CNA - Conference on Regional Medical Programs//1967/Washington, D. C./ CN - United States. Division of Regional Medical Programs TI - Proceedings./G IM - [Bethesda?]/National Institutes of Health, Division of Regional Medical Programs; for sale by the Supt. of Docs., U. S. Govt. Print. Off., Washington/[1967] CO - 127 p.:ports SE - Public Health Service publication,/no. 1682/G CA WA 540 A C6p 1967:02NLM EL FULL LEVEL IT MONOGRAPH MT - CONFERENCE NAME MAIN ENTRY DA - 680209 Ul 0127651 , --i - , -- @ 1 2 -I - ' . " @ 1,@' L@r- , ' @ . . -, ". @-- . - . - , . .. 1. I 7 igs eg on R ional M(doca@l Washington, D.C. Public ealt@ Servic @OF@ ED WE Proceedings: Conference on January 15-17, 1967 U.S. DEPARTMENT Regional Medical Programs Washington, D.C. OF HEALTH, EDUCATION, AND WELFARE Public Health Service National Institutes of Health Division of Regional Medical Programs For Sale by the Superintendent of Documents, U. S. Government Printing Office, Washington, D. C. 20402 Price 75 cents (paper covers) Foreword The "Proceedings: Conference on Re- son, Publications Director at the Uni- gional Medical Programs" is a report versity of Missouri Medical Center, and of the matters to which the 650 par- her colleague Mr. Normand Du Beau ticipants who attended the meeting in for their efforts in the initial organiza- Washington, D. C. on January 15-17, tion and editing of this material. 1967 addressed themselves at this the We hope "The Proceedings" will be first major conference on the new useful to the many persons who are program-authorized by the Congress of now developing the more than fifty the United States 15 months before. regional medical programs that have The presentations by the speakers, been initiated throughout the nation. the discussions by the panelists, and We believe it will become a valuable the background papers prepared by document to those individuals who in staff and consultants are published in years to come may be interested in full. It was not possible, nor would it tracing the views of the J)ersons most have served a useful purpose, to repro- actively engaged in establishing a new duce the discussions of the 25 groups and different mechanism for improv- which met for two hours or more on ing health care in our country. The three separate occasions during the volume will give a fair index of the Conference. Nor did it seem appropri- views widely held during the year ate to publish in full the more than Regional Medical Programs were in- fifty letters received by the Director of augurated. the Division of Regional Medical Pro- grams from the participants who wrote to give him their considered views on Stanley W. Olson, M.D.' the issues around which the Conference Conference Chairman and Editor was structured. In making selections of materials for these latter sections we tried conscientiously to reflect. the widely divergent viewpoints expressed. If we have failed in our effort to be impartial, the failure is a personal one rather than an effort to suppress views that might be regarded as less than helpful to "the establishment." Ac- knowledgement is due Dr. Joye Patter- 2 Introduction The Conference on Regional Medical realized in the future than they have accurate while the validity of many and closed with the following two Programs was sponsored by the Divi- been in the past. A major factor behind others are yet to be tested. sentences: sion of Regional Medical Programs of these movements is the accelerated ad- However, the Conference, like the ". . . the committee is thoroughly the National Institutes of Health, to vance of scientific knowledge in medi- Programs themselves brought together convinced of the great importance provide a national forum in which this cine and the need to relate this advance those of diverse background and in- of this innovative program to the new concept in health could be dis- to the needs of people. terest to inquire how best to relate health and welfare of every Ameri- cussed. Its dual purpose was to en- It is not possible to predict with any current resources to future potential can. The concept of' regional medical courage ideas from a representative degree of accuracy the results of any and how to relate advances in heart programs must be made to work, group of knowledgeable individuals that one piece of legislation, like Public Law disease, cancer, stroke, and related and no effort should be spared to could be used in preparation of the re- 89-239 which established the Regional diseases to the needs of people on a insure that it does." quired Report of the Surgeon General Medical Programs for heart disease, regional basis. In accordance with a request by the to the President and the Congress, and cancer, stroke, and related diseases, or There are a number of significant de- Coordinators of the Regional Medical' to provide an interchange of informa- its eventual contribution to an area as velopments that have occurred during Programs at the Conference, a meeting tion on planning, activities, and goals complicated as health. Yet, it is the the six-month period since the Con- of that group from both funded Regions for the Programs among all organiza- purpose of this report of the Proceed- ference. and those still in developmental stages tions, institutions and individuals con- ings of our Conference to record an One important development has been totaling some 53, was held in Bethesda cerned with the Programs, individually attempt to evaluate and probe for the funding and initiation of the first on June 16 and 17. Additional meet- and collectively. dominant trends and pervasive forces four operational Programs. In addition, ings of this group are being planned A sincere debt of gratitude is due all that might be more clearly identified the number of Regions involved in for the coming year. of those who attended the Conference. during the initial implementation of planning activities has been increased In late June of this year, based on The record of the papers and dis- Regional Medical Programs. The accu- to 48. These two facts indicate the in- the results of this Conference, the ad- cussions contained in these Conference rate understanding of these trends and creasing rate of forward' movement of vice of the National Advisory Council, Proceedings and the material contained forces of society is an essential base the Programs. and an Ad Hoc Committee, Surgeon in the Report of the Surgeon General for a Report to the President and Con- During this same period, the Presi- General William H. Stewart submitted to the President and the Congress, gress concerning extension of the law. dent submitted his Health Message and his Report to the Secretary of Health, much of which was drawn from the As pointed out by Henry Sigerist, a included the following definitive refer. Education, and Welfare for transmis- Conference, form the historical base medical historian, more than thirty ence to Regional Medical Programs to sion to the President and then to the and the documentation for projection years ago: "The characteristic features support his request for a 1968 budget Congress. As required by Section 908 of Regional Medical Programs into the of the medical profession are deter. of $85,314,000 for the Division activi- of Public Law 89-239 it appraises the 1970's. ies: activities of the Regional Medical Pro- Medicine, or more appropriate mined to a very large extent by the t "in 1968 we will: Begin operat- grams and makes recommendations ly attitude of society towards the human health, in the next decade will become body, and by the valuation of health ing the new regional medical pro- concerning the extension and modifica- an increasingly critical national issue, and disease. . . . There is one lesson grams which will narrow the gap tion of the law. This Report on Re- economically, because the cost of that can be derived from history . . . between the advanced methods used gional Medical Programs to the Presi- health continues to rise more rapidly that the physician's position in society at university hospitals and day-to-day dent and the Congress (Public Health than other costs; sociologically, be- medical practice in the community." Service Publication No. 1690) will be a cause of its relationship. to other is never determined by the physician In this same connection, both the basis for future legislative action. domestic issues including poverty, and himselfi but by the society he is House and Senate Appropriations Com- urban affairs; and politically, because serving. . . ." mittees have heard testimony to sup- Robert Q. Marston, M.D. of the rising expectations of Americans, Already, in retrospect, some of the port this appropriation. In its report, Associate Director, National Institutes and the promise that these expecta- ideas, comments and conclusions of the House Committee strongly sup- of Health, and Director tions may be more rapidly and nearly the Conference have proved unusually ported t he concept of the Programs, Division of Regional Medical Programs 3 Table of Contents Page Section I-Papers Presented ..... .......................... 5 Evalualion of Medical Care under Public Law 89-239 Remarks Paul J. Sanazaro, M.D ........................... .............. Charles L. Hudson, M.D ................................... 6 Continuing Education and Regional A New Era in Medical Care Medical Programs ............................................ Wilbur J. Cohen, Ph.D ..................................... 7 The Report of the Surgeon General to With the Patient in Mind the President and the Congress ................................... Robert Q. Marston, M.D ......................................... 11 Science and Service Section IV-Group Discussions .............................. James A. Shannon, M.D . ...................................... 18 Program Evaluation INTRODUCTION .............................................. Vernon E. Wilson, M.D . ........................................ 21 REPORTS The Idea, the Intent and the No Prospects for "Instant" Regional Implementation Medical Programs Sidney Farber, M.D ............................................ 25 Donald J. Caseley, M.D ....................................... Regional Medical Program Coordinators Section 11 Panel Sessions .................................. 29 Edmund D. Pellegrino, M.D .......................... .......... Practicing Physicians Bruce W. Everist, M.D .......................................... Program Evaluation ........................................... 30 Chairman: George James, M.D. Interpretation and Administration of Panel: Edward Kowalewski, M.D. the Act C. H. William Ruhe, M.D. Paul M. Ellwood, Jr., M.D ....................................... Harvey L. Smith, Ph.D. STAFF SUMMARY ............................................ Vernon E. Wilson, M.D. The Report of the Surgeon General Section V-Excerpts From Post- to the President and the Congress ............................... 36 Conference Letters .............................. Chairman: Storm Whaley Panel. Michael E. DeBakey, M.D. APPENDICES Bruce W. Everist, M.D. 1. Conference Program ............... ................ James T. Howell, M.D. 2. Registered Conference Participants ....................... Ray E. Trussell, M.D. 3. National Advisory Council ................................... Paul N. Ylvisaker, Ph.D. Review Committee .......................................... Ad Hoc Committee for the Report ............................. 4. Division Staff .............................................. Section III-issue Papers ................................... 45 5. Directory of Programs ....................................... 6. Guidelines ............................................... The Development of Cooperative 7. Public Law 89-239 ......................................... Arrangements ...... ........................................ 46 8. Regulations .............................................. 4 Section I-Papers Presented Remarks Representative leaders in the fields of Charles L. Hudson, M.D. medicine and health were invited to A New Era In Medical Care present papers reflecting their thinking Wilbur J. Cohen, Ph.D. on the subjects covered in the plenary sessions. With the Patient in Mind Robert Q. Marston, M.D. Science and Service James A. Shannon, M.D. Program Evaluation Vernon E. Wilson, M.D. The Idea, the Intent and the Implementation Sidney Farber, M.D. 5 Remarks Charles L. Hudson, M.D. President American Medical Association I am pleased to have this opportunity and the precipitant approaches there is come intrusion but also something ex- Believing the premises upon whic to add my voice and that of the Ameri- often conflict, even though the objec- tremely confusing to the public as well. these actions were based to be fais can Medical Association to those who tives of both'approaches be the same. The raison d'C-tre of such complexes and concerned that this was a revoli -' tionary change in the system of heali will participate in this meeting discus- We are present in this conference not we learned, was the provision of serv- care not in the public interest, the AM sing Regional Medical Programs. I am to emphasize our differences but to ices to people who were the target of sorry that previous commitments will determine as best we can how the re- the legislative thrust, based on the did not support the legislation. not permit me to stay on with you in sources of Government under the law allegation that a barrier of ignorance of Then, later, several of us from the AM the succeeding days, but my interest can best be directed toward the health what was new impeded the flow of were on a mission to Washington I will remain with you regardless of my care system that is primarily serviced health care through current conven- advise the Department of Health, Edi absence. by the private sector. tional channels. cation, and Welfare regarding the ne As everyone here knows, scientific ad- The origins of Public Law 89-239 to my vances have tended to divide and knowledge are to be found in the Re- stratify our profession, not only in what port of the President's Commission on we do but in our principal interests. As Heart Disease, Cancer and Stroke, from we become more specialized and diver- which document certain of its recom- sified, it should be recognized that we mendations were selected for legisia- become more interdependent. To coun- tive implementation. As I understand teract this divisiveness we should set fit, it is extremely difficult to reproduce ourselves to the task of formulating in the language of the law exactly what plans to assemble dissimilar elements a narrative report contains. But it of health service into an integrated seems reasonable to assume that the whole. sections selected for the Bill retain some relationship to that report from The problem posed in this endeavor is whence they originated. And thus the a mode of accomplishment of this task. How shall we do it? We in the Sen@te.Bill 596 was interpreted by the medical profession tend to favor the profession as recommending areas of retention of systems "that work" and service provision called "complexes" that described not only highly special- do best within our resources, to pro- zed medical and surgical treatments ceed in an evolutionary fashion, per- in a medical school center but also haps more cautiously than suits the i taste of everyone. While we are not dagnostic and treatment stations in "the last to lay the old aside" ' neither the periphery. We inferred that this, a in clinical practice do we tend to -e closed entity of indeterminate size, ex- D cluding others already practicing in the "the first by whom the new are tried." area, was intended to demonstrate in Government, on the other hand, a a disparaging way perhaps the inade- financing rather than a service mech- quacies of our physicians. A quantita- anism, with its great resources of tive capability to replace these physi- money and influence, has the capacity, cians or a visible means of improving and I would say inclination, to effect their capacity to provide health care rapid and major changes in patterns did not appear feasible under this plan. and procedures. Between the cautious This we viewed not only as an unwel- 6 A New Era in Medical Care Wilbur J. Cohen, Ph.D. Under Secretary of Health, Education, and Welfare Pi L. 89-97. Hearing the passage of the 89-239 as an excellent model for such We are meeting here today to focus on has high-lighted the need for com- legislation on heart disease, cancer, a purpose have led me to give public the future structure of Regional Medi- munity planning of all its health and and stroke in the House of Representa- support to the use of this legislation cal Programs. We are seeking advice medical care facilities and manpower tives was imminent, we reported to for educational purposes. I feel that the from those of you who will have to resources. Communities, many for the President Johnson our belief that pass- impact of P. L. 89-239, if used in this make the programs work. We are con- first time, have had to plan for an ade- ing this, the Senate version, upon the way, on the health care of the Nation tinuing to try to improve the formula quate number of facilities with a full heels of Medicare would be repugnant will be infinitely greater than if im- for bringing all groups together to fuse range of needed services-extended to the physicians of the country and plemented primarily in another fashion. the contribution of science, education, care facilities, home health services, tient clinics. Cooperative ar- would adversely affect their attitude The dissemination of the program's and service for the benefit of all of and outpa toward any and all Federal support pro- influence through the physician, espe- our people. rangements are being developed to as- grams, especially Medicare. cially those at the periphery, will be many pressures and trends for change sure that community resources are As a consequence, a revised version of broader than if its substance is used contributed to the health legislation of used to promote quality care with the the Senate Bill was prepared with the up on services to a limited number of the 89th Congress, which was the most most efficiency and economy. assistance of the AMA. It passed the individuals. health-minded Congress in our history. We are entering a new era in health - To conclude on the note on which I More national hea tionary period. Our chief concern is House, prevailed in Conference Corn Ith measures for pro- care an evolutionary, almost revolu- mittee, and became the law. began, I believe the assignment of viding the American people with the the achievement of high-quality, com- It is the AMA's interpretation of P. L. roles in an integrated system will best best possible health care were enacted prehensive care for all Americans. We -239 and its regulations that serv- be determined by a cooperative effort in the 89th Congress than at any other 1 89 time in the past century. The Regional are keenly conscious of not on y ex- ices will be given incident only to the on the part of all segments of the pro- Medical Program, Medicare, Medicaid, panding medical services to many needs of education and research; that fession rather than if it were made by aid to medical schools, comprehensive groups who have been without them the program, rather than a geographic legislative edict. it is true that differ' health planning, grant support for train- in the past, but also with the provision entity, is a sphere of influence, largely ences in roles will be perpetuated by ing professional and allied health pro- of a higher quality of medical services educational in intent and capable of variations in breadth or depth of edu- fessionals, and increased support for for all of the population. exchanging information and personnel cation and training, by the complexity - are just a few of the The achievement of our goal will not I of the skills required of us, and by the medical research there are serious between the center and the periphera developments that aim for the delivery be easy because institutions which are now called hos- character of the occupations we elect of comprehensive high-quality care. shortages in the health professions and pitals. to pursue. Today, as never before in history, you in health facilities. The inherent nature With this understanding-rather than the most are being asked to help create the of quality care rests with the health with an definitive interpretation by the The scarcest and probably m is the basic instruments to give people the professions, their ideals, integrity, and y essential element of the progra National Institutes of Health I must educational and research center, where kind of care they need, when and where vigilance. If they are going to meet the honestly add-I have recommended r they need it. demands for high-quality care, improve- one might anticipate the most efined jor new ments in the organization and the de- the program to the constituent and knowledge and techniques to be found. These programs represent a ma, component parts of the AMA in coun- thrust-a new momentum in the field livery of health and related services and they have re- Inherent in this recognition is the haz- of health care. A whole continuum of must be made. The Government can ties and States, embers of local ard that judgments of high position in fficient see to it that, in ever increasing num- sponded not only as m a vertical scale will disparage any other the most economical and e advisory groups but also by leading in forms of health care is being devel. bers, professional competence is ever the application for approval of Pro- contributor to the whole scheme. Other le, has present in providing patient care. We contributions, while less refined per. oped. Medicare, for examp are going to have to do a lot of re- grams. haps, may be equally valuable. For that focused attention on ways to improve s of utilizing reason I hope communication within medical care, and the program itself\ thinking about better way our search for another mechanism in have, how to train graduate medical the program will be open, free, mu- carries major incentives to provide new the personnel we this country for post ersonnel, how to rationalize our education and the adaptability of P. L. tually respectful, and multidirectional, and improved services. The program more p 7 rsities, hospi- The main purpose of the program is to services and how to create economy tual resources. The professions provide public and private (unive and efficiency in the organization and the specialized talent without which no tals, etc.) and we have no intention of afford, through such cooperative ar- delivery of services. modern society can run. Non-profit or submerging their identity in some rangements, the medical profession Every community will have to reex- voluntary associations provide a signi- rigorous master plan. The solution is to and institutions of the Nation oppor- amine how available personnel institu- ficant means of harnessing non-govern- be found in new forms of cooperation tunities to make available to their tions, and equipment can serve to a mental resources toward a public pur. among institutions." patients the latest advances in the better advantage. Business, labor, and pose.,, No program better expresses this con- diagnosis and treatment of heart dis- civic leaders, under the leadership of The complexities of the problems we cept and approach than the grants for ease, cancer, stroke, and related dis- the medical profession, can also help face in providing high-quality care re- Regional Medical Programs. The very eases. And I would emphasize again- to introduce innovations and create quire the best ideas and efforts of all first words of the Act setting up the as did the Congress in reporting on the new and improved methods of delivery the Nation's resources. Secretary Gard- programs call for "cooperative arrange- Bill and the President in signing it- of health care. Every member of the ner noted: ments" among the interested and that our purpose will not be achieved community has become involved in the "We have a multiplicity of institutions, affected organizations and agencies. until all medical practitioners and their patients realize the full benefits that organization and delivery of medical modern science and technology make care in this country and shares the I possible. responsibility for its improvement. Effective community planning, active @i So now we reach the real test. After cooperation between the educational the new legislation authorizing grants systems, health facilities and medical for Regional Medical Programs was and other professional organizations signed, it was up to you-the health gradients for implement- leaders of the Nation, private, volun- are essential in ing the new health programs. tary and public-to do something While the new programs enacted by about it. Congress in the past two years are national in scope, it is up to local In April 1964 when President Johnson groups to provide ideas and initiative met for the first time with members in carrying them out and making them of his Commission on Heart isease, Cancer and Stroke he outlined their a success. These programs are an ex- pression of "creative federalism." In task in the following words: discussing this concept recently before "Unless we do better, two-thirds of all a Congressional Commi+tee, Secretary Americans now living will suffer or die ase or stroke. Gardner pointed out: from cancer, heart dise "There is a great potential for innova- I expect you to do something about it." tion in the scope and variety of the Federal Government's partnership ar- The President was talking directly that rangements. Through these the Federal spring day to a small group in the Government taps great sources of White House Garden. But, indirectly he strength in American life. The private was setting a challenge for all persons economy is the chief source of eco- concerned with the Nation's health. He nomic growth and vitality. The uni- was calling upon the practicing physi- versities-State, local and private- cians who bear the heavy responsi- harbor the bulk of the Nation's intellec- bility for diagnosis and treatment-the 8 health workers who assist and support Programs. We need your advice on The Commission asked: "How are we lying problems of medical manpower the physician-the educators who train what more needs to be done so that we going to close the gap?" and communications, which the Com- the present and future generations- can help you step up the time between The answer to this question was mission felt had to be met to effec- the research -scientists who are extend- the discovery of medical miracles and strikingly similar to the answer found tively attack the so-called "killer" ing available knowledge and capability their availability to the people whose by many others in related social fields diseases. -the health officers who are con. lives may be saved by them. in recent years. Although the Commission's Report had cerned with preventing disease and Let us review the path we have traveled Scientific progress has outpaced many facets, there were two central disability-the volunteers and staffs of since April 1964. changes in human organization. As a themes. One was that people every- the private health agencies who are where, not only those near great medi- devoted to furthering the education of The President's Commission, under the society, we have more knowledge than the public and the work of the profes- Chairmanship of Dr. Michael DeBakey, we have know-how. As a result, the cal centers, should have the benefit sionals. To all of these, the President was convened on April 17, 1964 and benefits of scientific progress are not of the latest medical scientific ad- made its report on December 9, 1964. accessible in equal portions to all the vances. The second was that this goal was also addressing his charge: could only be accomplished by a fusion "I expect you to do something about it." The Commission contacted 60 private people of the Nation. Tonight we can tell the President that and professional agencies and organ- The Commission found that many of science, education and service. a good deal has been done about it izations and consulted over 175 wit. agencies and institutions were working After the Report was issued, it was up nesses. The second National Confer- on overcoming these problems. How- to the Department of Health, Educa- since April 1964. But while the job has ence on Cardiovascular Disease was been started well, there is still much to rescheduled so that the Commission ever, these efforts were often being tion, and Welfare to do something be done. Tomorrow and Tuesday, I could have the advantage of its find. performed in isolation-and sometimes about it. And we did two principal at cross-purposes. things. First, the Department requested, hope you will tell us how the job can ings. and the President and the Congress be done better. In looking back on the Commission's The Commission found that its concern approved, additional funds to begin to Regional Medical Programs were de- findings, we find eloquent testimony to with the heavy price of fragmentation implement several specific recommen- signed to fit into the complete spec- the gains that scientific progress has was shared by many others. Spokes- datiohs of the Commission. Secondly, trum of needed health services and made possible. But we also have docu- men of medical groups, medical schools the Department, under the leadership they represent the kind of innovative mentation that the results of this prog- and public health, among others, testi- of Dr. Edward Dempsey, Dr. Stewart, and experimental approach needed to ress is not being made available to the fied both about the penalties and prob- and Dr. Shannon, developed a legisla- achieve our goal. The authorizing legis- people who could benefit from it. The lems of separated efforts and their tive proposal to carry out that part of lation allowed three years for planning Commission Report pointed out: willingness to explore new approaches the Report which called for a joining and pilot projects to gain experience. "The rising tide of biomedical research and remedies. of the worlds of scientific research, In order to provide an early opportunity has already doubled and redoubled our On the basis of the extensive expert medical education and medical care. for review and evaluation, the Surgeon store of knowledge about heart dis- advice and its own staff studies, the In formulating the legislation, the De- General is required to report to the ease, cancer and stroke. Yesterday's Commission did something about it. It partment focused on the following President and the Congress next sum- mer on what has been accomplished hopeless case has become today's produced a 113-page report containing recommendation: and what changes are indicated. miracle cure. We stand on the thresh- 35 major recommendations plus a ref- "The Commission recommends that a hold of still great breakthroughs in the erence document including over 600 broad flexible program of grant support You have been asked to come to Wash- laboratories and clinical centers of the pages of documentation and many sub- be undertaken to stimulate the forma- ington to help the Surgeon General Nation. Yet for every breakthrough sidiary recommendations. The major tion of medical complexes whereby prepare this report to the Congress. We there must be follow-through. Many of recommendations covered a wide university medical schools, hospitals need your reports on what has been our scientific triumphs have been hol- variety of proposals. Some were con- and other health care and research happening in your localities in plan- low victories for most of the people cerned with strictly categorical activi- agencies and institutions work in con- ning and developing Regional Medical who could benefit from them." ties; others were aimed at the under- cert." 9 Perhaps the best 'way to recapture what Hospital Association, American Acad- agency staffs and consumers met to- vestment in research. For we realized the Department proposed is to quote emy of General Practice, as well as gether all over the country to begin to that only in this way can we achieve from the President's message of Jan- many individuals from medical schools, plan Regional Programs. Many of these our objectives for the control of heart uary 7, 1965 on the legislative pro- medical practice, hospitals and other sessions, I am told, have not been en- disease, cancer and stroke and other posal: concerned citizens. tirely comfortable-for the participants diseases. "A plan to improve our attack upon As a result of the views expressed, have not been used to working together Some have argued that there is an these major causes of death and dis- numerous changes were made in the so closely in the past. But you have .nconsistency, or even conflict, between ability should become a part of the language of the bill which, I might add, begun to work on something that is !ni@@ quality and widespread use. They fabric of our regional and community full of many problems and difficulties . .. . taxed all the ingenuity I had gained r)eiieve that excellence is such a rare health services. The services i)roviaea rom 30 years of legislative experience. and you are working them out. That is and tender flower that it can only under this plan will help the practicing progress and that is hopeful for the ' - AS Many of you know, the President bloom in special and carefully pro- physician keep in touch with the latest joined personally in these efforts, in future of all medical care in our Nation. tected environments. They have sug- medical knowledge by making available which Dr. Hudson participated, to find Reports indicate that our faith in the gested that we can lose everything by to him the latest techniques, special- just the right words and concepts for ability of local groups to develop new trying to mass produce what requires ized knowledge, and the most efficient bringing all the groups involved to. approaches is proving to be well- the most skilled craftsmanship. methods. To meet these ob'i.ectives, gether in a common attack against founded. We are also looking to the such complexes should be regional in these common enemies of man. regional groups to find the best ways This point of view, I believe, is con- scope; provide services for a variety of of fitting together the many related pro- trary to our national hist ry and corn-. diseases; be affiliated with medical The Act that was signed in October grams that touch upon these problems. mitment. I think we have the capabili- schools, teaching hospitals, and med- 1965 was the result of these combined The key problems of coordination must ties as a society to make the very best ical centers; provide diagnostic services efforts. be solved at the local level. If the Fed- available to all our people. This is our in community hospitals; provide diag- nosis and treatment of patients, to- The story of what you have done in a eral Government tried to coordinate all national goal. It is this goal that in- gether with research and teaching in little over a year is exciting and auspi- its programs at the Washington level, spires and integrates all the diverse a coordinated system. . . . Action on CiOus. Under the able leadership 'of it would end up imposing a pattern. programs for which the Department of this new approach, will provide signi. Dr. Robert Marston you have under- More important, only State and local Health, Education, and Welfare is re- ficant improvements in many fields of taken some of the most significant leadership has the knowledge of local sponsible. medicine." cooperative planning efforts in all our needs and resources that will enable health history. Planning grants cover- them to put all the programs together Regional Medical Programs have a The bill was introduced in Congress in ink regions in which some 60 percent in a way that makes sense. unique and extraordinary contribution to make in this movement. Their es- January 1965 and enacted in October' of the population of our country live Regional Medical Programs have been During the intervening months, all sential purpose is to speed up the dif- have already been awarded. Applica- described as having an obsession with fusion of knowledge-to bring together interested groups had an opportunity to tions for planning grants for the remain- quality. Nothing is more necessary-or science and service for the benefit of be heard and to participate once again ing regions are well along. Moreover, fitting. all. in considering the best ways to meet the proposals for the first pilot projects the identified needs. Many viewpoints for operational activities have already We are all aware of the tremendous In the last year or so, the Public Health were heard. Testimony was received been received and I trust grants for this investment that has been made in Service has reorganized itself so that from representatives of the American Durpose will be made within the corn- effort and resources over the last 20 under the leadership of Dr. Stewart it Medical Association, American Heart 'ing months. years to advance the frontiers of medi- will be able to make its maximum con- Association, American Osteopathic As- cal knowledge. The advance of this tribution to this effort. sociation, American Public Health Asso- During 1966, innumerable groups of movement has been one of our great ciation, American Dental Association, practitioners, educators, hospital ad- accomplishments as a Nation. We in- Regional Medical Programs are provid- American Cancer Society, American ministrators, health officers, voluntary tend to maintain and extend this in- ing an opportunity and means for 10 With the Patient in Mind Robert Q. Marston, M.D. Associate Director, National Institutes of Health Director, Division of Regional Medical Programs health groups all over the Nation to Regional Medical Programs have been that characterize any new health pro- Capricorn. In a short story entitled take a somewhat similar look at their launched at a critical time in American gram. He notes that in the first stage, "The Far Limits" he writes: needs and potentialities. It is important Medicine. The initial reception by the available data is limited and decisions "The Pacific is enormous, plural, con- but not enough for governmental Nation has been far more enthusiastic must be made almost entirely on the tradictory. One aches for limitations, agencies, either here in Washington or than many supporters believed possi- basis of the best judgments of respon- for boundaries that reduce the sensa- in State capitals, to examine how they ble. Initial financing has been adequate. sible persons. This is where we have tion of awe. For each person the limits can most effectively carry out their re- The program is now undergoing a proc. been during much of the past year. are different. For some people the sponsibilities. Nor is it enough for edu- ess of analysis to determine whether The focus has been on establishing Pacific is no-larger than a tiny village, cational and research institutions to the premises on which it was based are mechanisms and approaches which a strip of white sand, a reef. For a tiny undertake similar examinations. Rather, still valid; whether the initial imple- promise better utilization of existing group, that inquisitive body of oceanog- as illustrated by the composition of mentation has been effective; and information and the collection of addi- raphers, the Pacific is illimitable. So this conference, all those concerned whether experience suggests that tional data which will form the basis great is their curiosity that their Pacific with these disease problems and better changes should be made for the years for more confident decisions in the runs from the Bering Straits to the health must join in the process. ahead. The fact that this audience is future. In considering proposals for glittering ice cliffs of Antarctica." Happily this job has already been here to participate in these considera. extending the legislation, Congress The scope of Regional Medical Pro- started in most parts of the country. tions and decisions emphasizes the faces the same difficulties that we have s will certainly lie somewhere be- fact that this program is indeed founded faced. Congress will value, as we shall, gram We are doing something about it. ' tween Burdick's tiny village and the But on local concern for the needs of those the best judgment of those who have I trust you will not be satisfied-for we patients with heart disease, cancer, acquired wide experience in the health entire Pacific. will not-until the best of health care stroke, and related diseases. fields and who have assumed respon- As the Nation begins an innovative and is not only part of the continuing con- sibility for launching the individual ambitious venture in improving the cern of health leaders and a preoccupa- Much of this paper and most of the Regional Medical Programs throughout quality of health care for patients with tion of some but is part of the daily life meeting will be focused on the Report the country. To reinforce the limited heart disease, cancer, stroke, and re- experience of all our citizens. to the President and Congress required hard data that is available, the Presi- lated diseases, it is being watched in@ For the next two days you will be able by the enabling law. Such a Report dent and Congress will expect evidence tently by its neighbor nations. Lancet to concentrate on these problems. We comes at a very early stage in the de- of firmer commitments, clear purposes, in a recent editorial refers to the Re- hope that you will give us your ideas velopment of the program. Nonethe- and crisper definitions. These examples gional Medical Programs as "An Amer- and advice on how Regional Medical less, this Report will constitute the must be developed by you who are ican Catalyst." A description of the Programs can best be strengthened basic document on which the program involved at the regional level on the Connecticut program by Dr. Henry and facilitated. After you leave, we will for the period from 1969-1974 will be basis of your actual experience and Clark at a Boerhaave Conference in welcome statements of your reactions built. future plans. Since the very nature of Leiden, Holland, was of great interest and proposals as further experience is In his Issue Paper on evaluation, Dr. Regional Medical Programs involves to health leaders from Holland, Bel- acquired in the planning and operations Sanazaro has defined the several stages opportunities at the regional level to gium,. England, Sweden, and Turkey. of Regional Medical Programs. probe for workable solutions to com- At one time I was chairman of the I can assure you that not only the plex problems, we in Washington can. NIH Postdoctoral Foreign Fellowship Prepared in cooperation with Karl not conjure the required realistic ex- Surgeon General but also President Committee which brought young scient- Johnson and Secretary Gardner, as well Yordy, Assistant Director, Division of amples which indicate modifications ists from 40 countries for research as members of the Congress, are look. Regional Medical Programs, and Stan- are needed. Only your efforts and ex- fellowships in the United States. These ing forward as I am to your reports ley W. Olson, M.D., Chairman, Confer- periences can provide such evidence. young physicians and scientists uni- and recommendations. I am confident ence on Regional Medical Programs, A major problem is related to the scope formly praised our unique ability to you will, once again, meet and exceed and Coordinator, Tennessee Mid-South of the program. Gene Burdick's most bring together, for the purpose of the their expectations. Regional Medical Program pleasant book is one called the Blue of problem under study, the skills of those 11 from many disciplines. Our foreign col- we are now in the process of testing tions for RegioAal Medical Programs. leagues who have observed this inter- the progress and capabilities of Re- Deans and faculty members of all of disciplinary achievement in research gional Medical Programs. the Nation's existing medical schools will be greatly interested to observe STATUS REPORT. Secretary Cohen, and most of the schools under de- whether we can parallel this perform- velopment have participated in this ance in the field of medical care. To last night, presented a splendid re- activity along with most of their teach- bring this 'about, the primary focus view of the historical development of ing and affiliated hospitals. Represen- must be not on the needs of medical the broad policy and philosophy that tatives of State and local medical soci- schools, the needs of hospitals, the led to the establishment of Regional eties and health departments have needs of health departments, or even Medical Programs. The copy of a re- been part of the discussions in almost the needs of physicians and other cent paper of mine forwarded to you every instance. In addition, area-wide health workers. Rather, the primary in advance of this meeting summarized hospital planning agencies and State focus must be on the needs of patients. progress from October 1965 to Octo- and local hospital associations repre- ber 1966. A few illustrated facts should senting the Nation's community hos- This Conference is framed against a suffice to up-date that data: pitals almost always have been repre- series of difficult decisions facing 0 The National Advisory Council has sented. Members and staffs of cancer American Medicine. We must decide met six times. At four of these meet- societies and heart associations have how we shall provide health manpower ings applications for planning grants participated along with other public for ever increasing needs and demands. were reviewed. and private health agencies and repre- We must decide how we shall provide 0 As a result of decisions reached at sentatives of the public such as elected particularly for these receiving the 16 the April 1966 meeting, seven grants officials, businessmen, labor leaders, poorest care of all-the poor, the min- were awarded. and leaders of religious and ethnic orities, the isolated-both in the coun- 0 At the June 1966 meeting, three groups, try and in the heart of cities. Severe additional applications were approved. A study of the backgrounds of the in- economic pressures are being exerted 0 At the August 1966 meeting, eight divid,als who are assuming responsi- on the entire field of health, particularly more applications were approved and bilities as full-time coordinators and on America's hospitals. Urgency exists with respect to how we shall organize staff directors of Regional Medical Pro- to best use the many new technologies 0 Most recently at the November 1966 grams indicates that about half of that promise potential benefits if wise- meeting, the Council approved 16 ap- these individuals come directly from ly and effectively used. plications, bringing the total of funded the field of medical education. Another These problems and trends are pow- programs to 34. substantial number were forrilerly in- erful in their impact. They require 0 In addition, 14 planning applica- volved in key positions in hospital that instruments of great durability and tions which will bring the total popula- administration. The remaining came equally great sensitivity be structured tion covered by planning activities to from leadership roles in voluntary so that medicine may be favorably in- some 90 percent of the nation are ex- health agencies, State government, and fluenced to provide the greatest serv- pected to be presented to the February the private practice of medicine. The ice to those in need. We believe that Council Meeting. The first four appli- high caliber of person being sought Regional Medical Programs, with their cations for operational phases will also and employed for these positions is emphasis on local initiative and local be presented at that time. impressive. control, was created as such an instru-. There has been widespread involve- A study of the make-up of regional ad- ment to help solve these problems and ment of individuals and groups in the visory groups indicates that on an cope with these trends. To this end, development of all of these applica- overall basis . . . 12 21 yo are practicing physicians raised and will continue to be asked determine which of them are favorably of this meeting and grows out of the 18% are associated with medical whether these arrangements developed affecting the care patients have re- fact that the Surgeon General of the schools and affiliated hospitals for the purpose of starting to plan for ceived, and to what degree. Public Health Service is required by 13% are from Cancer Societies, a regional medical program will be the I have often referred to the clinical the law which established Regional Heart Associations, and other most effective arrangements for specific pathological conference as a unique Medical Programs to make a Report to voluntary health agencies operational activities in heart disease, feature of medicine. It is here that the President and Congress on or cancer, stroke, and related diseases. even the most senior clinicians display before June 30, 1967. A subcommittee 12% are administrators of hospitals Another issue suggested for discussion their clinical judgment for all to ee, of !he National Advisory Council on 8% are nurses and other health s Rag.0 nal Medical Programs and t e in the paper on cooperative arrange- It is a method for exposing error an Surgeon General concurred in our view workers ments is the nature of the local deci- thereby improving care. It and other 8% are from public health depart- sion-making mechanism. The law re- established traditions such as the that, in addition to the steps already taken toward the development of in- ments quires that all operational grant re- autopsy, the use of a case conference, . 14% represent the public at large quests must be approved by regional and the wide use of consultants has formation for this Report, representa- advisory groups. The question arises firmly established medicine's commit- tive groups from the entire country HIGHLIGHTS OF ISSUE PAPERS. Let whether this approval shall be merely ment to constant scrutiny and critical should be convened. As a result, re- us now focus attention on the issues ional coordinators, representatives of a pro forma endorsement based on con- evaluation of its judgment and tech- 9 ional advisory groups, and others that are emerging. These have been fidence in the applicant organizations niques. reg described in a series of Issue Papers and institutions, or whether it shall identified as key people in the develop- sent to you as background material represent a careful evaluation of re- We are now entering a phase of med- ment of approved and pending grant for discussion at this Conference. gional priorities based upon sound ical care which requires that we do for proposals have been invited to this populations of patients and populations Conference. Major health organizations The first of these papers entitled, "The knowledge of needs and capabilities. Development of Cooperative Arrange. This issue is closely related to the prob. OT physicians what we have done so) who have expressed an interest in this ments," includes a fine statement by lems of the review and approval proc- long and so effectively for the individ- program were also invited to send Dr. Charles Hudson, prepared four ess for operational grants to be d ual case and the individual practitioner. representatives. Appropriate representa- years ago, which expresses his views cussed later. is- The techniques of epidemiology, med- tives of other government agencies in- ical ca re research, of community cluding the National Institutes of on the desirability of developing co- In the second Issue Paper entitled, medicine must be adapted to personal Health, other bureaus of the Public operative arrangements. We have been "Continuing Education and Regional health, as well as public health. TO Health Service, the Bureau of the told that Regional Medical Programs Medical Programs," it is noted that this end, we asked Dr. Paul Sanazaro Budget, and Congress were invi'ted to have made considerable progress in continuing education has been ac- to prepare the Issue Paper "Evaluation attend. Also included are the 65 in- developing genuine cooperative ar- cepted as an article of faith by the of Medical Care Under P.L. 89-239" dividuals who have served as consult- rangements throughout the Nation. medical profession. Although it is re- and Dr. Vernon Wilson to discuss the ants to the Division in helping define Groups in virtually every region have garded as an essential activity for the problems in a subsequent talk. The policy and philosophy. Specifically, been probing to establish a work- scientific and clinical renewal of the issue is how rapidly the still-develop- these include members of the initial able basis for starting the planning physician, the Issue Paper points out ing techniques for evaluation can be Review Committee, members of the process. However, the initial ap- that this vital educational experience employed so that our effort to improve ad hoc Committee for the Report to proaches concerning the size and shape has often been characterized by lack care will be logically rather than em- Congress, members of the National of regions for planning purposes must of continuity. There are two key issues. pirically determined. Advisory Council, and liaison represen- be re-examined critically from time to First, how can programs be designed tatives of other National Advisory time, especially when the region moves that effectively reach the physician and THE REPORT OF THE SURGEON GEN- Councils with related interests. from planning into the establishment others in the health field; and second- ERAL TO THE PRESIDENT AND CON- of an operational program. Let me be ly, how can self-monitoring aspects be GRESS. The fourth and last Issue Paper All of the members of the Pr6sident's quite specific; questions have been incorporated into these programs to is concerned with the primary focus Commission on Heart Disease, Cancer, 13 and Stroke have also been invited. We port must also speak to at least four ment of cooperative relationships The planning phases of Regional Medi- are particularly interested in having other questions: among major health resources in the cal Programs are well on the way to them now refocus not only on the pro- 0 In specific terms, the type of con- region. These activities are generally covering the entire Nation. We are now gram as it exists today but on possible struction authority needed to achieve generic by nature and consequently in the process of reviewing the first future modifications. Their background the goals of the program and the have not significantly involved prob- applications for operational grants. of competence and the experience they urgency of this need must be made lems o.f categorical definition. In most The initiation of operational activities gained in producing the document clear to the President and the Con- cases in order to plan effectively for is the most vital element of our mutual which served to initiate the legislation gress. Any request for such authority heart disease, cancer, and stroke it task ahead. It is the operational activi- establishing Regional Medical Pro- must be substantiated by firm, objec. has been found necessary to consider ties to be approved, funded and imple- grams will prove to be invaluable. tive evidence of need, particularly if at times the entire spectrum of re- mented under the current legislation Public Law 89-239 specifies three favorable matching requirements are sources available for personal health that must constitute the central focus things that the Report must accomp- needed. services. However, the emergence of for recommendations for extension of lish: 0 Since the earliest days of the pro- the operational phase of the program the program. Based on experience to gram, questions have been raised re. will put a more intensive focus on its date which includes staff analysis, site It must appraise ... t)eatedly concerning the need to clarifv categorical purposes. Only projects visits, deliberations by the Review Corn- 0 The activities assisted by grants in ' il which can be shown to have direct the light of their effectiveness, and certain provisions of the law. We sha significance for combating heart dis- mittee and the National Advisory Coun- have an opportunity in the Report to ease, cancer, stroke and related dis- cil, and discussions with other Public It must deal with two issues . . . identify these areas and provide inter- Health Service programs, we have iden- 0 The relationships between Federal pretation. eases can be assisted with Regional tified some of 'the impo.rtant issues financing and financing from other 0 The law authorizes grants only for Medical Program grant funds." The im- which must be considered in the review sources of the activities undertaken on the planning and establishment of 'in- plications of this issue requires care- f applications for operational grants. behalf of the Regional Programs. dividual Regional Medical Programs. It ful consideration as you discuss the 0 The extension and modification of has been suggested that the goals of future of these programs. At the risk of generalizing from rela- tively few examples, I should like to the law. the program might be achieved more It should be emphasized that this Re- review with you the characteristics of We must give serious attention to the readily by expanding this authority to port to the President and Congress will the operational proposals as we have r allow grants for activities involving be the basic document on which recom- seen them in the initial applications. elationship of Federal and non-Federal multiple regions that will support the mendations for future legislation ex- Your actions in developing operational financing. Congress will examine this work of individual Regional Medical tending and modifying Public Law 89- proposals, and the actions of our Re- issue carefully. For instance, activities Programs. once started are not easily curtailed. 239 will be based. In addition to your view Committee and Advisory Council Yet the essential purpose of this pro- 0 A fourth major question has been participation in the discussions at this in approving these proposals, will ex- gram is to help bridge the gap between how rigidly or freely one may interpret meeting, I invite each of you personally press far more effectively the nature of the advancing frontier of new scientific the emphasis on the disease categories to send me any written suggestions Regional Medical Programs than gen- knowledge and the broad application to of heart, cancer, and stroke. I invite which you think will be helpful in the eral policy statements and will reveal patient care. All funds cannot remain your attention to two paragraphs from preparation of this important document. most clearly the importance of these tied up in Continuing program support the Issue Paper concerned with the We anticipate the preparation of a draft Programs to society. of yesterday's advances. A significant Report. "During the planning phase, of the Report shortly after this meeting. the major activities undertaken by Re - The review of the first operational pro- amount must be available to encourage - Thus, your comments can be most new programs at the cutting edge of gional Medical Programs have involved effective if they are forwarded to me posais has raised sharply the question the establishment of a planning staff, of what methods should be used to science. promptly. the initiation of studies to obtain the evaluate such applications. Each is Although not required by the law, basic data concerning pertinent health OPERATIONAL GRANTS. I come now to characterized by a number of specific experience has indicated that the Re- needs and resources, and the develop- a very important section of this paper. activities within the overall proposal. 