefiiiitioii of I not in the bioiiiedic. but the re III the utilization of iiiaiil)o%\-ei, oi- the i-elitiojisliip between \I.\R(;ULIEs. I think that is i fail- iiis@ei-. If bv research N.oti i lie demonstration of some technique IVe don't mean that. .'rlie heart. cancer .\II'. CARTER. . iiid stroke i,!]I. till' I)III.po.:e was to have bi-eaktlii-oii,,,,Iis iii' tli(@se areas and do I 1111(l about heart, c,.iiieei,. s \I.%It(;L-LiLs. Ye,-z. the intent was to utilize the products of re - such as those established tlii-,)tigli the -National Iiistitutez of 11--;iltll foi- tli e of rapid kli--z,-ZLllliii-,itiozi of this kiio\N'Ied4Te to i . . e t it-@)i,@icticing P=ll. I'. ('A lt'FER. That was onlv one of the -Nl.%R(;ULIES. Al'itli specific reference to wlietliei- R-IIP was de- ;Igiie(i for the purpose of aoili,, re;zeii-cli. I think in the terni,-z of ref- %,on are usin@ it. the answers is no. .\Ir. -CARTER. IVe-liave all R-NIP at N'an(let-bilt UniN-er,-zitv in Ten- all excellent one. Do tliev do research under R-AIP ? 1)1'.'-Nl.%RGULIES. NO. .Nlr. CARTER. They iust disseminate such information they mav ob- t:t;ii to certain areas, ii that ri-alit ? 1)1-. -IIARGULIES. In terms 6f biological research. that would be the b ,I ;-z' IC 1)ul-pose, @e S. CTRTER. as this been done ? Has this been accomplished? -NI.XRCULIEs. There has been. I think. II consistent effort to utilize research kiiowledae through the 'lt-NIP's foi- dissemination to others, @.eQ .@r. CARTER. There has been an effort. Has that efFort been successful ? 1)1'. NIAR(;t:LIES. I think it has hall some elements of success and some clients of failure. ,NII'. CARTER. How much of vout- moiiev goes directly to the medical different medical seli;ols in ou@ 'Country and really becomes I)allt of tlieii- funds for paying their teachers and for continuing tlieii, -@'I'Olastic work? Dl'- -NIARGULIES. Tlierf-@ are two ways in which medical schools derive filllti.-; from the regional medical program, one you already alluded t'): [)'at is. when the medical school is the Lyi-antee foi- a regional medi- C411 1)1-0(, - flititis. C-raiii: that is, it is responsible foi, handling the Federal grant FI'Olll that they derive indii-ect costs which go into the general ac- coulltilig office of the medical school. The ot)ier way is in II variety of 1 which the rfgional medical program may support projects cOlitlileted in the medical school or slia-re ii-i the sup- ort of staff people Oil the medical school facult p ,IV i)av riey II" Y. part of a salary for activities -%vliich are R-IIP de iliLted witli'tfie'school t)aviiig the other part. It is not nteiided4ige i t would pal. for the medical staff ui-less they %vei,e c for It.Ilp act@ ijiLs. onipeiisated IV .Nlr. CARTER. In maiiv cases Rlip f uiids have been used for payment of "le(lical faculty, ha;ii@t it, and there is not a fine line between giv- AA iii(,, information out to PlIN-siciilis ill .tile field and the .Nork professors do in the iiniversitv? Dr. -II.XRGI'LIY..@: Ithink that is a fail- statement. If someone desig- ii,,ites 2(i of ]'is till)(' to R.IIP and the rest to the medical school. it is difficult to break that tiiiie down. llr. CARTER. @k lot of funds (y "(@ to the medical schools? ,-o I think si,@iificlilt ftiiidc; have, yes . llr. CARTER. I %vou](I lik(, to know ]low ]Intel' went to the University of I@enttick-%-. Di-. NI.IR61-LIFS. I don't IlaN-P those figures with me. '.\fr. CART-ER. I NN-oiild like that foi- tli(, IIiiii-ersitv of Kentucky and Vanderbilt. [Tile following information was i,e(-Pived foi, the record:] RMP SUPPORT TO THE UNIVERSITY OF KENTUCKY AND VANDERBILT UNIVERSITY Direct costs Indirect costs Total Ohio Valley RMP: Support to University Kentucky Research Foundation: 1968 ................... .................................... $14,279 $6' 530 $20,809 1969 .......................... .............................. 59.490 2.698 81.188 1970 ................. .................... .................. 96, 567 40 000 136,567 1971 ......................................................... 10, 774 44@921 155.695 1972-73 ---------------------------- ------------------------- 275, 640 104,459 380. 099 Total .......... ........................................... 556, 750 217, 608 774, 358 Tennessee Mid-South RMP: Support to Vanderbilt University-Grantee: February 1968 to January 1969 ................................. 577, 028 79. 422 656, 450 February 1969 to January 1970 .................... ............. 889.4D6 182. 454 1,071,860 February 1970 c Januar 1971 .................................. 1. 032. 438 269, 043 1.301.481 9 to Decemter 1971 .......................... ... 907, 314 20 February 1 70 t 8, 737 1.116.051 January 1972 to February 1974 ...... ........... .......... 1. 932, 398 380, I D6 2, 312, 504 Total .................................. ............ ...... 5, 338, 584 1,119,762 6, 458, 346 -111'. CARTER. HaN-e R-IIP's staved within the limitations of the legislation ? 1)1'. '\IARGULIF.@. I NN-oiild say they real]N- have. although on one par- ticiilar issue it is a iiiattei- @f deaiiitioii. Ill the oi-igi@al and siibse- qlieiit legislation there(, is iii injunction against doiii,(-r anything which ,.A-Ill ilitei-fel-e with the 1)i,act ice of medicine. voii'lia\-e all V.\IP which is liell)iii(_,, to deN-olop a iienv p@o,@ram S()Illel)lac'e. it is difficult to sqv fl)at this is not ilteriii(-r the practice of medicine ill that al-ei. That particular prescription was an important one. I think the-\ . Nvei-e iiloi-e concerned in the early (lays of R.\IP's rela- tioiisliij) with the I)i-actice of n)ediciii(@ NN,jtll ],eTei-eilce to setting fees or pi-ovi(Iiii(,, direct sei-i-ices ' soiiietlliii(_r of t)i,,it l@iiid. BaQicalli- R.\IP's staved N@-itliili the limits of the lecli-,Iat loll. '-\I r. CARTER. Is it true some R.\Il)'s qi,e LettiiiL, into ll'\[O's? D I-. '-\IARCI-LIFs. They liaN e ]lad iiiN-ol\-@nieiit 'ivitli H'-\IO's in I)ro- N-i(Iiii(, assizt,,iiiee foi- those interested in (]eN-elol)iiig ,iii H'\[O. C.\rtTF.R. II'liei-e do the-\- (,Yet the authorization -\I.%RGULiy.,;. TI)ei.do that is a I)rof(-ssioiial activity. which I think- is a Treasonable thin(, to do. CARTER. T]i I-(-S])Ollsil)iliti- is ill the field of heart. el 11 kidney (liseasez:. isii caiicei,. sti-oke. iid t it 1)1'. Nl.@RGuLi.Es. Also to iiiil)i,ove delivei-N- of health sei-i-ices. Local lia%-e conie to tlieiii i'oi- advice oil I;o%@- to develop I)i-of@sioliil Zt;il)Ll@it-Lis of all H-NIO oi, ]low to to tlll'OU(Ill Elle process or ol.Lriliiziiig .NJ I'. CARTER. Cali vou show iiie in the legislation NN-liei-e tllev ]late this 1)1'. -IIARGULIES. Section !)10 of the I)HS Act is fi'i-IN broad lecisli- tioll .Nll'. CARTER. I bellei-e that is all ijitei,l)i,etitioii N-oti placed oil it. 11'e i-itt- legislation and soiiietljiies it is interpreted quite diffel-elitIN- than tilt, ifiteiit. kcttitll3-, I ani afraid in iiiaiiv cases different (it?pai-tiiieiits and a,,(Iii- -'It's ijitL-i-I)i-et le(-,islatioii (tiffei-eiiiIN.. 1 think- it is quite obi-iotis tiieN. (to. .%II-. li@ISTI-NG.":. if you art, tli(@ question of the 11.11(.;aii(I IT-NII' ill%.ol%,Clllellt. I think we iiil-c,llt ,,o to tfie. foi- 11-110's. 'I')iztiik 3-oti for yield@i(Ir. .Nll'. CARTER. How do R-NIP's actlitllx- i-elate to section 314(b) I)i-. Zipp. ll'itliin a State. I would sii-. except foi, the fact tliit the 1!17, iiiiif@iidj)ieiit. that Di-. -Ilai-aiilles mentioned a niiiiLite irro. tli(@ added i-i-iiiiii-i-iiiejit of revienv of R-IIP applications I)v tli(@ ai-ea%%-i(le 1)laiiiiiiit, that was part of tli(, Ilt@altli @i-N-ices liiil)i-oN-eiiieiit Act t)f I!)7o. ;ii-i-.tiigeiiients liaN-e geiiera]]V I)L'Oll 1).ised on the streiirtils Ili(i of the N-ariotis CHf, 1)eol)le'N%-itlilii tlieit- li,e.1s. Tii(@ oil'-]I. stitti- i-t,(Iiiii-eiiieiit conies fi-oni the I()7i),tiii(-ii(iiiieiits. (.'AitTER. Has the continuance educational function of R-111' been f-tri.4.ti%.e ? tr I),-. NL-iftGULIES. It is difficult to jud- the effectix-exiess of tii e(luca- toll@ll I)i-oai-aiii. I would have to respond. I think inore as ,i- -Nll'- 1?0(;FRS. You have had this program foi- 8 veii-s. Stii-elv vou siloill(i k-yionv whether it is efft@ctiv(, or not. Nl.%RGULIEI,;. In nit. jti(l(,iiiejit. it has not been effectiN-e. I'%I)GEP.-z. That is ivliat ?I- wanted to kiioiv. Do voii have aiiv hard (late oil this? 1)1'. -IIARGULIES. -N-O. ('.%RTER. Do voti evei- evaluate tl)ese pi,ooriiiis. have sonle- olit, Outside the house evaluate it ? If voii liqv-e in-house (@%-,tltiatioiis. ii-e i,,irelv Lyood. Hive voti had CTAO go o\-el, these? I.)I'- IIARGL7'LI'E'S. 11'e liai-e' liid e\-altiations ovei, the 1).ist 3 veaz-s that addressed this question. but I aiii not satisfied ',.vitli oui@ I-ii;tlllzltiolls. -Nfl'- CARTER. Have R.AIP-s been doin(r much of their oii-ii planning? I)I'- If@XPGt'LIFS. lie]]. ill the sense t]iLat tliei- are ol)li-,,ited to lav out 1)1:1" fol' I to 3 -vears. Yes. They planned foi- the activities i'n the medical i)r;gra@ii ill '911 cises. .Nfl-. CARTER. Ifow similar are the plans submitted bv tlic, @)6 different e.. kg(@lici Q? 1)1.- Tbev ,tz,e bi,(,Ybl.v varied. CARTIER. Just d bodaepod(re. tliev are not directed. tliev lack It'('(,toji. is that not true, reallv is niii'ch fi-oni the national level is else? Dr. '.NIARGrLIES. I think from the national level the variety is very striking. On the other hand. within certain kinds of regional medical programs. there is a hi(,Ylier level of consistency. You would not ex- pect to get the same kinds of activitv in Ilaine as in Iletropolitan New York, and those differences are stri 'n kl There are similarities between rela@ii-elv rural States and relatively urban States in what thev Propose to do. Mr. CARTER. lVhat aie the consistencies %vhich tend to occur in R@Nfp,s? Dr. MARGRLIFS. I think a fair number of the programs in rural areas have been concerned Nvith the improvement of cardiovascular medical care and use of manpower and placed higher emphasis on that, for example, coronary units or better utilization of hospital facilities. '.\fr. CARTER. ll'ould you give me some example of the training and teaciiing in cardiac care. emerlyencv cardiac care? Dr. MARrULIEs. There h,,iN-e been several approaches to that. The re- ional medical program certainly in the first few vears sponsored the Development of coronarv care units in a great rang@of hospitals around the countrv. That was a fairly consistent pattern which had a kind of flonvering, and then a setkling-down period. There have been a varietv of services. which include attention to people with cardiovascular diieases. These have had some consistency around the countrv. '.\fr. CARTER. Do vou have anv data about @eol)le with heart disease, how manv people @ave been tr;ated or anv data to show the effective- ness of th.is program over 8 years? Dr. '.\IARGULi-Es. IVe have some data on the effectiveness of the coro- narv care units. '.\Ir. CARTER. Hoiv much has heart disease diminished in the last 8 vears as a result of this program? .Dr. '.\IARGULIE:S. I think it would not be possible to find anv effect on heart disease as a result of this program. .Ft. R'-\IP's have real -been doing much of their own plan- '.\fr. CARTE ning. Each has its own plan. Is that correct. lYr. '.\IARGULIES. Yes. '.\fr. CARTER.'GOe.S its own \vav. Are some oil all R'-\IP.'s bound bv community health planning? Dr. '.\IAiCL7LIEs. There is a requirement that the plan of the regional medical program go to the CHP B agency for its review and comment. '.\fr. CARTER. Do R.\IP's n bette@th,,in CHP'S? Dr. '-\I.kRGULIES. ' \o. R'-\Flp@s can plan for specific kinds of provider- oriented activities which are ivitliin the range of that experience. but thev are not designed for nor competent to Ook at the total health pie- tiii-@ as a CHP agency would. In @ll fairness. the regional medical pi-o- gr,iiiis have not'inv6lved all the provider structure within a State oil reyon. hev have had a heavv concentration of people with categorical oi, acade 'Mic interests and hlaN-e not involved hospitals and hospital asso- ciationS RS they should. Mr. CARTERHow much of the R.NIP funds are spent for administra- tion of the programs? 13 Dr. -IIARGLLIES, It 'was indicated outside our structure in the Re- L,ioii.il Ifedical Program Service that that runs about 40 percent for of staff and Dissociated ictivities. -Nll'. CARTER. About 40 percent. Do vou have hard data on this? 1)1'. llkRGrLrEs. Yes. .111'. CARTER. Are some proo-rams spendiiio, less on adniinisti@,itioii ilinii others? Dr. IIARGrLIES.Yes. .Nlr.CARTER. Do voti liai-e aiiv information available Di-. -IIARGuLrE-,z. Yes. .Nfr. CARTER. ll'hat are the compeii-catioziz- iiid salaries of core staff ')II. iiiiii-erage ? I)1'. -IIARGRLIES. Tliev range coiisider,,ibli-. Eich regional medical 1)rozram has a chief executive officei- Ni-lio is known either as a co- or(litintor or some similai, name. ,iiid then tliev have professionals, times physicians ,ind -zometinies iioill livzici' ii4: Is e-aliiitorc. C@o' ollif a I' the salarv ranLre is coii@-idei-al) e. but I think it parallels (,IozeIN- a similar sala'i-v -ztr'ucture in an academic in,-ztittition wiili which ilie@, n'lialit be affiliated. CARTER. I'Vhit might that be Dr. IIARGrLIES. Salarv ranges for coordinators run as high as oi, S43,000 a ve,,ir.' and other costs run well belo,%v tliqt. -NII'. CARTER. HoNv iiiaiiv in tlie-ce core I)ositioi,,s Nx-otild draw salaries of -@").OOO or --45.000 in a 'region ? Di-. -AL%RGULIE-@'. '-\-o one but the chief exectitii-e officer. .Nfl'. CARTER. How minv more close to that raii(,e would vou get 1)1'..IIARGuLiFs. How i'n,,inv coordiii,,itorQ? c- .Ifr. CARTER. How nianv'close to that. HoNi- mailv eni lovees in a p re@on would have salarie-Iclo-ze to that lei-el ? r. IIARGt-LIFS. I thinl, none. -Ifr. CARTER. IS it true. as some claim. that R-IIP's are too closely ti('cl to medical schools? Dr. .11--tltGULIES. In some instances. % e@-. In manv ,ireas where they were. I think that relationship li,,is'6ecoiiie less binding. -Ilr. CARTER. Does such a tie help or hurt ? Dr. .11.%RGULIES. If it is oi-erli- zealous oji the pirt of the medical @Cliool. lvliich sees the R'-NIP as i'iiiech,,iiiisiii for gettiiio, tliingc, it can- lot otherwise Lyet. I think it is harmful. -Nlr. CARTE@ Nearly, I had -i-eat hopes on this bill, and I feel in @oiiie cases it has been extremeli- helpful, but we liai-e had such di- ,ve@-e programs and so little ],,icl- of -direction that the program has sort of lo@t its wav. 11'e have 56 di@ereiit groups that have lost their purpose. Some are providing services, and some are in ambulatory care. As vou said, tliei, have forgotten that thev ii-ei-e originated to disseminate-informa- tion about he@rt, cancer, stroke, and later on kidney ; isn@t that true ? Dr. IIARGrLrE's. I think t)iat is a fair assessment. In the last few weeks. I have bee -aoinfr over till the securities of the regional medical and it is ft re,,t]IN- fremei@dous actin-itv, s. q]] -roiiiz in different directions. i- de-ccrib@ it, it @voiild be im possible. d %ve spend on tlii-z program last vear? ?2 0 - 73 - 2 14 Di-. ';NfARGI-I,IES. In 191'2 the grant activities were around $110 million. 'Nfl'. CAIZTEFZ. Around $110 million. Some niateliing funds were used bv States ? '-\-o. This is fill] Federal support. 'Nfl'. ('.@RTY.R. Thank you.'-Nli@. Chairman. 'Nfi,. R@EttS. Di,. Ro y - .Ilr. Roy. I want. to thank Di-. Zapp and Dr. Ilai,@,ulies for being with us. Is it true that vou. Di@. '.Nlai-giiiies, said in Jaiiuari- 1972 thit R.NIP was the best of all Federal programs? Is that a propei- phi,asing of I.N-liat voti said? Di-. @AIARGI-I,IElz. It is possible that is what I said. .Ali-. Roy. II'liit liipl)eiied between January of 1972 and JIntiai,v of 1973 ? .11.%RGI-I,IF.I. Di-. Rov. let me go back and give voii caiidid all answei- as I call. liefoie I joined Piegional Ifedical !Progrims. I ]lad great doubts -,il)oiit it. I thought, it Ni-,is ,i so-so pro(ri,ani. and niv inter- est was modest. II'lien I became Director of the program 'it ivas in great trouble. but I entered it enthusiastically. I ptirsiied it as vigorously as I could. I could not Ill @-e been in it aiid remained objective al)oiie it -,ind when I work(@d foi, it. 1 worked foi, it with all iiii- heart. When I said strong. w,ii-iii tliiii(,Ys il)<)tit it. it was pai-tlv because I ivaiited to transfer ni-V elitliiisiasjii;tii(i support to what is a remarkable group of people. the coordinator,., of the R.IIP's. as much a-, I could. If I exa,@"ei-,itt-(l in the process. I feel no ii)ie,,isiiiess about it. It is the thing I needed to do. Plicijif,! the program in the total context and NA-itli the ran'L,(@ of tli(@ issti(@-, Di-. Zal)l) has laid out. I ]lave ]lad to be more objective. more witlidi-,,iivi). and take i view ivitliiii -,i larger setting'. i-(-@iii,.ii-kable happened exce])t is I ]lad to look at this pro- c,ri@,aill ill what I tliiiiii is i much wisei- failure of i-ef(@i-ence with a total look -,it tl)t@ Health svsteiii and a more cautious use of funds to get tll(' joI) (10)i('. 'Nli-. Ro(;Yp.-;. You are t(@llincr us that votii, I)rioi- statements ',Il-e now I.IY.S. @lioii](I I respond fiii@tliei-? '.\o. 1 tliijik Nv(@ liaN-o the picture. DI-. ZAI-l'. ll'Oll](I .1-011 -IlloxN- t response. ? I think that something liap- I)eii(,(i I)e@l(les the I)oiiits treat Di-. indicated. There are solii(, in iviii(-Ii Iiii(I t j)iijoi- part: that is. the passage of le(,isl,itioji in calictii. iiid licii-t ;iii(i Iiiii(r. tli(@ professional standards ie%-iew. pii-t of H.R. 1. kidiiev (full .sis. ill these ai@eas liid a signifi- cajit impact oil a (Iollii, basis. .\Ii,. If the gentleman ivoiild permit. tlien- lie Idliiiiiistered ii the same ii)aiiii(@i@. You ;ii-e iio@@- telliji@r us the iiiiii ivitli the resl)on- sil)ilitv foi- idiiiiiiistei-iiia this I)i-o,,ri-aiii foi- '3 N-eit@s his illo@ved tl@iiigs to dis4iiite(,,i-,ite iii siic)i I ('Ii,astic ii-av. I am not siii-t@ i\-6 (-;ill (-otiiit oil iiiN.programs being I)i,operlv adniiii- istei,e(i bA- HEIA'. I)i-. Z.%i-i,. I (I() iiot tliiiik treat is @i fair- @lli-. It is ;I f:i(.tllill I),.. Z.xi@p. I (lo iiot tliiiik Nx-o ciii I'lit, legislation -i%-es Its tlii@ I%'I) of choice witlliii tll(, of of tllt- Nit-. Yoii (lo iiot liax-t@ to the -@i-aiits iiiilt-ss tliv,,. coiiie !I staiidii,(Is. 'I'li;it i@ ii-t@ lvft tlizit zilitlioi-ita- x@-itli voli. I)tii-siie that jioNv. I-'..xt'llse iiie. Lo 'aiii ilitei-t-.zte(i ill tll(, )t- t)ie lack tliei-vof. I l:t..z till.@ I)Vt@ii I txi-o if I iiizl\-. I tliiiili tl!. lll.\I I ;Ill(l CIII),s it tile oil ill ill(ii\-I(l I I;il tllt@ I)ot(lilti;ll ot, ('111' to (It) it 11-:1@ Sill)- L-ofillilli!lit. N. ill :1 lk,ztl @l:liliiiji -;ill '-:,- of tilk-ii- ;Ill(l iiini,i, :il--,.,-,i-ez;zi\-t, -4,ti-t. it- iiiii(Ili iiloi-e of tl;(@ )f til(@ the \-ol- \V)ii,-Ii W(,].(. zl)ol@ell of So. tilL@\' fi(-](l II'lix- ll:IN (I tliei- :11)lk@ to (lo so I tililli@' ill 1);Il't till' ll:ltl fllll 1):tekiii,-, tll(, of iiie(lic@,i] sc]14)ols to IN-Iii(.il tllo.\- I)i(I it ll:IN. to (10 \%'itil t]IL@ f;l('t tllt@N- lll(l 11101-L' illillit-@- ('0111(i "t@t bett(,i- 1)(@ol)] I aiii siii-(, tli;it ]its[ soilliltllifi,, to (10 AA-itli it. Ill-. 4)lit of tli(. (lo \-oil tliiii]@ ('Ill')'s Nvill do Al v al.0 stl\. ill". llol)efilll\- Oil tAN-0 fi-nlits tli(, NA-ill ill(l ;also tll(,I.(@ is ]lot t] colill)(@titioll. Al-e AN-liit I)iit \\-t@ (lo iiot kiiow wlio ei @e tile decisions uiilez;z it is the CHP i,,eiicies. I-oti i k- iii capital exl)eiidittii-e ? IN-lio N\-ill iiizike tli(@ (let-isioii It d(,I)ejids oil Avlio til(@ -iiati%-o do(,s ]IC I)aN-e ? Ile wotild I)e ,il]oA\-ed. I siil)l)os(,, t of altei-liatil-('S. t I-e CHP (B) iii e-xisteil(,(,. tIlev iii:iv iiot lizil-e tll(@. zl)t,,ik. i-eview iild al)])I-oi-al aiitlioi-itv. I)iit' Nvoiii(I liai-e .'Ollljllellt. I tliiiik tlio eai-lici- iii(licati@l'i of (losiviiitioiif. I)v the (;Ox-l@1-1101-S liivt, I)eeii that il)oiit i-f) 1)ei-eeiit-I %N-oii](I p- iiot wziiit to I)t@ ]'(III to t),;It fi,-,tii-(,-of the CIIP's lil\-e I)eeii t]iL@ Go\-- 111'lloll@ fol, section ")")l ilill)lelllellt"ltioil. I)o voti tli iiilz tile\- wil I do that ? Ye'-_-. I do, ? PX. )Y. 11 Tilt@t,e is of tile ti-list fiiiids. III wliat aiiioliiit ? It iz '111 lilliottlit tll;lt I ilii Silill)]N- to ;it this ll-(@ (in lint kiiow. AVe li.(, fol- tile 111(@lit:itiOll of Z-7(,(,tioii 221. Tli(, fil-t is, tliev will I)e i-eiiiil)iii-se(l. 'Ill(l it Live them a sl)ecifi(' t which CHI"s liaN-e not had up to this Will - r-e point. 11'e think that with tli(@ fact of lia%-iii(,, a bi,,)ad mandate in the proj- ect. grant that %%-ill begin to them fo(-tis in cert@iiii areas and be iiioi; ett(,ctiN-e. I think the fact tlien, are not competing %vitli Lroups in the ';ii-ea such as 11.111)'s that piv fiialiei- salai-i@. tlie-N will te ,tl;le to 11 ' 'be iiioi attract some of the 1)eol)le that ii,-,Iit -e lie] I)f Ill. Iloy. Do voii-tliiiik people in the R.\IP's @ill go on State salaries to work i ii CH P's Di-. Z.@rp. At i-oiii- I)i-ofessioiial level, the coordinators or people liav- iii,r 1)oi.tiojis of S',ilii-i@s 1):iid bv medical schools- Roy. The profession-,%] feN-el ? Dr. Z.xi,p. Those people won't be fitti-acted to CHP'S. Geiierallv those I)eol)le in iiaiiv cases. portions of tlieii- salarie I s are paid b,% R.Ilp,s-. ii-id tliev lia@e a factiltv appointment oi, other involvement that coiietittites probably a priiiefl),Il @nioiilit of that sal,,irv. The '.)- will not be drawn into a CHP. but iiiaiiv of the people working for them. that have salaries I)robablv closei, to Nvliat CI4P.s could pay. we would hope tliev would be'l)icked up. '.\Ir. Roy. S:o, Y6@ii- feeling is that if CHP gets an increase from $35 million to *38 trillion. then all things that R.IIP's have done in assist- ICHP'S. the CHP's will be able to do themselves @ l@r. ZAPP. AVe think the CHP'S. on a statewide basis. are ready, as a result of ]la\-ilig @dditioiial fiiiaiiciiia mechanisms. to do better in areas like facilities i-ei,iew. and ])I-Ogi-am cost effecti\-eiiess. and developing Co )ertise. in these ai@eas in which they will ,ind probably should expand! I thin k one of our I)i-ol)leiiis is that all of us, the administration in- cluded, have expected much more from esseii tially a community of centl,,iflv base(i CHP's than tliev could deliver. .\Ir. Iloy. Isn't million @ii insignificant ,inioiiiit in this area? Dr. Z.tpr. If it %v,,is not supplemented bv additional trust funds, and tliev were to maintain their broad m,,ii;clate. I think it would be difficult. Roy. How (lo voti plan On iiit-i-owiii(r the CHP mandate ? Dr. Z.\Pl,. I think- tIl-e Social Security @kiiieiidments of 1972 to a de(-Yi-ee will begin to have them focus pi,incipal)N@ on facilitv review on an initial basis. '-\Ir. ROGF.@. If the gentleman will permit. .\Ii-. Roy. I Yield. .\fr. RO(;ERS. How iii,,iiiv people are covered bv social securitv health care? Di-. Z.%ri@. '\Iecliciid -,iii(I medicate? '\Ii-. ROCERS. HOW III',IIIN- I)eol)]E'@ Di-. Z.@pp. I think it is more t li-.in the people. '-\Ir. ROGER.@.,Ttist -,iiiswer iiiv question. Dr. Z.xpi,. ('Iiaii-iiiziii. 'I ao not have the figures in front of me. '\Ii-. Roc ple are covered .Fi?s. Approximately how iiiaiiv peo. Dr. ZAPP. I %vould sav perhaps SO percent of the facilities if not more. IVe are reviewing facilities. not beneficiaries. '.\fr. ROGIERS. Aren't ,ibout 40 million p 0- 17 the rest aLtbe-_p@opl@ln___. I PI-,iiiniiiglo dg;kl- on@t expect e@a I t I .Ali,. RoGERs. I am not sure we wq'it 'voll to rewrite Comprehensive II,.altli Planning. Dr. ZAPP. We have ,t proposal before the II-,ivs and '-\Ieaiis Commit- tee for extension of oui, proposal. ii-eftil oi,. iriii(lelizies. and I think this .Nfi-. Ro(;EK,. IVe liaN'e to be c, i,Ollllllittee would be iiiterest(@d in i z 'delijies that change the iiv iii tlii-iist of our la,%v. This coziiiiiitteL, wrote tilt? law. not IVavs and -Ifeans. Di-. Z.\Pp. I would like to point oiit that out of those 40 million. the file(lic,tre and mediciid bezieficiai@i(@s. it ;-z tli(, institution providing c:ii,(, to them. and tliev -,ire si)e-,ikiii,-, of .@l I oi- 1)") percent of the institu- tli)ii@ xi-itli niediciid ilici @lt ],-z those iiistitiitioliz ill of that Nvill Ili-. Ri)c.FRs. I Illl 11 tll:it ",(, W;Ilit I)!;tiiiiijig to be resti-ict(@(I to wli:it(,N-(,i iiie(licii(i lqii(I iii(,dicii-e lllzlv I't-4111ii.e. I)t-. 7,APP. I understand that. Nft-. R(,,GrRs. I think ive Should i el,,:ii- understanding of that. Ill-. Roy. Your r(,eoninleii(l,,itioii to Pxte!l(t CI-IP will not tak(@ cire of tlik- salarv I)i-ol)leni of t!ic, Election ')14 is tliiit coi-i-ect ? Z.@pi,: Still it iliel.t?,I.ze tile of tli(@ iiidin-idiial members' Ili-. Roy. Yes. Will it iiiet-east@ to (,o into the niii-ket- I)I:ice,ind get more competent J)VOI)le 1)1-. Z.@p'p. It would iiici-eist@ tot:tl i-zitli(,i- thin the IVithotit lnowiii,,, lioNN- iiiii(-Ii xi-ill flow into CTIP'S. I (in tiot know. -Nli-. Roy. It is not tli(@ amount of iiioiit,N- flowlii,,, Ill- Z.kpp. You are talkiii- of -k and I iiii talkiii(, of ill(, B -If?-. Roy. Yes. I am talkiii(, of .@'s. I),-. Z.App. That is true oii'-A's. Roy. The B a(yeiieies co%-t-i- NN-li,,it I)ei-ceiita (Ye of the population 7,Al,i,. About 73' t! Nfl-. Roy. Geozi-ai)lii@call-,-. Avli,,it in tli(, -N-atioii ? I)". Z.%',i,. I f i-ijikiv do ii-ot kiioN%-. III,- Roy. You reillv have no pliiis to increase the number of B ;kg-Pleies. is that corre'ct ? Yoiii, plan is to beef up those presently in t.xi.steiice? Dr. ZAPP. I think essentially that is what ive are proposing. 'We w(,tild propose to discuss witl; the coiii)iiittee Nvlieii the extension of t II(. (,Hp i - s before it. -Ili,. Roy. Let me ask. ivli,,it went as fai- as R.\Ip? -IOU i @ co @n I -d t-i r7, iTi .-sa@--tbere pact-- on Off-gbie-to-ai id--brir, ge to the In( pe ive have learned soniptli P over 8 3-t@, ,I i.s. If vou were not able to do it. ]low ciii we do it through the alterna- t ive @i,or.yrams that Dr. Zapp mentions? I 10 Di-. illARGr@LlFq. I would like to respond to that ful]N-. if I nlIN-. 11-heii eve beoan the ediicitioiiil ,ictii-ities Ili R,\IP. it was all extension of 1)ast exercises ivlilcii had iie\-er been much iiioi,(@ than rather pedes- triaii training programs where. a I)Iivsici@iii oil his d,,i-,- off itteiids meet- ings. hearings. lectures and goes home. IVIiether the teaciiiiig was relei'aiit oi, pertinent to his I)ractice pi@ob- leins -,vas iiei-ei- certain. There is -,i likelihood with the dei-elol)melit of activities such as those eiivis,,i(,e(I iiiidei- PSRO with a I)ettei- kind of qualitv review that the deficiencies that exist can be identified and there can be designed ,i I)i-ocri,aiii to meet those deficieiices. r- Mr. Roy. You didn't identify these deficiencies. Dr.'.NIAROULIEq ' I think not. Mr. Roy. ll'h%- not? Dr. '.\IARCU1,IEq. I don't think the skill of the continuing education activities had reached that I)oiiit. l,et me just use as a reference. if I mai., the Stite of Kansas, Ni-Iiiel) has been involved in coiitiliiiiiia edii- c,qtloii for manv vears. At its best. it (lesi,-ned coiitiiiiiiiic, education tii,otind'%vliit the teacli- ers thought ]carriers oiicht to learn rather than identifviii@r with learn- ersi needs to know. Mr. Roy. I object to that statement. Tlitv have gone to the I)Pol)le yeai- aftei- -%-eir in Colbei-. Great Beiid ind elseivllei-e qiid slid. '-Il'liit do voii need? Hurt information are -%@oii not (rettiiig?" Tliei. went to Great Beiid trviiia to teacli more ibotit sti-oke. I think -%-oii ire sini- plifviii(r and perhaps distorting it be, that statement. . rn Dr. '-NIATtCr-LIF-,. I disagree on tlii.,- basis. I don't aci-ee -,vitli tlizit 1)1(,tliod of ;iskiii,-, 1)eol)le. (lo N.oii ii(@e(I to kiioxn- Let.-, It tll(@ii, tl)(@ N- ;ii-(, not of tli(,ii- in practice. Mr. Roy. That wis not the oiilv method. tiiev tried ,ill ivays to (,et this information out. Dr. '.NIARGULIEq. Ili tli(@ il)seiice of oz-giiiiziii(r medical recoi.d4z and nl)i(@tii-e i,(@i-ipw of tli(@iii. tlioz(, ;11,(, i iii;ittei- of I have often attended the nieetiii(rs in Kansas. I know lio,"- the-,. are. I know ivlio event fill(] NN-lio didn't (-,o and I don't think R'-\IV';4 are aiiv more successful in iiin-olvin(r I)eople in leai-iiiii(r .ictiN-ities oi- aiin beitei- thin qii-%.oiie (,Is(,. no iii,,ittei- lioii- desio-iied. The 1)eople ivlioii,e not (,Oiii(,, to learn .iii(I remain in the ]),I(-kr'l-olilid practicing oiit-d,,ited medically were not i,eicii(@(l. I don't kiioin- lio\v to iiivol\-e them it is wit]) the P.@RO It requires I more formidable structure(, tliqii we li,,iN-L, had. You don't need to teioll the of a department of medical(, el t ,ind his it q iiiiivei-siti'. It is the li(,ol)lp out of air I a role that need it. and ,ve didii@t get to them. ll'(@ ii-(, !-,olii,-, iiito tll(@ ],,,;PO,s a).(, @,oiliLr to I)e able tc) identifN. the d(@ficiencies. '.\f.\ It i -., ])I N- 1101)(@. .\II'. ROCF.TIS. IN'll] the gentleman N-ield \fi-. Roi-. Cei-taiii]N-. Afi@. Cliiii@iii,-iii. '\II,. Roryns. I so)ii(, of the I)i-ogi,@iiiis liin-e not run too well. I)iit I don't Ni-,iiit to le;ik the impression in the t,(@(,oi-d that oiie (lei,Ives fi,oili N-0111. 'I'lie follnin-iii(r statement. fi-oiii ;Ili HFIN' publici- 19 III-efel-i-iii- tofis(-,il veai-Q I,).-I:iiid l)72 st at is. --III'\-ol.t II C,,ii-olilii a L, Sti-o@-e I)I,Ogl,;Illl NI'll-4 I,nflil)i-eliensiv@ . iiiiti,,ite(i wlii(,Il iiicliide(I nnio.iia of ictiA-ities tll(, of fol- Collitillill]tN (,dii itioii:il ;t--ti as ti-aiiiiiiL, I)i,o,-ri,:iiii@ f,)i- iiiii-seQ. sti-,)kt@ woi-k-4iol)s iii(I sti-oke coiisiiltatioii sei-i-i,--e@ fill. I)III-siciaiis tliroii,,Ii tli(, i.-ool)ei-atif)ll of tile iii,iii-olo"ical of title(, ceiitei's. ,-.k faiililv patieiit ediicitioii iiiiit %A-.is :il@o to ]fell) )-,Iticliits I :III([ tlit@'ii- flillilie.-, to (-nl)(, i%-itli efl'erts of Ztl.()kt@ diz- :illllitx'. OI)ei-atiii(r iii l@) coiitities. this filii,le(I l@N. the N,)I,tli (';ii-,)Iliia RIIP. has i-esiilte(I iii i iii lilol,t;ilit@. fex@-ei, Ill- 111)@I)it.ll coliil)licltioils. slioi-tol- I)o@l)lt-,Il @t;IN :111(l ].(,(Itik.tloll of I xv,iiild say that is a Ci)lllill,r fl-(')]Il JIF r- oil :III Nii-. Roy. Call voii difl'ei-eiiti:itt, -4)ii,4iilt;iti,iii fl'olll ])I-()jt.(.t iiii,iit ;iiid nl,.tiiaaeiiielit, oi. fl-011) iii:iii,,14-reilit@lit I tliiiik it is (lifli,-tilt. l'oit li:iN-(, ti) :11)1)1%. it']-I)it I-;I I.N. iiid ti-v to :illot-.tte t-i),zts. hot-. Cail'.iiivoii(, ill (in tlli,:. I)]-. Zll)l). (';ill tIlel. tell tile fliti't,l,eiice betxn-eeii C'OllltAlltitioll Ill(l :141]liiiii@ti-:itioll I I )I'. ZAI'll. YOII C,'Ill set 111) defiiiitioii@. I)iit liziN-(, to ize we ai-(, I:llkiii ibtit how nilicli tiiiie ei(@ii iiiilix-i(Iiial %%'Olll(l I)e iiii-o]N-ed iii :'(-tivities-lioAi- iiiiieli time @I)CIlit oil (:Oll@tiltitioll. ]lo%%- iiiiieli time fill I)I,oject review ail(I iiiaiii,,,eiiiejit. It is (liffictilt. 11-e kjiow the btilk is :il),)iit 4(i percent of tli(-se ftiii(Is: I otll(-i- words. the 1) 04,ri-ani iiii(le what I coiizzidei- ti) Ile tile best bi-ea@-otit we call I)a,-z(@ oil the iiifoi-iii;ttioii we had. I'kf@y. fiii-c N-011 i(iiiiiiiisti--.itioji fi-oi)i coiisiiltatioii ZAPP IVe have J)i:ogi-:iiii iii(I q(liiiiiii@ti,atioii at IO.S of the on-ei-zill : I)i-()jet-t aii(I iiiiiiia-eiiit,iit. r- I)t"'ceiit: professional coii@iiltitioii. coiiiiiiilllitv relations ali(I lia- isl)li, 11).4 I)ei-cejit : I)Iaiiiiiii,, stti(lies iii(I iiix-eiitoi-i es. 4.4 fei- r- sillilitil stii(lies. 2.8'pet-ceiit: i-e,yiotiil iii(I otliei- sei-'@-ices. 2.8 f,)I';' total of 40 I)et,e-eiit Of the fiiii(is. I-,'Oi-. I)o voii feel tlio-@e I)i-ettN- -!oo(I fiLIii,cs Yes. I)o N-oii tliiiik tlii@x- ii-e tli;izi tlit@ bliiikt@t. -4t;ltellielit that R.IIP's ti'e sl)cji(lijiL,, 4o i)ei-et@iit oil a(Iiiiiiii@-tratioii. N'Oii a little iiisiilted I)i- tli is (-oiliiiiel;t ? '-\-o. is a iii,,ittei- of fact. I tliotialit the figiii-e Colild Ile .1 little further-. Tt is iiit(@i,estiji(,T the Depat-tniciit didii't 11"1"t olit tli(, ,idiiiiiiistrative costs iii i-iiiiiiiii(v the R-AFP Service, -,vliieh 114)t inciti(led in this ictivitv. It (li(I iiot identify some of tlie iii(Iii-ect costs for i varietv of ,iffili- -Iti,(l ilistitiltiolls wliicli i-iiii exti-aoi-diiiai-ilN- high. I thotl(,,];t it wis a rl'@lsoll,il)le statement aild. if voii -kvaiited. ii cou@ld be made e-,-eii more l@OGER.,. You permitted this imbalance voii are now criticiz- .@RCCI-IES. Yes. Sit'. ROGERS. 20 Dr. '.%IARGur.TES It was one wav a program designed in this way oiild be iiiiiiia(,,ed. Tli(@ (-omzll(,Ilt Voit 1-11;i(re eni-liei- regarding the way this program was conducted is worth looking at. '.%fr. ROGERS. That is Nvhat Nve are going to do. Dr. %IARGULIFS. If vou want to design a program as this one has been designed. so it is'decentralized. as you wrote the legislation- dministered as we wrote it. .%fr. ROGERS '. I am not sure it has been a Dr. MARGUITFS. I think it has. It was written to be decentralized With regional medic advisory group and to be operated as a f itution. That meant the decisions should %vere made locallv, the more '-.t seemed t the purpose of tfie' legislation. '@fr. ROGERS. This seems to me to be the whole thrust of what HEW is attempting to do by turning everything over locallv. Now vou are sayin-a that is ]lot a Lrood philosophy. Dr. '.%fARGULIFS. It I-S a p@ilosop@@. that will -,vork in the right struc- ture. I think placing the responsit)liity in the hands of a li@ited num- ber of people-foi- provider care has not the same effect as decentraliza- tion that goes to-a State government. I think you would have diffi- culty in fi-ndiiil, the. same situation. . '.%fr. ROT. A@ you telling !ne State governments are not affected by the-se decisions. when these interests have skewered R.\ P proarams? Di,. '.\IARGX:I.IFS. No; but I ini savina the health interests 6f @'region call be identified and piirsued by a'po@iion of the providers of medical care in that State. but that does not provide a reasonable test of decentralization. mine in vour State. if you wish. )fr. Rooers, the makeup You can exa of the people iiin-olved in the R'@\IP and find major segments of the rovider group totally iiiiillvolved. Or. you can check on participation p Of nurses, many classes of physicians, hospital administrators. nursing home directors. and so forth. A limited number of peo le are ninkinc, most of the decisions. There p was no iTav to expand that because of the wav the program was established.- '-\fr. Roy. Isn't it true voii reallv said with this whole program We 'YO to the llssi,oots:find otit'tlieii, needs a 0 Will L 91'I iid develop fr in their need@? This is tile w,,iv I understand RIIP. You didn't reallv trv to do this. '-\Ir. ROGFR.S. He jIlSt Said the reason tliev lian-en't had good. con- tiniiing education was becati-e tl)ev didn't @o to the grassroots level ed. '-\-oAN- voti are saviii don' do it. I don't and find out what was want g t know ,vhat voii want. '\fr. CARTER. If the chairman -%vill vield. this is jiizt a little sheep that has -oiie iistr,,iN-. Tliev are not following the concepts .ve pre- seiitedintliele islatioii.Itiiasneverbeeiifollowed. It has not eii administered coi-rectl-,-. In some cases it has been verv good. In come cases tliev have N-ei,v .-ood programs. and in other areas verv i)oor. -it ip the opposite of (le iliz, -Ifr R(;Y:IV]i, centi,. itiozi ? Dr.'.\fARr,ULIF.@. Central control. - m 21 .Nir. Roy. This is the Nvav Nve should go. This has been the single greatect effort in Governmint health programs to decentralize. and you ;_av it has not Nvorked ? Dr. -@IARGr'LIF-'Z. I think decentralization to @ limited portion of the colliniunitv is ill advised. .Nir. Roi. You go along with oui- continiiiiic, CHP 314B agencies that wonderful things but have to get matching funds f ron ou go along with that ? Di think the basic concept of coniprelieiii-zix-e health planning is a good one and deserves sti,oiia support. lfr. @oy. I-ncluding matching funds from pi,oN-ider;: for 314B. Dr. -NIARGULIES. There has to be matching funds. I iin not sure of the requirements. I have not been dealing that closelN. with their -P -'bilities. re,z onsi .Nfr. Roy. I-i' I told you they come generally from providers. would you agree Nvith this temporarily Dr. -IIARGt:LIES. I think so. 11-hen it comes from a limited iiiimbel- of I)i-o%-iders. it provides ,in oppoi-ttiiiitn- foi, the indi@@-i(Itials to run the atfairs of Ia B agency. I Nvould pi-efe'i- to .see a bi-oadei- base of funds from the community. llr. Roy. Decentialization has not worked in R-NIP's becati,-ze it has been captured by local providers ? Dr. AIARGrLIES. I thi-nk it has not worked partly because of the pur- I)oses of the program as laid out were so multiple. and there were so iiiaiiv interests the group needed to respond to. and they have not been able'to keep a centralized purpose coiiz-istezitlv throughout the pro- grani az has been evident here. air. Roy. Is it filr to ptii-aplit-.i;-ze N-niii, testiiiioii%- that the core st,,iff cf)@-ts a lot of money becaiisl- i-oii (Ieceiitl-qlize(I into 56 iiiiits@ DI'. @NIARGUI,I]7s. I@tliijik tliat'is iiet-ess;ii-v if you have a freestanding institution operatliic,r with Federal fluids. I see no to reduce the 01'eilliead costs. .Nir. Roy. I have other questions. but I have taken far too iiiiicli time. I ,would like to ask a cou@le of (Iii(,stioiis litet- oii as to -%N-liat I think is (',Illed the adniinistration's health sti,ate(yv. Dr. Z.%Pr. Quite certainly. llr. R(vERs. Nfr. Hastiiiis? -Nf r. HASNNGS. I yield to'l)r. Cat-tei-. -Nf r. C.%RTER. \-o:'I have iiotliiii(,, i-i,,,Iit iioN@-. N[r. HASTINGS. Dr. -Ilar,(rtilies,t'yoii stited-I (lo not to be i-epe- titiotis. but in Decembei- 1971. not 11)7-'). N-011 Slid that IZ.11P,S. betwe oiil(l provide a test eii Government and the sector,. 1),,ick,qge and distribute new health concepts. Yo@l may have voiii- view, but I lizil-e not. I think we have to. oil cft a regional basis,'do @i-ecisv]N- t)iit. In the siiiie article in '@'-\Iedi- I ll'oi-ld -News.?@ a(Tain quotiiir v@iii-self. \-oti said: rrary to popular belief. today'., national Itill' (I oe.@ h,,tve teetti. Tlie.\ntional are, grades all I)rograiiis numerically like students In a classroom. to establish rel&tilre rankings with lagging programs. An RNIP can be put on i)rnl),itioii f(j'r 6 iiii)nths. liiiiititi,- funding to tlint period rather than 3 yenr.,;, which for(,e3 involvement in the community. recruits ,,,,inager.@, %i-bich iiiake our people more (of a i@olitit-al. social and economic instrument. I I N, lie If N-oii (loti't fee] to(l:iN- 11-111)'s ,"(, il'N'OIN-e(I ill ill(' et) I It - t 1-it(,@i ],file Si] I Iv (iiii riot %voi-k. 'FlieN: iveile iiot in l'oil (I() tli@it N:itiolll] -k(IN-isolIv Iloat,@l wltl) 'I)ilitN sotii(, i,esl)oiisi - in ]@.111"s. (to -N-oii not I)ti(Ilit : tll(@ ]".Nll),S, i limited s(-ol)e is de- S(,I,ibe(i liei-P. and i-, slid in the ol)(,iiiji(r ,tati,iiieiit. liix-P sotiie iisefiii It is ill f;l(.t 1)1.01);Il)]\. olle of tile iliost (.1-iticl] elellielits of I wlietliel- ()II tillit Side of the til)](@ ol. oil this one. foi- licaitli sci-N-i(@(@s tli;tt tij(@i,e I)c tii i-ela- tioiislill) I)et\VEILIII CYON'(Illlllll(lllt at iiiN. lei-el iii(i I)i,ofessioili] I)eople iii- volved in the de] of set-vi(-es. ll'])etliei- in this c@iiiiti-N- oi- others I iian-e stii(li(@d, that i-el,,it-ioiisliil)s is iii iiiipoiliiit one. \\-itli;)iit wili(.]) to ill)l)]-ON-e ille(li(.al serv- i(.(@s will ]lot (JeN-elol). II'llit I NN.,Is talkiii,r at)ol@t 1. I)I.eseiits -,I kind of e Iiiik.i(,,e wlii,-Ii NA-;is sei-i-iii(, i I)III-I)OS(' foi- I ]ill it (I I(.tix-i- ties. but it was too Iiiiiite(i iii scol)(,. (-'Fovei-iiillt@lit-I)i-of(,ssloiial coordination is iie(-essai-.%- in kiii(i of lipaitli sti-.ite(,N- 1),ise(I oil the kiii(I of tllill(,s I)i- Z,,11)1) lii(I olit ()II I I)roii(l(@i- bist, NA-itli i iiioi-e (,oiisi,,t(@iit iii(I listiii(, itiecliaiiisiii II'liei-e is the device to delivei- these services you talked aliotit ? I I)ave not seen t proposal saN.iii(y. as a substitute for an RIIP. this l@,- x%-Ii:it will go in ,iiid (le]iN-ei- the sai-ne tliiii(v to the coii)iiiiiiiltv. II'li,,it ii-e we talkiii(r al)otit I)i,. Z.xpi,. I do not think in aiiv case we have slid there will be in each ii-ea ;I iiiecliaiiisiii to diil)licaie tile ictii-ities. The R.\IP ac- tivitie.@ wei-e different in each qre,,i. II'liit we are siviii(, is that -,ve ))ave i-eQi(Iiiil ititlioritiec; that fit into these iiiajoi- ('oiiij)'oiieiits. I Nvould I)e to I)i-oi-ide tlieiii foi- the record. I)e(,:iiise tliol- I)reak down into c,ite(Y-oi-ies that ai-e easN. and one., that are fiiiiiliai- to tile coliiliiittee. TI)ev ii-e ;ill authorities wliicli this cojiiiiiittee ;iild the committee oil the @iiate side liaN-e;LiN,Pii the iiitlioi-it\. [.@ee "Resi(Iiiil authorities aN-ail,,ible foi- RAIP-ti.l)e activities." A'oii s;tvill(, the good I)itt-t, -will continue except iiii(lel. (.Xl@till("- iiltllol.itie:,, t)ie\- \-nii't Ile put ill to(,etliei, I)iit under ill HEIV 1)1'. ZAI-l'. )-es. Halt is Nx-i-oii" %x-itli coiisidei@iii,, the suggestion I iiia(le I)efoi-e :iiioiit t:ikiii(y tli(@ ]lost 1)@ii@ts of RAIJ)'s-NN-e Idiiiit parts not Teen ;iii(I tliei-e is no oil that. The P'-\IP 1)(@01)1(@ (lo llf)t that I)oilit. litit t;il@e the ('111). \'Oil "I(]\-O- of. \-oil ;11.(, fol. wit]) )lo cI II I I i II 'Fake into ;I (-niiil)iii;itioii of tli(,.se q,reiieies. still with ir lle.ioll,iliz;ltl,)Ii. I I)eliei-e iii. I (lo not tliiiik in iiiv i-iii@al part 0f -New ) ni-k State tli;it Voll (-;Ill (](,@i(rll ;I that Nvill 1.@e good ot- S;ii) I tliiiik tile.\- li:iv(' to I)e. different. I (lo not tliilil@ fi-;iii@-lv. .ii)(I this siil)coiiiiiiittee .tile a.-; fit- ;is solll(, tl)iiik. I think ';I little 1)(@iidiiig oil I)otli 'is to t ])Oiiit N@-liei-e we (-oii)(I take tile niost (,f Ilk" \Il"s. tike the (-'Ill"s we all indicate we 23 to continue. ijid piit then) tozetliei,. ti-i- to dei-elol) soille national liv@iltli polic@-, ii-Iiicli I think we are lickiii,-, to(l,,I%-. iiid cojiie iip with @(ilite oz-c'aiilzatioiial sti-tictlii-e that c;iji (I'elivei- 'tliezt ser%rices. I..;tliat real I %-tooii)iicli toisk ? Z.%i,i,. I'tliiiik fi-oiii A-otii- st-,iii(II)oiiit. it is ;i roo(I stitenieiit. -Ili,. ll'e Coll](I _,o (lo%%-ii the line of ,ill ill(, @o(I I)i-o,,,i-aiiis that we %%'Otil(l like to do. litit ol)%-ioti.41%- we ciiiiiot ftiji(i them all. I c;tji oiil%- i@eitei-,tte N%-Iizit I said I)efoi-e :iii(I lof)il%- foi-%@-@ii-(] to the op- 1)1)i-riiiiitv @vlieii we call (-oiiie I)efoi-e the coiiiijlittee to testifn- for I %A-ill to t injection to(iii-. II'lix- call we 11I)t I,xtt,'jit RAII-I's earth t siiiil)le extt@iizloji foi- 1 i-L,;it, to (,i@ -e ti@ t)IL, 1110]ltlls to I%-ol-k- oil train t%-I)(' of 1)1.()I)o:s:ll N@: e ;ti,e t;ilkiii,,, al)otit. is (Essential to tile (itit@stioll 11 c ill O( of 0 all kiio%@- it. Foi- tilat i-ea.-zoii, I t@iiiik it 1.@ tli;tt illy @tib- 4'1)jlllllittee ]late the tiiiie to (to 1)i-ecisel%- IN-li.,It wt, ti]@-ilicr ;11)ollt '111(i ;"!,:It I think HE"' is tall@iiit, '.Ibotit. t',xt,el)t voti iN,Oill(l I-,it@liet- iiiel(i it,, el f)ll the successful 1)ai-t of votii- I)i-O;I(l ititliot-ities. 11'e ivotild like to bi-iii.(, it tri-etli(-i- in a stattite that (Iefliies N@-liit we like to (lo iii of ]it-;iltli cai-e. I'e-QL@ai@cli all(] e(itic-,itioli. iil(l ])')lilt it it aiid sai-. liai-(@ we lived tip to tile iiiteiit of the liNN- oi- jiot. l (lo not tl)iiik 'we ii-e tliit fit- al)ai-t I x%-otil(i oii(,(- a@,,aiii 1)le:i(I i%-itli k'ijll that we liai-e the ol)l)ot-tttiiitN- to that ti.l)e of (iiiestioii be- f,)I,t, liot just this stibcoriiiiiittel, .I)tit -ill iiitei--@t(@d i),.ii-ties tlii-oti,,Iiotit tells (-otiiiti-i-. ivlio at.(, iii ftet iiitei-(,@te(I 'II 0111' Ileitil I tliiiik that is ivli,,it we ii-e t;illiiiig iboiit. @@(raiii I)ecaii-z(- of tile tillie lifilit.itioli-@. I 11.011 t PillStit, llil' (itiestiolis fill-tliel'.- -Ili-. Roy. Hill voii yield @ ' ' .If I'. 1)1'. Cii-tei- asked fli-st. -Nfl'. C@tl?TFR. I kiiow i.oti said tliit voti ai-a(le the 36 i-et@ioiiil I)i-o- Do @-ou lia%-e the i-(,siilts of il)at here I)]'. 11-@RCULIES. I (10 not liaN-e tlieiii liei-e. no. Nll'. ('ARTYR. Al'otild voit bi-iiiL@ tli(@iii ai-6iiii(I so we call see tilexii. how II''. (liffel.(.Iit oiles ai-c riti@d aiitl tile basi@ foi- zo i-atiii,, tlieiii ? .@RGULIES. Yes. l'i't,stil)]Ol]N- I-esiiilie@, oil 1). :31_1. foll@iviiig iiifoi-iiiatioji was i-tceii-ecl foi, tile i-e(.-oi,(] RE%'IEII- CRITERIA A,D RATI.NC OY.STE,,i-RFGII).;AL -IIEDI(.kL PitOGRA.,%fs TI,L, Reginlal liedical Prograrns Service utilizes a rating systeiii based on speci- ti,-(l review criteria in evaluating thi, grijit ,iiiiiiic:iti,@ns of the ;-)fo Helical Prograws. A eol)y of r:itiiizs is of Janii:try 31, 1973. the Cri- 11-ri@t themselves. aii(i the Scoring @heet i-ex-ie%vers i.@ itt@l(-Ile(l. USES OF THE CRITERIA Ttit. (lel,el(jj)ii)ent of revi(,%%- criterii %%-aq necessitated ill 1).'Irt l@T the decis;ion the R.Nll"s froiii tlit- niti.)tial levt-I in teriiis of their 4)i'et-all progress i)!-o@raiii. rather thin in teriii!z of the technical )f in(iii-i(Iii,,il I)roj- (liscrete. singular activities. I,:irt of the effort to 1)rt)niote re,;ii)n,,il dt-cisit)ii-itiakiiig tn(I fiin(iiii, -Itltllorit@- (it@@-t-lirr;llizi,tl tti tlit- -I(; ill iiii(l- Itt-gil-lis have the autlir)rirv. If their o%vii revit,%v liripeess" niept (lefined rnijii- st:liidird.,;, to iiiile the final reg:irditi, i I i tli4- technical of proposed operational projects and (2) which proposed activities are to be funded within the total amount available to them. This change from project to overall regional program review at the national level necessitate(] the development of program review criteria, aimed at assessing a Region's (1) performance to date, (2) the process and organization that had been established, and (3) its proposal for future activities. After using these criteria and the corollary scoring system on a trial basis, they were found to be operationally satisfactory, and were incorporated as an integral part of the national review process. Each region is rated annuallv. Regions requesting three-year approval are rated by the R.\IP's Review Committee. Applicants for recomluended second or third rear support of a three-.vear grant already approved by the National Ad- visor.v Council are rated lay R Staff Anniversarv Review Panel. In either case. the National Advisory Council (-t)iisi(lers and may at its discretion change tile ratings assigned bv the RevieNN- Committee or the Staff Panel. The Criteria are used to provide a relative ranking of R'\IP's on the basis of numerical scores. As a result, Regions are ranked and then grouped in term.,, of quality-(A) Those which have demonstrated the greatest maturitv and poten- tial. (B) those which are generally satisfactory in their performance and prog- ress, and (C) those which are below average. About a third of the Regions are reviewed at each review cycle. Therefore, the relative standing of an individual Region may change on completion of any ercle, based on the ratings for the Regions then under consideration. The scores represent the subjective opinions of reviewers at a given time and are only one of a number of factors considered by the staff and Director of R'.%IP',q in determining an approved level of support. THE CRITERIA The Criteria are divided into three groups: (1) "Performance." (2) "Process." and (3i "Ilrograiii Proposal." Each criterion is assigned n relative weight. Heights were originally developed on a sulije@-tii-e basis modified after a trial period and al)l@roved by the Review Committee and Council. In addition, a series of questions appear under each criterion. The questions are not criteria them- selves, but are used to illustrate and amplify the kinds of things covered bv the individual criteria. Copies of the Criteria are furnished to the reviewers at ea h Staff I)aiiel and Re%-iev%- Committee meeting. THE SCORI.NG SHEET The Scoring Slieet is used by individual reviewers to provide their ratings. Each column is used to record the revienver's ratings for an individual Region. The Criteria and the @veigbt.@ for each are ,;I)own in the left hand column. P-pace I., also also I)rox-ided on the Scoring Slieet for an overall assessment of the Region fliiie Di. n recommendation for a Developmental C@)iiiponent, if requested (line Ei. and finally for re(,i)r(litig the basis for the reviewer's evaluation ilines F, 1-7). The latter is used by RIII)S for monitoring and evaluating the rating sys- teni itself. The "Basis for Evaluation" lines are the R.\IPS use onlv and do not .iffe(-t the numerical Ea(,Ii revieivei- rates each region oil a I-;! scale for each criterion. The review- ers do riot sign tile .zlieets. At the end of tile meeting, the @oring Sheets are collected and a computerized composite s(-ore for each Region is generated almost immediately through the RIIPS '.Nlanagament Information System, The overall numerical ratings for each Region are made mailable to the Council @vhich may, at Its dicretion. modify any rating. 25 OFFICE OF SYSTEMS MA,4AGEMENT, REVISED RANKING OF R'@'P REGIONS (53 REG104S RANKED), JAN. 31, 1973 Ja.iuary Fe@ru3ty 1973 re.-ie,v cycle SARP, Dece.T,ber Rev. Comrn. Region Priorcycle,scorean@' date 1972 January 1973 reiions (326 and above): NeNjersty ................................... 413 SDece.-nber 1971 .......... 4CO .............. Ge,igia ..................... ................ 366 SSepte-nber 19'2 ................... iii ................ Ill,lais ....................................... 375RJanuary 1972 ............ l@.3 ........................................ 3.12ROctober 1971 ............ 357 .............. Cil,fornia .................................... 355 SSepte.nber 1972 .................................. '62s.hinglon/Alaska ............................ 330 S Septe-nber 1971 ............... ....... Fianda ......................... ............ 354'la@uary1972 ............ 3@2 .............. Cl@o Valley ............. .................... 323ROclober 19-,l ............ 338 .............. '4est Virginia ..... ---------- ................ 336ROctober 1972 ....................................... A,sconsin .................................... 336 S S:pte.nber 19'2 ..................................... Vale ....................................... 335 SS pte.-nber 1972 ........................ ............ ikesiern Pennsylvania ......................... 330SApril 19,2 ........................................... P@erlo Rico ------------------- ............... 326R'Aay 1972 ................... ....................... "B rei!ons (251-321)@ '*:rthiands .......................... -n ..... 325 .......... ......... 317 SDece. ber 1971 ..... A.'kansas ..................... .. ............ 341ROc!ober 1971 .......... 324 ...... ....... Carolina ..... ................... 321SApril 1972 ........ .................................. Crei-n ...... ......... ..................... 321R'Aay 1972 ........................................... Nassau 'SoPolk ................................ 319R%lay 1972 ....................... ................... Te.as ........................................ 314ROctober 1972 ...................... ................. Y:um!ain States ............................... 314SApr,[ 1972 ........................................... Hj*a,i ....................................... 309ROclober 19i2-, .... ................................ L:-.@s;ana ---------------------------- 241 RJanuary 1972 .......................... 306 nectic@i ............. .................... 312ROc!ober 1971 .......................... 305 A; @any ....................................... 303ROctober 1972 ........................................ 'labanla ..................................... 292 SDecenber 19,'l .......... 298 ...... ------- Teir,essee,'Midsouth ... ....................... 298SSepte,,nber 1971 ......... 29 . .............. "am Mexico@ ................................. 294ROctober 19,2 ........................................ C.forado/Wyoming ............................ 290SSeptember 1972 ..................................... -Y ch'tan ..................................... 290SSep:e-nber 1972. . I .................................. ?i!bfiska .................................... 288R'4ay 1972 ......................................... visslss,PPi ................................... 288 R October 1972.. ...................................... V;filnia ...................................... 287POctober 1972 ........................................ Tfis:ale ...................................... 3 .13SSeptember 1971 ......... 232 ........ Pi.'r.hern New England ......................... 282ROctober 1972 .......................... ------------- Ye.-nphis ........................ ............ 291ROctober 19?2 ........................ ............ h:rth Dakota ............ .................. 183SSepte.-iber 1971 ....... ............... Likes area ---- - - --- ...................... 277RJanuary 1972 ..................................... lr!efmountain ................... -nber 19' ........ ............. 298 SDece. I........................ 274 .............................. 287 ROctober 1971 .......................... F-chester .................. ................. 269ROctober 1972 ........................................ ..C.@Faisas ............................... ...... 264SApril 1972 ........................................... III ons (250 and under): 11 .................................. 247 ROctober 1972 ........................................ Susquehanna Valley ..... ............... 2.'4SBece.nber 1971 ................................ "-Uth Carolina ................................ 240SApril 1972 ........................................... Ce3,'ral New York ................ ............ 239ROctober 1972 ........................................ I.-@',,ana ...................................... 222ROctober 1972 ..................................... he* York Metropolitan ...................... 324SSepte.Tiber 1971 ....................... Ile,,,r lel,y,,r. Valley ........... ........... 213RJanuary 1972 ..................................... -yaryland. ................................... 245 R January 1972 ............. .... i@i. YeiroPolitan District of Colunbia --------------- 2G7RJanuary 1972 ------------ ----- 189 10,ssouri ....................... ............. 188RMay 1972 ................................ -------- 061ahoma ................ ................... 184RMay 1972 ........................................... pti 't-'f',heast Ohio ............................... 133RMay 1972 ........................................... :@s -@thout a score: DIII-are ................................ ......... C@;O-. ...................................................... S-,Jl@h 6'a 'o-ta -----------------------------I-----------------------------------------I ----------------------- ........... ........ ................................................ ............... I)ECE-,IBr,R 28, 1971. RAIP RE%-IEW CRITERIA A. PERFORNIAN-CE A4(i) 1. Goals, objectives. and priorities (8) (a) Have these been developed and explicitly stated? (b) Are they understood and accepted by the health providers and institutions of the Region? (e) Where appropriate. were communit@- and consumer groups also consulted in their formulation? (d) Have they generally been followed in the funding of operational activities? (e) Do they reflect short-term, specifle objectives and priorities as well as long-range goals? (f) Do they reflect regional needs and problems and realistically take into account available resources? 2. Accoiizpli8htnctit8 and -ititple?)zcntation (15) (.i) Htve core activities resulted in substantive program accomplishments and stimulated worthwhile activities? (b) Have successful activities been replicated and extended throughout the Region? (c) Have any original and unique Ideas, programs or techniques been generated? (d) Have activities led to a wider application of new knowledge and techniques'! (e) Have they had anr demonstrable effect on moderating costs? (f) Have they resulted in any material increase in the availability and ac- cessibility of care through better Utilization of maiil)i)iN-er and the like? (g) Have they significantly improved the qualit@- of care@ (li) Are otbei- health groups aware of and using the data. expertise, etc.. avail- able through RIIP? (I) Do physicians and other provider groups qnd institutions look to RIIP for technical and professional assistance, consultation ind information) (j) If so. does or will such assistance be concerned with qualit@- of care stand- ards, I)eer review meebanismq. and the like? S. Contittued stipport (10) (a) Is there a policy. ictively pursued. iimed at de%-eloping other sources of funding for successful RNIP activities i b) Have successful ictivitie.@ in fact been continued within the regular health care financing system ifter the xvitlidrawal of R.\IP support) lfiiir;rity ipiterc8t.,( (7) (a) Do the goils, objectives. and priorities specifically deil with improving I)e-,iltl) care delivery for tin(lerserved minorities? (b) Ilow have the RIII, -ictivities contributed to significantly increasing the .accessibility of primary Health care services to uiiderserved minorities in urban ,in(I riiril areas:, (e) How have tlil- R.NIP activities significantly inipi-oi-ed the quality of primary and specialized health Prvices delivered to minority I)ol)tilitir)nc;; and, have these ervice, been developed with tl)l)rol)riite linkages and referrals among in- extended care -ices, patient. out and home )iegltli ,er% (d) Have any R.