14 However, a Regional Medical Program of the proposed cooperative arrange- less, the written proposal should in- Not only are the reviewers concerned must be more than a collection of ments. In evaluating the effectiveness clude an exposition of the guiding that the focus of the program is out projects. The review process, there- of these arrangements attention is philosophy and administrative proc- towards the periphery, but that the ap- fore, must focus on three general given to the degree of involvement and esses which have gone into the devel- plications themselves reflect this con- characteristics of the total proposal commitment of the major health re- opment of the proposal and should ex- cern on the regional level. which separately and yet collectively sources, the role of the Regional Ad- plain how the specific activities determine its nature as a comprehen- visory Group, and the effectiveness of proposed relate to these overall objec- Activities which have been chosen sive and potentially effective Regional the proposed activities in strengthen- tives. A justification of each separate should seek to reinforce cooperation Medical Program. ing cooperation. Only after the deter- project, however worthwhile, cannot and mutual interaction between the ac- 0 The first focus must be on those mination has been made that the pro- provide a sufficient basis for making ademic community and the community elements of the proposal which iden- posal reflects a Regional Medical the essential determinations. Consider. practice of medicine. Such linkages will tify it as truly representing the concept Program concept and that it will stimu- ation of other characteristics of the be among the most important con- of a Regional Medical Program. Our re- late and strengthen cooperative initial operational proposals and their tributions of the program. If the view groups have determined that it is efforts will a more detailed evaluation review also reveal the essential nature specific activities proposed in an appli- not fruitful to consider specific aspects of the specific operational activities be of a developing Regional Medical Pro. cation fail to strengthen cooperative of the proposal unless this first essen- made. gram. They provide concrete examples arrangements or even interfere with tial determination concerning the core 0 If both of the two previous evalua- of most of the issues to be discussed such cooperation, the entire Regional of the Program is positive. In making tions are favorable, the operational ac- at this Conference. For instance, these Medical Program would be threatened. this determination the reviewers have tivities can then be reviewed, individ- proposals clearly lead from the The maintenance and nurturing of the asked such questions as: "is there a ually and collectively. Each activity will strengths contained within the region. cooperation established in the plan- unifying concept.ual strategy which will be judged for its own intrinsic merit, This is understandable and justifiable ning phase of the program will surely be the basis for initial priorities of ac- for its contribution to the cooperative and may be the most effective way to pose a major challenge to all Regional tion, evaluation, and future decision. arrangements, and for the degree to implement the first phase of the re- Programs, especially those with more making?" "Is there an administrative which it includes the coro concopt of gional medical prograi-n. Leading from complex institutional relationships and coordinating mechanism involving the Regional Medical Programs. It strength may develop some activities than are represented in the first appli- the health resources of the regions should also fit as an integral part of which can serve as models for other cations. Thus, the review process must which can make effective decisions, re- the total operational activities, and regions or a resource which can be uti. be concerned initially with the appli- late those decisions to regional needs, contribute to the overall objectives of lized by adjacent regions through cant's concept of a Regional Medical and stimulate the essential cooperative the Regional Medical Programs. effective interregional cooperation. For. Program and his total proposal rather effort among the major health inter- This is not a conventional review proc- tunately, there are examples in the ini. than with specific activities. ests?" "Will the key leadership of the ess. The total process for reviewing tial applications which give evidence of ,v@Ve also see evidence in these applica- overall Regional Medical Program pro- interregional cooperation in capitaliz- .. ns of the design of initial operation- vide the necessary guidance and coor- complex operational applications will ing on the particular strengths within tio f the program that can often require up to six months or in an@adjacent region. I would like to add al phases o dination for the development of the some cases even more. The applica- a cautionary note, however, that the serve through continued planning and program?" "What is the relationship of tions already in hand are providing us full development of a regional medical evaluation as the basis for further evo- the planning already undertaken and with a learning opportunity to develop program must show equal concern-f-, lution of Regional Medical Programs. the ongoing planning process to the processes. strengthening the weaknesses of u@ We cannot emphasize too strongly the initial operational proposal?" the most appropriate review tha ecessity of incorporating in the Re- Our experience indicates that the inter- region. n 0 After having made a positive deter- play of an initial site visit will be gional Medical Programs the methods mination about this core activity, the necessary to determine whether the Our reviewers question repeatedly how of evaluating and modifying the pro- next step widens the focus to include essential criteria for a Regional Medi- weaker institutions, the minorities, the gram so that it becomes to a consider- both the nature and the effectiveness cal Program have been met. Neverthe- poor, will he helped by the proposal. able degree a self-monitoring system 15 which will supply those participants at gional Medical Programs to consider explicit and concrete mechanism for them as we would like. There has never all levels with the information and the both the specific and broader ap- playing a meaningful role in the con- been a greater opportunity to link motivation and the flexibility to direct proaches for meeting identified health tinued development of the overall Re- science, education and service, but the future efforts towards those fulcrums needs in the region. While the many gional Medical Program a er e di icuitfes are very gr a . of action that accomplish best the ob- types of activities proposed in the ap- award of grant support, we are consid- But "no ashes, no Phoenix" jectives of the program. For this rea- plications complicate the process of ering the possibility of including in the son it is important to avoid freezing review, they show evidence of a seri- grant award for operational activities a Mythology offers no tale more dramatic the program towards permanent sup- ous effort to match resources with proportion of the funds to be used for than that of Phoenix. With his flashing port of all initial activities undertaken. needs and to bridge the gaps among carrying out the purposes of the RMP gold and scarlet plumage he descends Some of the activities should be self- science, education, and service. at the discretion of the RMP with the to the altar of the sun and is consumed limiting with the transfer of effort to approval of the Regional Advisory to ashes. With the rising of the sun he other priorities as the programs Regional Medical Programs represent a Group. This approach would lend sub. is reborn more glorious than before to evolve. If these programs become just new relationship between the Federal stance to the intent that the Regional signify for another 500 years eternal another source of funds to finance review mechanism and the regional Medical Program be more than the hope arising from disappointment. specific activities, we shall have lost framework for decision-making. Neither sum of its parts. Like the soaring Phoenix, Regional the opportunity to develop a uniquely grant support or formula grant sup- Medical Programs have arisen from effective mechanism in bringing the port can be applied. We intend to SUMMARY. The purpose of this paper previous hopes, expectations and dis- advances of medical knowledge to work closely with you in developing is the purpose of this Conference: appointments. They offer new hopes bear on the health problems of the the potential of this new relationship. 0 To help set the stage for a fruitful and opportunities for new achieve- people of the regions. The develop- Yet, there is a potential contradiction discussion of the Report to the Presi. ments in American medicine. ment of the self-monitoring charac- between the need to evaluate proPOs- dent and Congress; and teristic of the Regional Medical Pro- als at the national level and the intent 0 by free exchange of information, to grams is also a presumption of the that the Regional Medical Program be able to implement the next stages review sequence described, for the fu- represent a new framework for deci- of the program in the best ways possi- ture relationships between our review sion at the regional level. If specific ble. process and a regional medical pro- approval actions in Washington were gram are to be based more on an eval. entirely on a project-by-project basis, I have focused first on certain issues, uation of the effective results of the this would tend to move the major de- then on the Report to the President overall regional program and achieving cision-making responsibility for deter- and Congress, and finally on the appli- its goals rather than on a detailed re- mining the nature of each Regional cations for operational grants and view of specific activities proposed. Medical Program to the national level. their review, as the basic tools for you Under these circumstances regional to begin defining the Regional Medical As anticipated, categorical questions decision-making would be confined Programs to serve patients in 1969- do arise. The initial proposals are di- larizely to the choice of which activities 1974. rected toward the problems of heart to -propose for national approval, and disease, cancer, and stroke. Some -- Talented and distinguished speakers we will have failed to achieve a major and panelists will assist you. There are broader activities do involve the more objective of the Regional Medical Pro- effective functioning of the total - high hopes for this Conference and health-care system as essential re- grams. even higher expectations for Regional quirements for improvements in the Our whole review process is concerned Medical Programs-so high indeed that diagnosis and treatment of these dis- with strengthening responsible regional we must face realistically the possibility eases. The initial proposals show the decision-making. In order to provide that the many challenges may exceed unique opportunity provided by Re- the Regional Medical Program with an our combined ability to meet all of 16 ship 17 Science and Service James A. Shannon, M.D. Director, National Institutes of Health There was an article in a recent issue husband at breakfast the following of Science on "The Art of Talking day. about Science." The author-a distin- I suppose that the author has heard, guished British scientist@iscussed as have you and 1, many brilliant the oral transmission of scientific in- presentations of complex subjects in fill formation in a manner that is devast- which a clever and intelligent speaker tating to those, like myself, who have builds a complex structure in a man- been called on to make general ner that enables us presentations. His penetrating com- 0 to follow the construction point by ments on the foibles of lecture nt' poi rs are would even more apt for those who to understand the transition from engage in a luncheon talk such as i one level of complexity to another, and am about to make. 0 to have the feeling, at its end, that In fact, I was embarrassed to read this we have participated in a satisfying in- article at the very time that I was pre- tellectual tour de force, paring for today. only to find the next day that we really do not remember much about the His first rule is that a 'talk'-as distin- presentation except the name of the guished from a 'paper'-should never be read. He made the point that it is lecturer, the title of his talk, and the brilliance of his performance. At best simpler to read than to listen and un- e may remember some of the major derstand-implying, though not pre- w cisely saying, that to take the time of points made but not the logic of the setting in which they were contained a captive audience to read a disserta- northe way in which the major ti6n came perilously close to insulting t@ re@ sof thought were woven into a their intelligence even though t he significant and logical pattern. I sus, thoughts expressed are suitably pro- pect that, if we remember the pattern found. He argued that to deliver a at all, it is because it may be inferred tightly argued thesis in well-rounded from the title. phrases conceived in the leisure of one's study does not give the audience The author recommends that a lecture time to think and is like asking a be loosely constructed of few parts. It friend to go for a walk while you drive should along beside him in a car. 0 start from a base of knowledge His second point was that only a limit- shared by the audience, ed number of points should be ma 0 build the basic structure of thought, and few of these should be support( 0 provide for its elaboration within in great detail. He suggested that the the time available, and effectiveness of the discussion could 0 most importantly, allow time to best be judged by the extent to which summarize the major thoughts or the selected points presented could be ideas one wishes the audience to re,.' recalled when talking to one's wife or tain. 18 author made many other pertinent A further point of general under- Finally-and still within our base of A sifting of your informed discussion its but one I remember very well. standing is our common appreciation common understanding-you are with will be a major input of information to recalled the practice of the Royal of the fact that in our advanced insti- us for a few days to examine the cir- the National Advisory Council which @itution, from whose directorship he tutions, especially in our better univer- cumstances developing in relation to will advise and to the Division which just retired, of giving the speaker sity hospitals, there is little useful the Regional Medical Programs in must act. ie 30 or 40 minutes of solitude knowledge lying undisclosed in labora- order to determine how, within a broad You may well ask, at this point, "Of ir to his discussion even to the tory note-books or unread in journals segment of medicine, certain moves what concern is all this to the NIH?" @nt of placing a guard at the door and books in the library. Knowledge be made, in accordance with the inten- -an organization which, in recent prevent any intrusion into the pri- that can help to solve a patient's prob- tions of the law, to facilitate the devel, years, has been largely concerned with y of the speaker's thoughts as he lems is, indeed, utilized in the day-to- opment of excellence in our handling the development of new knowledge iposed himself for his presentation. day work of university-based physi- of a series of so-called dread diseases rather than the delivery of services. v I want to make three points. cians in such a medical center. -heart disease, cancer, stroke and re- One can give either of two answers to rhe article is commended to you However, a comparable situation doe lated medical disabilities. You will be such a question-either would appear s asked to comment, for the ultimate reading-it is serious but present- not exist in many communities- benefit of the President and the Con- to be correct and, indeed, each is in in a light, readable fashion; though I do not say all-where the gress, oii the adequacies of the initial fact partially correct. the adoption of its principles would physician has been out of the main- moves that are now being made or 0 The first answer would be that the ke for less slumber during presenta- stream of learning for a considerable that are immediately in prospect. You creation of Regional Medical Pro- is such as this; and, finally, period of time and where the diagnos- will also be asked to anticipate some grams permits a large social experi- my inability to match what he con- tic and therapeutic resources are less of the problems, assess the likelihood ment to determine what is needed to @rs the minimal excellence of per- than optimal. of success of current strategy, and on facilitate the rapid use of available -nance can be rationalized, in part, this basis, advise the Division of Re- knowledge in the solution of serious my inability to have the 30 minutes The next relevant fact is that through _gional Medical Programs on how they disease problems in the setting in so of solitude which he so strongly legislation-and particularly through may best project their action into the which these problems generally occur ommends. Titles 18 and 19 of the Social Security immediate future. -that is, in .1 typical community. In hall, however, in a rather halting Amendments of 1965-the Nation has More importantly, you will be asked to this sense it is straightforward opera- hion, attempt to abide by some of asserted that each individual has a assess, on the basis of an informed tional research. imperatives. Incidentally, he was right to superior medical care and has professional judgment, the extent to 0 The second answer reflects the fact opposed to the use of notes. begun to provide, through many Feder. which the Division should seek simple that in the best of our university medi- al, State and private mechanisms, for extension of present legislative author- cal centers we have a unique mix of hall start from a common base of payment systems by which this right ity or seek its modification in order to professional talents. This consists of Jerstanding. - heighten the prospect of success for scientists engaged in fundamental re- may be secured. We are agreed, how- the program. search, physicians eagerly attempting dical services at the community lev- ever, that such systems must not in- have a lesser degree of perfection terfere with our general private base Now, you will not be asked at this to apply such fundamental information in would be possible if all the avail- for the delivery of medical services. It time for specific recommendations but, to the solution of disease problems, e information were at the disposa . in view of the complexity of the under- and physicians primarily concerned ! is the national purpose to correct the physician treating the individual taking, to comment on the problems with the problems of medical care and 'ient and if the physician were sup- aeTIciencies in the delivery of medical of applying the proposed strategy to the education of young physicians. rted by all the diagnostic and thera- services by using the present system your own regional situation whether This combination of skills and inter- Litic resources that are needed to as the core structure for social embel- this be rural or metropolitan and ests makes possible the delivery of ply this body of old and recent in- lishment rather than by attempting to whether it be rich or poor in medical medical services in a professional set- mation to the problems presented. build a new system. resources. ting that approaches the ideal. It is in 19 s, evolve such a setting that the best of medical We look to you to help us do the latter their impact on the day-to-day happen- ing with State and local force services are delivered or can be deliv- two. ings in medicine will be profound. a system that will make available to ered. The problem is to determine how Let me hasten to add that, in our This transition will result in an even the bulk of the population 'Medical such know-how and such excellence view, the full elaboration of the new higher rate of professional obsoles' services that are excellent in quality can be exported for use by the com- mechanisms we seek will not be cence for practici g physicians and and adequate in quantity-at least in munity at large., Or, to put it another n a major segment of the diseases that way, how can the university-type hos- achieved in a year or two. will require a much more purposeful plague us all. system of professional renewal in the pital-and there are many of these We also expect that not all of your future than in the past. NIH does not have the responsibility that are not, in fact, part of or closely strivings will be successful. There will of achieving these desirable ends associated with a university or medical come a time in some and, perhaps, And this brings me to my final point. many@f your programs when it will Each regional advisory group must alone but in conjunction with a series school-how can such an institution of other programs with similar objec- yield the isolation that protects and be more appropriate to take your concern itself as much with the main- tives. But I believe that the Regional fosters scholarly activity and assume a losses and begin anew, profiting by tenance of the professional capabilities Medical Programs, properly developed, larger social function without, at the your own experiences and those of of local physicians in a rapidly chang, same time, placing in jeopardy its others- If this were not the case, our ing and increasingly complex situation is the keystone of a structure which present purposes. problems and yours would be very as with arrangements for improving will permit the delivery of the type of simple. Unfortunately they are not. the support for and utilization of these medical care services we all desire. As the one single institution most con- capabilities. cerned with these present purposes The problem will be made both more that is research and education-the difficult and more urgent by the rapid Now, following my British mentor's ad- NIH has been given the task of work- evolution of the medical scene. I be. vice, I shall remind you of the points I ing with groups, such as you, in devel. lieve that we are fast entering a period would have you remember. oping programs, suitable for regions of of really rapid pay-off from our large 0 The delivery of services is less than quite diverse character and medical re. investment in the biomedical sciences. optimal for many segments of our sources, that will Advances have been substantial in the population. 0 preserve the excellence of the past two decades but they are only a 0 The financial barriers to good serv- present programs, and, indeed, foster harbinger of what is to come. ices are being rapidly removed as a and develop institutional excellence in consequence of State and national science and education where it is now The biomedical science establishment, judgments that every individual has a lacking, in its present magnitude and diversity, right to excellence in the medical care 0 provide for the discharge of a large- is something less than 5 years old. he requires. ly new social responsibility in a man- This is a fact that is frequently over. 0 In a privately-based system for the ner that will strengthen, rather than looked. However, scientists now capa. delivery of medical services, general weaken, the current institutional pro- ble of entering the field, at either the excellence is now most frequently grams, and laboratory or clinical level, are better found in a situation where there is a 0 provide, under suitable auspices, trained and generally more capa mix of science, education and service. for the linkage between these science than was true heretofore. It is pre @ie 0 Although we must contend with cllc" able that as the biomedical sciences circumstances, NIH, in administering based programs and the community many diverse geographic and social apparatus within which medical serv- move from the empiricism so charac- the Regional Medical Programs, will ices are delivered. teristic of the past to the clarification strive to preserve existing centers of We believe that we can do the first of and generalization of our under- excellence in science, education and these three-given adequate funds. standing of biological phenomenon, service while, at the same time, work- 20 rogram Evaluation Vernon E. Wilson, M.D. Dean, School of Medicine, University of Missouri Program Coordinator, Missouri Regional Medical Program ie dilemma of a dean from the day We have already heard that the ap- his appointment is to know when to pearance of the Regional Medical Pro- grams through Federal legislation was )eak out and when to remain silent. )eaking requires at least an acknowl- a direct result of growing public and lged topic and at best a brief, flavor- professional unrest centered around I and meaty content. In pursuing the the slow rate at which new knowledge )mewhat evanescent title assigned was being put to use. This concern is r this topic-which evolved from not unique to the health field but it @rogram," to "Program and Evalua- is new as a major emphasis among the concerns of the health care profes- )n," to "Program Evaluation," I must )nfess that the merit of silence sions. The agricultural and engineering omed ever more attractive. experiment stations, long an integral part of the land-grant colleges, repre- nce detailed discussion of technical t to deal with this sent one attemp /aluation procedures would not be already have a )propriate under our limits of time, problem. The Engineers term for it. They label this activity the t us compromise and discuss some "transfer of technology." ell known principles of program and, @r the health field, some relatively It would appear then that the special nused principles of evaluation. We mission of Regional Medical Programs ill examine both in the light of oppor- is primarily one of research in the inities presented by the Regional "distribution of health care" with the ledical Programs. focus placed firmly upon the patient's he challenge to Regional Medical Pro- needs, rather than upon those of the rams, as I see it, is to demonstrate institution or the health professions. iat this new endeavor, established Until the early part of this century the rimarily in behalf of heart, stroke, ancer, and related diseases, is more healing arts possessed a dismally ian a static assemblage of existing small amount of scientific information', @sources, This in itself is a basis for consequently, the need was primarily ery careful thought. Most of the prin- for basic medical knowledge. With the !pies and programs which can be con- momentum now established in basic idered in the field of health and research we can give increased empha- ealth care have been studied by one sis to indirect factors, such as popula- r another of the existing Govern- tion size, number of related organiza- iental, academic, professional or vol- tions and groups, increased capabilities ntary groups. Thus, at the outset it in communication facilities, and an eems apparent that the aim of the ever accelerating rate of obsolescence !egional Medical Programs must be of knowledge. The magnitude of recent ne of synthesis, an effort to combine a !S Congressional appropriations indicates hese various factors into a whole the need for immediate action. Addi- thich will be greater than the sum of tional and similar legislation is under he parts. serious consideration. The comprehen- -21 sive health planning act provides a professional and academic con- The first step is the establishment of and those of the profession are not logical outlet for knowledge developed tributions; it will require a formal and need, either recognized or unrecog- always the same. To accomplish our under Regional Medical Programs. scientific search for an appropriate re- nized. The next step, after the need is task we must now direct extensive Thus, research being done in the more lationship between all academicians determined, is to define it and to study toward the patient and his needs limited field of Regional Medical Pro- and professionals whose skills can be create recognition of that specific need within the context of his normal pat- grams can be of value throughout the helpful. Concurrently, the integrity of in both the consumer and producer. tern of living. total health care field. the academic and research communi- Here we have a direct parallel with the Professional action has classically Because of the large amount of time ty must be preserved, both as an in- opportunities open to Regional Medical been one of response, after the patient and money to be expended, realistic ternal system and as a part of society Programs. requests and is given .access to the evaluation of the results is mandatory. at large. Thus, the analogy of market- Having identified a specific need or formal health care system. We must Unfortunately, we are hampered by a ing is in all probability much more needs, it is necessary to undertake now accept responsibility for health lack of effective measurement tools. than an analogy. It may prove to be basic and applied research in materi- care of the public as a dynamic, inti- We must start by using available and an actual pattern which will provide us als, resources and their synthesis. The mate part of daily performance. simple techniques, while admitting with illustrations and some basic prin- medical profession has expended pro- their inadequacies. It is essential that ciples for fruitful pursuit of the tasks portionately small amounts of its own Identification of needs for concentrat- collaborative research in system de- ahead- energies in the endeavor of synthesis ed research endeavors will require the sign for the distribution of health care _, development of end points or goals be initiated in concert with those aca- ine Distribution Process. As a layman and at the same time has frequently against which the effect of change in in this special field, may I off;r the poorly utilized the contributions which qualitative performance can be meas- demic disciplines which have a long oversimplified explanation that the could be made by other disciplines. tradition in simulation, systems re- ured. Unfortunately, at present, such search, and communications research, production and distribution process Having completed the "basic" research end points are few and largely unpro- thus providing a base for continuing amounts to a coordination of ma nY and formulated working models, the ven. analysis and measurement. disciplines, assembled for the con- next step is the production and de- of the measurement systems cur- tribution which each can make to a livery of materials and services which Most Existing resources for use in the single goal. While such grouping of re- may come from a variety of places. rently used in the health professions design of such systems are impres- sources, particularly in the research In the analogy the patient may move are quantitative rather than qualitative sive. indeed. If one looks at the great process, suggests the antithesis of the to the resources, or the resources may in nature. We can measure quite ade- array of governmental health agencies, traditional academic departmental or- be brought to the patient, but finally quately deaths, morbidity, numbers of ,a personnel, and similar items, but we academic institutions, voluntary and , nization, the concept is not unfamil- the delivery process requires that the have few means by which we can test professional groups, as well as sup- iar to academic institutions. It is end product of health care be synthe' the impact of health care upon the portive organizations like welfare agen- exemplified frequently in institutes on sized in a coordinated and personalized daily performance of a given individual. cies, community action groups and university campuses, in land-grant ex- manner for the benefit of the consumer. others, it readily becomes apparent Deriment stations, and , research Thus, our first requirement is for a that the major problem is not that of 'centers. These patterns allow manv Market Identification. If we consider measurement system which can assess creating resources which could apprO' disciplines to proceed in a systematic health care in the light of the patient's the ability of the individual to perform priately handle the problem but rather fashion in searching for new informa- need, recognized or unrecognized, the as a useful member of society and his a coordination of those resources into tion and combining that information first painful but necessary step will be own attitude toward that performance. an effective unit. Although to some the into an orderly whole. a shift in emphasis. Much basic re- Also required will be a measurement of comparison may be a bit unpalatable, search has been sponsored upon the the social or peer group's estimate of I submit that this is a market and dis- Taking the marketing analogy one step assumption that improvement of the the value of the individual's contribu- tribution process and should be han- further, the rational distribution proc- professions and institutions will auto- tion to the group and their attitude dled as such. An approach of this kind ess would be simulated and developed matically benefit patients. However, it toward that contribution. No single one does not deny the essential nature of as follows: may be that the goals of the patient of these factors can be used as the 22 sole parameter but when assembled lished knowledge about health is not most highly motivated party in the in- A third problem concerns the obsoles- assigned him cent mind, both as it relates to the as a pattern they should provide at utilized even by those best acquainted terchange, yet we have least the first steps in a qualitative with it. Advertising research has a rich the most passive role. Patients, I sub- medical profession itself and to the measurement of health care. body of basic knowledge and tech- mit, may not be so helpless as some public at large. It is clear that Since diagnosis is also a part of mar. niques dealing with facilitators, or why of our practices would seem to imply. planned, continuing education for the ket definition and since diagnosis of. people choose one service or product Our friends in sociology should be able profession and the public is necessary. ten opens communications between as opposed to another. These tools to help us here. A searching look at potential integra- professional individuals, early detec- and techniques used so successfully in In the fourth and final phase of our tion of such education with the care tion of disease would appear to be a advertising could be adapted and analogy, we will face a variety of prob- process seems called for. Feedback logical first research effort for improve- should be useful in broadening public lems in the delivery of health care. mechanisms.must be established for a ment in the distribution of health care. education and personal responsibility These include implementation of re- progressive analysis of cause and Such research avoids the necessity of in health care. search and development in dis- effect, or, at least, correlation between premature decisions having to do with Turning to the third item in our analo- tribution. All patients should, have ac- continuing education and change. delivery of health care and would allow gy, namely research in materials and cess to the best source of care , A successful distribution system will it- a "tooling up" of the communications resources, we should comment first on regardless of geography, financial re- seif require an integrated information - basic research which has a long uni- sources, or special interests of r)articu- system under reduced emotional ten service. Information should be derived sion. Much diagnostic support can be versity tradition and is the foundation lar professional groups. New patterns provided. to individual practitioners upon which applied research is con. are required. from the home, from the avenue of access to the health care system, the with a minimal change in their present ducted. Basic research in almost all The relationship between centers of local hospital, and the large medical practice patterns. academic disciplines will make imPOr- excellence and the population which center. It will require the development Status of the patient needs study. In- tant contributions to health care. High they would serve will need to be of common identification systems and teraction between individuals is heavily on the list should be research in defined. Most organizations which sup- vocabularies. Many of us hope that in influenced by the status, stated and synthesis of systems, including model port health care use politically deter, the very near future the social security building. In our past, testing through mined boundaries, i.e., the city, number will be issued at the time of felt, of each person. We are proposing major changes in the status of the pa- models has had little systematic and county, or State. The probability 'Of birth, or entry into the country, and tient in the health care system. This comprehensive attention. It could gaining coordinated support from all will provide such identification. The calls for a "shorthand" method inter- produce large savings in time, as well interested organizations for the assist, proposed information system should woven into the system itself to assess as funds, but will require the talents Of ance of a single and specific individual be designed to utilize, assist and icu a variety of existing disciplines-the will be enhanced by a maximum over- refine present systems, not compete status, and change in status, part _ engineers, for example, who until re- lap in geographical areas of designed with them. larly of the patient. cently were seldom formally invited into responsibility. This is particularly im- An interesting correlation exists be- the health research conversation. portant in evaluation procedures, The decision for diagnosis and treat- tween the way we use the time. of An interesting facet of the dilemma re- which depend upon many groups for ment of the patient will take into ac- others and our estimate of their iT- lated to manpower shows in the fact their information. count his desires which, among other portance. Consequently, accurate "e' that although we are faced with a tre- A second problem to be considered things, relate to the distance from termination of our expenditure of the the patient's knowl- patient's time through the design o mencous shortage of health personnel deals with control. Should such dis- health care and and a low level of national unemploy- tribution systems be totally under the edge of and confidence in the recom- health services is accessible, measur- ment, we as a health care group have control of the health professions? If mended resource. Other considerations eable, and potentially valuable. largely ignored one of our greatest po- not, how much of the process should are the adequacy of the health care Another little used field of knowledge tentials-the patient himself. He is be conducted in cooperation with other resources, the cost to the patient and is that developed in advertising re- usually the most involved, often the interested groups? When should con- the involved agencies, and the maxi- search. A significant portion of estab- better educated, and certainly the trol be turned to them? mum benefit from the care process 23 which includes such by-products as met by a specific answer to the ques- cause progress toward them can be integrated with detection and health education, research, and economic im- tion, along with additional synoptic measured. Their evaluation should give care systems. pact upon the community at large. background information or bibliogra- us some insight into whether or not 0 Lay health education will be a vital Finally, as we have already heard, no phies which should be helpful in his we are moving in the direction that part of the regional program. Existing matter how one may describe a Medi- continuing education. Such inquiries may be most effective in meeting the adult education and extension pro- cal Region, it must interact with other will also serve as a guide to the physi- actual needs of patients. grams and activities of voluntary or- regions. Mechanisms must be devel- cian's needs. In this manner diagnos- 0 The primary goal is to deliver the ganizations will be utilized so that the oped which will minimize the mech tic and delivery patterns of health care highest percentage of quality patient potential recipient of care may be in- .@ni, can quickly be modified in detail when care as close to the patient's home as formed as to the role which his physi- cal problems of interregional relati n- research indicates the desirability of possible. This is not only economical cian, the hospital, and the various sup- ships and permit us to focus upon tne doing so. in the total picture but in keeping with porting agencies will play and to the patient. the desires of most patients. Certainly things which he, the patient, can ex- The Example. With no claims to as- The data handling facility developed at the latter assumption merits study. pect. We need more scientifically de- sured success, the Missouri Regional the University of Missouri for the pur- 0 Every patient should'have equal ac. signed studies of public attitudes to- @rogram has attempted to face these pose of extending the competency of cess to any needed national resource. ward health care. challenges in the planning process. the physician will be integrated with For very special services which are not 0 Finally, in my view, a crucial goal cooperative data handling programs Projects will arise from community established by hospitals, physician's available in the area, patients can be will be for each of the several regions groups and be funneled through a offices, and state agencies. This inte- sent to centers of excellence else- to take a unique approach to the spe- refinement process. This should en- grated system is expected to furnish where, thus eliminating the necessity cial needs for their particular areas. courage maximum motivation and par- feedback and monitoring which will for needless duplication of expensive Through meetings such as this one, ticipation at the grassroots level. make it possible to provide the desired equipment, staff and facilities. we can share ideas so that a minimum A general objective of the program is information while studying and coordi- 0 Maximum coordination will be of waste will ensue as we seek to meet the development of models of early nating the total process in an objective sought between the inputs of those our respective responsibilities. detection integrated with continuing and efficient manner. who provide health care directly, as New paths are seldom explored by education. well as those involved in supporting faint hearts. We need to be mindful in A University muleidiscipline research that care, such as welfare, community the development of new systems that Primary emphasis will be placed on unit is developing new tools with resources, environmental control one may at times work with less than those endeavors which can be quanti. which to measure achievement. Its groups, and others. perfect parts in order to set the sys- tatively evaluated, and the initial as. staff members have joint appointm'ents 0 The development of programs to tem itself in operation. It is possible, sumption is made that adequate infor-, with other schools on campus, includ- assist in early and effective detection even desirable, to have "proof runs", mation and communication will ing Nursing, Education, Engineering, of disease will be an important goal. a practice long utilized by the printing provide qualitative improvement. The Journalism, Business and Public Ad- The information gained can be used to industry. From less than perfect initial long range plan provides for qualita- ministration, Liberal Arts, and Veteri- effect changes in delivery of health operations, changes and corrections tive measurement of delivered health nary Medicine. Presently members of care, both through personnel and can be made to improve the final care. this unit are studying two different systems. Early detection is perhaps product. Only a few projects are proposed for communities in which they will meas- least threatening to the present health As participants in this national pro- studies of delivery of care. It is our ure efforts toward community health care professions and is among the gram, I believe we dare not do less intent simply to be supportive to exist- goals, such as rehabilitation of the pa- easiest procedures to measure quanti- than marshal the best available tal. ing care patterns while setting up the tient, family reactions and the like. tatively. It also possesses,the highest ents, from whatever quarters, to join necessary information-gathering mech- In conclusion, let us review, quite potential for successful qualitative in this quest for improved health care. anisms. Under this plan, a request for briefly, some goals worthy of consider- measurements of health care. The opportunities are attractive and information by the physician will be ation. These goals were picked be- 0 Postgraduate education should be challenging, to say the least. The Idea, the Intent Sidney Farber, M.D. and the Implementation Director of Research, Children's Cancer Research Foundation Professor of Pathology, Harvard Medical School The privilege of speaking at the First nessed, that has won the enthusiastic uate much more quickly, safely and technology between and among region- Conference on Regional Medical Pro- interest and cooperation of medical so- effectively, new methods of diagnosis al programs for the rapid dissemi- grams is one for which I am deeply cieties, sharpened the focus of many and treatment; to achieve actual pre- nation of knowledge to assist doctors grateful. It is hard to believe that in a diverse agencies concerned with hu- vention of the complications and everywhere in the care of their pa- little more than a year since the his- man problems of disease, and inspired progress of these dread diseases; and tients. toric signing by President Johnson of medical schools and hospitals alike to to communicate with the aid of meth' The development of the policy under Public Law 89-239 on October 6, look beyond their own institutional ods already available and perfected by which power and responsibility for 1965, with less than a year of ad- concerns to broad community needs? whatever happens is placed at the re- ministrative operation, it has been Many reasons might be mentioned and glorfat level has answered the fear that possible to bring together repre- must play a role, but the one of over- the Federal Government and specifical- sentatives of the health professions riding importance above all others I ly the National Institutes of Health from all over the country for a report am certain is the motivation behind all might dictate to any applicant or on progress and a discussion of future activities of the health professions: the group what to do and how to do it. plans, plans for 90% of the people of desire to give to all our people the The only requirement that I can find this country. This evidence of truly very best in medical care. It is clear that the Federal Government has im- phenomenal progress must be heart- that the response of the Country to posed is that there must be assur- warming indeed to the President and the remarkable opportunity opened by ances that there is understanding and the members of the Congress who Public Law 89-239 stems from our de- commitment to the purposes of the have shown such deep interest in this votion to those who are ill, and this program with true regional concert in- program, and productive of new hope transcends personal considerations or volving representation of the various and courage to families throughout the pre-occupation with the interests of health agencies and the p@lic in any land with loved ones suffering from one discipline or one institution. This, given region. As a close observer of the dread diseases with which we are then, is the greatest attraction to all of this program and the way it has been here concerned. I see here today am- us-the opportunity to develop a pro- administered, I have satisfied myself ple evidence for the statement made gram which has as its goal the deliv- that this point of view on the part of repeatedly during the past few months ery of the best of medical services and the Government is genuine, and in line by veterans in the health professions diagnosis and treatment to every man, with the great traditions of the re- that this program has done more to woman and child in the Country, with- search and training programs of the bring the many segments of the health out the intolerable delay between dis- National Institutes of Health. It was activities of the Nation together than covery and application caused or ex- for this reason that a wise Surgeon any other event in the history of the plained by the lack of the needed General put the program under the ad- Nation. medical strength, mechanisms and fa- ministration of the N.I.H., under the What is the magic which has been r..- cilities which will be provided in these leadership of Dr. James A. Shannon, sponsible for the achievement of a Regional Medical Programs. The idea who, with his Deputy, Dr. Stuart Ses- creative concert among the many -se- behind these programs is based on the soms, and a splendid staff, has presid- arate health interests that in the past simple desire to save lives-of those ed over the greatest and strongest have never worked together in this people willo could be saved today with growth of medical research and train- fashion? What is it that has bridged the knowledge available today, if they ing programs in history. You are all the gulf between town and gown and could have it; to save even more lives thoroughly familiar with the insistence lured the medical school faculty from if we speed up and intensify clinical on quality by the N.I.H. and the great its ivory tower into community activi- investigation to match the great tradition that major reliance for final ties in a manner never before wit- strides in pre-clinical research; to eval- decision must be placed on the expert 25 review by non-Federal groups or our cussed the many programs of the ministrative regulations and has been fidence that these Regional Medical peers, our own peers, to assure that N.I.H., and he spoke of his deep inter- under discussion as one of the issues Programs would be a great success quality is maintained and scientific est in the several categorical institutes at this Conference. The need for the throughout the country. Just 20 years and professional freedom is protected. and in the Institute of General Medical provision by the Federal Government ago, January lst, I organized a Chil- The caliber and dedication of the pri- Sciences in which he had great pride. of enough support to insure a critical dren's Cancer Research Foundation, a mary Review Group under Dr. George He then turned to a consideration of mass of medical strength, however, is private institution affiliated with a James and of the members of the Na- the rapid progress in the Regional a prerequisite to fulfillment of the Pro. medical school and surrounding ex- tional Advisory Council on Regional Medical Program activity and remarked gram. We should remind ourselves and isting hospitals. This Institution was Medical Programs have been responsi- that this was the goal for which every- the Government, too, that all experi- concerned with both fundamental and ble for sound and important decisions thing else in the N.I.H. was dedicated, ence in the support of biomedical re- applied research and with the care and for, as he put it, "this is the payoff." search and in the support of construc- study of children with acute leukemia so far. I have had the opportunity to "I attend a number of the meetings of It is here that the newly generated tion of research and hospital facilities and all other forms of cancer found in this new Council, as a representative knowledge from medical research must has shown that substantial Federal children. From the very beginning we .of the National Advisory Cancer Coun- be applied as rapidly as possible for support attracts substantial support established a relationship with the cil, and can assure you that the stipu.- the good of patients everywhere. I can from other sources. doctors of the region of our country lation of the Public Law concerning still hear his words of deep concern These words so far have been spoken with these words: "We are here to as- membership on the Council has result- about the availability of sufficient mon- sist you in the care of your patient." ey properly to support the Regional in gratitude and recognition of the What we did was to accept any patient ed in the appointment of men and Medical Programs in this time of budg. great progress that has been made in sent to us by any doctor, make all the women in whose vision, fairness and etary pressures. I am confident that such a short period of time. There are diagnostic studies and then carry out wisdom you can have complete confi- among the large number of devoted some tough issues, however, that all the expensive laboratory studies dence. It is a great pleasure for me to and informed members of the Con- must be faced now and in the imme- and specialized therapy. As soon as add that in continuation of the highest gress there will be found a leader diate future in connection with these possible we put the patient back under standards of excellence which the worthy of taking his place, for the program activities. I would like to dis- the care of his own doctor, because N.I.H. has always maintained in its ad- Congress has shown its dedication to cuss a few of the sensitive problems the best place for any patient is at ministration, the Division of Regional health and medical research and its that must be solved, particularly in home as soon as that is possible. The Medical Programs staff, headed by Dr. understanding of the importance of connection with the Report that must doctor is backed by a partnership with Robert Marston, is one of the most the N.I.H. programs by their appropri. be made to the President and to the a research institution, one kind of a able, enthusiastic and helpful groups I ation record these past 20 years. Congress on June 30, 1967. regional center, which carries out all have encountered in or out of Govern- These years witnessed the construc- the expensive diagnostic and follow-up ment. tion of a remarkable foundation for The first question which was raised studies and provides the specialized The appropriation needs of the pro- the programs with which we are con- particularly before the Congress passed treatment not available to the doctor in gram will require solid justification and cerned in this Conference. Unless this Law was whether this program s own community. the strongest support from all of us, there is adequate volume and continul- could make effective progress without interfering with the practice of medicine I am happy to report to you that in so that its full potential may be real- ty of support, the great promise of in a given area. It is my hope and these 20 years of close cooperation ized. I have a sad personal detail to this Program cannot be fulfilled and expectation that there will be interfer- with doctors throughout New England, share with you. Just a few days ago, the high hopes which have been raised ence, of a very special kind, with the I have not heard a single complaint actually two weeks ago last Thursday, throughout the Nation will end in bit- practice of medicine by these programs from any doctor that We had interfered before the tragic sudden death of Con- ter disappointment. -interference that will bring good both with his relationship to the patient, or gressman John E. Fogarty, I had the to the practioner and to the patient. the family, or taken anything from him privilege of a long discussion with him The principle oi diversification of sup- May I cite my own personal experience that properly belonged to him. What on one of his periodic visits. We dis- port is built into the Law and the ad- in this connection which gave me con- we have done for the doctor, however, 26 is to place behind him the knowledge knowledge of cancer and cancer che- though broader than the categorical I believe that the categorical thrust is and skills of experts who are not in motherapy; the pathologist; the hema- areas with which we were concerned. important to this program, particularly the private practice of medicine, and tologist, and any other specialist re- Thus attention was given to the sup- at the outset. Specialized activities to provide for him forms of therapy for quired in a given case. Such a port of medical and continuing educa- must be related to the more general- his patient for whom he had nothing patient's family, too, should be given tion, and of medical libraries, better ized functions to be effective. I think else to offer. The doctor makes his the benefit of study by epidemiologists methods of constant communication this is why Congress made so clear in contribution to the generation of new and trained fact finders who seek to between and among centers and be- enacting the law that the program was knowledge by his reports to us which learn more about the background or tween centers and doctors, and the to have a broad involvement of all of parallel our reports to him. By this causation of cancer in a particular need for some mechanisms for achiev- the health activities in the region. method we enable the doctor to face case. Rehabilitation, long-term care fa- ing cooperative relationships among Clearly, the program should not serve both himself and the family secure in cilities, as well as home care pro- the major health resources that were to bring about further fragmentation in the knowledge that he was obtaining grams, are all required if patients are considered essential to progress against the health field. Its very nature is that for his patient the results of research to receive the best care possible. Spe- the problems of heart, stroke and can- of an instrument of synthesis among carried out anywhere, and diagnostic cialized activities, therefore, require a cer. Mention should be made, too, of diverse elements, agencies and individ- and therapeutic assistance of a caliber framework of cooperative arrange- the broad scope of the recommenda- uals. A representative of a medical so- not otherwise available to him. ments involving a wide variety of indi- tions in the DeBakey Report which were ciety is quoted as having said "If this It is true that one cannot easily apply viduals, institutions, and agencies if not included in this legislation at this cooperation among all of these health what has worked in one part of the they are to be effective. In view of the time, but which can be supported in resources in our state is good for country to another area, and this is problems stated in the Issue Paper in part today through other programs Of heart disease, cancer and stroke, good, but I am confident that the var- this regard, I would like to review the the N.I.H. These include the creation of shouldn't it be good in helping to meet iations best suited for a given region manner in which the President,s Corn. Centers of Excellence in the sciences other health needs?" I think the can be worked out along the lines of mission on Heart Disease, Cancer, and basic to medicine and in the several answer is obvious. It should be of the formula I have suggested. Above Stroke dealt with this question. disciplines in the clinical fields. It is my such benefit. I am sure we all agree all, I plead for flexibility in this pro. hope that these recommendations will that if the cooperative pattern of the gram from region to region in this Early in its deliberations the COmmis' not be neglected and that adequate regional medical programs for heart Country, flexibility within any one re- sion faced up to the issue that was support will be found too for the educa- disease, cancer and stroke has by- gion, as experience dictates what is inherent in the categorical nature of tional and research activities which are product values of importance to the best for the progress of this program. its charter. On the basis of thorough essential for the successful operation total health problem of the region in- discussions of the full Commission of these medical programs. volved, we have reason for satisfac- I have spent the major portion Of my and the advice of expert consultants, tion, not dismay. life in the field of cancer research and the policy decision was made that it The question has been asked by many: care and must state that the time has could not react adequately to the three "Is the present program weaker or These programs are developing just as long since passed, if it ever existed, categories of health that were its better than that advocated in the De- the medical schools are taking meas- when any one doctor, no matter what charge without becoming involved in Bakey Report?" The answer is clear., ure of the needs of the communities his specialty, can give proper care to the broader gamut of health problems. When all the planning carried out by around them. These programs, I be- any one patient with cancer. From the The Commission in its Report stated, the hundreds of experts in the many lieve, are responsible for accelerating moment of suspicion or discovery of "But heart disease, cancer and stroke regions of the country is complete and this trend. There are still those who the tumor, the patient should have the cannot realistically be considered apart all the new needs discovered or uncov- oppose involvement in a meaningful benefit of discussion and consultation from the broad problems of American ered by such studies are supported, way of the medical schools in these of a whole group of people, which will science and medicine." the program will, indeed must, be bet- programs on the ground that a medi- include the surgeon who must operate, ter than the original recommendations cal school is only an educational insti- if operation is the choice; the radioth- It consequently gave consideration to or Dr. DeBakey and the Commission tution. I believe that a medical school erapist; the internist with special some of the underlying problems, al- will be sorely disappointed. is an educational institution-and 27 something more. It must be a center strength and greatness can be achieved with which we are all familiar, cannot "We need to match potential with of medical research, not restricted in within a university or medical school be met by the available manpower and achievement, to fuse the worlds of amount and kind merely to meet edu- framework. Those who solve this will facilities utilized and distributed in the science and practice. We need to de- cational needs. The medical school find rich rewards. I have worked out manner presently employed. And now velop and support a creative partner- must take leadership in the solution of such a plan, which will preserve and in- at this Conference we proclaim the ship among all health resources. This problems of disease, in identifiable crease greatness of the discipline struc- right of every man, woman and child way, which is the way of a democratic programs, in addition to the conduct ture of the medical schools and permit in the categories under discussion to republic-is the true path to conquest of basic research. the development of maximal interdisci- the most expert in diagnosis and treat- of heart disease, cancer and stroke". @linary. cooperation with those whose ment available in the medical world to- And finally, to fulfill its mission and We must never lose sight of the goals . . aeeDest concern and dedication is to day. These needs of our people, for make its full contribution to societv. category of the dread diseases. the best in medicine-let us not call of all who work in the health fields- the medical school must make t 0 e eradication or prevention of disease Onther plans and better ones-can be them demands-must be met either greatest possible contribution to meet- and will be fashioned. by voluntary methods with Government and, through the application of new ing the medical needs of the commu- support through programs of the kind knowledge from research, conversion nity in which it has been nurtured. There is another question deserving of we are discussing here, best suited to of the incurable to curable. And while s This can be no token contribution, frank discussion-one of greatest im- these goals are being achieved, let u tossed from the ivory tower. If the portance to the future of the health of each particular region of the country, furnish assistance through the Region- medical %schools do not meet this chal- our.people. I refer to the charge made or some system of Federal health serv- al Programs, to every doctor in the lenge, they will lose the greatest op- by some before this Bill was passed ices will be invoked. May I express a care of his patient, and to those who portunity in the history of medical that the Regional Center plan would personal reaction to the frequently ex- have no private doctor too, thus mak- education-now so happily offered lead to socialized medicine. I sha" not pressed fear of what is called the "threat of Government Medicine"? V in available for every patient in the ,y em e t g through these regional mediCia[ pro- attempt to define this common - will are talking not about some alien land, co un, care of the kind all of us grams. ployed and badly abused term, but but about our Government, in this de- would like to have for all patients. This Cognizance should be taken of the fact assume that what is meant is Federal mocracy. I do not share such fear, nor may be defined as the application of that medical schools traditionally are control of the practice of medicine, or, all knowledge of medicine, surgery and in short "Government Medicine". As will I as long as there is a forum laboratory science for the prolongation discipline-oriented and have given little where I have the right to speak, as support to categorical developments of Dr. DeBakey has pointed out repeated- , ng as there are men and women to of life, the relief of pain, and hopefully ly and, with him, all the members of 10 the cure of patients suffering from real strength. A critical mass of re- the President's Commission this piece harken to my words. what the Congress calls the dread dis- search and clinical strength is required of legislation and the programs that All of us have heard, I am sure, the eases. The only guideline of enduring to develop, accumulate and apply truly will be created by virtue of it provide background sounds of predictions that value in the construction of these Re- expert knowledge in a given field as, . best means of preventing "Govern- the way of voluntary cooperation is gional Programs must be defined in for example, in modern cardiology or the. in the field of cancer. The time has meni: Medicine". We all realize the sure to fail, and that it will be neces- terms of what is best for the patient. come for the medical schools to em- vast increase in demand for good med- sary for the public sector to take over In the final analysis this is what the brace the development of categorical ical care since the end of World War 11 and bring order to the health field. Regional Medical Programs are all strength and no longer to reject such alone. This is shown by several thou- This I do not believe. I am confident about. The idea which gave birth to developments as a cardiovascular in- sand community hospitals built with that the Regional Medical Programs this program is clear. The intent of the stitute or,,a cancer institute as foreign the aid of the Hill-Burton Act, fathered have already demonstrated the poten- programs should permit no misunder- in the Senate by that great champion tial to fulfill the promise and meet the standing. The implementation, within bodies ill-suited to the traditional ta- of medical research and health, Sena- challenge that was so clearly stated in the guidelines of the law and the regu- bles of organization of a medical tor Lister Hill. The demands for health the introduction to the DeBakey Re- lations, remains, as it should be, in school. The challenge is here to work services which have increased so rap- port to the President's Commission, the hands of those who plan in each out in each region how categorical idly in the last year alone, for reasons from which I now quote: of the many regions of the country. 28 Section II-Pan el Sessions Program Evaluation Two panel sessions on the second and third days of the Conference provided The Report of the Surgeon General representatives of the medical and to the President and the Congress health fields an opportunity'to express their views on two@of the major issues of the Conference. 29 Program Evaluation CHAIRMAN: On my far left is Dr. Carl William Ruhe The practicing physician is interested the perils and pitfalls of evaluation as George James, M.D. who is on the staff of the American particularly in how one measures and I see them. Dean Medical Association with particular in- evaluates the programs that serve the What I see is the future of evaluation Mt. Sinai School of,Medicine terest in continuing education pro- ambulatory patient. in terms of the opportunities and chal PANEL: grams. There are some questions that have to lenges of the regional program anc Edward Kowalewski, M.D. Dr. Kowalewski and Dr. Ruhe are be asked of Dr. Wilson, and we shall something of the necessary first steps Chairman, Board of Directors members of the Review Committee come to those as we go along, but the Lest any of you thinks I am here aE American Academy of General Practice that has been working diligently to re. problem of evaluation, as shown by the Olympian sociologist and listinf Harvey L. Smith, Ph.D. view the many proposals which have the applications that have come in, is somebody else's system, please be as Professor of Sociology and been submitted for either planning or certainly not solved. In many of them, sured I am deeply involved in t es( operational grants. an attempt has been made to answer problems myself so it is my own limi Director, Social Research Section the problem by the use of mechanical tations that I am speaking of here. University of North Carolina We shall begin with Dr. Kowalewski. help. This perhaps will offer some We are at the moment, I think, ver C. H. William Ruhe, M.D. answers but certainly not all. In the Assistant Secretary DR. KOWALEWSKI: We have two con- academic area there is a difference in 1mperfectly equipped to undertake th4 cerns. First, as members of the Review. major tasks involved. Let me start witi Council on Medical Education Committee we have been given respon- degree of refinement and evaluation. American Medical Association the one about which I know least. Wi sibility to evaluate the program appli- At this time, I will conclude by saying have heard suggestions offered to u! Vernon E. Wilson, M.D. cations that come before us. Second, that I don't believe we can provide one as to the kinds of things we need t( Dean as physicians we try to interpret and rule that will apply to all projects be- evaluate, our involvements, for exam School of Medicine bring into focus the practicing physi- cause each project has a different pie, in cost accounting. I myself knov University of Missouri and cian's responsibility in. the area of origin and a different end point. (and have heard often from medica Program Coordinator evaluation. We attempt to integrate the DR. SMITH: Dr. James, Dr. Wilson, fel- administrators and deans of medica Missouri Regional Medical Program latter concern with the continuing edu, low panelists, ladies and gentlemen: I schools) enough of the problems o cational process in which we have 'shall try to keep my remarks within cost accounting in the field of healti DR. JAMES: I shall introduce the great interest. categorical limits but I suspect before care to know there are relatively feN members of the Panel and then ask It is evident that to measure properly I am finished I will be talking about things we can pick up and easily appi, each to speak in turn without further there must be a starting point. This evaluation in related diseases. in this new and complex situation introduction. program is in its infancy, but it is The Division of Regional Medical Pro- There is a great deal we shall need t( Beginning on my right is Dr. Edward where we must begin our thinking in grams, in asking us to evaluate a thing learn and experiment with. Kowalewski. He has been active in the terms of evaluation of the programs as complex as a regional program, has Other suggestions have involved focu! Academy of General Practice with par- our committee has reviewed. While asked us to do the almost impossible. on the patient, i.e., patient improve ticular interest in continuing education many persons are vitally concerned Yet I think the existence of the region- ment or patient cure. Certainly this i but also in the delivery of medical and already have knowledge pertaining al programs provides us with the hard enough to demonstrate in th care. to evaluation, others submitting aPP[i- necessity for trying to do this and pro' difficult relationship of physician an, cations do not have this background of vides us also with the opportunities patient. It is hard enough to demor Next to him is Dr. Harvey Smith who evaluation so it will have to be intro- and perhaps the beginnings of techni, strate improvement in many patient is one of the friendly sociologists to duced. cal resources to try to do this almost and even more difficult to demonstrat whom Dr. Wilson referred. He is on the faculty of the University of North In addition, we' have the problem that impossible task. a relationship between that improve Carolina but he has also played a lead- regions differ; i.e., each particular area I would like today, in responding to ment and the ministrations of the ph5 ing role in the North Carolina Regional has its own scope. We can't apply one material presented to us both here sician. This is correspondingly muc Medical Program. rule to all. and in other'packets, to talk briefly on more difficult to do in a large system. 30 I oil- $I George James, M.D. (Chairman) Edward Kowalewski, M.D. C. H. William Ruhe, M.D. Harvey L. Smith, Ph.D. Vernon E. Wilson, M.D. 31 I am reminded of what was enunciated are easier to monitor. The others be- ble. We are handicapped at all turns Similarly, hospital administrators anc by Robert Redfield, the anthropologist, come more complex. by the inadequacies of record keeping public health medical care personne who said the further away you were We have heard a good deal of talk (or should I say the irrelevancies of are now living in each others pocket, from the universe you were studying about systems analysis. My comments record keeping to the present task at and elbowing at each other for a morc the more generalizations you could on this will of necessity be superficial .hand?). The basic materials we require effective role in the new program. make. I think we tend to fall into this. because I am not deeply knowledge- in epidemiology of illness and preva- Medical schools are beginning to teac@ The larger universe looks easier to ience rates-i.e., getting effective base generalize but all of us agree we need able about systems analysis but I lines from existing records-are all but community medicine and beginning tc a tremendous amount of caution. Sim- think some of them, in my exper- impossible to obtain. search for practitioners and teacher@ ience, have perhaps been analogies who have this kind of orientation. The) ilarly, quali@ of medical care has been advocated as a focus of emphasis. rather than analyses. I think it inter- Now, one of the things that the region- too are now standing side by side wit@ This literature is filled with controversy. esting, for example, to point out some al program is doing which initially may public health people for the first time. We have some things with w'nic'n we analogies between the line-up of cus- complicate the task of evaluation but The medical schools, in a ver) can steer our way through but unless tomers in a cafeteria and the waiting would ultimately become its greatest significant way, are beginning to relatE we keep it awfully simple we shall rooms of our out-patient services, but contribution is that it is changing the medical teaching to the tasks and really bein peril. I doubt that analogy at this level will functions of individual professions. For means of health care systems, rathei help any of us to become either better example, sociologists are emerging in- than to some internal criteria intrinsic The results of education are another customers or more successful pa- to the real world in connection with to the profession itself. factor we have been asked to evaluate. tients. the regional program. (I don't say this There are new emerging divisions ol Well, this is Asomething that has de' It is extremely important that a much may be its greatest achievement but it professional relationships and profes- feated educators over a long period Of better bridge be erected between the may be its most difficult in time.) They sional responsibilities. Medicine is not time-I include ourselves in this. What work of many of the systems analysts also are mixing and mingling with just content (as indeed it never was, epidemiologists and biostatisticians in but the order of magnitude has are the impacts we want to measure and those who, like yourselves, are meaningful working relationships and changed) to deal with the acute with our educational programs?-the deeply knowledgeable about the health number of people who come in?-the tnis is really a kind of minor revolu- phas@of illness but is now increas. kinds of professions they represent? care systems. They, too, find it mucn tion. It may not solve all the health ingly assuming responsibility for other easier to generalize about the health ca re problems but it may well develop stages of patient care. New emphasis This is one method of evaluation. care systems the less they know about some important resources. is emerging on rehabilitation which will them! I think they require the correc- Then we have to evaluate whether the tive action of much deeper informa- Medicine and public liealth are now be better coordinated with other content of our programs is in line with tion. working far more closely together, @spects of medical care and indeed our goals. This is another problem, We shall have to evaluate problems of (without stepping on each other's medical rehabilitation itself is undergo- then, to determine whether we have coo toes), in a very significant, rewarding ing planning which will require synthe- communicated it, whether it has been rdination. This, in almost every fashion. What this means, I think, is sizing and evaluation in connection aspe vior, .. internalized, whether it changes behav- ct of complex human beha ' inat problems are being looked at in with the programs being discussed ior on the part of the practitioners and has been extremely baffling to us. new ways by people viewing them here. whether this'has any impact on your There are some research projects un- afresh or learning to view them Again, we have the problem of preven- they derway now to see whether some '- clients when return to nome . cr' through the eyes of their colleagues. tion as we plan to evaluate what we bases, or whether it has impact 'an iceria, and mechanisms at the program their own institutions. level among agencies, can be ana- From this kind of mix will come elabo. have done. This enormous opportunity lyzed, isolated and communicated. rations of our frame of reference that and primary challenge addresses itself Some of these things we can monitor. Here again, we may have some leads will permit us to develop evaluative to all of us. I suspect as an inverse relationship for evaluation but it's only a beginning criteria and evaluative methods that I think perhaps the time is also past here the things of lesser importance and the materials are somewhat fee. we don't have now. when mavericks like myself can be 32 -essed 'into service to do planning We have all had to take the first leap levels at which evaluation can and individual projects again, the way in id evaluation. I think we now need to into program development without an should take place and that when we which one looks at each individual @gin to train planners and research effective data base. This base will have use the term evaluation we may be re- project from the national level is in /aluators. The mix of professions and to be established and its impact ferring to any one of these levels or to terms of the total overall gain. Now, I @ interests that I have indicated Pro- brought to bear on the program. I all of them. suspect that the people ultimately are des us with an opportunity to pool think it will also permit gross monitor- Consider, for example, the responsibil- a little concerned with these kinds of ir resources in many directions to ing of broad program impacts if we es- ity of the Division of Regional Medical things. The expectation of the public @gin training for this field. tablish base lines in this way. Programs to show what has happened. as to what would come out of the Re- le need also new record keeping sys. There is a clear and present need to It has the responsibility as a Division gional Medical Programs is pretty !ms-health monitoring systems- begin to work closely with individual to report to the President and to Con- clear. iat will endure over time and insure projects to develop, where feasible, gress and to the people, to show what I think the legislation has been estab- iat we shall not have need to scram. evaluation designs so that we aren't has been done with the money, what lished on the basis that many people le again in the future, as we do now, constantly required to salvage even has been done under this new pro. are not getting the ultimate or the ) find what our base lines are. We will these at a later stage when we might gram which has been started. best care in the areas of heart dis- uild these base lines into the sys- have been more constructively in- This can be done in a variety of ways ease, cancer, and stroke, and that !Ms. volvcd earlier. and no doubt will be. Some of tlies! under the impetus of the program and ly comments have struck a somewhat In short, the way of evaluation is a have in them activity-a measure Or through the provision of money to egative note, emphasizing our prob. very difficult road. I think it is a feasi- success. Because this is a new carry out the program, this care would Pro' be provided in a way which is better !ms. I don't think they are insur- ble road, although some of what we gram it is possible, for example, to than it has been provided before. iountable. They will have to be sur- attempt may turn out to be impossi- show that activity exists where none iounted and within the context of this ble- Now it may be necessary to plan existed before or at least measures of As long as people continue to die from rogram. In the meantime there is for a future system that will enable us activity. It is possible to show that heart disease, cancer, and stroke, the iuch that can be done. to do it. It certainly is absolutely "X" number of projects are now in ex. ultimate goal, the ideal, has not been necessary. Thank you very much. istence. It is possible to show that ,X,, achieved. Obviously we will stop far fe need to monitor the systems. We DR. RUHE: Mr. Chairman, the panel number of the population is "covered" short of that potential but the ques- eed to study our aims and institu- by the projects. All of these things will tion is: How far can the program take ons, their caseloads, their needs. We has been kind to its members, if not no doubt be done. People in the Divi- us down that road? eed to monitor our occupations and to the audience, to give each member sion are conscious of evaluation of In the final analysis, I think this is rofessions, their programs, their of the panel an opportunity to . sa@ this kind-that is, just enumeration Of really the thing which the public is in- similar things from a different set Or eeds, their functions and the key re- what is going on-and also of an at- terested in. Evaluation can take place itionships in implementing those. We biases and backgrounds. tempt to compare this with what the not only at this level from the, total eed to do analyses of whatever ill- I don't know that I have anything new potential might be for the program so national concept but from the regional ess and prevalence data we can mus- to contribute but I guess I will say' that even though one might be able to level or within an individual institution, ?r and it is important to find where some of the same things in a little show gain, he is not necessarily show- and here again it is dependent upon ur peaks of illness are, in which cate- different way. I would like to plant at ing the proportion of gain which could what the objectives are and the bias of ories of people, which kind of III- least a couple of thoughts in the have or should have taken place in a the person who is looking at the pro- esses, which areas. minds of the audience and perhaps in given period of time compared with gram. ery important program guidelines will the minds of the other panel members. the ultimate possible gain. I have talked with some people who merge from this effort that can serve First of all, there is the thought that in The ways in which the gain is meas- represent individual institutions-gen- s precursors of a more extensive Pro- a program such as this, as complex ured, of course, are multitudinous. erally educational institutions. I sensed ram development. and as large as it is, there are many When we get down to the details of their feeling that if the program ena- 33 bles them to strengthen the education- Now this way the congregation got an thing more than this be done, that we becomes really to ascribe the change al program at their institutions then immediate feedback on its own efforts do get into the more sophisticated at- to what has been carried on in the they believe it has been worthwhile. It and the minister got an immediate tempts at evaluation, recognizing that program. would be difficult to quarrel with this feedback on the success of his efforts there are pitfalls. As one reads DR. JAMES: Thank you, Dr. Ruhe. in a general philosophical sense. If at exhorting the congregation. through Paul Sanazaro's paper and lis- I think it is fair to say that every pro. this money enables us to make a bet- .. . tens to Vernon Wilson talk and to the It was kind of interesting the attitude gram is evaluated. Many of them are ter medical school, surely in the long +his would produce in you as you other members of the panel, he must evaluated by what I would like to call run this will be better for the care of walked back home. If you had more stand a little bit in awe at the com- the "ice cream soda" test. The pa- the people. If we are able to establish -- plexity of the job; and of the attempt a new set of courses in continuing people there this week than last week to establish a base line of health tients like it, the doctors like it, the education and bring these courses or and a greater collection this than last care, recognizing that the base line administrators like it, everybody likes educational opportunities to more phy- week, even if you had nothing to do changes all the time you are working, it. directly with the collection, it sort of sicians and other health workers, sure- that it would change any way; and of What we are after of course is some- .-- ade you feel good inside. You got a ly in the long run this will result in rr' trying to say whether what you are do. thing deeper. The Academy of Medi- better health care. good feeling that things were going ing in one project out of 25 in one cine in New York which is composed forward and progressing and every- - . I think this is a reasonable expecta- thing was better than it had been the region, and what is being done in one of the more prestigious practitioners in tion. It is another method of measur. week before. institution in that region, or in one re. the community and which is about ing. Some of these kinds of measures gion compared with the national effort, 120 years old has had a public health I think that this is a kind of measure that any one of these things makes a committee for many years. The major are relevant and simple. Others are ' complicated. we could make readily. We could take difference. ticket to admission to the public some comfort, for example, if there This is the kind of thing which occa- health committee has been that you While sitting listening to other speakers were approximately 175,000 physician sionally overwhelms us and I would know very little about and certainly I was thinking about years ago when registrations reported in all formal urge simply that we make an effort. It have had absolutely no formal training I was young and spent all my sum- continuing education courses during is most important to have the attitude in public, health. Yet the amazing mers on a farm. We were about the year '66 - '67 as compared to only record these men have compiled for two miles away from the 150,000 reported in the year '65 - '66. of seif-monitoring, to make an attempt asking searching questions, of bringing nearest to look at these things critically, to set village and we used.to trek across the I don't know exactly what that means out exceedingly intelligent and provoc- hills every Sunday .1 morning-we called and I am not sure that it means there up measures which are reasonable and ative reports on public health prob- it Sabbath morning-to attend Sab- was better health care but it is a reas- in the long run will lead to what we lems and programs is truly phenome- bath School Church-and in this little suring statistic and it is one of the are trying to do. nal. village church there was a signboard kinds of measure which can be made The planning phase of all of this pro, Similarly about 20 years ago public on the wall to record attendance. it relatively easily. gram is extremely important to the re- health people began to evaluate the had the number up for the attendance gion. The planning projects, I think, practice of medicine and during the We can measure head count, dollar are very wise for that reason. Most of last 10 years the sociologists have last week and blank for the attendance amount, number of regions and you are in the planning project stage this week. Because of the Scotch back' number of projects. We can measure at this tiIme. This is a time when you been evaluating both. To the best of ground of the church, immediately un, the population cared for. We could can most effectively set up the means my knowledge no one has yet started derneath these figures they had their count things like this. by which critical evaluation may take to evaluate the sociologist. collection for last week and a place for It is true that in order to carry out a collection this week. Before the service I don't mean to deprecate these or to place later on. program of this nature there must be was over for the morning they always minimize them. I think it is valuable to The longer you wait to do it, the more evaluation. The men that appeared be- put in the figures for the attendance do them. But I guess what I am trying indistinct becomes the base line from fore you today have given you a few this week and the collection this week. to get around to is to urge that some- which you start, the more difficult it clues. 34 f you came here searching for cook- of the panel like to make additional them by the physicians in the ivory All of you, I believe, have been on one Dook answers, obviously no one has comments? towers. side or another of the National Insti- @'hem for you. We have a few minutes tutes of Health grants award process; remaining and I thought perhaps some DR. KOWALEWSKI: Mr. Chairman, I pro- The time required for diagnosis is very either you have applied for grants, of you, if you speak up loudly, would pose that one practical means of eval' easily measured. The amount of activ- have been on study sections and site like to direct a question to one or all uation will have to be based around ity or participation of the patient isn't teams, or have been on the staff that of the members of the panel along any this statement: What is helping me as hard to determine, and I would argue has been involved. All of you, there- of the lines that your minds have been the provider of medical care, the phy- about the utilization of patient time as fore, know that evaluation is something proceeding during this period. Would sician, and what is helping my patient? a measure of quality of care, because which is mentioned in practically every any of you like to comment?@h, yes, I would hope that the individuals who if any of you has done a study 'in grant. All of you have written' evalua- Go ahead. are able in this area would attempt to out-patient clinics, a close one, in a tion criteria diligently. I won't embar- iarge clinic, and have looked at the rass any of you by asking how many QUESTIONER: I will stick my neck out. build in a system around these two people who leave without receiving the times you have carried them out. We have about 9,000 fellows coming factors. What is helping me provide attention which they came to get you the service? What is helping my pa- This process of review is perhaps a lit- into the medical profession every year. tient? it must be built in because we will find there is a larger number of tle bit different because there will be We probably have 120,000 doctors these people than you think. Not only practicing now that don't understand must spend the majority of our time in that, but if you have someone in your visits, probably by site teams, to gran- anything about what we are talking treating patients. If we will have to school of journalism or some other de- tees as this program continues through spend the majority of our time in eva@- nd the years. It therefore becomes evident about. uating, then we are indeed not partment do a study of patients a that if a section is written on evalua- Is anybody besides Dr. Smith from fulfilling our purpose. So this practical their reactions to this process, you will tion in a grant request it is apt to come ing to do anything must be find there are a number of people who back to haunt one later on. down in Carolina try area of evaluation somehow do not seek care when they should be- to orient these people to the problems built in to answer these two questions. cause of bad utilization of their time. It therefore means that evaluation is a they are going to run into so that DR. WILSON: Everybody who tries to subject which will receive and perhaps when they do get into practice (where impart his own approaches finds it These are simple things. These are not sho'uld receive an enormous amount of they will have a hell of a time trying to amazing how little he really was able hard to measure, and I suspect that if attention and if our group here today make a living) they won't act in the to transmit. I would submit that if we we would measure a few like this to- have been somewhat lacking in same stupid way many of us have can get all of these groups to work gether as a whole region we would answers at least you can see that this done for the past 20 years. together to gather any kind of informa. have made a significant move forward. is in the process of developing and (Laughter) tion, no matter how simple, related to I hope that when those of us, now at everyone looks to you people in the DR. JAMES: I think you @erhaps posed progress, this in itself will have been a the ivory tower, set up measurement field who are working with grant something which is a problem. I won't major move forward and there are systems we don't forget the individual, Drojects, working with Regional Medi- refer to your adjectives, but at any as Dr. Kowalewski has just said, 'al'Programs, to begin coming up with some very simple things which can be do c rate there is a need for continuing used for such an information gathering who has a lot of other things to the answers which will then be rapidly education all the way beyond medical system. besides work with measurement Sys- shared with everyone who is working school in relation to all of these tems. if we make this simple enough in this area. different programs. The way that many One of these is the action that pa, so we can all get started together on of these regional programs are being tients take in response to prescribed it, perhaps the system itself will give Thank you. planned is to reach out into the com. therapy. Our social service people em- us ways to do this easily for everyone. munities and to continue the instruc- barrassed a number of our physicians tion of physicians in ways they would recently when they did a review of DR. JAMES: Thank you very much. One like to be instructed and in ways in what patients really did with the pre. final word and then we shall proceed which they need it. Would any member scriptions which had been given to to our group discussions. 35 The Report of the Surgeon General to the President and the Congress CHAIRMAN: As one who participated in the devel- has in the past,, there will be need to shows it was wise to make the law as Storm Whaley opment of this program and since authorize in some fashion the support flexible as possible. And I would hope Vice President for Health Affairs then has witnessed its birth and now of construction. This is the one area that we would continue to hold to this University of Arkansas lusty growth, it is most gratifying to that I think deserves our most serious flexibility. see the tremendous interest and con- consideration at this tirrfe, because, if Obviously there are certain standards PANEL: cern at this conference in relation to this is an essential ingredient to the and guidelines necessary to maintain Michael E. DeBakey, M.D. this program's activities. And I must undergirding of the program, then now quality and excellence. But flexibility is Professor and Chairman echo one of the thoughts anyway that is th.e time to put it in. essential to meet the varying condi- Department of Surgery was expressed so well by Dr. Farber. I personally believe it is an essential tions and circumstances that exist College of Medicine And that is that such interests, such . Baylor University exchange of information and really ingredient. throughout the breadth of our country where there are so many different James T. Howell, M.D. thoughtful consideration by so many I believe there will be need to provide ways of doing things; and these vary- Executive Director people, can't help but make the pro- space space to carry out a number ing ways are not necessarily less effec- Henry Ford Hospital gram better. of the various activities of the program tive or less successful. They should be Paul N. Ylvisaker, Ph.D. We are at that stage in the program that really are essential to the pro- adapted or at least be adaptable to lo- Commissioner, New Jersey Department when, as required by Congress, we gram. And I doubt that there is any cal circumstances so as to take the of Community Affairs must give it scrutiny and appraisal and other way to provide that space except best advantage of the local circum. Formerly, DirectoIr of Public Affairs suggest, if there is need to suggest, by funds that will support that type of stances and to use them in the most construction. I doubt seriously that effective way. Program, Ford Foundation modifications in the legislation. there are enough local resources for .Ray E. Trussell, M.D. I must say that when legislation was funding this type of construction. In I would doubt that we would want in any Director originally drawn, there were certain fact, I am sure that there are not. And way to change the legislative authority Columbia University School of things that we fought for but which therefore, I think we need to give this to provide for any lessening of that Public Health and Administrative were, through the wisdom of Congress, most serious consideration. So I should flexibility. I would urge that we main- Medicine omitted from the original law. And now place my greatest emphasis and per- tain that as strongly as we can. Bruce W. Everist, M.D. time has passed allowing us to give, haps my own focus upon this aspect Those are the two main things that I Green Clinic perhaps, more prudent thought to of the report and this aspect of any would say are most important to our Ruston, Louisiana these items. .1 do not now feel there amendment to the legislation. future in effecting this program as a has been any great loss, but at one successful and useful one in achieving time I thought there might have been.- Now, the second, and perhaps equally the goals that we are all seeking for it. Mr. Whaley introduced each of the In light of the development of the pr important, aspect of the report should Thank you, Mr. Whaley. 0- be concerned with whether or not the panelists and then asked Dr. DeBakey gram, we really lost little or no ground legislative authority has sufficient MR. WHALEY: Thank you, Dr. DeBa- to begin the discussion. in this regard. In fact, perhaps t@e breadth and flexibility. And here, key. Another member of the commit- Dr. DEBAKEY: I had hoped to-take ad- program will be strengthened by tne again, i think we owe a great deal of tee who has been working on the re- vantage of this opportunity say fact that we will have had greater time thanks to those who worked on the port, also a member of the National !O. to think about how best to do these some things to this group @,,n @e- things. language in the original draft and in Advisory Council of the Regional Medi- spect to the purposes and implementa- the subsequent modifications of it. For cal Programs as is Dr. DeBakey, is Dr. tion of the program. But Dr. Farber The one factor that still gives me con- this purpose, I would specifically call James T. Howell, Executive Director of who has preceded me has said it so cern, and I think there is reason for attention to the tribute we owe Dr. Henry Ford Hospital. He has brought eloquently I feel now it would be anti- this on the basis of our experience, is Dempsey in this regard because of the to the Council his experience in hospi- climactic for me to say anything that if the program is going to move many hours that he spent working on tal administration, particularly teach- further in this regard. forward as rapidly in the future as it this. I believe that experience now ing hospital administration. 36 p- @@ @j I @, : i, @@ I II I - @i , "@ I All I ','I e I It - 37 DR. HOWELL: My enthusiasm for this The second challenge, I believe, will go the evaluation of physicians. And I be- nounce your name? How old are you? I public law in its initial year of activity to the arena of the community into lieve we,,need to think of some other could answer the latter by saying: "I has stemmed primarily from the sim- which the law and its activities will elements that must come into evalua7 could go to the bar with any of you ple flexibility and the brevity of the penetrate. I believe that arena we tion procedures, ones that perhaps in without embarrassment." And, finally, law. It hals provided lots of latitude in must consider to be the hospital. It is our initial efforts may take precedence when this was all done, one of them which we may work. At the same time, here where modern instrumentation is over the others. observed, "Well Commissioner, I will in its simplicity and in its brevity, it m -ost likely to be placed, where s@ace give you one thing: you are the first does lead to some interpretative ques- provisions may be made for education, These deal with phenomena; these Commissioner in New Jersey who ever tions for which we must provide the for research effort. It is here that most dea .I with processes; these deal with came into office with a black eye." solutions. physicians by tradition congregate for various types of measurements which One must look to the legislative his- various types of meetings. Accordingiy, we mav place upon goals or objectives I would like to complicate the lives of of the program, rather than evaluation my friends here in this room and in tory for some of the answers to the I would say that the second challenge of physicians themselves. the National Institutes of Health and questions about interpretation which must be issued to the hospital itself. the Public Health Service. Perhaps this naturally arise. Like Dr. DeBakey, those of us who Accordingly, I would hasten to ask you is the wrong time to do it because the The National Advisory Council in have been working at the National Ad- to think of evaluation procedures in mood of the country right now is that terms of phenomena or procedures or "we have done enough for a while" drawing up guidelines has had to look visory Council level on this law, believe processes rather than an evaluation of for proper solutions to these ques- in its simplicity and its flexibility and human events. and "let's retrench." And the mood of tions. In doing so, as Dr. DeBakey has feel that relatively little needs to be an administrator must always be, "in said, we have attempted to keep this changed in the law itself. The National Thank you. that case, I will retrench a little more flexibility, this simplicity. This may Advisory Council and the staff of the MR. WHALEY: One of the members of th3n the public expects me to. I cer- bother some people, as is evident Division of Regional Medical Programs the committee who brought us his ex, tainly am not going to rouse any from discussions in the corridors at have attempted to take each of the perience and a refreshingly different sleeping dogs. And once I have got a this meeting,' in telephone calls that proposals brought to us from various point of view is Dr. Paul N. Ylvisaker good thing going, I don't want to risk have come in, in questions to the regions and really have tried to find it at this time." of the Ford Foundation. Dr. Ylvisaker staff, in visits that I have been asked some mechanism by which a grant can has been advisor to the United Na- But there are a few of us, I think, who to make to various places in the be awarded once the proposal is deter- tions, has' served in many different foolishly or otherwise are willing to say country with regard to some of these mined to be within the intent of the roles for the Federal Government, and a few things that have to be said in questions of interpretation. law. This, 1, personally, would like to soon will begin his career in State gov- the United States today. And that is, Keeping the flexibility, permitting op- see kept. If the lack of structure or the ernment. His particular concern has "yes, we have gone a remarkably long portunity at local levels for the deter- lack of precision in spelling things out, been in the area of urban affairs. He distance in the last few years. And this one, two, three, bothers some people, has moved the committee (and some- legislation, and Medicare in your field, mination of local need as well as local then I would hope that we could look times jarred the committee) with the certainly are cases in point. But we desire, in mechanisms by which the beyond this toward a greater oppo@u' things he has had to say. And I hope have a fantastic distance to go." various professional elements of our nity for participation at the local levei. you will jar us this morning, Dr. Ylvi- health resources may work is some- One other thing thas has been brought saker. We are facing an incomplete revolution thing which, like Dr. DeBakey, I feel in the United States which is working to me as a problem has to do with DR. YLVISAKER: I have just returned itself out with great rapidity. And this must be preserved in the law. ine evaluation procedures. I listened to it from some eye surgery and yesterday revolution is on top of an even greater penetration will be to the community. yesterday in a discussion group. And I had to face the New Jersey Senate revolution going on in the world And the first challenge, in my estima- have had many questions posed to me Committee for a confirmation of a new around us. The revolution is simply tion, will go to the physicians of the with respect to evaluation. Most of the appointment and they asked me the the assertion of the individual for community. problem, it would seem, centers about usual questions. How do you pro- equal treatment at a time when re. 3 8 Storm Whaley (Chairman) Michael E. DeBakey, M.D. James T. Howell, M.D. Paul N. Y[visaker, Ph.D. Ray E. Trussell, M.D. Bruce W. Everist, M.D. 39 sources are very scarce and they can stantaneous communication so that ul- to come when this legislation comes great growth industries of the United scarcely go around to do the things we timately a patient in need of help up before some of the committees, States which is medicine, like educa- presently want. knows exactly where to get it, how to and when some of the more consumer tion, like law, and like these other But in this mood, I would like to com- g@t it, and those in the medical profes- public oriented figures are going to be- services. How are you organizing this? plicate the discussion and the life of s,on know where research is and how gin to ask you questions. Unfortu- How even physically will you distribute the United States and its administra- to avail themselves of it. nately, they will tend to be of only one the resources? Will it contribute to an tors. The point I would like to make Now, the point I would like to drive kind which are the more familiar ones orderly growth of the community or, has to do partly with the phrasing used home very hard is that you cannot re- you have heard, the most important like the highway program, will it be- treat from the complexity which has ones of which relate to the patterns of come engineer-oriented-or in this in this legislation. . I care and to that consumer out case doctor-oriented - producing a become urban America, into either re. meclica This is a Regional Medical Program. -ional patterns exclusively or into there and how this will affect his life. wonderfully engineered system with Those of us who have worked with re- "' cloverleaves and the rest,. but very lit- gional problems for a long time know orofessional patterns. And what I fear Let me add a few other considerations. tle relevance to the community of what a Holy Grail this thing called a basically about the way this legislation es, go- which it is a part? has been drafted and carried out so We are now, in the United Stat region is. And as a matter of fact, far is that it has been given too ing into a service economy based on Second, the growth sector of our econ- usually when you use the word, you narrow a base, which is the medical large metropolitan areas. We have Pat- omy is the service sector. It is here are oversimplifying this issue. And you Drofession and largely the medical re- terned those metropolitan areas on that the great market for employment are doing what they said in the book @earch academic community, to work manufacturing and the mass produc- will come. Is there in your planning for African Genesis-"What a human being out what is one of the great moving tion and consumption of material these regional centers, which is the usually does is to add a territoria forces in the United States today. goods. The organizing principle of the planning for the profession and the ambition to an otherwise complicated metropolis in the days ahead will be- . And let me draw this perspective a bit science and the growth of medicine, existence." for you. Ted Howell said that the prob- come the mass production and con- thought@for how you can distribute the Now a region some wag once defined lem is going to be that of the commu- sumption of strategic services. And employment all the way from the high- as that area which is safely larger or nity. I could not agree more. The prob- these services will be largely in the est levels of skill down almost even to smaller than the last one whose prob, lem is going to be to relate the growth hands of certain guilds and certain the leaf raking areas which we are go- lems we couldn't solve. of medicine, both in its excellence an public professions. For example, City ing to be called upon to provide in the Hall is going to be picketed because it next years? That is, have you got non- And when we begin to work for the n its patterns of service, to the pat- doesn't give garbage services equally terns of distribution of the American professional employment worked into perfect definition of a region either as population and its mood and its to Harlem and the rest of the commu- this? Are you extending this research principle of organizing medical serv- aspirations. nity. And you will be picketed because and the work of the profession down ices or principle of organizing any you are not giving adequate medical to new occupations which are available services, we soon realize the tremen- Now, we have got to become, in all service and equal access to many of to the poor? Which is one of the ques- dous complexity of American life. It professions, in all the services, market these consumers. tions that I think you have to answer cries out, perhaps not so much for de- and consumer oriented. If you do n't, ow, the planners of the future me- before you are through. centralization which becomes a cen- within two years, your medical schools tralization, as for instantaneous corn- will be picketed by a combination o TroDolis are going to have to get hold And the final thought to throw at you of ihe service economy and its growth munication among people who are the American Mayors Federation ana and try to get some kind of pattern for is: Are you going to develop consumer doing remarkably similar work in very CORE. it which provides equal access to the complaint mechanisms in your busi- different places, and the need some- And I wonder if your medical faculties citizen consumer. ness? If we become market oriented, if times is not so much to centralize or are ready for that experience. this is the day of the consumer and to concentrate even at the regional You people are now like the highway you are the growth industry, where is level, as to produce this kind of in- The prelude to that experience is going engineers, laying hold of one of the the consumer complaint mechanism? 40 Now, you have noticed that the police word "health" appears. And there are And yet the community and the vacuums and only when they are con- review board is a beginning. The Om- some people in the upcoming Consti- scientific community must come to- vinced that they absolutely must bundsman is coming, and you better tutional Convention in April who would gether if we are to satisfy what is move. Yet, the public expectation is watch out for the Ombundsman. in do away with any reference to health, clearly the expressed intent of the such that the Government has clearly your profession. There is not a single holding that the police power in the public in the use of public funds. Yet, moved far beyond the thinking of the local medical group you have ever State is enough to take all necessary there is ambivalence in the minds of scientific community. talked to whose Young Turks have not measures. the Government about how these We have an enormous opportunity to said nervously, "We are not policing There are others, and I share this things are to be achieved. maintain a working partnership in this our profession; we are not market view, who believe that a positive state- We have the Regional Medical Program country in contrast to the rapid or oriented." ment indicating the extent of the pub- legislation underway. We have legisla- slow collapse into a total governmental The Ombundsman-will it come your lic concern should be included in the tion, passed in the last week of the system which has occurred in other way or will you anticipate it? State Constitution so there would be last Congress, which will put a similar countries. I look for an uneasy but These are some of the questions, and no mistake about the will of the peo- but broader planning function in the happy marriage between the Govern- [ hope I haven't rocked you too much. ple with this respect to the kinds of hands of the State agencies and also ment and the private sector as a Thank you. problems that we are discussing here parallel or competitive areawide plan- consequence of Regional Medical Pro- at the present time. ning agencies as soon as it is funded. grams. And I feel if they do not fulfill MR. WHALEY: Dr. Ray Trussell is Di- The Congress has enacted since 1956 Now, appropriately, this legislation has the expectations that the marriage will rector of Columbia University School about 65 major pieces of legislation in not been discussed here in this confer- get very lopsided and may, indeed, be- of Public Health and Administrative the health field. if this leaves any ence because, as was explained to us come no marriage at all. Medicine. He has brought to our com- question in anybody's mind in this very clearly by Dr. Marston last night, It is coincidental that in this ve ry mittee rich years of experience in the room that the public intent is that the there are discussions going on at the building, in the next room, is a con- field of public health and education. best that the scientists and medicine policy level. And nobody knows how sumer group, the Teamsters, who con- Dr. Trussell. have to offer shall reach the most peo- much money there.will be, but those trary to their headlines are a very con- DR. TRUSSELL: I want to congratulate ple, they really should go and read the of us who have had to do with the cerned group of union leaders, the Paul Ylvisaker on his carefully planned preambles to the various pieces of I eg- delivery of health services are urging largest union in the country and with out career. He has gone from the in- that in the report to the Congress ern in you and your prod- i,lation for refreshing instruction on +here be mentioned the need for coor- a deep conc ternational level to the Federal level, what the public wants and what the @ination of these multiple planning uctivity and with your concern for the and now he is going to the State level. public hopes it is going to get. efforts being engendered by Federal total needs of the public. We have And I only want to invite him to New The Congress has handed back to the action in the longstanding Hill-Bu on worked with this kind of labor leader York City where we could use help. for -many years and his management scientific community the particular job program, the Regional Medical Pro, The legislation which we are discuss. of saying under what conditions the gram, which is now getting off the counterpart. They finance research, ing toda@yesterday and today-is scientific community thinks it can de- ground, and the as yet inactive but up- they finance demonstrations on a re- the manifestation of a positive attitude liver what it already knows and how it coming State agency approach. If the gional basis in the New York area. They on the part of the Congress toward can deliver what it will know in the scientists can't get together with the support legislation. They supported leg- health. This is an attitude which is not future as a consequence of research. administrators at the local level, then islation in New York which provides shared universally throughout the Unit- This is an unusual function for the the vacuum that will result will be a this looking-over-the-shoulder function ed States. scientific community. It is not used to vacuum into which Government moves, that Paul talked about-namely, medi- In New York State which has some of planning for anything that it doesn't I can tell you, from my own experi- cal auditing by the State Department the most progressive health legislation want to do. It is used to planning very ence, that with the limited amount of of Health. in the country, the State Constitution meticulously and very effectively for tax money available in this country, But the State Department of Health in has but one sentence in which the the things that it does want to do. Government tends to move only into turn has turned to the State Medical Al Society for a partnership arrangement and brief that it seems the law could yet responsive enough to effect this And I will recognize anyone who so that Government and the profes- only have been passed by accident. change. wishes to be recognized in the panel. Dr. Howell. sions with consumer support have an The lack of obfuscation and the seren. Public Law 89-239 cannot mean a11 opportunity to discharge this function dipitous nature of the law leave it de, things to all men, but it is probing for DR. HOWELL: One of the very major of keeping an eye on how well -the void of the usual stringent measures public is served. new and better ways of delivering concerns that I have had with the law for coercion and regulatory function. health care without wholly disrupting itself has to do with the interregional There is much going on around us- This is enough to unsettle the most the established tradition of medicine. program. What do we anticipate will so much that we must be careful not sophisticated of Government staff. For example, continuing education re- happen one of these days when meth- to be like a fish. The fish swims around in the water all day, and he This lack of regulatory function and of quires no dissembling on our part. We odological approaches for evaluation never stops to think about the water in coercive power is also new to the pri. recognize our need for current knowl. or measurement determine that some which he is swimming. And yet the vate sector. And they have under- edge. And most of us will admit that plans have more effectiveness than water in which the scientific communi. standable misgivings when they see we don't always have it. Cooperative perhaps others? ty today swims has changed tremen- Government acting like a true Chris- arrangements among all health agen- Another concern in the interregional dously as a consequence of public un. tian gentleman. Incidentally, the clarity cies have already begun at this confer- area has to do with gaps of areas of derstandin'g and uf Congressional and of the law is not matched in this co n. ence. And they have been relatively the country that are not now covered. legislative action. And I think it is ter. ference. painless. Demonstration of patient And what will we do here on the Na- ribly important that we realize that the care is not a restrictive or nebulous .. Mix as used in Washington means put- term, but rather a unique opportunity tional Advisory Council to make certain water in which we scientific fish are ting Dr. Hudson, Mr. Cohen and Dr. for broadening the educational process that these areas have been covered? swimming has changed. And we'd bet- DeBakey on the same program. I am to include the patient. I think there is a major problem for us ter get used to it and adapt to it and not a lexicographer, but I think the try and meet the new temperature of word should be not "mix", but "cour- It is a good law. It was a good la@ to consider with respect to the sharing our times. of information from one region to an- age." Semantics aside, Public Law when it was written. And I think it is other. I think I have said enough for the mo- 89-239 has other virtues than clarity, the good fortune of the people at this ment. brevity and conciseness. It places a conference to make it a good law in And another of the problems is the new emphasis and a new direction on practice, not by accident, but by de- one that Paul Yivisaker has mentioned, MR. WHALEY: A member of the Nation- local responsibility for the health of all sign. the regions within a major urban area. al Advisory Council who is in private citizens. Doctors in the past have as- How may they be put together? How practice of medicine in Ruston, Loui- sumed this responsibility for the indi- MR. WHALEY: I am sure you can under- mav they share information? What is siana, is Dr. Bruce Everist. gent as a good neighbor, for the stand now that it was truly restraint the communication across these re- DR. EVERIST: I would like to ask the affluent for a fee. This can no longer on my part when I refrained from gions? indulgence of this audience, and some obtain for the poor for our current mentioning that Dr. Everist is the poet concept allows for equal medical at- laureate of our Council. His perform- Now, I propose this as a major issue empathy if you can imagine a country ance today is just as I have seen many about which we on the National Advi- doctor having to follow one of the tention for the poor as for the rich. times. (I have applied for the publica- sory Council are going to require a tre most honored physicians in the But as a right, not as a gift. tion rights of the gems which he has mendous amount of feedback from country, two directors, a vice president I have no doubt but that this change dropped: so far I haven't gotten you people. You will note that this pro- and a commissioner. It is obvious that can be made by local physicians in them.) Some of you might shudder to vision is not in the law. How this coop- I can only be dilutely paraphrastic. concert with Government, but with the think he happened to be the reviewer erative arrangement is to be made is Public Law 89-239 is a good law, new, lines of responsibility clearly drawn. of your application. He gets to tile largely going to depend upon you, ob- innovative, imaginative, and even artis- American medicine is conservative point. I am sure we have other com- viously upon us at the National Advi- tic. The language is so clear, concise, enough to resist undue pressure and ments from members of the panel. sory Council level as well. 42 MR. WHALEY: Thank you, Dr. Howell. lice Review Board is a warning in point porting back to them about the activi- Others? Do you have questions fr-OT-Ti that no one group is probably going to ties. Among these are this particular TRIBUTE TO accept this, but probably you will have request that we return to Congress a the audience for just a few minutes? an overview. statement of the relationship between JOHN EDWARD FOGARTY We have about 10 to 12 minutes. Federal financing for this program and DR. OLSON: During the past week, Yes. Whether this is adaptable in the medi- financing from other sources of activi- we have all been shocked and cal field, I don't know. I would think QUESTIONER: I would like to ask Dr. that the medical profession, seeing the ties. grieved to learn of the death of Mr. Fogarty who has had such a deep Ylvisaker with whom I agree entirely in trend of the times, might begin invent- This, of course, points up the variety interest in the health problems of terms of being consumer oriented or ing a variant of the Ombundsman and of sources of financing for the various this nation. We have asked Dr. market consumer oriented-Dr. Trus, to begin experimenting with it before medical activities that we are engaged Sidney Farber if he would come and sell referred to it as the environment the public might foist it on to the var- in today. And they wanted a statement pay tribute to Mr. Fogarty. in which the fish swim-whether his ious professional groups. indicating what sources are being DR. FARBER: Dr. Olson and mem- reference to the Ombundsman and used. And I think it is important also bers of the Conference: Just one consumer complaint bureau was a So, as I say, yes and no. I am talking to point out that there are non-Federal week ago today, we lost John Ed- figure of speech which he used with about a wave, a concept, a demand, something more explicit in mind. And but I am feeling my way in the institu- sources of financing that are being ward Fogarty, longtime chairman of tion. used in this program, the extent of the Committee of Appropriations if he had something more explicit in which is sometimes difficult to deter- concerned particularly with matters mind, would he be good enough to tell MR. WHALEY: Other questions? mine, but it would be certainly highly of health and education. us what he had? QUESTIONER: What type of construc- desirable in your own thinking in your There are some in this room who knew him as a devoted friend. There DR. YLVISAKER: Yes andno. tion did -Dr. DeBakey have in mind be- own regions to try and make some es, are many more who had the privi- I have been interested to see how this ing built into this law? timate of this. Because, for one thing, lege of appear4ng before him as a Ombundsman concept has begun it is important to maintain it. And in a citizen witness and learned then of sweeping the DR. DEBAKEY: Well, actually, I think it sense, it is part of the partnership that his great integrity, his deep devo- country. Inside of ten might be best described as construc- exists. tion, his compassion and, above all, years, it has gone from, you know, tion that is essential or needed to car, So I think Congress would take some his great knowledge of the needs of where did that come from, to almost a rying out the program, wherever it interest in having information on these the country for, medical research, common figure of speech in the Unit- training and care. ed States. It is being adopted in a may be-affiliated institutions, the aspects of the financing. I believe it can be said without ex number of jurisdictions, in Long Is- center itself, and so on. It is related MR. WHALEY: Our time has run out. I aggeration that no man in the his- land, as I recall, in one of the New primarily to program activities such as had written down a few comments on tory of the House of Representa- those related to continuing education, York suburban counties. And I think e remarks of each of our panelists, tives has made a contribution to the you wIill see probably many munici- those related to demonstration of care, th but in the words of Dr. Everist, I don't health of -the country as great as palities adopt it very shortly. It will be those related to administration of the wish to be dilutely paraphrastic be- that made by Mr. Fogarty. The program, and so on. enormity of his contributions will be an experiential thing. It will grow. cause it would ruin the very fine state- felt all over this country and over There are several things about it to , would say that this type of construc- ments which we have had. the world for generations to come. keep in mind. tion is pretty hard to come by from So, members of the panel, the deep It was felt proper that all of us who other sources-that is, from other appreciation from all of us for what had benefited so much from his One is that there is a public receptivity financing. And speaking of that, if I labors might stand for a moment in you have done. om nts, his memory. to the idea of a consumer complaint might just take a few more m e I (Applause) mechanism. Second, that they are not would call your attention to the fact (The group stood in silence.) satisfied to start in one field. The fact that there is written into the law cer- that you overthrew the New York Po- tain interests that Congress had in re- 43 The second we hope yoti will make discussion group for this final ion. DR. OLSON: This concludes the final We are deeply grateful for your pres- sess plenary session of the conference. The ence and for your contributions. We after you have returned home and I met Dr. Pellegrino in the corridor as 1 attendance has been a splendid one. would ask that you make two further have had an opportunity to reflect on was coming into the hall this morning. We have had approximately 650 regis- contributions. the matters you have had under dis- He said, "Stan, is there anything spe- trations. We have had outstanding reP- The first you will make in the discus- cussion these past two days. I would cial you want out of this discussion resentatives of the health field both on sion sessions to which you will adjourn hope you would write to Dr. Marston group?" And I commented that he the platform and in the audience. in just a moment. and give him your considered judgment ought to use his judgment; that the about any aspect of the program you discussion group should feel free to consider to be important and pursue anything it wanted and in significant. depth. I told him we had had plenty of breadth in the last couple of days, Dr. Farber made reference to the capa- what we needed now was some depth. ble, dedicated and loyal staff that Dr. Marston has developed in the Division So I would hope that participants and of Regional Medical Programs. I have chairmen alike would address them- come to know this staff and their ca- selves to the issues that have been so pabilities in the past seven weeks that ably presented here this morning and I have been associated with the prepa- that you will come to your own con- ration of this conference. I should like clusions about what is right with the to take just a momen recognize law, what is wrong' what needs to be several people that have performed in retained, what needs to be changed. an outstanding fashion. Dr. Marston, is there anything you want to add? These are Mrs. Judy Silsbee, Mr. Ly- man Van Nostrand, Mr. Edward Fried- DR. MARSTON: No. lander, Miss Dale Carter, Mr. Charles DR. OLSON: I would just like to say Hilsenroth, Mr. Stillman Wright and Dr. this has been a wonderful experience John Hamilton. for me to work with Dr. Marston. And I In addition, as you know, the staff hope that many of you have an equal has served as recorders for the discus- opportunity to get to know him as I sion sessions. The stenographers have have. worked, some until one o'clock, some Thank you. all night, to get out the various things that were needed for the conference program and registration. I should like to ask the staff that is here to stand so that we might recog- nize their very significant contribution. (Applause) I would call your attention to the fact that you will be going into a different 44 Section III-Issue Papers Four Issue Papers were prepared to Cooperative Arrangements provide a focus for discussion. "These Program Evaluation are not the only issues calling for at- tention, but, certainly, these are areas Continuing Education of common concern. . . " said Dr. Surgeon General's Report Marston in his Conference speech. 