%IP-sulil)orte(I activities resulted in atti-acing and training rueuil)ers of minority groups in health occupations', I., this area included in next year', activities? i e) What ,;tep., have been taken br the R'.Nlll to assure that minoritv patients and professionals have equal access to RIIP-suppoi-ted (f) Are minority providers and consumers adequately relire.,zented on the Regional Advisory Crnuli and corollary comniittee structure; in(I do they actively participate in the deliberation.,;? (g) Does the core stiff include minority professional and supportive employ- ees ,ind does it reflect an adequate consideration of Equal Employment Op- portunity ? man 27 th) Do organizations, communit@, groups, and institutions which dell pri- iii;irily trith improvin- ))eilth services for minority populations x@@t)rk closely ivitti the R'%IP core staff? Do tl)ey ictively Ixirticil);ite in R'%IP ,ictiN,ities? it What surreys and studies have been done to assess the health needs, proli- -i:iF services of minoritv izroups', It -, and utilization of B. PROCESS -:,51 i. rrjr)rdiytator (10) i a i Ha-; the coordinator provided st ron,-, leadership" ilwi Has he developed I)ro,-ram direction ;iiid c(,h@ion and established in ef- functioning c(ire staff., i Dries he relate iyid N%-ork well with tlit- RAG, i Does he have an effective deputy in ii:true or fact? ('orr staff (3) la) Doe:, core staff rpflevt i tiro)a(l tif professional :in(I discipline corn- ,ind posses :id eqii,,ite i(Iiiiiiiis:trlTive and ni:iiii,-,euiezit e;il)zibility, krf- nio,-,t eorest:iff t,.,@t-ilti;tliy ,,,j Is there in atle(iii:itt- (,eiitr:il (-(,re s,@-iff i;i@ if) illStitiltiOD,'Il COUI- ? advisr@1-11 1 5) 1;l I Are all key health izitt,rests. iii@tirliFi.-Ils. :ill(l --rotil):4 .vitliiii the re-.ion represented -In tlit- It.k(; i:iii,l .-(-r,lll:iry I)I:Illllin,- elluiliiittee striie- t it r(, i ',, D,-,ei the RAG iiieet ;is;t lit le:i--, 3 ,r 4 tiiiie:z iuiiu:illy'! Are iiieetin;.,.@ well ,,I i Are consztliiiers a(leiiii.,itely relir(@-enTt-11 oil the RA(, :izi(i corollary (-riiiiiiiit- -triii-tiir(-? Di) they ;i(-tii-i I., the RAC, i)layiti,- in ri,le in prt),-,r;iiii policies. estiblish- and I)rit)ritit-s. aiitl loroA-i(iiiiL, -iii(l:in(,e -iiitl direction of ,-,ri- st:iff activities? - f I I),-" the RAG have -,in e-,eciltive to provide iiinre freqii(-iit ad- iiiiiii!41r:lti%-e I)rogriiii -tii(lijice to ill(- iii(I core stiff., ';: i Is that coiiiiiiitteeilso fairly relirc-,Piit:itive! (;,',iplfci-tirgaiiiz(zlioit. (2) 1),)es the grantee organization I)rt)vi(le -ideqiiAte a(Iniinistratii-e iiid o)tber it) tile R%IP, it periiiit stiffi(,jetit iiiii tit,xiliility. especially insofir is the IH)li(!y-iiiiling role is con(-eriit-(] I"Il'ticiP(itio)i ('3) ey health interests. iii@titiitif,iis. in(I groups actively pirticipat- Are tile k tile I-ri),-raiii? 1),Pes it il)l)e,,ir t(i have heell (,:il)tiire(I t)r by -i in;ijor iz)terest! tile I)Iex .; lioliti(-;il .111(l (,I.till(.IliiL7 I)ilwtl. i-,Illl Ilfl,l?l itig (3) Has It-iIII lit conjunction %vitli CHI' hell)e(I develop effe(-tive local planning I.- there ezirl3- invf)lveiiieiit 4)f these I.P(-iii I,Iiiiiiiiig gr(itip.-i in the develop- -r 1,r,)graiii I)rol)osal.,4? kri, there @i(le(ju,,ite iiiecliaiiisiii@ f,,r obt:iiiiizl,, fiitistantive CHP review (if ii-ceds (zii(I rcsotip-res (3 i there a qysteni;itic. continuing iileiitification of needs. problems, ind tlii, involve iii a.@se.,4siiieiit final iii:ilysis liased i)ii data Are i(teiltifie(i needs ind I)roi)lezii@ traiiQlite(I into the Region's I)Illls ;iii(I l@rioritie@'! Are they al -ind .so reflected in the (-c)lie tii(I nature of its emerging core . "I-'r-itit,lizil activities? L 2S 8. management (s) (a) Are core activities %vell coordinated? nitoring of projects, con, (b) Is there regula N-stematic and adequate rilo d other activirie:by specifically assigned core staff? tracts, an t eports required? (c) Are periodic progress and financial r 9. Evaluation (3) (a) Is there a full-time evaluation director and staff s-, reporting? manage- (b) Does evaluation consist of more than niere progre Its to program (c) Is there feedback on progress and evaluation resu RAG, and other appropriate groups? program ment, - satisfactory results been converted into (d) Have negative or un .11 ally have unsuccessful or ineffective activi- decisions and modilcations; specinc ties been promptly piiased out? C, PROGRAM pROPOBAL (25) 1. Action plan (5) (a) Have priorities been established Ioals and objectives, including strength- ruent with national g (bi Are they cong served areas@, ate to its stated priorities, enin t proposed by the Region rel (c ? ed activities realistic in view of resources obJ e and the prop, in ncei @ora I c aval be qed to anv a gnifi ant degree? results been rti 'a hments and assessing ngacopl , sed ically rerie,,ved and updated? prol (I Ar@ priorities period 2. Di88eminati4on Of ln(nclcdge (2) tions that,.vill benefit been tarzeted? (a or iiistitu iques to be disseminated been ldenti- (b ation" egion actively tied'. r institutions of the R (C involved'., to more people likely to result? (d) is better care costs of care. (e) Are they iiely to moderate the )li(:fible and CUrrentlv i)raetiCRI techniques t I widely PI)l me services? f ) kre l@y directed to .s if highly specialized, low volu rather than care or rare condition 3. L-tilizatiri?, nianpoicei- and facilities (4) be more fully or effectively (.a) Will existing comniunity healtli facilities ower will be utilized''I etivity of physicians and Other health mELnp (b) It is likelY produ l@inds or combinations increa allied health personnel, either nenv (e) if so, is it proportionately reflected In of exi oritr area (d) ram? this a ved areas or populations benefit significantly as a (e) result? 29 improvement of care (4) to which ambulatory (a) Have R31P or other studies (1) indicated the extent ,I)anded or (-') idet,tified problem areas (e.g., care iiiight be ex geogralibic, illStitU ti-)tial) in this regard" ib) Will current or proposed activities expand it" (c) Are communications, transportation services and the like being exploited that iiiagtiosis aijd I reaLlIJellt oil III 4)Utlillliellt I)IISi.@ Is I).ISSil)Le.' (d) Have problems of access to care and continuity of care been identified by R.Nlll or others? le) Will current or proposed activities strengthen primary care and relation- ships between specialized and primary cLre! if) Will they lead to improved access to primary care and health services for persons residing in areas presently iiii(lerserved., ig) Are health maintenance and disease prevention components included in current or proposed activities! (h) If so, are they realistic in view of present knowledge, state-of-the-art. and ,,[her factors? Sltrjrt-term pay,)ff (3) in I I.,; it reasonable to expect that the operational ictii-itie.; proposed will in- crease the availability of and -,iceess to services. enlian@ the quality of care and or moderate its costs. within the next 2-3 years, II,) Is the feedback needed to document ictual or pr ospective pai-offs I)ro- Is it reasonable to expect that R)IP ,upl)ort can be with(Irt%vn success- fully within 3 years? 6. Regionali.-atio?z (.,,) la) Are the plan and activities proposed iimed at assisting multiple provider Kroitps and institutions (as opposed to groups or institutions lb) Is greater sharing of facilities, manpower and other resources envisaged lei Will existing resources and @ri-ice., that are especially scarce andi'or ex- ,,er , tn(I )i4)1)tilati(iii than be extei:ded and iiiade an-.iilalile to ;I I:ir, ire.,i presently? idi Will new linkages be established (or existing ones strengthened) among I'Pfiltli providers and institutions? le) Is the concept of progressive patient care (e.g.. OP clinics, hospitals, ECF's home health servicesi reflected? Other ftinding (.3) (a) Is there evidence the Region has or will attract funds other than R'.NIP? II,) If not, has it attempted to do so. le) Will other funds, (private. local, state, or Federal) be aviilalile for the activities proposed? (di Conversely. will the act,ivities contribute financially or otherwise to other 'Ignlfi(:ant Federally-funded or locilly-.,iupported health programc;" 08-872 0 73 3 ADMINISTRATIVFLY CONFIDENTIAL SCORING SHEET AND INSTRUCTIONS: CD t@iW 91--P) Region Criletia -------------------- ----------- --------------------- ----------------------- Date ol most iecent %ite visit ... - - - ------------------------- A. Petiormailce 40 1. Goal%, ol;lective% ind l,tiovilies ........ . . ............................. ----------------------------------- 2. Accomplishments and inil,le- .............. I @------------------ ------------------------------ ------------------- melitalion ------ ------------------------- ----------------------------------------------------- --------------- 3. Continued support ....... ... I ----- --------- ------ ---------- ----- ------------------------------------------------------------------------------------ 4. Minorityiiiteresis. - ----- ---------------- ------ ------------------------------- B. Process. 35: ----------------------------------------------------------- 1. Coordinatrr .............. ......... I --------------------------------------------------- 2. Core statl .... ... . . - --- ----------------- --- --------------I--------------- I....I------------------------- ---------------------------- ------------------------------------ ---------- 3. ReRintial advisOlY RfOlIP ------------- ----------------------- ------- ------ ---- ---------------------- ---------- 4. Grantee eiRatitzation. -- ----- - ---------------------------------------------------------------------------------------- ------ ----------------------------------------- 5. Participation. @--------- - ------------ ------- ----------- --------------------------------------- ------------------ --------------------------------------------- 6. Local plaillil'IR ... . ..... ------------I--------- ------------- ......... ------- -- I------------ 7. Assessment of needs and -------------------------------------------- resources ---- --- ----------- ------------ --------- ------ --------------------- --------------- -------------- 8. Management --- - - ----- ------------------------------------------ ------------------------------------------ 9. Evaluation ---------- ------------------------ ---------------- --------------------- ----------------- C. P'cRfam proposal, 25: -------------------- -------------------------------- ----------------------- 1. Actio,i plan. @------------ ---- ---- ------------------------------------------------------ ---------------------------------------------------------------- 2. Dissemination of knowledge - ------------------------------------------------------------ -------------------------------------------- 3. Utilitillg Mal)POWPF and facilities @ ---------------- ----------------------------------------------------------------------------------- --------- ---------- --- -- .............................................. 4. Improvement of care ------- ----- ------- - ------ ------ ------------------------------ --- --------------------------------------------------- --------------------------- 5. Short-term PaYoH - -------------------- ---- -------------------------------------------------------- ------------------------------------------------------------------------ 6. ReRionalization ----- ---------------------------------------------------------------- -------------------- ---------------------------------- ----------------------------- 7. Other fu"ding ------------------------------------------------------ I------------------- -------------------- ------------------------------ ------------------------------ D. Overall assessment -- ------ ------------------------ -------------------------------------- E. Developmental component (If Yes, --------------------------------- -------------- ----------------- check).-. ------------------------------------------------------------- --- ---------------- F. Basis for evaluation (Check all applicable): --------------------- ---------------------- ----------------I----------------------- 1. Current site visit, ------------------------------------------------------------- ----------------------- --------- ------------------------- 2. Previous site visit, -------------------------------- ------------- ------------------------------------- ------------- -------- ------ 3. Application . .. ........ .--------------------------- -------- ---- -- ----------------- ---------- ...... ----------------------------------------------------------------- 4. Corn in ittee d@ctission .............. ---------------------------------------------- --------------------- ------------------------- -------------- 5. Other . ...... @"1.1--l .... ----------------- ...... @- -1 ... I ...... .------ -------- ---------- ------- ----------- 6. Primary reviewer ......... ........ - - -- ------- -- -- ------- -- ------- -------- -- --- --------------------------- -------- 7. Secondary reviewer. ------ ------- ---------- ----- ------------------------------------------- ling on a 1-to-5 basis in item D, overall assessment. Note: Using a I throu5h 5 scoring scale (5, outstanding; 4, good; 3, satisfactory; 2, fair; I poor). assessment of the region and its application by ra res (e. in - i to rate the region n accor ance with the ctiteria set forth below, Reviewers ate reminded consult Feel free in makine your overall assessments to use decimal sco item E, develop iie@f-ii component, it in your best judgment this region has M. tion the RMP ,iview ciitefia document (dated Dec. 28, 1971) which includes subcriteria or elements a . I in the form of questions designed to make these broad, general criteri a more specilic and under- maturity and status o warrant ward of a developmental component n in standable. These are intended to be of help to the reviewer in a n g a s@ore to ec" of the criteria. indicate for each region the basis for your evaluation. When appropri@ d t,,, done by staff; item F may be checked for each region. 'S'g Multiplic.tio. of scores by the assigned weights and the nece'@. d n will be ..ad ..I make those computations. Reviewer, should P.@ ,,. h i, overall subl@ctiv. 31 Mr. Roy. Mr. Hastings, I want to identify myself with your state- ment. I believe regionarlz'ation is the correct way to go to it. It hurts me to hear Dr. Zapp criticize it so fullv as he has. Second, I want to identi:N- mvself with your concept of bringing together the present author4ties'in order to do a bette-r job thaii"in-the past. Mr. HASnNGs. Thank you. Ilank you, Mr. Chairman. Mr. RcZ@. Mr. Kyros? Mr. KyRos. No questions. Mr. RoGEm. Mr.- Heinz? Mr. Ihi.Nz. First. Dr. Zapp. let me sincerely commend you for, I think-, setting a new' record. pe.rhaps for aiiv w@itness. I received your tesitmoily la@t night in advance of vour appearance here today. a-nd I want to sincerely commend you for havii!g made that ossible. ions I had in ended p I think a lot' of the quest t to ask- have been touched on one wav or another. There is one area I would lik b e y to get into, because' I do not think it has been specifically touc e on. That is, where CHP's or, for that neater, R.NIP'-s fit in with certificate- of-need legislation. Dr. Z imatelv 20 States. where they have certificate- of-need aries C'onsiderablv' as to honv the CHP's fit in, as to WI the bodv %vhere the State requires review and comment. or they -actually givi them review and a 'proval. p I would be pleased to Provide that for you. but I do not have that 'With me today, the chronolog,,- oi- ailalvsi's of the certificate of needs that are in effect. [Testimonv resumes oii p. 13@;.] (The following material was received for the record:] c 0- V% 138 .\II'. HEINZ. Do we mandate tli(@ dei-e]OpDieiit of cei@tificite of legislation '\-o. that his I)ee -t)l'. ZAPP. t State I tltiiik we alwaN.s said from the standl)oijit of tli(, I)el)"Il@tili(,iit that ivliel-c it exists. wewill lioiioi- it. As ,iii example. we will not c@,o :ii-niiiid :111(i ;in indii-idii:tl Stat,e where their(, has been (,(,i,tifi(-at(@-of-iieed ](,aislatioll. .LNII'. IIEI,.\z. Does the ageiicv lia%-e i-eviexi- and ;ippi-oN-,i] Dr. Z.%Pp. 11'e liaN-e :iii(I (-Oiiiiii(,iit. -Ifost 1)"])Iic ]'earth CZ('rk,- ic(,. acts provide foi- i'eviewiiid comment. not approval. 1%fi,. HEI-,Z. One thin- ('011(,(@i-lis nl(, "I.(@:itlv 11)ollt tlLl PittSI)III.(,)l area health I)Iaiiiiiii,, is i 11 i(,@eiiev established I)ack'ii, 1969 as a review-,iii(-I-(,oiiinieiit ('](,ai-lv tli(@i-e is I amount of work to I)e done in tli(@ tiid I)Illlllillqr of mk,(Iical Yet it is iioNv 191-:1. (YO'Ill(r Oil 11)74, and tlie-v do little if anN, planning. @%at tll(,.N- (lo is the.-%- sinil)].N- iiiale comnieiit iil)oii proposal,- tll:it otl)(,i- I)Pol)le to them. Tli(,ii, coi-nniviit cqii never I)e fi,,ini(@(i water,, the constraint Of sozii(@ kind of niastei- I)eeiiis(@ there 'IS 110 plan. I was woiidei-iii,., if had foiiii(i this to 1.)e a problem ill otil(@l. CHP t-% .I)e B the coiliiti-v Dr. @,-App. T thin], essentially voii coii .Id that of most CTTI) (11) ,,i.zeiicies. Their interests diffei- from to is R.\IP's (lo. It l@ triie in iilort (-a.-Ps tll(@ if it exizts. li'l,.; not ('fotteli 1)(@v facilities or niiiil)oNv(@i- I)iit the in i-plation to tli,. delivei-i- of sei-N-i(,Ps qii(i fa(,iliti(@ is ;t ,t(,I) I)evoiid what tli(' CHI) B i(,encies li(iN-(, (rone to. I-TET-, z. Tli(@ i,(,,tqoii I that Ill). of cotirse. is b(,CIlli@(, the effectiveiipss of ('TTP'., is ;i issii(,. if. -is oii propose we (YoiiiL, to 1)llas(@ olit 'R.\fPs. I h,,ti-e ;I ('01111)litel. ])]-illtollt of some eXI)PIlditill-(@ Wliicll 11IN- looq] R'.\IP ill tll(@ pI.o(lllc(,(]. It is:i of ]'%'\Ill flill(lq Two of tlit@ ;II.(. iteiii ;Ill(] Tti,tli tl()fll (-ol'(- tl-.iillili,, :111(i e(Iiication. IN'olll(l 1-nii ('011si(lel. tIlos(. (.0st items ill the T stil)l)os(, ti):it tliii@stioii slioiil(l 1)(@ to I think till@N, ill til(@ I)]-. Ziipp TTI@T-\Z. 'I'll;lt \N-oii](I 1)(: iii tl)t@ fi@,iii-es oil pa(,(, i- 01' of voiiy- ? i)r. Z-%Pi,. That is coi-i-i@et. ]-'ol- the in we@t(,i,i) R.\TP. the @77s'.000. Tli(@ CO],(, ])I-ofessioiit] tr@iiiiiii,_, @4:1-s'.O()O. :amid ill the otliei- finite Were r,574.00f). Tiiis \@-oiii(I tell(] to stil)l)oi-t fi(@iii-c that ;I Iii('ii I)I-ollot., tioii (lo('.-; _,o iiito :i(Iiiiiiiisti,ati\,(, (costs. and @-oiil- iiijilil)(-I. i@ I do not kiio\@-. 1):ise(I oil this 01)(@ itf@Ill. It nii(-,Ilt well I)". I must six-. front wit]) 111N \N-itil tlieii- efl.ol-t.@ to (lei-(,Iol) soiii(,tliiii(,, HFll' li;is ii-,, iiiii(-]) li(-Il) Nvitli. -iii(I that is -.i mission in the p 139 iiiil)lenieiit.itioii of ,iii RI[P coiicel)T. tlipi- li;i@-e (iolie sollie (-,ooci t iiiiist s;ix. tli(, dic:(,ii@sl()ii to(ii-,- li,,i-z iiidicit(,(l to iii(, tli:it I-IEII'. I tliii)k. coti](I (Ioiit, iiioi,(, to e;,,cotii-a(,,e It"\fP's to (lefii)(' tlieii- ll)iS;ZiOlIc: Oil ill t]IL@ tlit,l-e i,- ]lo (1011I)t tli,,it tilt, ;I(.til-ities It(-k(,(l fociis oi-oi- i pei-iott of ol. ]poll. vt@,il-z Ill(] tli-,it Nl-(, -,iliioiiiit of ilioilt,-,. I it iiiaiix- Iiei- t Iik!N- sr @ II t to.I'lizitil@ N.oti. Did the I)II:lQf.ol"t to Ill of tilt, iiii(I is tile ilifol-ill:ltlt-)Il oil r;l,. (I:lt(@ '-: tif tll(), @(, ]lot I-'L,@ Di-. Z.@i,i,. -Noti(,(,.-; NX'(Izlt ollt tit nil I oil Febi-iiii,A- 2-1. 1 ;iiii tlit-i-i, I)L'tXA'et'll siiiee that ti 'riie i iti:il olit- N\-t, .t ()lit tit(' iiie. n I I siil)lnis-@ioil of liis SY.-,[I-,(;ToN. ll']I;lt tilt, fol- tli:it 110 -tltiliol-V 1)(@l- SL' tji:lt lii:kl-. IN'liit %\.,oillkl to 111) to .1@tilliii-N t'liit W(, I!)74 t I'I)lllllltt@. r)t I I- tilt, Ititllol.;tx. \%.,)Il]Ll I)(. to Oil .111111@ I')7:',. ;t-z it Ill f: t,) tit(' I)(-ol)lt' iiii-ol%-(.(l ill tilt. I)I'o- fol. I!l I I)I-ol)OS,-Ij tli:it fol. ill #if illolitll-:. iii(ii(-ate-@ tli:it I".AfP's liot cost (@tl'ectix-e Iil(i tli:it N%-olll(l ttk(- @otiii, sttt-.IN- to :III([ oil(, of tli(- NN-e wotilti 111@t, to kiiox\- is. ljo%@ j)jziiii. i)t@ol)le I)o x-oil of tli:it k-iiii.1 f Di-. Z.'Xi,i). I iN-oii](I jlf)t oX]lll:tteIN- :@ll I)t@i-ci,iit is lise(I foi- tile of N\-ollitl to 1-t-ft,t- to 1)1-. if tli(@v li;l\'t, tilt! li,,rlli-e-z oil the of' 1):itit,jits I'lill Iii,,Ii iiiii-ks to tliiiil@. tile N-oti lice(I -,i tilt-ill lii,,Ii Ii it tile 1)('Ol)lt@ ili:tll)lt. of tit(' of.@,iliizlitioii tlii-oii(rii a i(@t\. of ill(.Illo(Is ill(.Illtll.(l @it(. tilt@ IN-,IV ill Al-lilt-li \-Oil ill@t itlitl,)Il:ll to Wil(Itli(-i, tll(@ p@All' @(@t I foi- it@t-If ill-] I)I.Ojvcts to Ill('(,t tliit I f(,It the ])I-ol)lt,lllcl Of' (@(111;11 (,Iil)oi-riiiiitit@s, II'(, tool@ i look it the 0 tili@ t,x (111-ilitA- of til(. (.Ool-(Iijl;lt )I.. tll(@ A\-;IN -,ilii:ltioii w:i@ olit. a o,f AA-(, coiiltl. 140 \oil (-oiii(i siil)l)]\ ft)i- tli(@ i-(@coi-d a i-@stilli@ (%II that al)l)roach. II'(, in,oiild I)e ,-rlad to. [See '@Re\-iew Ci-itei,ia aii(i @,,itiiig @vsteni-Re-ioii,,il ',\I' p- edical Pro. 23.] Do voii kiioiv lio@x. lll@iliv (loctoi-,.,- aiid iiiii-ses i.e. ceii-ed coiitiiiiiiii@r edticat .ioii tlii-oii(,Ii tli(@ R.\fP's? Di-. Af.%iRcx-i,iFs. '\ot offliiiid. ,\II'. SY---[I-,GTO-,. Al'Oll](I'VOII Slll)l)]N.tlllt ? Dr. Yes. [Tlie followiii(r iiifoi,iii,,itioii was foi@tlie record:] COURSE REGISTRATIONS IN RMP-SPONSORED EDUCATION ACTIVITIES FISCAL YEAR 1972 (LISTED BY TYPE OF TRAINING RECEIVED AND DISCIPLINE OF RECIPIENT) New skills Total Continuing for existing New Discipline education I personnel 2 personnel 3 Number Perlent Physicians (MD,IDD) ... .............. 46, 328 10.140 ...... 56,468 29 Dentists ------- ..... .... ......... 1. 442 197 -- ----- 1.639 1 Nursing personnel-.. .............. ... 36.301 25. 072 146 61,519 32 Allied health personnel .. .... ...... 23,011 12, 362 1. 205 36. 578 10 Hospitallnursing home personnel ---- 10 414 694 11.108 6 Medical. dental and nursing students 6@ 106 1,139 7, 245 A Other ... .. ....... ........ ....... 8. 582 9, 579 1. 19, 225 10 Total ----------- .............. 132,184 59, 183 2. 415 193.782 100 I Continuing education-courses aimed at maintaining or improving the level of practice of the health professional, 2 New skills for existin oefsonnel-training aimed at enabling the person trained to assume new responsibilities in the already chosen career field or addinf skills in a different but related health field (e.g., coronary care training for nurses, career mobility for licensed practica nurses). INew perso'net -development of training programs for such new categories of personnel as physicians' assistants nurse practitioners, and community health workers. If iiiii-se., wei-t@ i-e(-ei\-iii(r (-oiitiiiiiili4,T education. liaps.tlieii iiep(l to ,;ee@- ()tliei- foi-iiis of siil)l)oi-t. atid I \\-oii(it@i, if I)i-ovision wt.,- iiia(le to lii-11) tht@iii (-oiitiiiii(, Dr. I tllillk' 111OSt ('olltiliiiili,-, e(III(@,,itioli of ]lilies t4),)@. )]"Ice ill a lif@SI)ital S(@ttil)(,' Ill(l to \\-Ii;it tlien- woiild (r(@t. I I)elieN-e that l@iii(I of iiistitiitioiizil stil)l)oi-t \\-ill still I)e "fit (I call I)e exl);ill(le(I fill. tli;it I I tliiiik 1 i-,iii :,tibiiiit tli(@ lliv (iiiestiolis. Olle (ille.@tioii woll](I I)e tliqt Pi'-\IP i@e\-io@v NN-ei-e first (leN-elol)(@(i oil 2,s. 11)71. I.,4 tll;lt ti'lle, tlllt i- trial date ? YOS, sit'. 'I'lieil there NN-;is I ('(')Iltl@;lct 1)1-. Yes. We are studviiig tli(@ effectiveness of those I-t-- %-iew ci-itei-ii. SI-AIIN(;To'%. Ill Otllel' A\-Ol'(]S. I.oil !II-(, stti(lviii,(-, the of the ci-itei-i;i aftei, the (](,(-is'oii t( tei-iiiiii;ite. )i- did the vil of tli(, ei-itei-ii oceiii- 1)(@foi-e tli(- were i@ ii(@(I 'S 11'e S('t tlllt ',I('ti\'itV ill 11)OtiOll It I tiiiie N\.Ilt@ii till. fill] ol)ei-:itioii. ]it tiiN' case, I tliliik it is a iisefii] kiii,l of tt-cliiii(itie wlii(-Ii 11 ee(l-, to 1)(, stil(iii@(i Iiiv cii-eiiiiistii1f.t@s. 141 .Ilr. SY-III.VGTO-\. Do voti k-iiow if aiin. of the ei-iterii cliaiiged Dr. -NIAPGL-LIES. '-\-o. we kept tlieiii constant so we could cai,rn- out all effectix-e If we tlieiii %-ell%. ii)iieli. it x%-oiiltl I)e (liffictilt to ililll-z'e tlieii, ;Ali-. SY-%I I N(;To.N. Is t II t@ (.o II)I)](@te Dr. NIAR(;I-I.IYS. -NOt %-Pi. -Nfl'. SY-NfI-NGM-,. Biii stifficieiit]3- coiiil)let.e. to,,,(@tli('t- NN-itli o+)iei- Coll- siderations, to jiiztlf%- iii N-oiii- iiiiii,l t,,i-t,illilttill,r flit@ i@le:l @is It is I part of the iiil)tit III the tlecl:slt)ii ? Dr. '-Z. Tlit@ ii:ze of his (-oiitiiiitt.(l l,tit. iii the I)li;iscoiit. acti\-itx-. we lia(l otlioi- kiii(14-z of coii4-zi(l(,i-ations \x-ei-c iiial)l)lical)le to tiii.@ k-iii(I of ti-c)iiii(ille. .Ali-. Ro(;Fizs. l,et iiie ask ;I few (tilt@@tiolls, I t:il@(@ 1011ILr. You did i-ateill tli(@ It.IIP's bx. tlle"ze L'I'ltel'll. .Ili-. RocF.R!z. ll,)N\- (II(I \-(.)II t)lt-ill Di-. -Nfl'. RO(;FttS. I)id i-oit ii;-zL, A. B. oi- C Di-. 'kilel. were listi@d iii tlii-pe (.,i-otips: A. B. -.I n (I C. ('@XR-1-YP. ll'I'I;lt %\-otilt] @i of :')2:, iii(@till ()fl'liziiid. I doii't i-ecill. Pi-ol)al)]N- the 13 I ani iii)t ztire at tells iiiolil(,Ilt. Ili-. Ro(;EPS. 11'ell. ]low lil;tlln' "lot)(I 01- [()W 111,11IN- Avel-e ]lot ? 1)1'. I tliliik tli(@ Izi@t iiiii(, we it. tli(.I-e %vei-e "I)oiit 14 rated "C.-' Hill-. RO(;ER-A. Otlierwise. the 13 -,iii(I woti](I gi(riiifv tire\. NN-ei-e @ood or excel ielit. Dr. NIAR(;UI.IYS. I-es. Sill. RocFR.,;. I A%-I]] siil)iiiit tlii..; foi- tlit, is votii- rqtiii(, of tlieiii AvIliell Nv;ls llll(le less tIl'all L'oO(I. t)lv Otliel's tr()O(l )i- ex(-elleiit. e S isa I--,, i:liik iiiv state- II)ellt I)oilite(i olit tl Ill'- RO(;EP-1. I i%-;iiit to kiio%%, \\,Iizit \\-@is the foi- the (1@,CiQloll to tei-iiiiiiate a I)t-o(reaiii witei-t@ \-oii li@i \-e iii-zt i-ate(I tli(@ x-;i@t iiiijoi-itv of Dr. Z.ipi.. I ill, iiixioiis to tlizit (itiestioii. I woli](I tliizik vou I've :I pi-o(yraiii tliit is 1)ez-foi-iiiiii@, A\-ell ill- ;I Si,-riiifi(-,ifit iiiiiii))er' of. tilose ii-eIL)ez-foi-iiiiii,r well ])tit tliztt (I(ies iiot iiieiii the Federal Crovei-lillielit@sliotil(l coiitiiiiie I(.)t-) fiiiid .iii(r of tliit P-, I)rocri-ai)i. Tlipi.e (,,ill I)e ;I v;ti,ietv of i-eisoiiq @i-li tii-,it pro"]-aiii-iii this ('.'Ise lott tz-e t;ilkiii(-, of ;I v;ii-ieti- of ils oii i iiatioiiii I)asis- shot ot 1.p(.eive ftii-tliei-stil)l)oi-t. 11'e ;iz:e s;t.N iiig. fi-ojii the st-iii(lpoiiit E'xl)eiidittii-(-s iiiti Fetlei-a'] I)III'I)oses. it i@ ]lot j]iQtified to coiitizitie treat t@pe of li:itioii;ll L.111V of the (-oiiil)ozieiit.; iii tiioize slioii](I I)e (,oiitiiiiied. till@nk Coji,,z-(-ss liis i-Lsl)ojtde(I iii the I'ast couple of vf-,ii-.q to iiiniiv Of those iiaiiie tli-,It tilen- lllx-e ill tile ceiitei-s, for 98-872 0 .-,3 - 10 142 (,oiiti-ol I)ro(,raiiis aiid lie iltli it 'is ll:)It:ljll-t tile 1)1-01--,,-;klil@ ll:iN,e I)erforiiied ;ii-e iiot I kill(,- tli:it of t)ielii have, but iii;tii\- lia\-(, iiot. Rix;yi@.,. 'I'li@it \\-oll](I 110t Sk@('111 t(@ 1)(@ tile till'IlSt Of the testinjorly t ll'otil(i N-oii vie](I -Ali-. I Avoll(it I@ )low. iii tlit@ liv;ti-t, stroke, aiid kidnev bill we c;lli ]five tile ol,@,,;iiiiz;itioii ;iii(I the 1)li-%-sici-iii :issistaiits. patient 1111(l C()ol.(Iill:ltioll of ]@e(,,ioiial r esources, ]low (loes tli:it to '111(t sti-ol@(,@ Those -,ire the I)iir. :11-ONV(@(I 01' :1 I)al.ti(-Ill:ll. I))-. I N\.olll(l Ile to i-ei(I t)i- I)i@oN-ide foi, tile I,e(lol'il. tiiii(@ :I 2@.',-I);tge (I()(-iiiiieiit \\-Iiieli I)i-eaks doNi-n by tri,oill)s tile \-:Il.ioils till-list (-)f 1.111),s st;ii-iiii(,, N@-itli 1),iti(,iit call, llo\,:Iti()Ii ()I, 11(@:iltli i-.ii.k@ ;ii-(@ residual 'kiltliori. \\-itliiii tli(@ I)el);ti-tiiieiit. .Nll-. 11N. I-t,@l(Illill (It) \-(,it :I I)i-oa(l atitlioi-iti.? 1)1'. ZAPP. '\O. 11.(, ;;Iltllo,l,ities we II-( 1)1.01)osillL, foi- ext(,Ilsioll oil wili(.Il (.ol)tlflll(,. III otlit@l. :111 :Iiitl@ol-iti-'tll;it woiil(i (".K. oil .11111(- :"(I. we ;il,(@ fill- (-Olltilill,'Itioii. I tl)illl@ it \\.all to tli:tt fol' the ]@eeoi-d. I tliiiik it 1)(@ foi- '\-()II t(i (-I@ililloilelit-, IN-lii,,Ii will (.(Olltiliiit@ :I(.tl()Il if) tile (if ;"'(I till, fiiiidiii(,r all- tli(.I.it\-. Ct)lll(l \.oil let ii@ that Z.\],),. )'(@S. \\'(@ N\'()Ill(i Ile ill (lo tli;it. I tl)iiik we have, that fill- the record:] ;IL.-iiisis iiji ir(-. Tiii- I it@-irt ;lilt] iii tl"lfi"ol f"l. :it -iiiiil;ti- tio ;tt-ti\-iiii@s siiiiii4)t-te(i ii.v lte,,ii)ii;ii ill lilt, I,:i@t. fi-;Iiiliii@. :trial 143 f I,,, -",,-j,l I ,Z. ('11 /'it !/ I)'I, )"] ,, , IIIIt] k' I' rt,it;ti 1-ility r;i I tllt;itl..ll :tlitl II I; iiil,o tl Eioit .1 il, flit-,II Sil't' ))I'- :Iii4 @vsteill, Avill lot! siiltlw,irte(I iiiiilt. I- tlit. f ti,.ii :',4)4. (; /',I 11. -t Ill. -f,,I- //, it-)-A v;iriet%- i,f 'I'llit -:iiiiilit! "I -liTs oil' lit,:iltli :li(It I -S. I-: :1 :1 lit II. 'I .if tilt. It.111, *,ff,,rt lit Tilt- -ivvr 1,@- tlti- ,,III,. 7.4- t lit -:I I It-;Ill 11 I, I, ftol,/ :',114--A v;i i-it-ty if -,I lit iliz;t tell -f fill Ill,- 4.1. IICNN' tylit.@ .If f-ir lit- .If flit,/ .or till, tyl,i. 1.@ IC.NI I' \\.ill lit, lov t I\'. CON'TIN'X:I'\G FI)I'C.%'rlO.N OF F',ISTINr, H@:.%LTII If(-filth - E,Iiir(itioll I)Iifi,ltii-i- .1 i-4-llr,,ji@(.t!4 siii;il:i r tll-lse sul)l,,.,rte(I 1-y RIII ' lir-,iiititiii,-, ri@,it)ii:tl \\Ili(.II tilt! -,Cti\'ities of ll(,:Ilttl lio!4 it:ils -Ili(I lit,;iltli (-:trt- -li@r ti: Ill,li\'ery :irt- iiii is :iiltllfll-it@- til V, IIF.ALT]L @F.RVI('Fs ttF.S@:.'%RCB 'L.Nil I)t the activities stil)li-,iteil I tlit, ;treat iif lie;tltli (It'veloll)Liieiit t-;iii I,(, fiiiitli@il iiii(li-r tiik, 304 ;iiitlit@rit@-. VI, PRor.R.,L.\[ -('ORF:, ,TAFF ACTIVITY A- Cri)iir)rrhc?iiii-i- ]If,(ilth plol)l?lioi!l 314 ;I Itt:ttt- ('HI' ill%",Ivvll witli 'I V.11-ii-ty off jiiiilt iiivillvt- witli li;irtit-iil;i 1.1y tile I-lt.;Iitli llii';Z :Igencies. It I, e-\I)t-i-tk,(i tli:it tiill(,.Il of t it, fill, :I(.tii 111) 1),@ tile ('111' 144 Lg@Ll@aL@!t)Lqries-Section 397(a)-some of the RMP suPport B. RCgLotl-a 6,li@@iiieationandinformationsysteinscan -'for c ervice., sticil as e id@,il Nledical Libra ri@s. "\II'. PIOGF.RI. Also. I .voiild like copies of the telegrams sent to the directors of tllt@ 1-(,(_rioiial medical I)I,oat-anis adi-isill@ them Of termifia. Iv for the record how tioii. Pleas(@ siil)pfi that foi- the record. Supp . , the decisii)ii wis made ,iiid who. b.@- name. made tile decision. I Avoill(I like coi)ie., of the memoranda jtisti-fving tei-iiiiii-,itioii so that. iii recast- e A@ill fiave the I)enefit of vour revieiv, iiig the legislation. the coiiiniitte -also for the record. I)le,,ise stibniit the review of the re(,ioiial medical programs ,iiid cive iis what voti see taking place iii these programs aiid its fiiiidiiig. I Nvon't 1)iirsiie some qiiestioiis I was goliig to ask of Dr. ',LNIargulicq. I thiiik we ii-e cleai- that voii did have the gi@adin(, aiid we have the results of that. Yoti will fet. iis have all tlie-critei@ia. [Testiinojiv ),esiiiilt@s oii 1). I(;2.1 [The follo'wiii(,y iiiforiiiatioii Ai-as received for the record:] 145 TELEGRA@)ilC %kESSAGE DOE'.r, ?HS, ES,:'A, Regional @edical A@ Progra=s Service 3-3?71015 753032@ 23.6i Feb. 1. 1973 Gerald T. Ga:,dell@ THIJ $PICE ION tSi Of CCVXL.I/C@TIO' U.IIT .ESSACE TO If T.@.S-,niD 'LI, TO: TO kLL iL':'S PER A-LIACtir-D L-.57 THE M-SI:)E,T PAS SUBX-,=--D HIS BLDCT-T PROPOSALS TO 7t!F CONCRESS. ViILr THE i'IOL@, FOR F-.S,-AL Y--,Ltt 1973 FOR P-@L-5 C.@,':S X;D CC;-,.IAC:S IS AS $125.100,000, AC7UAI. Al.'OVI7 AVAT@LT- TO THE PRCC.@ll FOR G7,@iS 'LiD Co.,;,-?-AC-ls 7.@t- Ptt--Sr-:@T F@SCAI- Y---;,R IS $55.358.'@0. ACTL:@ REUUCTIO.1; Is; '.FT- L-Ot7,T AVAILASL7- IS DErAll---D O, PACE 38" OF THE A?pr-:;DIX: TO T;-;--- 0----ic:AL st:B@,iss:r,@,. YOU ARE T?@- '-A;E 3E7:,' O?TRA-.T:,C L@r.:t A C -SC' --.C E-L'LLY I.'I THE FISCAL Y@, 17 !L'Ts '.ER: -@,.DED :-OR @NOT'.-.7-R YEAR ";ITi S,:.@, 5 DATES 0- 1, 1972. I',' I S'.'-AS rOLLC:@7E:) 3Y @::D 0- DECE:3r.:k -ro IS Lk, ?s ,;17.i START DA-,75 OF IA:;L,,LltY 1, 1973. THZR-R RE@!AI.1; 'IT:! AY 1, 1973 START DA::ES. 21 IL,?s BY TELEC@,T Oll DEC---@CBr-@ 29, 1972, 1 ADVISED THE 18 R.15s WITH JA.;UAIY 1 START DAT=-S OF -!HE AVAILABLE, THEIR X.,A.US VERE At7,HCR-.Z--:) O:;LY -,E.@OI:C;i JL-,E 30, 1973, r,7.\,DED AT CNLY HALF THE AXO'47;T ES-..A.:,--ISR:D yet 0,;-- YEAR. SIMILkuy -,;ITH THE FLNDS AVA.!L- ABLE @'E :)r T;: T-:i- 21 I-kl::T@NC S 1 -.i ,@y 1 c@. B-- 4 146 TELEGRAPHIC MESSAGE C. Cll@, .4LIIC.Tlol &.SIT Jl;iE 30, 1973. pREs-.,)E:,,rls BLDGET REQUEST FOR R.'!P ll;o C.@T FL-,DS ll%CLI:DED 1.4 THE 'DS PROPOSED THERSTORR, No _@D!Tlc,4A.L Flr TO BE FISC,KL YEKR 1974. @Lo-- A'@'ALk3'-E I': FISCAL 1974, A.ND WITH THE LI@!ITFD FNDS kVAILABLE rLilS YEk@, T-,iF ABOVE F,@@'Dl'.qG DECISIC:;S @IADE TO AVOID In- POSS131LITY: T!SCKL YEAR 1973 is ORD--,.k TO TREAT OF O'.--T:@ ALL 56 @:?s AS Elt:ITABLY AS POSSI@@L-- k.';D AIT--@2T TO PROVIDE F@.@r)S TOR @:DST CR---,-@CAL :SC.;,,- 1973 G.@N: A,A.US WILL C:; @L7;r- 30, 1973. IT FOLLO'.,'S, 'Z'@- THE 17 GF-@,S A@,'.ZaDE:): --C!'-C 7 - D r-r @,'.@S @rD, G- AS ? R 1 PERIOD BY :'.'.\DS. AS SA.7-D ABO,;:, O.4 :@-Z 20, '.973. R:!7 IT IS OL'.k -.0 PE@:IT G.RX;T @x BT-yc",D jL7;r- 30 BL7 TO %,C: B-r EXC---?-. AS TO -.3 0- TRZA'N: -,H:S :CL'LD ST- -.0 A"-'C'2:-.- B 2 147 TELER,RAPHIC MESSAGE Li TO: :T!tL'!L%iA7--:) BY .!A- ZA7--- -.o :;--7D ?L'B'-ISH E-,C. ',?C" F Bt 15, 1973, ? s 5 or AilA@s '.@.:C,;! C.;:; -o TEC t-'ILL :@OT 37- AB'-- SY YCU Br---,kCET 07 :H-- C'-' R? Br 15, rdk'i !C-.C-,! 15, 1973. PLA.': Rz:.U:, I. Do .CT ACTIVITIES OR R-rQUIRI'@'G FLI.':)S -;:'.AT ?@0:"C-- A R-RSL'LT Jt:S-,17"-:;G :)R 3. R-rQt;--sT su- OR: 7CR 7-ss7@;T:r.L -S ;7-ir-RE A 148 TELEGRAPHIC MESSAGE TIPE OF FOR I.FCI..'!O@ CILL n El THIS JP@CT FCk LSE Of CO.M.Ilt.'[C.4TiOl L@'IT .ESS.rf TO St "",-I TO: IT IS R-RQLESTED TKAT YOLR PLA; BE SUB@RITTED L4 @'RITI.';G, kCCO@[P@IED BY PACES 1, 6, 15 and 16 OF THE APPLICA-10'; FO'.LI 34-1, FOR PHASI\'C Otrr ALL R.I(PS S.:??C-,- BY Jt7;-- 30, 1973, AN:3 A ?7-AN A!:D SE- OF FO;L-IS FOR ,kCTItI-.:T-S ?:LO?OSED FOR CONTI'.%'CkTIO@; BR-YO@ZD JL\E 30, 1973, BLT I.,' "NO EVENT B--Y';:,D FL3Rt:A.kY 15, 197.. MAY I ALSO YO'@ T.'-kT YO'@'R PL@,' FOR Pi:-kSr,'@' O'@'T OPFRATIO.'@S ILST INVOL%-- l@r- C.@'-NTEr- OFFICIAL A:;D THE @'S I,' ACCO?@';CE '.,'@T.4 !HEI.R RES?01;5:3:'-:::---S DAED A'@'CUS! 30, 1972. STAFF 1% THE DIVIS:OL OF O?r-.-@TIC.'@'S A:;D DT-'.---LC?:.-Z;T ARE A7.AILABLE TO CO.N;SL'LT WITH YO'-' P2-7?A.UT:ON OF YO@R IT IS '...-Dr-R @-.-.S -;-,LL SE RECEIVED I; F.,L-S BY ';o LATER iL7;7- 15, 197-. I A.'! S.-Z 0- Y@,"@' -,@E LlGw- OF T7'.T- PR-rSI:)@-'.;T'S -10 OF PF.ASEOCT 149 DEPART%I.ENT OF HEALTH. EDUCATICN. AND viELFARE PUBLIC HEALTH SERVICE HEALTH SERVICES A.%D @!E,4TAL HEALTH ADMINISTPAT:O.'4 AC-CK@.LLE, 2.0-2 Fcbruar)' 22, 1973 RE5tON L &IEDIC-. PROGRAMS SER@:CE TO ALL RMP COORDINATORS AND G;L'-,iTEE OFFICIALS 7he.purposes of this letter are to refine and clarif@. points in the telegra,3 sent to Nlou on Februa-v 1, and to provide you with as definitive information as is nossible at this time about (1) current plans for phasing out both indivic!u.3, Regional Medical Programs and the Regic.-.al Medical Progra:--5 Service in accordance with the Ae--7.iniStrat;on's budgets for FY 73 and FY 74; (2) the process by which phaseout Dla-is will be reviewed and the criteria to be e:noloyed in review; (3) wliat additional items of info-raticn 7.,ust be submi-,te@' by each Regional kied4cal P.-og-a--, at the time it sub-i4ts its phase-out plan; and (4) a--:)rop.-iate regulations and policies for a number of specitic issues wnici -ia.-iy or all Regional Medical Progra.-.is face and about which a nL7.ber of questions have ariscn. 7hese topics are e;scusseL'. below in order. 1. Because no funds for Regional Medical Programs Service have been requested by the Administration for FY 74, a phase- out plan had to be developed bv Regional %Iedical Programs Service for the Office of the Administrator, HS@Ut,, and a maximum termination date (February 15, 1974) set for the Regional Medical Progra:-.s. Irned4.ately on receiving approval from HSKUM for this plan, a teleg-:@,n was sent to you on February 1 indicating that each region should sub,-.it two written plans, one "for phasing out all Regional \Iedical PrograrLs Service support by June -,O, 1973, and a separate plan and set of forms for activities proposed for continua- tion beyond June 30, 1973, but in no event beyond February 15, 1974." Following the telegra-m our staff has received many questions, some of which lead us to believe that possibly some inappro- priate interpretations have been placed upon the February 15 date. Ibis is an important matter which I i.-ish to clarify in in the event that any region is proceeding upon such an interpretation. The February 15 date is merely the last possible termination date for any Regional Medical Program, in that no Regional Medical Progra-4 Service funds can be expended beyond then for any purposes except where funds 150 previously were obligated under contracts which subsequently are pproved during the forthcoming review of phase-out plans, or :here otherwise specifically authorized bX Regional @tedical Programs Service. Apart from any consideration of how much money may actuallv become available for possible redistribution among Regiona1 @ledical Programs to support extensions of approved activities beyond June 30, let me emphasize three important points. First, approval by Regional @ledical Programs Service for the extension of any proposed activity beyond June 30 depends first and foremost upon the ability of the region to demon- strate fully that any activity identified for Regional @ledical Programs Service review is meritorious and meets one or the other of the requirements (02 or #3) stated in the telegram. Approval will not depend upon whether funds might be available within 3 Regional kledical Program for its support beyond June 30. (Note: To meet requirement N3 the region will have to provide a written guarantee, or equivalent proof, that continued support will be provided from another source by a date consistent with the needs of the project.) The second point is that support of program staff beyond June 30 can be given only to the extent that the work to be accomplished within the Regional @tedical Programs Service- approved phase-out plan for the region including completion of required final reports, clearly justifies the proposed staff level(s). Although ever., possible consideration will be given to circumstances which rav be unique to a given region, the Adrinistration believes that the February 1 notification of phase-out constitutes reasonable notice to all program elements. In a parallel action and consistent with this philosophy, the Department is requiring a sharp reduction in headquarters staff by this June 30 with further reductions scheduled thereafter. I The third-point is that no advance assurance can be made that an)- regior. will retain at least its own unexpended balance beyond June 30. All funds unexpended as of June 30 will be available to Regional @tedical Prograr.Ls Service for disbursement or redisttibuion in a manner to best iinvlement the phase-out of the overall vrogra.,i. Some regions ri ay voluntarily terminate their a ctivities as of June 30, others undoubtedly will be required to do so because of an inability 151 to meet the criteria set forth for requesting extensions of activities. Thus, in vic-.c of the uncertainties, it is our judgment that Regional %Icllic3l Prog.-a..@ should realistically consider June 30 or soon thereafter as li'hely te-.ninat;@on dates, with perhaps or.1% t..c Regional @led;cal Progr37, under exceptional circtl-.isances continuing its activities into FY 74 for a limited time. In no event can grant fjnds be used for any purpose, includ;ng preparation o@ final reports, beyond Februa-y 15, 19@4. In stating these considerations we in no wav are attempting to anticipate either wlia- an@ g; ve., Re;; ola Vertical Progra:r,'s phase-out plan will be o,- t'@e merit thereo-7; we do @4sh to inform you for your consideration a- this poi- . ..il ,n t@-.e realistically what we see fro-.i our posi-,@or. in 2. General Critcria fo.- Re@.,;e% o-.' Phasc-o-j-, P3ns and to be E-irloved. Each region's plans will be reviewed thoroughly b%- all a.-Dr3- priate senior professional staf;, -with and analyses made of ke.%. elements both for -eg4crs and across the en-ire prcgr@7. relat;ve to seek factors as proposed costs, timetables, s-.af-7-.-.9 le,,,cls and ius-,.f4cati,-rs for those grant and contract act:v@:ies ;.nicn arc -e-,ueste@@ for continuation beyond June 3@'. 7ht merit of a region's proposed activ ;es will be dete=ined in he light of whatever can be o@,ta-,-el @ro:7. records for that region 5:-o:r, Review C@-nittee and Nat;oral Advisory Council del;@bc-ati,@:is which bca- upon the subject, together with an independent staff assessment o,7 ;-cw well the phaseout plan meets the conditions cited in the telegram. It is expected that all t.-ie infor,-.it;o-i re-,ui:ed to arrive at sound decisions nay not be available to us from our records or from a thorough study oF your plan. 'Pie.-efor@, should further information be needed telephone calls will be place' and, as dee-,cd necessary bv the Director, visits to the regions will be arranged. Visits will be -nade fo- specific purposes which will be clearly identified and discussed in advance with the region. In the limited tire available we will be requ;rcd .to utilize both our staff and our pro@css;onal discretion to the fullest extent. ',Iajor decisions rzdc b%l Regional S!cdic3l Prograr,,.s Service as t!ie result of rc-.,ie-@in'g the plans of the Regional @ledical Prograr-s ccrta;rl)- will be subject to rev@ew by IIS@ULA an! the Departrcnt. Such reviews will be conducted as CxPcditiou-,;I@, 35 possi")lc so that decisions can be trans- 'Oittcd to you n@ later team April 15. 152 To assist you in preparing your phase-out plans and to assist us in reviewing them prior to arriving at final funding decisions, attached are three sets of requirements we would appreciate your incorporating in your phase-out plans.-- Sincerely yours, ix @ Harold Margulies, CDl Director Enclosures mm 153 ATTAC@IEI;T 1 REQUIR-.MZ.;TS FOR TFE JL.\E 30, 1973 PLK@S TO BE S":BX:-;T7-D NO Lk-iE.k TIIA-N @',.kRCH 15, 19-,3 Fifteen (15) copies of t.-ie following items are to be sent to Regional @ledical Prograras Service, Room 10-12, Parklawn BL,,'-Iding, 5600 Fishers Lane, Rockville. @',a-vlan@' '0552. 1) Page I of Form 10'.P 34-1 2) Page 2 of For,-r. MP 34-1 3) Page 6 of For-. ;LI? 34-1 listing staff on dutv and date of departure 4) Page 15 of Form :Z@'2 34-1 for each operational project now funded whether or not support -is being requcsed beyond June 30. include in le'c hand "Progress column, infcr:n3tior@ on status of- project as or June 30, i.e. , ccm?letc@'. ter-.ira:ed .:@t@out completion, co-it;.nua@-.or, under other a---spices, etc. Also when possibe, ist accomplis@.-.ie-is of project. 5) Page 16s of Form !LI!? 34-1 for: a) total budzet for your current budget period through June 30, 1973 b) program staff budge@ c) developmental component, if any d) each operational project now funded 6) Concise narrative describing overall phase-out plans including information regarding ste:)s taken to comply with equipment accountability, financial reports, record retention, etc. (See Attachment 3 for details.) 7) Please list feasibility -studies, amount of support under current award and statuF as of JL-ie 30, 1973 (i.e., completed, etc.). If possible, we would appreciae a brief description of the studies. In addition, lisc central resources, amount of supper, under current a-wards and proposed disposition of materials after p@ase-ouc. 8) Finally, list activities suppored u:ider develop7,eital component, dollars invested under current award t!,.rougli June 30, and a brief description. 154 ATTAC@NT 2 ILEQUI@TS FOR PiiASE-0t,T P@N'S DUE No I.ATER 7"N @Oi 15, 1973 FOR Fr.,_DS R JL\E 30 Fifteen (15) copies of the plan are to be sent to Regional Medical Progr@ Service, Room 10- 12, Parkiawn Building, 5600 Fishers Lane, Rockville, Haryland 20852, and should include: 1) Page 1 of Form RMP 34-1 2) eage 2 of Form RMP 34-1 3). Page 6 of Form @ 34-1 listing names of any staff for which support is requested, description of functions they will perform and termination date of employment (no later than February 15, 1974). If funds are requested to enable staff to be supported from other sources, include signed agreement regarding future support. 4) Page 15 of Form F4MP 34-1 for any operational project or which support is requested beyond June 30, state the reason for the request. If it is for requirement 02 outlined in the telegram, state the results predicted, the specific date the project will terminate, and significance of Federal investment (i.e. , impact geographically, demographically, and on specific target grou;s). State when a termination report will be available to Regional .4edical Programs Service, and who will develop it. If continuation is requested to enable funding from other sources, indicate source, exact date when ot@ier support will co=ence, and attach necessary documentation that can be verified. 5) Page 16s of Form R.@ 34-1 for Program Staff Budget attach narrative justification for each line item requested. The same information is required by line item for each project proposed for support. 6) A listing of activities by priori ty proposed for funding beyond June 30 would be helpful to Regional Medical Programs Service. 155 A,-rAC@1E.,.-, 3 MN'RS Y-k@Ga--N-i P'ol-ICIES FOR XTI)TCAL Pv!C.@,.'-IS vVASF-OL'T ACTI%'ITIFS Historically, it has been the fundamental requirement of grantees to be responsible and pri7-i.-ily liable ;or bat' fiscal a,-id administrative operations involved in the r-.anaze7:ent of a Regional Medical Program (See News Infor.@tior, Data--Vol. 6. No. 15& a' August 30, 19 72) . This means specifically that grantees are held accounta'ole for all Regional Medical Programs Service funds a-@ar@-ed, and tie Federal Government .,ill continue to hold the grantee fu,!-.- accountable and responsible for all Federally suppored a--civicies under t-ie grant. Therefore, it is assumed that each Regional Medical Program has c-.ade the necessary arrangemerts to safeguard its interests and also @he of the affiliaces by including appropriate provisions in the cc.-i::acts and agreements as set forth in the existing policy eocuzekt, NID, Vol. 4, No. 32S of July 10, 1970. The following set of policies are considered to be most significant regarding accountability in developing a phase-out plan to protect the grantees' interest and that a,' the affiliaces: 1. Lease Costs for Stace, Ecui-,menz, etc. (XiB Circular A-21, Section j.45.e, provides that rental costs under unexpired leases, 4.e., leases for space, equipment, and/ or maintenance contracts, etc., are generall%. allowable if (a) the amount of such ren.@ai clai=s does no t exceed the reasonable use value of the pro-,ert-.- le3se@ for the period of the activity, and (b) the grantee and a@f;-I-'.a -e. make all reasorable ef-or.-s to terminate, assign, settle or ot-.er-.i4@se reduce th c cost a.- such lease. 2. Equipment Accountabilitv Grantees are responsible for utilizing equipment purchased with Regional Medical Programs Service funds for continued activities under Title IX of che Public Health Service Acc, as amended. The same policy applies to af@-'-Iiates once title to and accountability for equipmer.: have been transferred to them. Therefore, the following options may be applied and included in the phase-ouc plans due Farch 15, 1973. (@' Grants Administration Manual Chapter 1-410-50A.2.a.). A. Transfer title to and accountability for equip7.ent to eitl-.er another grantee, an affiliated institution o.- other Institution that provide assurance to the grantee that the equipmen: will continue to be used for activities within the scope o@ Title IX of the public Health Service Act, as amended. To effect 'such transfer, documentation should be ciade in accordance with the N'ID, VoltLne6, No. 14S dated August 9, 1972. 156 ipment within the B. Present proposal to utilize equ ities that are within the grantee on health-related activ cope of Title Ix of the Public Health Service Act, as uipment should be itemized in the phase :mended. Such eq ou t plan. In the event equipment used in project or program acovity is no longer needed for purposes under Title IX by the Regional Medical program, grantee or affiliate, accountability may be satisfied by either (1) crediting the grant account with an amount equal to the Federal share of the fair market value of the equipment or (2) refunding to the E @ proceeds from the sale of the equipment. -Appropriate documentation should be submitted by each Regional 14edical Program with the phase-out plan to justify the option selected. Severance Pav ctiB circular A-21, Section J.36, provides that severance pay is an allowable cost only when it is required by (a) law, (b) employer employee agreement, (c) established policy that constitutes, in effect, an implied agreement on the institution's part, or (d) circumstances of.the particular employment. Regional Medical Programs Service will not consider severance pay an allowable cost unless the basis for payment for any of the four options listed -above is a fo@l written policy or agreement of the grante, institution, which existed prior to the February 1, 1973, notice of phase-out. 4, Requir d Fiancial Re,)Orlg In addition to the phase-out plans to be submitted by March 15, 19' the following reports are required to be submitted: A. prior to the submission of the final Reports of Expendituret (1) a report listing all non-expendable equipment and personal pro;e ty on hand and a request for approval from Regional Medical Programs Service of the proposed dispositt, of said equi;>renc and property, and (2) a list of all ex- pendable equi;=ent and property on hand with a value of at least $50.00 with a request for approval from Regional Programs Service of the proposed disposition of such iteits. B. Reports of Ext!enditure within 120 days after the closing date of the Regional Medical Programs Service grant. (Note: As stated before, grant funds cannot be used for preparation of required financial reports beyond Februarv 1974.) 157 5. Audio-Visual Policy ,Audio-visual materials developed with grant funds may be disposed of as follows: (General Counsel's opinion dated March 15, 1972 and included in General Counsel's Report of March 1972). (a) They may be sold by the grantee to a distributing . organization, '(b) They may be retained by the grantee institution, and distributed as appropriate, (c) They ray be turned over to a Federal distribution center, (i.e., National Audio-visual Center, CSA) Any royalties or prof-.ts realized by grantees on these items must be returned to the Federal Govern--e-ic up to its share of the in- vestment as provided in General Counsel's opinion of March 15, 1972. 6. Records Retention All records on Regional Medi cal Program activities must be retained in accordance with existing Policy contained in Regional Medical Programs Service Guidelines. Reg;on4Ll Medical Programs should indicace the names and addresses o-' appropriate personnel to be contacted to determine location a; records and to be available should audit questiors ar4-se subsea'uent to (a) termination of Regional Medical Programs Service sup;ort, or (b) dissolution of existing organizations funded by Regional Medical Programs Service. 7. Grant-Related Income All unexpended balances of grant-relatecl income are to be identified as to location and ac:ount and reported as part of the phase-out plans. Plans due March 15, 1973, must contain requests for use of any grant-related income realized or anticipated. 8. Additional Funds Awarded in June 1972 for Specific Projects - (LNS, HSF.A, PEDIATRIC FLU'O'%ARY) The provisions of the February 1, 1973 telegram are applicable to all funds awarded the Regional Medical Programs for specific projects @der this heading. Therefore, any savings accruing as a result of application of these provisions will either be used to accommodate funding requirements for the programs during phase-out and/or be made available for meeting other needs as determined by Regional Medical Programs Service. 9. Contracts AlthoLigh the February 1, 1973, telegram indicates that no new contracts or agreements should be entered into which commit Regional Medical Prograc-.s Service funds, this statement has been modified to indicate thac contractors may enter into subcontracts during the phase-out period only if (a) the subcontract was part of the 98-8-12 0 - 73 - 11 158 original contract, which is considered essential during phase- out, but which had not been executed prior to Febru@ 1, 1973, and (b) the subcontract increases the rate of phase-out activities without additional costs. 10. Re ,ired Audits fr R. in.1 @t@dic.1 Pr- r-- 'It is the policy of Health, Education, and Welfare that fiscal records be maintained for a period of at least five years (Chapter 1-10D-20 of the HEW Grants Administration Manual) subsequent to the termination date of the budget period or longer until audit has been conducted and all findings have been resolved. Since most of the grantees for the Regional Medical Programs are ud,, .the cognizance of the HEW Audit Agency, that Agency plans to schedule audits as soon as practicable for those financially dependent, non-profit organizations that have been established solely to receive and administer the Regional Medical Program grant. Regional Medical Programs ma y schedule independent audits by certified public accountants prior to the termination of the grant provided it is grantee policy. However, the HE4 Audit Agency reserves the right to perform an audit regardless of whether an audit has been pe@for--ed by a certified public accountant. The Federal Government maintains the right to recover amounts questioned at final audit whether or not the audit is performed prior to the termination of the Regional @tedical Program grant. 159 Prooosed Ter@,inat;cn Dates of Termi nat ion dates for the 56 R,4P's are grouped bv the fo IIoqi ng dates, with all RMP's expected to be phased-out by Februa!-y 14, 1,@74. June 30 5 Nover-ber 30 4 July 31 1 Dece@er 31 2 August 31 3 Janu a@y 31 . 1 37, 4 Septerribe r30 4 Februar-@ 14 27 October 31 6 -- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - June 30, 1973 e-ber 3--, 1 r,3 Delaware Al abar.-.a North Dakota Florida Northeast Ohio V;rgtria Ohio Western Pennsylva6ia Puerto Rico D@e-b@r 31. 1973 July 31, 1973 Northern @iew Englan@' wi s cons in Ohio Valley ir,..,y 31, 19,-' Albany Bi-State Greater Delaiiare Valley Louisiana Nassau Suffolk South Dakota Susquehanna Valley September 30, l@-73 Arkansas Maine Connecticut Oklahoma Arizona Memphis Northiands Nocth Carolina California Michigan Central New York Missippi October 3 . 19'3 Colorado/Wyoming Missouri Georgia Nebraska Hawaii New Jersey Maryland Illinois New Mexico Metropolitan Washington, D.C. Indiana Oregon Mountain States . Inter-Mountain Rochester New York,Metropolitan Iowa South Carolina Texas Kansas Tennessee Mid Sout Tri-State Lakes Area Washington/Alaska West Virginia iuv sed Termination Dates of Proposed Region Termination Date 1. Alabama 11/30/73 2. Albany 1/31/74 3. Arkansas 2/i4/74 4. Arizona 2/14/74 5. Bi-State 1/31/74 6. California 2/14/74 7. Central N.Y. 2/14/74 B. Colo./Wyo. 2/14/74 9. Connecticut 9/30/73 10. Delaware 6/30/73 11. Florida 11/31/73 12. Georgia 2/14/74 13. Gr. De]. Valley 8/31/73 14. Hawaii 2/14/74 15. Illinois 2/14/74 16. Indiana 2/14/74 17. int. Mt. 2/14/74 18. Iowa 2/14/74 2/14/74 19. Kansas 2/14/74 20. Lakes Area 1/31/74 21. Louisiana 2/14/74 22. Maine 10/31/73 23. Maryland 2/14/74 24. Memphis 10/30/73 25. Metro. D.C. 26. Michigan 2/14/74 27. Mississippi 2/14/74 28. Missouri 2/i4/74 29. mt. States 10/31/73 30. Nassau/Suffolk 8131/74 31. Nebraska 2/1'4/74 32. New Jersey 2/14/74 33. New Mexico 2/14/74 10/31/73 34. N.Y. Metro. 9/30/73 35.1 N. Carolina 161 Pro'osed p Region Termination Date 36. N. Dakota 6/30/73 37. N.E. Ohio 6/30/73 38. N. N. England 12/31/73 39. Northiands 9/30/73 40. Ohio 6/30/73 41. Ohio Valley 7/31/73 42. Oklahoma 9/30/73 43. Oregon 2/i4/74 44. Puerto Rico 6/30/73 45. Rochester 2/14/74 46. South Carolina 2/14/74 47. S. Dakota 1/31/74 48. Susq. Valley 8/31/73 49. Tenn. Mid So. 2/14/74 50. Texas 10/31/73 51. Tri-State 10/31/73 52. Virginia 11/30/73 53. Washington/Alaska 2/14/74 54. W. Virginia 2/14/74 55. W. Penn: 11/30/73 56. Wisconsin 12/31/73 162 @Oll N'("'v 1)1-. (list of of -kl'k'@l foi- I),.. Al'illi@iiii .T. lia(,),ood. - of tlit@ lioiise of I of tile So(-Ictv of sl)e;ikei liniii)i,(,(l to \\.itli its Hill \\-III 1)(' N\,e to \.oil t:ik@t@ 'N.0111. ;it I (r]A'(, voiii, stateiiit,iits @it it lliit \\. (I ill-k@ to fe\\- o this tilli(@ ;Iii(l tlit,il tli file, loll., STATEMENTS OF A PANEL CONSISTING OF DR. FAXON PAYNE, CHAIRMAN. AREA ADVISORY, SW, KENTUCKY FOR TENNESSEE. MIDSOIJTH RM11: DR. WILLIAM J. HAGOOD, JR.. SPEAKER, HOUSE OF DELEGATES, THE MEDICAL SOCIETY OF VIRGINIA: AND DR. ROBERT E. CARTER, DEAN OF SCHOOL OF MEDICINE. UNIVER- SITY OF MINNESOTA if it \\-ill leail ()ff. I :iiii F:ixoi, y., t It N\,(, III II t o II I- St ;Iti- III(,)It S I)] l(@ I ft el, :I iiot II(,], :III, I II if,II t4) -,II) l)t@;l I- 1)(.fol.t@ t IIIs I i St i lsll(,(l oillillittei- to I)I.i@,tiv stlite sollit@ of Ili v \.I i@ .. s;Ill([ itllll IIZIN'T- I)k-(@ll ill ti It' Ill i,'illtl Ili ;I )f :ilil)t,oxii I i:ttolv 24.i)(11, I!):):"., ;Ili , ;I ])It, 'I ,,,e ()f,;l foIll.-Ili: I11 I)Zl 1-i lie]-sli i 1, -,I-olll) (1, it's t lit. 1,;I(Iiolo foI. ti\-(. lin@ iii;11.4. '111@titiitit)lls, ill tilt, l-el,iO]l@ll '111 I Oil. :Hill of tilt, i-I)IIIII I'l, the N pill . tlizit Ill(. ])]'Ol-rl"llll ]]Ito (@xll;t(Illtlt,. )I.II \\.(,St of (illite ill .s 1)(ItIT) t@ iii@litiitl-,ii-; fi-olli it@ liliv@(.1,111 1-i@til'ill(r froiii the iiiiii- fol. solitlilvest K(,iitti4,k\ tai-v st@t-N-i(-e t tli;it. liki- ;ill oti,ei- iiitioiinvide I)i,o"i-aiii.; of a ol- lioll(-Ov(@i'llilli@iit@il iiatiii-t@. tl)ei@e ,ire so,ii(, re- p- .(I tll(,il ., it'lil all\'(, ll(,;Ilizt - poteiitiil oi- litiliz(.ti tl t,ii- fiill IN'(@ (lo ]lot ft,t,l this li;i- I)OCII the Cls(, ill (111T fol. iiiiill\ Ili(, I)e(,illlllll(r the iiid ]it,:iitl) iii@tltiitl(,)Il, ill oill. to tll(, I-(@l:ttioll-iiiii tli:it @vi, soll(,Ilt 1101' k,livisiniii@(i Ili tlii- ill oill. :ire;i (.olltiiiil(@(I to tli(, will Ill(Il'illlS(l ill @iz(@ ziil(l ill tilt, flitill.(,: ilIN-olvill(, (I COOI)el.,Itiv,, 163 aiiii II, el It. NN- II i ('11 II ON@ -(,a. eflectill(- ' co])- sei-ves (,I-I)t ]lo-ZI)itils ill the N\,t,.,tt,]'II I e(,Ollollll. qzs"(l ()II to tlit@ 1):Itieiit. lik(, it f1,011, IIP. I)i witli II( ll(,N R. woi stiff ill wa- tll(, ].(Islllt of tile stiilliilils ;tll(l of ',Ill - a I oflic(, iii -Naslil,illc,. the Teiiii(@ssi-t- Ali(isolitil 1)1'0 I';"' Teii!i. See(] iiioiiev Ili -if ti@il tlii-oiiLl 11) ill oill. zli,czi t(-) (,stiblisli tivo ftill scil(:Col,oll;ll,x, tillits ;iii@l txN-0 i7oi-oiiii-@. cai,e iiliits -,iiid oiie q(,Iiool ft)t- ti-;illll i,r llill'Sk. f,)I. oiii- S,)Iltll- II- I, -oll](I iii@vei- ]liver o(,(,iii-red it, ()lit .tiid oiir d(@:itli 1-;itt@s: fi-oill (.:Illt]N- of finite. .