45 The Development of Cooperative Arrangements Prepared by the staff of the Division of for its superiority over systems estab- ternist - pediatrician - psychiatrist, and the hopes and aspirations of physi- Regional Medical Programs as back- lished by government and welfare. other mixtures. If the profession fulfills cians. ground to the first discussion session ,Evaluations could be made of the its promises, there will be new and in- "As I finish this chapter after six needs of the public for medical care, of creased efforts to keep people well, an months of struggle and interrupted In an editorial in the November 23, the kinds of services required, and of emphasis on health rather than dis- effort, I am at my desk, having just re- 1962 issue of Science, Dael Wolfie the numbers and kinds of physicians ease, an augmentation and an en- turned from seeing a patient with dis- pointed out that honesty and objectivi. and institutions needed to provide hancement of the field of preventive seminated tupus erythematosus who is ty, reliance on the evidence rather these services. Based on these evalua- medicine. alive and at the moment well because than upon bias, wish, authority, or per. tions, educators could construct curric- "The greatest challenge of the present of the miracle of medical progress. In sonal advantage, is one of the greatest ula to deliver graduates consistent with is inherent in the job description of this recalling her happiness and the took gifts,hat science has given to society. modern requirements. Community hos- physician, who must feel the signifi- of fondness and gratitude she gave A goal of the groups applying for Re. pitals could continue to employ direc- cance and importance of his practice me, I cannot help reaching out in ap- gional Medical Programs is to work to- tors of medical education required to and must believe in his unique ability preciation to those persons, some ward meaningful relations which will be provide excellent training programs of as a true specialist to perform duties known to me and many unknown, based on objective data and real perhaps a different character but of that others in the more narrow special- whose efforts have permitted me this, needs. There has been concern for quality equal to those in the university ties might find impossible. Under no the supreme reward of the physician. some years because health resources centers. Differences between university other circumstance will there be effec- and organizations with nonidentical hospitals and community hospitals tive competition to careers in sub- "A moment's reflection will show us but related and overlapping goals have would disappear in the collaborative specialism. The divisive forces in the what we all must know: we are not self- often not been able to work together efforts to train interns and residents profession of medicine themselves sufficient, even as an individual one effectively or to seek joint solutions to through an interchange of teachers and point up the interdependence of its does not practice alone." new problems. trainees, the sites to be determined by parts and the real need for cooperative . the competence of the hospitals to effort. With such a sincere effort I Congress and others involved in the Many have defined the problem and satisfy the future service requirements would predict that our intraprofessionai development of Regional Medical Pro- have offered a logical solution. A fine of the trainees. differences would disappear. grams were convinced with Dr. Hudson example is given in the following state- that individuals and even institutions ment by Dr. Charles L. Hudson at the "The inevitable centralization of knowl- "Numerous unilateral attempts at ad- cannot cope with the complexities of 1962 Teaching Institute of the Asso- edge and techniques with stratification justment of medical practice have modern medicine in isolation. Public ciation of American Medical Colleges: according to levels of knowledge and failed, because any undertaking that Law 89-239, which authorizes grants "A restoration of harmony among the competence would continue, but seeks to alter the position of one ele, for the planning and establishment of elements involved could be effected by equally important would be the areas ment, without regard to the effect on Regional Medical -Programs, begins a sincere collaboration among physi- manned by the physician with broad the integrated system, causes unhappi- with the following two statements of cians as physicians, in teaching and training. His primary contributions to ness and strife in the whole profes- purpose: research, in training of interns and-resi the system would be in medicine, with sional complex and will increase its 0 To encourage and assist in the es- dents, and in patient care in the 'nos- occasional exceptional additions where susceptibility to outside interference tablishment of regional cooperative ar. circumstances required them. and even domination. pital and in the office. This, an educa- rangements among medical schools, tion and practice complex, could be "The key to success of an integrated "As to the medical practice of tomor- research institutions and hospitals for formed if physicians were willing, if medical practice would be the proper row-if intelligence, good will, and research and training (including con- necessary, to surrender some preroga- identification of the physician now technological advances exert their po- tinuing education) and for related tives in the interest of creating an sometimes referred to as the general tent force-the changes should hope- demonstrations of patient care in the effective private medical care system practitioner, personal physician, family fully go in the direction of better care fields of heart disease, cancer, stroke, that would be recognized by the public physician, first-contact physician, in- for the sick and greater fulfillment of and related diseases. 46 0 To afford to the medical profession vanced capabilities, private practi- and medical institutions of the Nation, tioners, community hospitals, and through such cooperative arrange other interested private and public ments, the opportunity of making avail- agencies throughout a Region. able to their patients the latest ad- Through such channels, information vances in the diagnosis and treatment and assistance can be moved out to of these diseases. upgrade and maintain daily practice at the highest possible level. The same Other sections of the law and the leg- local groups can feed back information islative history that led to its enact- on needs as a basis for further re- ment indicate that all organizations search and training. In this way, and groups concerned with realizing science and service may be linked in these purposes are to be included as systems of mutual support and an integral part of the cooperative ar- benefit. rangements. These include, in addition to those identified above, medical so. In the development of the )rogram, cieties, health departments, voluntary emphasis has been continuous y placed agencies, other health professions and upon its cooperative and c( ntrifugal individuals concerned with health. Sec. features. It is believed that t,e exten- tion 903 specifically provides that the sion of excellence in health care to all parts of a Region can be facilitated by Regional Advisory Groups must be "broadly representative" and must ap. bringing together all the major institu- prove applications for operational tions and interests for planning and grants. action. The product of the efforts of A organizations working together can be The Program Guidelines emphasize the much greater than the sum of the sep- essential importance of regional coop- arate efforts. As the President's Com- erative arrangements among these mission on Heart Disease, Cancer, and groups throughout the planning and Stroke pointed out: "A creative partner- operational phases of the Regional ship among all our health resources ... Medical Programs. While it is recog- is the true path to the conquest of nized that the full development Of heart disease, cancer, and stroke." such arrangements involves all medi- During the first year of the program, a cal institutions'organizations and indi- great deal of emphasis was placed on viduals within a Region, and may take the term "cooperative arrangements" considerable time, the initiation of this , effort is a critical aspect of the plan- DOth by the applicants and by the re- ning process for a Regional Medical viewing groups. One applicant, who Program. was also a consultant to the program, stated that in the strictest sense, "Cooperative arrangements" are in- justification of the program would rest tended to facilitate effective exchange on the ability to demonstrate the de- of information and ideas and working velopment of cooperative arrange- relationships among centers of ad- ments where they had not existed pre- 47 viously. All have agreed that the complex problems which cannot be made on a basis of the wisdom and C. Commitment of effort by individuals, documentation of this aspect of the met by individual institutions or or- experience of the participants and the organizations and institutions program is an appropriate accomplish- ganizations. In the early stages, it is advisory groups. A primary goal II. Regional Medical Program vs. collec- ment to report to the President and inevitable that most decisions will be should be, as Wolfie suggests, to begin tion of projects Congress. by establishing mechanisms which will .A. Relevant characteristics of Regional The requirement for the development allow the substitution of objectivity for Medical Program on which this judg- of regional cooperative arrangements bias, and data for wish or authority. ment can be made was the major factor in determining Some insight into the problems to be 1. Overall leadership and guiding phi- the sizes and shapes of Regions as anticipated in the future can be gained losophy various parts of the country probed for from a study of the issues which have a. Is there a unifying conceptual strat- what seemed to be the best workable arisen in the review of the early opera- egy which will be the basis for initial conditions. A part of the planning tional applications. priorities of action, evaluation, and process will be to reexamine the ' fac- A primary goal of Public Law 89-239 is future decision making? Are there suf- tors that lead to the conclusion that a the establishment of decision-making ficient feedback loops in the strategy? given Region offers the best opportuni- mechanisms on the local level which b. Is there an administrative mechan- ties for effective utilization of re- assumes that different priorities exist ism which can: sources. In some instances, political in different parts of the country. On 0 make decisions considerations may have deserved a the other hand, neither the National 0 relate to regional needs relatively higher priority in the estab- Advisory Council nor the Public Health 0 stimulate cooperative effort among lishment of an application for a plan- Service can delegate their basic re- major health interests ning grant than will be the case with sponsibility and accountability that C. Are the key leadership persons iden- regard to operational grants. In others, Federal funds will be expended wisely- tified? Do they work with the major deficiencies of resources may require A number of Regional Medical Pro- health interests? Do they have experi- the development of cooperative ar- grams have submitted applications for ence and skills appropriate for provid- rangements across great distances, at operational grants which are currently ing leadership to a complex endeavor? least for Interim purposes. Almost being reviewed. These applicants, the d. Is there involvement and commit- surely, close relationships between ad- Review Committee, the Council, and ment of the major health interests such jacent Regions will prove beneficial . An staff have identified issues in the proc- as: editorial in the August 12, 1966, issue ess of working with these applications. of The Journal of the American Medical The following list is not meant to be 'D Medical schools Association comments that cooperative complete, for future grant requests will 0 Practicing physicians arrangements within Regions seem as- bring out additional issues, and one 0 Hospitals sured and that the next question is could speculate that still others will 0 Public health agencies whether such cooperation can exist be- a ri se: e. Will the ongoing planning process tween Regions. . interact with the first operational steps The development of cooperative ar- 1. Characteristics of early operational in the development of a program that rangements requires organization and proposals meets the broader needs of the entire A. Many projects contained in each region? communication, sharing of resources, ability to reach joint decisions, and the complex proposal 2. Nature and interrelationship of spe- development of the capability to B. Sizable budget requests, including cific proposed activities in regard to evolve new and creative approaches to large hardware requests the goals of PL 89-239 48 Evaluation of Medical Care Under Public Law 89-239 B. Evidence that priorities have been erational activities as necessary for Paul J. Sanazaro, M.D. in the quality of care. For example, in- set at the regional level further development, extension, and Director, Division of Education creasing the number of trained person- Ill. Quality standards solidification of regional cooperative Association of American Medical nel or providing specialized facilities arrangements Colleges and services in areas where these are A. Regional vs. National standards VI. Length of commitment Chairman, Health Services Research marginal or nonexistent constitutes, on B. Emphasis on grantees' own evalua- Study Section, Public Health Service the face of it, a distinct improvement tion mechanisms as quality uplifting A. Degree of emphasis to be placed on Consultant, Division of Regional in the quality of care. In this sense, factor at regional level self-limiting nature of projects Medical Programs evaluation of a Regional Medical Pro- IV. Criteria for judging appropriateness B. Need for long range commitment gram can be directly comparable to of support for "core" activities which are essential Prepared as background to the second evaluating the quality of care. A. Scope and limitations of Regional investment for conduct of specific proj- discussion session term "medical care" has several ects The Medical Programs legislative authority, Evaluation in the field of medical care unique meanings depending on including categorical focus VII. Relationship of operational pro- consists first in collecting information whether it is defined as a process, as B. Availability of other sources of sup- posals to ongoing planning activities on the operations and end-results of a a system, or as an area of study. It is port A. Need for documentation of relation- program, then making judgments re- also analyzed in different ways de- C. Priority on innovative and leverage ship garding the effectiveness and efficiency pending on whether individual pa- effects B. Extent of prior planning and its re- of the programs or services under tients, a community, or the entire Na- lationship to proposed operations and study with respect to both individual tion are the recipients. The following V. Criteria for judging level of support continued planning patients and communities. On a short- components of medical care are partic- A. Geographic distribution - Should C. Extent to which needs of periphery term basis, evaluation identifies need- ularly relevant to the evaluation'of a consideration of availability of funds of the region need to be documented ed revisions and improvements in an Regional Program: for later proposals be a part of deci- as basis for undertaking operational operating program. Its long-term func- 0 Supply or availability of health care sion on amount awarded to first appli- activities tion is to provide a rational base for personnel, facilities, and services, in- cants? Vill. Need to spell out relations policy decisions governing the cluding preventive measures. B. Partial or phased support as mech- @ip = directions of such programs or 0 Utilization of personnel, facilities, with adjacent regions and to justify services. When conducted with a high and services, including preventive anism for: the proposed region order of technical competence, evalua. measures, by individual patients or 1. Allowing fuller development of plans IX. Adequacy of administrative arrange- tion may also contribute substantive population groups. before proceeding to fuller implementa- ments, including fiscal accountability knowledge to the field of health serv- 0 Process of patient care: accuracy tion of grantee ices research and is then designated of diagnosis, adequacy of treatment, 2. Permitting better decisions on dis- Examples such as these coming from as evaluation research. and appropriate utilization of consulta- tribution of funds early operational grant requests, and A distinction exists between evaluating tive resources and specialized technical 3. Early review of progress 4: others yet to come, will continue to a Regional Medical Program and evalu- services. C. Need to support "critical mass" 0. test the workability of developing co- ating medical care. Public Law 89-239 0 End results: the effectiveness of a activity which will have a sufficient im- operative arrangements over a wide and the Guidelines emphasize the de- treatment or program as determined pact to permit evaluation of results range of activities. The first Confer- livery of medical care, i.e. the person- by the consequences for the individual D. Support of costly activities as na- ence discussion session is directed at nel, facilities, services, and resources patient or population, including ex- tional or interregional resources when reviewing experiences in the develop- necessary to improve diagnosis and pressed views of patients and potential justified by the involvement of unique ment of these regional cooperative ar- treatment. However, only in certain patients toward the availability and ac- capabilities in a specific Regional Medi- rangements and considering plans for limited situations will increasing the ceptability,of medical care. cal Program extending and modifying these ar- capabilities for delivering medical care 0 Unmet needs: individual patients or E. Extent of need for support of op- rangements in the future. automatically assure an improvement population groups with identifiable dis- 49 the only objective of the program, then eases not yet diagnosed, or diagnosed the evaluation of this program rests but not under treatment. entirely on the fact that ten rehabili- In a limited, technical sense the re. tation aides were or were not trained. quirements for evaluating a Regional By analogy, this level of evaluation ap- Medical Program in accord with the plies to the establishment of special- stated purposes of Public Law 89-239 ized patient care units, demonstration can be met by limiting the evaluation programs, diagnostic or treatment of medical care to its first component, services, and so on. The fact of their supply or availability. However, in establishment provides the necessary order to evaluate the effectiveness of and sufficient information needed in the increased supply of personnel, fa- judging whether or not the objectives cilities, and services and their im. were met. proved distribution, it is necessary to 2. Objective description and analysis. include the other components of medi- For this level, descriptions of educa- cal care: utilization, the adequacy of tion and training programs, facilities, Its, diagnosis and treatment, end resu services, and capabilities of personnel needs. The assumption and unmet are compiled in accord with prevailing seems warranted that the law was professional concepts and standards. passed with the implicit belief that For example, a program for training there would be demonstrable improve- nurses to staff coronary care units ment in the care, and in the results of should be described in terms of the care, of patients with the specified dis- functions nurses will be expected to eases. It appears to be a legitimate perform as a result of their training. responsibility of those conducting Re- ill have been defined gional Medical Programs to ascertain These functions w by appropriately informed and experi- so far as is feasible the relationships enced experts. Evaluation of the train- between improved h'ealth manpower, ing program will be directed at answer- facilities, and services and the other ing two questions: (1) Has the defined elements of medical care. program been designed in accord with As stated, evaluation is a dual process generally accepted principles of such of data collection followed by judg- training? and (2) Was the program car- ment. Depending upon the particular ried out as planned? Descriptive data program or services, evaluation may bearing on these questions must be be carried out at varying levels of pre- coilected before a judgment can be cision and sophistication. These levels made. Similarly, with respect to the will be described separately. operation of coronary care units, the 1. Evaluation to determine whether the basis of judgment regarding their ade- quacy is simply an accurate descrip- stated objectives of a particular pro- tion of the services which these units gram were met. If the stated objective provide, together with a description of of a program is to train ten rehabili- tation aides, and this is accepted as their overall operation and administra- 50 tion. These descriptions are then com- the adequacy of utilization will rest on or program element are achieved eco- the next step can be taken. The se- pared with prevailing professional and two comparisons: (1) between rates nomically in terms of dollars, man- quence may be outlined as follows: administrative judgments of what con- per 1,000 general population in control power, time, space, and resources. 1. Collection of information and data. stitutes proper staffing, organization, and experimental communities or be- Competence in operations research 0 Specification in detail of the objec- resources, and administration for coro- fore and after the introduction of a and economics is required. Two or tives of , the programs, services, and nary care units. program in the same community, and more training programs for aides end resu ts which are to be evaluated. 3. Evaluating utilization by patients or (2) between utilization rates and might be compared to discover 0 Establishing the criteria on which known prevalence of the target dis- whether comparable skills can be populations. The question of whether eases. achieved more economically. Appropri, judgments will be based. or how the improved staffing, facilities, in the ate economic bases are needed to 0 Designing the instruments or rec- and services bring about improvement 4. Evaluation of improvement compare these programs with training ords for data collection. in medical care cannot be answered patient, care process. Direct compari- programs which produce fully qualified 0 Applying the appropriate methods without information concerning the uti- sons on a controlled basis are required for collecting the relevant descriptive lization of such personnel, facilities, to determine changes attributable to professional personnel. Similarly, the information with minimal bias. and services by patients. Two ap- the program in accuracy and ' costs of establishing and operating Statistical analysis and/or summary corn proaches are possible. Prior to the in- pleteness of diagnoses, adeq uacy of different types of coronary care units of descriptive information. stitution of the program, baseline data treatment programs, and appropriate need to be compared in relation to 1. 0 Interpretation and comparison of can be obtained on the utilization referral of patients for specialized demonstrable improvements in the rates of various personnel and services services. This level of evaluation en- outcomes of care given in these units. results against agreed-upon criteria. by all persons with the specified dis- compasses the techniques of the med- It is also appropriate to compare costs 11. Judgments regarding adequacy or eases in the population served by the ical audit in office, clinic, and hospital and staffing economies or the func- inadequacy of program, program com- Regional Program. if baseline data are settings. tional efficiency of such specialized ponents, or results. units with an at-large monitoring sys, Quality, effectiveness, and efficiency of not available, a comparison group of patients to whom the new resources 5. Evaluation of end results. This level tem dispersed throughout the hospital. medical care cannot be measured di- are riot available must be studied in constitutes the definitive measure Of The critical element in such evalua' rectly in standardized units. They can order to determine that other changes effectiveness of personal health serv' tions is an agreed-upon set of criteria be inferred from one or more objec- totally unrelated to the Regional Medi- ices. By use of matched populations, of adequacy for services and end re- tively specifiable indexes derived from cal Program have not brought about data can be compiled on decreases in sults. Only then can the relative costs established professional standards. equivalent changes in utilization. Both interval between onset Of Symptoms be rationally analyzed. These indexes can serve as the base approaches require the use of edidem- and receipt of care; end results of . .information or data for judging the de- care; prevention of complications; alle. 7. Evaluation of the effectiveness of iologic methods applied to probability viation or reduction of disability; im- preventive measures. This is the most. gree to which a program or its results samples of general populations. It is provement in social functioning; in. difficult level of evaluation since it at, meet or do not meet the criteria inappropriate both in terms of the creased longevity; and so on. Whereas tempts to determine the extent to specified. Judgments of quality are overall objectives of Public Law 89-239 techniques for the preceding four lev- which diseases are being reduced, con- based on consensus of physicians and and correct methodology to base eval- els of evaluation are well worked out trolled, or eradicated from the popula- other professional personnel. Effective- uation on changes 'in the numbers or tion by the application of pre.ve.ntive ness and efficiency of a program or characteristics of only patients who and can be applied in pre-tested form, ogic procedure can be defined somewhat receive care. Similar approaches the determination of end results is still measures. The use of epidemiol more objectively, because data can be under research and development. methods is also essential for this form are necessary to determine whether of evaluation. collected on effectiveness, and the changes in frequency of duration of 6. Analysis of cost-effectiveness. This dollar and manpower investment can hospitalization for equivalent disorders form of evaluation focuses on the Evaluation is a sequential process, be objectively related to outcomes or their complications are brought efficiency of a program and questions each step of which must be appropri- (cost-effectiveness analysis). However, about by the program. Judgment of whether the results of a given program ately planned and carried out before even under the best of circumstances, 51 evaluation is a difficult and demanding cilities through education and training made to the evaluation of the impact methods of data collection; failure to procedure, especially in the field of of health care personnel and demon- of any program on the medical care specify clearly the goals and end re- personal health services. strations of patient care; system and on the quality of care. sults to be evaluated; failure to estab- Section 908 of Public Law 89..239 0 extending the productive interrela. Study of one component of the medi- lish criteria before attempting evalua- states that the Report to the President tionships of extensive research, teach- cal care system will not provide tion; confusion of availability of and Congress will include "an apprai- ing, and patient care activities to com- sufficient information to make possible services with utilization or with actual sal of the activities assisted under this munity hospitals and practicing wise decisions concerning needed patient benefit; inadequate access to title in the light of their effectiveness physicians; modifications in other components and or lack of availability of standardized in carrying out the purposes of this 0 creating an effective environment links. The evaluation of medical care rates for prevalence and incidence of title." On page 65 in the first para- for continuing adaptation, innovation within Regional Medical Programs diseases. graph, the Guidelines stipulate that' and modification without interfering must be comprehensive in scope and One approach of proven merit is the long-range in perspective. The most "special effort" is to be made to incor- with the patterns or methods of productive attack on this problem will establishment of a health services re- porate evaluation in the planning and financing patient care or professionsi result from cooperative efforts by uni- search unit, a form of an operational operational phases. "Research into practice, or with the administration or versities and private organizations uti- and epidemiologic research unit, as an better means of accomplishing the hospitals. lizing the resources of a number of integral part of a health services pro- purposes and objectives of the Region- It is legitimate to question whether units within the Public Health Service. gram. By this means, an administra- al Medical Program" qualifies for sup- augmenting existing patterns for the tive mechanism is set up for feeding port in an operational grant. In order Evaluation as Operational Research. the results of evaluative studies to to analyze the role of evaluation in the organization and delivery of services those who must make decisions gov- Regional Medical Programs, it will first wl 11 automatically bring about maxi- The particular form of evaluation mum possible improvements in the which is undertaken and the technical erning the day-to-day operations of be necessary to identify the health of the population in proportion competence of those who design and the program as well as future im- and provisions of Public Law S= to available knowledge and techniques. conduct the study are essential consid- provements. Given long-term responsi- which have implications for the pur- The potential impact and the projected erations. In addition, failure to proper- bilities, such units are more likely to pose, scope, level and limitations of total investment in Regional Medical IY utilize or apply the results of evalua- develop and maintain records which evaluation. Programs are such that considerable tion will defeat the basic purposes of cumulatively become more valuable Within Public L@w 89-239 and the pub, effort should be devoted to the devel- evaluation, namely, to improve pro- and informative because of the docu- lished Guidelines, the following major opment of standardized data on inci. grams and their effectiveness and mentation of changes over time. This categories of objectives are defined: dence and prevalence of the target dis- efficiency. resource is not likely to be developed 0 making available to patients the [at- eases in the general population (as when ad hoc evaluative studies are Many circumstances may vitiate evalu- carried out on a short-term basis by est advances in prevention, diagnosis, described in paragraph 1, page 16 of ation and prevent its effective con- consultants who have no continuing treatment, and rehabilitation; the Guidelines). Furthermore, signifi- tribution to the continual improvement responsibilities to the program. 0 developing more effective distribu- cant effort should be devoted to of programs. The list of potential con- Even under the most advantageous cir- tion and utilization of all types of medi. analyses of factors which determine taminating factors is long. It includes cal resources; the degree of success achieved in im- such factors as the introduction of cumstances, continuing evaluation of 0 establishing cooperative arrange- proving the delivery of medical care to undue bias and subjectivity by those health services based on operational ments among medical institutions and all persons who could benefit from it. administratively responsible for the and epidemiologic research encounters professions to overcome fragmentation It is only by using techniques of evalu- program; resistance of professional certain problems with predictable regu- and insularity and meet the diversity ation which link together personnel, fa- personnel to evaluation; arbitrary re- larity. These will be listed briefly: of needs, resources, and existing pat- cilities, services, utilization, end re- striction of the limits of evaluation; 0 One of the most important poten- terns of education and services; sults, and cost-effectiveness analyses changes in the program while it is be- tial contributions of evaluation is the 0 improving health manpower and fa- that an approach can begin to be ing evaluated; use of inappropriate analysis of alternate approaches to the 52 attainment of program objectives. Very when cumulative evaluation, studies, this decision was made when the par- Medical School Departments of Pre- often the decision at issue is not reports, and research have both ticular program was instituted. None- ventive Medicine and a few other uni- whether a particular program in opera- defined the system and its component theless, it is legitimate to subsume, versity departments, medical care tion is effective but whether an alter- parts and related their operations to under evaluation, questions concerning research units have developed well- nate program might be more effective. objectively specifiable effects. In this the appropriateness of the program in qualified faculties in medical care To base evaluation upon an all-or-noth- period, the data base becomes more terms of the cultural attributes of the and patient care research, health eco- ing answer for an entire program is important in supporting operational area or population and the likelihood nomics, medical sociology, operations much less productive than providing decisions than empirical judgments of that elements of the program might be research and systems analysis, epidem- alternate program components which administrators. applicable to other areas and popula- iology, demography, health, services can be independently evaluated with Many Regional Medical Programs are tions. The methods used must take in- statistics, and medical care adminis- respect to their consequences and in the first stage. It will be some time to careful account the possibility that tration. costs. before the second stage is reached. the unique circumstances operating in The national impact of Public Law 0 It may be that the major con- The third stage can only be dimly a particular program may make it Im- 89-239 will best be evaluated through glimpsed in the distant future, and will possible to achieve comparable effec- the cooperative efforts of the Public tribution of evaluative research is to eness and efficiency in other areas. determine whether the traditional ways not be reached at all unless activities 'EIV Health Service, other governmental of carrying on professional practices in acquiring appropriate data bases Sources and Resources for Evaluation. agencies, the individual Regional Pro- and delivering medical services are, in are promptly established. A sound program of evaluation in the grams, and a number of other public fact, the most effective. If arbitrary as- 0 Evaluation of demonstrations in field of medical care requires the di- and private resources. The National In- which the purely medical aspects of tive involvement of a stitutes of Health, the Bureau of sumptions and unwarranted limitations @rect and coopera are placed upon the scope of evalua- the services rendered are assumed to number of disciplines and compe. Health Services and the National tion, even though some limitations are be effective may be based on a false tences. Background or experience in Center for Health Statistics as well as always necessa , the hope that con medical care is' not essential for all other offices within the Public Health ry - assumption. To the extent feasible, tinuing experimentation and innovation evaluation should concern itself with contributors in order for them to make Service have unique sources for medi- will lead to dramatic improvements.in all the factors that actually or poten- substantive contributions; the princi. cal care research and evaluation. The ples of evaluation can in many in. task of evaluating the effectiveness medical care is less likely to be real- tially influence effectiveness, as it has ized. been defined for the purposes of eval- stances be transferred from other and efficiency of Regional Medical Pro- uation. These factors include the relia- fields. Many individuals will have to be grams calls for the cooperative effort bility and validity of the medical meas- recruited into the medical care field to of staffs of universities, members of 0 There are several stages in the evo lution of new health care programs, on ures of diagnosis and treatment. In make possible the level and scale of the health professions, and of units of a local, regional, or national level. Ini- settings where such access is feasible, evaluation that is called for. governmental agencies. Only then can tially, decisions are made and imple- such factors should be identified as the requisite talent and competence be mented on the basis of best judg- the objects of evaluation. If this is not Potential sources of professional as. mobilized to provide the data essential ments of those responsible for the istance or consultation include many to local and national policy determi- es- done, programs may be evaluated as Sluepartments in the university: SO- nations which must shape wisely the program. After a program has been highly effective in terms of their opera- tablished, a number of new, unrelated tion and costs, although they may not ciology, Social Psychology, Economics, future of medical care for all our citi- facts begin to influence decisions, but be advancing the actual care of pa- Political Science, Business Admin- zens. in the absence of an organized and tients. istration, Administrative Science, Ed- definitive body of data, the administra- ucational Psychology. Schools of tors of the program require wide lati-, 0 Finally, the question may properly Public Health generally possess high- tude in making decisions because fac- arise whether a particular program is level competence in epidemiology and tual guidelines are still imprecise. The an appropriate one for the area or medical care organization. In several third phase of such programs emerges population to be served. Presumably such Schools, as well as in several 53 Continuing Education and Regional Medical Programs or- should give consideration to these only an additional increment in the ex- between all individuals, groups and reas of interrelated function. It is Prepared by Staff of the Continuing array of activities already un. ganizations involved in continuing edu-a Education Branch of the Division of tensive he region. Difficult judg. meaningless, for example, to design Regional Medical Programs also as derway along with widespread discus- cation int background to the second discussion sion of needs and solutions. Yet there ments will have to be made as to educational programs for physicians in session is cause for thoughtful concern and awhich educational programs will re- the functioning and appropriate use of hard took at past accomplishments ceive priority, for all educational needs intensive care units without consider- Continuing education and training ad, and future prospects, for there are acannot be met at once. Strong consid- ing the education of the other per- dress themselves quite directly to the number of knowledgeable persons who eration to the health needs of the re- sonnel essential for the unit's opera- primary purpose of the Regional Medi- have entertained serious reservations gion should be given in setting these tion as well as the availability of the cal Programs-to make more widely about the effectiveness of current ac- educational priorities. necessary facilities and equipment. It available to the patients of the Nation tivities in continuing education in im- is also wasteful of scarce human and the latest advances in the diagnosis proving patient care. The approach to Design of Education Programs. The de, physical resources to carry out such and treatment of heart disease, cancer, developing truly effective training pro- sign of educational programs to meet programs where they will not be uti- stroke and related diseases. Because grams must be viewed in the broad these needs req u i res considerable lized optimally. the more successful continuing educa- context of health care. creative thought. Based on previous Continuing education by definition im- tion and training programs are often Educational program design takes its experiences, however, some of the im. -plies some continuity to the education- dependent upon cooperative efforts of origins in identification of the educe-portant factors to be considered in al process, yet the continuing educa- a number of individuals and organizes tional needs of the health professional effective educational design can be tion of most individual health person- tions, the creation of regional coopera- -identified. Many educational experi- tive arrangements by the Regional These educational needs in turn have ences which have staying qualities are nel today is characterized by the lack, Medical Programs may provide sign their origins in the health needs of in, characterized by active participation rather than the presence, of continuity. if" dividual patients and in the patterns of of The framework of the Regional Medical cant new opportunities for the develop, medical care and the total health the learner in the learning experience, Programs provides an opportunity for ment of effective continuing education needs and resources of the particular These experiences have also linked program design which can achieve bet- activities. The regional nature of the region. The sequence of educational that participation to the ultimate focus ter continuity. The challenge is to struc- Programs can also provide other assets design commences then with the of the educational process-care of ture programs which relate not only to to continuing education and trainin@ identification of the health needs of the patient. The clinical clerkship, in- current educational needs but which an opportunity for close relation of the population accompanied by an ternship and residency programs in take into consideration the previous teacher and learner in development o.fanalysis of the existing resources to medicine have recognized the irnpor- educational experiences of the partici- programs, convenience and accessi. meet those needs. Out of these con- tance of participation. Judged on this pant. bility of programs, and opportunity to siderations, discrepancies between re, basis, the standard two-day program Consideration must be' given to other build together links between education of sequential lectures may not be the sources and needs become apparent. factors which have inhibited effective and health care. Indeed one of the rea1 most effective mechanism for contin u. The challenge then becomes the de- "' educational activities in the past such potentials of continuing education and sign of methods to meet these dis- ing education. as the problems of time, distance, training within Regional Medical Pro- crepancies. Although health care has become in- commitment of available effort to the grams is the opportunity to integrate Some of these discrepancies can be creasingly complex with resulting re- actual delivery of health care, financial these activities into the larger sphere met by programs in continuing educa- quirements for close collaboration loss, and established habit patterns. of health care which they subserve. tion and training. Often, however, the among specialized personnel, our edu- Modern technology offers potential for Relation of Educational Needs to human resources available within a re- cational programs continue to be de- overcoming some of these problems. Health Needs. Although Regional Medi- gion for continuing education are signed in a manner which suggests The use of television, computers, cal Programs have stimulated addition- scarce. Conservation and appropriate each health professional is functioning teaching machines, or other applica- al attention to the problems of con- utilization of these scarce resources independently. Educational programs tions of modern techniques and hard- tinuing education, this new interest is requires close working relationships designed to meet patients' needs ware is being explored in some places 54 for had direct involvement with education s yed are li mited. One potential resource the in health affairs the potentiality of ind many Regional Medical Programs care. These factors need to be a sa advice, counsel, and training is ring the effective utilization at each step in the process for one to ividuals who have their involvement is very real and are conside relative signifi, modest cadre of ind of these educational tools. The com- understand fully the ultimate established units of research in medi. should be encouraged. ments in this document about design cance of their effect on the cal education in recent years. A re- Cooperative Efforts in Educational Pro- and evaluation are, however, very rele- goal of improved health care. se who source exists in the colleges and grams. In addition to ongoing evalua- ucational programs utilizing The manpower resources of tho -- schools of education throughout the tion and modification of educational vant for ed ri these techniques. By providing an OP- have competencies and expe ence in country graduate activities in programs, consideration must also be use of these educational evaluation as it applies where portunity to integrate the educational research are being carried given to the development of effective specifically to continuing education cooperation among the people, institu- techniques into a total educational t. Although few of these units have d agencies al- program related to the real education- and training in the health professions ou tions, organizations an al needs of the region, the Regional ready involved in the education of Medical Programs can help to avoid the danger that these techniques may health personnel. The development of be developed in isolation from those improved programs requires utilization needs. of their strengths and should, in turn, provide a mechanism for those Educational Evaluation. Even if the de- strengths o expand and grow. Cooper, sign of educational programs gives ative activity in continuing education areful onsideration to the factors and training should become a symbio- c c discussed, one may anticipate that the tic relationship. If possessiveness by resulting programs will not be totally any single group occurs, or if monolithic successful in meeting the educational programs are attempted, the benefits needs. The successes and the failures of symbiosis will be lost to the detri- nlLJSt be evaluated and analyzed to ment of better health care. serve as the basis for appropriate de- The necessity of cooperative efforts for the improvement and cisions about effective continuing education is inher- continued renewal of the educational the nature of our medical sys- Since resources for continuing ent in termined both by the re. activity. tem. it is de education and training are scarce, con- modern medicine and quirements of tinued evaluation of educational effec- the patterns of our society. The Re- tiveness is necessary to assure the gional Medical Prop-ram provides a efficient use of these resources. As mechanism for cooperative relation- discussed above, the ultimate criterion n the medical environs ships betwee of offoctive@ of am dto,!stionpi ag, RP@mimpilp moti*Otmod ilm ooool. o,,,, . , ISO owfoo FMO"T vtsih I Ali, po(41hdiot ON opment and dissemination of new m n of change In th care. There Knowledge and the environment pri- are many components, however, of the effectiveness, including the success in marily concerned with the delivery of reaching the desired audience, effec- health services. Only if both environ- ments are involved and cooperating tiveness of information transfer, effec. will the full impart of continuing edu- tiveness in bringing about behavioral i-,ati(,n and training programs be made change, and the effectiveness of the behavioral change in improving patient 55 The Report of the Surgeon General to the President and the Congress Prepared by staff of the Planning and portunities for major innovations. It is the experience and insight of a wide The fundamental purpose of the Act as Evaluation Branch of the Division of impossible to say with any precision at variety of people concerned with Re- formally stated in Section 900 (b) is: Regional Medical Programs as back- this time what the nature, extent, and gional Medical Programs through a na- ". . to afford to the medical profes- ground to the third discussion session diversity of these medical complexes tional conference. One of the major sions and medical institutions of the will be in the future. We do know that objectives of the Conference is to pro- nation . . . the opportunity of making PREFACE these developments will be closely vide a forum for this purpose and a available to their patients the latest The Report to the President and the watched by the Congress and by the common frame of reference out of advances in the diagnosis and treat- Congress is set forth as a specific re- American people. The Committee does which an additional input of ideas can ment of these diseases." quirement in Section 908 of the Act expect that, as experience is gained, be secured before drafting the report. B. Prescribed Mechanism for Attain- authorizing support for Regional Medi. the various aspects of the program IDENTIFIED ISSUES ment of Objective cal Programs, as follows: may alter to deal with new problems Divisional Staff and the Ad Hoc Com- The prescribed methodology is region- "On or before June 30, 1967, the Sur- and opportunities and to extend the mittee have identified certain items al cooperative arrangements among coverage of the complexes into new geon General, after consultation with communities and situations. The im- ano issues. These points are set forth medical schools, research institutions, the Council, shall submit to the Secre- pressive endorsements of the concept on the following pages for discussion and hospitals, with broad based advi- tary for transmission to the President give a basis for launching the pro- during the meeting on January 17. In sory committees to insure commit- and then to the Congress, a report of gram as soon as possible, but the final addition, conference participants are ment to broad regional needs and the activities under this title together encouraged to identify and discuss is- guard against the domination of any with (1) a statement of the relationship form in all its particulars is not and sues and topics not included in this individual institution or group. between Federal financing and financ- cannot be clear at this time. Therefore, paper. Ill. Progress Report ing from other sources of the activities the need for careful and continuous re- In accordance with the specifications undertaken pursuant to this title, (2) evaluation assumes a special import- 1. Background of the Report an appraisal of the activities assisted ance for this program. The Comnlittee There will be brief discussion of broad in Section 908, this Section will report under this title in the light of their urges that the program be adminis. trends in science, medicine and educa- on 0 activities supported under the tered at all times with a view toward the program, 0 the relationship between effectiveness in carrying out the rpur- identification of productive modifica- tion, and social and economic aspects ,Federal financing and financing from poses of this title, and (3) recommen- tions for submission to the Congres leading to the enactment of Public Law other sources of the activities under- dations with respect to extension or s 89-239. The legislative history will be modification of this title in the light when the extension is considered in summarized including the Administra- taken, and 0 an appraisal of activities thereof." the future." tion's proposal (S. 590 and H.R. 3140), assisted in the light of their effective- the Senate and House Hearings, and ness, The purpose and importance of this INITIAL APPROACH their respective Reports. A. Activities under the Program provision was clearly stated in the fOl- The Report is a staff responsibility of 1. Chronology of implementation [owing excerpt from the related Report the Division of Regional Medical Pro- 11. The Nature and Purpose of Public 0 Bill signed into Law' - October, of the Senate Committee on Labor and grams. A special Ad Hoc Committee Law 89-239 1965. Public Welfare: of leaders in the fields of health, edu- A. Basic Objective and Purpose 0 First Council meeting - December, "The bill calls for reevaluation of the cation and community affairs was es- Primary objective is to ensure that per- 1965. program and the submission of a re. tablished to furnish expert advice. sons throughout the country have the 0 Division of Regional Medical Pro- port to the Congress by June 30, 1967. The Committee held three meetings benefits of medical scientific advances grams established at NIH - February, The Committee views this requirement between September and November of in heart, cancer, stroke and related 1966. for accomplishments and recommenda- 1966 to help shape the approach to diseases. Attainment of this objective is 0 Firstapplicationsfor.planninggrants tions of further development as an im- the Report and identify issues which impeded by the gap that exists be- received - April, 1966. portant and integral part of this legis- require consideration. In addition, it tween scientific advance and day-to- 0 First awards for planning grants - lation. This program provides the op- was considered important to obtain day practice in parts of the Nation. June,1966. 56 0 First applications for operational 3. Estimates of type of non-federal re- grants received - October, 1966. sources likely to be made available in 0 First national conference on Region- the future al Medical Programs - January, 1967. 