\II tilt-k@ finite il't, I)OW fall-% ;III (I\\.i II (-OfIt i III I t@ t() II Io] IeV zot t I)(' I o(',I I liosl)italst)\-t,i-tlit-litiiiij) illitl;i I I N- f(,i- t I IISi\ (,(Ill I I)li ii,iit iiix-oli-ed I)OSI)itals :111(l tl)P'Iiosl)it:ils ill I :111(l (.)Ill. liosl)ital to 'Ill tlit, 1)1-,I(-tici 11 Vs foi, El I)lt iciaiis iii tli(,izi- folii- ll;IN,( (@asN ;I, -oll@tilt;itloll. ;II-l':Illl-rllla lil)l)()illtlll(@lits witli div. SI)('(-i-,Ilists ill tlli- (,t".. :it tli(@i v Tlii.s (,sttl)li:zlit,il I)\- Ptlll,) :111(i tll(@ 1).I@t %,Pai' \N,as I ov( I- .)-,- tile II,,' 4!ilt:il@ ,ill(] i@ llo\v fiiilded lo,--,illv \N-itlioiit fliil(ls. Al'@I]:I(] liolies of this svs- t(lili into l@iit tliizz I\-ill 1)(, if P@lfp (10(@s flot (,Olltiiiiit@. 11'e liavp tli(- i-;il)i(I of @l (-olitilillilig ('(Illr"ltinllal I)t-o,rraiii foi- iiiii-ses. te(-Iiiiolo(rizt@. iiiiist@4 t(,(,Iiiiicians. dietitians. ,Ill(] liosl)itii -,III(] ti-iistees. a,; 'I-, plivsi- ,-iaiis -,i-ow ,iii(I dev(@iol) ON-(,i- tlii@ iiir-t ', I.; I I-('slilt of'tlie file(liril li:i@ fili-iii@i(@d tli(, iiioiiev foil all(liovisilil e(I 11 :II c;iiltiiits iiip' I('Ilt. Visitiiiu ('011. @iiid si)(,ak(,i,,, :Ill(] tlit,]-e is lio ciil(,Stioll ill mv iiiiiid tliit tli(, staii(].,Il.(] of '11)(I the of II)i(@(I lieiiltlI1)(,t-soiiiitl iii:i.i-k(,(]].v ,is ,i dii-(,ct result of this coilti)lllill.z P(III(,iitniial 1)111) ail:iill. (oil](] Lyo Oil .11)(I oil of 0111- @ti,ol@(' I.( aisti-v @ill(I P\-l II tile II lili;ltt, foI.lll:ltioii of a fix-(, coiiiitn- iiie(li- ,a] socit,tv to'sliow tile f:liitisti(- tlllt I-('(Tioli'll iiie(Iii-',il pi,o- gi,aiiis li,-ive ]);I(] ill Oill- s(@(.tioll of tiiiie does iio't siieli -,I dis(,iissioii. ,ill) sill.(, tiiit tll(. (.C)IlllllitteE, li;iz lie:ll.(l Of tll(, 11)01-0 Ile- iii(I ]It-, lie:ti-d i-el)eate(IIN- tli(, tli,,it R.\fP ,i I)I)eii i-s to Ile ;iii ideal 1)i-o(,i-,ini foi- the I)t-iN-at(, s(@etni- ill a all(] iiinoN-,itiv(, 1)i,o,-raiii of li(,:iltli (-ai-P blit T Aynii](I like to state iiinst 11IN- St)-nil!r fe(,Iill" that tll(, @"i,a@si,oots ,Isl)eet of PI I I,(, of fp is it;: ;ISS(,t. 'File eiitii-e qtl.llctl tili@ Si-steni i@ @tieli tli.@t tlit@ (lecisioll@ iz to Ill(, (@XI)PII(Iitlll.e of tll('S(' tax dollars is iii the lost] I)eol)le of tli(@ iiid i,painiis ilIN-olN-Od. ]',live sei-I.P(l oil tll(, I.(,%-iow ill(l of tll(, 164 -e seeii tile '\I'dsoiit II I,(,(riollil 1)1(,(IiCll 1)1'04@rl',Illi fol. liaN . I r- ' l'illl)lic I,:tNv So-23f). aiid sti,ict to til(@ Arlilt til(@ -lose tlit,se ]Oczll 1)(,Ol)le liIN,e kt-I)t oil tli(@ fuiids ex- -e s lli(,N tliiiii@ I liii . eeii -(@@ tll:l)l ill Illv ('oV- less -,@-aste ill ll(,(@rl( 11 6i-iiiii(@jit,il a@,(@iiev tli;it I kiioxx- of tli(, tio,Il of tile is N\-Iizit distiii-1)(,(l rf-; ssi-oots l@ol' the ])lit tll(@ IIItilillit(@ (.()Iltl.ol of ;11)1 i-ol)i-iatioliq still i-iiiii(@lit ill(l is dete I-iiiiii(@d bv the il)l)l,o. iiiaiii-, in-itli the (ToN-e 1)lliatioiis of ('oil illt'S,:. tile iil)1011]lt tlizlt is (lele"",Ite(i fol- :1 coiiiiiiiiiiitv rea(,Ii(@s tile I(.t tlizlt ill aiii lost ])Ottolii it is illo,-"t (,;Ill(lfil]]Y Tito f, st,ill(.e tile I)eell ill la)(, foi-ill of s(@(@(I Illoll(.v wili(.Il lizls li"(@ of otilel. lf)c, lo(.;II ll:,t'tiitiolis to )lie tliit tile tixl)av(,i, ],,is Ili, (iollai- iii j-(@(rioii;il iiiedici] 1)i-o,.,","Iis tlllll lie ]life -rot - tell lllol'(, foi ?- tell ill iliv otil(@i- ;II-oiill(l. sl(,rll Oil e\-ei-v I)I-OJPct tii@it it lias I-nfoi-iiiii:iteli - ll'Ni 1) It's 'lot ])'It fostei-ed. stitiiiil.:ited. oi- 1)ai-tiall,,- ftiiide(I .iiid this ]iris '11)]'( lot 1.(@,iliz(@ tli:i ll',IIIV ol' tlit, its (.1-1-ol.. I'll(@ I - (10('S I t I ]lo-,I)itals 01'. tlieil- lo(.:II lal.(-F(@ 110SI)it@ils. li;lve tile I.(,stilt of set@(I iiioll(,v ;Ili,] ill. lo,,\. fl.0111 the li;IN-e fi-olli I)eol)](@ wlif) AN-oi-k iii tl)(@ 1)i@o(,i,aiii tlizit tli(@ i(](@,q is to sliift tli(@ iii;tiin I feel this iz iiiel,e]N- ;I (.i)lll Nvol.tllwllile ilito otli(@ll ( t oiis wai- of otli(@i-:, wlio liax-(@ \N-itli as ;I f(@('l -,Illl)O-t cei,t;liii tll:it \\-ill S(,(@ I of iliotiiei, AN-itliili tll(, ]text f(@w N-(@,ii-s NA to t@lk-e tll(' 1)1:1(1(, of iiiifoi-tiiiiate]N-. tli(, ,-ri-(@at of fiiiid.-, to yo ox-(@i- tile suit(, "ri-oill)(I tll',It Bell, ));Is (,Ov(@l.(,(] foi. tile ,l (lo )lot tliit tli(, tlioii-4aii(l;z of \-Olllllt(@el- Nvol.l@(,Is Pt'\[]' liki@ iiiN.s(,If A\-]lo li;iv(@ it foi- ti)(@il- @jlellt 1)1,0(rl--,Illi will Nl-,Illt to ,o tlii,oll-ll tll(, 0.1-olill(i\\-or@- i(-(,s to tlii.,- (@x(.( ,Ilitl ;,,roli,%- of tl);It will s(@(@ fit to tilk' ;II). 111-0;1(.Ii of :is ]lot ()Ill.\- ill(l ]-;itioii,,il. ])lit :11-,i :ill ilisti-iiiii(@lit to tll(@ iiii1lioll. of doll:ii-, iii fit- '.\f Avoill(i -%.oil z liot to iliti,O(Iiict, 'Di@. Pivii(@. II(, ic I IkN- a. I llIN-C w-,itc,ll(@(i tlll., I1)1-0(ri,iini aii(I s(,eil the woii(lei-fiii I produced I)y it. It i, oil(, of tli(- oiitstiiidiii.- i-P 'Lrioiiql iiiedicil Of the 1-nit(,(] @tit(@s iii(i I :iiii 11:11)1)N . tli;it oiie bp"l(](,(] this -I-oiij) :iii(I li,,is (-al.l.i(@(i it oiit to tile I(,ttel- of tile --celleiit job. opiiiion. Yoii liaN-P doii(@ all (@., T)I'. P,\T-,F. Tbilil@ voii. ])I-. Cni-tei-. '\fr. R@FRI- a : I . IV(, i(@ to liefil. tlli-,. doctoi,. ,iii(I yotir (,.ivillcr 11,; tli(, 1)(@ii(,fit of voiii, e\l)ei,ience. 165 STATE.,@IENT OF DR. WILLIAM J. HAGOOD, JR. )(;El'@. )CtOl'. I t IIIII i@ AX-t, @! Io] II I I It -t t Iit'('0111111it I kiion\- of tilt- ()if )f of I -giiii;t (if I-':tiiillx- fit' V'i of 1)ele,,;Itk!Q-. -@iii fit' let\-" Di-. :11i'l :till ]Ill\\ ill fill, of faiiiii@- ill(.(II I I I I f x I I I I: t t tllk! I)ielliti(ilit iif I li:t peol)]t! I).\. oill- @lli;tll zli-t- Ill ical ])fit :Iiitl Pei-@oiiilt@l to tlit-lii @l\ @i:t\., :11-t- filit-ii woi,@-. biit it I., li:i Ill)\- \x-oi-k. Mc.(Ii(,Zll ti, olit- XN-t. I 1;1\.(. t to) lit) it, fol. the liit)@t 1):Il.t. T pl,o,rl,.Illl@ if I I-(-- t(.( I I I I t I II I I i-@ i I I :I i-I I I: I :I I I I I t I .1 s point Ollt ill tilt.\- -;Ill @:I\- title to 1")I' tllt@il- I)\X-ll Poz-zt (r i,:idii;tti, :iiitl. fit' it,@ stlill:lt,-; specific,ill@- to otilel. ]ill f;i fill I iiiii@-t- )I,:If.t it 11 i@,-i )I i 11(@s. lilt-(I i - cal Even fill- iiinlit.\- ill; I.\. ]it- II(, to I lit@!."If '@ I - to) leave oiie's fol. t!,(@ ..o I i.@iiit;liit to tile "il)herv. Tlit, 1).itit@iit-is I)\- lot to) ,iii(i bN. I),.t fi-olli :1 11101'i- t\\-o to Yoti. tile Ill(] I think trips(. lettc,]-s fol- Ill, lit,il,fill ;Iiiil t)lt@\. @\-ill I)(- lli:l(lt@ :I I):Il.t of tll(@ r(,col.(] follo\vil),r of %\.,]] Tilt ;I I)t, iiit-tli,,tl@ ,I' Milan) 11' lliit Until W(. t( ) till i(It@lititii'(] ]lot t;tx (loll, . liot S11I)j(@(.t to III\- I)OIit- tli(@ I)ztsis of iii(,i,lt at tlitt \N-e takeii ol@l, w:ll,(Isllil) tile of tll(,Se t;ix (Ioll:ll.s llio,;t sei-iolisi\.. Ste -v to (lo tile I)est jol) \V(' (.:III to s(@(, tli;it tlit@ liioli(,\. is I)Ilt to troo(I ;iiid ti ?- Ilse. is tilde I,kl\,(Illlle I)Ilt NN-itilolit tile of "oill" till-oligli ;I sti,ll(.tlll,i,. I'Iii@- is I I)oilit. Ill(l oll(@ oil whicli I believe li;IS ('011tl,ii)llt(@(I to wliat(@\-(Ill Sll('(,(:Ss \\-(, lillv(, I)e(,Il ;11)1(, to Iccollil)lisll. ',\-ow I toilet wisli to of fi-ii-4- ti-,itiolls. ilivol\-(@(I with' li:l@ olle of tll(, illost becii isso(-i:ite(l. 'File i-eisnits ftil, this i-,-, til(@ i,eisoii I iiii Ix@foi-t@ -,.oil to(]:t\-. It is, foi, I;iek of :I tli(@ fi4,@k . of tile 1.1(@41(@i-zl l it.@lf. Are li;i\.e il:i(l I itilolit lioti(.(, Oiii- sliifte(l. fitii(i., \N- bi-4)keii. (-oiiiiiiitill(.)Its iiiiiiiet. tol(i to (10 olle iiiiii,, )]I(@ (1,1\- ;Ill(l ;Illi)tlii@'r tilill',' ;illotilel. (I:lv. '111(l oiill of trat-v ziii(I .oil., of Fe(]( I)iii,(@,iiici,ats iiioi,t, of olit ill tile I,(.k.ll the of lli:tll@- of ]'X.Nll)'s l@1-4)1)lellls. ;Ill(] tili, fiiiiii-e of owIl ii'lll sitolil , I lii)t 1)(@ ti '(I to tll(, )I; I stiff' iiieiill)t.l., Haiti of I)le(I f -fill tile ilifli(,Illt t;i@ -I Si il)@ :Iil(l (Iesi,,rll(@(i to 1)(@ o I)PII(@fit to ilit. ll;ltitlllt I,o (.1 t t oil ]lo\\, N\,Oilltl I)c ;I iiioFt s(@t-lotis f I i wzlst(@ of tll(, ki)(1, I \\.ollltlll,t 1)(@ @l bit if soill(@tliill,,- 'I@ )'lot ])],ollll)te(I ill :1 of v(@;ii-s to do the siiit@ tliiii@l, ]..z (to] 1, I I()W. '111(l it \Vill to st:ll,t fi-olil sci-ilt(.]I-lt li;ls t;ikeii 4 to fill. iii:lll\ . ill tll(, li(,;Iltll ti(l](I to fill-,il]N :ifl(i to -o, (IeN-elol) t-oliti(l('Il (ri-iiii. I (-:III :isstii-t- tli;it Ill\. fiitlil-t, I)Ittk,l, \\.(@ li;l\(@ N\.itll of is ;ill(] ]-;itioll;ll. It still fill\ liot 1)(@ too 1;11(@ t ) I)Ilt lillilll)t\ . -1 )Illlll)tN . to,,,(,tl)ei- ;t@,aiii-if voii Iiiii-i-v. W.JLYNFSBORO CON[NFUNITY HOSPIT.%I.. 11'aynesbr)ro. I'a., April li. 110.3. El-GE.\F, PEREZ. 1-ir!liiiin R('gil,@lql .11('(Iicill P)'O.-71'(10)1. II)C.. Richi)16?1(7. 1'.7. DFAP GE.XF: Tlii, is to r(@i)ort oil the visit.,itioii I)v T.)r. Frink file Wiynesl)orii (' "Iiiiiiiii!iT\. H-isl)it:il I;ist week :is oiir "I'Iiyqici,,iii in Resi(If-iit -x-i-r y @ift(,rtiooii iii(i sl)eiit two lit)iir.,- witli oiir iiiirsitii: staff. iiiclii(ling ilit- ,tii(It-iit of the I,P,\ scil(lol. slieikiiig on Reli;il-ilit:tti,-ti in \iirsiiit.,. Ili@ t ;ill@ 411]ift@ \N-I'll 1. @ the iiiii-sili,-, still T7iift)rtiiii-,itely. the -riiiij) #)f niirses friiiii Eastern '.Nleiiii,inite ('ollegi, \iirqing wlio ha(l iieen exiiected to attend were iizial)le to lieciiiil-e of conflicts in s(-hp(iiiliii,,. Tilc-@(l.iy fr.)iii 4 :30 iintil -) :30 Dr. '.\Ic('ue reviewe(i eiglit ca@e,, of iiijuri(-@ c.,iri@(I for toy tile I)li.vsiciiiis in the '\Iedie:il Iiiiil-litig 167 gi,ving excellent pointers in the niiiiagenient of L,,,Icll cise. There were four I)rix-,ite physicians involved in this conference. At 5 :34) 1).ni, we liid dinner. At 6 :15 Dr. presented Ills t;tll, nil of Arthritic Joints". foll-)Nve(I liv iii extended iterio(I of discussion il'Clll(lill,' tilt- case I)resentati,)ii of :i 1.@tit@tit friiiii NN'on(Irti@N- Wilson Belial)ilit@iti(iii C(@ii- ter with the est:ililisl)Ld (li:i,-Ilosis of Di@zi.,ie. There were 3., people iiielti(lin,-, iiiedi(-:il -t:iff in(I iiiir@in,, staff at tiii, conference. iiieet- iiig adjourned at il)out I)-iii. Wednesday front 1.):(K) until 1'-':Iio. Dr. the operating rooiii reviewing certaii teclizii(-al l@rolileiiis in ortli,)Ijedic stirgeri. cal staff. Frotii 1 :00 1).iii. until "-) :()O i).iii. lie re\-ie%N-etl x-rays of Imminent of athletic injuries %,-itli five liliv.@ici;tiis. Yr-)tii 2 :()() until 3 :311 i eliiiie in nient of iniiiri(-s in the Eii:erzeiie@- ]join \\.;I.Q ]It.l(l. @I)CCifle:ill I- %vitli tlle use of c:istilig. t;ll)ill-, ;iiitl iiie@istires in iciitt- Front 3:30 until 4 :3i) I)r. iii, worlt@(I NN-itli lot-. H. B. R3-(Ier in the It@.(iiii deruojistratiii,- tlit- rel);iir of ictite injury including I;iceritioii of I tt,iltl,-Ii. It I.,; niy considered c,-zicliisi--ii fri)iii -)iir k-xlierit,iict! %-,-itli I)r. '%IcCii(- tli:it the "Physician in Resid( --,r:iiii is ;i iliost v@ilii:iipl(, I)rtL ()lie which C,,Il- tiniie(l. As in ill ill I.(,Iltiiliiili;., P(Itl(,:Itiiiii (ill tit(, level. tll(. old I)robleiii of iii(livillii:il leariiin,- aiitl :il)lilic:iti--ii )f this new letriiiiig in daily l@r;it-tict. to I,(, tIlf@ iii:,ji)r Dr. .1leCiie'@ ci)iitriiiiiti(-ii to this le;irilill, situation %\.: is lietter Haiti \\-t, eXI)ecte(I fr-iiii t-)itr lirevi,-ii@ \\-itli liiiLi. Ills range of :111(l I)re.ientiiti,)ii (of subject iii:tttt!r (-tit :ill of slieci,,ilt'v tr;iiiiiiic: :iil(l Ills v t!its itio:it lir;ictic, Av(liil(l recriiiiitit@ti(I deliver. wis ijiost effe(-tiv,, -mind his i(I i 1. I that lie return for further teiteliin,-. -lust lit)iv the involv t, iiieiit :tzi(I I)artieil)ati.,zi of the local lilirsici@iii, call lie au,-Wented is (liffi(,iilt for its to i,v:ilti;it #, :it tliiQ tiiiit-. Tlit- AN':iviiesi@iiri) ('4)iiiiiiii- nity Hosl)it;ll plans t.) lizivi- in,@tlier I)rogr:iiii of this tN-I)t@ Ili the y(-:ir I!)73'TliL@ I)t)stgr:i(lti:itp :Ilitl CI)Iltifillill, etliil-,iti,yll (-IPIlllllittt,k, :111(l tlit@ Staff have alrei(i@- viitt,(l t,) di@dic:ite ill efforts to%vir(I -ticli :tiigitiejittiti,pii of ri-sitina tetclit-rs is Ili Lt,t tile tli:ink fr.@iii the liottoiii (if iiiy lit,.trt (ill 11(@llilf of tile -'t:iff of the W-,iyneslii)r-, II-isl)it:il ffir @-i-iir ,:illpl)()rt Ili li:in-iiia I)i-. COME visit us. A;.,@iiii. let ill(, state tli;it rlii.@ @viiiii(I secui to lit- ;i \-it;il ;t(l(liti-in lit tile coiitiniiii), -if the t,i iiiil)rt@)N-e his (111:11it.v of daily care of his I)atietit:z. A.'ery sincerely P.013ERT G. BX;SBOONI. '.\I.D.. Pi-esi(lc?zt .11(,(Iicfll @taff. r.)FPART.\IE-,,-r OF OILT]IOPEDICS. U.NIN-EltS]Tl' OF X'IltGl.';IA '.\IFI)ICAI. CF-,TER, Dr. Ed. E. Perry. 12, 19,3. l'irginia Ret7ir)it(ii Rich)ttr))i(l..I-ot. DEA]T J)lt. 1'EFtny This is tile i-i-iiiit,@tt,il oil toy visit .Is I)Ily:zi(.iqll ill s AN . -iviie@l re.silleii(:e at the i,iiiiiiiiiii,it@- II(. I.it;ll ill -,Pr(i. 4)ii -11.11'cli 27 iri(i -114. 1!17:t. I certainly fet-I tli;it :is this x-;ilii;illle ill the continuing education of 1)raetitiotict-s Ili any situation. slw(-Ifie questions that -.ii-t- ili,l lilt- iiif-oriii:iti--ii I, ll;isst-ii ;iiiil f,irtli NN-ill nirv fi-iiiii "itll;lti,-Il to situatit@ii (it-liviitlil)g ),, tlit@ iijt,(Iik.;Il I)iit --I,.ailing i.@ far is tile oirtholiedic is :is 3-i-ii ;t i-k@l;iti\-ely I)road irea Ili ill ramifications. I believe it ti; be especially I cer- totally bol)t- that ti,t, I , %v:is of I)tll(@ht t4i the Ili,. itilit-i- ', i-f lilt- ('011,Mllliity ll,,sliitiil. ;titil I -.t-rt;iiiily ft-t-I l)t,t.s4,ll;llly that it (if viliit-. jil(lill, from tile %A-Ilii.ll \N-i@rt- r;iist-il. I was certainly :iii4i nitrate ;it \\-i,l] Ili,. Aii(it,rsitii iild the remainder i,f the st;iff ;it t)it@ ('11111111111)it@- li@)@ltit:il liqtl the lirogi,aui org:iiiiz(-(]. iii(i li-,%v fully tlie@- Ili tile i-:triifiis s(-pir;tte -iinilar programs lirevioii section.-. I have been ,oil , sly. but this t@is is AN-ell organized n,; any tliit I lia%-e erer seen. ;iii(I covered -i great iiiiuibvr .f and .1 grett number of (lill't-i-eiit gr-@ill-S lit illtli\.i(iii:lls %-Vi-y effe(.til.el3-. N%-itli ,i iiuriiber of iii itst-If S WIlII ;IS I-S]Hlk'i:tlly %X'ell ti,iiiiii-il Iii,;i(-titioiiers. I would S;13- ill tile- ll;t(I Very few ill:lt @litl atteii(i the Tlit@i-(@ is ;I III %%';I ;I, I state(] before. ilit4,1'llzll fill@4]i('illt, ;like] were ilso iiiluilier elf II'(' lli;llltl ill tile ,irel. Tlit,y ill(- it) tileiii dire(.tly, nc,t I)F illie!4ti,ilis left li@- tII4.il. fet@Iiii-,s .ti file- s'lllje('t. ',I., far ,i,, th,@ (Iiila(,ti(- l(@4-ttires ;iiiil t,,ills 'I'Iif,.v :tls-@ (Iil'(@,-tlv liarticiii;ite(i ill the clinicc; "-Iiieli Nvei-f@ lielti III tile- :1 "(I tile ol)er@itil:;: -iiiii (,xl)erieiiee(I iii(li\-i(Iii;ils. there x,-, In tlii, ntimber of well tr;iiii@l . (lp:ll for v-.il-i;itioll it %\-;is (-ertztiiil.v to iii(@ (to It-iii-ii elf lilt- tiltilllits. 'Ill(l of i)tlier!z. Tlit@re "-.is ;I gi,t,:It iiiliiiliei. 'if I'l.illllt,llj (.;Ises 1)(itli ill \-ray, 11 'v (lirt-(-t ex.qtllill,qtioll ;ill(] III tlit- :1 @,r(,;it (lea) (if C()nlllllillif.:I. tiol) all(] ,,it lilt, siii.j(.(.t,. i,iit. (if I gl'tl:lt si)ll)f. t4i less :111(l :I f(@\\. II-it ;it -ill. Howei-(,r. tllis is II.-Zll.'IIIY tile I):irti(,iilari@- :I 'Of Ill(] @elit@r;tl -,ire :1 Still -t t..",(.t lir.ictiti,)iiei,@ it@( The I)rel).iratioii liro,-r@iiii of \vliielt 3-o)ii liave received ,i col)y. I tilougllt e.x(.ellejlt ill(l (.. IV(II' I 11 1-@ f I, .1 .1111 1- it it If t-:i St ;I 1r. 1.1tit t li@- iitir:,ijig ,t;tn, Colilliolielits :Is 111;1301. S(,Ill 1, i@s (if i -if t lit, I ii-i i,,r@i III. Tiiis l@eriii(I (if tiiiie. of (-Oll"@e. is t(if) sliort to ,ili inforniitioii (it :ill t))(Illgllt(, Oil ;I liroq(l groill) elf Illlje(-ts ,Ilcll 'Is elitailetl liei-t-. TliO III (Iel)tli (lis. (Iii@@i,.ii is III :ill sitll:iti(ifis. I tiiink tliilt it is :1 W4)rtliwliilt, ijit,;iii!z elf (-fiiitiiiiiiii--, :It li-:ist :is far :is I lvzl.@ I tllilll, ".:Is )f iiiiiii-tii- @,in(i pr,,icti(-;il 111:1. teri;il lteiii,-, :tit,] is tllis tiiiie. I ?])is illf'-I.lll;lti,-ii \\.ill N'.11111(@ If I ('@iii ]it? ,f itil@- -,r :iiiy iiif-i-k- (Iiit@stjt)lis let Ill(. kii,-@w. -(,rely Boilers. )(1. fol- olit, sl:ill.- \.\Ill lit, lii(ist STATEMENT OF DR. ROBERT E. CARTER ;I iiid the (le:iii (if the '@it\. of )ii tli(, Dtiliitli Call)- in I't,fol,(, this (.ollllllittee to t@tif.\ slil)])Ol.t oi' :1 (@N14,11@ioll ()f fiiii(iiiiL, f(,i- the i-(,(,'Iolial 1-jilte(i St!lt(@.@ :111.1 (1:1 I1 li(@:iltli cai-e in tlii@ ti,@-. ili;lklll,-@ the i-eil I)eii(@lits 11) I 'II S(,I.io1144 ill @(,I.I-ice@ foi- tlit, illol't, @ti . ill ]fell I)OOT. ;Ill(] tll(- (ill if) is i@ il@o tells fol. lii;lll.N- of oiil- citizens witli 11 ill(-Olll(,s Haiti] ill II 1-11;ili The feel. that tliei-e li@(, iiiiii)(@t tli;it tlit@.,ze iiee(l@ ;ii-e i,eq]. ()ill- 1):'(] NN-itli otlit,i- id- liot -iii- t tlielii oil I)t@ol)lt- ol ev(@it oil the el(tei-IN- @x-lio tliei- fk@1-1 %%-()Il't 11@k@ tllk' ]'";'It 11 SN. tt'll' ("t .;III to iiii )i,oN,e t I I ,(T ft, el tli:it %%I- iiiii@t !Jet,]) ti -lizit totill 11(@;tltli ill till@ li;i@ lit@t@ii tile of NN the eff,)i-t nf live(I i@ limit. tli:iii iitf:ilit iii!ll,t@ilitN. :111(l tlit, ](')I ill "f lift!. It is k.II. lillti-t@:ltt,(l ilik-lit;ll lizil)l)t@ll if N\-(' fill], ])')S- too to, eN-t,i,x,oiie to "I:ll oi. .()Il;it I,\, tli;lli. @11IN-t. The I(] -filit- tilt. !li oill. f tliev fl.,)Ill tilt. !-t;il,t. 'I'! @;li,l ll;t(l to lie. ;Itt(,Ilt If ill oil flilt,it@ :ill( I 11, IN\- to tlielli I w,irl@ed \\.Itll flit@,111-:il @t;lll'. ;lilt[ til(lill iiiil)l,ON,e I-t, t i,t,;It iiit,iit t II I-oil --rl I( )tit the .)It.;Il illilt-. :Ill([ IIP\V te(.] illililit-S to tioll foi- (lo(-toi,.4 iiiid (,()Iitllilllll- I ;ill,! it NN-t@iit Ill N\.l . tilt, \v:i-4. iii the delti I):Il-t@I)f the St:ttt@. Y,)Il fzl--t@ :111(i lilt list Ill(. it-11 \-(Ill iii-@t lk;tiil :11)olit :1 ti-ill lilt,( :II I)II@),-rllzllil@. It. Itt) to \\I (14-1):l I ]Ili lit @t;l tl' ;Ilill liif:tiit iiiiii-t;llit.\ :It ;) i,o@t i'@ ;I :1@ !law Ilt.1.11 t lit, ill II I':Illt I I(-:II II- :Ill, I t lii@ 1)(@ttt-l- lie,iltli foI. t@lit II-,- fi fill I it,@. t tli l@ iiiii--e@ tti t@Xit,fill t[it@ to) tilt, tt,;tiii It ii-k-. It i-4 \\'it!i iii-ill@ to) tilt. to) t @:it tilt, ,;(.Ilooi 170 r I lieiltli lliiit is 1)1"111(r to 2:) (10('to"less towils. A to\\,Il is ll()NN-1114" ]lo\\ to i-iiii i bi@,iiiel, iiiiit oil ;k(i ;I(.ellt I III of It] I, II()II I. @i i-@i. II os I)it;II (I i I'(@(-to ]'S. (lo(-tol'@, 11111@ses. jtinioi, ('011e.,-,(, :ili(i :I(Illlillistl.:Itol.s fi-oill .1l'Ill]lesot.,l .Ill([ ll'ist.,)Ilsill sit NN, I ,to(r to illil)ol.tlllt J)I;tiis tiid to cai-i-v tllelll ()Ill. 'I'lik@\1 :IN-Oi(i (Itil)li(';Itloll. aSSI(rll t;tsks to tli(@ iiilit NN-ilicii call do tli(@iii I)t,st. ;iii(i tii(,N- look to s(@t@ ]to"' tliiii,,-,s (loiie iftel,- ]Ze,,Ioii:il iiie(li@-.il stii-tt@(I ill tliis. 'FlieN- ai,e the oiie." wlio 111) %\-itli i(l(@:is :111(i 11(@ll) iii:ik(@ it N\-oi-k foi- as I(;iig as tli(,\. @ii-e iiee(led ot- foi- :is ;is tli(@\- (-;III. ,;Iloill(l @ill this stol) ,;o siitl(](,jil ll']iN- slioiild otliei- woi,tlly lie (.lit oi- stol)l)t@(i ill :I Silililii- fisliloii ? The oi-i,7iii,,il idea of \N.,IS ,;Ollll(]. '1'11(, cr (@@it iiia -itN- of ioi tll(@ ivol-l@ %\-;Is fii]]. N- 1)-N- I)i,ofessioiiils. (-oiiil)eteiit ,Ill(l I)Y S(@l-ioll', ;Ill(l (1011,,tiiii(,i-s. Tli(,s(@ ;ii-P the qctloll I)ro- (ri-aiiis: trial i,:iii iiiil)i,oN-e tli(@ etti(-ieii(,N- of oiii- lie-,Iitli cal-e deli\-el.\. ill this (.01illtl.\ II,(. this fl(@xil)ilitN, Ill(] tll(' 01)1)01.tllllitN- foi' to ](,:Ill t 11(@ till-oil,,,lloiit oill- tli-,it tlle 01, ,()o(i i-esiilts iii tli(@ @,i,e;it iii;ijoi-itv of It slioiii(I I)t@ ,ix-eii t to go oil ill ilill)oi-tziiit NN,oi-k. A_Oll ll'N' liiii(Ili. fol- Nolll- 1-(@l'Y liell)flll st:lt(,Iilelli. I lillist @;IN ill tll(@ i-;tiiiig of the N\-oi-k (loii(, i-e@.,ioiial ii)e(ii- I:', oi- 14 ilot 1.;It(,(l good ol. I tliiiik tli:tt slil)st:lllt@@it(@s iii;lfl\. oftli(@ st@it(,Ill(@lits N.011 ]list ili;l(le. 'I'li;iitk \-oil, 'liiii-iiiziii. .@olil(, of ill(, illfoI.ll;;Itioli trial (.01lies to ilie \\'Oil](] indicate trial ti,k@ rl,t into e:l(.ll otliel-'.,- jiii-is(li('tioii ill ;I of 4-ti,ol.t. I)o @-oll zlilv (.olllliiciit aboiit trial iii oii]N- sl)e,,ik fi-oiii III\- O\\'Ii ill t\\,o ;Ill(l I ]lot Stl(lll tells to be the (-:is(.. fl.()Iil oill. al-t@;i fi-olli Aliilll(@soti ;Ill(l fi-oill \-if@w was tliit ('111) Was :1 iol) tli:lii of to flit@ ill Ill\- I tliiiik Ili-. ll:i.4titi --,s iii:lfl(@ ;ill ltill)ol,t:liit a f(@w iiiiiiiit(@@ .,I,ro lit, S;ll(l that tll(,],(, :II " - I'Iii-t, t)f I)otli tli(@ tiid Clil' NX'Iii,-Ii (I()iii(r :I -,oo(i it lie that tli(@ t\\-o I)k,ttl@i- ;is ()]I(@. iiii(i [bit tli(@\- Iioiii(I be I)o \.oil tlill)l@ this I-oll](I 1)(@ (]oil(, I ;ill[ liot ;11) ill this I (-,III oiilv sav. it si,t,ll]S to) 1)(@ ill 1):Il.t lei-slil \\'()Illii lil@t' to) I)()illt ()lit tll:lt I \-e,,V liii -II (ii.;- it tll(, Nfiiiflesot'llis, il)oiit 2 tllilOll\, ;i,,O. I-('t,(,iits ivt,i,e ill to\\.II :111(l to fit(, N\-:Is ]lot 4-ollilli,-r tIll-oll"]l ;is 171 I soille of [I) 11-4 f, I.()III I)X- tilt' to tlle total (tolIzil t Ii:lt :tl,k, Ill,' II (:Olltilit;lll,-, to (to :1 jol). I tlizit it i@ iiii- 1)01.t;iiit tf-lzlt N%-t@ L-olitiilllk. ti) fliiii.l .)Ill. iili ]lot -,it o(iti-4 %%-Itll t:,) doll,ii-. I itji (,it ;I i-e Ili )t (,It I it, I'. k it, i it t I i:t I t Ill- II I I ii(,sott @Nlt,( [I- c.il :Scllool is Iz to) \.Oil ;is ti) iti-4t \\-@itit to) iii:ikt- hill ol)- :111(i tliztill@ tilt, foi. :111(i t l t,) tli:tiik \-oil. It I.-: to tlil.@ kilILI of rt,.-ztililoll\. film tilt@ :Illtl fi(iiii till. -NI I R Ni I 'I'll;lflk -\I I-, ( 'li:tll'lli:lll. Ili @t:ltt,ilit-llt. I )I-. ( I kii@)\\- ;ii,i, I,)e,iii of tilt, Of Nilljllt-@I)t;l I )Illlltll. ki-L' ill tlit@ I-e \%-Irli till. I f riii[t, i@@ this ;it fill, tillit'. :it tells oil]\ to) tilt. oil tilt. I)itliitli o%,ei- @22.11,it) l@ to tilt. olll(,I. tlit@ liosl)it.ils. tire jiiiliol- :Ill([ Ill(- ()tllt-l. ilistititti-)Il@ ill 4)111- R, I:i I iiit(-i-i-iii,t I tfillllltk@ fo I't' Ili'llll)k@I'S 'IO to ,Iiis\%,ei, tlio cill. II'(- %Vill ti-\- to it o'(@lo i I t ii., i-oo o lie,,ii, the i,(@!st of t] iii(I tlit.li %A-,)I ijito exe(-iiti\,e session. is :I x-ote ]lot\-. ;I X-ot(, llf)\\- I)Ilt tll(@ S(.(.Oil(l liot ki-e voll l'olititillill'-, t@(ill,.:Itloll iiiii-s(, S. ('0111 31111111ir to :it ille S(.Ilool ;Ill(] lint I Y(,t coiiie to tlj;it I)oiiii of ()Ili- fii-@t (-]:Iss last this veil-. R(.(;Fp@. I)i-. l@ov. \@-:Iilt to,ill:llll@ \-oil foI. tt,stliiitlll\.. I )I-. of the excellent jol) N-oll ));I\-k. (ioll(@ ill I)IIN I ('Olil(l (,oiiil)liiii(@iit ea(, of \-@ii I)iit I rliiiilz the A,-;id(-iiiv ' Si;.i:ilis li;is iloll(, ;ill olitst:tli(lill!-r of Fiiiiil\- I'll\- 1):",ti(-;I)'atioti I tliiiik. iz li'liat do voii to si\- il)oiit Di.-. tt@llill,r llz PtA f P'S I I 11 \-e a ei I)t i \-e o f t I I e I Of @,l I 1) I-o i (IC' I- -,I-oi'i ])!Z Is :t t-,,i t i I ));I t of t], I (toll't eel t Iiit Al,(. 1111N,e li@l(tsil(!Il ;lilt to ito oil(, t II) it, I I I it. t zi t t I-( .1 I tt I I I zi j@ II 'it site ZIS :1 l'ill)l.t@St-litit IN'(' f I-ol II \\.,@Ilt till.oll.,Ii oill, till.\. tol(i II., \\ li;it @l 'oil N@'(' ,is s it,, sit(, ]Sit iii)lllitt(@(I till. N-isit tl-;illi s 1,11(, ]It.xI to]([ Its to tlii,ii tlii., tliili,, ii@otill(i :III([ 11 till' 'I'liis lizi,- ,)tell olit, ill' \-oil (I'(Ill't lilloIN- foot i'(@(it to I)Ilt \'Oil :111 (IN )I@iii@lltli)ll of Nvll;it til(@ )lot I-iilt,s I)Ilt. 111@i, till- fi-oill tile I S() ;Ill(] so to lie I f N-oll ii'(. \\'iS(@ (@11011(_rll. \'fill :11k@ ll()t (roIll.r to I)Zl@s 111) fill- rili(lk@lill' P- 1)('tt(ti- 114)1) to Ill:N-()Il x%-Oll't r(,t till- (1011:11-q. I %\-olilti S:I\ till- It'lil) is Its It til@it itioIl :111(l @:lt ill ()II ill;lll\- )It ll,r ill' I I) t7 V-Ofll()l ;ill( so \\-itliolit I soil)(, I tli:iiik \-()it fill- \'4)il :ill ili@i)l,(,@i,lit;iti\.t.@ of till. \-(,I. ];I I' \\-Iio woi-k(-tl t.x- 11:11.1 ill tills ;@ :lilt ;kill :Itti,lililii,-, :iliil fol' if I fi-tifil till- is 11(@II)flll ill fi-oill till' ;it to :It :It 2 to ol-il(@i-. II'l@ :I!.I. 1)14..Ist.ql to t') tl]4- Sill) t, tlii-, Toliti It'. F. Pt'.\TP. 17:3 -]to I i)iaii )f -ki @Irr,,Iltl as 1-k " T,("-" I :tll(l fl it,1141 ,f III' to tlle p Piiiil I oil '\[P. 1)1-. Ivil- iol) \@-'tll It'lli of )III,, N \%-t@ II -o IIit )II -rt- IIt It, II it -IIt III IIT t I f x-I)II ti; illt'lltifn to tzikk- ;I si,:it :lt'tlit, t:llilt@. I lit'll)fll jl' ,Iiiilil :)till tilt. STATEMENTS OF A PANEL OF REGIONAL MEDICAL PROGRAM COORDINATORS CONSISTING OF DR. R. F. INGALI. EXECUTIVE DIRECTOR. IAKES AREA REGIONAL 31EDICAL PROGRAll: DR. R. PHILLIP HA@AIPTON. CHAIR.NIAN OF THE BOARD. FLORIDA REGIONAL MEDICAL PROGRA;)I: DR. WILLIAM H. McBEATH. DIRECTOR. OHIO VALLEY REGIONAL MEDICAL PROGRAi)l: AND PAUL D. IVARD. EXECUTIVE DIRECTOR. CALIFORNIA COMMIT- TEE ON REGIONAL MEDICAL PROGRAMS ])I-. this @ift,-I-Ilooll. i(l(ll it] 11 I('. I:1111 tilk' t'.X('(-Il- 1):Ist of t[l,, \,;Irlflll:ll !I;It, f.,4 )III). III \- 1.1 -,] It i., Iiiiii) lf;tlill)li)ll. \k-ll() is (-Illil.lll:ltl -If III,- of (II- of )Ilio :111(t to liis iiiiiiit,(Iiltt. I-i,rlit %\.II() tilt. of tilt. (',ilifoi-iiia (")Illlllltti-t@ oil itefiil fill- t4i Lri\-(@ tilt. tit(, lit-iit.fit of advice Tliiiil@ vi)ii -,I 1141, iii(,Illl of tit(, @til )..oliltli it t("@. I tliiz ol)- 1101-tililit\- to \,()II tili- ;I t'ti-i-ilot'll. %%-It II tl;it:i ;IiI-I. I II\- tilt. of ,I '@itii:itlilli '@t;it II, :1 It l@@ ill(. AV@IN- ill oil :II-(, ll :1II ol IT :I I i(lil@Ll of 'Fit,, I)i.olili,lii.4 ti) :ill ai't, til(@ I)I-ol)lt@lli;z of of I ])(Little iti;il-l@t-t ,I Illt,.tlls j I I zt i t I I I I I I, I I t, t I I I'( I I I 0 t' (I (I w) II I,() I I 98-R',2 73 iit(@i)t ill iml)leiii(@iitiiiff i)i(@astii,(,.s to solve tli(,ii- iii( i%-idual problems I leave been bi,oii(,Iit to i-(@cogiiize the (Iiiil(,Ilsiolls of these Oil a POPula. tioii liqsls iii(i liave I)e(@ii ciiible(I to @ittack scielitificaliv, efTec. tli-eli- and evoiioiiiieallv R.111)'.q. ('Ii:tii-iiiaii. ]i,,i%-e (lesci-il)e(I -,i@ I)eiiia the 1110st effee@ tiA-e iii(I tit(, oiil-,. national iii(@(-Iiaiiisiii of 1)@ittiii(,r ltogetl,,r ivliat. Federal 'Istill(lel'-" l@'O"(r'%-e file lit,,'-Lical ,iiliisioli. ]out I (lo feel flat tire R.All' I)I-OC(@ss is tll(@ first stel) i@l eciiineiiisi@iii of lie,,iltli iii(I iiie(lic-,it R'.NIP's ]fare attracted Iii(_,Ii staff iii(i Nvill contii)tie to (lo v o I)ecaiis(- the concept. is soiiii(I aii(i N fiat tliev'j-e doiii(, ii)akes sense. It lias iiivoli-e(i tiiose witl) long experience at tl)e el railcar seri,ice ilit(@i-fa(,t@ wlio believe in their, (,ollet(,,iies. aiid their ciil)al)ilitv to deliver s(,]-%-' I'li(@v know content as well as process. II) iiii State. testiiiionN. to tll, is. li-,ts been (,]%-eii bv resolution-, of siii)l)oi-t fi-oiii the State Ale'liczll S Ci(@t'V. parents of (Iill)etic children. allied ]i(@aitli (-Yroups. the aiid iiiaiiv others. Ti ie strength of this bodi- of R.NIP people witli wlioni I lia%-e tiie iitiiiost pride ill :is:4ociatill(r. is manifest I)v tl)eli- retention of eff(,,.t, staff ;iii(i ibilitN to retain to iii,(rii gear as we i-ecentlv iiifoi,ill(,(l t,,ii-N, Edi%,ards. f)e%-Plol)iiieiit of this (-.ipacitv. Cliiii-iiiaii. does not O(eiii, Over. night. as I ini siii,(@ N-oti \i-ill i(r -ee. '-Not- call it I)c achiei-ed b v FIAT-it comes 1.)i- ](Haiti] L-r tiie concept iii(i exl)erieiicill(y far(. I)IIOC. ess. R'.\IP i,-, -01-el,lic(l I)v til(@ I)eol)](@ '111(i fol- ti)(@ I)eol)](,. It I.(,(.Oglli zes that t)ie to (lo so z-(@(iiiir(,s a staff .11)ilit-v to-,lllel,ilt(I tli(' a(l. miliistl-qtii-e btii:lleii iii(i titiie coniiiiitnieiit that 'prevents, iii(i it)(]"(I detet-,-z the iiii-oli-eiiiei)t in of t)ios(, \-])o.@e job it is to I think tliei-(@ w(-i-e I)PI'tilielit ol)-,Ol.l-qtiolis ill this illol.Ilill(y.s lieai-iil,, to tiiat effe(-t. It i@ iii this ii-ea tlizit A\-(, c(,z-tiiiilv ]life "il@ trust. I\'e ]i,,iN-e :I,, tli(, Soci,etarv fol, Ifeilti) ackiiowle(i,,e(l.fli:it \,oii i-:ii)iiot dele,,,ite new aiitlioi,itvo@,ibillt\.toall old a,,eii(-N-: olit@ that li:is. I)v the slow of comnliiliitv :iriiin(, (,()III(, to lx- Seel) as ;I (.olltl,ollillt, ol, I-esti-letill(- Yoil Cilillot ex. 1)(@(-t (-ool)(il-.Itioii \\-itil ;Ill oi- wlilcli (,arri(@s i\-itli it all pool, ti-,i(-k i,ecoi-(l in tli(, of tll(, (.011stittienev it 'I@ I)o,4(@(I to i-e(.-o,.,-iiiz(@d this iii tli(, eai,lv -\-eai-s. R.\IP's recognize] that all. tlioi-itv )iaiiii(@(I Ill) niii(-Ii (,t-eat@l, tIlqll alitlioritv liaii(le(i (loivii, Those of %-oil treat ill(] ])live to to I colistitll(,Ilc.v will 1.(@(.Ofr lize tliis. For the fit. t tiiii(@ in this (,oiiiiti,N ive (Carol .1 - ICK-ilowle(](,(,Illellt I)\. flat, and (,ozistiiii(ll:, treat ill exists. to lielp in d(-fiiiiii,,, iiee(Is iild witli the cipacitv to suitable I.esl)olls(@. I sti.-gest ('Ii,-iirni,,iii tli,,it R.\IP':-, ii,,itioi):illv qre.tlie oiil.