4. Policies and procedures for assuring diversification of support 2. Basic data concerning applications C. Appraisal of Effectiveness received and approved; amount of 1. Methods of evaluation being de- awards; population served; participat- veloped and applied by Regional Medi- ing organizations; staffing; nature and cal Programs variety of cooperative arrangements; 2. Data on scope of cooperative ar- feasibility and other studies under- rangements taken, etc. 3. Approaches being developed to 3. Analysis of Major Planning Activities measure changes in resources and facilities that will extend "opportuni- 1) Organization and staffing of plan- ties" for applying the latest advances ning unit. 4. Approaches being developed to de- <> Collection and analysis of data on termine impact of programs on the resources, problems and needs. diagnosis and treatment of heart dis- Strengthening of communications and relationships among health re- ease, cancer and stroke 5. Examples of "critical incidents" in sources. the development of Regional Medical Development of feasibility studies Programs and proposals for priority operational IV. Problems and Policy Issues Requir- Arrangements for continued plan- ing Consideration This section is most important since ning. recommendations for extension and 4. Analysis of Major Activities of Oper- modification of the law will arise from ational Programs the problems and policy issues which have been identified. Inclusion of an 5. Interregional Developments item for discussion in the report does Multi-State (New England, Mid- not necessarily mean that a change in West, Rocky Mountain area) law is indicated. the Intrastate (New York, California) A. Continuation of Program B. Relationship of Federal and Non- There is considerable and compelling Federal Financing evidence of the effectiveness of the 1. Resources made available from non- Act in bringing about cooperative re- federal sources for pre-planning prior gional efforts among the major health to grant awards resources for the purposes specified in 2. Resources made available from non. the Act. Attainment of the fundamen. federal sources for planning and opera- tal purpose of assisting all physicians tions after grant awards and medical institutions to bring the 57 benefits of medical research advances space for educational programs; acute process and should not take over total terials, standardization of data collec. to their patients appears realistic on shortages of patient care and support- support for the application of all medi- tion, refinement of evaluation proced- the basis of early experienciD. While ing facilities have required immediate cal scientific advances. ures. The available methods of financ- current legislative practice makes it attention. The same conditions gener, Congress has evinced interest in the ing of these needed services are often unlikely that a new authorization will ally make it impossible to meet the amount of non-Federal resources made awkward and inadequate. not include a time limit, the Regional needs for space for continuing educa- available to these programs as an in- It has been suggested that modifica- Medical Program effort should be es- tion programs through renovation and dex of local commitment and support tion of the Act to permit grants di- tablished as a continuing program. remodeling. and as a reflection of budgetary reali- rectly for these "support" activities Such a long-term commitment is par- During the conduct of feasibility stud- ties. It has been emphasized that may be desirable in order to facilitate ticularly important in order to enlist ies and pilot projects, Regional Medi- diversification of fund support will en- the development of individual Regional the participation of all institutions and cal Programs have been forced to rent hance local initiative and control. Medical Programs. Proposals for such to provide a sound basis for recruit- space,outside the hospital for the con- In reviewing grant requests, primary support would have to be directly re- ment of high caliber manpower. duct of educational programs and the attention is given to the extent and lated to the achievement of the basic S. Construction of New Facilities use of the educational staff. This aP- nature of local support. Continuing purposes of Public Law 89-239 and The original Administration proposals proach is not only costly but it consideration will be focused on the would be made only after review and for authority to support Regional Medi- significantly reduces the impact of policies and procedures that are em- approval by the National Advisory cal Programs included provision for these efforts. It is more difficult for ployed locally for ensuring diversifica- Council on Regional Medical Programs. grant assistance to aid both new con- many medical practitioners and allied tion of resources for Regional Medical E. Interpretation of Act struction and renovation. This provi- personnel to participate. It is impossi. Programs. It has been felt that a poli- A keynote of Public Law 89-239, in sion was amended in the Congress to ble for certain desirable programs to cy placing responsibility at the local oth its legislative and administrative limit the definition of "construction" be organized, particularly those involv- level for assuring balanced, diversified D so that only renovation and remodel- ing demonstrations of patient care. support is a more effective and aDDro- aspects, has been flexibility of ap- proach. The primary purpose of this ing costs were eligible for support. The The issue of matching requirements priate approach than a rigid matching approach is to place maximum respon- Report of the House Committee on In- for construction also needs further requirement, particularly in view of the S]Diiity on local leadership to develop terstate Commerce stated that "the consideration. Reports indicate that cooperative and innovative nature of appropriate mechanisms, plans and lack of this authority for new construc- many community hospitals have insur- this new program. programs. Administrative guidelines tion should create no serious problems mountable difficulties in raising funds D. Inter-Regional Support Activities and policies have encouraged local ini- during the 3 years authorized in this for the construction of facilities for legislation and when a request is ma a continuing education. There is a Public Law 89-239 authorizes grants tiative while, at the same time, ensur- for extension of this legislation in tne danger that a -rigid matching require- only for the planning and operations ing the established statuto 'ry purposes future, the committee will review this ment in this respect will distort or im- of individual Regional Medical Pro- are pursued. Instead of rigid national question again. . . ." pede progress toward the achievement grams. No consideration was given directives, heavy reliance has been Experience to date during the development of the legisi@- placed upon the review and evaluation has identified of the program's purposes. number of areas in which authority to tion to other types of grant support. of local program proposals by non-Fe- assist new construction is essential to C. Relationship of Federal and Non. deral consultant groups, both at the Reports have indicated that certain re- the development of Regional Medical Federal Funding sources and activities to facilitate and regional level through the Regional Ad- Programs. Priority needs have been re- Regional Medical Programs provide, support the development of Reizional v'sory Group and at the Federal level ported for space in community hospi- through cooperative arrangements, a Medical Programs may, in some in- by an expert Review Committee and tals to conduct continuing education broad systematic framework for plan- stances, best be developed on an the National Advisory Council on Re- programs and to carry on demon- ning and action. It is recognized that inter-regional basis, e.g., training of gional Medical Programs. strations of patient care. Most commu- the Federal grant funds should not continuing education and other leader- Specific examples of flexibility of ap- nity hospitals do not include adequate finance all the needs identified in this ship staff, preparation of teaching ma- proach are: 58 1) The fundamental recognition that ministration proposal requested au- operative relationships among the ma- attention must be given to developing thority to make grants to encourage jor health resources in the region. and maintaining a sound foundation of programs of regional cooperation These activities are generally generic clinical capability upon which more among the major health resources for by nature and consequently have not sophisticated programs can be built. heart disease, cancer, stroke, and other significantly involved problems of cate- For example, it is recognized that in- major diseases. The law as enacted gorical definition. In most cases, in creased accessibility to the most recent provided for grants to encourage pro- order to plan effectively for heart dis- advances in cancer treatment is in- grams of regional cooperation among ease, cancer, and stroke, it has @een effective if there are serious gaps in the major health resources for heart found necessary to consider at times basic diagnostic and treatment capa- disease, cancer, stroke and related the entire spectrum of resources avail- bilities. Similarly, it is recognized that diseases. able for personal health services. "improved diagnostic and treatment The categorical emphasis of the pro- However, the emergence of the opera- capability." must necessarily include gram has been widely discussed. Some tional phase of the program will put a preventive and rehabilitation activities. have felt that it is not prudent or prac- more intensive focus on its categorical 2) The establishment of new organize. tical to develop Regional Programs on purposes. Only projects that can be tional mechanisms to reflect the co- a categorical basis. Others have ar- shown to have direct significance for operative relationships required in the gued that the efforts of the program combating heart disease, cancer, stroke program. One expression of this devel- should be exclusively focused on and related diseases can be assisted opment is the organization of new non- immediate measures to reduce losses with Regional Medical Program grant profit agencies to serve as the co. from the three "killer diseases"; they funds. ordinating agency for the Regional have pointed out that the highly corn' The experiences of the Regional Medi- Program. These new arrangements can plex skills and facilities required to ap- cal Programs will be especially impor- involve a spectrum of new administra- ply the recent scientific gains against tant in determining what modifica- tive and fiscal problems that require these categorical diseases make it tions, if any, are necessary or innovation and inventiveness for their particularly desirable to organize such desirable on this issue in the legisia- solution. efforts on a regional basis. Others ti,e authorization. The impact of the On the basis of experiences to date, it have suggested that the scope of the categorical limitations on the potential appears that flexibility of approach has three diseases and related diseases is of the Regional Medical Programs to facilitated progress toward accomplish- so broad that their control necessarily contribute most effectively to improved ment of the aims of the program. requires attention to fundamental health of the people and the best use However, reports have indicated that, questions of manpower and facilities. of available manpower and facilities in some instances, unreasonably rigid The initial period of program develop- needs to be determined. Similarly, the or lax interpretations of the Act and ment has provided opportunities to best ways of facilitating the diffusion test these viewpoints through a variety of knowledge concerning the diagnosis the Guidelines have complicated un- f experiences. and treatment of heart disease, cancer, derstanding and action. The question 0 at issue is whether portions of the Act During the planning phase the major stroke and related diseases needs to or Guidelines need to be clarified or activities undertaken by Regional Medi- be identified. These discussions must amplified to insure needed flexibility. cal Programs have involved the estab- take into account the fact that the lishment of a planning staff, the initia- legislative proposal for extension of F. Categorical Emphasis tion of studies to obtain the basic data Public Law 89-239 will probably request The legislative history of Public Law concerning pertinent health needs and authorization for the program through 89-239 indicates that the original Ad- resources and the development of co- 1973. 59 60 Section IV-Group Discussions REPORTS prepared by four group dis- The registrants participated in three cussion leaders, each of whom repre- discussion sessions held during the sents a different health interest, and Conference. The sessions served as a SUMMARY report by Division staff on forum in which participants could free- thoughts and attitudes expressed in ly express their thoughts on the topics the group discussions regarding key which had been underscored in the Is- issues of the Conference sue Papers and in the presentations of the principal speakers. 61 REPORT: No Prospects For Introduction "Instant" Regional Medical Programs Deans of medical schools, practicing Donald J. Caseley, M.D. referrals, which were all accomplished MONDAY MORNING AND AFTERNOON, physicians, regional information offi- Medical Director, Research and with no more than relatively modest JANUARY 16 philanthropic support. The twenty-five discussion groups were cers, hospital administrators, and other Educational Hospitals and structured so that the health profes- categorical groups met for the same Associate Dean, College of Medicine Discussion group productivity can be University of Illinois sions, public and private agencies, purpose. measured in terms of both the matters practicing physicians, and citizen mem' The reports by four group discussion Chicago, Illinois discussed and those that, although im- portant, never managed to surface. bers of Regional Advisory Groups were leaders attempt to encapsule the con- represented. The groups averaged everal ingredients for a viable This exercise covered rather well most tent and preserve the tenor of the ses- Of the s twenty persons. sions they chaired. A staff summary of and productive group discussion, none of the principal subject areas upon A typical group included representatives the problems and policy issues is more indispensable than to have at which the conference concerns re. from fifteen States, six Regional Med"brought up during the discussion ses- least one participant who has had real- volved. Cal Programs, and the Advisory Groups sions is also included. life, three-dimensional experience with of three of these Programs as well as the subject under examination. Group On the issue most vital at this time the Program Coordinators of two four was more than thrice blessed. whether or not the regional medical others. The same group included three This optimistic and enthusiastic group program concept should survive medical school deans, a private practi- included a former USPHS surgeon gen- there was no dissent from the position tioner, a hospital administrator, a mem- eral, highly sophisticated in health that it was far too early to make ber of the National Advisory Council on care planning; a former assistant to definitive judgments which would sup- Regional Medical Programs, the public the secretary of the Department of port a phaseout of the effort. It was information officer from a State uni- Health, Education, and Welfare, who well recognized that an "action-orient- versity medical center, a member of a had been deeply involved in the devel. ed" Congress and a highly expectant State board of health, a staff member opment of the legislative program public were geared to the "instant pro- from an agency of the Department of under discussion; and a participant gram" concept and that the energy in- Health, Education, and Welfare, and a who had been intimately involved, for put requirements to achieve true mo- representative from a voluntary health years, in a successful, ongoing proto- mentum were far too great to warrant agency. type regional medical program. His comprehensive appraisal for at least The participants brought to their group skillful and objective account of the three years. Some felt that 1975 would discussions attitudes reflecting their operation of the Bingham Associates, be an optimum target date for overall respective regions, professions, and in- a regional plan to relate small, rural appraisal for purposes of continuing or stitutions or agencies. In the sessions Northern New England hospitals to a phasing out the program. they spoke with candor about the is- metropolitan medical center, produced sues of the Conference and in the en- an affirmative climate for the discus- How to Change Without Changing? suing exchange brought out other mat- sions. A real tone of optimism and ex- One reason for the requirement for an ters of concern. citement was injected into the pro- extended period of trial for the pro- TUESDAY MORNING, JANUARY 17 ceedings by the fact that for more gram needed discussion in depth, but For the final session the structure of than two decades a voluntary arrange- was well repressed. This had to do the groups was altered so that partici- ment had been in effect for physician with the very basic nature of a concept pants of many groups shared the post-graduate education, improve- that aims at improved patient care and same interests. In this way, for exam- ments in professional staffing, periodic implies experimenting with different ple, Program Coordinators had the op- exchanges of key personnel, upgrading methods for the delivery of health portunity to discuss problems of mu- of technical personnel and services, services, but there seemed to be an tual concern and to share ideas. and effective mechanisms for patient almost instinctive desire to avoid con- 62 fronting this essential component of the operational phase was so indistinct the law with specific funding mecha- the program in the face of the lan. that the addition of a facility construc- nisms for effective implementation. guage of the law, "to accomplish tion component would further becloud The categorical emphasis of the Re- these ends without interfering with the theissues. gional Medical Program seemed to be patterns . . . of patient care or profes- sional practice." A careful review of Federal and Non-Federal Funding an area where attitudes of the discus- sants reflected with remarkable preci- the intent of the Congress to upgrade When the relationship of federal and sion' the nature of their professional the operational effectiveness of the non-federal funding was discussed the backgrounds. The participants whose health care establishment and, at the usual doubts were expressed about the occupational orientation was toward same time, declare a state of perma- slim chances for new outlays by state program planning for health care felt nent immunity against any change for and municipal governmental units for that casting regional arrangements in the present methods of delivering any reason, even though this program a disease oriented manner would be health services could have been a neat might well prove itself to be most use, virtually self-defeating. Their own plan- and lasting contribution to the confer, ful and productive. The group did not ning in the program had virtually 19- ence. If experimentation with different appear to be sensitive to the fact that nored the categories in favor of health means to organize and deliver health patient care, as a process, is presently care of patients as a comprehensive services is desirable, the program being funded from a variety of sources process. The participants whose back- should indeed be continued and aand with high dollar outlays' By rea- ground was primarily in the private guaranteed life expectancy of the law ligning some of the funds into some, practice sector were overtly apprehen- should be such that an appraisal of what different patterns, the necessary sive when total health care was sug- the results would be valid from the local and regional resources to blend gested as the framework for regional standpoint of time as well as content. with federal funding might well be- medical program planning. It would Construction come available without the need to de- probably be fair to say that some of Experience over the past decade with velop new local funding sources. them would have felt a bit more com- a host of other programs would lead fortable if a single category, such as one to assume that attitudes of the Inter-Regionai Relationships cancer, had been made the central fo- participants would be almost uniformly one area where there was total una. cus of the planning process. Specula- in favor of generous federal funding nimity was the need for the law to be tion on the part of the majority of the for construction of new facilities. This either amended or reinterpreted with group centered around the distinct assumption proved to be in error. Sev- respect to the relationships and activi- Possibility that when the'real core, is- eral good and valid reasons were ad- ties which are sure to develop between sue was faced, i.e., the operational vanced for postponing this issue for aregions. Patient care services for popu- phase of the program, it would be vir- couple of years. The one most strongly lation groups normally follow tradition- tually impossible to maintain any real espoused was that as some of the al trading area lines. Because so many semblance of a categorical approach. strong suspicions of one or more of of these are at complete variance with the involved groups are beginning to political subdivision boundaries, sub. Continuing Education abate somewhat, it would be the stantial efforts will be necessary to The nature of the discussion on con- height of folly to reintroduce this fea- maintain productive and smooth work- tinuing education has been purposely ture, which had raised serious doubts ing inter-regional arrangements. This left until the last, because this subject about the earlier versions of the bill. It aspect of the Regional Medical Pro- was interlaced throughout the three was clear from the discussions that gram was regarded as sufficiently im- sessions and seemed to be the one on the nature of the program direction in portant to warrant an amendment to which most of the participants claimed 63 REPORT: Regional Medical Program Coordinators I Edmund D. Pellegrino, M.D. there was a real need for construction at least a bit of expertise and concern- Flexibility-the Real Challenge Director, Medical Center and Professor of facilities at community hospitals to ing which there were some strong and Withal, the discussions pinpointed the and Chairman, Department of Medicine implement programs of continuing under- flexibility which is intrinsic in the pro- ether this should come fixed feelings. it is entirely state university of New York at education. Wh standable why groups, such as this grams and served to assure partici- area and Stony Brook from Hill-Burton funds, the hospital it- one, should seize on such an pants from widely separated regions of Member, National Advisory Council on self, or a revised RMP law was not tease away at it, if not continuously, the country that the potential for ' agreed upon and no firm recommen- 'M' Regional Medical Programs and at least repeatedly. Continuing educa- aginative and innovative thinking at tion was made. The impression was tion is a subject that is uppermost in the local and regional level is the real member, Ad Hoc Committee for the da Report to the President and the clear that if the concerns of the prac- the minds of both academicians and challenge of the legislation. The con- Congress ticing profession could be allayed, con- practitioners, for each is forever re. ould indeed satisfy versations reflected further a sense of struction funds w minding the other that there should be relief that no single area of the The discussion in group 5 was con' an important functional need not pres- more to it and it should be better. The country had either a corner on plan' ditioned somewhat by its composition- ently met by rental, renovation or Hill- chairman attempted to probe precisely ning competence or any magic potions it consisted of the coordinators Of all Burton funds. what was meant by "continuing educa- that could produce a live, effective, regional programs approved to date. tion," what its content should be, how "instant" regional medical program. The opinions expressed were based in Relationship of Regional Medical content should be determined and More th,an anything else, the confer- some operating experience, however Programs and Comprehensive Health tested for validity, by whom and how ence brought together individuals with slight, and covered most areas of the Planning Legislation often reviewed. it was further asked, widely diversified backgrounds, objec- country. A matter of obvious concern for all the "What is the proper setting for this edu. tives, attitudes and motivations for a coordinators was the present and fu- cational process? How will the results tools and day and a half of ventilation, idea ex- Construction Funds ture relationship of P.L. 89-239 and be appraised? What kinds of speculative conversation. The c ordinators did not exhibit a con- P.L. 89-749. Very few were familiar techniques are needed? How can they Change and 0 fwith the details of Comprehensive best be utilized?" There was as wide aAs the chairman said in summarizing sensus on the important matter o disparity in responses to these ques- the conference, "Regional medical pro- construction funds as part of any re- Health Planning legislation. One urgent tions, in this setting, as there has grams have brought together strange vision of P.L. 89-239. Most were need seemed to be for each coordina- been on the national scene where it bedfellows; however, they are still a bit greed that the housing of central fa- tor to have as much information as may not be much of an overstatement reluctant to turn out the lights." cilities and administrative staff was asoon as it is available. The group ap- to call present efforts something of an functional necessity in regional pro- parently felt that much depends upon educational wasteland. grams. But, rather firm differences the agency selected to administer P.L. in spite of the generally expressed were expressed on the matter of how 89-749 in any state. In those regions doubts as to both the goals and the to finance such facilities and where to involving cooperative arrangements techniques of contemporary continuing place them. There were clear indica- which cross state lines, there was gen- education 'Programs, many of the par- tions that the relationships fostered uine concern that confusion and ticipants were willing, even eager, to thus far between medical schools and conflict would occur if Comprehensive settle most of the efforts, funds and practitioners by RMP were still rather Health Planning were assigned to state precarious. Construction of an RMP health departments. hopes for, the regional medical pro- gram concept on this one area, which facility on a medical school campus The need to coordinate the efforts of both the medical education establish- would reinforce the fears of the prac- these two pieces of legislation at the ment and practitioners readily agree is ticing profession that the program will national level was seen by all. Further important and essentially n6nthreaten- ecome medical center dominated. questions concerned better definitions ing to existing patterns of the delivery Both practitioners and medical school of relationships of Regional Medical of health services. representatives, however, felt that Programs to all Public Health Service 64 programs and to Hill-Burton programs. ongoing evaluation of methods and of matters of immediate concern-like Inter-Regional Coordination Most coordinators seemed to feel that Procedure. In addition, such meetings developments in CHP, awarding of Some form of inter-regional coordi- their present efforts under Regional would impart some sense of unity to grants, etc.-was suggested and wel- nation was considered desirable by Medical Programs would eventually the entire program and facilitate inter- comed by all. any of the coordinators. Some have regional cooperation. A meeting between representatives of m evolve into comprehensive planning already engaged in such meetings with even though the present effort is cate- The program coordinators expressed the Comprehensive Health Planning programs in contiguous areas. Support gorical. As "related diseases" are the need for an organ of communica- group and the program coordinators for other inter-regional activities be- gradually included in RMP planning tion with the RMP Washington staff. A was strongly urged and is recommend- sides meetings was acknowledged by and operation, they thought some newsletter informing all coordinators ed unanimously to the staff of RMP. means of interdigitating with CHP some. Such support might be used to would become essential at local as encourage inter-regional evaluation well as national levels. efforts to enable the sharing of scarce Some of the coordinators indicated personnel and to foster comparability I I of computer programs and information that in their states RMP and CHP might be handled by the same body. networks. Others suggested interlocking boards as providing a reasonable means of Categoric@ Emphasis communication and coordination. The present categorical emphasis of One view held that RMP should be lim- RMP apparently has not produced any ited to demonstration and that it serious problems to this point. Most should turn its programs over to CHP coordinators felt that at this time when they are fully operational. An- there is sufficient flexibility to permit other opinion stressed the importance of RMP even in the presence of a well rather broad planning. developed CHP. Under these circum- No strong impressions were recorded stances, many said, the categorical ap- on the functions and responsibilities of proach would be an advantage since it Regional Advisory Groups. Apparently covers a more manageable and easily A the coordinators are feeling their way identified set of disorders. and trying to meet the requirements of The coordinators were unanimous on a the legislation in a variety of ways number of points: suited to local requirements. There was general satisfaction with the Increased Communication for law as now drafted and a general con- Unified Cooperation Action sensus that the program was too new All expressed a need for continuing to sustain drastic changes. The gener- contact with each other under the aus- al nature of the present law permits pices of the RMP staff. Regular meet- the high degree of flexibility which ings were recommended to provide each coordinator apparently feels is each coordinator with the benefit of essential in evolving a program which experiences in other parts of the meets the specific needs of a particu- country and afford a ready means of lar region. 65 REPORT- Practicing Physicians Bruce W. Everist, M.D. practitioner for continuing education ious about the ways and means of might be 10 years ahead of its time. Green Clinic seemed to be the key issue as seen by evaluation. No one mentioned the pos- Others felt that we should wait until Ruston, Louisiana this group. They felt that this was a sibfe invasion of the privacy of prac- the medical manpower situation had Member, National Advisory Council on more serious problem for physicians tice and it seemed the paramount is- improved before continuing the pro- Regional Medical Programs and than for paramedical personnel where sue was improvement in patient care. gram. Member, Ad Hoc Committee for the motivation can more easily be sup- -federa f nancing Report to the President and the plied. The group felt funds for training A less surprising, but unexpected, turn The question of non I i Congress paramedical personnel were a neces- of the discussion was toward the dol- was brought up briefly. It was felt by sity. lar value of the program. The group several that local initiative and sharing dealt with the problem unemotionally of cost was a superior arrangement to Discussion group 13 was made up, in Cooperative Arrangements and reiterated the need to show the 100% grants. general, of doctors in the private prac- Cooperative arrangements were men- economic advantages of this program There was a near consensus on the tice of medicine with strong repre- over others. Several felt that the desig- inadvisability of changing the law in tioned by several, noting that this law nation of regions allowed for better ad- sentation by the presidents of organi- has given impetus to many coopera- any important area at this time. The zations representing men in practice. ministration of the program and th!t group felt that it was too early to give Most of the discussants had come to tive arrangements not previously made. the federal government should voucn- a valid judgment and that they would Washington to criticize, the program, Several had noted the frequency of safe quality control. like to see the law continued long meetings among health officials, hospi- not to praise it. Initially, there was the tal administrators, practicing physicians enough to make a proper evaluation. usual ritual of damning all federal pro- and lay health organizations. The Categorical Emphasis In general, they felt that the law as it grams but in this group it was carried demonstrations of patient care section The categorical emphasis of the pro- is parallels other federal programs that on with more ceremony than meaning. of the law was applauded. The men in gram seemed agreeable to most of the are directed in large part toward di- Most of the group had a clear idea of practice felt this was still the best discussants. The views expressed were rectly affecting patient care, rather what the program is about. A minority known method of continuing education. those relating to a need for limited than indirectly affecting it through had a distorted view. and workable programs in the disease research. Pervading the meeting was the overall Evaluation categories cited in the law. In summary, the group was in favor of feeling that though those present were A surprising aspect of the discussion extending the law virtually unchanged. certainly critical of the program they was the sophistication and concern rel- Construction They were not in favor of a request for were also cognizant of a need for ative to evaluation of the program. The majority of the group was not in construction funds. They were con- change and were willing to consider Most felt that an unexamined program favor of requesting construction funds cerned about program evaluation, the any reasonable proposal. The con- would be worthless and that meticu. at this time. The reasons were sever- co.st dollar, and new ways to motivate tributions to the discussion were con. lous care should go into new ways and al, i.e., too expensive, adequacy of private practitioners toward continuing cerned with the major problems of the means of evaluation, and that the re- present construction authority, the fear education. program and scant attention was paid suits of each region's experiences of a change in the emphasis of the to petty issues and personal idiosyn- should be shared by all. The majorit@ program, and the quality of patient crasies. felt that the program must be provea valid before long term extension can care should have priority over build Continuing Education be advised. On the other hand, it was ings. Continuing education was discussed at agreed that several years should length by the group and though nearly elapse after operational programs are Other Items all felt that it was needed, no one under way before a pertinent analysis Some general philosophic questions seemed to have a clear idea of meth- can be made. No one in the group arose. The question of timing was dis- odology. Motivation of the private seemed particularly concerned or anx- cussed. Some felt that this program 66 REPORT: Interpretation and Administration of the Act Paul M. Ellwood, Jr., M.D. pered by knowledge that few programs the categories be hardened rather than Executive Director had full-time staff, acknowledged lead- softened? It might be speculated that American Rehabilitation Foundation ers, or time to develop agreement on there was unspoken and perhaps naive and Clinical Associate Professor of real or tentative plans. Even with the belief that greater categorization just Physical Medicine and Rehabilitation passage of time and with the emer- couldn't happen. Clinical Associate Professor of gence of structure and leadership it Neurology and Pediatrics must be assumed that highly success- Money, Sharing, and Continuity University of Minnesota ful new regional arrangements for the Payment mechanisms outside Regional Minneapolis, Minnesota diseases under attack will be rare Medical Programs do not exist for events. It would therefore seem wise starting or sustaining a program of to construct a superb educational and this scope. Money as an incentive to The flexibility that is evident in the intelligence system to spot these valu' begin and to continue will be neces- enabling legislation and the initial ad- able rare events as they emerge and sa ry. ministration of the Regional Medical 1 to rapidly permit others to hitchhike Program for Heart Disease, Cancer i, on the originators' successes. If per- There was general support for the and Stroke apparently is conducive to massiveness is next to godliness, so is ideal of a partnership between the pri- individual initiative and hopefully, in- plagiarism next to originality- vate and public sectors in financing novative solutions in the several re- the Regional Medical Programs. Some gional programs. The participants ex- Categorical Emphasis: "We can live expressed skepticism that private sup- pressed satisfaction, even enthusiasm, with it if you don't enforce it." port would be more than token for the permissive features of the pro- The Regional Programs' avowed pur_ amounts until ideas proved themselves gram. If there was any manifest anx- pose of breaking down old inhibitions @nd .look their place along with other iety about the present approach it to the rapid diffusion and application Tunctional elements of the health care came from some allied health profes- system. sions and voluntary health agencies of discovery to everyday medical care who would advocate the use of guide- coupled with the programs' retention The medical school deans in particular lines or regulations to assure inclusion of hardened categorical disease em. were outspokenly reluctant to start a of their particular group. phasis may seem inconsistent. It program without some assurance of would indeed be inconsistent were it continuing but not necessarily spiraling At this admittedly early stage in the not for enlightened administration of financial support. life of the program, group 6 demon- the Regional Programs thus far. Our strated few if any tangible evidences group did not dispute the political, so- Random but Important Thoughts of the possible benefits of the permis- cial, or perhaps even the biological Information systems are critical to the sive approach in the form of truly wisdom of focusing this effort on program. The contents of the Blue creative regional planning. None of the cancer, heart disease and stroke. They Cross information system are available programs represented defined specific didn't wholeheartedly support it either to the program. integrating methodology or concepts -they accepted it. They accepted it There is not such a great disparity be- that held promise of delivering on the on the premise that this is a realistic tween the physician and new methods original vision of regional arrange- way to achieve a difficult objective. as there is between the needs of peo- ments, It is important to recognize the con- ple and the demand for medical care. Creativity text in which this endorsement was given. It was given passively, without This estimate must be strongly tem- consideration of the question: Should 67 Staff Summary Group Ditcussions: funding for Regional Medical Programs the regions. The group felt that such which has not yet been laid to rest, Problems and Policy Issues seemed high. Some misunderstanding allocation is necessary in order for and accentuate the town-gown split. 0 Continuation of the Program of the program was also evident, as each region to receive a fair share of Others felt that construction needs 0 Construction of New Facilities fears were expressed concerning the available Federal funds. could be adequately met under present 0 Relationship of Federal and Non- development of regional medical "cen- -programs ' through changes in existing ,d Nearly every group discussing the top Federal Funding ters" to which patients wou be ic related continuation of the progra mauthorities, or through more extensive 0 Inter-Regional Support Activities directed. to (1) the need to resolve the relation- use of the construction possibilities 0 Interpretation of the Act At one session there was extensive ship betwen Comprehensive Health under the present RMP authority. 0 Categorical Emphasis discussion of the need for continuing Planning (P.L. 89-749) and Regional Among those who favored construction planning activities as part of the Medical Programs; and (2) whether the authority, either now or in the future, Continuation of the Program operational phase of regional pro- scope of Regional Medical Programs the need was recognized for specific Discussion of this issue focused on the grams. There was uncertainty about should be categorical or comprehen- facilities which fell into four broad progress made in the development of long-term support for planning activi- sive. categories: cooperative arrangements, and on the ties in contrast to "action" programs. 0 For continuing education and train- potential for future progress. The con. It was stated that rushing into the Construction of New Facilities ing purposes. The needs of community sensus seemed to be that although the operational phase of a program with- Comments on the need for construc- hospitals in this regard were particu- ultimate effectiveness of the program out careful planning could prove detri- tion authority covered a wide spec- larly stressed and included the up- cannot be accurately determined at mental in the long run. trum. No clear-cut major@ "for" or grading and expansion of laboratory this early stage, progress to date ap- 0 the as.sumption that Congress will "against" construction emerged. This facilities to be used in training para- n pears promising and that the . program extend the life of Regional Medical issue clearly posed a dilemma for medical personnel. However, needs of has great potential. The discussions Programs, several factors were dis- many. Some of those who saw a clear medical schools for postgraduate facili- concerning current needs and desirable cussed as being important to its suc- need for and philosophically favored ties were also mentioned since no programs indicated there should be a cess: construction, argued against it on money is available for these under continuation of the program. 0 Advisory Committees must be deep- pragmatic grounds. They felt that plan. existing programs. It was generally felt that the present ly interested and actively involved. ning was not far enough along across 0 For specialized facilities for demon- 3-year authorization will not provide 0 Regional programs must not be re- the country to build a good case for stration purposes necessary for both enough time to put adequate regional garded as merely a means of setting such authority. Some felt that a clear continuing education and up-grading programs into operation. It was point- up medical complexes. idea of the types of facilities which will of care. ed out several times that wit h only two 0 Active participation of practicing be needed when programs are estab- 0 For central or core facilities such as years of the present program remain- physicians is essential. liihed has not been developed. Others computer and tefe-communication ing, it is difficult to recruit personnel 0 Proprietary hospitals should be in- had reservations in connection with centers. of the quality needed to insure the cluded in the program. how this would affect the funding of 0 For housing administrative staff. success of regional programs. Several 0 Adequate support must be acquired other construction programs such as Most of the alternatives to RMP con- statements were made to the effect from State and private sources. Hill-Burton and how Regional Medical struction were viewed as providing on- that it will be 5 to 7 years before Re- n one group it was emphatically stat- Programs would coordinate with them. ly partial answers. For example: gional Medical Programs will affect pa- tient care widely. ed that local advisory groups cannot References were made by those not fa- 0 Renovation is frequently not possi' effectively establish priorities or make voring separate RMP construction au- ble. Many hospitals, especially smaller Some practicing physicians felt that decisions without some indication of thority at this time to the fears "con- ones, do not have any "excess" space' the gap between medical knowledge the dollar amount available to the re. struction" would arouse on the part of The same is true, though to a lesser and practice had been exaggerated, gion. It was recommended that mini- practitioners and community hospitals. extent, for certain medical schools- and that the contemplated level of mum operational funds be allocated to It could revive the "centers" concept, new ones and the "have not's." 68 0 Rental might in large measure meet become self-supporting. This would ments might be destroyed if these the needs for office space, but not for not only bring in local funds, but were required. The concept of a flexi- specialized facilities. would phase demonstration projects ble, balanced support mechanism 0 Hill-Burton is not really a viable al. into the overall system of local health seemed more desirable. If construction ternative-the funds are insufficient services. Concern was expressed, how- authority was approved for the pro- and matching would be a very serious ever, that support might be withdrawn gram, then more specific requirements obstacle. prematurely and projects abandoned. relating to construction might be de- In this same connection the apprehen- veloped. In sum, the reactions of the discussion sion was expressed that Regional Medi- groups were mixed. Many Conference cal Programs might prime the pump Inter-Regional Support Activities participants recognized that new facili- and then leave regional res.ources to ties'would be necessary to accomplish support the cost. It was noted that local The need for interregional cooperation the objectives of Regional Medical Pro- money would be obtained more easily was recognized by virtually all of the grams. But the question of "when" if the operational projects were of ob- discussion groups. Some felt this need and "by what mechanism" such con- vious benefit to the public. should be met by informal relation- struction should be supported turned ships among the regions, while others out to be the real issue. The problem of providing a mechanism felt new mechanisms to support in- for coordinating multiple financing was terregional activities should be devel- Relationship of Federal and Non- discussed by some participants. One oped. Federal Funding group recommended that the regi na @ . 1 Interest in this area is indicated by the The question of Federal and non-Fe- core receive full Federal support, wniie number of interregional conferences deral funding was discussed by most the operational projects would be ]ready held, including a regular series funded on a variable matching basis, of the groups, with few strong feelings depending on the local resources avail- In the Northern New England-New York as to how the problem should be able. Others suggested that there was area, meetings of Ohio Valley regions, solved. Most of the groups agreed to merit to partial local funding of the and others for the Western States. In the principle that the private sector core unit. the Northern New England region, must supplement and complement the a formal interregional relationship has MIMI funds provided by the Federal sector; Some discussants related funding to been developed for data gathering and that sharing of costs increases local the view of Regional Medical Programs communication. initiative and forces a greater commit- as an interlocking, collaborative effort. It was generally agreed that regional ment to the program. In this connec- This view holds that in order to coordi- boundaries are not yet firmly delineat- tion, the large investment of time and nate funding, RMP must defin! th! ed, and that they should remain flexi- money by interested individuals and principles governing the distribution Or ble in order to respond to future devel- organizations in developing applica- funds, possibly by defining more clear, opments. In addition, since regional tions was cited as evidence of such a ly the role of the various interested boundaries do not lend themselves to commitment. groups involved. Some voluntary health cope with all the health problems of Several discussants recognized RMP agencies were participating, for exam- -n area (e.g., regional distribution for ple, but were concerned about losing a funds as "seed money" but each dis- ,- patient care is not necessarily the cussant came to a slightly different Eneir identity in the program. same as for education programs), conclusion about it. One individual in- Specific matching requirements were flexible regional boundaries and strong sisted that it be clearly understood generally opposed, with the feeling interregional cooperation are useful that pilot programs must ultimately that developing cooperative arrange- and necessary. 69 The discussion of grant support for interpretation of the Act Group members may represent more ed covered the entire spectrum of pos- certain interregional activities brought There were a number of issues than one of the required categories sibilities. The consensus, however, forth a number of advantages which brought up which reflected either: (a) was also raised as a question. seemed to be in favor of retaining the might be derived: confusion about and misinterpretation It was felt that the program needs categorical limitations, at least for the ,O interregional communication and of the Act; and (b) suggestions for health manpower training provisions present. the sharing of regional capabilities and clarification or improvement of the leg- with emphasis on paramedical person- strengths would be encouraged. islation or guidelines. nel training. There is uncertainty about 0 Scarce, skilled manpower and other The phrase, "the opportunity of mak- what can be funded by RMP in this specialized resources would be more ing available to their patients the lat. regard. effectively utilized. 0 Comprehensive evaluation on an in- est a . dvances," caused some confu- tthhee prroloegraofmthweaspracticing physician in terregional basis could be developed. sion. Among various interpretations, it stressed, noting that 0 Communication and computer net- was taken to mean that Regional Medi- it is through him that individual pa- works could be made compatible. cal Programs would support basic re- tient care is improved. For this reason 0 National leadership and coordi- search, diagnosis and treatment to the many believed the practicing physician nation might be developed. exclusion of prevention and rehabili- should be closely involved in the de- 0 Such efforts would contribute to tation, and research in the delivery of velopment of the program. It was rec- maintaining the flexibility of regional health services or actual improvement ognized special provisions may be programs. in such delivery. necessary to reach those physicians The most frequently mentioned activi- Questions were raised about the re- with no hospital affiliation. quirement that the program not inter- ties recommended for interregional fere with patterns of financing, patient There was some confusion as to support were: care, or professional practice. It was whether local programs were intended 0 Education, including programming, to become self-sustaining after the via TV, radio and telephone. pointed out that changes in patterns planning phase, or whether they could 0 Development of compatible hard- of patient care are obviously going to expect continued Federal support. ware, including computers and com- occur as the program is implemented Would funding be limited to experi- munications networks. and that the whole purpose was to mental programs, or would wide-scale 0 Data collection, including the estab- bring about a change. It was stressed demonstration projects be supported? lishment of compatible techniques re- however, that the program would noi lated to disease patterns and medical change the physician-patient relation- It was felt that RMP should build eval- care administration. ships per se. uation into the program. There was 0 Development of interregional sys- In connection with Regional Advisory some suggestion that RMP offers many tems of evaluation to effectively iden- Groups, it was suggested that a clearer' avenues for setting the criteria for im- tify national as well as regional trends. delineation of responsibility be defined proved patient care, possibly by pro- 0 Research programs, including opera- for these groups. The word "advisory" viding guidelines listing indices and tions research, studies of manpower seems a misnomer, since the Guide- their applications for evaluating pro- and facility utilization, and studies of lines state that the group is em- grams. health needs of minority groups. powered to approve or disapprove Categorical Emphasis 0 Development of interregional facili- projects. Some commented that the ties and resources. program has not placed enough em- Discussion on whether the categorical 0 information exchange systems among phasis on public or consumer repre- emphasis of Regional Medical Pro- regions. sentation. Whether Regional Advisory grams should be retained or eliminat- 70 Reasons for retaining the categorical seemed to prefer leaving this limitations ranged from questions of undefined and up to local judgment. proper timing to outright opposition to Those who favored broadening the leg- broadening of the legislation. A islation felt that the emphasis of Re- number of participants felt it might be gional Medical Programs should be premature to modify the law; heart upon effectively coordinating diverse disease, cancer and stroke are major efforts to improve the Nation's health problems and they will provide further and upon raising the quality of medi- experience as to how the program can cal care delivered to the patient wher- be expanded; let RMP take hold as a ever he resides. It was stated that concept and an approach; don't con- these goals necessarily transcend cate- fuse progress by introducing questions gorical limitations. This group felt that about disease categories now. In rela- the program should expand to include tion to this, it was felt that there was the entire spectrum of health care in plenty for RMP to do within its present the framework of regional cooperative categorical limits. Some offered the arrangements; at the least, the law opinion that RMP would be overbur- should be changed to read "and other dened if it had other major diseases to major diseases." deal with. Fear was expressed that if the pro- Some felt there was no need to end gram were limited to heart disease, the categorical limitations now, al. cancer and stroke, this would only though they assumed that the scope lead to further fragmentation in the of the program would inevitably be health field. The fundamental need for broadened; if the concept of coopera. everyone to have comprehensive health tive arrangements proved to be a valid services was expressed, with the view one for heart disease, cancer and that categorical limitations are a step stroke, it would be a valid concept for backward. Planning of Regional Medical Programs should be approached in other diseases. terms of patient needs. It was stated that the cooperation Of Although one group did not consider the practicing physician is essential to the categorical limitation a hindrance the success of the program, and that to good regional planning, they did see categorical limits on the scope of the it as a problem in developing practical program were and may still be very and completely "economical" opera- important to a large segment of the tional programs. Certain of these pro- practicing physicians. There was also grams, such as continuing education, . are sure to extend beyond the Cate- some discussion of whether "related gorical limitations imposed by the diseases" should be defined. It was present legislation. It did not seem recognized that some medical groups prudent, therefore, to limit use of RMP wanted definition of these "related dis. operational grants on a narrowly cate- eases," but most of the groups gorical basis. 71 Section V-Excerpts From Post-Conference Letters All participants were urged to express their opinions not only during the Con- ference itself but afterward by letteri Many did, and in doing so helped the. St'aff obtain a clearer picture of how Regional Medical Programs are viewed at the "grass roots" leveL 73 PARTICIPANTS EXPRESSED THEIR VIEWS ABOUT ... when the grant is not made specifical- groups to a certain extent parallel and implementing operational grants ... REGIONAL ADVISORY GROUPS ly to that organization. their responsibility for decisions. for particular regions using some of what I have learned in our sessions. I Much concern regarding the structure, Darrell C. Crain, M.D. George E. Wakerlin, M.D., Ph.D. am writing this letter, however, as an the representation, the veto power, Delegate, D.C. Medical Society Program Director individual physician in the program. and the tenure of the Regional Advi- Washington, D.C. Missouri Regional Medical Program one of the sory Committees was expressed. . . . It seems to me that Several regions jumped the gun, ap- significant strengths of the current leg- pointed advisory committees which The present advisory groups associat- The possibility of giving authority and islation is the clear fixing of responsi- ed with Regional Medical Programs responsibility to Regional Advisory bil'ties for took charge of the whole situation with I health care planning and almost complete disregard of impor- should be strengthened by more exten- Councils to establish priorities in programming in the hands of Regional sive lay representation. In my opinion grants, before grant applications go to Advisory grou tant segments of interested groups ps who are individuals within their areas. the legislation should encourage active Washington, was discussed. I believe identified with and committed to the There was much concern expressed of participation by business and con- that Regional Advisory Councils al- region they serve. It is this facet of sumer groups not excluding the insur- the tenure of these Regional Advisory ance industry which serves as trustee ready possess this authority. Some the program which makes it distinctly Committees for many reasons. There for some hundred million consumers. i-zuidelines from Washington indicating different from systems tried in other is no law or.regulation limiting the ten- that they were expected to do this sort countries where responsibilities for the ure of these committees and they can James F. Oates, Jr. of thing would make their discussions decisions about the delivery of health and probably will be self-perpetuating. Chairman of the Board and decisions much more meaningful. care have been progressively central- There was a strong feeling that these The Equitable Life Assurance I believe that ours would be willing to ized. In watching dynamics in different committees be subject to rotation and Society of the United States accept this responsibility. regions to date, I am encouraged by limited tenure such as in the case qf Russell C. Mills, Ph.D. the fact that various health groups are our Advisory Councils at NIH. beginning to really talk to one another The medical schools of the country Program Coordinator for the first time, to explore the actual Cornelius H. Traeger, M.D. may have too important a role in this Kansas Regional Medical Program and needs in their area in a thoughtful and Practicing Physician program. Associate Dean, University of Kansas responsible fashion, and to design re- New York City and P. M. Huggin, M,D. Medical Center search programs to determine what Member, National Advisory Council on Medical Director kind of health care is required and Regional Medical Programs East Tennessee how it can be delivered. These groups I want to take this occasion to con- Tuberculosis Hospital gratulate you on the Conference on are beginning to take real pride and It is necessary to include more laymen Regional Medical Programs held 'in pleasure in mutual cooperative efforts in all stages of the program. r)articu- designed to create better medical care. larly as members of the Advisory Com- Missouri RMP has found that commu- Washington on January 15-17. It was mittees. nity cooperative arrangements are fa- an impressive assemblage of talent, cilitated by requiring each project pro- the Conference addressed itself to an I realize, however, that unless the Re- Many feel that private practitioners posal to provide for a comm ni important problem, and I felt all of us view Committee is terribly clear about have been excluded by either the med- u ty learned much from the proceedings. its function, it runs the risk of making coordinating committee composed Of ical schools or the State health depart- representative health profession and As a member of your Review Commit- centralized value judgments about ments. The private practitioner should lay leaders and vested with decision- tee, I have had a chance to think quite what is "important" in this or that be represented on the planning council making responsibility. intensively about the program. I thus program within a region. As planning in every region. Particularly should this thought I might try to spell out some and operational grants are reviewed, representation be from the State, There appears to be evidence that the of my thoughts about the role of the the Review Committee will become county, or city medical association contributions of regional advisory Regional Advisory Groups in planning progressively more sophisticated. This 74 may cause it to develop unwittingly in which we serve the health needs of I note the lack of any official repre- those who are not participating either some rigidity about what is needed in the American people. sentation from any voluntary health locally or nationally; this would do regional programs. I thus hope that David E. Rogers, M.D. agency in the Regional Medical Pro- much to alleviate the effect of rumors this group will try to keep the initiative Professor and Chairman of the gram National Advisory Council, the and false notions regarding the pro- in the hands of the region and careful- Department of Medicine, RMP Review Committee, or the Con- gram. sultants representing National Advisory ly avoid making specific judgments re- School of Medicine, Edwin P. Jordan, M.D. garding operational priorities or Vanderbilt University and Councils with related interests. Executive Director specific items within the context of 'in- Member, Regional Medical While it is true that advisory commit- American Association of dividual proposals. To do so would Programs Review Committee tees to planning groups have repre- Medical Clinics create the hazard of making each re- sentation from the American Heart As- gional program resemble every other- sociation and the American Cancer precisely the thing which the legisla- Society, these are inevitably isolated A newsletter should be developed by tion is designed to avoid. ... THE REVIEW COMMITTEE AND THE NATIONAL and fragmented and not capable of your Division which could keep all of ADVISORY COUNCIL bringing to bear the full organizational us informed as to the progress of the I thus believe that all involved must strength and capabilities of the volun- program. This newsletter could also keep in mind that the only centralized tary health agencies. point out some of the obstacles that responsibility to judge is whether a re- gion does or does not understand the Voluntary health agencies are not How important it would be to utilize may have been encountered and how concept of a regional program, whether specifically represented on any of the fully this wealth of dedicated individ- these problems were solved. its advisory group has real commit- committees which comprise the review uals in a systematic organized manner information meetings held periodically ments to it, and whe*er they are process -for Regional Medical Pro- to bring into reality more quickly and perhaps on a regional level might be moving to obtain the kind of personnel grams. Insofar as the American Heart completely the goals of Regional Medi- very helpful as the program develops. who will plan broadly and imaginatively Association is concerned, I realize that cal Programs. Guy F. Robbins, M.D. for the regions that they serve. Deci- on most committees there are individ- sions regarding priorities for specific uals who for one reason or another W. A. Krehl, M.D., Ph.D. Director of Planning projects, what particular programs are strongly oriented towards Heart. Director, Clinical Research Center Memorial Sloan-Kettering would be most profitable for an area, Even so, I hope that in the future University Hospitals Cancer Center what data will be required to mount an when vacancies occur on these review University of Iowa effective program, etc., should and committees that representation of the must be decided by the region. Clearly, appropriate voluntary health agencies I would like to emphasize the impor- the Regional-Planning and Regional Ad- will be considered. . . . IMPROVED COMMUNICATION tance of Dr. Vernon E. Wilson's visory groups must feel true responsi- ABOUT suggestion concerning the dissemi- bilities for both the design and the Lewis E. January, M.D. THE REGIONAL MEDICAL PROGRAMS nation of information with regard to ways of implementing their particular President FROM NATIONAL SOURCES the manner in which individual regions program. American Heart Association are proceeding with their work. The "Newsletter" that Dr. Wilson suggest- I felt your conference went far to clar- My general impression from the con- ed would be extremely helpful. ify this important, indeed, central the- I was distressed by the lack of any ference is that one of the biggest J. S. Denslow, D.O. sis, upon which regional programs emphasis or consideration of the role problems is the dissemination of infor- Kirksville College of should rest. It is an exciting new con- of voluntary health agencies as full mation both by regional planning Osteopathy and Surgery cept and will make important and, I partners in the development of "coop- groups and at the national level on Kirksville, Missouri believe, profitable changes in the ways erative arrangements." what is being done, particularly to 75 ... EVALUATION OF Others are dismayed by the complexity NEW CONSTRUCTION FOR several members in attendance were a OPERATIONAL ACTIVITIES of the process of evaluation- REGIONAL MEDICAL bit unhappy. Apparently they felt much PROGRAM PROJECTS as did Dr. Hudson about the construc- My opinion after a lengthy discussion tion of large centers to which patients Some regard evaluation as one of the was that we might have to forego the Planning is not far enough along- would be referred. They felt that the chief strengths of the program- Regional Medical Programs for lack of only function of the doctor in the field adequate methods of evaluating our I do not think any major changes are would be to beat the bushes to find The evaluation effort holds the great- progress. I do feel that an obviously needed in P.L. 89-239 this year. It is people who needed referral. est responsibility and challenge for the good program should not die for lack simple, permissive and allows wide lat, William H. Raymond, M.D. of ultra-sophisticated methods of itude of support for planning and oper, Member, Albany Regional future. RMP staff should draw together measuring progress even though one ating activity. those interested in evaluation from the Advisory Group several regions, so that they might be Of the most encouraging aspects of I do not think an attempt should be in contact. This could also encourage the Regional Medical Programs is this made . . . to provide money for new _, session with quality production. construction. From what I heard in The proposal for developing actual a uniformity in data collection that 'Olj would make one program comparable Guy D. Campbell, M.D. Washington, planning is not far brick. and mortar facilities for health to the other in the future. Program Coordinator enough along across the country to care is beyond the scope that this pro- Mississippi Regional Medical Program build a good case for such money gram should now be considering. James E. C. Walker, M.D. and a poor case would tend to cast Hector W. Benoit, Jr., M.D. Professor of Medicine and Society doubt on the value of the total pro- Member, Missouri Regional School of Medicine It is impractical for each region to de- gram. Advisory Groups University of Connecticut velop its own methods for evaluating Henry T. Clark, Jr., M.D. care and for documenting the effect on Planning Director delivery of care of Regional Program I was quite concerned about the possi- Research in the area of patient needs Connecticut Regional Medical Program bility that attempts might be made to activities. Methods of evaluation could and how best to meet these needs, - modify P.L. 89-239 in this session of modes of practice, use of allied health more reasonably be developed as re: To me, this program has tremendous the Congress. In my opinion, this search programs in a few regions ana professionals, specific and n w eauca- .. potential to upgrade the caliber of would be a strategic error since many tional processes, is greatly ni ded and tnen be made generally available. medicine in our country. However, I of us have just now been able to reas- should be specifically stated. The voice of practicing physicians at don't want to consider changes in sure the uneasy private practitioner the Conference seemed rather faintly category, financing or construction un- segment and other groups that the By title, the Act is disease-oriented. heard. . . . Future legislation should be til experience with the present pro- Regional Medical Program was not a You have noted that it should be pa- acceptable to physicians and to the gram clearly shows the need. Federal enterprise, the nature of which tient oriented. Here I think greater pre- AMA, for without their active support W. J. Hagood, Jr., M.D. was going to be dictated from Wash- cision in the definition of goals would and enthusiasm, a great barrier will Little Retreat Clinic ington. be valuable, both as a guide for the exist between the Regional Program Clover, Virginia Basically, I would oppose at this time future and as a healthy exercise for and its goal of improving patient care. an inclusion in the law of funds for the administrators and educators work- ing them out. Charles P. Summerall, III, M.D. Brick and mortar authorization will construction of general facilities relat- Secretary open the door for construction of re- ing to the Regional Medical Program E. S. Bowerfind, Jr., M.D. South Carolina Regional Advisory gional "centers"- because most of us do not yet have a Assistant Professor of Medicine Group and Acting Regional clear idea of the types of facilities University Hospitals of Cleveland Program Coordinator Following the plenary session at which which will be most suitable when our Dr. DeBakey spoke of construction, programs have been fully developed. 76 I . . .On the other hand, there are some The legislation should be changed to voice-the basic purpose of Regional 0 While the funds noted above should impoverished areas of the country allow for construction. Medical Programs is education. The be of first priority, there should be where serious problems exist and Merrill 0. Hines, M.D. basic form of this education is con- monies available to assure proper and where able people are struggling to Medical Director tinuing education, with the explicit complete utilization of these educa- cope with them. Ochsner Clinic purpose of making productive in pa- tional facilities. One of the greatest Marc J. Musser, M.D. New Orleans, Louisiana tient care the billions of dollars which problems for those Iof us with practical Program Coordinator have gone into basic research in the experience in continuing education North Carolina Regional last three decades. concerns curriculum design and moti- Medical Program Possibly the time has come to add At this time the educational muscle of vation. These are inextricably interwo- construction components to the legis, the ncin-university hospital is so weak ven with-a need to know patterns of Spaceis needed for continuing educa- lation. The great diversity of programs that it is difficult for it to do its pres- medical care and physician function. The greatest single area of information tion and for administrative activities- may cause problems in defining con- ently assigned task. If it is to become struction needs. I hope that when con, the cornerstone of the Regional Medi. lack and misinformation is in the field We wish to particularly encourage your struction features are built into the cal Programs and their educational of the function of physicians in care support of legislation which will allow program, they will be coordinated with muscle, then the non-university teach. and their needs and motivations in re- new construction. There is a need Hill-Burton, health research facilities, ing hospital needs a great deal of lation to continuing education. To within the Medica]'Centef and COMMU' and health educational facilities legis- help. make the primary building funds noted nity Hospitals for office space and for lation in such a way that insofar as above really effective, we sorely need facilities devoted to education and university medical centers are con- I am writing to ask in the strongest support within non-university hospital training. cerned, structural needs can support Possible voice that your report to Con- settings for the measurement and The Medical College hopes cost shar- educational concepts. gress in June make clear request for evaluation of continuing education, ing will not be required, for if con- funding in two very important areas: and for the measurement and evalua- struction funds are awarded contingent John Parks, M.D. <> Funds to provide educational facili- tion of physician performance, drive upon matching funds being available, Dean, School of Medicine ties and equipment in non-university and motivation. We should be able to it might be impossible in many cases George Washington University hospitals. These should include, most really find out what it is that we have for the construction to take place. importantly, auditorium and confer- to teach, and what changes in behav- Frank M. Woolsey, Jr., M.D. I am writing both as an individual, and ence room space and their accouter- ior we are trying to bring about with Program Coordinator as the President of the national organi. ments, library facilities and materials, our continuing education. It is of great Albany Regional Medical Program zation (Association of Hospital Direc. audio-visual materials, audio-visual de- importance that within each region, tors of Medical Education) which partments, and areas designed depending upon factors peculiar to If additional construction authority and represents over 70% of the nation's specifically for educational demon- that region, there be one or more non- funding seems necessary in the health non-university teaching hospitals. strations in patient care. These are university hospitals with funds availa- care field, it should be thought of in While the universities and their medi- brick and mortar and equipment funds ble to construct and staff divisions of terms of multipurpose facilities (gen- cal centers may be the nervous system measurement and evaluation in con- eral health care, professional educa- of the Regional Medical Prograkms, which most hospitals simply cannot tin ing education. These would be u tion needs). there cannot be much doubt that the ' upply from monies available in their staffed with physicians, educationists, James F. Oates, Jr. non-university teaching hospitals and local communities or through their pa- educational psychologists and sociolo- Chairman of the Board the community hospitals will be the tient care efforts. They are the very gists. Each region is sufficiently The Equitable Life Assurance muscle of these programs. It seems basic equipment most of these hOsPi- different to have different needs and Society of the United States that the people, in the form of Con- tals must have to adequately perform to require different approaches and gress, have spoken in a loud and clear their task in the future. measurements. Thus one center or 77 RMP should be Though I do not know the merits of cleaning is necessary seems obvious. one university center would not The program goals of the requests before you for operating The major benefit from this law at the suffice. emphasized, and the categorical nature present time, and for some little while de-emphasized. I would like to add the funds, I have major misgivings about Robert L. Evans, M.D. feel making awards in this field at the into the future, will lie in its effect in President weight of my views to those who nd present time. Such awards would put bringing together diverse groups with- Association of Hospital that ,cooperative arrangements" a d huge pressures on program coordina- in and without the medical community, Directors of Medical Education distribution of services are primary, an nd the country to develop re- with community health as a common "Heart Disease, Cancer, and Stroke" tors arou quests for operating funds before ade- goal. RICAL EMPHASIS are just means to that end. quate planning has been done. This ... THE CATEGO The overlap between 89-239 and type of "hurry-up, half-baked" ap- Walter Hume, M.D. GIVEN BY CONGRESS TO Ms 89-749 will be confusing and hazard- proach would, in my judgment, put the Louisville, Kentucky REGIONAL MEDICAL PROGRA ous to the future. I would hope that I Programs de- Member, Ohio Valley Regional these two programs are made identical whole Regional Medica Advisory Group we have found that we can work quite lopment in jeopardy-just when a uthori- at least where state and regional areas ve effectively within the present a lot of first class people are becoming zations for heart, cancer, stroke, and overlap. aware of its bright promise. ... HEALTH MANPOWER related diseases. it would perhaps be James E. C. Walker, M.D. somewhat easier to do what we think Professor of Medicine and Society Henry T. Clark, Jr., M.D. the program is designed to do if au- School of Medicine Planning Director The most critical immediate problem to areas Connecticut Regional Medical Program in organizing successful regional pro- thorization were expanded University of Connecticut try will be covered by all of the other National grams throughout the coun institutes of Health, but this is not a ... THE RATE ( F DEVELOPMENT PARTICIPANTS SPOKE TO the shortage of manpower. However, critical problem with us at this time. OF REGIONAL MEDICAL PROGRAMS THE IMPORTANCE OF ... once this is solved the success of the Russell C. Mills, Ph.D. ... CONTINUING EDUCATION regional programs will be determined We may, by moving too rapidly, re- ultimately by two factors: (1) the in- Program Coordinator strict planning and, as a result, devel- terest and enthusiasm that can be en. am and I feel that the focus in this program, Kansas Regional Medical Progr op operational programs which will give genaered and maintained in the two Associate Dean, University of Kansas very little direct help to weaker institu- in its operational phase, will and m will Medical Center tions. This, in turn, will tend to in- should be aimed toward continuing groups around which the progra medical education, both for medical tend to polarize, namely the clinical In the Missouri region categorical em- crease dependence on existing centers faculties of medical schools, and prac- phas'is has not significantly interfered and fail to stimulate growth and devel'and paramedical personnel. There is titioners in community hospitals and with program planning and develop- opment of presently weak but poten. the problem of motivating physicians, (2) the extent to which motivation can ment. Not unexpectedly, several physi- tially strong centers. as probably the people who need such be stimulated. cian leaders in fields of medicine other I believe that the planning phase education most would tend to use ait should be well de least. Some sort of obligatory educo- Samuel Proger, M.D. than heart, cancer, stroke and related veloped before we r gret that sugszest changes in the legislation. tional program, or re-examination f 0President diseases, have expressed re recertification at set intervals seem tBingham AssociatesFund their fields are not involved. Ultimate- Once the need is documented, through be the only sure method o@ keeping ly, expansion of the RMP concept to careful planning, necessary changes the medical populace current. include all fields of medicine would ap- can be recommended. . .. PATIENT CARE There seems to be overlap in areas of pear desirable. Frank L. McPhail, M.D. responsibility, and indeed of financing, ity for Montana State Director I programs di. I was impressed by the necess 'George E. Wakerlin, M.D., Ph.D. of the various medica Mountain States Regional That some form emphasizing our efforts at improving Program Director rected toward health. y other con- Missouri Regional Medical Program Medical Program of governmental and legislative house- patient care rather than an 78 sideration. This should be emphasized the objectives as "improved capability in the Report. for diagnosis and treatment." I am Kinloch Nelson, M.D. sure that those of us who have a Dean broad point of view understand this Medical College of Virginia and means diagnosis obviously has to in- Program Coordinator clude preventive medicine. . . . and Virginia Regional Medical Program detection programs.... In fact, if, when the new legislation . . .DENTISTRY comes into being, I personally would like to see two words added. These In relation to Section 903 (b) (4) of would be "prevention" and "rehabili- the law, perhaps future regulations or tation." I believe it would clarify what administrative guidelines might be obviously was the intent of the Com- written to spell out the intent that the mission and the Congress as well as specific mention of "practicing physi- the directive from the President. cians" should not be construed to ex- I would like to make a plea for con- clude "practicing dentists" and that tinuing aid to the supporting services representatives of "medical societies" -facilities and medical education, should not be construed to exclude both undergraduate and continuing "dental societies". education. The last sentence of Section 901 (c providesIthat "no patient shall be fur- Howard A. Rusk, M.D. nished hospital or medical care at any Director facility unless he has been referred to- Institute of Rehabilitation Medicine such a facility by a practicing physi- New York University Medical Center cian." The term "practicing physician" should be expanded to include "or dentist" or a term such as "health practitioner" or "practitioner of the healing arts" should be substituted. This would allow referrals by dentists for such problems as oral cancer. Maynard K. Hine, D.D.S. Immediate Past President American Dental Association ... AND PREVENTION AND REHABILITATION I have been somewhat disturbed about the language in the Act which defines 79 APPENDICES 0 Conference Program 0 Registered Conference Participants 0 National Advisory Council Review Committee Ad Hoc Committee for the Report 0 Division Staff 0 Directory of Programs 0 Guidelines 0 Public Law 89-239 0 Regulations 81 Appendix 2-Registered Conference Appendix l@onference Program Participants Conference on Discussion Sessions: 10 a.m.-12 noon Introduction of Speaker: ACHTER, Mrs. Renee "Development of Cooperative Arrangements" Edward W. Dempsey, Ph.D. Chief Occupational Therapist, American Regional Medical Programs Occupational Therapy Association; Director, Luncheon Meeting-International Ballroom- Professor of Anatomy Occupational Therapy, D.C. General Hospital SUNDAY, JANUARY 15 East, 12:30 p.m.. Columbia University College of Physicians and Surgeons ACOYA, Clarence Registration-Concourse, 3-6 p.m. Chairman: Executive Director, New Mexico Commission Opening of Conference Stanley W. Olson, M.D. Speaker; on Indian Affairs; University of New Mexico School of Medicine Reception-Terrace, 6:30 p.m. Speaker: Sidney Farber, M.D. 'ADAMS, Wright, M.D. Director of Research Associate Dean, University of Chicago James A. Shannon, M.D. Children's Cancer Research Foundation Dir.ner Meeting-international Ballroom- Director Professor of Pathology School of Medicine West, 7:30 p.m. National Institutes of Health Harvard Medical School ALPERT, Louis K., M.D. Chairman: "Science and Service" "The Idea, the Intent and the American Diabetes Association; Professor of General Session-international Ballroom- Medicine, George Washington University Robert Q. Marston, M.D. West, 2 p.m. Implementation" *AMES, Verner J., D.O. Remarks: Panel Session: "The Report of the Surgeon Professor of Practice, Kansas City College Charles L. Hudson, M.D. Panel Session: Program Evaluation General to the President and the Congress" of Osteopathy and Surgery President Chairman: ANDERSON, Gaylord W., M.D. American Medical Association George James, M.D. Chairman: Director, School of Public Health, University Leo J. Gehrig, M.D. Dean Storm Whaley of Minnesota Deputy Surgeon General Mt. Sinai School of Medicine Vice President for Health Affairs ANDERSON, Otis L., M.D. U.S. Public Health Service University of Arkansas Manager, Washington, D.C. Office, American Introduction of Speaker: Speaker: Medical Association Philip R. Lee, M.D. Vernon E. Wilson, M.D. Panel: ANDERSON, Robert S., M.D. Assistant Secretary for Dean Michael E. DeBakey, M.D. Professor of Medicine, Meharry Medical Health and Scientific Affairs University of Missouri Professor and Chairman College U.S. Department of School of Medicine Department of Surgery ANDRESEN, Donald C., M.D. Health, Education, and Welfare Panel: College of Medicine Chief, Cardiology, Darthmouth Medical Address: Edward Kowalewski, M.D. Baylor University School Wilbur J. Cohen Chairman, Board of Directors Bruce W. Everist, M.D. ANDREW Edward ., r., Under Secretary of American Academy of General Practice Green Clinic Dean, College of Medicine, University of U,S. Department of Health, Education, and Welfare C. H. William Ruhe, M.D. Ruston, Louisiana Vermont Assistant Secretary James T. Howell, M.D. ANDREWS, Neil C., M.D. MONDAY, JANUARY 16 Council on Medical Education Executive Director Assistant Dean, College of Medicine, General Session-International Ballroom- American Medical Association Henry Ford Hospital Ohio State University West, 9-10 a.m. Harvey L. Smith, Ph.D. 'ANNIS, Jere W., M.D. Professor of Sociology and Ray E. Trusself, M.D. Chairman: Director President, American Association of Director, Social Research Section Medical Clinics Stanley W. Olson, M.D. University of North Carolina Columbia University School of Conference Chairman Public Health and Administrative Medicine 'APPEL, James Z., M.D. Discussion Sessions: 3:30-5:30 P. m. Paul N. Ylvisaker, Ph.D. Immediate Past President American Speaker: "Continuing Education, Research and Patient Ford Foundation Medical Association Robert Q. Marston, M.D. Care" ARBONA, Guillermo, M.D. Associate Director Discussion Sessions: 11 a.m.-I p.m. Professor of Preventive Medicine and Public National Institutes of Health TUESDAY, JANUARY 17 Health, School of Medicine, University of Director General Session-International Ballroom- "Surgeon Generat's Report on the Regional Puerto Rico Division of Regional Medical Programs West, 9 a.m. Medical Programs to be presented to the "Philosophy and Goals of the Regional Medi- President and the Congress" Physician indicated in Conference cal Programs for Heart Disease, Cancer, Chairman: Registry that activities also Stroke and Related Diseases" Stanley W. Olson, M.D. Adjournment-1. p.m. include regular practice 82 ARONOFF, Billie Louis, M.D. BELL, Louise N. BOREL, Richard A. Center; Member, North.Carolina Regional Associate Professor of Surgery, University Research Assistant, Department of President, WBNS-TV Inc.; Member, Ohio Medical Program Special Committee of Texas S.W.; Member, Texas Regional Preventive Medicine, University of Regional Advisory Group Advisory Council Pittsburgh School of Medicine BRUCE, John M., M.D. BORHANI, Nemat O., M.D. Alternate Member, Louisiana Regional 'BABSON, William W., M.D. BENNETT, Granville A., M.D. Program Coordinator, California Regional Advisory Group; Director, Division of Local President, Massachusetts State Medical Dean, College of Medicine, University of Medical Program; Chief, Bureau of Chronic Health Services, Louisiana State Board of Society Illinois Diseases, California State Department of of Health Public Health *BACASTOW, Merle S., M.D. 'BENOIT, Hector W., Jr., M.D. BUNNELL, Kevin P., Ed.D. Director, Medical Education, Maine Medical Member, Regional Advisory Council; BOSTICK, Warren L., M.D. Program Coordinator, Mountain States Center, Portland; President, Applicant Missouri State Medical Association Dean, University of California College of Regional Medical.Program; Regional Medical Agency, Maine Regional Medical Program BENSON, W. W. Medicine, Los Angeles Programs Review Committee BARNES, David A. Member, Mountain States Regional Advisory BOUGHN, Pete Council; State Registrar of Vital Statistics, Director of Public Information, University of BUTTERWORTH, Theron H., Ph.D. Medical Administration, Mayo Clinic Idaho Department of Public Health Nebraska College of Medicine Member, Board of Trustees, Society of Public Health Educators; Health BARNES, James T. BOWEN, Ted Communications Branch, Public Health Executive Director, Medical Society of BERNSTEIN, Dr. Leon Branch Chief, Basic Policy Division of Member, Texas Regional Advisory Group; Service North Carolina Political Standards, Bureau of Health Hospital Administrator, Methodist Hospital, *BUTTRICK, Walter W., Jr., M.D. BARR, Robert N., M.D. Insurance, Social Security Administration Houston President-Elect, Vermont State Medical Secretary and Executive Officer, Minnesota BOWERFIND, Edgar S., Jr., M.D. Society; President, Vermont Heart State Board of Health 'BERRY, Leonidas H., M.D. Secretary, Citizens Commission on Graduate Association Member, National Advisory Council on Medical Education; Assistant Professor of BARROW, J. Gordon, M.D. Regional Medical Programs; Professor, Medicine, Western Reserve University *CALL, Lloyd S., M.D. Director, Medical Education, and Clinical Cook County Graduate School of Medicine; Member, Executive Committee, Professor of Medicine, Emory University Senior Attending Physician, Michael Reese BOYD, Richard F., M.D. School of Medicine; Member, Steering Hospital, Chicago Regional Health Director, Public Health Intermountain Regional Medical Program Committee, Georgia Regional Medical Service (Region Vill Program BERSON, Robert C.. M.D. CALLISON, M. K., M.D. Executive Director, Association of American BOYLE, Richard E., M.D. Dean, University of Tennessee College of BARTLETT, John C., LL.B. Medical Colleges Assistant Professor of Medicine, University Medicine; Member, Executive Committee, Assistant Program Coordinator, Iowa of Colorado Medical Center; Representative Memphis Regional Medical Program Regional Medical Program; Administrative BICKNELL, William J., M.D. of Program Coordinator, Colorado-Wyoming CAMPBELL, Charles W. Assistant for Plans and Operations, Medical Director, Job Corps, Office of Regional Medical Program Albuquerque Community Council; Member, University of Iowa College of Medicine Economic Opportunity BRANCH, David R. New Mexico Regional Advisory Board BATSON, Randolph, M.D. BIHLMEYER, Earl F. Associate Director of Public Relations, Dean, School of Medicine, Vanderbilt Administrative Assistant to the Dean, University of Rochester School of Medicine CAMPBELL, Guy D.. M.D. University University of South Dakota School of and Dentistry Program Coordinator, Mississippi Regional Medical Program; Chief, Pulmonary Disease Medicine BRAYTON, Donald, M.D. Section, Veterans Administration Hospital, BATTISTELLA, Roger M., Ph.D. Director of Regional Medical Program, Jackson Assistant Professor, Hospital and Medical BISTOWISH, Joseph M., M.D. Assistant Dean, University of California Care Administration, Sloan Institute of Director of Public Health, Metropolitan School of Medicine, Los Angeles *CANNON, Bland, M.D. Hospital Administration, Cornell University Nashville Health Department BRINKLEY, Sterling B., M.D. Vice-Chairman, Tennessee Mid-South BAUER, Franz K., M.D. BLAIR, Lucy Vocational Rehabilitation Administration, Regional Medical Program, Medical Center Associate Dean, University of Southern Executive Director, American Physical Department of Health, Education, and Planning Council; Member, Council on California School of Medicine, Los Angeles; Therapy Association Welfare Medical Education, American Medical Los Angeles County General Hospital BOETTNER, Charles H., M.D. BROWN, Ray E. Association BAUMAN, G. Duncan Executive Director, Health Advisory Member, Ad Hoc Committee for the Report CANNON, Wilson P., Jr. Business Manager, St. Louis Globe- Committee, Appalachian Regional to the President and the Congress; Director, Senior Vice-President, Bank of Hawaii; Democrat,, Chairman, Bi-State Regional Commission; Medical Director, Public Graduate Program in Hospital Chairman, Hawaii Regional Advisory Advisory Group Health Service Administration, Duke University Medical Committee 83 CLEERE, Roy L., M.D. COOK, Ellen, M.D. CARAVATI, Charles M.. M.D. CASTLETON, Kenneth B., M.D. ssistant Professor of Medicine, College of Assistant Dean and Director, Continuing Chairman, Intermountain Regional Medical Member, Colorado-Wyoming Regional A Education, Medical College of Virginia Program; Dean, University of Utah College Advisory Council; Director of Public Health, Medicine, State University of New York at of Medicine Colorado Health Department Syracuse CARPENTER.. Chester J. COOK, Ernest W., Ph.D. Director, Planning and Program CHADWICK, Donald R., M.D. *CLINE, John W., M.D. Development, Arizona State Health Director, National Center for Chronic American College of Surgeons Chief, Division of-Medical Care Standards, Department Disease Control, Public Health Service COBB, Alton B., M.D. Rhode Island Department of Health CARPENTER, Robert R., M.D. Member, Mississippi Regional Advisory COON, Robert W., M.D. Assistant CoordinstOr-Sayfor, Texas *CHALECKE, William E., M.D. Committee; Director, Chronic Illness Program Director, Northern New England Regional Medical Program, Saylor President, Health organization of Western Services, Mississippi State Health Regional Medical Program; Chairman, University College of Medicine Methodist New York Department Department of Pathology, University Of Hospital -CHAMBERS, J. W., M.D. COCKBURN, Thomas A., M.D. Vermont College of Medicine CARR, James G., Jr. Program Coordinator, Georgia Regional Medical Director, Poverty Program, COONEY, James P., M.D. Administrator, Memorial Hospital of Medical Program; Member, Medical City of Detroit Senior Vice-President for Research and Natrona County,' Member, Colorado- Association of Georgia ert J., M.D. Medical Affairs, American Cancer Society COFFEY, Rob Wyoming Regional Advisory Council CHIAZZE, Leonard, Jr., Sc.D. Past President, Medical Society of D.C.; COOPER, Nathaniel H., M.D. 'CARR, T. L., M.D. Assistant Professor, Community Medicine Professor of Surgery, Georgetown University Director, Community Program, American President New Mexico Medical Society and International Health, Georgetown School of Medicine Heart Association, Inc. CARROLL, A. J. University School of Medicine COGGESHALL, Howard C., M.D. Assistant Director of Operational Studies, CHONTOS, Stephen A. Program Coordinator, North Texas Regional COPELAND, Murray M., M.D. Association of American Medical Colleges Health Professions Representative; Medical Medical Program; Associate Professor of National Advisory Cancer Council; CARSON, Bruce F. Alumni Publications Editor, University of Medicine, Southwestern Medical School at Associate Director and Professor of Surgery, chief, Legislative Reference and Liaison Pittsburgh Dallas M.D. Anderson Medical Hospital and Tumor Branch, National Institutes of Health CHOTAS, Georgia A. COHART, Edward M., M.D. Institute CARTER, John M. Health Sciences Editor, Office of Health Secretary-Treasurer, Association of Schools CORDAY, Eliot, M.D. Member, President's Commission on Center Relations, J. Hillis Miller Health of Public Health; Chairman, Yale Immediate Past President, American Heart Disease, Cancer, and Stroke; Center, University of Florida Department of Epidemiology and Public College of Cardiology; Associate Professor Editor, Ladies Home Journal Health of Medicine, University of California School OCHRISTOFERSON, Lee A., M.D. of Medicine, Los Angeles CARTER, Robert E., M.D. Chairman, State Development Committee, COHEN, Raphael Associate Dean, University of Iowa College North Dakota Regional Medical Program; Director, Medical and Allied Health COX, Dr. Sherman of Medicine Associate Professor, University of North Education, General Learning Corporation Special Assistant to Deputy.Chief, Division ,CARVER, Terrell O., M.D. Dakota School of Medicine COHEN, Wilbur J., Ph.D. of Dental Health, Public Health Service Member, Mountain States Regional Advisory CHIOCCO, Antonio, Sc.D. Under Secretary, Department of Health, 'CRAIN, Darrell C., M.D. Council; Administrator of Health, Idaho Acting Dean, Graduate School of Public Education, and Welfare Medical Society of D.C.; Clinical Associate State Department of Health Health, University of Pittsburgh COLE, Warren H., M.D. Professor of Medicine, Georgetown CASELEY, Donald J., M.D. American College of Surgeons; Emeritus University School of Medicine Medical Director and Associate Dean, CLARK, Dean A., M.D. Director, Program in Medical and Hospital Professor and Head of Department of University of Illinois Hospitals; Vice Surgery, University of Illinois College of CRANER, John L. Chairman, Illinois Regional Advisory Administration; Member, Western Association of American Medical Colleges Comrniftee Pennsylvania Regional Advisory Committee Medicine osephine K., R.N. CASSIDY, John J. CLARK, Henry T., Jr., M.D. COLLINS, V. P., M.D. CRAYTOR, Mrs. J Director of Public Relations, Albany Program Coordinator, Connecticut Regional Consultant in Radiology to the National Rochester Planning Committee Member; Medical Program Institute of General Medical Sciences and Associate Professor of Nursing, School of Medical College and Medical Center Baylor University College of Medicine Medicine and Dentistry, University of Hospital CLARK, R. Lee, Jr., M.D. Rochester CASTLE, C. Hilmon, M.D. Member, President's Commission on Heart COLYAR, A. B., M.D. Disease, Cancer and Stroke; Director, The Commissioner, Oklahoma State Department CRISPELL, Kenneth R., M.D. Program Coordinator, Intermountain SI Dean, University of Virginia School of Regional Medical Program; Associate Dean, University of Texas M.D. Anderson Hospital of Health; Member, Oklahoma Region College of Medicine, University of Utah and Tumor Institute Advisory Council Medicine 84 CROCKETT, Charles L., Jr., M.D. DEBAKEY, Michael E., M.D. DUCKWORTH, T. A. ELIEL, Leonard P., M.D. Associate Professor and Assistant Dean, Member, President's Commission on Heart Chairman, Wisconsin Regional Advisory Member, Oklahoma Regional Medical Continuing Education, University of Virginia Disease, Cancer, and Stroke; Member, Committee; Senior Vice-President and Program Executive Committee; Vice School of Medicine Ad Hoc Advisory Committee for the Report Secretary, Employers Insurance of Wausau President and Director of Research, to the President and the Congress; Oklahoma Medical Research Foundation; CROSBY, Edwin L.. M.D. Member, National Advisory Council on DUNN, Donald W. Professor of Medicine, University of Consultant, Executive Vice-President and Regional Medical Programs; Professor and Executive Director, Minnesota Hospital Oklahoma School of Medicine Director, American Hospital Association Chairman, Department of Surgery, Saylor Association; Member, Northiands Regional ELLER, C. Howe, M.D. CULBERTSON, James W., M.D. University College of Medicine Advisory Committee Member of the Executive Committee, Proposed Chairman, Professional Education DECESARE, William R., M.D- DUNN, Marvin R., M.D. Bi-State Regional Medical Program; Committee, Memphis Regional Medical Chief, Science Review Section, Division of Associate Dean, Woman's Medical College Commissioner of Health, St. Louis County Program; Professor of Medicine; Chief, Research Facilities and Resources, National of Pennsylvania Health Department Section of Hemodynamics, University of institutes of Health DUTTON, C. B. ELLWOOD, Paul M., M.D. Tennessee College of Medicine DEFRANTZ, Robert Attorney, Member, Indiana Regional Executive Director, American CUMMINGS, H. W., Jr., M.D. Director, Community organization, Flanner Advisory Group Rehabilitation Foundation; Faculty, Member, Texas Regional Advisory Council; House, Indianapolis Du VAL, Merlin K., M.D. University of Minnesota Chief, Internal Medicine Service, Methodist DEHNE, Edward J., M.D. Acting Coordinator, Arizona Regional ELMORE, Marjorie J., Ed.D. Hospital; Professor of Medicine, Saylor Nevada State Health Officer Medical Program; Dean, University of Member, Mountain States Regional Advisory University College of Medicine DEMPSEY, Edward W., Ph.D. Arizona College of Medicine Council; Dean, School of Nursing, CUNNINGHAM, Joseph A., M.D. Member, President's Commission on Heart DYER, N. Allen, M.D. University of Nevada Professor, Medical College, University of Disease, Cancer, and Stroke; Liaison, Member. West Virginia Regional Advisory ENGLE, H. Martin, M.D. Alabama; Council Member, National National Institute of General Medical Committee; Director, Bureau of Heart Chief Medical Director, Department of Committee for Medical Technology Sciences Council; Professor of Anatomy, Disease Control, West Virginia State Medicine and Surgery, Veterans Education College of Physicians and Surgeons, Department of Health Administration Columbia University CURRY, Mrs. Edward *DYGERT. H. Paul, M.D. ENNES, Howard Member, Kansas Regional Advisory DENSLOW, J. S., D.O. ashington-Alaska Regional Assistant Vice President Co@mmunity Council; Member, Board of Directors, Vice President Kirksville College of Member, W Osteopathy and Surgery; Member, Scientific Advisory Committee; Trustee, Washington Services and Health Education, Equitable American Heart Association and Kansas Review Subcommittee, Missouri Regional State Medical Association Life Assurance Society Heart Association Medical Program EASTWOOD, Richard T. ENSIGN, James M. -CURRY, John J., M.D. DETMER, L. M. Fiscal Agent and Secretary, Texas Regional Vice President Blue Cross Association Member, Maryland Regional Advisory Assistant Director, Division of Long-Term Advisory Committee; Executive Vice Committee; Maryland Heart Association Care, American Hospital Association president, Texas Medical Center, Inc., EVANS, Robert L., M.D. *DAILY Houston President, Association of Hospital Directors , Edwin F., M.D. DIANA, Joseph A., Jr. of Medical Education Health Insurance Plan of Greater New York Secretary to the Faculty, University of EDDS, M. V., Jr. DAVIS, Burnet M., M.D. Michigan Medical School Director of Medicine, Brown University,' *EVERIST, Bruce W., M.D. Chairman, Rhode Island Advisory member, National Advisory Council on Special Assistant for Continuing Education, *DIEZ-LEE, Marina, M.D. Committee Regional Medical Programs; Member, Extramural Programs, National Library of Chief, Medical Branch, Smithsonian Ad Hoc Committee for the Report to the Medicine Institution, Science Information Exchange EDWARDS, Charles C., M.D. President and the Congress; Green Clinic. DAVIS, Edwina *DIMOND, E. Grey, M.D. Director, Division of Socio-Economic Ruston, Louisiana Science Editor, Emory University Director, Scripps Clinic and Research Activities, American Medical Association FARBER, Sidney, M.D. DAWBER, Thomas R., M.D. Foundation EICHMAN, Peter L., M.D. Member, President's Commission on Program Coordinator, Tri-State Regional 'DREW, Frank E., M.D. Member, Wisconsin Regional Advisory Heart Disease, Cancer, and Stroke; Director Medical Program; Associate Professor of President, State Medical Society of Committee; Dean, University of Wisconsin of Research, Children's Cancer Research Medicine, Boston University Medical Center Wisconsin Medical School Foundation DEARING, W. Palmer, M.D. DRISCOLL, Dr. Edward J. ELAM, Lloyd C., M.D. F", Dr. Marion S. oman's Medical Executive Director, Group Health Associate Director for Extramural Programs, Dean, School of Medicine, Meharry Medical President Emeritus, W Association of America National Institute of Dental Research College College of Pennsylvania; Member, 85 President's Commission on Heart Disease, FORD, Malcolm J., M.D. GEHRIG, Leo J., M.D. GRAZE, Gerald Committee, New York Cancer, and Stroke Acting Program Coordinator, Florida Deputy Surgeon General, Public Health Member, Working Regional Medical Program; Florida State Service Metropolitan Regional Medical Program; FELGNER, Leonard Assistant to Dean, Albert Einstein College Board of Health GEIGER, Frank L., M.D. of Medicine Division of Hospital-Medical Facilities, FORDYCE, Alice Chief, Cancer, Heart Disease and T13 Silver Spring Albert and Mary Lasker Foundation Services, South Carolina State -GREENE, Laurence W., Jr., M.D. FELIX, Robert H., M.D. Board of Health Governor's Advisory Committee, WICHE; Member, Bi-State Regional Medical FORNEY, Vernon J., D.D.S. President-Elect Wyoming State Medical Program Committee on Organization; Dean, Regional Health Director,Public Health GENDEL, Evelyn, M.D. Association St. Louis University School of Medicine Service (Region V) Assistant Director, Maternity and Child *GRIZZLE, Claude O., M.D. FETTER, Franklin C., M.D. *FRANKLIN, Max S., M.D. Health, Kansas State Board of Health; Director, Wyoming Study Program, Dean and Vice President Medical College President, St. Louis Medical Society; Associate Professor, Preventive Medicine, Program of South Carolina Member, Si-State Regional Advisory Group Kansas University Medical Center Mountain States Regional Medical FRANTZ, Ivan D., Jr., M.D. GENTRY, John T., M.D. GRONVALL, John A., M.D. FISK, Shirley C., M.D. hool of Medicine, University Deputy Assistant Secretary (Health and Member of Executive Committee and Assistant Dean, School of Public Health, Acting Dean, Sc medical), Department of Defense Regional Advisory Group, Northlands University of North Carolina; Member, of Mississippi Medical Center Region; Research Professor of Medicine Board of Directors, North Carolina GROSSE, Robert N. FITZ, Reginald H., M.D. and Biochemistry, University of Minnesota Regional Medical Program office of Assistant Secretary for Program Program Coordinator, New Mexico Regional Medical School; President, Minnesota GILBERT, Robert P., M.D. Coordination, Department of Health, Medical Program; Dean, School of Medicine, Heart Association and Welfare University of New Mexico Associate Dean, Jefferson Medical College; FRECHETRE, Alfred L., M.D. Member, Greater Delaware Valley Regional GROVER, M. Roberts, Jr., M.D. FLAGLE, Dr. Charles D. Commissioner, Massachusetts Department Advisory Committee Director, Continuing Medical Education, Professor of Public Health Administration, of Public Health; Trustee of Tri-State University of Oregon Medical School; The John$ Hopkins School of Hygiene and organization, Tri-State Regional Medical GILES, Julian W., M.D. Program Coordinator, Oregon Regional Public Health Program Member, Alabama Regional Advisory Medical Program Committee; Hospital Director, Tuskegee *FLANAGAN, Thomas, M.D. FREYMANN, J. G., M.D. Veterans Administration Hospital GRULEE, Clifford G., M.D. Member, Central New York Regional Association of Hospital Directors of Dean, University of Cincinnati College of Medical Program Medical Education; Medical Director, Boston -GLADUE, J. Raymond, M.D. Medicine FLEMING, George M., Ed.D. Hospital for Women Special Consultant to Bureau of Health, Member, Texas Regional Advisory Group; FRIEDRICH, Rudolph, D.D.S. Social Security Administration; Baltimore GUTHRIE, Eugene H., M.D. Medical Administrator, Methodist Hospital, Director, Division of Oral Surgery, City Health Department; Private Practice, Assistant Surgeon General. Public Health Houston Columbia University Internal Medicine Service FLORIN, Alvin A., M.D. FULLARTON, Jane E. GOLDSTEIN, Gloria -HAGOOD, W. J., Jr., M.D. ram Coordinator, New Jersey Regional Office of the Director, Legislative Reference Assistant to the Dean, Medical College of Member, Virginia Regional Advisory Prog Committee; Medical Society of Virginia Medical Program; New Jersey State and Liaison Branch, National Institutes of Alabama Department of Health Health GRABER, Mrs. Joe Bales HAINES, Thom W Ph.D. as ;evelopment Office GALLAGHER, Joseph A., M.D. Director, Research FOLEY, Paul of Health Special Assistant to the Director, Bureau Public Health Service (Region IV) Administrative Assistant, Metropolitan Deputy Director, Bureau of Disease Prevention and Environmental Washington, D.C. Regional Medical Program Manpower, Public Health Service Control, Public Health Service -HALL, Wesley W., M.D. *FOLLMER, Hugh C., M.D. GALLIHER, Herbert P., Jr. GRAHAM, W. Donald, M.D. Chairman, Board of Trustees, American Associate Director, Mountain States Consultant; Department of Industrial Deputy Director, Hawaii Regional Medical Medical Association Regional Medical Program (Nevada) Engineering, University of Michigan Program; University of Hawaii School of HAMILTON, T. Stewart, M.D. FOOTE, Franklin M. GARCIA-PALMIERI, Mario R., M.D. Medicine Member, Connecticut Regional Advisory Committee; Executive Director, Hartford Member, Connecticut Regional Advisory Secretary of Health, Puerto Rico GRAPSKI, Lad F. Hospital; American Hospital Association Board; Commissioner of Health, State of Department of Health Chairman-elect, Executive Committee, Committee on P.L. 89-239 Connecticut GARDNER, Clair, D.D.S. Council on Teaching Hospitals, Association FORBES, Charles M. Chief, Program Planning, National Institute of American Medical Colleges; Director, HAMILTON, Wallace Director, Division of Support Activities, of Dental Research, National Institutes of Loyola University Hospital; Associate Dean, Director of Institutional Development, Memorial Sloan-Kettering Institute Health Loyola University Stritch School of Medicine Columbia City (Rouse Company) 86 HAMLIN, Frank H. HAYMAN, Charles, M.D. 'HILL, Lucius D., M.D. HOWE, Robert D. Chairman, Rochester Regional Advisory Member, Metropolitan Washington, D.C. Member, Executive Committee, Member, Mountain States Regional Group; New York State Hospital Review Advisory Committee; Associate Director, Washington-Alaska Regional Advisory Advisory Council; Hospital Administrator, and Planning Council; The Papec Company D.C. Department of Public Health Council; Washington State Medical Billings Deaconess Hospital HANDY, George H., M.D. HAYNES, Colonel Inez Association HOWELL, James T., M.D. Member, Planning Committee, Wisconsin General Director, National League for 'HILL, Luther, M.D. Member, National Advisory Council on Regional Medical Program; Assistant State Nursing Member, Board of Censors, Medical Regional Medical Programs; Member, Association of State of Alabama Ad Hoc Advisory Committee for the Health Officer, Wisconsin State Board of 'HECKLER, G. Barrett, M.D. Report to the President and the Congress; Health Chairman, Medical Education Committee, HILL, S. Richardson, Jr., M.D. Executive Director, Henry Ford Hospital HARDIN Robert C., M.D. Wilmington Medical Center Member, Alabama Regional Advisory Program Coordinator, Iowa Regional HEDMEG, Andrew, M.D. Committee; Dean, Medical College HOWELL, Harold N. Medical Program; Dean, College of Louisiana Regional Advisory Committee; of Alabama Managing Director, Blue Cross Association, Medicine, University of Iowa Utica, New York; Member, National Board President and State Health Officer, HINE, Maynard K., D.D.S. of Governors, Blue Cross Association HARDY, Robert C. Louisiana State Board of Health Immediate Past President, American Dental -HUDSON, Charles L., M.D. Executive Director, Oklahoma Health HEINTZELMAN, J. H. L., M.D. Association; Indiana University School of President, American Medical Association Sciences Foundation Director, Division of Medical Care, Dentistry HARKNESS, James P., Ph.D. Tennessee Department of Public Health HUGGINS, Perry M., M.D. Medical Sociologist, New Jersey College of HINES, Merrill O., M.D. Medical Director, East Tennessee Medicine and Dentistry HELLER, Ben I., M.D. Medical Director-Trustee, Ochsner Tuberculosis Hospital, Knoxville Acting Program Coordinator, Oklahoma Medical Center HARKNESS, Stuart F., D.O. Regional Medical Program; Professor and HUGHES, Gerald E., M.D. Administrative Dean, Michigan College of Head, Department of Laboratory Medicine, *HIRSCHBOECK, John S., M.D. Secretary for MAetings, American Academy Osteopathic Medicine University of Oklahoma Medical Center Program Coordinator, Wisconsin Regional of Pediatrics HARRELL, George T., M.D. HENDERSON, Robert R., M.D. Medical Program HULL, Edgar, M.D. Dean, College of Medicine, Medical Director, Hunterdon Medical Center HISCOCK, William Dean, Shreveport School of Medicine of Pennsylvania State University Office of Program Planning and Education, Louisiana State University; Member, HERRON, John T., M.D. Public Health Service Louisiana Regional Advisory Group HARRIS, Robert State Health Officer, Arkansas State HUME, Walter I., Jr., M.D. Supervisory Budget Examiner, Office of the Department of Health *HISCOE, D. Bonta, M.D. Member, Ohio Valley Regional Advisory Secretary, Department of Health, Education, *HESS, Orvan W., M.D. Michigan State Medical Society Council and Welfare Member, Connecticut Regional Advisory HOLECHEK, James A. HUMPHREY, George D., M.D. HARRISON, Bernard P. Committee; President, Connecticut State Public Relations Director, Maryland Member, Mountain States Regional Advisory Director, Legislative Department, American Medical Society Hospital Service, Inc. Council; President Emeritus, University Of Medical Association HICKS, Al HOLLOMAN, Frank Wyoming; Wyoming Chairman, Cancer HARTFORD, Thomas J., M.D. Public Information Officer, California Executive Director, Memphis Mid-South Crusade Vice President for Area Medical Programs, Regional Medical Program; Public Medical Center Council HUMPHREYS, George H., M.D. American Cancer Society Information Officer, School of Medicine, University of California, Los Angeles *HOLLOMAN, John L. S., Jr., M.D. Professor of Surgery, Columbia University HARVEY. A. M., M.D. President, National Medical Association College of Physicians and Surgeons; Director, Department of Medicine, The *HILDEBRAND, Paul R., M.D. Chairman, Physicians and Surgeons Johns Hopkins School of Medicine Director, Colorado.Wyoming Regional HOLTHAUS, Joseph M., M.D. Faculty Committee on Regional Programs HAY, George A. Program; Immediate Past President, Associate Dean of Medicine, Creighton HUNT, Andrew D., M.D. Administrative Vice President Woman's Colorado State Medical Society University Medical School; Member, iffee, Secretary, Michigan Regional Advisory Medical College of Pennsylvania; American HILL, Dudley A., M.D. Advisory Group and Executive Comm of Human Medicine, Nebraska-South Dakota Regional Medical Council; Dean, College Hospital Association Committee on Commissioner of Health, Niagara County Michigan State University P.L. 89-239 Health Department Program HILL,Joseph K., M.D. HOWARD, Ernest B., M.D. HUNTER, Thomas H., M.D. HAYES, John J. cellor for Medical Affairs, University Hospital Administration Specialist, President and Dean, Downstate Medical Assistant Executive Vice President, Chan Veterans Administration Central Office Center, State University of New York American Medical Association of Virginia School of Medicine 87 JOHNSON, Trois, M.D. KELLOW, William F., M.D. KISSICK, William L., M.D. HUTCHISON, Meryle V., R.N. Dean, Hahnemann Medical College Director, Office of Program Planning and Assistant Director, Washington, D.C. Regional Health Director, Public Health Evaluation, Office of the Surgeon General, office, American Nurses Association Service (Region 11) KELLY, Ann S. Public Health Service IREL.AND, Charles S., M.D. 'JONES, A. Curtis, Jr., M.D. American Association of Medical Record bia Member, Mountain States Regional Advisory Librarians KISTNER, Robert A., D.O. Member, Metropolitan District of Cofum Committee; President, Idaho State Medical Dean, Chicago College of Osteopathy Regional Advisory Committee; College of KEMBLE, Elizabeth L., R.N., Ed.D. E., Ph.D. Medicine, Howard University; Assistant Association Dean, School of Nursing, University of KLARMAN, Herbert tion, Medical Director, Freedmen's Hospital North Carolina Professor of Public Health Administra JONES, Edith A. The Johns Hopkins School of Public Health IRELAND, Ralph L., D.D.S. American Dietetic Association; Chief, KENDALL, Patricia L., Ph.D. M.D. President, American Association of Dental Nutrition Department, Clinical Center, Bureau of Applied Social Research, Queens KLIEGER, Philip A.,, Schools; Dean, College of Dentistry, National Institutes of Health College, New York Medical Consultant, Vocational University of Nebraska Rehabilitation Administration, Department 'JONES, Frank W., M.D. KENDRICK, General Douglas B., U.S.A. of Health, Education, and Welfare JACOBSEN, Carlyle F., Ph.D. Member, Board of Directors, North Carolina Commanding General, Walter Reed Army Chairman, Central New York Regional Regional Medical Program; President, North Medical Center KNUDSON, A. B. C., M.D. Advisory Group; President, Upstate Medical Carolina State Medical Society Director, Physical Medicine and Center, State University of New York KENNEDY, Thomas P., Jr. Rehabilitation Service, Veterans JONES, Warren L., M.D. Chairman, Tennessee Mid-South Regional Administration; immediate Past President, JACOBSON, Leon O., M.D. Vice Chairman, Planning Committee, Advisory Board American Academy of Physical Medicine Program Coordinator' Illinois Regional Nebraska-South Dakota Regional Medical an, University of KENNEY, Howard W., M.D. and Rehabilitation Medical Program; DeBiological Sciences Program; Assistant Dean, University of Member, Regional Medical Programs Chicago, Division Of South Dakota School of Medicine Review Committee; Medical Director, John KOLB, Mary Elizabeth JAMES, George, M.D. JORDAN, Edwin P., M.D. A. Andrew Memorial Hospital, Tuskegee, President, American Physical Therapy Member, Regional Medical rograms Executive Director, American Association of Alabama Association Review Committee; Member, Ad Hoe the Medical Clinics KOOMEN, Dr. Jacob Advisory Committee for the Report to KENNEY, John A., Jr., M.D. Member, North Carolina Regional Advisory President and the Congress; Dean, Mt. Sinai JORDAN, Harold B. Member, Metropolitan Washington, D.C. Committee; Director, North Carolina State School of Medicine Administrative Assistant to Dean and Public Regional Advisory Committee; Associate Board of Health Information Officer, College of Medicine, Professor and Head, Division of -JEHL, Joseph R., . - oward University College -KOWALEWSKI, Edward J., M.D. Chairman, New Jersey Ad Hoc Committee, Howard University Dermatology, H of Medicine Member, Regional Medical Programs Inc.; President, Medical Society of JOSEPHINE, Sister Ann Review Committee; Chairman of the Board New Jersey Member, Executive Committee, KERRIGAN, Gerald A., M.D. ican Academy of General Dean, Marquette University of Directors, Amer JOHNSON, Clifford F. lntermounta 'in Regional Advisory Council; School of Medicine. Practice Chief, office of Research information, President, Utah State Hospital Association, Office of the Director, National Institutes Administrator, Holy Cross Hospital KETTERING, Harvey E., It KREHL, William A., M.D. Executive Director, Baltimore Goodwill Chairman, Ad Hoc Committee of the of Health JOY, Dr. E. H. Industries, Inc. American Heart Association; Professor of JOHNSON, Emery A., M.D. Montgomery County, Maryland, Health KING, Dr. Imogene M. Medicine, Clinical Research Center. Assistant Director, Bureau of Indian Health, Department Division of Nursing, Public Health Service University Hospitals, Iowa City Public Health Service KAREL, Frank, III Associate Director of Public Relations, KING, M. Kenton KUSHNER, Daniel S., M.D. -JOHNSON, George D., M.D. The Johns Hopkins University and Hospital Dean, Washington University School of Director of Medical Services, Mt. Sinai President, South Carolina State Medical Medicine, St. Louis Hospital of Greater Miami Association KASSEL, Henry W., M.D. KINNARD, Charles M. LAND, Francis L., M.D. JOHNSON, Kenneth L. Regional Health Director, Public Health Vocational Rehabilitation Administration, Chief, Division of Medical Services, Bureau Public Relations Director for University of Service (Region Vill) Department of Health, Education, and of Family Services, Welfare Administration, Tennessee Medical Units -KAY, Raymond M., M.D. Welfare Department of Health, Education, and Member, California Regional Advisory KINZER, David M. Welfare; Representative of Council On -JOHNSON, Maxwell A., M.D. State Medical Committee; Southern California Permanente Executive Director, Illinois Hospital Medical Education to the Ad Hoc Committee President-Elect, Oklahoma Association on Education for Family Practice Association Medical Group 88 'LANG, Leonard P., M.D. LEVITT, Le Roy P., M.D. MALONEY, William F., M.D. McCLENAHAN, J. Everett, M.D. Medical Society of Delaware Dean, The Chicago Medical.School; Member, Dean of Medicine, Tufts University Member, Steering Committee, Western Coordinating Council of Medical Schools Pennsylvania Regional Medical Program; LANG, Robert A., M.D. and Teaching Hospitals of Illinois MANNARINO, Emanuele U., M.D. President, Pennsylvania Medical Society,, Executive Secretary, Academy of Medicine Chief, Neurosurgery Section, Department of Medical Director, McKeesport Hospital of Cleveland LEWIS, Irving J. Medicine and Surgery, Veterans Chief, Health and Welfare Division, Administration McCLURE, James A., M.D. LAWRENCE, Clifton F., Ph.D. Bureau of the Budget President, Kansas Medical Society Associate Secretary, American Speech LIEBERMAN, James, M.D. MARSH, Homer F., Ph.D. McCOMBS, Robert P., M.D. and Hearing Association Vice President, University of Tennessee; Member, Tri-State and Maine Regional Director, Audiovisual Facility, Communicable Representative, University of Tennessee. Advisory Committees; Professor of Graduate LAWTON, Robert P. Disease Center, Public Health Service Medical Units Medicine, Tufts University School of Associate Dean, School of Medicine Yale University; Member, Planning Committee, LINDEE, Robert G. "MARSHALL, John F., M.D. Medicine Connecticut Regional Medical Program Assistant Dean, Stanford University United Progress, Inc. McCORD, William M., M.D. LEE, Lyndon E., Jr., M.D. School of Medicine MARTIN, Dr. Samuel P. Chairman, South Carolina Regional Advisory Chief, Extra VA Research and Director of LINDSAY, Dale R., M.D. Provost, University of Florida Group; President, Medical College of Surgical Service, Veterans Administration Special Assistant to the Chancellor, College of Medicine South Carolina LEE, Philip R., M.D. Health Sciences, University of California, MASLAND, Richard L., M.D. McFADDEN, R. Bruce, M.D. Davis Medical Committee, Chronic Disease Assistant Secretary for Health and Director, National Institute of Neurological Section, Oregon State Board of Health Scientific Affairs, Department of Health, LOW, Richard J. Diseases and Blindness, National Institutes Education, and Welfare Executive Officer, Dartmouth Medical School of Health McGRANAHAN, Robert S. Health Sciences Editor, State University LEIN, John N., M.D. LUKEMEYER, George T. MASUR, Jack, M.D. of New York at Buffalo Assistant Dean and Director, University of Program Coordinator, Indiana Regional Director, Clinical Center and Associate Medicine; Member, Washington-Alaska Medical Program; Associate Dean for Director, Clinical Care Administration, McHUGH, Thomas J. Regional Advisory Committee Continuing Education, Indiana University National Institutes of Health Member, Western New York Regional School of Medicine Advisory Council; Administrator, Emergency ILEINBACH, Samuel P., M.D. MATTINGLY, Thomas W., M.D. Hospital, Buffs o Iowa State Medical Society LUMMIS, Wilbur S., Jr., M.D. Program Coordinator, Metropolitan Deputy Director, Hawaii State Department Washington, D.C. Regional Medical Program; 'MCKEAN, Robert S., M.D. LE MAISTRE, Charles M., M.D. of Health District of Columbia Medical Society Director, Mountain States Regional Medical Program Coordinator, Texas Regional Program (idaho) Medical Program; Vice Chancellor, *LYNCH, Richard V., Jr., M.D. MATTISON, Berwyn F., M.D. Chairman, Executive Committee, West Executive Director, American Public Health McNULTY, Matthew F., Jr. Health Affairs, University of Southern Texas, Member, Alabama Regional Advisory Board; Austin Virginia Regional Medical Program; West Association Director, Council of Teaching Hiispitals LE ROY, George V., M.D. Virginia State Medical Association MAYER, Andrew, M.D. "MCPHAIL, Frank L., M.D. Medical Director, Metropolitan Hospital, LYONS, Richard H., M.D. Assistant Director, Professional Activities, Director, Mountain States Regional Medical Detroit Program Coordinator, Central New York American College of Surgeons Program (Montana) Regional Medical Program; Professor and LESSER, Arthur J., M.D. Chairman, Department of Medicine, State MAYES, William F., M.D. MEADOW, Henry C. Deputy Chief, Children's Bureau, Welfare University of New York, Upstate Medical Member, Board of Directors, North Carolina Associate Dean, Harvard Medical School Administration, Department of Health, Center Regional Medical Program; Dean, School MEADS, Manson, M.D. Education, and Welfare of Public Health, University of North Dean, The Bowman Gray School of Medicine MACER, Dan J. Carolina of Wake Forest University LEVINE, Peter B. Director, Veterans Administration Hospitals, Coordinator, Program in Health and Pittsburgh; Member, Executive Committee, McBEATH, William H., M.D. MEEK, Peter G. Hospital Administration, University of Council of Teaching Hospitals Program Coordinator, Ohio Valley Regional Executive Director, National Health Council Colorado Medical Center Medical Program "MAC LAGGAN, James C., M.D. MEILING, Richard L., M.D. LEVINE, Rachmiel, M.D. Member, Coordinating Committee, ';McCALLIE, David P., M.D. Dean, College of Medicine, Ohio State Professor and Chairman, Department of California Regional Medical Program; Private Practitioner, Chattanooga, University; Program Coordin'ator, Ohio Medicine, New York Medical College President, California Medical Association Tennessee Regional Medical Program 89 MEINERSHAGEN, Charles W., M.D. MORSE, Robert W. NEMIR, Paul, Jr., M.D. ORGANICK, Avrum B., M.D. Member, Cleveland Regional Advisory Director, Division of Graduate Medicine and Assistant Coordinator, Wisconsin Regional Director, Section of Chronic Diseases, Committee; President, Case Institute of Associate Professor of Surgery, University Medical Program; Assistant Dean, Marquette Missouri Division of Health; Member, University School of Medicine Scientific Subcommittee, Missouri Technology of Pennsylvania School of Medicine Regional Medical Program MOSES, Campbell. M.D. NICHOLSON, Hayden C., M.D. O'ROURKE, Edward, M.D. Member, Western Pennsylvania Regional Dean and Vice President for Medical Assistant Director, Bureau of Health MENGER, James M. Advisory Committee; Medical Director, Affairs, University of Miami School of Services, Public Health Service Staff Assistant, House Committee on American Heart Association Medicine PALMQUIST, Emil E., M.D. Interstate and Foreign Commerce, Regional Health Director, Public Health U.S. House of Representatives MOU, Thomas W., M.D. NIGAGLIONI, Adin, M.D. Associate Director, Central New York State Chancellor, Medical Sciences Campus, Service (Region III) MERCER, Dr. Sherwood R. Regional Medical Program; Associate University of Puerto Rico School of PARKER, Ralph C., Jr., M.D. Vice President and Dean, Philadelphia Professor of Preventive Medicine, State Medicine Program Coordinator, Rochester Regional College of Osteopathy University of New York, Upstate Medical NILSON, George T., M.D. Medical Program; Clinical Associate -MEREDITH, Lawrence C., M.D. Center Field Director, Bingham Associates Fund; Professor of Medicine, University of President, Ohio State Medical Association MUELLER, Ralph R. Secretary, Applicant Agency, Maine Regional Rochester Medical Center MERRILL, Joseph R., M.D. Budget Examiner, Bureau of the Budget Medical Program PARKS, John, M.D. Chief, General Clinical Research Centers MURTAUGH, Joseph S. NINE-CURT, Jos6, M.D. Dean, George Washington University Branch, Division of Research Facilities and Chief, Office of Program Planning, Office Resources, National Institutes of Health of the Director, National Institutes of Health Director, School of Public Health, University School of Medicine of Puerto Rico School of Medicine PASCASIO, Anne, Ph.D. MILLER, Brewster S., M.D. MUSSER, Marc J., M.D. I NORTH, John Paul, M.D. Member, Regional Medical Programs Medical Director, United Cerebral Palsy Executive Director, North Carolina Regiona Director, American College of Surgeons Review Committee; Associate Research Research and Education Foundation, Inc. Medical Program; Professor of Medicine. Professor, School of Nursing, University Duke University School of Medicine NOVITCH, Mark, M.D. of Pittsburgh MILLER, George E., M.D. NADEL, E. M., M.D. Office of the Assistant Secretary (HSA), Member, Regional Medical Programs Chief, Pathology and Laboratory Medicine, Department of Health, Education, and PATE, James W., M.D. Review Committee; Director, Office of Welfare Program Coordinator, Memphis Regional Research in Medical Education, College of Veterans Administration Central Office Medical Program; Professor of Surgery. Medicine, University of Illinois NAHM, Dr. Helen NYBERG, Charles E. University of Tennessee .MILLER, J. E., M.D. Dean, School of Nursing, University of Assistant Executive Director, American California, San Francisco Academy of General Practice PATTERSON, Dr. Athol J. Chairmar?, Board of Chancellors, Acting Head, Division of Public Health American College of Radiology NEFF, Kenneth, M.D. -NYE, Dan A., M.D. Administration, Tulane University ShcOOt .MILLIKAN, Clark H., M.D. Administrative Director, Nebraska-South President Nebraska State Medical of Medicine Member, Natior?al Advisory Council On Dakota Regional Medical Program; Executive Association Regional Medical Programs; Secretary, Nebraska State Medical 'O'BRIEN, William A., II[, M.D. PATTERSON, Joye, Ph.D. Consultant in Neurology, Mayo Clinic Association Publications Director, University of Member, Mountain States Regional Advisory Missouri Medical Center MILLS, Russell C., Ph.D. NEIBEL, Oliver J., Jr. Committee (Nevada); Chairman, Nevada Program Coordinator, Kansas Regional Executive Director and General Counsel, State Medical Association Professional PATTISHALL, Dr. Evan College of American Pathologists Education and Research Committee Professor and Chairman, Department of Medical Program; Associate Dean, Behavioral Science, Pennsylvania State University of Kansas Medical Center NELLIGAN, William D. O'DOHERTY, Desmond S., M.D. University College of Medicine Executive Director, American College of Chairman, D.C. Medical Society Committee MONAHAN, Jack F. Cardiology on Regional Medical Programs; American -PAUL, Oglesby, M.D. Executive Director, Florida Hospital Academy of Neurology; Medical Director, Chairman, Illinois Regional Advisory Association NELSON, Kinloch, M.D. Georgetown Hospital Committee; Professor of Medicine, Program Coordinator, Virginia Regional Northwestern University School of Medicine ,MORGAN, Robert J., M.D. Medical Program; Dean, Medical College of OGDEN, C. Robert President-Elect, Nebraska State Medical Virginia Member, Washington-Alaska Regional PEAVY, James E., M.D. Association; Chairman, Steering Committee, Advisory Board; President, North Coast Commissioner of Health, Texas State Nebraska-South Dakota Regional Medical NELSON, Russell A., M.D. Life Insurance Company Department of Health Progra m President, The Johns Hopkins Hospital 00 PEEPLES, William J.. M.D. 