\. tlii., ti-iist aii(I cai)-,il)ilit-,. (-oiiici(le. Tiiis obsez-\-,itioii 1)1- t I ]la-, ali-eidv I)eeii \-oi(-P(l I)N. of the present adiiiiiii@ti-ittinii: :t siii,-mtlai- example of I)eiii(T (le;if to tlleii- owii ol)sei-vqtioil@. Tl)ere ,ire great d,,iii(rei-s inherent in the disni,,iiitliiiL, of tile ]Hill' process. It cannot be i-ebiiilt iiiv qiiic@i- tb,,iii it b,,is it Avill not to :I])NI gi-eit degree \N-lioqe witli entliiii:i@iii anii 175 ded'e-,it'oii: peopl(, N@-itli s(,ii'oi-itN- iii(I statiii@(, fi-oll, wiloiii it (,iii-t@(,ntlv I)i-ofit-z. It is iiin- coiin-ictioli that i-oiii- coiistittieiicv aii(I olii,- ;II-i, i(teliti- cal-N-oti liai-e ,i coiicept tliit ill it@ WIlz(lolll ('011(,rr@@ss I)Ut ilito t(@-xt. that is iin(lotil)t(@dlv efl'e(,ti@-e. t])@it lilis a i-ec-I)oiisiN-eii(@ss that cat(@- .0j@@(,tzz at, iiiiz troi,ical pi able to n)iistt,i-. aiid tliiit lias effectIN-e 10(@zil coll- trol aiid evaltiatioii. Fliia]]N-. ('])ali-niiii. I ii-oii](I i-cltel..It(. fl-ol)l 11IN- 1)1-('I-iolis tt,@ti- nioiii- tliit all til(@,ze J)Ieces of leirisl@itioll liee(t I.k,Nx-l.,Itiila to tlieiil ilito ]life NN-itli tll(@ of 11)74-,ii-,(l tli(,N- (,oiitliiii(- to sa-tlie i-e(-o,,ziltloii of till,, lizi@ bt,t-ii %-oi(,(,(i tioii:illi- ztii(I tt-e I)otli al)](@ aii(I cztl)zil)lk- of tlils e@oi-t. A@-E, ai-(, coiitliiiiall@- till-nli,-,Ii oill. (,N-;Ilii@itioli se(.tioll@. (loil)@, this at tli(@ ffi-az@ i-oots. I\'(, Nvoiil(l \-oil t'I'llf1lelit Ill tIle of ill(' elitli-t, I'l f@ R()(-.El.@. 'riiziiik voii iiiiit-li. 1.)I.. IIIL,:Ill. I aiii ti)(, sill,- COIliril'ittet, NN'Otll(l Ni-elc,ollle zi]iN" ill tllt@ of tli,-@e I thiiik it iN-otil(i I)e N-ei-@- ll('Il)flll. Di-. Hanil)toii ? STATEMENT OF DR. H. PHILLIP HAMPTON H-%-Nii-ro-\-. I ;fill Di-. I-I. Pliillll) 11@iiiil)toii of I'ziiiij);L. a claii Ill tli(2 of ii)e(liciiit, iii(i I lizik-e a-, (-Ii:iii,riiaii of the boai-(l of t]iL@ Floi-l(la I'L@'-,ioiial it@ loii ill I!)(;' ;Ill) t I -. 1 \N-otil(I like to 1)()iiit f)tlt. listc(l oil the i@ coot-(Iliiatoi- of I-'Ioil(lzi i-t-,@iolizil ilit@(11(-Zil I)I-n- I aiii not iii the seii@e of tlit, fill] tiiii@- ;t(,tlN(, I'lizit 11. DI-. Gi-aiiN-ilik, l,ai-inioi-e. I aiii liste(I :is (,Iiiii-iiiaii of cal Coiiiie'l oil l,egislttioti. I aiii ii(-)t t(!stifN-iii(,r to(la.,,- ill that clit(,(Tol,v. I'lie Floi-l(izt i@e(r]'ozial medical ]):is 1)@i(I a i-ockv and coiiti-o- life aii(I b(,lii,(-, cliiii-ni-,iii of the I)i)ai-(l of lt:is I)et@ii one of iiin- iiio@t frusti,atill- At tiriies. national (Ili-(,ctioii of iiie(lical s(@ell)(@(I illlc(,I.t,qlll. R@\11' I-eiioll:ll ol-(rlllllZZItIollS crl",I(JlIZLIIN- t)tCIllle niore aittotiotiioiis and oi-leiite(I to their, pit-ticLil:ii, re(,Tiolis I)i-loritv '\Il"s I)ei-foi-iii(-tt Ni t@l I in tlleli- role of iil)port to iiealtli cai-(, problems. R- lik,altli care 1)i-o\,](Iers as catilvsts fi)i- iiiiioN,,itioii. (,duration aii(i :itioii. In Floi@ld@i. eai,]-,- coiitroN-ei-s\. bt,tNN-e(@ii ,4t:ite nie(li(,Zll seli0ol@. tll(, ])]IN Siciaii aii(i lioczp'tii] of li(@altli (1011(1(11'lllli,r tlit@ @ti,iic- tti@e of the R'\Il) ol,(,r:iliiz;ltioli (I(@IaN-ed foi- -2 N't,ztl'S (Iesl("Il:ltlon of a nonprofit corporation IS tl)e ri-ailt(,(, A,N-Itll title I)Oai-(l of directors p- lil;lllli(,d I).\- health citi-P pi-oN,I(Iei-s @iii(I e(Iiicitioiial (@,i-oiil)s Avltlilii t],@@ The niajoi- portion of the fiiiids iNlLrdt?d and the iiiajoritv of the initial pi-o'k@cts apl)i-oN-ed bN- th(, I'L.111' N-atioiial A(I\-lsoi-i- ('oiiiicil NN-ere iis oriented and liai,dlv al)l)ai@ei)t to practicing @h@-sician@ and I)ati(,iitF,. -@s the I)T-o4,,,riiii lilattii-( t le @, d. iii'ativ of the projects of the Florida R.\IP oiitstaiidiii(,, successes. siicli as the stateside doi-el- OPnleiit of (,oi-oiiiii,v @ai-e iiiiit--. it @-idliev transplant I)rort-ani, a state- AVI(le ii;edical serN-i(,e protein ;iiid o -tli(,r ciii-i-(@nt pi-oi(lot;z de-,6@ib@(T 'ill tii@ apl)eii(led [see 1) 1 sill)l)leni(@iit to tl)e '@Jotirnil of it,(' Floridi '-\I(-,dical -kssociatioii." In accoi-daiic(, with instructions fi-oiii R.NIP's. these pro-raiiis and projects are being tei-niiiiited witi, the total Floi-idt P,,.\IP to be coill- I)Iet(@iv il)):Isetl out I)N. 1!)7:i. Tile iiep(l foi- tlie'develol). lli('Ilt.of ('00I)ei-,itiv(, I)I'ol i(i(ls iiii(i 1, I-. -NONN- that e(lii,-atioii:il institutions is Is (ri e \'( dii@ectiv fiii;til('ill(-r tile ('Ost ofIi(@-,iltli (@ai-(, foi- 3,s of tile I)OI)IIIZI. tioll, tl'e 11(@e(i fo' li:tisoii I)etw(@(," (To\,ei,iiiiielit Ill(l tile I)I.i\-;Ite I 11 qlliz;ltioll I-, S(,ctoi- is gi-eatei- tli-(iii If tll(@ 01,@r will ttke its place ? The recently. ciiacted PSRO law giving physicians the initial ol)l)or. poll abilities foi- tll(' llloiiitor. tuiiiti, to formally tssiiiiie enormous I'(,S s . ing @iid evaluation of health care delivery requires expertise ,Ill(i t(@('11. iiical support. such ,is R.\IP's have been providing. to fulfill tit(, XI)ect"ltioiis of the legislation. R.,\IP's have unique qualifications to cal collimilllitv ii, meeting these needs. assist the niedi The Floridi R@\IP has been involved recentli, in two projects Nvitil the foundation of the Floridt Nledical Associ,,tiion which. if to their logical conclusions. niay provide sonie direction tow,,li-(l iii(.et- iiig these and others pressing needs and i)roblenis in Florida. One of these projects is concerned with ,i studv of alteriiatii-P ii(,:titll care financing ,t-iid delii-erv svsteiiis. In conversations with del),ii-tnieiits of tile State Dei)artmeiit. the Floi@icli R.\IP ,ind tli(@ foilli. datioii have been exl)loi-iii(,r ilie possibility of the foundation the deli\-ei,v lip-,,iltli care to M(,diciid r(-eipieiits. To til' . of adequate Is point. the State Depai-tiiieiit of Health and Relial)ilitative has expressed a ivilliiii-riiess to entei, into q contrict with the Florida I II its foundation. foil tli(@ conduct of (leiiio]I- -\fedical Association. tlii-oila- @,ti-atioii projects in geoarapliic areas foi- the deliverv of conipi-(,Iieiisi%-(. health care to ,II] lile'dicaid recipients in that ,irea. ObN-ioiiglv. to undertake such a pro(ri-ain. there must I)e ,iii ol)(,i-:iti\-(@ syst(@iii and staff foi- I)i,o,-i-ani management. data collection. and I)r&- (,ssiii,(-r that would eii'lll)le efficient I)rocessin(,y of claims for 1),tN.iii(@iits and provide all i-eirioii,,ilized dati I)as(, foi- peer evaluations. The Qe(-oiid I)i,oje@t with the foundation and its peer (-oiii- de\-elol)jil(,iit of iii(,tliodolo-v foil (Evaluation (if ]it-:tit], cai-(@ (Iolivei,-%. N@-iiieli must ,Ilso be dependent oil a SVSTPDI of data tioil a)id 1)i-oc(-ssiii(,r. if pi-opei,lv (lesi(,riit-d iiid iiiijilenieiited the system call I)i,ox-iti,- :I common d,,it.; I)a--(@ foi- iliedi(-al I)j-o(,rraiii iii,,tiiafrenieiit. peei, @itiliz;lti(it) re\-i(,w. P@Ro (,valuations. tji(I health care planning. Such -.;' will facilit;iti@ the (@\-oliitioiiai,v of 'Ilt(,riiative Health (-:irt, financial, :iiid delivery methods appropriate to the needs of th(- I,(,giolls. 11'e feel tliit te(-Iiiii(,,,il iii(i st@itT support ,iiid coii@tilt;it' 1 sei-vi(.es to tliest- actii-ities is i fill)(.tioli of ,III Pt'.\IP :lilt] be in ,iccoi-(] \N-itli rovei,lillielit:ll I,nle@ ill Health receiit]N- 'foi-e call 14ospital Association recently. These are: (1) iiisiire health cii,e foi- tile I)Ooi- :ill(l (2) (-i,e,,ite iiieell:iiii@iliq that will I)t.l-lllit :I private enterprise to i-e@riil:ite itself. 177 State ii)e(li,,:il fi-,)iii I)I;iN.1114-Y 11 1):Il,t III tile of (,ffe(-ti\-e (Iii@ilitv lior the i)liil,)soi)li\- (-xi,i-e@'@(@il I,.%- 1-iilltll' Tii(, 4)f tli'l.@ i@ )I-)\%- to the exl)ei-ieii,--e iii(i t,- t'iitl I't, I) t I)] (1@ .@ II I (-r 1.01)1(,Ill@ of fie,iltli cii-e deli\-ei-i- ill Ol'tlel- to rit@ll\-Ze iiiiin\-@itioll. e\'Ili)li@itiozi. iiid e(Ilic,itioli. [Tez-ztiiiioii.i- i-eciiiiie@ oil -)I 4.1 [Tll(- Slil)l)](,itiviit to III,- of tlit, Floi-i@l;t -1 Florida Regional Medical Program Supplement To the journal of the Florida Niedical Associatioii m 179 Contents Florida Regional Niedical ProgrAm-An Over% iew Granville 'W'. Larimore. NI.D.. Gordon R. Engebretson. Ph,D. and Co.N le E. '%Ioore. Ph.D. 3 Emergen@ Niedical ScrA ices Program in Florida 7 William T. Haeck, NI.D. and Spero E. Nioutsats,)S. -NI.S. Regional Niedical Program of Hospital Infection Surveillance .N. Joel Ehrenkranz, NI.D . ...... 10 P,orida Neonatal Intensive Care Program Richard J. Boothb%, NI.D. 12 Florida Renal Disease Program William %N'. Pfaff, NI.D.. Ben A. X'andcr'X'erf. %I.D. and Don Riede5el Continuing tledical Education %Iichael J. Pickering. Ni.D. 20 Comment Robert P. Lawton . ............ 21 Coron@ Care U-nit Training program Louis Lemberg, %I.D. and Azucena G. Arcebal. '.%I.D. 22 Intensive In-Smice Education for Ph%sicians Arvev 1. Rogers, NI.D. and 5idne.% Blumenthal, %I.D . ............. 25 -Ne@ Scalar Computer EKG Program for On-Line EKG Processing Lamar E. Crevasse. @NI.D. and Niario Ariet. Ph.D . .................. 28 Cervical Cvtolog@- Revisited James E. Fulghum, NI.D. and John C. Reagan, NI.P.H. 31 R-%IP! - RIP? H- Phillip Hampton, @%I.D . ....... .......... ........ ................. .. .... 3(> VOLI:.%IE f4) '%U.%IBER 5 Y\t 4 foi- i grtat stat(@- ilielit. I)i-. E. McBEATH STATEMENT OIF DR. WILLIAM lillii;lii :till] tilt, ol)I)Ol-tlllllt\' to ; 1)(.fo],(, tl)ls sill)- t it e- eoiiiiiiittee to i,(I)ot-t oil tll(' , at s of tll(, i-e-ioiial i)iedical I)i,o(ri,;Inl tl)e ()Iilo I';Ill("V. I' 0 f tlit@ ()liio I .Ifedical Pilogi-aiii-ON'li,\Il)-N\-Ilicll sei-ves ,iii ai-ea '%Vitli ovei, lioii I)eol)](- iii 141 foIli, Stitt's. 'I'lle "("'iO" 1)01111(111"ltl@ Oi-iaili,illx- (lefilit@(i to )I' Iit II t II (@ I III I,s @it II ('i IIIl;lti. IA@NI II Nlo@t of oil]. I-(@4rioll ll()I)Iil:ltioii 'Ill(] ll(,:Iltll [See regioiiii iiial). p. 216, aiid selected liealtli resoiii-(,e--, m.i 1), 1). 2 16 oil ft)l. ()Ill- fi-oill tll(@ fil-st. tilt, (I :11111 liolil-@- ()f ()Ill. li;is I)e(@ii .qll(l of ])I'olllillellt s'zt, i@ tix(@(l. it@ Ve,i], witli -,vo(_ri,al)liie aiid interest i,el)reseiitatioji,,- (,:ii,t,filliv ()f itS Ill(, ) - Si ill] ;II.(. I)IIvsi@-1:111S. 1-2 "(@s(.Ilt otlit'l. lit@@iiiii :iii(i 12 la.\- iiieliii)(@i-s of tli(, fo]. ;I :Iil(litioli'll N\.:l iiiiii, ;It(,,I tli@it the ille(,Iiinisiil of, I-(.. II t to tl.i(@(i to (@ilil)]I:Islzt, tllls ),;It IN, I)] I()Il:ll S(,Ilools ;fill k I)II@ii(illi,_r of tit(. e(tilt.:Itioll ;Ill,] IIll 11,S 1.@ :1 til(@llit@ (-:111 I)(- Se(Ill t])I-Oll,rili)llt 1,111, :111(t is of total.\ I!. to i(@l-iiiiii:ltt, )()]I- ill lit these 41 ') %\t@ fiiii(l(@il 2!) witli ilitilt'l)l(- fiiilils t II (I I1-t II) (,II t S. 11)(@(I i@-:1 I -:It (. t II o@t@ -'I S('(@ I ):I 1-t i(,i I):It i II, :1 of ai-eas. jl)l)ol-t 11,1@ rolle to ;I VIlll(lt\- (-Ooll4lill:ltol.@, ot, :Ill lt'.Ni I),s ill ]!)T.-) ()))if, (f its i-esoiii@ces to ])ol,tloll @ of 17 I)t-r (.(,lit of iiiii- (Iil.e(.t (.I).4t ;IF- (,i)llll)lll,ed to i ii:itioll:ll t)f 27 k -,till (I The 215 (It,\.ot(,tl to ]it Like ;ill otliei- of ,oil" I)"o olit. coiiiicil. III t!](, 01' to Olll':'Illllll- cil. 0111, Colill(.ii ti) tlit- (.oll..Ill@ioll tlj:it If I,, :it.liieN-o i-e(rioiial ilill):Ict. it S]IOIII(L efl,(,(.tlve litiilz@itioIl of !it,:iltli tol.x- tliil(. t!it.;]. title efl,ol oill. \% itli;ll tlii@ tlii-iizzt II lllzllll)o@Vt!l. 41t@\ I" ":Il,!Zu tilt, :III([ ti-ziill,;IIL@ of tilt, Of @Ill)- re,-rioiial I)i@:lltil e(lil(!,Itioll ('011tiliiiill(, e(iii(.;It;loll t It il),-, (lefliolist 1-:itlol) late -,f iiiiie lie,,., ililliti...,(IlltN- liollit@ lltziltli of ()Ill. re @-r: Oiii- e fl't ii-t I I I I I i le(I .1 I I II)i I I:i to )I.\. 1-t@ I i:l f i@k.(l ,II @t :I I,[ I 11) 1) l'o- t'Ir'llils to ,r II(,\, Avitli Cill) of ]lIt-ti.ol)l,llt:lii I.:.Nfl-4 to tot:ll POI)ll- He liai-P ,oiitiiiii(-d selp,-te(i I-el;ited to he;ii-t aii(I i-eii:il :iii(i ;II-(, tise of . p- pi,oi)lejii-oi-lejite,l 1);ttieiit iiietii,-;il ill :1 of -.11111)tll-,Itorv ,Zt)lll(l of tll(l I tlit@ 1):I@t ii-ei@ii. 1)ttotiz. pre- lllatiil,(@ t(,I,Iilillitlr)ll of fiiil,lili,-, :111 too ,I-:iplilc. -NIO@ZT Of 0111' I(-tix-e ll;l\-t- jii@t ilit@ iii-.4t (.)f :1, \-eai-s tilo:.p "-ill I)e ,oiitiiiiied ollIN: I\-itil sel-ioll@ :iii(I ;it cost to) To 'be Sit I,(,. w caii t:ike soiiie (@niiifni't Ili' the @oo(i alre,idv ,iccoiiil)liclic(l ))A- ni:iiin- ()tli(-i- tasks \A--.iit siis- pendea foi- otli(,I,s to 1,1,si.title 1)1.. ()II tlitl Otllill' 11:111(i. ;I 1)01'tloli of tlll@ tifil(, :11111 tiiil@ I';ii- iilx-t-stt.(i ill I)I.o"l.;Illl I'llil(lil@l(r 'Will be lo@t if R.\fl)'s ii-il t4) (11(' liolN.. I'll:it \N-ill represent tli(@ I)i-ox-ei-I)ial stef., bat-kiv:il-d fi)i- (-,tell tNA-0 jiist iiil(lt' fol-- 'w,trd. Ili soiii(, fiittii-t- da\- soiii(.oiii- "-ill to this ]()St (.rl-otlll(l e'vL,zi to i,estart. [Tli(, i-efei,t-e(l to follo\v :1 216 REGIC AL GEOGRAPHY 16:000 P.P.kli.. SC.-, l.'SA 0- KENTI@CKY 00 SELEC'TED HEALTH FTESDURCES 26 ODO 26.000 6 ODD Mo. 1.30, A.k4 TO' T,-, 217 0 O.. PARTICIPATING AGEtiCIES AK.W ..d SI f..d.d a- C. O., S, C., 71 O.", cl@ .0 11 t ittOllieI1 t Tli;liik \Oil .\fr. Ward? STATEMENT OF PAIJL D. WARD ul D. IN-,ti-d. director of tile Cl I- @lli-. IVARI). Nli,. Chairman. I aiii Pa tQ that cattle III) forni.t pro(,-i-.iiii. 1 was .iske(I to rel)]-% to certain poill - . to two Of tileill since the list I this moi-iiiii,,. I would oii]N like to refei- --zt i.ef(@l.s to to to I'll(@ fit lia\-e is III of tll(,Ill de@ning a clear r.ole foi- tile pi-o(,raiii. It lllz-z 1)0(,Il su@zested tliqt the C7 ives tllLt tIleN regions could not find i real purpose 01. .1 set Of Ol)j(@et could follow over the pist -i veii-s. -Since I served ,ic-: cliaii,iii-,iii of tii(' national coordinators dui,iii,;tlie eai.1v 1)ei-iod of t]iL' pi-oi,,i,am. I det-piv it, tile ile,-@oti:itloiiz tilt, (.olll.@L@ that tllt@ 1)1'0(ri,aiii would take and I ivoiil(l like to take just i iiionieiit of -%.otii@ tinic to repeat some of that history. If you will \\-Iieii tile extt@ii,ioli ])ill 3 yeii-@ "I,-ro was 110111(y tlirou,-Ii the Colial-ec . tliel-e wis llill(.Il (li@elisrioli 11)ollt -tvl,etlier oi- not R.\IP's slioiil('l retain itz iiiia,-e. '.\[;iiiv of it" argued iii favor of retainiii(,, the c,,tteLoi-ic;l iiiia, ('re I)eciiise we belieN-ed that to have ,i coiiii)t,elieiisi\-e voii liti(I ti) I)Ilil(l Oil the building blocl,-- iicl of 'lie citeEroi-i(-ii interests to I)e sure of tl;e specialties a eventually voli could I)i-o:t(leii i tile Ilror iiii out to in- ciiide a n'i@i-e coilil)i-elieiisi\-e l e;zc V( ..eIti,,,,,r )it ]live to approach ni.,iiiN- of tli(,Qe iii-ol)lei al I)azi.z. Tiiis were quite a debate an(] ilie -i(Iiiiiiii@ti-atic, ,it their tiliie. was Opposed to tlic, I oil,-ri-ezs (le(,i(led to coii- tinue tile cate(roi-i(,.il-al)l)l-oac@. liox\-evei-. ,iii(I tl;e 1)'ill wis pa--,ze(-l and 218 s',,ji(,(l oil ti),it I)as'iz. Iiiii)i(@(liite]N tliei,(, was -,II, iiidi(,iitioll tli,it filling, !-roIll(-r ti) ]it- Aga'lll, tile qiieFtioii.;4 of tll(@ , :lt(,(r ILN N%.itll the ;,(Illlil)istl.:Itioll ,])(),It titi., iiii(i Nx-(@ I iiiee ilig of til oi-(Iiiiatoi-s i.@ i til;it iii(@t@tiiig II(-](] iii A (liscii-,se(I tlii., I)i-oilleiii with tll(,Ill ;III(] we to](] the co, we liad to the iiitioIl:ll (@N t)L-Lt-ti (@t±LI-Lf -t, )ol.t ;It tllzit 1)(,],io(i of tiilie. Al' of low-illeolll(@ gl.olll)s wei-t@. itieiitioiie(I iii tile Fiiich pi,ioi-itit.@ ])I :it tli:it I)Oillt fl.()iii -,I I 1-v 11 tlioiialit we were (,oiifoi-iiii]IL" %%-itli tile li;itiolil sti-@ill(re to Fti@i@ Lii.Wli o )e sr roii fol, (le@ei-till,7 Tl(, tile I)ill.,Bllt tile I)ill N%.:Is I)I)tll es tilit I ,i(I )eeii -its t le le eli iif -P(- ioii iiid ie Inc I I l@orit@ we ti @tt it, foi. --ih f i@ ow I (I e(,tloll. le s(,coll( I)olllt tliit I like to i-efei- to is the 4() t I t his I)eeii (@liiii'ed is -roiii,-, ilito iii;tii:i(reitieiit oi- qdniiiiistrzitit)ii (if the was f-olifilsill.r to Its ill til(@ I)t,@r'fillillg tlien- i-eferi-iii(r to becaii@e we lot' e- dii-e4,t i-(@ts. I tliiiik is :ill of %-()it kiio%%-. N%-e liaN-e iiotliiilg to s:i%- @ilm)tit the iii(Iii-e(,t (-O,,t 1,;Ite til;lt is'l):ii(i to iii@tittitioiis wlier(@ the%- I)ate III i iri,:Iiit 'I')ie So-(-alle(i let(] rite ai)i)li(-. wlit@ilier .111(l "-e Si PIV f li@N@ til@it that is the I)OI ) ol. tile I Ill . 0 Ill,. Ro(;I-,Its. NI:IN.I ilit(lili'lll)t IN'llilt voii are saviiilr i@ tii:it if ol. tt) :ill ill@titiitioii. tile --T,iteria -how-tli@- x (r)(@@ tlit,l-e is set 1).N, tli(, I)epart)ileiit itsi@lf. ii,it I)v e iliolle.- S. is set ill iii ().Illi (,ii-etilar which sets foi-tll tile @rl@l'.%RD. I'till'Ilt. It I cliai-geabl(@ iteiiis that (-,Ili 1)(@ iii,ei-te(I its iiidii-ect cost. That iii-lirt-(,t cost is tilell lie@)-Oti:lt(@(I I)N. .111 .111(litol. fi-oiii HEII' oi- ;III ;iii,litor fi-olil tile ;)f 1)av that rate. III f:i--t. we tile, .;It(,. 1)(@(-aiise it is iii a fraud iii tij(@ iwai-(l its(,If. set isl( II'(, have Si sli,)iii(i iiot I)av the fill] i-:itt@ sitit-o, -it a ol)viollslv I lot 1. tilo,4(, ti,iiios tli. le listed :is ;I join of the I-,Ite' It liis I)ei@i) said that it %%-Olll(l 1)(, collflisilig if W"r" that xN.(. sli()iil(l (-oiitiiiiie to pav tli(@ so-@-:tlleil "It(, illol'ilifi@-r's ilis- 1, lilit front tl;is, (li,l lot .(,fei- to tliit al'oiie becatise s(,i-(,I,;Il )tlii-r ssi iti-ilis AVOII]D lik(- to tll(, sill),.Ollllllitt(@(, to the (-riiideiiiies wlii,-Ii itilli- to call tliiz @,c- (,,It(, how 0111. flill(I.,4 ;,,.e to ].(, ,tllo(,ati@(l. He have come tioll tit(. s(@N-eii stel)@ to heaven. Tt is a kiiiti tf Ill that N%-e liin-e of tll(@se steps. Tli(@v ai-(@ ill:liitiiiig @l a steps to i-t@gioiializatioii I)iit Noll lql,(, obligated to spell of voiii- 1.(.Solll,(Itl@ foi- t@a(-Ii (;jit@ of these stePs. If voll (10 'lot ill'"' nio'iii(.iit i I)i,o .grain, all(litol. iii(I cb(,els the program lit- r:ii.-A-s Ol)i('Ctioiis for iiot liaviiig ill this wav. 1, tit(. I,,,(r'niial ties 0 ,%II'. Ro(;FRI. '40 f medical tll,"t tl'P.v have asked foi- ,ind that Noll Ill? 211@) .Ilr. AI)soliiteIN-. I,('t 'Ile (,rO ON'("' tllos(, steps. The first, N'Oil iiiiist seek tilt, ilivolveillellt f the medical so(-ittN-. p- tli(- liosl)it:ll@. tll@ NO]III'till'V I@soci,,itiolis aiid iaeiicies. tv I)eol)l(l alid otli(@ z ill(.Illtlil This i,ecliiires iat 1.011 go Olit .111(i Lt-t IKIOI)lt' ;iiitl I)I-ill" ti,t@iii iiito the I)i-o(ri-ani. cei-taiii iiiioiiiit of 1)(. :1111)("Ite(I fol- this ].,Ill.pose. The ii(,.xt is iiii'tli('.Il Ilt'LI(I. %N-o liave i-giied foi- -,I ]oil(, tiiiit, tli;tt tlii@ i@ tlit@ :'.14]i @e I)elieve tll(, :@,141-') zlioIll,l t@@t:illli@ll tilt, fle(,(l of tll(@ eolii- ltillltV :111(l ';Ilolllll ile till@ II(-"LIS to ill(, best of oiir ',)ilit@. Iiiit %,Oil ;,I,,, voti ii-e aii(lited foi- vour st of niedic-,,il .111(i if \.Oil ll()t soill(I ilesoiiilces ill rder to ol)taiii tlie@(- tilt-II \'4)11 llt)t (II)IIE @'olill iol) ('01.1-ectIv. I XA-011](I liistell to 1(1(1 e I)i(,(,Vs of (Izita to et. Tli(@ .-111(i lio@I)it;ils aiid !fltlii-e. a (life] of riiiit- .111(i "ti,ol-t :Ill(] liioil(,I. I'Iiis T(,Il iis wliei-e atieiits coiii I(I final. \\']):it tlit@\. f,)i-. %\-Iiit tlieii- treat- ieiit xvis llo:zl,it;tliz:it"Loli. \\'Ii:it t)it, di-t:tii,.@(, was foi- I(, I)Ztt,l(lllt. :Ili(] it!ii-i. ififol-ill;lti(.11. lik@111-: li@ to lo,.:Ite 0111' litlil(Is nd it is liiit this @lii)iiiii iif)t 1)(@ I)i-iiiiai-ilv oiir -spoilsil)llitv. It sli(ill](I I)e tlit@ .)f tll(@ :11411 ut tliev ]live ]lot lll(l the to (to tells. ,\-(.Xt, w(@ II., 11(@ tt) tlit@ of tlit@ foi@ f le(,t ill,, tll(@s(@ ,late Is. it is ill tlit@ TI le ;I"ili- -es. tilt@ I)I'Ofl'@SiOll:ll-: :1111 I Iltilk-l' ]Tilt it is liot I)Ilt .111 of ;Ill(t iii:ik(@ ;III il)oiit \-oil I- of tli:it kii(i tlii@ is oil(, f ill(, v tilt- :114B Of this iz doiie iF- to (-,ollllllitt(@e ?t-, tilt-, -;tli i,itilt,l, si@t tlit@ I)I.Iol,ltlt.s ill ;I 01' X.Oll :111 (rlill tlil@ :I(I(Iiti( )11:11 (I:lt;t to st,t Ill(.:Illill,-,flll LXt(litt tli:lt \-oil tiollii-@ it; tlii.4 it takes IW;I'% roiii N,oill. ol@L'I..Itioii:il Tlie' lit,.xt st(,I) if oil will. A,,;iiil. Illotll(@l- sti),.\- i-: s(.t f,)I.tll k lot of @\.Il:lt NN-e ill 'I'llis of f f;l--t trivial to 1)(, iiii(i (@d I)\- otli(@i- soill-41(l.11 of fliil(lill,". (It. (1011:11-S tli:lt \%-(, sl)f.llt ill tli-,it will (' fiiiid(@(i I)\- otlit.l. :,,.e is iii-,ikes 0 Sells(, ill xvi@ rt.,t (11)\Vil to tilt, ll'i@ fiiiid tilt@ I)I-i).ri@,1111S I)\- 0111' Stk-l) is tillil. .\,;Illi;ttioll (@:lii 1)(@ (10110 ill I sit@)I)Pl "I\. 01. it (.:II) I)(. til(@ of tl:it;i 'I'o the tliit %-oil wiiit ) ilo it IN-t@ll ;11141 t I,.\, to ])I-o\-i(' fill it too (,Osts 'oil(.\-. ]lilt lt@t fill. t'.11 \.,;II tilt, Iit,.Iltli trivial. iflol.(, tillii ikiii- otlii,i, field. it,ks'tii(,;Illill,,rill t Zile Of iliol-I)i(llt\- ;Ill([ )Ill(- (1011;11.s to ol it;liii (I:lt;l. jil-4 (.:Illliot (I() it :ill(] \\-]lo 220 saN-s lie call do it is lot teiiiiig the truth. If -,-oii look at tile adillilli,- ti,atix,e cost.s iii tei-iiis of tlic- giiideliii(!s. it least a iiloi,e liol,,.,t iilterl)i,et,itioii of tlxeiii. iii(I a(Iiiiiiiis@ratik-e costs iii the accepted classi- cal d-fiiiit'oli of adiiiiii'sti,atioii, it coiiies iiiiicli iiiore close to - e I I tliaii it does to the 4(i 1.)ei,ceiit. '\Ill. ROGEIZ@. Pel'Cellt ? Mr. AV.I.Ri). Sex-eii pei-ceiit aiid the 7 I)el-eeilt is ,,,iviiig tliejii tii(. lieiit,. fit of the doubt. -Now we liaN-e I would be liopeftil aii(i if you would iiiake i)ai-I of the i-ecoi-(I-we have prepared a bi-eik(IoNvii of the l@i-o,,i-aiii exi,@c-ii(littii-es iiatlo]IN\'ide, %vliicii insNA-ei,s iiiiiin, (luestioil@s raised this iiiol-ilill'-'. IN'licii :11)pl.o.,tclied about tlicsc, wlieii asked how do we kiionv tliit tlien, are accurate, let iiie tt,ii this. 11'e had vii-titilin. tile N\-Ilolt@ Pi-og",Illi. ojice it was about ti; pli,ised out, ttirzie(i iiiside out to obtiiii these pit-ticul,,ii- (lita. I\'t. ft.(.1 tliei- are a 'ctit-ate. iii(I iio olic has galleried tlieiii todav. c 'fliaiik i.ott A-ei-%- iiiticli. Mr. Ro'GERS. 'l"iiiiik voii N-ei-N- Israeli. IN'itliout objection that will beiiiade a partof the record. [See p. 221.] Are there al-IY highlights that we sfiould direct our atteiitioii to Mr. HARD. 1 lioticed this iiioriiin,, the question was i-,iist-ti ;,I.Ollt the actual iiiiiiil)ei, of people treated oi, sei,%-ed by the pi-otrt-;iiii. 'I'll')S aiiiaz(,d us. but we call 'back it tiT) with facts aiid figures. ll'(@ -ii-otiiid tfic t'nited Stites, perhaps iiioi-t@ Iiiiiiil)ei- of fi@ee cliiiics , area tliaii otliei- places. AVe did iiot provide the seri-ice iii tIlost@ IVe (lid iiot i)av the doctors. but we were tble to get voltiiiteei- fi-oiii the ii@edic,,il societies ,iiid otliei- qi-eas aiid also fi-oiii tlit@ N,,- tioiial (;ii-,ii-d which proved to be a very ,-,ood source of doctoi-,,. Ill that area aloii(@ iiatioiiN%-Id(,. I)ettei- tliaii 3 million I)eol)lt@ sniiie kiiid of ti-t,,itiii(@iit iii tll(, kiii(is of 1) I'llilarv ell,(, svst(.Ill tli:it creating b@- this '.\ONv we are tile fii-si to @idii'iit we di(] llt)t ]):I% foi- tll(@ sel.%.i(.e. i)llt w(@ found ;I WIN. to I),IV fol- tile k lot I;f these projects blended into county support or sonie otlici- kiiitl of siii)])Ol@t. 'I'I)t,y would not have I)eeii there without our liell). 1 thin],. sl)eaks foi, itself. eitivi-(,-eiiev iiiedi(.;Il Al'e not oiiIN. il'Ol-e E.IIS programs tIlq]l aiiv otli(@i- source ill tll'(, U-Iiite(i St, t iiiost of the 1,C) million tliit for 'Ites. ])II ,ii-@-ed fluids wei-(@ 1)i-o,-,i-,iii)s f i-oiii vai-iii pi-iiiiai-ilv I)v IRI.\[P. Al i-(@ceii-ed fluids fi-oiii outside of P,,'.\Il). II'lit@ii Vol] total tile iiiiiiibei- of i-)eol)le who received sonie kind of :is it result of R'\[P (@ffoi-ts in I)i-iiiiai-v care, better tliaii 1) iiiiiiloll ei-soiis in 1()7--) aloii(, (-are. This is not an iiisi-iiifi(-:iiii p when i-oii coiisidei- that not eV i,vl)o(lv needs i doctor evei-v N-P:I I.. ()ill% e a 1)01,iioli of the Pill)lic goes to title (!Octoi- and this is. I think. :I meaningful fi(,riire. I would point out that we ]life I)eeii asled to participate III ell-,ioii lll(,Ptillas recently. I list(@iied to oi)e pi,o-raiii ,iiid to tlii- t e- of its continue.tion. But ,it the saiiie tinie I had to reiii(,iiii)t@i- tli:it :ii iiiost evervoii(- of those efforts was financed directly oi- R3fP ,in(! tlye livl)ei,teiision effort would virtually di-ol) (](,:Ill :1@ if Febrii,irv of tliis'v'etr if soiiie quick iiieaiis is not taken to contain-, its fin-incin'g- [Testiiiioiiv resiiiiie-- oil p. 233.1 [The report referred to follows:] 221 SPECIAL LROGRESS REPORT REGIONAL tiEDICAL P@OGA"' The fo )lowing su-raryreport, ini@iaI findings of a special progress report of the 56 Regional Med ic al Programs. The progress was analyzed for three program year periods beginning with 1970, including 1972, and projected to the 1973 program year. Many v n Regions ha"e already initiated those acti ities i cluded in 1973 projections. Each RIAP provided comparable data which serves as the basis for this report. Measures of progress and assessment Of irmpact is divided into five basic sections: ..... Benefit to Consumers ..... Benefit to Health Provider Community ..... connunity Based Activity Resource Allocations ..... Location of Effort 1. Benefit to Consumers The RMPs have had a rnajor impact in serving health needs of consumers. lv Served While RMPs do not ordinarily provide d irect health services, there are numerous instances where direct services are provided as art of a demonstration. Examples include:. (A) people p .ng project, (B) patients treated screened in a multiphasic screent by project staff of a demonstration unit for specialized cancer care ,or (C) patients seen by a nurse practitioner or a neigh- borhood clinic supported by an RMP. 98-5-12 0 - 3 222 The following table summarizes people directly served in ner (all tables rounded to nearest thousand). this man TABLE I PEOPLE DIRECTLY SERVED BY RMPS: SUMMARY 1973 ,749,000 Primary Care ,064,000 EMS 000 4,143,000 085,000 All Others I S 000 9,640,000 13,898,000 T Table 11 summarizes in further detail People directly of RMp activities. important trends are served in the course the increase in peop Ie served in primary and emergency care and the decrease Of People served in "heart disease." inclu- ding oronary care. A projected resurgence of effort in hyper- tens cn indicates RMPs' flexible posture to respond to io opportunities to meet local needs. TABLE 11 PEOPLE DIRECTLY SERVED BY RMPs BY PROGRAM CATEGORY 0 Primary Care 00 Emergency 00 Heart Disease 00 Cancer I o: 00 48 000 2 0,000 stroke 41,000 Kidney 13,ooo 33,000 .000 I ooo Hypertension 00 Pulmonary Di3ease Health Services/E Activities Conso 000 Other Shared Re@ 000 223 . . . People served by new types of health providers or those who have acquired new skills The RMPs have made substantial progress toward accomplish- ment of their early mission of "bringing advances in medical knowledge to the bedside of the patient." For example, many physicians and nurses have developed new skills related to coronary care units; many stroke teams have been developed; large numbers of neighborhood health aides and clinic assist- ants have been trained, etc. Also, thousands of health pro- festionals have improved or upgraded their skills to reflect new findings and latest advances in patient care procedures. Table III below summarizes services to people during selected one-year periods after health providers developed or improved their skills through PMP activities. TABLE III PEOPLE SERVED BY HEALTH PROVIDERS WITH NEW OR IMPROVED SKILLS 1970 1972 1973 Served by New Types of Hea Ith Manpower (e.g., 969,000 5,033,000 6,203,000 nurse practitioners) Served with New Skills developed in existing 19,383,060 25,392,000 32,524,000 Health Manpower Served by Improvin5l Existing ki is of 41,052,ooo 64,086.ooo 74,006,000 Health ;anpower . . .People served by increased cap th systems The P.MPs have served consumers by supporting the develop- ment of increased capability of the health system in measurable ways. For example, several P.MPs supported the development of a transportation and communication network for emergency situations In a defined service area; %everal RMPs markedly improved the accessibility and availability of primary health care by thedev- clopment of health centers, clinics, screening programs, and disease control activities. The numbers of persons "at risk" for that specific situation in the service area were thus served by the increased capability. 224 Another example is the number of heart attack victims in the service area where health system capability was markedly increased through RMP efforts. People actually using the system are counted in Table 1; people "at-risk" or potentially served by increased capability of the delivery system are sum- marized in Table IV. TABLE IV POTENTIAL PEOPLE SERVED BY RMP DEVELOPMENT OF INCREASED HEALTH SYSTEM CAPABILITY 1970 1972 1973 Primary 37,725,000 67,798,000 74,458,000 EMS 24,425,000 71,937,000 75,696,000 Regionalization of Secondary 6 Tertiary 82,583,000 92,476,000 76,770,000 Care . . .Peoole served by. ce programs The RMPs have increasingly invested resources in foster- ing the development of SY 5tematic programs to improve the quality of health care. The RMP definition of Quality of Care Assurance refers only to systematic efforts of determining deficiencies in individual or collective acts of medical care, developing corrective action, and implementing activities to result in demonstrably improved quality of care. The RMPs more than doubled their investment in quality assuran Ca programs between 1970 and 1972 ($4.5 million to on respectively). The projected 1973 expenditure $h9asmialglaiin almost doubled the 1972 expenditure ($14.6 million). Quality assurance programs have also had the effect of moddra- ting costs to the consumer (e.g., fewer days in the hospital, less "overtreatment"). Table V summarizes the RMPS- accomplishments in this area of patient service by demonstrating the extent of RMP staff involvement and the numbers of health providers trained in medical audit, problem oriented records or PSRO activities. Dramatically increasing numbers of in-patient and out-patient facilities are participating in RMP quality assurance programs. 