'RAYMOND, William H., M.D. ROGERS, Arthur M. ISAWARD, Ernest, M.D. Temporary Program Coordinator, Maryland Member, Albany Regional Advisory Council; Chairman, Connecticut Regional Advisory Medical Director, The Permanents Clinic, Regional Medical Program; Commissioner, Medical Society of New York State Committee; Director of Traffic, Scoville Portland; Kaiser Foundation Health Plan Maryland State Department of Health REIDY, William G. Manufacturing Co. SCHAEFFER, Joseph N., M.D. PELLEGRINO, Edmund D., M.D. Association of American Medical Colleges ROGERS, David E., M.D. Professor and Chairman, Department of Member, National Advisory Council on RICHARDSON, Arthur P., M.D. Member, Regional Medical Programs Review Physical Medicine and Rehabilitation, Regional Medical Programs and Ad Hoc Chairman, Georgia Regional Adviso Committee; Professor of Medicine, Rehabilitation institute, Wayne State 'y University Advisory Committee for the Report to the Group; Dean, Emory University School of Vanderbilt University School of Medicine President and the Congress; Director, Medicine ROSE, John C., M.D. SCHEELE, Leonard A., M.D. Medical Center, State University of New RICHWAGEN, Lester E. Dean, Georgetown University School of President, Warner Lambert Research York, Stony Brook Professor of Hospital Administration, Medicine Institute; Former Surgeon General, Public PENROD, Kenneth E., M.D. Mary Fletcher Hospital, Burlington, Vermont ROSENOW, Edward C., Jr., M.D. Health Service Member, Indiana Regional Advisory -RIFNER, Eugene S., M.D. Executive Director, American College of SCHLOTFELDT, Rozelia M. Committee; Provost, Indiana University President, Indiana State Medical Association Physicians Dean and Professor of Nursing, School Medical Center RIVALL, J. W. ROSINSKI, Dr. Edwin F. of Nursing, Western Reserve University PENDLETON, John L. Member, Executive Committee, Northlands Office of the Secretary, Department of SCHMIDT, Alexander M., M.D. Chief, Grants Programming and Regional Medical Program; Hospital Health, Education, and Welfare Assistant Dean, University of Utah Coordination, Public Health Service, Administrator, Eitel Hospital, Minneapolis ROSS, Mabel, M.D. SCHNAPER, Harold W., M.D. National Center for Chronic Disease Control ROBBINS, Guy F., M.D. Regional Health Director, Public Health Associate Director, Research Service, PHILLIPS, Basil A. Director of Planning, Memorial Sloan- Service (Region 1) Veterans Administration Control Office Administrative Director, Tennessee Kettering Cancer Center ROSS, Ralph H. -SCHNEIDER, Margaret J., M.D. Mid-South Regional Medical Program ROBBINS, Lewis C., M.D. Member, Northern New England Regional American Medical Woman's Association POLICOFF, Leonard D., M.D. Consultant, Health Hazards Appraisal, Advisory Board Member, Planning Committee, Albany National Center for Chronic Diseases SCHWARTZ, Herbert A. ROWDEN, Dorothy Public Relations, American Cancer Regional Medical Program; Chairman, 'ROBERTS, David L., M.D. Assistant to the President, The John and Society, Inc. Albany Subcommittee on Stroke; Professor Regional Director, Mountain States Regional Mary R. Markle Foundation and Chairman, Department of Physical Medical Program (Nevada) RUHE, C. H. William, M.D. SCHWARTZ, Mortimer L., M.D. Medicine and Rehabilitation, Albany ROBERTS, Dean W., M.D. Associate Secretary, Council on Medical Member, New Jersey Regional Advisory Medical Center Committee; Professor of Medicine, Director of Greater Delaware Valley Regional Education, American Medical Association, POPMA, Alfred M., M.D. Medical Program at Hahnemann Medical Member, Regional Medical Programs Review New Jersey College of Medicine Regional Director, Mountain States Regional College; Department of Community Committee and Ad Hoc Advisory Committee *SCRIVNER, W. C., M.D. Medical Program (Idaho); Member, National Medicine, Hahnemann Medical College for the Report to the President and Illinois State Medical Society Advisory Council on Regional Medical the Congress Programs ROBERTSON, George J., M.D. SESSOMS, Stuart M., M.D. Chairman, Committee of Application, RUSK, Howard A., M.D. Deputy Director, National Institutes of PORTES, Caesar, M.D. Tri-State Regional Medical Program; Director, Institute of Rehabilitation Medicine, Health President, Illinois State Medical Society; Bingham Associates Fund; Assistant New York University Medical Center Medical Director, Cancer Prevention Center Professor of Medicine, Tufts University SHAFFNER, Louis, M.D. of Chicago School of Medicine and Dentistry ISABATIER, Joseph A., Jr., M.D. Associate Professor of Surgery, Bowman PRIMAS, H. R., Jr., D.D.S. ROBERTSON, J. D., D.M.D. Member, Louisiana Regional Advisory Gray School of Medicine President National Dental Association Cancer Control Branch, Public Health Committee; President, Louisiana State SHANHOLTZ, Mack I., M.D. Service Medical Society Member, National Advisory Council on RAMMELKAMP, Charles, M.D. Member, Cleveland Regional Advisory ROBINS, Hugh B., M.D. SANAZARO, Paul J., M.D. Regional Medical Programs; Member, Committee; Professor of Medicine, Western Allegheny County Health Department Director, Division of Education, Virginia Regional Medical Program; State Reserve University Association of American Medical Colleges Commissioner of Health, Virginia ROEMER, Milton I., M.D. Department of Health RAUSCH, Verna Professor of Public Health, School of SARGEANT, John SHANNON, James A., M.D. President American Society of Medical Public Health, University of California, Executive Secretary, Medical and Technologists Los Angeles chirurgical Faculty of Maryland Director, National Institutes of Health 91 SPIELHOLTZ, Jess B., M.D. STRONACH, William C. rican College of Hospital Administrator, University of Member, Washington-Alaska Regional Executive Director, Ame SHEEHAN, John F., M.D. I Center and Arkansas Medical Center Advisory Council; Deputy Director, Radiology vice President for Medica Ph.D. Washington State Department of Health STURM, Herman M. tics, U.S. Department De'an, Loyola University Stritch School of SMITH, Harvey L-, Bureau of Labor Statis Program Coordinator, North Carolina ries C., M.D. Medicine Regional Medical Program; Professor Of SPRAGUE, Cha medicine, Tulane of Labor SHEPS, Cecil G., M.D, Sociology, University of North Carolina Dean, School Of er, Louisiana Regional SUAREZ, Ram6n M., M.D. General Director, Beth Israel Medical University; Memb Medical Society of Puerto Rico; Director, -SMITH, Robert, M-D. Advisory committee Clinices; Center, New York City Mississippi Medical and Surgical Society Fundacion de lnvestigaciones -SPRING, William C., Jr.. M.D. Professor of Clinical and Experimental University of SHERMAN, Charles D., Jr., M.D. SMITH, Robert Leslie, M.D. blic Health Program Coordin ator, Greater Delaware Medicine (ad honorem), Chairman, Subcommittee on Cancer, Regional Health Director, Pu Valley Regional Medical Program Puerto Rico Rochester Regional Medical Program; Service (Region IX) SUMMERALL, Charles P., III, M.D. Clinical Associate Professor of Surgery, STACEY, John M. of Rochester Medical Center; SMITH, Robert M. edical Program Coordinator, South Carolina Univ Chief, Hospital insurance Branch, Division Director, University of Virginia M Reional Medical Program; Associate, New j State Medical Society of Health insurance, Social Security Center Department of Medicine, Medical College SHOREY, Winston K., M.D. Administration STEBBINS, Ernest L., M.D. of South Carolina Chairman, 'Arkansas Regional Advisory SMYTHE Chaves M., M.D Dean, School of Hygiene and Public SURGENOR, Douglas M., Ph.D. Group; Dean, University of Arkansas Director,'Assc)ciatiOn of American Medical Health, The Johns Hopkins University Program Coordinator Western New York Schoolof School of Medicine Colleges STEPHAN, pauiine H. Regional Medical Program; Dean, SIBLEY, Hiram ital Planning SNODGRASS 'Glen staff Assistant, office of the Director, medicine, state University of Nev York Executive Director, Hosp Assistant to the Dean, School Of Medicine, National Cancer Institute, National at Buffalo Council for Metropolitan Chicago University Of California, Davis Institutes of Health SUTER, Emanuel, M.D- ge of SIFONTES, Jose E., M.D. SNYDER, Joseph E., M.D. Dean, The University of Florida Colle , School of Medicine, University Of Assistant Vice President Presbyterian STEPHENSON, Sam E., Jr,, M.D. Tennessee Medicine Dean Hospital, New York City; Hospital Chairman, Visitation Committee. Puerto Rico Mid-South Regional Medical Program; , of TABLEMAN, Betty SIGMOND, Robert M. Association of New York State Associate Professor of Surgery, Schoo Assistant to State Has ith Director, Michigan Executive Director. Hospital Planning SOLOCHEK, Bernard Medicine, Vanderbilt University Department of Public Hearth Council of Allegheny County Barkin, Herman and Associates STEWART, Thomas B. -TAYLOR, George E., M.D. ittee, Rochester SIMARD, Ernest E., M.D. SORG, Nathan F. Member, Washington-Alaska Regional Member, Planning COMM !dent, College of American Pathologists; Member, Iowa Regional Advisory Committee Advisory Committee; Judge of the Superior Regional Medical Program; Rochester Pres pathology, Salinas t Alaska Regional Hospital Council Chief, Department of ital SOULES@ Mary E., M.D. Montana State Court, State of Alaska; Presiden TERRY, Luther L., Valley Memorial Hosp Director, Disease Control, Heart Association M-D. vice President for Medical Affairs, SIMS, Helen M. Board of Health *STICKNEY, J. Minott, M.D. y[vania; Former Director of Informational Services, SPARKMAN, Donal R., M.D. Program Coordinator, Northiands Regional University Of Penns- blic Health Service University of Kansas Medical Center Program Coordinator, Washington-Alaska Medical Program; Consultant in Medicine, Surgeon General, Pu Regional Medical Program; Associate Mayo Clinic THOMA, George E-, M.D. uls SLATER, Robert J., M.D- Former Member, National Advisory Council Professor of Medicine, University Of STONE, William S-, M.D. Assistant to the Vice President St. Lo on Regional Medical Programs; Washington School of Medicine Dean, University of Maryland School Of University Medical Center I Consultant; Director, Association for the SPEERS, James F., M.D. THOMAS, Mrs. David N. tive and Aid of Crippled Children Deputy Commissioner, Iowa State Medicine Member, West Virginia Execu Board, Department of Health; Member, Iowa STOREY, Patrick 13., M.D. ember, National SLFF-TH, Clark K., M.D. community Medicine, Advisory Boards; M Member, Ad Hoc Advisory Committee for the Regional Advisory Group Professor of of community Health, American Cancer Society Report to the President and the Congre!Sl. SPENCER, William A., M.D. Department John F., M.D. rdinator, West Virgt Advisory Group; Hahnemann Medical College *THOMAS, council; Acting Program COO pl@ Member, Texas Regional Member, Texas Regional Advisory gram, Dean, School Or professor and Chairman, Department of Regional Medical Pro iversity College of STRICKLER, James C., M.D. New York Member, Committee on Cancer, Texas medicine, West Virginia University Rehabilitation, Saylor Un institute for Assistant to the President, The Medical Association SLEIGHT, Robert.E. Medicine; Director, Texas Hospital-Cornell Medical Center member, Arkansas Regional Advisory Group; Rehabilitation 92 THOMPSON, G. D. Carlyle, M.D. @RER, Ray A., M.D. WALKER, James E. C., M.D. WHITNEY, John M., M.D. Member, Intermountain Regional Advisory President, Memphis-Shelby County Medical Chairman, Research and Evaluation Regional Health Director, Public Health Committee; State Director of Public Health, Society Committee; Member, Advisory Committee, Service (Region VI) Utah States Health Department ULSTROM, Dr. Robert A. Connecticut Regional Medical Program; -WHITTAKER, L. A., Jr., M.D. THOMPSON, Spencer B., M.D. Professor of Medicine, University of President, Arkansas Medical Society Associate Dean, University of Minnesota Connecticut School of Medicine Interim Planning Director, Texas Regional College of Medical Sciences WHITTEN, E. B. Medical Program (Galveston); Assistant -VADHEIM, A. L., M.D. WALTER, William A., M.D. Director, National Rehabilitation Association Dean, University of Texas Medical Branch President, Montana State Medical Chief, Special Programs Branch, National WICKS, Edwin O., M.D., Dr. P.H. 'TILLMAN, Walter W., Jr., M.D. Association; Member, Mountain States Cancer Institute, National Institutes of Member, Steering Committee, New Mexico Vice Chairman, Missouri Regional Regional Advisory Committee Health Regional Medical Program; Director, New Advisory Council *TOMITA, Theodore, M.D. VAN NESS, Edward H. WARD, Paul D. Mexico Department of Public Health President, Hawaii Medical Association Executive Secretary, New York State Joint Program Coordinator, California Regional WILBAR, Charles L., Jr., M.D. TOOMEY, Robert E. Council on Regional Medical Programs Medical Program Secretary of Health, Pennsylvania State Member, South Carolina Regional Advisory VAN ORMAN, William T., Ed.D. WARREN, James V., M.D. Department of Health Committee; Hospital Administrator, Regional Health Director, Department of Professor of Medicine, Ohio State University WILLARD, Harold N., M.D. Greenville Hospital System Health, Education, and Welfare (Region Vill) College of Medicine Thayer Hospital Rehabilitation Center, TOUSIGNAUT, Dr. Dwight R. *VAUGHAN, William O., M.D. Waterville, Maine Director of Professional Practice, American Tennessee Medical Association; Associate WATTS, Charles D., M.D. *WILLIAMS, Jasper F., M.D. Society of Hospital Pharmacists Medical Director, North Carolina Mutual Chairman, Council on Hospitals and Professor, Pediatrics, Vanderbilt University Life Insurance Company 'TOMPKINS, Harvey J., M.D. School of Medicine Medical Education, National Medical President, American Psychiatric Association VAYDA, Eugene, M.D. *WATTS, Richard W., M.D. Association *TOWNSEND, Thomas E., M.D. Medical Director, Community Health Member, Steering Committee, Cleveland WILLIAMSON, Kenneth Member, Arkansas Regional Advisory Foundation Regional Medical Program; Chairman, Director, Washington Service Bureau, Committee; Arkansas Medical Society VIGORITO, Thomas F., D.O. Professional Education Committee, Heart American Hospital Association Association, Northeast Ohio *TFTAEGER, Cornelius H., M.D. Dean, College of Osteopathic Medicine WILSON, David B., M.D. Member, National Advisory Council on and Surgery, Des Moines WEGMAN, Dr. Myron E. Hospital Director, University of Mississippi Regional Medical Programs VOLKER, Joseph. F., D.M.D., Ph.D. Dean, School of Public Health, University Medical Center,, President-Elect, American TRUSSELL, Ray E., M.D. Vice President for Birmingham Affairs and of Michigan Hospital Association Member, Ad Hoc Advisory Committee for Director of the Medical Center, University the Report to the President and the of Alabama in Birmingham WELLS, Joseph A., M.D. WILSON, Leslie Associate Dean, Northwestern University President American Society of Radiologic Congress; Director, Columbia University WAGNER, Henry N., M.D. Technologists; Department of Radiology, School of Public Health and Administrative Director, Nuclear Medicine, The Johns *WESTLAKE, Robert E., M.D. University of Missouri Medical Center Medicine Hopkins Hospitals Member, Ad Hoc Committee for the Report to the President and the Congress WILSON, Marjorie P., M.D. TUREN, Milton WAKERLIN, George E., M.D., Ph.D. Associate Director for Extramural Programs, Budget Analyst, Bureau of the Budget Program Director, Missouri Regional WHALEY, Storm National Library of Medicine TURIEL, Samuel N. Medical Program Vice President for Health Sciences, WILSON, Vernon E., M.D. Executive Director, Association of Hospital *WALKER, A. Earl, M.D. University of Arkansas Program Coordinator, Missouri Regional Directors of Medical Education Professor of Neurological Surgery, The *WHISNANT, J. P., M.D. Medical Program; Dean, School of Medicine, TURNER, Thomas B., M.D. Johns Hopkins University School of Mayo Foundation Director for Northiands University of Missouri Medicine Regional Medical Program; Associate Member, Steering Committee, Maryland WILSON, William L., M.D. Regional Medical Program; Dean, The WALKER, Cornelia B., M.D. Professor of Neurology, Mayo Graduate Professor of Medicine, University of Texas, Johns Hopkins School of MedicirFe Director, Heart Disease Control Program, School of Medicine South Texas Medical School; Progam TWISS, Maurine C. New Hampshire State Medical Society,, WHITE, Joseph M., M.D. Director, Texas Regional Medical Program Director of Public Information, University New Hampshire State Health Department Ex-Officio Member, Oklahoma Regional (San Antonio) of Mississippi Medical Center, Member, WALKER, Howard, Ph.D. Medical Program; Associate Director and *W"TEN, Carroll L., M.D. Pre-Planning Committee, Mississippi Director, Statewide Academic Extension Associate Dean, University of Oklahoma President, American Academy of General Regional Medical Program Service. University of Kansas Medical Center Practice 93 Appendix 3-National Advisory Council Review Committee Ad Hoc Committee for the Report WITTRUP, Richard D. NATIONAL ADVISORY COUNCIL George E. Moore, M.D. Edwin L. Crosby, M.D. Director Director Member, Ohio Valley Regional Advisory ON REGIONAL MEDICAL PROGRAMS Roswell Park Memorial institute American Hospital Association Committee; Administrator, University of Leonidas H. Berry, M.D. Buffalo, New York Chicago, Illinois Kentucky Hospital Professor, Cook County Graduate -William J. Peeples, M.D. George James, M.D. (Chairman) WITTSON, Cecil L., M.D. School of Medicine commissioner of Health Dean Member, Executive Committee, Nebraska. Senior Attending Physician Maryland State Department of Health Mount Sinai School of Medicine South Dakota Regional Medical Program; Michael Reese Hospital Baltimore, Maryland New York, New York Dean, College of Medicine, University of Chicago, Illinois Nebraska Edmund D. Pellegrino, M.D. Howard W. Kenney, M.D. *Mary 1. Bunting, Ph.D. Director of the Medical Center Medical Director WOOLFORD, Robert M., M.D. President State University of New York John A. Andrew Memorial Hospital Member, Ohio Valley Regional Advisory Radcliffe College Stony Brook, New York Tuskegee Institute Committee Cambridge, Massachusetts Tuskegee, Alabama WOOLSEY, Frank M., Jr., M.D. *Gordon R. Cumming Alfred M. Popma, M.D. Program Coordinator, Albany Regional Administrator Regional Director Edward J. Kowalewski, M.D. Medical Program; Professor of Post- Sacramento County Hospital Mountain States Regional Medical Program Chairman, Committee of Environmental Graduate Medicine, Albany Medical Center Boise, Idaho WOZAR, Louis Sacramento, California Mack 1. Shanholtz, M.D. Medicine Member, Ohio Valley Regional Advisory Michael E. DeBakey, M.D. State Health Commissioner Academy of General Practice committee Professor and Chairman State Department of Health Akron, Pennsylvania Department of Surgery Richmond, Virginia George E. Miller, M.D. WRIGHT, Jane C., M.D. ga@for University Member, President's Commission on Heart Houston, Texas 'Robert J. Slater, M.D. Director, Cbnter for Medical Education Disease, Cancer, and Stroke; Adjunct Dean, College of Medicine College of Medicine Associate Professor of Research Surgery, Bruce W. Everist, Jr., M.D. University of Vermont University of Illinois New York University School of. Medicine Chief of Pediatrics Burlington, Vermont Chicago, Illinois WRIGHT, Thomas H., Jr. Green Clinic William H. Stewart, M.D. (Chairman) Anne Pascasio Member, North Carolina Regional Advisory Ruston, Louisiana Surgeon General , M. D. Committee; Wright Chemical Corporation Charles J. Hitch Public Health Service Associate Research Professor YAKEL, Ruth M. Vice President for Administration Bethesda, Maryland Nursing School, University of Pittsburgh Executive Director, American Dietetic University of California Pittsburgh, Pennsylvania Berkeley, California Cornelius H. Traeger, M. D. Association New York, New York Samuel H. Proger, M.D. YEAGER, J. Franklin, M.D. John R. Hogness, M.D. Professor and Chairman Silver Spring, Maryland Dean, School of Medicine Depattment of Medicine University of Washington REGIONAL MEDICAL PROGRAM YERBY, Alonzo S., M.D. Seattle, Washington REVIEW COMMITTEE Tufts University School of Medicine Member, Tri-State Regional Advisory President, Bingham Associates Fund Committee; Professor and Head, James T. Howell, M.D. Mark Berke Boston, Massachusetts Department of Health Services Executive Director Director Administration, Harvard School of Public Henry Ford Hospital Mount Zion Hospital and Medical Center David E. Rogers, M.D. Health Detroit, Michigan San Francisco, California Professor and Chairman .YLVISAKER, John R., M.D. -J. Willis Hurst, M.D. Kevin P. Bunnell, Ph.D. Department of Medicine Professor and Chairman Associate Director School of Medicine Pontiac, Michigan Department of Medicine Western Interstate Commission for Vanderbilt University YLVISAKER, Paul N., Ph.D. Emory University School of Medicine Higher Education Nashville, Tennessee Commissioner, New Jersey Department of Atlanta, Georgia Boulder, Colorado Community Affairs; Member, Ad Hoc ident Clark H. Milliken, M.D. C. H. William Ruhe, M.D. Committee for the Report to the Pres Consultant in Neurology -*Sidney B. Cohen Assistant Secretary and the Congress Management Consultant Mayo Clinic Silver Spring, Maryland Council on Medical Education YODER, Franklin D., M.D. Rochester, Minnesota American Medical Association Vice Chairman and Director of Public .*Deceased, April 1967 Chicago, Illinois Health, Illinois Department of Public Health *Former member 94 Appendix @Division Staff Robert J. Slater, M.D. Boisfeuillet Jones PRINCIPAL STAFF OF The Grants Management Branch interprets Executive Director Director THE DIVISION OF grants management policies and reviews The Association for the Aid of Emily and Ernest Woodruff Foundation REGIONAL MEDICAL PROGRAMS budget requests and expenditure reports. Crippled Children Atlanta, Georgia Chief ................... James A. Beattie New York, New York Charles E. Odegaard, Ph.D. The Office of the Director provides program John D. Thompson President leadership and direction. Director, Program in University of Washington Director .......... Robert Q. Marston, M.D. The Grants Review Branch handles the pro- Hospital Administration Seattle, Washington fessional and scientific review of applica- Professor of Public Health Assistant Director tions and progress reports. School of Public Health Edmund D. Pellegrino, M.D. for Program Policy .......... Karl D. Yordy Acting Chief ............ Martha L. Phillips Yale University Director New Haven, Connecticut Medical Center Associate Director Head, Operations Section .... Lorraine Kyttle Kerr L. White, M.D, State University of New York for Continuing Director, Division of Medical Care Stony Brook, New York Education ......... William D. Mayer, M.D. The Planning and Evaluation Branch ap- and Hospitals Carl Henry William Ruhe, M.D. Executive Officer ........ Charles Hilsenroth praises and reports on overall program goals, School of Hygiene and Public Health Assistant Secretary progress and trends and provided staff work The Johns Hopkins University Council on Medical Education Assistant to Director for the Surgeon General's Report to Congress Baltimore, Maryland American Medical Association for Systems and required under Section 908 of Public Law Chicago, Illinois Statistics . . @.......... Maurice E. Odoroff 89-239. AD HOC COMMITTEE FOR Clark K. Sleeth, M.D. Assistant to Director Chief ............... Stephen J. Ackerman THE REPORT TO THE PRESIDENT Dean for Communications and Assistant Chief ............ Daniel 1. Zwick AND THE CONGRESS School of Medicine Public Information ... Edward M. Friedlander West Virginia University Head, Planning Section Roland L. Peterson Ray E. Brown, L.H.D. Morgantown, West Virginia Public Information Officer ..... Harold Wolfe Director Graduate Program in Hospital Ray E. Trussell, M.D. Administration Director The Continuing Education and Training Duke University Medical Center School of Public Health and Branch provides assistance for the quality Durham, North Carolina Administrative Medicine development of such activities in Regional Michael E. DeBakey, M.D. Columbia University Medical Programs. Professor and Chairman New York, New York Department of Surgery Burton Weisbrod, Ph.D. Chief ............. William D. Mayer, M.D. College of Medicine Associate Professor Assistant to Chief ......... Cecilia Conrath Saylor University Department of Economics Houston, Texas University of Wisconsin Head, Evaluation Bruce W. Everist, Jr., M.D. Madison, Wisconsin Research Group .... Frank L. Husted, Ph.D. Chief of Pediatrics Robert E. Westlake, M,D. Green Clinic Syracuse, New York Ruston, Louisiana Storm Whaley (Chairman) The Development and Assistance Branch, James T. Howell, M. D. Vice President of Health Sciences serves as the focus for two-way communica- Executive Director University of Arkansas Medical Center tion between the Division and the individual Henry Ford Hospital Little Rock, Arkansas Regional Medical Programs. Detroit, Michigan Paul N. Ylvisaker, Ph.D. Chief ............ Margaret H. Sloari-, M.D. George James, M.D. Commissioner Head, Liaison Section Ian Mitchell, M.D. bean New Jersey Department of Mount Sinai School of Medicine Community Affairs Head, Clinical New York, New York Trenton, New Jersey Programs Section ......... Philip A. Klieger 95 Appendix 5-Directory of Regional INDEX Medical Programs OREGON .......................... 106 Regional Medical Pro, Region Page MASSACHUSETTS, see Tri-State , see Greater Delaware The Directory list ........... 102 PENNSYLVANIA grams for which Planning or operational ALABAMA (see also Tennessee MEMPHIS .............. Valley; Susquehanna Valley; grants have been ,warded or which are in M id-South) ....................... 97 C. 102 Western Pennsylvania earlier stages Of development. urposes ALASKA, see Washington-Alaska METROPOLITAN WASHINGTON, D 103 PUERTO RICO ...................... 107 Regions were defined for planning P 97 MICHIGAN ......................... In the planning applications. State designs' ALBANY ........................... 103 RHODE ISLAND, see Tri-State tions do not necessarily indicate that the 97 MINNESOTA, see Northlands ......... regions are coterminous with State bound, ARIZONA .......................... 103 ROCHESTER ....................... 107 aries. The original definitions of the regions ARKANSAS (see also Memphis) ....... 97 MISSISSIPPI (see also Memphis) ...... may be modified on the basis of experience. 98 SOUTH CAROLINA .................. 107 BI-STATE .......................... MISSOURI (see also BI-State; August 1, 1967 98 Memphis) ............ .." ........ 103 SOUTH DAKOTA, see Nebraska. CALIFORNIA ...... ................ 98 MONTANA, see intermountain; South Dakota CENTRAL NEW YORK ............... Mountain States SUSQUEHANNA VALLEY .............. 107 CLEVELAND ....................... 98 MOUNTAIN STATES ................. 103 TENNESSEE MID-SOUTH (see also 99 Memphis) ....... :................ 108 COLORADO-WYOMING ............... NEBRASKA-SOUTH DAKOTA .......... 104 99 TEXAS ............................ 108 CONNECTICUT ..................... NEVADA, see Intermountain DELAWARE VALLEY, see Greater TRI-STATE ......................... 108 Delaware Valley NEW HAMPSHIRE, see Tri-State UTAH,7ee . intermountain FLORIDA .......................... 99 NEW JERSEY (see also Greater Delaware Valley) .................. 104 VERMONT, see Northern New England GEORGIA .......................... 99 NEW MEXICO .... ................. 104 ....... 108 GREATER DELAWARE VALLEY ........ 100 VIRGINIA ................... HAWAII .............. ............ loo NEW YORK, see Albany; Central New WASHINGTON-ALASKA ......... .... 109 York; New York Metropolitan Area; IDAHO, see intermountain; Rochester; Western New York D.C., see Metropolitan WASHINGTON, Mountain States NEW YORK METROPOLITAN AREA .... 104 Washington, D.C. ILLINOIS (see also Bi-State) .......... 100 NORTH CAROLINA ... .............. 105 WEST VIRGINIA (see also Ohio Valley) 109 INDIANA (see also Ohio Valley) ....... 100 .101 NORTH DAKOTA .................... 105 WESTERN INTERSTATE COMMISSION INTERMOUNTAIN .................. FOR HIGHER EDUCATION (WICHE), .101 NORTHERN NEW ENGLAND .......... 105 see Mountain States IOWA ............................. 101 NORTHLANDS ..................... 105 WESTERN NEW YORK ............... 109 KANSAS .......................... 109 KENTUCKY, see Me-phis; Ohio Valley; OHIO STATE (see also Cleveland; WESTERN PENNSYLVANIA . - - Tennessee Mid-South Ohio Valley) ...................... 106 .. 110 . 101 WISCONSIN ...................... LOUISIANA ....................... OHIO VALLEY ...................... 106 .. 102 WYOMING, see Colorado.WyOming; MAINE .......................... ....... ..... 106 intermountain; Mountain States MARYLAND ........................ 102 OKLAHOMA ........... 96 Name Of Region Alabama Albany Arizona Arkansas Preliminary Planning Area Alabama Northeastern N ew York and portions of Arizona Arkansas Southern Vermont and Western Massachusetts Estimated Populatioa 3,500,ODO 1,9DO,000 1,635,DOD 1,960,000 Coordinating Headquarters University of Alabama Medical Center Albany Medical College of Union University University of Arizona College of Medicine University of Arkansas Medical Center Program Coordinator Benjamin B. Wells, M.D. Frank M. Woolsey, Jr., M.D. Merlin K. DuVal, M.D. Winston K. Shorey, M.D. University of Alabama Associate Dean and Professor Dean, College of Medicine De@n of Medicine Medical Center Chairman, Department of Postgraduate Medicine University of Arizona U iv' School n ersity of Arkansas 1919 Seventh Avenue South Albany Medical College of Union University Tucson, Arizona 85721 4301 West Markham Street Birmingham, Alabama 35233 47 New Scotland Avenue Little Rock, Arkansas 72201 (tele: 2@325-4794) Albany, New York 12208 (tele: 602-884-1505) (tele: 501-MO4-5000) (tele: 518-462-7521) Program Director Grantee University of Alabama Medical Center Albany Medical College of Union University University of Arizona College of Medicine University of Arkansas Medical Center Effective Starting Date January 1, 1967 July 1, 1966 April 1, 1967 April 1, 1967 of Planning Grant Program Period for Two years, six months Three years Two years, three months Two years, three months initial Planning Effective Starting Date April 1, 1967 of Operational Grant 97 Central New York Cleveland Name of Region Bi-State California s acuse, New York and 15 Northeastern Ohio yr preliminary Planning Area Eastern Missouri and Southern Illinois California surrounding counties Estimated Population 4,700,000 18,600,000 1,800,000 Medicine California Committee an Upstate Medical Center, State University Coordinating Headquarters Washington University School of Regional Medical Programs of New York at Syracuse Richard H. Lyons, M.D. William H. Danforth, M.D. Paul D. Ward Medical program Coordinator Executive Director Director Regional vice Chancellor for Medical Affairs California Committee on Progr@'m of Central New York Washington University Regional Medical Programs 750 Eist Adams Street 660 Soq-th Euclid Avenue Room 1500 St. Louis, Missouri 63110 Room 304 State University Hospital 665 Sutte@sStreet Syracuse New York 13210 (tele: 314-361-64DO, ext. 3013) San Franci co, California 94102 1 (tele: 415-771-5432) (tele: 315-473-5600) program Director Research Foundation of State University Application under development Washington University School of Medicine California Medical Education of New York Grantee and Research Foundation Effective Starting Date April 1, 1967 November 1, 1966 January 1, 1967 of Planning Grant Pr,, in Period for Two years, three months Two years, eight months Two years Effective Starting Date of operational-Grant 98 Name of Region colorad@Wyoming Connecticut Florida Georgia Connecticut Florida Georgia PreliminarY Planning Area Colorado and Wyoming Estimated Population 2,300,000 2,800,000 5,910,000 4,400,000 Yale University School of Medicine and Florida Advisory Council an Heart Disease, Medical Association of Georgia Coordinating Headquarters University of Colorado Medical Center University of Connecticut School of Medicine Cancerand Stroke, Inc. Samuel P. Martin, M.D. J. W. Chambers. M.D. C, Wesley Eisele, M.D. Henry T. Clark, Jr., M.D. Coordinator for Georgia Regional program Coordinator Program Coordinator Provos@',J. Hillis Miller Medical Program Associate Dean for Post-Graduate Connecticut Regional Medical Program Medic I Center Medical Association of Georgia Medical Education Universi y of Florida 272 George Street tle, Florida 32601 University of Colorado Medical Center Gairiesvil 938 Peachtree Street, N.E. 4200 East Ninth Avenue New Haven, Connecticut 06510 Atlanta, Georgia 30309 Denver, Colorado 80220 (tele: 203-776-6872) (tele: 404-876-7535) (tele: 303-394-7376 or 8406) J. Gordon Barrow, M.D. Program Director Paul R. Hildebrand, M.D. Director for Georgia Regional University of Colorado Medical Center Medical Program 4200 East Ninth Avenue Medical Association of Georgia 938 Peachtree Street, N.E. Denver, Colorado 80220 Atlanta, Georgia 30309 (tele: 404-875-0701) Medical Association of Georgia Grantee University of Colorado Medical Center Yale University School of Medicine Effective starting Date January 1, 1967 July 1, 1966 Application under development January 1, 1967 of Planning Grant Two years, six months Pr gram Period for Two years, six months Two years "I Initial planning Effective Starting Date of operational Grant 99 Name of Region Greater Delaware Valley Hawaii Illinois Indiana Preliminary Planning Area Eastern Pennsylvania and portions of Hawaii Illinois Indiana New Jersey and Delaware Estimated population 8,830,000 800,000 10,700,000 4,900,000 University of Hawaii College of Coordinating Committee of Medical Schools Indiana University School of Medicine Coordinating Headquarters University City Science Center Health Sciences and Teaching Hospitals of Illinois Wright Adams, M,D: G .0. William C. Spring, Jr., M.D. Windsor C. Cutting, M.D. Professor of Medicine and Associate Dean A University Program Coordinator Program Coordinator Dean, School of Medicine Division of Biologic8i Sciences Greater Delaware Valley University of Hawaii Univ rsity of Chicago aItCenter Regional Medical Program Mall Chicgo, -Illinois 60637 2538 The 301 0 Line Avenue Honolulu, Hawaii 96922 Bal.@ty'nwyd, Pennsylvania 19004 (tele: 312-MU4-6100) (late: 317-639-8877) (tele: 215-MO7-1790, 91, 92) Program Director William D.aGraham, M.D. u''rctor yMedical Program H@-a Re'a Leah H-apt.I 3675 K,IaAv@ nue H "IuIu,Ha ai, 96816 (tele: 808-78660 or 722) University City Science Center University of Hawaii College of University of Chicago Indiana University Foundation Grantee Health Sciences Effettive Starting Date April 1, 1967 July 1, 1966 July 1, 1967 January 1, 1967 of plaiming Grant program Period for One year Two years Two years Two years, six months initial Planning EffectiVO Starting Date of operational grant 100 ie of Region Intermountain I owa Kansas Louisiana liminary Planning Area Utah and portions of Wyoming, Montana, Iowa Kansas Louisiana Idaho, and Nevada imated Population 2,200,000 2,760,000 2,200,000 3,5DO,000 irdinating Headquarters University of Utah College of Medicine University of Iowa College of Medicine University of Kansas Medical Center Louisiana State Department of Hospitals gram Coordinator C. Hilmon Castle, M.D. Willard A. Krehl, M.D., Ph.D. Charles E. Lewis, M.D. Joseph A. Sabatier, Jr., M.D. Ch irma Department of Preventive Pro Department of Internal Medicine a Lou;ram Coordinator Associate Dean and Chairman san Department of Postgraduate Education University of Iowa Medici9n'e and Community Health a Regional Medical Program Un I"' rsity of Utah College of Medicine Iowa City, Iowa 52240 University of Kansas Medical Center Claiborne Towers Roof 50 North Medical Drive 39th and Rainbow Boulevard 119 South Claiborne Avenue Salt Lake City, Utah 84112 (tele: 319-353-4843) Kansas City, Kansas 66103 New Orleans, Louisiana 70112 (telat 801-322-7901) (tole: 919-AD6-5252, ext. 422) (tole: 504-522-5678) igram Director intee University of Utah University of Iowa College of Medicine University of Kansas Medical Center Louisiana State Department of Hospitals ettive Starting Date July 1, 1966 December 1, 1966 July 1, 1966 January 1, 1967 Planning Grant I Period for Two years Two years Two years Two years t'..rl, MP,,,,,,g active Starting Date April 1, 1967 June 1,1967 Operational Grant 1 f)l Name of Region Maine Maryland Memphis Medical Region Metropolitan Washington, D.C. Preliminary Planning Area Maine Maryland Western Tennessee, Northern Mississippi, District of Columbia and contiguous counties and portions of Arkansas, Kentucky, in Maryland (2) and Virginia (2) and Missouri Estimated Population 985,000 3,520,000 2,400,000 2,050,000 Coordinating Headquarters Medical Care Development, Inc. Steering Committee of the Regional Medical Mid-South Medical Council for District of Columbia Medical Society Program for Maryland Comprehensive Health Planning, Inc. Program Coordinator Manu Chafteriee, M.D. Thomas B. Turner, M.D. James W. Culbe rt' 'n ;sD@ Thomas W. Mattingly, M.D. .i OM Pro ram Coordinator Dean, School of Medicine Professor and Cardp g Program Cordiralor 9 Metoplt@@ W.Sh, ngton, D.C. Maine Regional Medical Program The Johns Hopkins University 'apar'm ant ofdlnternal Medicine Regional Md IProgram f Me icine , C. 295 Water Street 725 Wolfe Street College0 Di@trr a Medical Society 't of Clumbi Augusta, Maine 04322 Baltimore, Maryland 21205 Un,,e r, ity of Tennessee 858 Mad iso n Avenue 2007 Eye Street, N.W. (tale: 203-622-7566) (tole: 301-955-3181) Memphis, Tennessee 38103 Washington, D.C. 20006 (tele: 901-JA6-8892, ext. 437) (tale: 202-223-2230) Program Director Grantee Medical Care Development, Inc. The Johns Hopkins University University of Tennessee College of Medicine District of Columbia Medical Society Effective Starting Date May 1, 1967 January 1, 1967 April 1, 1967 January 1, 1967 of Planning Grant Program Period for Two years Two years Two years, three months Two years, six months Initial Planning Effective Starting Date of Operational Grant 102 Name of Region Michigan Mississippi Missouri mountain States Preliminary Planning Area Michigan Mississippi Missouri Idaho, Montana, Nevada, and Wyoming Estimated Population 8,220,000 2,320,000 4,500,000 2,200,000 Coordinating Headquarters Michigan Association for Regional Medical University of Mississippi Medical Center University of Missouri School of Medicine Western Interstate Commission for Programs, Inc. Higher Education Program Coordinator D. Eugene Sibery Guy D. Campbell, M.D. Vernon t. Wilson, M.D. Kevin P. Bunnell, Ed.D. Executive Dire ctor Regional Coordinator Executive Director for Health Affairs Associate Director Greater Detroit Area Hospital Council Mississippi Regional,Medical Program University of Missouri Western Interstate Commission for 966 Penobscot Building University of Mississ ppi Medical Center Columbii, Missouri 65201 Hi gheir Ed ucation Detroit, Michigan 48226 2500 North State Street unive rs ty Ea st Campus Jackson, Mississippi 39216 (tele; 314-449-2711) 30th Street (tele: 313-963-4990) (tele: 601-362-4411) Boulder, Colorado 80302 (tele: 303-443-2111, ext. 6342) Program Director George E. Wakerlin, M.D. Alfred M. Popma, M.D. Director, Missouri Regional Medical Director Program =rl States Regional Medical Program Lewis Hall 525 West Jefferson Street 406 Turner Avenue Boise, Idaho 83702 Columbia, Missouri 65201 (tele: 208-342-4666) (tele: 314-449-2711) Grantee Michigan Association for Regional Medical University of Mississippi Medical Center University of Missouri School of Medicine Western Interstate Commission for Programs, Inc. Higher Education Effective Starting Date June 1, 1967 July 1, 1967 July 1, 1966 November 1, 1966 of Planning Grant Program Period for One year Two years Three years Two years Initial Planning Effective Starting Date April 1, 1967 of Operational Grant Name of Region Nebraska-South Dakota New Jersey Preliminary Planning Area New Mexico New York Metropolitan Area Nebraska and South Dakota New Jersey New Mexico New York C and Westchester, Nassau, and Estimated Population 2,200,000 Suffolk Couint6es 6,800,ooo 1,000,000 11,400,000 Coordinating Headquarters Nebraska State Medical Association New.jerseY Joint Committee for Implementation University of New Mexico School of Medicine Associated Medical Schools of Greater New Yaq of P L. 89-239 Program Coordinator r" " Mor'a r''M. D. Alvin A. Florin, M.D. "O'ram 'O(, rdinator New Jersey Re Nobr@ska-S.-t h Dakota Regional Regi Medical Program De Vincent de Paul Larkin, M.D. Madice I Program 88 Ronal, Un New York Academy of Medicine a Sha .,Iding Oss treat L@ rp B East Orange, New Jersey 07018 90( 2 East 103d Stree-t n.1,, Nebr. ka 68508 Alt New York, New York 10029 87106 (tele: 402-432-5427) (tele: 201-675-1100) (tele: 505-277-2321) (tele: 212-TR6-8200) Program Director Grantee Nebraska State Medical Association Founda!ion for the Advancement of Medical University of New Mexico Educetion and Research in New Jersey Associated Medical School$ of Greater New York Effective starting Date Of Planning Grant January 1, 1967 July 1, 1967 October 1, 1966 June 1, 1967 Prpgram P riod for Initial pla:ning Two years Two years Two Years, nine months Two years Effective Starting Date of operational Grant 104 Name of Region North Carolina North Dakota Northern New England Northiands Preliminary Planning Area North Carolina North Dakota Vermont and three counties in Minnesota Northeastern New York Estimated Population 4,900,000 650,000 550,000 3,600,ODD Coordinating Headquarters Association for the North Carolina University of North Dakota University of Vermont College of Medicine Minnesota State Medical Association Foundation Regional Medical Program Program Coordinator Marc J. Musser, M.D. Theodore H. Harwood, M.D. John E. Wennberg, M.D. J. Minott Stickney, M.D. Executive Director Dean, School of Medicine Program Coordinator Northlands Regional Medical Program North Carolina Regional Medical Program University of North Dakota Northern New England Regional 200 First Street S.W. Teer House Grand Foiks, North Dakota 58202 Medical Program Rochester, Minnesota 55901 4019 North Roxboro Road University of Vermont College of Medicine Durham, North Carolina 27704 (tele: 701-777-2514) 25 Colchester Avenue (tele: 612-224-5738) Burlington, Vermont 05401 (tele: 919-477-9685) (tele: 802-86@ll, ext. 244) Program Director Grantee Duke University North Dakota Medical Research Foundation University of Vermont College of Medicine Minnesota State Medical Association Foundation Effective Starting Date July 1, 1966 July 1, 1967 July 1, 1966 January 1, 1967 of Planning Grant Program Period for Two years Two years Three years Two years, six months Initial Planning Effective Starting Date of Operational Grant 105. Name of Region Ohio State Ohio Valley Oklahoma Oregon Preliminary Planning Area Central and southern two-thirds of Ohio Greater part of Kentucky and contiguous parts Oklahoma Oregon (61 counties, excluding Metropolitan of Ohio, Indiana, and West Virginia Cincinnati area) Estimated Population 4,480,000 5,900,000 2,500,000 1,900,000 Coordinating Headquarters Ohio State University College of Medicine Ohio Valley Regional Medical Program University of Oklahoma Medical Center University of Oregon Medical School Program Coordinator Richard L. Meiling, M.D. William H. McBeath, M.D. Kelly West, M.D. M. Roberts Grover, M.D. Dean, College of Medicine Director, Ohio Valley Regional Medical Program Professor and Head, Department of Director Continuing Medical Education Ohio State University 1718 Alexandria Drive Continuing Education Universiiy of Oregon medical School 410 West Tenth Avenue P.O. Box 4025 University of Oklahoma Medical Center" 3181 Southwest Sam Jackson Park Road Columbus, Ohio 43210 Lexington, Kentucky 40504 800 Northeast Thirteenth Street Portland, Oregon 97201 (tele: 614-293-5344) (tele: 606-278-6071) Oklahoma City, Oklahoma 73104 (tole: 503-228-9181, ext. 519) (tele: 405-CE5-9421, ext. 395) Program Director Grantee Ohio State University College of Medicine The University of Kentucky Research Foundation University of Oklahoma Medical Center University of Oregon Medical School Effective Starting Date April 1, 1967 January 1, 1967 September 1, 1966 April 1, 1967 of Planning Grant an Period for One year Two years Two years Two years, three months Planning Effective Starting Date of Operational Grant 106 Name of Region Puerto Rico Rochester South Carolina Susquehanna Valley Preliminary Planning Area Puerto Rico Rochester, New York and surrounding counties South Carolina 24 counties in Central Pennsylvania Estimated Population 2,630,000 1,200,ODO 2,500,000 2,130,000 Coordinating Headquarters University of Rochester School of Medicine Medical College of South Carolina Pennsylvania Medical Society and Dentistry Program Coordinator Ralph C. Parker, Jr., M.D. Charles P. Summerall. III, M.D. Richard B. McKenzie Clinical Associate Professor of Medicine Associate in Medicine (Cardiology) Executive Assistant School of Medicine and Dentistry Medical College of South Carolina Council on Scientific Advancement University of Rochester Department of medicine Pennsylvania Medical Society 260 C rittenden Boulevard Medical College Hospital Taylor Bypass and Erford Road Rochester, New York 14620 55 Doughty Street Lemoyne, Pennsylvania 17043 (tele: 716-4734QO, ext. 3112) Charleston, South Carolina 29403 (tele: 717-238-1635) (tele: 803-723-9411) Program Director Grantee University of Rochester School of Medicine Medical College of South Carolina Pennsylvania Medical Society and Dentistry Effective Starting Date Application under development October 1, 1966 January 1, 1967 June 1, 1967 of Planning Grant Program Period for Two years, nine months One year Two years Initial Planning Effective Starting Date of Operational Grant 107 Name d Region Tennessee Mid-South Texas Tri-State Virginia Preliminary Planning Area Eastern and Central Tennessee and Texas Massachusetts, New Hampshire, and Virginia contiguous parts of Southern Kentucky and Rhode Island Northern Alabama Estimated Population 2,600,000 10,500,000 6,925,000 4,500,000 Coordinating Headquarters Vanderbilt University School of Medicine and University of Texas Medical College of Virginia and University Maharry Medical College of Virginia School of Medicine Program Coordinator Stanley W. Olson, M.D. Charles A. LeMaistre, M.D. Norman Stearns, M.D. Kin .loch Nelson, M.D. Professor of Medicine Vice-Chancellor for Health Affairs Medical Care and Dean, Medical College of Virginia Vanderbilt University University of Texas Educational Foundation 1200 East Broad Street mlinical Professor of Medicine Main Building 22 The Fenway Richmond, Virginia 23219 eharry Medical College Austin, Texas 78712 Boston, Massachusetts 02115 110 Baker Building (tele: 703-M[4-9851) 110 21st Street South (tele: 512-GRI-1434) (tele: 617-734-33DO) Nashville, Tennessee 37203 (telei 615-255-0692) Program Director Grantee Vanderbilt University University of Texas University of Virginia School of Medicine Efective Starting Date July 1, 1966 July 1, 1966 Application under review January 1, 1967 of Planning Grant m P:riod for Two years Three years Two years la P ning Effective Starting Date of Operation[ Grant 108 Name of Region Washington-Alaska West Virginia Western New York Western Pennsylvania Preliminary Planning Area Washington and Alaska West Virginia Buffalo, New York and 7 surrounding counties Pittsburgh, Pennsylvania and 28 surrounding counties Estimated Population 3,200,000 i,aoo,ooo 1,920,000 4,200,000 Coordinating Headquarters University of Washington School of Medicine West Virginia University Medical Center School of Medi no, Stat University of Now University Health Center of Pittsburgh York uffa 0, in cooperation with the c 0 at B Health Organiza tion of Western New York Program Coordinator Donal R. Sparkman, M,D. Charles L. Wilbar, Jr., M.D. John R. F. lngall, M.D. Francis S. Cheever, M.D. Associate Professor of Medicine West Virginia Regional Medical Program Director, Regional Medical Dean, School of Medicine School of Medicine West Virginia University Medical Center Procm for Western New York Universit-y of Pittsburgh University of Washington Morgantown, West Virginia 26506 2211 n Street Flannery Building AA 312 University Hospital Buffalo, New York 14214 3530 Forbes Avenue Seattle, Washington 99105 (tele: 304-293-4511) (tele: 716-833-2726, ext. 32, 50) Pittsburgh, Pennsylvania 15213 (late: 206-543-3498) (tele: 412-683-1620, ext. 320, 321) Program Director Grantee University of Washington School of Medicine West Virginia University Medical Center Research Foundation of the State University University Health Center of Pittsburgh of New York Effective Starting Date September 1, 1966 January 1, 1967 December 1, 1966 January 1, 1967 of Planning Grant Program Period for Two years, ten months Two years, six months Two years Two years, six months Initial Planning Effective Starting Date of Operational Grant Name of Region Wisconsin Preliminary Planning Area Wisconsin Estimated Population 4,100,000 Coordinating Headquarters Wisconsin Regional Medical Program, Inc. Program Coordinator John S. Hir ec D, s':' 'M Wisconsin R@g@,.' ". I Mad i@. I Program, Inc. i@c 110 East W .r, si,, Aeru, Milwaukee, Wisconsin 53202 (tele: 414-272-3636) Program Director Grantee Wisconsin Regional Medical Program, Inc. Effortive Starting Date September 1, 1966 of Planning Grant Program Period for Two years Initial Planning Effective Starting Date .of Operational Grant 1 1 0 Appendix 6-Guidelines for Regional Medical Programs Division of Regional Medical Programs If the applicant believes there is a conflict The Commission presented 35 recommenda- the diversity of needs, resources and exist- National Institutes of Health between the provisions of the Guide-and the tions aimed at reducing the toll of these ing patterns of education and service. Bethesda, Maryland 20014 effective implementation of the proposed diseases through the development of more 0 Cooperation among all. essential elements U.S. DEPARTMENT OF HEALTH, EDUCATION, program in his region, he is encouraged to effective means of making the latest medical of the health resources in a region is an AND WELFARE consult with the staff of the Division of Re- advances available to a greater portion of essential means of coping with the com- Public Health Service gional Medical Programs. This is a new pro- the population and through the provision of plexities, specialization, high cost, manpower July 1966 gram in an exploratory phase. It is expected additional opportunities for research. The needs, and educational and training needs that policies and procedures will evolve with major recommendations of the Commission which are the by-products of the dynamic time as both the applicant and the Division are the basis for the proposed regional advances of medical science. The objectives learn from actual planning and operational medical programs authorized by Public Law of the Act will not be achieved by a pro- TABLE OF CONTENTS experience. As with all statements of policy 89-239 (hereafter referred to in this text as gram which serves the interests of a single AND USE OF THIS GUIDE and procedure, the Guide attempts to strike "The Act." See Exhibit). category, institution, or organization. A basic a balance among desirable and necessary aim of the program is to overcome frag- 1. History and Purposes of Regional procedures. The Division encourages diver- The Act is intended to assist our medical mentation and insularity. Medical Programs sity and innovation in the development of institutions and professions infcapitalizing 0 In order to insure an effective linkage the Regional Medical Program. But this on the rapid advances of scienti ic medicine between research advances and improved 11. Composition of a Regional Medical flexibility of approach must take place within in the prevention, diagnosis, treatment' and patient care, it is desirable to establish a Program the boundaries of the legislative authority, rehabilitation of patients afflicted with heart continuing relationship among the research applicable general policies, and the neces- disease, cancer, stroke or related diseases. and teaching environment of the medical Ill. Policies and Definitions sary accountability for public funds. To paraphrase the statement of purposes in center, the patient care activities involving [V. General Grant Information the Act, these grants are to encourage and the community hospital, and practicing phy- V. Preparation and Review of Ap- 1. HISTORY AND PURPOSES OF REGIONAL assist in the establishment of regional co- sicians. The impact of research advances on MEDICAL PROGRAMS operative arrangements among medical the development of high quality patient care placation schools, research institutes, hospitals and has typically been most direct in the uni- The impetus for the Regional Medical Pro- other medical institutions and agencies for versity medical-centers or other medical grams was contained in the President's 1964 the purpose of affording the medical pro- centers which combine extensive research Special Health Message to Congress when fession and the medical institutions the op. teaching and patient care activities. The This Guide is for use in applying for support he proposed to establish a Commission on portunity of making available to their primary benefits of this interrelationship, under Title IX of the Public Health Service Heart Disease, Cancer, and Stroke "to recom- patients the latest advances in the diagnosis however, have often been confined to the Act (Public Law 89-239), which authorizes mend steps to reduce the incidence of these and treatment of these diseases. Grant funds medical center itself and affiliated hospitals. grants to assist in planning, establishing, diseases through new knowledge and more will support through these cooperative ar- A basic premise of the Act is the desirabil- and operating Regional Medical Programs to complete utilization of the medical knowl- rangements research, training (including con- ity of extending this productive interrela- combat Heart Disease, Cancer, Stroke, and edge we already have." In March 1964, a tinuing medical education) and related dem- tionship to additional hospitals and to prac- related diseases. It is therefore intended to Commission of distinguished physicians, onstrations of the highest standard of patient ticing physicians through the establishment be used for both planning and operational scientists, and informed citizens was ap- care. Through these means the program is of regional cooperative arrangements. grant applications. pointed to accomplish this task. The Com- also intended to improve generally the health <> The financing of patient care is not the mission collected information from agencies, manpower and facilities of the Nation. The objective Gf the regional medical programs. The contents of this Guide include the his- groups, and institutions concerned with these Act states that these purposes should be The payment of patient care costs is limited tory and purposes, composition, policies and diseases through letters, staff visits, surveys, accomplished without interfering with the to those costs incident to research, train- definitions and general information regard- etc., held hearings at which expert witnesses patterns of professional practice or hospital - ing the preparation and review of applica- ing and demonstration activities supported from the widest possible range of interests, administration. by these grants. tions for a Regional Medical Program. The both public and private, presented their The intent of the Act is built upon. the follow- 0 It is assumed that the development of the provisions of this Guide are intended to views, and submitted a report which in, ing basic premises and assumptions: full capabilities of a regional medical pro- carry out the purposes and objectives of cluded the following points: 0 The program will utilize and build upon gram will take a number of years. The pur- the authorizing legislation, consistent with ,Our Nation's resources for health are rel- existing institutions and manpower resources. pose of the first three years of legislative overall policies of the Department of Health, Education, and Welfare and sound fiscal atively untapped. The rising tide of bio- 0 The active participation of practicing phY- authorization is to encourage and assist in procedures. These provisions must be inter- medical research has already doubled our sicians is essential to the success of a re- the planning and implementation of the preted in light of the basic objectives of the store of knowledge about heart disease, gional medical program. first steps toward the establishment of a program, and the clear intent of the Con- cancer and stroke. . . ." 