225 People "directi Y" benefited are those patients visiting in-patient facilities or admitted to out-patient.facilities during the time remaining in the year shown afte the quality assurance program was developed. "Indirect" patients bene@ited are the people served by the institutions or offices where quality assurance programs have been fostered by RMP efforts. TABLE V PEOPLE SERVED BY RMP DEVELOPMEN7 OF INCREASED QUALITY OF CARE ASSURANCE 1970 1972 1973 Professional staff involved in planning, 1,208 2,438 2,975 development &instruction Providers trained 6,872 58,574 Nurr.berof facilities par- ticipating in Quality 1,165 3,312 8,269 Assurance Programs People directly served by Quality Assurance 4,572,003 l@,585,OCO Facilities People indirectly served by Quality Assurance 37,911,009 65,152,OCC 87,505,000 Facilities 11. Benefit to the Health Provide RMPs' efforts have resulted in a substantial number of innova- tive, new types of health personnel to provide needed service to American citizens. For example, RMPs have supported train- ing and placement of nurse practitioners and physician assist- ants to extend the services of the family doctor in underserved rural and urban areas of the nation. RMP efforts alone in 1970 resulted in the addition of some 7,500 persons of this andother types of critically needed new health manpower - By 1972, almost 14,000 people had been trained through RMP efforts. Projections for 1973, based on the RMPs' program requests to RMPS, indicate plans to train almost 38,000 new Allied Health Professionals to serve in essentially new roles to f.ill gaps in service. The RMPS have provided opportunities for a wide array of health providers to de velop new skills or improve existing skills In order to provide Improved service to citizens. Table VI surmnarizes the numbers of health providers who have developed skills in RMP-supported activities. TABLE VI NUMBER OF PROVIDERS TRAINED 1970 1972 1973 MD DDS DO New Skills 13,561 16,164 9,567 - Existing Personnel improved Skills 62,323 62,153 65,924 - Existing...Personnel RN, LVN New Skills 38,159 42,812 28,845 - Existing Personnel improved Skills 79,030 95,480 106,557 - Existing Personnel ALLIED HEALTH New Types of Allied Health 7,526 13,825 37.926 Professionals New Skills 34,641 48,663 48,158 - Existing Personnel improved Skills 6 lo4,144 120,662 A C.@.n',t Br,.d Activ"t The RMPs are a decentralized national program working with local health provider systems with decisions made by a broad-based local citizen and professional advisory group. The RMPs have large numbers of volunteer citizens concerned about involved ar volunteers health Pro blems of the nation. Almost 19,000 regul serve long hours, often at considerable personal financial sac- rifice, to study and act upon health problems lrf a way that is 227 best suited to local situations. RmPs' regular voluntary advisory structure includes: Number % - Members of the Public 4,505 23.7 Doctors (MD, DO, DDS) 6,920 36.5 Nurses and Allied Health 4,090 21.5 Health Administrators 3@469 18.3 TOTAL 18,984 100.0@@ Of this number, over 2,600 advisors are from minority popu- lation groups--a significant proportion compared to national averages. RMP staffs are a unique and effective blend of the wide range of skills, training and experience necessary to move effec- tively toward solution of today's complex health problems. In 1972, composition of full and part-time staff of the 56 RMPs was as follows: Number % Doctors (MD, DO, DDS) 1,691 18@B Nurse5 and Allied Health 2,294 25.5 Social and Behavioral Sciences 2,434 27.1 Supporting Staff 2@569 28.6 TOTAL 19 100.0% Of this highly qualified and experienced staff, 1,617 persons were from minority population groups. Few other federal pro- grams can make such claims. IV. Resource Allocations The RMPs have allocated their program funds in four basic programmatic thrusts: . . .More effective use of manpower including new skill de- velopment, improved skills, sharing training resources with underserved areas, and coordination and improved utilization of health manpower training. liability of Pr ces such as fam center d ambulatory care centers. In response to a recognition of severe access problems to pri- mary rare in underserved areas, RMPs have projected more than twice their resources to primary care programs (including EMS) in 1973 than in 1970 (approximately $37 million projected in 1973, $24 million in 1972, and $12 million in 1970). . . . nd tertiary (specialized) care i sharing of Scarce resources such a purchasinganddirect categori- cal dii , cancer, stroke and others. While percent of total dollars devoted to efforts of regionaliza- tion of secondary and tertiary care has diminished SI ightly, Rmps have actually increased the number of dollars invested indevelop- ing shared resources and regionalization of care in cancer,heart disease, and other categorical programs. . . . re Assurance i@cluding RMPs' work withhospi- tals, ar ments, ano physicians in privatepractice to sti audit and improved medical records as a method of assuring high standards of medical care. Table Vil summarizes distribution of RMPs' resources. TABLE Vil DISTRIBUTION OF RMPs' RESOURCES 1970 1972 1973 Function More Effective Use of Manpower 24,1 24,790,000 29 30,930,000 27 ibility of Primary Medical Care A. Primary 11,4 3,000 15 18,205,000 21 28,427,000 24 B. EMS 5,695,000 6 8,637,000 7 R.g',.n.r-zat',.n of Secondary and Tertiary Care 23 26,675,000 23 quality of Ca 0 6 8 14,622,000 1 3 Assurance Ad,nin'.Str-t'l@ 62,000 14 11 ,o4g,000 100 116,834.000 100 T 0 T A L 75,000 229 . . . Ad-,ii n including relating the program to the gr ons. They show a substantial (50%) decrease from 1970 to 1973. This trend reflects the fact that as RmPs continue to become more efficient organizations, more program staff time goes directly to service programs. Conclu- sion is that RmPs are wel I honed, efficient organizations, and have become increasingly so over the five-year period studied. V. Location of Effort A previous study of nine Regions from which data were readily available provides an indication of RMPs' resource allocation by location of effort. Rt'Pt have succeeded in implementing a greatly increased number of progra.-is and projects located in community organizations and community hospitals while retaining their efforts located in .nedical schools, medical school affi I- iated hospitals, professional organizations, and voluntary societies. Simi far data are not yet avai ]able for other Regions. Table VI I I summarizes the location of effort of the selected Regions. TABLE VIII LOCATION OF EFFORT IN SELECTED REGIONS s 1970 % 2,943, 16 2,234,000 11 7- 2,406, 214,000 11 4,218,1 574,000 22 2,260,000 14 February 8, 1973 PEOPLE SERVED 0 0 1970 19 7?. 1973 231 Pro\/'idet-s Tr3ined 1970 1972 1973 MD, iK,3'-3 1 5 3 DO RN, LVN 4 2 A- 1'2 4 5 ALLIED HEALTH +S,l 56 3Z5 13,t moroved new new impr@ new new imc ,ew new i tTes skills sg'ills tyys typfes 0 nd f)ersonnd e@ist:i.. perSOnrtl exists perscnriel existin permnne@ personnel PerSOnne 232 I(.)70 197'2 ,,13 adt,lin'tEtrative, CoSt-@ el Re j 12.5% ui more in e@ve, \/ @ Of yp_ mnpmer "285% ta yatiiy cart asr,uranct ;m@ro,,e L 6"1 675,5 67,049,000 0 0 NL-M6er of inst;tutions it, Quil-ity of Care 3,3 233 -,tiik voti ioll@. 4)111\ to TO coiillll(lllt otlici-. l'i-ettv -o,r I ',IIII ;I ft I- 1) I - 1-11 ."(,t@ sooii tlit@N. )it . I " fill II "I, II,,, SI)ell(lill@-r ''Jose Oil itlliiilli7-ti :Itl 1) ;t II (I I t t ),-r, IIIt' I ill )fit, NVOII(I(:,. if (111 .:t, '1)11. it 1) ]it :11.@ Oil" 110 )(@ of (toil)", ;' I,)I, of ;Ill iiiii-ti 11 t'lloll"]l III)T tile iiioiie\, to to :it fOl' if r- tliiiik w(, :Ill \%.(II till 11 \- liot i(lits of wilzli voli Ill\ - ;I ]);it the t,olil- f !I;lt tll;lll oiie illotl)t@'. e little if I)c@voll(I flit-ill t') llt!tlkl lit-II, T'ii:it Fli--:t It-I 'lit' iitlt@t@ fo 0 ( I i:IS 1, 'k@ got \,e t :1 T!li 1)(.fl)re it \\@ll fl-04, ,'II, t, . iiii(li@i-,ztot)ll till, tile liee(lell ;It tlit@ ('411111111111it\- I)Izll .I tell ol ilito tli' I.: 'k' @11141 lill)l,tl 'I, \Ve r @t Of tll itil(lel.-Zt:l ilk, - ' \. f 11101'k' :11-ilitiE- -tilt,v 11 - I,t!t(! 1)],Ill to (loii't kiio\V \\'ii-,It tllL'\ oil( to. . liot \\':Ilit 14, _,4) I)Ilt :111 illiv 1;iol.(@-to (le\-elol) :1 .\. . ' LI title fill. i I I s t I i I I,-,@ I)Iztll tlilt ;t till-ll(.it I( . ..I. t i 11 , )W" I I ll:il,t of it, llt'v ell tliev (.@iii to 'Ill(, iiii tllt.ll 1. ;Ill tl,,,\' to fliliill. ( )]III llli@ ]lot to -NON\-. IX'ill) Ill )Osit ioIi ll()t I() t'i,lzlttl to tilitt 1)], 'Ili li;t\-v lot st,eii .t :')14B ti-e eiitii-el.\- t"-o tlill't'l't fit ;Ill(l all) oil ;Ill s(lell ;Ill f.11-ol. of to iiill)lt.l ]lot Ili, qiiest) itil Of tile 1)1:111. Ile it iS liot ill it tile I)IIIII -;Ilolilt Mr. NELSE-,. You are det)eiidiiig oii Federal dollars. aren't you? I mean, without that stippo@t vou -would not be able to carry on the program. Is that so? Mr. IA'ARD. NIOSt regions could not carry on the program. I suppose 90 I')ei-eviit could not. 'I'liei-e ii-e some i-e@rioiis that have otilet, Sources of income and there are some i-egions that have been doing things sel),t. rate from R.L\IP dollars, but that is wav in the minority and the \-.ist part of the program would be crippled if the IR@IIP dollars were not ihere. Ni.LsEN. A\'e ii-e running out. of dollars here too. That is olit, of our problems. )i-ever '\II-. E(K;t:its. Tli-,iiik -%-oti. Ali-. I .111'. PRFYER. I'liaiik- you. I think- this testimony has been ver\, ful. I have one question. Dr. Iii-aall and others have spoken @f pride in theii- associates and pi-i& in their ability to retain staff in til' program. I wonder what is happening under the present stances. Sav. within a month from now that Congress extends this I)i.o. gram for a veai-? Will you be able. to retain your present staff @ IN'ii:tt is happening in that area right now as a result of the present c'll'Ctllii- stances ? Dr. I.NGALL. I would like to speak for mv rogram and in the iiifoz,- p matioii we have ali-eada. provided to Secretary Edwards we answered these questions. Currently I have lost no staff and no st;itl' are intending to leave between now ,ind September 30 of this 'I'liat (rives x,oii t x,ei,N. sti,oii(r parish i-el)]@-. The composite i-epix. fi-oti, the coiiiiiiiiiiiti(@s is A-ei-N. (,iicoiii,aLriiig. Tli(,i-e is one exception that f(@(.Is thev could not really get. going ,igaiii. but. out. of 56 programs that Is 'I 1)@ettv good Mr. RorERS. Dr. Hampton? Dr. HA.-,XPTON-. III Florida regional medical programs our core stiilT 9 -is it is hoped tlie-v will have fuiict' intends to be present as ]on ioli@ to perform. We have lost some clerical staff. but none of the essential (-Oz-(@ staff. '-Nlav I speak to this iiiattet- of the 0 ercent over ie,,i cost wlil(.]] Is i-id:i r @onal medical program admiliistl-:itix-j, definition. is less than 5 percent. If voii take, ili(@ lie e-,peiises of the coi@e stiff which is f,,ii- I)e 'x'oii(i adniinisti-atiN-(@ in tlieii, tctivities' it is oiilv 14 percent. So I (lo flot understand this 40 percent administrative overhead. -N-ow. I sli:it-t@ Di-. Cai-tei,'-, (-ojicei-ii -ii)oiit some of these projects. ,ind hive front tli(, ;III(! tli(, institutions sti(-Ii ;I:, medical schools tliit threat' automatic oN-ei-i-ide oi, -,administrative expenses. As.Nlr. Hard saN.s. %vi- -sitv of Florid, foi- ilist;iii,-I- ,ii-e liai-dli- iwij,(@ of that. I)tit if the Univei -I gets ,i project from medical I)ro(,,i-a@i. that. is @100.000. this is r- not ineltidiii,,, equipment. that would be for the operation of tli(@ ;III :11)ollt $55.000 extra foi- i,iiiiiiiiic, the iiiiiversitv. Tlitt includes the sal:ii-v and the janitors. Ali:. ]3iit tli;tt (-oiiie;z fi-oi)l TIEII' ,iiid the Office of 235 Di-. HA--NIP-rO-,. Pialit. tliit is aiitoiiiatil, -,iii(I the,' tl'eN assit'll t t to us ,is beiii;zox-erliead. But %%-c, iiei-ei- '@iezil-d of it. Alr. Ro'-ER@. That is wli;it I tlioti,rlit ill(, %N",Is (1r),Il" fi-oili G .- I ?- I , some of tli(, I liid seen. adi-is, Dr. HA3ii-ro,\. I questioned tlit il)illtN-. i.@ -Ali-. IN ii-d s,,ivs lie has. He s,,ii(i Iii;z w .Nlr. ROGER-4. is 7 at it iiiixiiiiiiiii. and 1-0111@@- I)k'l'('Cllt Iiiqxiiiiiil)i. This led to niiiin- i-erv r. iniit@c coiiti-oi-ei-sit@s of wlileli I -,till bell- scir-q I)ecaiis(, tli(@ medical schools Nx-e)-e i-eallv III)oii NTH .,-ri-aiits to fund tliej.ii,@elx-es. That is the oii]N- @vtv iliev kel)t wliirli is t to run .t se)iool.'Aiiii tlit@N . lookeil til)oii tli(, RATP ftliidz is the Sam(, soy-t of tlit-x- ivoill(I to i,iiii tll(. sclioolz if tliev ]la(] fail (,oiiti-ol of -tlit, fiiii(l@. k;4 Nvt@ let tlio@(@ initial (,Yraiit-,. at the %x-o xi-oiii.1 ;ii)otit the of fiiiidQ ,iiid we tolti tliit XN-:i@ alone of voiil- I)IIsilless. I'li;it is 0111, moiiev now ;iii(I I%-(, will 110 l@-itli it ;I-; IN.(@ fit. Fiiia]]N-. I had to enil)lol- Pee to niakt, iii qiid@ e-et NV rl (I out %%-Ilzlt (I()iji,(-r all([ that ilee(](@(I (I(..fillit(. kttt@iitinii. ]Hit t)li@ is ;I 1)1-01)li,ni in nie(li- ea] III the, ;Ill(l :111(l the (Iii(@stioii is xvlit,tliei- this slio'iil,l (-Olltllllle :laid I)e I);Il.t of 'IctiN.itv. You sav t.]);it N-oti iii;i(it, soiiie (@\iiiiiiiiatioii ill(l -,.oil it oiit. yoii laid ill(, Iiitllol.it\- to (to this. didn't to ])tell soille out tli-.It St r@ill-r Ye.,: ive did, it, I woii(l(@i- how tliizz ties in with the testimony we heard this moi-iiiii(,. s(,t,iiie(i to I)t@ ei-itl(-istii of HI-'IIl': tli@it tlien- did not direct tli(- pi-t),,,z-aiii -kii(I Yet it iioav appeals tliit N. oti have this iittlioi-[tN-. Isii't it l,le tli:lt soiiit@ ll;l\-e ]lot (loans NA-ll:lt you have done. Tliev list stepl)(,(l in to strai!rhteii tliiiiErs out. Di-. H.\ -,\I r-s .N. I ( 'o have enil)!' N-e(I out- I ii't k-noi\- lio\\- iii:iilv I)i-o-i-@iiiis 0. side ie(-otliitiii,- fii-iii-, to iii;ik(, iii @\ft-. I tliiiik tile 1)oiiit we :it,(, tt.\-iiia to make is that tlio-Qe that ]I-,I(l ]lot out St .)oil ](I liai-c bevii (](@alt with I)v HFIA'. it-,I(l tlit, illtllol.it\- to (10 so :Ind. ol)l-iolisiv. tll(,N- ]I'll-(, ii@t doiit, it. E:ii-Ilei- to(lt\- tlit@ (iii.(,(.tol. of tile t)l.ocrl.,Illl Ilillicelf said tliei-e.wei-c I)a(i III- )I;I(l tll(@ ilitlioi@lt%.to Staunton them out. That is wliit concerned tile. .Ali-. ('ai-ter) -Ali-. I'li:iiik voti articles Di-. \Iclieatli. \vliat (to voti \-otii- mandate iiiidei- rezioiial medical foi- voiii- acti4-iiis in l@(,iittickN' I II'liat do voil think You are gtipi)ose(I to d'o tecoz-diiir to ill(, ]aNv? I. I\lr - Tit The Ite-ional '\fedic,,il Pi-o-i-.ini Act as it exists now I r- i rather broad. but it cleiriv iii(ii(.:It(@s that we should woi,k--iii mv opinion of the interpretation of it-witli our Council to (letel-mill e- what the needs of otiz- ai-t-;t ire zid lioni- iev ciii -vv the c 0111, the 1,0(,,Oil)tli ,I,,eeds that i)ai-ticulai-IN- call be addressed through re(ri-ol-,,t,l 'It I-e .Nll'-('.ITZTER. Ili-. ('Iiaii,iiiaii.lAvoiildliketoaskacotiplp-of qu(,.,itiol)s. I)oes that iiieet in-itli votii- coiicept of the Regional Iledical Act ? .Ili-. Roe.FRs. I think we fashioned the ,ict to be iiioi,e cat(,(r Ifl'. ('ARn.R. II'lltt was it. foi@? L-0 '.Nf I'. R(K;Elts. Foi- cancer and stroke. CARTER. And kidiiev. ROGER,. And ki(IiieN- and related diseases. I think the a(iiiilf,l,,- ti-atioii of the ict has I)i-(;ti(@ht that into less categorical- CARTER. -Nei-ei- Once did I)i-. \fcBeatli mention oii(@ of tll,, 11 II-- I)OSes foi- %viiicii this ict was wilitteii. Not once. I i@i .\II-. ROGERS. lioi)(, -,,Oil ii-e doiii(,r aood woi,k (loi\-ii '@ilit it seeiiis tli;it \,oi tol,!-rotteii tile (r I jl:IA,(, oi S. in-liat is Ai itt(.Il ii, I II,- I I'll-, )e(@ll ]II eri.)i,ete(i ijicoi,i,ectiv. I i,eiri-et t ii@ICI@ aii(I is iie,,tz-t. HoNr mtic I iiioii(@@. %-eji ii(-v III votir v,@ ev region ? I)i-. IlcBEATIT. 11'ell. I believe Coligilesstiian C,,ii-tei--](,t here -,I secoii(I-oiti- It-,t fiscal I)ei-iod w@is not i 12-iiioiitli l@lit lia\-v the i,e(rioii's exi)(@iiditiii-e figxires here foi, the last l@Q, i'ilolitli@. tll;lt.-,zltisf;l(.tol.l- ? I'Iiis is oiii, fiscal l@)72 period. All'. ('.@l,-rFR. 11'e (';III ttke two-thirds of that iiid ficriii-e. I)i,. Tiiit :iboiit $2 million iii direct costs. .\II'. ('.tRTER. I the cojiil)titer printout here that I Nii. 2(). 19,-2. 1 stil)l)o,-e. gii-es S.@) i)iiflioii iii one else -,iii(I iii -ise --).')72.0()o wlii(,Ii NA-oiil(l 1.)p i little bit iiioi-e. III another, s:;.- ()21).I)()(). @@ii(i liav(, voti reached (lovii iiito these coiliiiltiilitl,-,. into tll(. (.01111ti(@F; to ti)(@ I)ll-% Siciaiis to ti@v to (,ix-e them :111 I)oi-tiiiilt\- foi-coiitiiiiiiii(re(Iii(,:ttioii '\I( 1)1'. . ']iE.\Tll. A we f(@('] Olii-coiitiiiiiiiig education ictii-iti,@s de(-(@iiti-;tlizt,d, pii-ticiiiat-I.i- in the orbit ii-oiiii.1 II,,. of Centralization call cover a nitiltitti.i.@ 'If sji)s. ki-P \,oil e(iii(-atiii(,tliose doctors doin-ii tliei,eit tli(@t,iiiiiit\ IN,(@ Nve II-v. la\-(@ \-oil been in some of these coiiiiti(@s@ ]Sell it ti,tie tli:it N,oti I)e(-ii in soiiit, of them ? 1)1'. ])as 121) cotiiiti(@ and there iiiii- I)t@ Solely. -f tli(-iii I iiot I)eeti iii. 1)'Iit I NN-oii](I s:ii- I been in Di'ost. I am ;-,-Ohio to tell i-oii tliei,(, are some coiiiitieg i,oii late, iiot ill .111(l )lo oil(, ill -%.oiii- @i-oiij) has been insofii- ,is I'e:i?i t,.Il. _tied I i-egl.(@t this. I tllilll@ in some ii,(,,is vou )iave probably (loll(, woi,k. I liol)t@ that voii liaN-(@. ]Hit -%-Oil lia@e a different coii@I)t from that foi, Ni-iii@li tli(@ bill wis'iiiteiided. T don't kiioiv.. I I)ol)t- tl::it A-011 liix-e liiii(ile(i -t.0111. filitiii(-es eve]]. I have not seen niiieli iiiisiis(, of fiiii(Is. @iit Join, I)rogi-.ini does not have much of ;I 23 )I) i itiii t at ,ill. @iid I lieli)ocl wi-it(. the ])ill. It lia@ beeil i-,itliel sit 0 1 It I ]i:ix-t, riot 1)(,c@ii qble to see ill ]Ill' Ol%'ii lvllx- tli(, i,estiltz:. I)eiieti(-i;il i-e.qilt,-z of in-liit Ill-, 1)(@vii dnii(,. tIli4 ,1,1.4 (@@ilise(i !11.(,:It ;Ilzii-ili. voli befol-t- ill',.CO)II]Illttk'(' :111,1 1-oll the colict@I)t of this ](",is- latioji. in-lilcli ]la., beeii calle(I oi-t@i- the N,eai-s licai-t. (,aiie(@i-. zti-ol@e ill(l ki(lileN-. -,iii(I N-oti (to iiot e%,t,ii iii@,iiti(iii oils of tilo-e ,o:ils fol' %N-Ilicli this bill i;z wi-itt@ii. I tliiiik it ic I talkt@(I %N-itli soiiit, of tlit- plivsicizilis ill -t-oiii- Yoii li:i%'i- collt:lt-ts @N,itli -zOllltl Of tlit@iii I foiill(l oiit'. I doii't ki'lonx- liox%- L,,)otl. Iiiit zt@t@iii to lik(@ it. Otlit,t-s S-IN- tliev ]late jiot iiiii(-Ii ])A. 1)11011(' illl(t liave talk(@(I witli tlieiii Do voti lis(I tllt- ll(,:Iltll ll'Ii,lt -%-oil li@IN-e 14-tll;llll, golit, ilito iz Qel.x-it-e I-e:illi . rBl@.%Tli. Tlici-(- I)k-(-ii of oiii- 1) that I)I.ox-i(l(' at,e iiiiiin, tli;it no iiot. I caiiiio't fiii(I f:itilt \vitli tli,,it if voti (,Yettill(T se]-%-Iee to tilt! I)(,o I)Ilt I ztill Z:iv tliit N-011 :il-e (iiffei-ii)L, fl'olll tli,@ iliteiit of ill(. iii tlia t it .@liotil;l 1)(@ fo,:Iisi,cl oil llt?ili-t tiid caiicei-. sti-oke. aii(i ki(Iiie-N-. Tell tic: soi)i(, of tli(@ tilill'-'S tli:tt @-oii ,ii-e i-e.:illv doiii(,, dowii tlioi,t,. I wait to s(,e soiiit, of Nx.llell I -,o to Keiitiicl@N. a--,,illi. I jlt;4t got I)acl@ I ziiii toiii(Ylit. I)i-. '.\I(.I I \.()Ii ;11,1. llf)t %\'t' ]la(] (IOIIL' '-'()O(l tliiii(rs iii voiii- disti-ict. I rfioii--,!, %-oil iiifoi-lliltloll lql)ollt, ]low some of tll(@ I)IIN-.ilelIlis 1_11 V liq%-e zotteii ,i catalo- oi, I tllat is iil(,aiiiii(rfiil. If N.Ou WI-ite oil oil(. oi, two Ili, lizi@ lio tilli(@ foi- (-;itilo,,s. Eicli wil(@ll it ivi-it(,s a I-PI)Ort. solids ill a cat,,tlot,. (I it jiiv!t is al)soltitelv foi- iiii. Coiiri-(-ssillaii oi- aiiv 0111) -it -oss II'] gli of COII','I-('SSIIlell to I.("I(l olle -iltli of AN-liit comes ,IC] s c as]. Actu,,ill'v iii the I)ast 6 \-eai-s I -@L'I'll N.Oil al)l)i-o.Niiiiat(,Iv tivice. is that coi:i-e(.,t ? Oiice oi- t-,@ice ? Di-. Twice liere iii IN-azliiiioToii. ves. set'li \'O.11 iliol. Di-. ]la'%-( e tliei-e. C.XRTYR. I doii't k-iiow' I tiii iii liol)es that yoii ai-P doiji- -ood wol-l,- arid I siij)l)oi-ted tl)icz l@)III -.iii(i I wotild lik(, foi- voii to i-enienibei- tl)e iiiteiit of i-t.-Tlie IK-Ilill(i it. Tli,,iii]@ i-oti i-ei-v miicli. [Tli(, followiii(, iiifoi-iiiatii-iii NA'as i,ecei%-e(I fo?- tli(, i-ecord 98-S'.2 0 - 13 - 16 Ohio Valley Regional Medical Program SERVICE ACTIVITIES Fifth Congressional District of Kentucky One of OVpmpls most sucessful pati ent care demonstration projects--the Somerset Home Care Program-. I$ in this district. It is the oldest and largest of nine multi-county home care programs no. operational which ere begun withoOVRMP seed money and developed with the technical assistance and professional consultation of Our VRMP core staff. We have focused particularly on rural areas ith these home care ;rejects and their progress has been gratifying indeed. This initial program (bsed at Somerset City hospital) started with three counties in 1970. expecting to eventually serve five counties through tne development of satellite service units. It is now already serving eight counties (Adair, Casey. Clirton, Cumberland, McCreary, Pulaski. Russel I Pand Wayne) anj two ore currently are being phased ir! (Five other 5th District counties are in the ,es ant or Projected service are, @, other OVRMP-sj;=rted home care programs. ) During I972isoofer 7" 'th 'istric t relle'ts we@e r.01,11,,d Ze leal'th le"'C es through the base and satellite uni the Somerset rogr.. . on.. . e . ror@ @, e, by the CHP agency in this area, now being met by this effrt. Fin@nci .1 't""@ ty of these progra-s rtas been better than expected, permitting OVRMP to support expansion. extension, and r placation of tn4.s activity on an accelerated basis. This success reflects the enthusiastic support ep and cooperation cf a,:ayph@sicians. Total OVRMP support to this project, Phased over three years amounts to appro.imat IS225,000, (it is interesting to note that while this type program I, @t usually cownte, as 'categorical", most of the people It directli serves are Patients with chronic- degenerative disease such as heart disease, cancer. and stroke. Rural Clinic De,elc7,ent Another patient care demonstration in this district supported by OVPMP is the rural Clinic proo,a, of United Heal,,, Ser@ an isolated 4. Whitley, and tw- azjo t venture or t Appalachian Rei:@al Commission, w tstri support and Involvement. Three struggling I ng community ssion/settle:i-, -Jinics have coordinate and expanded their service program, integrated their administrative c:erations, adopted a consolidated problem-oriented medical record system, incor,rtd the use of upsr!:ec nurse practitioners and community health extension workers, and secured the local services of a f,!'@-time primary care physician. OVRMP has invested over $100.000 in this progra@, which will be see,ely comproii@ no. by the involuntary termination of RMP Support at the mid-peint of an intended trree year project. The project has now served about half of the 1,000 families ir the area. Pediatric Heart Clinics OVRIV support t: a Reqional Pediatric Heart Clinic s project is an effort to coordinate and stabili.,, a inulti-ageny of special field clinics for ambulatory pediatric heart disease patients. an,: to expand the s-.::e :f clinic services while extending sessions to new patient groups. Since our rticipatior, te-!i in 1972, the itinerant cardiologists and supporting staff have had @t@@,t PI ,,sits at the Beattnille, Campbellsville, Harlan, Hyden, Irvine, London, Manchester, Monticello. rd c@nd sites. 'II patients are referred and followed by their local family physicians. Computerized Ra@i,:.hera Dnsim-etr Ab ancer -.,6ien Ile have benefitted from better dosimetry planning for is 'ri't out 'o c fr' 't' " ea- s.:@,, -i.ter. -Y -t the University of Kentucky since OVRMP began support ol ter,,.T I _, t.'er.- this project i, 7-,-2 he lir 't h@@e link dthe three university medical centers of our region t- p - a joint ccpute,i 'ad I"ea r or "a .i n, c@aity which du ickly gave radiotherapists a highly oot,,ize, treatment plar ':' a'h patient. A second phase (now threatened by loss of funds) would have pr"':ed telemetry lins t: this systefr, for all cobalt units in the region. Emergency Medical Services OVRKP recently s--.nedacontract with the Kentucky State CHP agency to provide for Emergency mecical Services devel-;re,,t personnel in those rural areas of Kentucky which do not have local CHP agenc, staffs. This will apply to ! la This effort is being closely coo,ct,4tg, with the ernerge-cy services act icate of Need Board. April, 1973 239 Ohio Valley Regional @ ic6l Program EDUCAT:Dli ACTIVITIES Fifth Congressional District of Kentucky aHealth Edc -ion Metwork@ re an for long_range sub_ _ f A:,nc regiona I health mAmmer development is l continuing major them 0 3VRW operatiors. with Current e-onasis on the development of Sub-regional Organizations for Health Education and Training (SOP.ME.) in selected pilot areas over the region. The present effort is funded by OVP.I.P but is being implemented in concert with Kentucky's Comprehensive Health Planning agency and bot-.i university medical centers. E'e@ h District (Sell. Clay. Harlan. Jackson, Knox. Laurel, Lee, Leslie. Owsley, Roc@c ce area of a nly the second de@e',o-@&j der OVPMP ausp Ca and otner L izi i ns, and twelve hi-@.e, education institutions (all within the area) have Joined the University of Kentucky Medical C'enter in promotina this ne. area health education netork. these SOKF..-Ts offer -Considerable potential for irorovement oi our health manpoer problems. by IrKreasing training program caoacity (aiding supply) 'I'd by using geographically dispersed locaticns for on-site ecication (aiding distribution). Ire inc rea@ed involvement of private patients And 3ractitiorters in stjdent learning situations will have a positive effect on both Professional education Ind medical care. 41mi-Residenc-, sicians (from COlurbia. Oi@en, Lynch. Manchester, Middlesboro. Oneida. Russell .Ieven 5t@ District Dhv Springs. and @.e,sell ave tie,, ,n I'll P-!, ord"mini-residency" in a clinictl area of their -hoice. In each Ca se. ", dc. ersity meoica, .c ret.,@L r for one. two, or more eeKS carefully planned. well structured individual '.earning experience especially designed to enhance his knowledge and and has then returned ti the community better equipped for his practice. 4Wcal Center Courses 155 physiciars (and 129 other health professionals) L, h,,ve tel 'n "O rler t' 'i' trict 'rtic' :Ourses and rounds at one or more of the three Tedic Ca, n fu -S 'or a re n, costs of their continuing education prograns. This @,rise, 60 . fthe a@ti" a ptlet 1. , y )f the district. .Ocal Ooportunities Tom ire all these CE opportunities confine, to the medical centers. DVR.MP supports the University of (entucky medical CE extension program. which has held last 3 veers within t!ie Sth District (at Buckrorn. coI I eY a. lclmnd. R-issel'. prings, and Screrset). (ten 15 the average attendance) to share in a special Arta. ll@ Ext, @i.. Ser@ic @.@ular WATS line r Libr ry E te,,,,@, te.eDhc of ou a project. During a tenty mont"e KETudl g 108 i ;7 a) Jsed this VATS reference service to request zici nt services. When it looked like the service -lignt nave to be terminated bec4 RMP support, several of its Constituents wrote letters to let us kno. it as a valuable service they wanted to see continued. The Problen-orien-.ed -.edical record represents one significant instrument for restructuring patient records. health education, and nedical care. It focuses on ambulatory care, emphasizes cor;rehensi@e service, encourages prevention. facilitates continuity of care, enhances care for the chronically ill, Supports health professional education. accepts multidiscipline inputs of team care. adapts readily to Automation. and aids peer review. OVRMP has awarded eleven contracts in an effort to impleiren !-nstrate a@d hese s T; ,T April, 1973 Ifr. RO(,-ERs. Thank vou. '%II-. HIstiiigs? HA@Tl-,(;.,. Think Nloti i-erv much. Crentleiiieii. I am deliglite(I t@ see we lian-e Dr. Iiigall here who has maintained %-ei-v close associatio)i Nvitli me and 1)i-oN-ided me ivit), pi-ol),,tblv more information than I li:ti-e been 11)le to assimilate. I)octoi-. ]iii-e N-oti talked AN-itli Di,. Edwii-ds i-ec(@iitIN- ? Dr. INC..%LL. -@o, we have in fact iii invitation to iii'eet ivitli him next in about 10 davs t .iine. I gitliei- lie is out of the coiiiitiT at the moment. .%fr. HASTI-,'C-S. I liqN-e some reason to believe Dr. Edwards niav be a little closer to feeling tliit RIIP's should be in fact kept in operation for a while until we can take ,t closer look and I hope the results of yoiirnieetiii(,, with Iiiii) will beartliat out. Dr. I@N(;ALL. I think with resl)ect to everything that has gone before this is the only logical 01- selisi6le thin- to.(Io. I li,,ite to sort of buri-oNN- in the ,tbseiiee of people tliit ire not present to defend tlieniselvesz I)iit I was worried this nioriiiiii, foi- example tliit the ,(I- ministi-atioii told its that $,50(-l million had been spent. That is .el.- t,.iiiili- a long wa.N- from t)ie truth: -500 iiiililoii was appropriated but the q,ctllal ,iiiiotilit SI)ellt NA-as in the @3@)f) oi- @400 million mark. '.Nfr. Ro(;Fn.@. That f.-, an iilterestiii(r point .floiv much did voti saN- has bee -it-spent ? -taiii]N- less than tlieiiiioiiiit il)l)ropriated. '.Nft-. ]@ocFn.@. 11'e liid appropriated $;-)OO million but vou have not had -,III of treat to @iLI)OIlt .,.)150 million ? Di,. @35() oi- @4()') ii)i llioii. That is -,i figure I would like to confirm. R(,)(;FR.@. It %%-oiild be helpful if we (@oii](I have that fi(rui@e foi- the record. [The fol]oNN-iii(rilifoi-iii:itioii wi,, i-e(@eiN-ed foi-tiie record-] r- DATA ON RMP APPROPRIATIONS AND RMP SPENDING lin millions of dollarsl Budget Fiscal year Authority request Appropriation Obligation Outlay Planning years: 1969 ........................... 65 62.9 56.2 72. 4 42.0 1970 ............................. 120 73. 5 73.5 78.2 74.2 Operational years: 70.3 84. 3 971 --------------------------- 125 79. 5 99. 5 11972 ------------------------ 150 40.0 90. 5 135.0 88.0 1973 250 125..l 159. 0 55.4 134.6 Wi;i-s-e6 (55. 4) Total ........ ....... ..... 710 381. 0 478. 7 411.2 2 Revised ........................ ----- (311. 3) 'I'lie A(lillillisTr;tti(@ii's testimony that lias ,pent $.@)OO iuillion appear,; t-, lt(@ overstated li%. I'lie A(Iii)llli!4t,.,Itiipll Jill., Ilsp(l ,ilutlit)riziti(pli" trained repeatedly to :I Iiii.@ter" (.iilor;itiijii tio 11.1t. -)6118. It ligs I)eeii rIlWored tli:it y(iiir %%-ill lil;irk lili file 1-ill to lil;ik(@ the extension iutli(irizatioiis i(leliti(-@ll t(i re(,elit fiscal '-,4 llr(-,itti@iiti:il Internet request.,. The ex(-el)tioii. of course. w4,iii(i lie t(i us(, I:'Y l!i73 %%Iiere the Ilresi(leiit indicated lie tvi,iiiiii.ite programme If this is ;I rtitii,il-. I AVotil(i stri)iigly stigge.,4t it lie iiiqde a fact. It lielio iii the c;ie (if -I vet4l. 241 ill filet. froni b(Icollil", i bild,,et buster the nioney for terrni- T,) l,revent the it@, '-Nleiital Ht.,Iltll Center FY ii.ite(I T-r(,,,rlill@ c-iii be tl@eii fr,iiii the ConitilulIIdre(I IlliliOll for pbising-okit [)U(Iaet wilic)l ill(.Ill(le@ :4everil I tin Center leaders )n t"'@ "-r@e '-"74 bxid2et t,) phase out CO"' t P l,ri), the F ires ().',I BI)ut lill)"('Y ell(' ,sic 1, Cilric,U!41Y. ,,, Fy .78. Wlijl(. the 1), I%N- re(ju e@Iltil CeiitErA tliri-ii bli,-ations are \Ient',Il " r -,r;iiit .,,Iigltiolls oll(.e tb(ise 0e(led tbrougli tilhil :11, elite- f i@tle. that tlie' Ilresi(leiii I'llt III'llie@ tie t n, atlc,. it is 011(1- If llc't 1111 - list it', there and. unLIer iii extension. won I 'Y 7s into the FY '-,4 bii(l-,et. Ile nee(Ic-(l in FY '-i4. AitF.,L the ('Vt".S'.,Iit Pro- ex,-Plitit)" le- \vitTio@ses 1)()rti-@iying the .11@ all ,ii-tu;il ex- liui)(littire. This lettt,i, is tk!:4tiilit,iiN- for the rei.t)i,(l as re(Iiiired by oil rectir-I :is til,ii4-titi--, t-) tilt, teL'Iliiiqtie \vherel),v iutlioriz@ition iiionev SI)ellt. This is utitriie. 'I'lle iiiiltlic:itii,ii tl);ik- alil)r(@i)ri:ite(I funds have I)eezi continually expende(I .II tleli\,erv sv-tem au,,ruetits the inaccuracy I!i66 to iiiipr4)ve tlit- hour of the kdtt)iiiistr-ilti-iii'., testiiiioii.,r. The facts ;ire 1. That frotti I.')(;G Tliroiit.,Ii to l')C.S illost of the fund,- distributed %vere for fil.1 llill',7 ;Itl(l strii(-turitiL., '\Ie(licil Trip' aiiis into existence. n ,-i. Fr(,iu I!";!) the. fuii(]!z %vere iiililv iv;iil;il,le-@rlir oper.,lti4)nal I)rojects under til ori,-in;il f @illi teriiis of the It%v. e 3. The fi:zcal year I!)72 budget released in J-,inuarlv ll,)Tl was the first @tement of le%v foi- Ite,-ii)ti:il Nie(Iii-I shift in emphasis . . . directed t(owzir(l@ iiiij@ri)ve(l ;Ill(l exi),,kylile(I Si iilivAciaii.@. ete. .. 4. Tlie_!iii(l, e for 197- der'al expenditures in excess of y E c b to ithe i)recetliii,, sentence of t t sti eiiie . eeIeve'nt:z %vitli consuiliniated nce the new e(I in 3 itiove) our eXI)e,,,Iittire t, frit-tilinilly vour ei)iiiiiiittee to C( tlitt niillion bad )S.therefi)r( . even iiit)re nii-lea(Iiii-, than w(itild ap- r oil e .%Iy fa( i c( le fi-oill tl nutritive for Itegiuiiil.'.Nledic-al Pro,@ranis over "I e year: st;i (I :iiitl fr-) ii the It.Nlll,, Fit-t B.),Du. hour of %which -ire produ(-e(I by ti.e A(luiini-4tr:ition. Yoitrs .zincerely. JI)Hs R. F. Ei-c-cittit-e Dircetor. el,eStt,il-,lll(l if voll %%-ill I,ri-e(@ to ,iiiswei-- N .11 I tit the '.\ation-.il ii)IISIV 1)@- 1)1-. . 1, -.rillies a )o in a statement nll(le I A(Ivisoi-v lioii-(t aii(I lionv tlie'v maintain Follie ON-@l.sifrllt oi- control - tli( ioiis ')(; pi,otTi,anil--. Have they in fact maintained trial tvpe o%-ei vai 'if voii ai-e of 1'11(,y talk ttl)ollt tlit,iii -,iii(I sayiii,,@ li@ title of jol) trial tilt@ le,rislitioll li:i,.; ilitell(le(I voll to (lo. not doiii,- t or the -,t(Iiiii Iisti'atio-i li;ls intended @ii to (10. trial tiiey I)IIII ofl' the and "O into a f;-Illolltll fll)l(lill" J)el.io(l to Olit. Ilas fuiidiii - z- - --.ct I Ill')'s ill this coiilitl,N, threat ill f. I'apl)eii(,d tliroti(,,Iit)iit tli(, 11 The tlii-(@;lt ]",Is 1)0.,e,l to It ](':'.-t two "ecriolis that I (-all tliiiik of. I I)elieN-P tliit oii(- NN-:is I)llt ()II I)i-ol),ition. -Nll'. ll.%STIN(@.S. l'Oll ()Ile NL-,IS I)Ilt Oil I)]'()I):Itioll -Nll'. 11'.%PD. -kS I Yet tiliS St;ltellielit tlien "put oil I)I'oi):Itioll tili@N. ]lot ]iN.(@(i lip to 4ratioii. obli,- iiii sl)eikiiig fi-oii iii(,iiioi-N iioN\-. iiot II, (1, cliall kRD. to look that Ill). The '.\:itioll:ll (loes I-evieNN- I]I of the ftiiidiii(, of i i-e(,ioii iii(i tti(@ll it foI' I-.N 2- veai- I)et-io(t. oi- it 0(l. I)i@",.ioll-; t li:it :11.(@ to 1)(' 01)('I-- iiti oi, fliiictiollil;s, well iisii:ill\- @,(@t \\-Iiit is :I ti-i(@iiiiial 119 III Otliei- wol.(Is, tli(@N. (,ro tli(@ fill] \\-itlioiit tlielii. Ilegioiis tilit ii-e l(r \v(-]I-;iii(i this is a 1)itz-t of ill(, ftiii(is tliev call ,idiiiiiiisti .ttiN-e (-Ozts-,,-It@t \vll@it is a (]eN-(@lol)- iiieiital coitil)oii(@iit. -Now this (](@N-elol)lllelltil ('011,I)OI,Ollt (-;in be aNi-ai-(Ied foi- that at,e not si)(,clfi(.,Illv stzlt(@(i ill \.Olll. of-i@,illzll gi-,ii@t al)l)llcat -e flill(le(I foi- :; N-eii-s. I-oil 11111st stilte ioii. liilt if N'o I l specifically wli(it kiii(i of tiiiii,,rs \,oil iii-(@ @roiiiLy to (lo diii@iii(r tlios(@ 1),Ill- ti(-tilai- :i iii(i if N-oii dei-i;it(, too iiill(.Il fi-oili t)izit, tileii voii iiiiist seek aiiotli(-i- al)l)i,oi-;il foi- t)tat (lei,iitioji. I'lie oiilv tiiiiicr 'tliat @'oll liive a gi-eit (lea] of fi-ee(loiii Nx-itli,. ot- i-elatiA-(, fi-ee(loiii. is tile ol)lllt-llt.11 colill)oiieiit. )'oil (-@iii iiiike siiiill :i\\-:ii-(Is foi- a N.oill. I Nvoii](I tlso like to ]iia,e to soil)(, (-Ilal-(re," bN- tli(@ i(Iiiiiiiisti-,itioii not ill(l I N\-],]] (itiot(@ fl-0111 I)i-. Zll)))'S testiiiioii\- this iiioi-iiiii,,. '-I?.Ill"s litv(@ 1)(ICII between cit(,(,,ot-' I- ;Ill(l lit@;tltli I)i-obleiiis." Dr. INGAI,[.. I listings. I think oil(, would be tempted to really i,iiii ,iwav \\,itli this as t do@ woi-i-y@!lg I boii(@. I think the question of c,iteL,oi-ical and coiill)z-(,IieiisiN-e iiiectical raises the question that I re- latea last time Nvlieil l@vro,- was cliaii,iiig this committee. You know. if voit ,ire looking it @oilil)i-(@lipiisiN-eiiess You have to take for ical sei-i-i(-(@ as we example. the eiii(@t-geii(-v III(,(] discussed it. Corollary heart, diseise IS ill LY(III(@v. People die in tile first 2 hours. It did not seem (,eoiioiiiiegllv i-easoiiif)l(, not to that a cancer patient could hive a siirlaeji ,iii obstruction. i thoracic collapse, and would i)ot iiee(I tli(@ saiii(@ treatment. It di(] not seem unreasonable to sav a I)ei,soii with sti-oke. that lit(l a hemorrhagic stroke that could be svplioiied off so II(, could get I)ii(-k into tii(@ community as a pro- ducii-ve individual. should not fall iiito this comprehensive -,tttitude to heart. sti-ok(,: the siiii(, to kidiiev disease, the --,Into applies to traiiiiia iii(I the siiii(@ il)l)ii(,s to ])Oisollillg. It was this com- prelleiisiveiless of thought that has ]-well ,i problem when people have said. "Don't the regional medical program ,idlipi-e to the 'Categories. Bv CTe-oi-gp. it adheres to tll(' categories. I)tit it idlieres to them economi- Ill otilt.l. A%-ol.(Is %%-]I:it is "O()(I foi- one -@ttet,o is eqtllllv goo([ foi- tli(, otli(-i- -,iii(i oii(- t)iiiqt look to tli(@ ill ;Ill the categories if tliev ii-c going to serN-e the community at large. '%[I,. H.%.',TI--GS. Do I iiltei@I)i,et tliit to mean that v6u do not agree with the iiiterl)i-etatid)i outlined I)v Dr. Z,,ipi). that @ou do not agree? Dr. I-,C.All.. Yes. 243 '\Ir. HAZTINGZI. '-\-ext lie si:,d. ;"fllel,e is 110 significant evidence that iii@ research ,idvances in reg@- R@IP's have liciiieved tlieii- goal of gett , r lai-,_,e-seile I)i@.,ictice. The filing I)i-o,,ri-aiiis undertaken are t@pi- la liv 6f lililite(I scope and diii-atiol-I there is no substantiating za it these have ]lad i sio_iiificailt iiiii),Ict oil actual medical !vidence tli, oul(i vou care - I .1 -ov ,,,lit%: IV practice or in deiiiolliztl"qtll -r 11 II)i ('(1 cll to coniiiieiit oil t liat. one oi- a'fl of 'Voii ? .0fe-czioiial point of vieNv. I would tal,-e di- Dr. I-NG.%LL. Froi the ])I else wliqt is III tefliiia a i,tivz',,iall ol, soiiiebod, rect issue oil til'it. -e,-ea -e'l x@-ili@ii i- medically and ciiiii(,allv .available to iiiiii at the I - re e% (rettiiig that ii-it:ssage a(,I,O-@-@ is the marketing businesses applicable. , t is gettiii,,r the that RNIP has been iii. It is not jiist teaciiiiia people. I -They just 'II( - a.-k- t@ll ilifol-Ill, ;),,Lll to lisc, it. ,Itioll 'I .% ilifol ti-a-@fel- has been crucially want to ktio@v it is tliei-e. "II-itlo II- 'i)@ 't-iiliz to I.k."Ilize tll-,It ill fact successful ill )Ill. It !it-, 'I Col'o colilillitllltllt. fol cxzlll to iiai,%, cai,c, iiiilt is iiiore than ,i-e't deal of (,xpciiditiii-e ill a oi,oii,,irv care ?ve-i-v siii@-,](- l'Itt]L@ Ill c@1101' ,IIIOIIS C .. NN-itli tlils iiifollllzltloll ti-aiiQfei-. this of wait are tli(- --t-,iiidards ill tli(@ ac(,el)ted ." llt@ to I'(,;Illz(. tll(,v ciii niect thosc, tiistitutiolis-tlit@N )Ilk\-t. (,(, - .1i;lt ( Tii:it this real]\' Ill,'(Ie t(; A\ Xt@lit tllp.\- (-:ill (lo it. it@1'4 Ill 0111' it has ;ilso made siii,@ilai- to tli(@ I)i-at-titini , t.,It(, iiii(, for (example. to diffel-eii(I-L!-,iii(I I lia\:k@ to tiit@ S Peiiii--,vlviiiiq sail. --Il'e iiiN,e ILariiecl one ")tllel. iiiiji,. Tiii@ l,atit,iit N\-itli ION-,Ilty to oil,' old in--tittitioii p- 'It "-e ll;l(l I)eeli St.fl(lill(, 1),ttit-tit. 41,111 jot, liell) wliei,eis w(, should lint goo(, ti,ettiiieiit tiL,iits travel. .)()ti iiii]eq aiviv." Tli-,it 'I'liat is saviii!z i),' It stIN,'. It is sa\-Ill(" (lis(lolilfoi-t aii(I it is saviii!: illoiiev. 'II 11111)4)1-treat to -No\\- ]low sll(,(Iessft These are tllt, -e I)eiii-, Ill oill. o\\.Il 'lit i-eill@- "-II; till(litl',' iiii-zt bN- tli aiid ;II-(- tlii-iii oilt of liozi,it;il-;' 'riies(, ,,.e Ill @-f-i-V iiiil)Ol.tilit f;ll.t4)1,@ to Coll@ittei liot(@ tlit- t] :it I)IIvsit.i:llls 11-(' %V(@ll 11)1(@ to lettei- fi-olii liot (-ro @,lyil (r Ill tilt I (,;IItI t,il@llf.,Itioli ill I)ro- @;lv@ tilt-i-i- :11.(@ of tll(,Qe i)i-ogi-aiiis. I,\.(-i-v d;i\- I (,'(-t ill tit(' final ;ilillnllll(,(,Ill(llit Of a total. to fol- ot- tli(@ ol' oi, soiiietliiil(, 1,011(joll. klitl it is ii-lit@ I)II@--4ici;llls (-,Ill r to these ])]-,Ices I P-0 til(I (r(@t these tlvii;illii(. Ili tli(-ii- medical S(.Ilool.;. but %\-])(It I-el-rioll;ll ll;t\.e 1)0(111 tlieiiisel\-es to ;IS fit- ,I@ illl';Itioll (if I)II@ is to ti-@- to iii@ike it tvail- -.Il)le ti) tlit@iii %I-itliill tlit,ii- tiil-oll"ll (-4)IISII]tzitioii set-A-ices tliit tt-ii-I)Ilolit.. 01- otlit@l- of i)i-o\-idiiia thwart Avitli 11-(. f;l,.(,(l the I)eil oi- :i-,i,o-- the table from the I-i,,Ilt tilt-I.e. t-tilIL':ItiOll- %N-Ilell \.Oil lit\-e the problem Tiiit is the best tiiii(, to giiii I)Vfoll(l Von. ll'iieil I g,( to le(.tlll.es ill al)ollt I.-) illiiiiites 1 often find iii\self astee 1) Illol I tliiiik this is not t vei (rood wav for coii- I tiiiiiiii edii(,-,ktioii, oi. to go otT to oi- or (',ii-ibbeaii. H.%STI\(,.@. if voti N\,ei,(@ a ll(,iiib(@i- of ('oii(Ti@ess tikiii(y those trips to fit- off ])],Ices \-oil wotild be (Ti)iii,, jiiiiket. not (-oiitilitilli(r edii- catioii. I am if oil i t- I do N-ei-v iiiticii il)l)i-eciate the testliiioii\- of ill fotii- of voii gentle- men. I hope we liaN-e the ol)l)ortiiiiitv after. iN-e li;ive extended this pro- tr 11- liopeftilin.. to free togetliei- to ti-3. to (levelol) ,-i-aiii for the ye the best pa continuing pi-ocri-,,iiiis. eiieoiiij), i-ts of R.\IP's. Thank voti .igaiii. Ro(;FRs. -\It-. Roy ? Roy. Tli:iiik voii vei-v much. Isn't it esseiitiillv co]-i-e'et that RAIP did start oiit to provide to the local )I-.Ictitioliel-, the kiiowled,,e tliit we ]life -,iboiit cancer and lleai-t. sti-oko@ and so forth. 1)1'. Yes, sir. Hill-. 110Y. I'Iiis IN-as the thrust of the program (Iiii-iii- the first few ve@irs? T)i-. IN(;.\I.L. Yes, sir. Iloy. Isn't it -,ilso true there NN-ais a ivliite I)al)ei- bv IIEIV under this present idiiiiiiisti-atioii. The Fiiicli paper. '.\Ir. Roy. IV!iit (lid that wllite i)ai)(,i, i,e(,oniiiieiid? Tii(, Fiiieli I)al)ei- --et foi-tll the priorities in the health field iiisofai- is the -,administration was concerned. Oil(- of those iiiajoi- premises so fit- as we were (-oiieei-iie(I was the (lelivei-v of health care -iii(i it ii- ol to those who did not li;ix-e it , I iiiied fin-c cite(T -ies of citizens-, mothers witil children Harder. fi%-e. Iiidi;tiis, i.iiigi-aiit workers et cetei-a. -;is :i cate(,oi-i(-- It wis I)oiiiteti otit that ]%'.Ill) %N il -,approach and the coii- p- -,tiii iiid tliei -6t fit in with tli(@se training c(iii(-atioii I)i-o,,i -efoi-e did 11 I)I.iol,iti(@s .111(l if fluids (roill.., to 1)(@ fol- the I)i,o(,ram it had ?- L- to find .1 wtv of tittiii,,, into these i)i-ioriti(@s. .k loil@, it. NN-..Is lit@1(i water til(@ 11'e iielrotiated these I)oilits. He (-,title to ;I gell(@l'.11 ;I,,i-eeiiieiit oil lion%- the I)i-of,i,aiyl shotil(I Fiii(-Ii -Nli-. Roy. @o tlle fle(.;Itt@,,oi,lz@itioii (,.line il)otit tsi i-esiilt of the tlii-iist of ill(- Fiii(-Ii wilitt- isil.t thwart (.ol.l.e(.t ? IV.ti,,i). Iti(rlit. It changed the emphasis in otir pro(rraiii, not lie(,t,ssai,ilv ill(. t@litii-t@ -,approach. biit certainly the emphasis. '\It-. Roy. ks I liea I- it tll(, adiiiiiiist)-atioii savs 4@11'e are going to (.I,itic-ize voii I)ecaiise voii are not doiii(, those things which the pro(,Yi-,iiii oi,iL@iiialiv said voii N,%-et-e going to do". I)Ilt now Von are doin(, iiiaiiv. ni@iv tlli'll(,rs. Is it correct to sav -%-oti are doiii(,, iii,,iilv. many tliiii(r because HFIV ?-S uiidei- the -Nixon a@iiiiiiiisti--,itioii i-pqtie;ted that voii do'nianv, 1111,I]IV things. '.\fl'. IVARD. AVe have felt that was triie ,ind we felt somewhat ]iiii-t I)v the fact that those 11(@,rotiatioiis Nvellcl ]lot remembered. 245 -Ilr. Ec)y. 14-zii't it also correct tliztt the l@-NIII's %%-Iiicii %%-ere to (ri-It tire greittei- :ijizti-c oi the iiii)iie%, iiiLteeLl tjiu--:e ii-%llj s tiitt ilill)lelllelltCLI the %-ai-iet)- of service pi-oui-iiiiis otttlliie(I I)v tiie Fliicli %vlilte I)al)@!i-I l@'.ki'D. aii(I is cooi-(iiiiitoi, we wei'L, ol)li(rite(i to go back aiid sell oil il([%'i,-zoi,v coiliiiiittees oil the feisibilitv all([ the a(l%-islbilitv of .,Oill", Iloii,, this pli-tictll-,Ii- lille: illtl we (licl. -Ili-. lioy. was the oiiIN. tliiii@, I to iilzil@e cleai-. @111'. 1'%WERS. I tliiilk it is well foi- the cotiiiiiittee to iiiidei-staiid tliis. D i-. Aloli@, the saiiie Iiiie. Oile of the criticisms of t]iL@ ]i;i@, ],,t!eii that it litis iiot qcliiex-e(I the i-e(,ioiiilizzitioil of liealtli care (leli@-ei-v eiiN-isioiied b3- the program. l,lliz5 is II.)t ill tll(@ 'I'li:lt Ill tlit, ol-i,,iii;il I)t@li;ikeN- C'oiiiiiiis- sioii i,e(:ollllllell(llttiOll I)tli til',It (-oii(-el)t. lie are ill fact I)i-oliil)ite(i to tiiiiipei- I%-itil the lieziltli care Z-N-steiii to t]),it extent. .Nli-. lioy. Let iiie foi- tllt- tli(- Fiji(:Ii %%-Iiit(@ I)Zll)ei- :3 @.e-.ii-s ;i(ro requested N-oti iiot to ,o 'II (-,itt,,,,oi-ics. lie-,Il-t sti'Okt'. aiid Iiiii(, to tli(@ \.oil lia(i foi-iiiei-IN- btit voti (to a iiiiiiII)CI. of otlici- II'liat \vei-e those otil(,I. tliiiizs It (11(i iiot sav iii:it. It jiist (ii(I iiot list N%-Ii:it Av(' IN-01-e dollar-, "-itli :itin- ;Ill-[ tlit,@l.k'fOl'(' %\.:IS ;I 1'elill'tZlll('e to I,Cle'ISC tllt@ :tl)l)l'Ol)l'iite(i fIlliLIS fOl' tll(' This isslit, I)N- tili@ iiiillilit\' to --rest filil(l,-z foi, the 1)i-ioi-'t'es target (-otilti .11;1)lv 'to lie 1) I)I-O(Ti, I i-ioi@iti(,.,; treat dealt pi-iiiiii-il\. \\-itil tilt, t,i,eitinii of foi- those I)eol)le Nvlio did iiot liax-e I t. I aiii iiot siti-(@ I c-,iii i-ecill q]] of tli(@ (@ate@1--oi-i(@s I)tit tliex. .vere, Is I soniebodv li(@ll) iiie %vitli the otliej- t\\-o-izitei-eities. biit tlit@ i-el)ort that was dite(I Fel)i-tiat-v ll)i-'). set foi-tli tlit@se I)i-ioi-ities tlieii a -T-olip of co- oi@diiiatoi-s tried to cojiil)lv Nvitli tli(,iii. Ali,. Roi-. 'I'liit is til(@ @oijit I to iiiike. Yoiii, iiiissioii %%-as siil)st:iiii i-,illv 3 tii(I :3 iiioiitlis i,,o it tli(, i-e(lii(,st of I-IFll' i-e;ziiltofvolti.o\\-Ii ifiitl:ltl\,(,. N%-].iit tll(@ (.()Illlllittee. ll,(@ IN-1-it(@ tlle Iiw aii(i tlieii IIEAV. iii this iii-st;iii(-o tlii-oii,.,Ii @\-Ii.,itw(, write. -Ili-. Hciiiz 2 I lv;ilit to i@otililiell(i ill(. cool.(Illlltol.s fol- 1)1-011'@dit to t)ie colii- NA-011](I coilillielits Oil ]low fl-oll, tilt, of lll(,Il il; tll(, fiord. I I I-'I i r it a b -o t al)o:lt tile ft)lioxN-ill(" situation. I litve lici-e tl)e I)ti(IL,-ets of tNA-o different Rlfl".;;. botli fired qtiite satisf,i(-toi-ilv I)N- IIFW. Oil(, of tiies(, is tli(@ Iliiiii(@sot;i rt'.\[P -%vii(,i.e I' ' 0 I- the 1)1-0"i,,ii I st,iff coiill)oii(@jits 1.@ tl)oiit .1)00 of a total direct c'o-stsof foi-tli(,O-31)i-oLi-.iiiive:ii-. ill tllis CIS(@. staff IC(-Ollllt @oi. i'littli, less tliiii oiie-tliii-d of total cost. III tilt, "ttiii,- lii,,,Ii ).Ooo ?,It ol 'is , ilisti,ativp- i-ks f "Oil' II F" -tllli.ds a(in,i iiia ti\-(- costs llo-\,v there dii, (:Ollllll(,Ilt. Oil co t. if I call t@l front N,Olll, 1),,vll ex \vital the s . 1)(@l,leiice IVOIII(L ,Ill@bO( ai,i ,file 'V@t, ,II liave taiiiiii- coiild be sucil "I oriiie( evalti',ItiOlls I)e" ilV 'Viiii. -Ills\vel. tl"lt' iistial aiiiollllt Pf ellts' 1). I ti,irik I call be flilide(I a@ IN -In Fii-@t tllis pi,@gi,a,,i li,,is iiii(I -,I)ect i@cloilai, level. anct is. %,ve get all,lllll)"o 11, otliei, Nv@"( AVe do o,jr piaiiiii" the .1 certain l@vel- 11 list cannot (10 tili Yoi-i iiiidel-st,,iiid YO - ,Vll tllis it takes I"Oiitlls to )" 1 bv jeli are @eli is @ pl,ov 'Von cycle @N", v a ti-acted etc )p ed get votir 103 11 liave ll,,ive 'f e! 01' e I)eol')Ie tllat 'VO gets Clit and til for. level. Tli@ll t t. wei-(@ to be yoll tool 111) to Illeetr this jilst before tile new P"03ec '- ellt ill iiiaiiv cas(@s I",Is ('Oil'( 1.011, iiienio@y_ L",Iill this is i ed projects f if 1'ec ill illillllid lvezztel'Il PC The ex- lolls e 1, eii done 0!1- the t before ti,eir f tindiiig and tll('S(' be 1)(,C!Iqtiolls "VI 'Carrie at Pei-io(I illy filli(li,19 cycle C,,inl(, ,Iltlio 11 we stiff ered a foi- are \,VS 'VOIJI. stl s siicli ,I it I li,,I\,e ol ese N-el-V the t l'y jillr to (ic V611 ol't Of t NV'.,ivs to Cl,ts collie "se of PenTISY 1, 'It 11, ,,,If iiiid(,(l 111'0,lt'Ot' ' !till ti",It is Ipp(,Ii,,d ill tlle C' all, ),.(,ttv (,(Il't d -,vere frOnI 1. iiiiiII)OIls I exist (illotc, vqlll,t -till I",IPPL"" ild NJ I., I Iz- fol. tll(,il. 4tll 'flit. Z. ' tiOlls. I I fill (rollcl into tb-.xt so'" 'wb"t till' )f 'voll 'k- t ea r (,(I 11-:1 10 I. voii ,",P- Sp it t SI I till 11 ) jjl,r to lilt'. Jim list (,et ill of di,iii! ill t it fol-ili;ltiol 11 11 d. Yoll S"lv Iiiis @,oo si)olis or I)ai-t of it- 247 '.\IC]iE.%Tll. Nfziv I resl)oilLI Oil the di-it,,, iiif,)'-iiittioii ])I'Olect. Tile iiifoi-iiiatioii I)i-ojeL't %V.IC- (I',-ecte(i to\x-,ird 1)i-o\-idiii(Y i--,tetitioiiel'S iii the fi(@1(i. I)IiN-siciiiiz. @\-itli iiizt-,iilt t(,Iel)lioiie collillitilli- :iti(ii)s \%-itli -,i di-ii,, iiifoi-iiiaiioii s\-stei-ii to pi-o@-ide tlieiii witli iiifoi-iiia- ;oil -,il)oiit di-ii-s tiiat woii](I b(@ ti@e(I tliei,apeiiti,--aliv in tlieii- practices iicl it N\-its used tli;it @N-.tv until we li:tcl to cut oiii- aii(i out- s lice([ a lo\@et- I)i-ioi-itN- oil tlia ei-iiiiiiate(i it. ,)Illlcll it elf 1)]. t project and t '\II'. ('.%RTER. 11',is that e\-el' ) I)ai-t of \.Out, 's iiii it all. (It-titi- ot- iiN.tliiii(, to do water Are tisii;ill\. ttk(, of that iiii(It.l. felt (11-11" iiifoi-ill;ltioll IIIIIL'll 11 1):Il.t Of tile XI)et.tise tiiit liad (I(@i-elol)e(i in t)it@ itio(li(.,Il ill tile lill(II.1 f c,,iiicej-. iiitl sti-ok(@. to (lo witli tlit@i-- I)\-: Ill([ to r(,t trait (IiSSCIIIjIl;ltt,([ till-oll,,Ilollt 0111- I-( io I w ),)(I ll)l)t)l-t of tile (-.Ite,roi-ical eiiil)liizis of tll(@ IVL@ lil\-e liit,llt;il lit,altli cejitt@i-4 witli aiid be(is ;iii(I foi- tliis. don't oil tliiiik tli;tt is .iiiotlier oil ill(, tli-,it voit'i-(, ilito it area voii ]lot. I'llis is ilf)t \,()Ill. fiL@1(i It :111. Di-. -@IcBFkTH. To I)i-oN-ide iiiioi-iiiatioii about clinical pliai-iiia- )Iogv il 11 di-iias. Tli-,it i-ezilli- is not sl)('Cifie(I iii t i ],intent I'lli-z I)I-oiect )II(l liotlijil,r to (I() Nvitli :addiction i- ill(, illicit of derives. mutation .111(l tile ])ill jlist Z,;I\-s ilifol o(,s ]lot radiation (11-il,rs IS to cliicvt-. tid sti-oke. I)i,. I tliiiik this is in treat (-Ii@iiiiiel. It is tilkiii(, ')out the latest fiiidiii(,,s witli to clinical 1)liai-fiiaeolocrv in con- (,Ctioii \\-itli caiicei-. iiicl sti-t)k(l. (',tr,rElt. You lia\-e fotii- I tliiiik -role prob@ib]N- den-el- 1)('(l soiiie ,,ood. I liol)e soiii(, ,oo(I lloiiie-eii-e facilities ill this area. I otic(@d vote spent quite -,i I)it of iiioiie\- oil this in tli,,it area. ll'oiii@l N-oti di,s(.-i-lbe \i-liat @-nii (loii(@ in the field of lioine c,'Ii-e? ])]'. If('IIF.XTIF. Tli(@ is slil)l)oi-tt,d \vit)i st,(,d funds to start I)-azid %\-itli considerable te(,])iii(-al ;issistaii(:p iiid consultation front iii- core stiff-tlie formation of iiitiltl(-otiiitN. lioiiie It altli i-encies. lost of tlitlii ill rural 11.(,.,ls. There are nine of tbeiii now. These programs are -iided in starting p in areas wliere it ,ippeai-s tliit tliei-C is -,-_ood receptivity to them on ie part. of local plivsi@iaiis. Tliev I)i-o\-ide sei,\-ices-.,il)oiit 60 percent f the sci-N-i(-es. is I !-(,call. (To to iii(I iiie(li(,.iid patients. The later 40 Percent are to patients 1)ai(I fi-oiii otli(,i- iiispices '\fr. C ARTER. li'liat part do voti I)Iiv in that ? Di-. \IcBF-tTll. Of Iiiidei-w'ritiii(r tile deficits of these prozranis dur- t- iL,- their earlv inception until tliev are self-siipl)ot-'i n@ a-iid. of Pro ,il assistance and oriiiiizatiojial skills , are reqi -e i@iii,- teelinii. th 'I; ,it put tlieni toaetlier. CARTFR. IV]iere do vou pi-oi-ide kidnev dialysis? Dr. '.\IcBEATH. IVe do not @i,oN-ide kidii@v dialysis T)er se. He triin ,iial dialysis teeliziolooists and we lia\-e @i-o\-id'ed considerable staff )I)oi,t to the OlliO COO"(Iil",Itill'y ('0111"littee oii Reiial Disease sill . p- and the lieiittickv Kidnev Institute. ,%fr. CARTER. Do you i)i-ovide funds for training people in this area? Dr.'.NlcBEATIJ. In tliel'i-eiial dial@-sis area; riglit. .Nlr. CAITTER. IVIiere do you do tliat? Di,. '.\IcBF-@Tll. University of Kentucky. -111'. C-@RTY.R. Ulii \-ei-sitv of Cincinnati ? Dr. '.%IC13EATH. '.\-O: just University of Keiittickv, that project. -111'. C.%ItTEP@. I\'Iiat is the approximate cost of that I)ei- veai-2 Di-. \[cBEATIt. I liqve to i-efei, to iiiv notes. About $50.000 I)ei- -veai- is btid(,ete(f foi- that project. 11'e liad,,i)lothei- kidiiev project that Nvas turned down. '-\II': IOAP.TF.R. I tliiiik it sliou](I liave been iiioi-e i-,itliei- tliaii less. '\II'. ROGI@RS. Tliaiikvou. If tliei-e are no otliei- questions the coiiiiiiittee is -a'-,Iteful foi- your presence liei-e todiv and your testimony lias been iiiost liell)fiil. Ro(;F.Es. Tliiiik voti. The coiiiiiiittee isidjotiriied. [Tlie fol]oN%-iii, lett@i-s,%vei,e recei\-ed foi- the i-ecot-(l AMERICAN NURSES' ASSOCIATIO.N, INC., Kaii8a,v City, Uo., Ilay 4,1973. Hon. G. ROC;ERS, Citair))za@i, Stibconii)iittec o?t Public Healtli and E)tt!it-oni)teiit. co))i))iittec on in. t(-)-@tate and Forcig?i Cot)itiicp,cc, Raybii?-ti Biiilfling, IVa8lti?igloii, D.('. DF--TR IIR. ROGERS: The abrupt termination of,Regioiiiil \Iedicil Ilrograiii.-; even - is iiio.,t (lislieni-teiiiii;., to tlios before its legal @iiitliorizatioii exiiire, -e concerned with improving the health care of the Aii)ericail people. This eotiiitry's lea(lersiiij) in the field of health research his long been a.,iource of national pride. lle:iltli reeireli. if it il to result in lietter health (-,ire. must be rapidly fed into the health care delivery system. The Regionil Ile(lical Pr(igraiiis have iiiade it possible for thousands of health personnel to be brought up-to-date On changes in care, thus maliiiig possible better services to the !II. 'Nlaiiy R.%Ill groups liive been iniiovtitive in developing I)rograiiis of continuing education tliit iiieet the ,pecitic needs of their voiiiniiiiiities. For example, T. 1'. communications for an area Ni-liere travel is difficult, development of teaching materials to be used when convenient by busy, overw(orled Health professionals, and educatiiiii;il meeting., arranged at locatioii.-4 tljit (lo not usu(illy have access to continuing education offerings. It is now beiii, said I)v DHEW sl)oke.,iiieii that R.%IP'.-; lirovide continuing edu- cation to tli(o.@ that ciii well ifford to liay for it. The reality is that it costs, oii the iverige, three time, nation charges for most higher education programs. ,- Lre consi(leritil@- more. Sul)l)ort of staff ivhile Health I)rofe.,;sioi)al edticiti4iii co.,t.,, course., are being planned and developed is tlsi) costly. SI)eikiiig for nursing, there ire staff iiiirses in ruril iiid other ireas tif tiara c4oiintry, many of them with f@iinili" to supports eiriiiiig $7-S@',OOO a year! llo%N- realistic is it to expect them to ii,,iy $30(@,@4(.)O fear i wqjrkslitilo I if full costs were to be charged) here in the Distri(-t of (', 'S.500 . Right R-N's start :it s i year and you .ire well aware of tlieliig)i ci-,,;t ofliviiig in tliisari-.i. Jii addition to the educational l@rograili@ liy R.\IP'.-. the deinoiistra- tit)iis of serviee@-to-I)e,fl)le portion of the lirogi-,,iiii @lli)iild not lie underestimated. The (-atastropliie nature of the disease.,; fociise(I oii in this legislation ind the large number of American,, disabled by them indicates that there continues to be i need for iiiil)roi-eiiient in prevention measures and care for l@eople with those diseases. lVheii -I)ecifle legislation is introduced to revise iii- exteii(I these R'.NIP pro- grams, we will id(Ire.", oiirselv"., to the ql)ecifies but ;it tlii@- time we want to indicate our suliliort for iiiiiiy of the R'%IP's tlirotigli4iiit the (-i)iiiitry. This dipe.,; not mean tlifit we Fairport long-term renewal without (-Iiizige., in the IoNv. but pre- cillitou., cloi4e-olit of program,. without plans for the fiitiir(@ most wasteful of resources it took vears to develop. 249 I ,isk thit this stiteiiieiit al-I)e@ir iii the )f the OvL-r@iglit IIL@irings oil Rt-gioiial -Iledical Ilrugriiiis. Sincerely, EILEE.N Nl. JTCOBI, Ed. D., R.N., Execiitive Dii-ectoi-. .KMERI(AN COSTI-OllkTIIIL k.-;',O(.IATIO-N. L;. ROGERS, Pfitli,- III filtif (I)I,l Etii-il-u)lttl()It. (iti Ill- tcl,sfiltf.. U)I(l (iffic( liiltl(li))Y. iiigttj)i, D.('. I)k..ILR Nllt. CIIAIlt.Nit.N : Aiiiei-i(:;iil Ote,-i,;Itliiu If-)Sl,ilti of L)Stetjl)allji4- -Ilt-ilicilit-. "(- 3ledicii Ilrogi-:iiii@ ili.Nll, f-ii- .1 I I 30, ]! 173. Iljl)r(jxiiiiitely 7-i lit-rt-i-ii, ii' is tie- lively #)f lie:iltli cirt- ;iliil lli;lfi@- ,f flit@'(- are:t.-i. III 11311"s :I %-ii:ti N%'Iieii Re;,Aijii@il iiiiiiistr.itioii. tlie@- "-t-r#, %%-@tli lilt- til@k. ei;izis. I)otli ., ;izi(I ..f liit-tll(.:Il ;Ill- Vitil(It...; ;lilt] teciiiiiijII4.1@ :i(-tliiire. sti-i(it-S liiv,- iii(i -itlit-i- iiiiiiit-r-,iis lp:ttio-iit, itilli lif-i@ II,-;iltfi I., tilt, (-i-rt@ ir(,a tliit iiee4ls t,, 1-t- o)l)iiijo)ii. If tilt. -),; tilt-it. I-ffec- klilj,@iigii :tri- ,i ft-%,- %%-t, iiiiile :I ceirrt-viiii;, tilts I)r,olier lit-.iltli care lit this It %N@ill I,(- ill(- I)(,,,r. the el(l(-t-ly. ;III(] tlit@ r(,.-zi- (leftist fpf riir;tl irt@as %N-li(i %%-ill tilt, iijf)st %%-iili the tof this IN'e @triiiigly tirg4@ the it.@t-if %N-iT]i ill(- rt-:il ]iiii(I ,iii(I ri,-ex:ttjiiiie it iliti III this lirfir;iiii iliii4)s:t ;I (leei(le -iL,,. Rny J. ROB@:RT W. Chair))za?t, Legi-slatit-r Co)iziitittec. AY)ic)-ira)t 0.3t(,rpafliic Hi).3pital A-9-10- :4(i %v;is