0 The purposes can best be achieved regional medical program. It is assumed gress to stimulate initiative and innovation "Yet for every breakthrough, there must be through initiative, planning, and implementa- that the development of a plan and the at the regional level in planning and im- follow-through. Many of our scientific tri- tion at the regional level under conditions implementation of the initial elements there- plementing regional programs that are fitted umphs have been hollow victories for most which encourage innovative approached and of will constitute a learning experience which to the needs and resources of the region. of thle people who could benefit from them." programs specifically designed to deal with can be utilized in taking additional steps in 1 1 1 the cooperative effort against heart disease, throughout the Nation. The consequence of The Regional Medical Programs present the option of the applicant, related disease or cancer and stroke. rapid expansion in the body of medical medical interests within a region with an diseases; but only if such group The background against which these assump- knowledge is increased specialization, re- instrument of synthesis that can capitalize 0 is situated within a geographic area, tions and premises are set includes a num- sulting in the prolongation of the educa- on and reinforce the various trends and re- composed of any part or parts of any one ber of trends and influences which have tional process. A continuing process of sources seeking to make more widely avail- or more states which the Surgeon General been affecting the nature of medical serv- education throughout the career of a phy- able the latest advances in diagnosis and determines, in accordance with regulations,@ ice, education, and research for some years. sician is therefore of great importance. treatment of these diseases. It is the inter- to be appropriate for carrying out the pur- The opportunities created by the impact of The continued evolution of medical ea. action of these trends at this time, rather poses of the Act; science on modern medicine have already ucation than an abstract conceptualization, which not 0 consists of one or more medical centers, been mentioned. Along with the creation of and the growth of the medical centers car- only justifies but requires a synthesizing one or more clinical research centers, and opportunities, however, the increasing im- ries with it increased problems in maintain- force such as the Regional Medical Pro- one or more hospitals; and ing an effective linkage between the medica, grams. The Regional Medical Programs rep- 0 has in effect cooperative arrangements pact of science has changed the nature and center and the practicing physician. Recent shape of modern medicine, raising a num- reports have emphasized the need for those resent a general concept, rather than a among its component units which the Sur- ber of situations which are very difficult to concerned with medical education to assume specific blueprint. The opportunity is pre- geon General finds will be adequate for manage, including increased specialization, responsibilities in meeting national needs for sented to go beyond concept into specific carrying out effectively the purposes of this increasing complexities and costs of diag- improved health care. It has become clearly planning and implementation of programs program. nosis and treatment, and the difficulties in apparent that the medical center represents which represent pragmatic steps toward the transmitting a rapidly expanding body of an indispensable resource for improving achievement of the ' overall goals of the S. The National Advisory Council on knowled&. The tremendous growth a,f health in its area of influence. In the en- legislation. It is an opportunity to mix crea- Regional Medical Programs knowledge through large scale research vironment of medical education, new atten. tive ideas and specific actions in developing 'he National Advisory Council on Regional efforts is a characteristic of our times, not tion is being given to the need to cope improved means for advancing the health @edical Programs consists of the Surgeon just In medicine but in most aspects of our effectively with the problems brought about standards of the American people. General, who is the chairman, and 12 mem- society. Wherever this phenomenon is seen, by the developments in modern scientific bers, not otherwise in the regular fulltime it calls for the development of new means medicine. employ of the United States, who are leaders of coping with steady and dynamic h t:n, in the fields of the fundamental sciences, if the benefits of the knowledge are c b: @.ny medical leaders are stressing that 11. COMPOSITION OF A REGIONAL the medical sciences, or public affairs. In realized. inose involved in health care must maintain MEDICAL PROGRAM particular, one of the twelve council mem- a continuous relationship to the educational A. Definition of a Regional Medical bers must be outstanding in the field of The forces of change can be viewed as part process and that medical. schools and hos- of a continuum existing over many years, pitals should have an increasing involvement Program heart disease, one in cancer, and another in rather than a revolutionary or radical alter- in the process of continued learning. The B. The National Advisory Council on stroke, and two must be practicing phy- ation of current patterns. This trend calls very forces that have tended to separate the Regional Medical Programs sicians. The role of the Council is to advise for the development of Regional Medical centers of medical knowledge from the prac- C. Categorical Emphasis and assist the Surgeon General in the formu- Programs which create an effective environ- ticing physician are creating an ever greater lation of policy and regulations regarding ment for continuing adaptation, innovation, need to bring physicians into continuing D. The Region the regional medical programs, and to make and modification. The development of a great contact with the environment of teaching E. Cooperative Arrangements Among recommendations to him concerning ap- medical research effort is the product of and research. Resources Within The Region proval of applications and amounts of grant a deliberate national policy to stimulate and Another trend is usually described as the F. Interregional Cooperation awards. No grant may be awarded unless it support the development of new medical has been recommended for approval by the knowledge at a rapid rate. The passage regionalization of medical services. There G. The Regional Advisory Group Council. of the legislation authorizing Regional Med- have been numerous regionalization pro- H. Relation of Regional Medical ical Programs represents a corresponding posals during the past 35 years and efforts Programs to Programs of Other C. Categorical Emphasis commitment to assist the development of have been made to implement various ap- necessary measures to bring the benefits of proaches to regionalization. The concept of Health Agencies The focus of the Regional Medical Programs this new knowledge to the patient in the Regional Medical Programs includes the re- under the authorizing legislation is on prob. field of heart disease, cancer, stroke, and gional approach to the provision of highly lems of heart disease, cancer, stroke, and related diseases. related diseases. This rather broad categori- specialized services involved in the diagnosis A. Definition of a Regional Medical Program cal approach must be a consideration in the The process of medical education in aII its nd treatment of heart disease, cancer, The Act defines a regional medical program development of specific program elements aspects has also been undergoing a change stroke, and related diseases. The legislation as a cooperative arrangement among a under a Regional Medical Program. Heart under the impact of the growth of knowl- provides a very flexible framework for the group of public or private nonprofit institu- disease, cancer, and stroke are appropriate edge. The development of great medical implementation of a regional approach which tions or agencies engaged in research, train-, targets because of their prevalence as killing centers built around education, research, is appropriate to the voluntary nature of our ing, diagnosis, and treatment relating to and disabling diseases. These diseases pre- and high-quality patient care has taken place medical institutions. heart disease, cancer, or stroke, and at the sent a complex challenge to the research 112 investigator, and the advances which are tive attitude and stimulate participation and professions, voluntary health agencies, and ation of effectiveness of the regional coop- being made require diagnostic and treat- initiative among the program elements; representatives of other organizations, in- erative arrangements established under the ment techniques of great sophistication. 0 Provide for the necessary decision-making stitutions, and agencies and members of the Regional Mefical Program. Because of the broad scope of heart disease, framework for the activities conducted under public familiar with the need for the services cancer, and stroke it would be difficult and the Regional Medical Program grant; 0 In- provided under the program. It should be H. Relation of Regional Medical Programs perhaps detrimental to some types of medi- clude administrative and fiscal arrangements, broadly representative of the geographic to Programs of Other Health Agencies cal services and educational activities if a which provide for adequate program coordi- areas and of the social groups who will be An essential function of Regional Medical rigidly categorical approach were adopted nation and fiscal accountability; 0 Provide served by the Regional Medical Program. Programs is to plan and to provide an en- for all relevant program elements. However, for effective administration of central pro- The Regional Advisory Group should provide vironment for coordinating the health re- the emphasis of the program does require gram elements which serve the entire region; overall advice and guidance to the grantee sources of the Nation in order to assure the that the program elements be shown to 0 Include mechanisms for the evaluation in the planning and operational program availability of the best of medical care to have significance for combating heart dis- of the effectiveness of the Regional Medical from the initial steps onward. It should be all persons. It is not the intent of a Regional ease, cancer@ stroke and related diseases. Program, including the acquisition of uni- form data for the use in evaluating effective- actively involved in the review and guidance Medical Program grant to supplant other pr and in the coordinated evaluation of the sources of support for the various program D. The Region ness and the means to evaluate specific o- ongoing planning and operating functions. elements that are related to achieving its gram elements of the Regional Medi . cal it should be constituted to encourage CO- purpose. The Regional Medical Program pro- A region is a geographic area composed OT Program; 0 Provide for continual planning 0 part or parts of one or more states which. ' - peration among the institutions, organiza- vides an opportunity to introduce program the Surgeon General determines to be ap- and implementation of the further develop- tions, health personnel, state and local activities which draw upon and effectively propriate for the purposes of the program. ment of the Regional Medical Program. health agencies, and with the state Hill- link activities already supported, or support- It should be an economically and socially Burton agencies. It should be concerned with able in the future, through other sources. cohesive area taking into considerat ion such F. Interregional Cooperation continuing review of the degree of relevance Current examples of other Federal programs factors as present and future population The definition of a particular region neces. of the planning and operational activities to that provide essential inputs into the health trends and patterns of growth; location and sarily requires consideration of relationships the objectives of the Regional Medical Pro- resources of the region are-. 0 The Bureau extent of transportation and communication to adjoining regions. Interregional cooperation gram and particularly with the effectiveness of States Services; 0 The Bureau of Medical facilities and systems; and presence and is to be encouraged, especially in program of these activities in attaining the objective Services; 0 The National Institutes of distribution of educational and health facili- elements where a uniform approach is de- of improved patient care. Therefore, Advi- Health, particularly the National Heart In- ties and programs. The region should be sirable. Some examples where interregional sory Group members should be chosen who stitute, National Cancer Institute and Na- functionally coherent; it should follow ap- cooperation might be beneficial include: will provide a broad background of knowl- tional Institute of Neurological Diseases and propriate existing relationships among in- 0 Development of standardized criteria for edge, attitudes and experience. Blindness; 0 Other constituents of the stitutions and existing patterns of patient data gathering and analysis; 0 Continuing The grantee institution named on the face Department of Health, Education, and Wel- referral and continuing education; it should education programs drawing on the educa- fare, particularly the Social Security Admin- encompass a sufficient population base for tional resources of more than one region; page of the application is legally and ad- istration, the Office of Education, the effective planning and use of expensive and 0 Referral of patients for highly specialized ministratively responsible for the conduct of Vocational Rehabilitation Administration and complex diagnostic and treatment tech- diagnosis and treatment not available . the Regional Medical Program. The Advisory the Welfare Administration; and 0 Other niques. every region; 0 Program planning and cc). Group does not have direct administrative government agencies, particularly the Office ordination between regions. responsibility for the program, but the clear of Economic Opportunity and the Veterans E. Cooperative Arrangements Among intent of the Congress was that the Advisory Administration. The Regional Medical Pro- Resources Within the Region Regional boundaries should not cut off ex- Group would insure that the Regional Medl'. gram grants should concentrate on catalyz- It is recognized that the full development of isting relationships and patterns and should cal Program is planned and developed wit ing and synthesizing efforts in achieving a Regional Medical Program, which involves not operate to the detriment of the objec- the continuing advice and assistance of . more effective communication among all of otentially all medical institutions, organize- tives of the legislation. group which is broadly representative of the the health related elements in the region. p health interests of the region. The'Advisory New sources of possible support for activi- tions, and personnel within the region, could G. The Regional Advisory Group Group, therefore, is an inherent element of take a number of years in many area S. The a Regional Medical Program that helps to ties related to the Regional Medical Pro- program emphasizes the development of The Act specifies that an applicant for a accomplish the basic objective of broadly grams should also be considered during cooperative arrangements which are effective planning grant must designate a Regional based regional cooperation. both the planning and operational phases. in making the latest scientific advances in Advisory Group. The Act also specifies that For example, the reimbursement principles these diseases more widely available. Con- the Advisory Group must approve an applica- In order to serve these purposes the Advi- for hospitals and other providers of Medicare siderable flexibility is provided for the devel- tion for an operational grant under Section sory Group should operate under established services should make available to these opment of cooperative arrangements that 904. The Advisory Group must include prac- procedures which insure continuity and ap- institutions additional amounts of capital are appropriate to the needs, resources, and ticing physicians, medical center officials, propriate independence of function and ad- funds, which may contribute to accomplish- patterns of the region. The cooperative ar- hospital administrators, representatives from vice. The Advisory Group is expected to ing the objectives of the Regional Medical rangements should: 0 Encourage a coopera- appropriate medical societies, other health prepare an annual statement giving its evalu- Programs through a cooperative approach to the use of medical resources in the 111. POLICIES AND DEFINITIONS the program and members of the public sire to incorporate systems ana lysis method- region. A. Policies familiar with the needs for the services pro- ologies into their applications. In order to assure coordination within the vided under the program. The use of systems analysis methodologies Federal Government, the Division of Regional 1. General Responsibilities - The named The recipient of an operational grant must in regional medical programs is encouraged, Medical Programs is developing an active grantee is obligated, both for itself and co- comply with the assurances under Section but only to such an extent as it is con- operating institutions, to administer the 0 exchange of information with these agencies grant in accordance with regulations and 04 (b), namely: sidered applicable as an essential integral to assure that all pertinent activities are policies of the Division of Regional Medical a. Federal funds awarded to any grantee component of the individual program pro- effectively interrelated. Programs. Where a policy is not stated r (1) will be used in accordance with applica- posed by the applicant. The applicant should the development of innovative, where the institutional policy is more restric. ble provisions of the Act and the regulations emphasize tive than the Regional Medical Program thereunder and (2) will not supplant funds adequately formulated studies of realistic- policy, institutional policy prevails. that are otherwise available for establish- ally restricted problems involving the ap-, Ill. POLICIES AND DEFINITIONS ment or operation of the Regional Medical placation of "systems" methodologies rather 2. General Assurances-Specific attention is Program with respect to which this grant is than submit an application dominated by A. Policies directed to the requirement to honor the as- made. general proposals for the utilization of large 1. General Responsibilities surances provided in the Act. b. The grantee will provide for such fiscal scale "systems" approaches for the design 2. General Assurances The recipient of a planning grant must com- control as fund accounting procedures as of a regional medical program. 3. Surveys and Questionnaires ply with the assurances in Section 903 (b), are required by the Surgeon General to as- The Division of Regional Medical Programs 4. Systems Analysis namely: sure proper disbursement of an accounting will explore through contracts and selective a. reasonable assurances that Federal funds for such federal funds. studies the applicability of systems analysis 5. Publications awarded to any grantee will be used only for c. The grantee will make such reports in to the planning and implementation of a 6. Patents and Inventions the purposes for which awarded and In such form and containing such information regional medical program. One approach to 7. Other Public Health Service Grant accordance with the applicable provisions of as the Surgeon General may from time to the use of systems analysis in current grant Policies the Act and the regulations thereunder, time reasonably require and will keep such applications, within the framework of this b. reasonable assurances that the grantee records and afford such access thereto as policy, is the incorporation of limited num- a. Clinical Research and Investiga- will provide for such fiscal control and fund the Surgeon General may find necessary to bbrs of personnel with such analytic skills tion Involving Human Beings accounting procedures as are required by assure the correctness and verification of into the planning process. These personnel b. Protection of Individual Privacy the Surgeon General to assure proper dis- such reports, and may come from university departments or in Research and Investigation bursement in the accounting for such Federal d. Any laborer or mechanic employed by any schools of industrial engineering, schools of 0 Administration of Personality funds, contractor or subcontractor in the perform- public health, commercial systems firms, c. reasona le assurances that the grantee ance o work on any construction aided by those with experience in program planning Tests, Inventories or will make such reports in such form and payments pursuant to any grant under this and budgeting, and a variety of other Questionnaires containing such information as the Surgeon section will be paid wages at rates not less sources. It is expected that from such a 0 Investigation of Persons Below General may from time to time reasonably than those prevailing on similar construction beginning areas worthy of more detailed the College Age Level require, and will keep such records and in the locality as determined by the Secre- activity may well become apparent and afford such access thereto as the Surgeon tary of Labor in accordance with the Davis- qualify for subsequent additional grant sup- c. Animal Care General may find necessary to assure the Bacon Act, as amended (40 USC 276a- port. Applicants are encouraged to direct B. Definitions correctness and verification of such reports, 276a-5); and the Secretary of Labor shall any questions they may have -relative to the 1. Approved Program and have with respect to the labor standards use of systems analysis to the Division of 2. Budget Period d. a satisfactory showing that the grantee specified In this paragraph, the authority Regional Medical Programs. 3. Clinical Research Center has designated an advisory group to advise and functions set forth in Reorganization 5. Publications-Grantees may publish ma- 4. Construction it (and the institutions and agencies partici- Plan Numbered 14 of 1950 (15FR 3176; 5 terials relating to their regional medical pating in the resulting regional medical USC 133z-15) and section 2 of the Act of program without prior review provided that 5. Grant program) in formulating and carrying out June 13, 1934, as amended (40 USC 276c). such publications carry a footnote acknowl- 6. Grantee the plan for the establishment and operation 3. Surveys or Questionnaires-Surveys or edging assistance from the Public Health 7. Hospital of such regional medical program. The ad- questionnaires arising from and supported Service, and indicating that findings and visory group includes practicing physicians, by a grant should Include a positive state- conclusions do not necessarily represent the S. Medical Center medical center officials, hospital administra- ment clearly setting forth that the contents views of the Service, 9. Non-Profft tors, representatives from appropriate medi- are in no way the responsibility of the Public 10. Practicing Physician cal societies, voluntary health agencies, and Health Service. 6. Patents and Inventions-The Department representatives from other organizations, of Health, Education, and Welfare regulations 11. Program Period institutions and agencies concerned with 4. Systems Analysis-This policy statement (945 F.R., Part 6 and 8) provide as a condi- 12. Related Diseases activities of the kind to be carried on under is to be used by those applicants who de- tion that all inventions arising out of the 114 activities assisted by Public Health Service 7. Other Public Health Service Grant Policies caution to assure proper care and humane 3. Clinical Research Center-A Clinical Re- grants must be promptly and fully reported -The following Public Health Service grant treatment of research animals. The booklet, search Center is an institution (or part of an in the Public Health Service. Any process, policies are also applicable to any such Guide for Laboratory Animals, Facilities and institution), the primary function of which, . art or method, machine manufacture or im- activities supported through a regional medi- Care (PHS Publication #1024) should be is research, training of specialists, and provement thereof, may constitute an inven- cal program grant: obtained from the Division of Research demonstrations and which, in connection tion 'if it is new and useful and would not a. Clinical Research and investigation In. Grants, Information Office, National Institutes therewith, provides specialized, high-quality have been obvious to a person having skill volving Human Beings-This policy state- of Health, Bethesda, Maryland, 20014. diagnostic and treatment services for in- in the art to which it relates. ment is currently being revised by Public The Public Health Service endorses the patients and outpatients' The clinical re- s:arch center may be a part of the medical In order for the Public Health Service to Health Service. following guiding principles in the care and c nter or it may be a separate institution. carry out its responsibility under these b. Protection of Individual Privacy in Re- use of animals: patent regulations, it is essential that the search and Investigation- 0 Animals should be acquired, retained, and 4. Constructio@onstruction means altera- Service be advised before awarding Govern- used in compliance with applicable state and tion, major repair (to the extent permitted ment funds of any commitments or obliga- (1) Administration of personality tests, inven- local law. by regulations), remodeling and renovation tions made by the institutions or by the tories or questionnaires. No grant or award of existing buildings with prior approval professional personnel to be associated with of the Public Health Service Extramural 0 Animals should receive every considers, (including initial equipment thereof), and the activities carried on under the grant Programs in support of research or investiga- tion for their bodily comfort, be kindly replacement of obsolete, @uilt-in (as de- which would be in conflict with the inven- tion involving the administration of person- treated and properly fed, be kept in sani- termined in accordance with regulations) tions agreement. When submitting an appli- ality tests, inventories or questionnaires tary facilities, and be provided with suitable equipment of existing buildings. cation for Regional Medical Programs, the shall be awarded by the Public Health Serv- medical care. grantee must provide in letter form either: ice unless the application includes a de- 5. Grant-A grant is the total amount of scription of the manner in which the rights 0 With any operation likely to cause greater direct and indirect costs which is awarded a. a statement indicating no previous com- and welfare of the subjects are assured, that discomfort than that attending anesthetize- to a grantee for support of an approved mitments or obligations have been made, or is, how their informed consent is obtained !ion, the animal should first be rendered program for a specific period of time. b. a detailed explanation of such commit or why this consent is deemed unnecessary incapable of perceiving pain and should be - or undesirable in the particular instance. maintained in that condition until the opera- 6. Grantee-The grantee is the applicant ments or obligations where they do exist. tion is ended. Exceptions should be made institution who is named'on the face page One such letter will suffice for the named (2) Investigations of persons below the col- only when anesthesia would defeat the ob. of the application and who assumes re- grantee and all cooperating institutions re- lege age level. No grant or award of Public jective of the experiment. In such cases, the sponsibility for the grant. ceiving support under the grant. It is the Health Service Extramural Programs in sup- anesthesia should be discontinued only so 7. Hospital-The term "hospital" includes responsibility of the institution named as port of research or investigation involving long as it is absolutely essential for the general, tuberculosis, and other types of the grantee on the application to ascertain administration of investigational procedures necessary observations. hospitals, and related facilities, such as the facts relating to patents and to report to persons below the college age level shall If the nature of the study requires sur- laboratories, outpatient departments (nurses' these on behalf of all entities participating be awarded by the Public Health Service 0 cautions home facilities), central service facilities unless the application includes a description vival of the animal, aseptic pre in the Regional Medical Program. of the manner in which the rights and re- should be observed during the operation, operated in connection with hospitals. and In subsequent years an annual invention sponsibilities are respected, that is, how the and care should be taken to minimize dis- other health facilities in which local capa- statement Form PHS-3945 must be filed informed consent of the parents or guardians comfort during convalescence comparable to bility for diagnosis and treatment is sup- whether or not an invention has occurred. is obtained, or why this consent is deemed Precautions taken in a hospital for human ported and augmented by the program estab- Where there are no inventions to report, a unnecessary or undesirable in this particular beings. If the animal is severely incapacited lished under this Act. It does not include single form PHS-3945 is all that is required instance. and survival is not a requirement of the institutions furnishing primarily domiciliary for the institution named on the application experiment, the animal should be sacrificed care. Proprietary hospitals may participate as the grantee and for all cooperating in- The professional judgment of the grantee will in a humane manner immediately following in the Regional Medical Program but may stitutions. Where there are inventions to determine what constitutes respect for the final observation. not be funded under the Act. report, a separate annual invention state- rights and responsibilities of parents or 8. Medical Center-Medical Center is a ment must be filed for each one. Here again, guardians, what constitutes informed con- B. Definitions medical school or other medical institution it is the responsibility of the grantee to re- sent, and what constitutes a validation for m-An approved program involved in postgraduate medical training deeming this consent to be unnecessary or 1. Approved Progra port on behalf of itself and all other entities ity approved by the and one or more hospitals affiliated there- articipating in the Regional Medical Pro- undesirable in a particular instance. is an identified activ p I Division of Regional Medical Programs for with for teaching, research, and demonstra- gram. The Regional Medical Program grant c. Animal Care support for a specific period of time. tion purposes. for the following year will not be issued until the invention statement form PHS 3945 has Each person assigned or appointed to @ 2. Budget Period-The budget is the period 9. Non-Profit-Non-profit as applied to any been received by the Division of Regional project receiving any Public Health Service of time within a program covered by a institution or agency means an institution Medical Programs. support is required to exercise every pre- specific budget, usually 12 months. or agency which is owned and operated by 115 one or more non-profit corporations or asso- D. Relationship to Other Sources of under Section 903 and operational grants C. Eligible Activities ciations no part of the net earnings of which Support under Section 904. The operation of a Re- -. . !.n!s section gives examples of types of ac- inures, or may lawfully Inure, to the benefit gionaf Medical Program obviously should be of any private shareholder or individual. E. Single Grant Approach based upon sound planning. For example, itivities which would be eligible for support . . under a Regional Medical Program grant. one purpose of planning for a region is to 10. Practicing Physlcian-A practicing phy- . . The intent of the program is to encourage sician Is any physician licensed to practice IV. GENERAL GRANT INFORMATION help establish the geographic boundaries innovations and creativity in the develop- medicine In accordance with applicable state A. Types of Grants that are necessary for effective and efficient ment through cooperative efforts of program laws. operation of the region. Planning also pro- elements to be included in the Regional 1. Planning-Section 903 of the Act au- vides an opportunity for the advisory group Medical Program. The listing therefore is 11. Program Period-The program period Is thorizes the Surgeon General, upon the rec- to participate in the initial stages of the intended to be helpful in the understanding the time for which new or continuing sup- ommendation of the National Advisory Coun- program. In some areas of the country, of the scope of a regional medical program, port has been recommended. The initial cil on Regional Medical Programs, to make much relevant planning may have taken rather than to be definitive. grants, may be for any period up to June grants to assist in the planning and devel- place before passage of this legislation. In 30, 1969. opment of Regional Medical Programs. such instances the grantee may request an Many different types of activities can be 12. Related Diseases-Related diseases are !. Operational-Section 904 authorizes the operational grant without having first applied supported under a Regional Medical Program those diseases which can reasonably b burgeon General, also upon recommenda- for a planning grant under Regional Medi- grant. Special attention must be given to a the functional interrelationships among the considered to bear a direct relationship to tion of the National Advisory Council on Re cal Programs. various program elements, and how they heart disease, cancer or stroke. gional Medical Programs, to make grants to assist in the establishment and opera- A grantee who has received a planning relate to the goals of the Regional Medical tion of the Regional Medical Programs. The grant need not wait for the completion of Program. initial authorization of this program through that planning grant before applying for an Certain program elements deserve special IV. GENERAL GRANT INFORMATION fiscal year 1968 Indicates that operational operational grant under Section 904. The discussion. Applications for a Regional Medi- grants under Section 904 will be considered grantee may wish to request funds under cal Program grant, both planning and op- A. Types of Grants pilot projects for the establishment and op- Section 904 to finance operational activities erational, must include specific reference to 1. Planning eration-of Regional Medical Programs. The which represent the first elements of a program plans for education and training of 2. Operational designation of operational programs as pilot complete Regional Medical Program. Such health personnel. Continuing education 3. Supplemental projects emphasizes the exploratory nature grants for the partial Implementation of a should receive particular emphasis as an of the first period of authorization. Regional Medical Program will be awarded, integral part of the total Regional Medical B. Relationship of Planning Grant to however, on the condition that the planning Program. However, meritorious programs of 3. Supplemental-The exploratory and de- for implementation of additional phases of continuing education presented in the ab- Operational Grant velopmental aspects of a Regional Medical the Regional Medical Program will pro- sence of, or unrelated to, plans for the fuller C. Eligible Activities Program, both in the planning and opera- ceed. Grants for partial implementation will development of a Regional Medical Program 1. Under a Planning Grant (including tional phases, lead to the expectation that be awarded for limited time periods and the cannot be supported through grants under Feasibility Studies) the grantee will wish to add additional continuation of such a grant will be condi- this program. Therefore, the relationship of 2. Under an Operational Grant program elements or to expand existing tioned upon the submission, review, and continuing education to other aspects of the program elements subsequent to the award approval of additional elements of the corn- proposed planning or operational activity 0Continuing Education and Training of the Initial grant. The practice of submit- plate Regional Medical Program by the must be indicated. 0Research ting requests for supplemental funds is en- end of the initial period of award. T@e pur- 0Demonstration of Patient Care couraged insofar as the submission of a pose of these conditions Is to allow initial Both the planning and operational phase of 0Support of Administrative Core supplemental request is preferable to the steps in the implementation of a Regional a Regional Medical Program should stress 0Alteration and Renovation inclusion in the Initial application of pro- Medical Program, while at the same time, the development of more effective relation- gram elements which represent only very Insuring progress toward the full develop- ships between ongoing research activities in 0Communication Systems preliminary Ideas or for which It Is diffi- ment of the Regional Medical Program. the fields of heart disease, cancer, stroke, or 0Communications and Public cult to justify particular budget requests. related diseases and the other proposed Information Supplemental grant requests will be submit- Planning should continue after the initiation activities of an educational or service nature ted on the same form as the Initial appli- of an operational program under Section 0Computers cation and will go through a similar review u er the Regional Medical Program. The 904. This continued planning may be financed _nci 0Diagnostic and Treatment Equipment and award process. either by continuing the planning grant un- Regional Medical Program should seek to 0Support of Staff ln'Cooperating der Section 903, or by the inclusion of the maintain an effective interaction between B. Relationship of Planning support of planning activities under the ongoing research activities and other aspects Institutions Grant to Operational Grant operational grant. Conversely, however, op- of the Regional Medical Program, so as to 0Consultant Services The Act does not provide a specific sequen erational activities may not be supported assure that the activities specifically directed <> Transportation of Patients tial relationship between planning grants from planning grant funds. toward the goal of improved diagnosis and 116 :reatment may receive the benefit of future educational and training programs within proposed project will extend those efforts. However, if special justification exists for research advances. the region; evaluation of additional educa- It is anticipated that such major investments the support of research which is essential to tional and training needs in the region; pro- for equipment and supplies will more ap- the effective accomplishment of the objec- 1. Under Planning Grant (including Feasi- jections of methods of meeting those needs propriately be in pilot projects or operational tives of the Regional Medical Program, and bility Studies)-The scope of planning activi- including specification of appropriate curri- grants rather than in feasibility studies or if it can be demonstrated that the other ties which are related to accomplishing the culum content, etc.; preliminary thoughts planning grants. sources of support are not appropriate, a objectives of the Regional Medical Programs relative to the mechanism of evaluating the Considerations under the Regional Medical limited amount of research activity could be can be quite broad. However, planning and effectiveness of future programs in meeting supported under the Regional Medical Pro- conceptualization concerned with general of Programs will be given to continuing educa. the needs; the relationship ontinuing tion and training programs for medical, gram grant. health matters but not related to develop- education and training programs toc the over. <> Demonstrations of Patient Care ment of a Regional Medical Program should all objectives of the Regional Medical Pro- allied health personnel and associated pro- Demonstrations of patient care may be sup- not be included. c fessions. However, it should be emphasized gram including their anticipated effe tive- that the primary intent of the legislation in ported when related to the research, train- In general, planning should include studies ness in bringing about cooperativesarra@ge- this area is the support of those activities ing, and continuing education activities of of resources, distribution of services, patient ments between the various health in titutions that are beyond those normally accepted as the program. The Act provides that the costs flow, and program elements that are needed, and personnel within the region. basic preparation for work in the health of patient care may be supported only when design of specific program elements that in- 2. Under an Operational Grant-Pilot proj- field. Thus, support of basic programs in such care is incident to research, training, cludes a mechanism for program evaluation, ects for the establishment and operation of medical education, residency training, and or demonstration activities encompassed by planning for cooperation among institutions' a Regional Medical Program can cover a basic education and training in allied health the purposes of the program and only if the and plan@ing toward the more effective dis. great variety of activities. areas is not normally anticipated. If, how- patient has been referred by a practicing tribution and utilization of all types of medi- ever, the applicant can demonstrate that physician. Grant funds could be used to pay cal resources. 0 Continuing Education and Training funds are not available from other sources the other costs incident to the demonstra- The development and operation of regional It is assumed that before applying for an and the particular basic educational program tion activity, including staff and equipment. medical programs, individually and collec- operational grant in this area, certain activi- is essential to the success of the Regional 0 Support of Administrative Core tively, can be aided by well conceived, ties will have been undertaken during th! Medical Program then consideration will be The grant may be used to pay the costs for properly implemented, and continuous com- planning process (see above). Operationai given to such a request. the central administration of the total Re- munication and public information tech. grant funds can support costs of programs gional Medical Program. This could include including teaching staff, equipment, educa- Applicants are encouraged to explore Inno- the salaries of a program coordinator and niques and activities which are designed to tional materials, transportation, rental or vative training approaches and the develop- other administrative staff as well as the provide a maximum of understanding, par- renovation of space and related demonstra- ment of new types of health personnel to other costs incident to the central coordina- ticipation and support among cooperating tions of patient care. However, the grant meet the manpower needs of the region as tion of the Regional Medical Program. organizations and individuals, as well as may not supplant previous support for on- identified in the planning process. 0 Alteration and Renovation among lay publics for whom the programs going activities in this area. Documenta- Ninety percent of the costs of alteration and will be established. tion of the additive nature of the proposed 0 Research renovation may be charged to operational program should be made. Stipends for Research into better means of accomplish- grants. No such charges are permitted to To plan and implement such activities, pro- trainees and participants in the program will ing the purposes and objectives of the planning grants. vision for including professional staffing and be considered only when it is fully docu- Regional Medical Program is supportable 0 Communication Systems budgetary support for a communication and mented that such funds are not available u grant. Since other A grant may support the purchase or rental componen nder an operational public information t may be in- from other sources and their expenditure is Public Health Service grant mechanisms of communication systems to be used for cluded in grant applications. absolutely necessary for the implementation provide excellent means for the support of educational, diagnostic or other purposes. The emphasis on continuing education in the of the program. biomedical research, the grantee under a However, if such requests represent major Act deserves particular mention. Creative In instances where major expenditures for Regional Medical Program is required to look funding investments, they should include (as approaches in the development and manage- equipment and supplies are requested to these and other sources of support as mentioned under Continuing Education and ment of cooperative arrangements to achieve special emphasis should be given to meas- well. The support of research activities Training above) documentation of: the meas. high quality education programs as well as urements of effectiveness of the program; urement of effectiveness of the program through other Public Health Service researcn new ways of applying educational researc the numbers of people affected by the sys including measurements in change in per- support mechanisms does not lessen the tem; the degree to which the information findings are vital. Indeed the history of the formance of participants, numbers of par- importance of planning and implementing produced might be generalized to other Re- legislation itself stimulates this aspect of ticipants, and degree information produced a Regional Medical Program in a manner gional Medical Programs; and knowledge of regional medical programs. might be applicable to other regional medi- which insures a close and continuous linkage related efforts already accomplished by Examples of activities for consideration in cal programs. There should also be acknowl- between all of the activities of the regional others with indications of the manner by planning in the area of continuing education edgement of related efforts already accom- program and the environment of research which the proposed project will extend those and training are: identification of existing plished by others with indications of how the and 'teaching. efforts. 117 0 Communications and Public Information the purposes of the program. The location of V. PREPARATION AND REVIEW OF L. Change in the Program Period A communication and public information such equipment should be planned with its APPLICATION component as an integral part of the pro- efficient and effective use in mind. M. Early Termination of the Grant posed regional medical program might 0 Support of Staff in Cooperating Institutions A. Eligible Applicants 1. By the Grantee include: The grant can be used to pay the salary of B. Method of Obtaining Application 2. By the Public Health Service staff involved in the conduct of the Regional C. Method of Preparing Application N. Reports Utilization of a qualified communication and Medical Program, not only in the grantee public information specialist, and necessary institution but also in the other instit tions D. Review of Application 1. Progress supporting staff, in both planning and opera. u E. Notification of Applicant 2. Regional Advisory Group tional activities. cooperating in the program. The level Of salary support must be consistent with t he F. Financial Management 3. Expenditures Development of studies to evaluate profes. salary policies of the institution concerned. 1. General Requirements 4. Time or Effort sional and public attitudes toward the pro. The staff might be engaged in supervising 2. The Amount Awarded 5. Invention grams. and coordinating the activities of the Re- 3. Direct Costs 0. Miscellaneous gional Medical Program in the institution or Development and maintenance of a flow of be involved in specific program elements, 0Personnel 1. Safety Precautions professional and general information to all such as those discussed above. 0Consultant Costs 2. Federal Income Tax special and general interest groups and 0 Consultant Services publics, among other existing regional medi- The grant could pay for consultant services 0Hospitalization Costs 3. Military Service cal programs, and between them and the related to any program element of the 0Travel Division of Regional Medical Programs. Regional Medical Program and justified as 0Rent V. PREPARATION AND REVIEW OF Preparation and distribution of printed, visual the most effective means of accomplishing 0Communication APPLICATION and other information material for profes- a particular purpose to be served. sional and lay publics. 0 Transportation of Patients 0Printing and Reproductions A. Eligible Applicants When justified as the most efficient means 0Equipment The following are eligible applicants for bot Participation of this component in planning of carrying out the purpose of the program, 0Alteration and Renovation planning and operational grants: public, c and conducting programs, seminars, con- grant funds may be used to pay the costs "Construction" private non-profit universities, medicE ferences and other means of exchanging of transportation of patients referred for 0Costs not Permitted schools, research Institutions, and othe professional general Information. diagnosis and treatment In other Institutions public, or non-profit private agencies an Plans that do not specifically further under- as part of a research, training or demon- 4. Indirect Costs institutions located in any state, the Distric standing, participation and support as pre- stration program. The use of grant funds to 5. Rebudgeting of Funds of Columbia, Puerto Rico, or the Virg! viously defined, or which would appear to pay transportation costs should be carefully 6. Refunds Islands. The applicant must be authorized t . . d against the use of funds for other represent the participating institutions wh, provide only for publicity for the program 0Interest or Other Income I and aggrandisement of its officials, shou-- =s within the Regional Medica Pro propose to be involved in the planning ani not be included. gram. 0Royalties and Profits operation of the Regional Medical Program Questions related to these aspects of D. Relationship to Other Sources of Support 7. Unexpended Balance The applicant must be able to exercise pro r expected that no institutional funds 8. Obligations or Expenditures gram coordination and fiscal responsibility th: D @ ! t s posed program may be directed to [VI: ! in assuring the effective use of the gran sion of Regional Medical Programs for an- ?ormerly devoted to these activities will be 9. Accounting, Records and Audit funds. The applicant is legally responsible swers or special consultation. displaced by the use of the Regional Medical 0Accounting for expenditure of funds both by itself ant Program grant. Not only should the grantee 0Records cooperating institutions. 0 Computers avoid substituting these grant funds for Grant funds may be used to purchase com- other sources of support, but he should also 0Audit puter time, or if the needs of the program continue to seek additional resources for 10. Equipment (Titfe and Accountability) B. Method of Obtaining Application are sufficient, the rental of a computer. As carrying out the objectives of the Regional G. Additional Funds Application form NIH-925, which is used bott with all other activities, the costs of acquir- Medical Program. 1. For Continued Support for planning and operational grants, whether ing computer capability must be measured they are new, continuation, or supplemental against the benefits to be derived for the E. Single Grant Approach 2. Supplemental Funds may be obtained by writing the Division o@ program. Planning as well as operational grants will 3. Support Beyond the Program Period Regional Medical Programs, National lnsti 0 Diagnostic and Treatment Equipment each be single instruments of support for H. Program Evaluation tutes of Health, Bethesda, Maryland, 20014 Funds may be used to purchase diagnostic activities under the Regional Medical Pro- 1. Changes in Approved Program C. Method of Preparing Application and treatment equipment which is Identified, grams. The single grant approach Is Intended through the planning process, as being a to Insure an appropriate degree of cohesive- J. Change of the Grantee Applications should be prepared in accord. specific need of the region in carrying out ness in the cooperative approach. K. Change of Program Coordinator ance with information contained In these 118 guidelines and with the specific instructions Programs in advance of the performance of owned automobiles are chargeable under Operational grant funds may not support included with the application. the act which requires the obligating or this category. more than 90% of the cost of such "con- expenditure of funds. Less than first class travel accommodations struction" or equipment. D. Review of Application 2. The Amount Awarded-There is no fixed shall be used except in extenuating circum- New facilities may not be constructed under Applications will be reviewed by the staff, limitation on the amount of funds that may stances. Automobile mileage and any foreign this program. Where construction of new by consultants to the Division of Regional be awarded. The budget must have a direct travel must be in accordance with institution facilities is considered necessary for fur- Medical Programs, and as required by relationship to the activities proposed. The policy. Any foreign travel must receive prior thering the program, the applicant may statute, by the National Advisory Council on size of the various program elements in- approval from the Division of Regional seek construction funds under other applica- Regional Medical Programs. Under terms of cluded . in the budget should be carefully Medical Programs. ble Federal programs, such as the Hill- the law, a grant may not be awarded unless considered in terms of the relative effective- 0 Rent Burton, Health Research Facilities, and the Health Professions Educational Assistance it has been recommended for approval by ness in accomplishing the purposes of the The expenses for rental of facilities not programs. the National Advisory Council. Regional Medical Program. The budget owned by the grantee or participating insti- The rigorous review process requires that should also have a direct relationship to the tution may be charged in proportion to the 0 Direct Costs not Permitted sufficient information be provided in the reasonable expectations for the rate of im- space actually utilized for the program. The following direct costs or charges are application to enable the reviewers to reach plementation of the proposed programs. Rental costs may not be in excess of corn. not allowable: considered and informed judgments con. 3. Direct Costs-The following are examples parable rentals in the particular locality, and - Honoraria as distinguished from consultant cerning the nature, feasibility and soundness of direct costs that may be charged to a must be in accordance with institution policy. fees of the proposal and to weigh the use of Regional Medical Program grant: 0 Communication - Entertainment (cost of amusement, social grant funds for the particular proposal 0 Personnel That portion of communication charges nec- activities, entertainment and incidental costs against benefits to be gained from the use Salaries, wages, and fringe benefits of per- essary to the planning or implementation of thereto, such as meals, lodging, rentals, of grant funds elsewhere. sonnel in proportion to the time or effort the program or project may be charged to transportation and gratuities) expended on the program and in accord- this category. In no case may institutional .. yment to Federal employees I'a A complete, informative application will fa. -Petty cash funds cilitate and expedite the review of an apple ance with institutional policy, may be local and regular monthly telephone costs bgranting (a subgrant is any allocation charged to this category. Adequate time and and normal postage charges not related to -Su cation. When necessary in the judgment o? effort records must be maintained in order the Regional Medical Programs be charged of grant funds by the grantee to other indi- the staff or consultants, additional informa- to substantiate these costs. to the grant. viduals or organizations for purposes over tion or justification may be required either 0 Consultant Costs 0 Printing and Reproduction which the grantee institution named on the by supplemental documents or by confer- application does not maintain scientific and ences and visits. Grant funds may be used to pay consultant Printing of pamphlets, brochures and other financial responsibility. A grantee may con- fees for services related to any program materials necessary for this program may be tract for services, but may not subgrant.) E, Notification of Applicant element of the Regional Medical Program charged to this category. providing that these services are the most 0 Equipment 4. Indirect Costs-Institutional indirect cost Copies of a Notice of Grant Awarded are effective means of accomplishing a particu- Rental and purchase of equipment for the rates will be based on the percentage rela- sent to the grantee. This notice indicates lar purpose, and that the consultant is not tionship that total institutional indirect cost planning or implementation of a program is to the total direct salaries and wages paid the program period, the amount being on the staff of the grantee or cooperating may be charged to this category. When ac- by the institution (not just the research in- awarded (including the budget period cov- institution. If consultation is obtained from quiring equipment, consideration of the rela- direct cost pool). ered), and any special conditions under a staff member of the grantee or cooperat- tive advantages of lease versus purchase which the grant is awarded. ing institution, a proportionate amount of should be considered. Data taken directly from the grantee or his regular salary may be paid by the grant. c rating institutions most recent annual Alteration and Renovation ("Construction") .oope F. Financial Management In either case, consultant costs must be linder the Act "construction" means altera. Tinancial report and immediately available 1. General Requirements-Funds granteol supported by a clear statement of services tion, restoration to a sound state, remodel- supporting information will be utilized as a performed and if appropriate, the number ing and renovation of existing buildings basis for determining the indirect cost rate may be used only for services, materials .of man days of service. applicable to a Regional Medical Program and other items required to carry out the ap- (including initial equipment thereof), and re- grant at the institution. proved program. Circular A-21 of the Bureau 0 Hospitalization Costs placement of obsolete built-in equipment of of the Budget should be used to the extent The method of determining hospitalization existing buildings. Built-in equipment is Total expenditures as taken from the most practicable in determining allowable costs re- costs is still under consideration by the equipment affixed to the facility and cus- recent annual financial report will be ad- lated to the grants for Regional Medical Division of Regional Medical Programs. It tomarily included in a building contract. justed by eliminating from further considera- Programs. Where the Division of Regional will be distributed at a later date. The applicant is required to furnish in suf- tion the following items or categories of Medical Programs requires prior approval 0 Travel ficient detail plans and specifications, as well expenditure: for items not listed in the approved budget, Per them reimbursements to travelers, per- as a narrative description, to indicate the 0 The costs of equipment, buildings, and a written request must be made by the sonal transportation charges, and reimburse- need, nature and purpose of the proposed repairs which materially increase the value grantee to the Division of Regional Medical ments for authorized use of personally "construction." or useful life of buildings or equipment. 119 However, depreciation and use charges may all institutional indirect cost rate has been and protection of the institution's physical material shall be refunded to the Public be Included in determining total expenditure. audited and approved by the PHS, another facilities; Health Service. 6 Advertising other than for recruitment of Government agency, or an independent ac- 0 Reimbursements and other receipts from 7. Unexpended Balance-Continued use of personnel, procurement of scarce items or counting firm. In addition, the total institu- the Federal Government which are used by any unobligated. or unexpended funds re- the'disposil of scrap or surplus material. tional indirect cost, and direct salaries and the institution to support directly, in whole maining in the grant account at the end of 0 Bad debts wages should be stated as separate amounts. or in part, any of the administrative or the budget period should be justified by the 0 Contingency reserves The institution should indicate whether service (indirect) activities received pursuant grantee when the Expenditures Report is 0 Commencement and. convocation costs fringe benefits are included in the salary to an lnstitution's base grant or any similar submitted to the Division of Regional Medi. 0 Entertainment costs and wage base or not. A detailed Indirect contractual arrangement with the Federal cal Programs. If adequate justification is 0 Fines and penalties cost proposal should accompany each new Government shall be treated as a credit to received, the Division of Regional Medical 0 Interest, fund raising and investment or continuing grant application. When an the total indirect cost pool. Such set-off shall Programs will advise the grantee that such management costs applicant is submitting a planning grant be made prior to the determination of the funds may be used during the subsequent 0 Losses on other agreements or contracts application to the Division of Regional Medi- indirect cost rate submitted to the Division budget period. If inadequate justification, or 0 Profits and losses on disposition of plant, cal Programs, the above ' procedures also of Regional Medical Programs. These credits no justification is presented, unexpended equipment, or other capital costs apply. include indirect cost reimbursements con- funds will be used toward payment of the 0 Public Information services costs Indirect costs are those which, because Of tained in payments for hospitalization, total amount requested for the subsequent 0 Scholarships and student aid costs their incurrence usually for common or interdepartmental charges and centralized budget period. The unexpended balance as 0 Special services costs incured for general joint objectives, are not readily ldentifi ad facilities operated by the Institution. shown in the final Expenditures Report must public relations with individual projects. All costs represent- S. Rebudgeting of Funds-The grantee or be returned to the National Institutes of 0 Student activity costs ing charges associated with the activities cooperating Institutions may depart from the Health, PHS, DHEW, Bethesda, Maryland, 0 Student dormitory costs of the grantee or cooperating Institutions approved budget and use the funds for other 20014. 0 Student services costs which are supportive of the conduct of the items required for the project, except for 8. Obligations or Expenditures-Obligations, 0 Costs used In arriving at a hospitalization Regional Medical Program, except those the following restrictions: commitments, encumbrances, or expendi- rate or interdepartmental charge which are specifically approved by the Div!- 0 Grant funds may not be used for any tures will normally be made within the 0 Unrelated hospital costs sion of Regional Medical Programs as direct purpose contrary to the regulations and period indicated on the notice of grant 0 Other inappropriate costs costs, are classified as indirect costs. The policies of the Division of Regional Medical award. Grant funds may not be used to Where any types of expense ordinarily general types of indirect costs are: Programs or the grantee or the cooperating reimburse any such obligations, commit- treated as' general administration and gen- * General administration and expenses institutions. ments or expenditures made prior to the eral 'expenses or departmental administra- which are Incurred for the executive and 0 Grant funds may be transferred between beginning date of the initial grant for a new tration expenses are charged to a Division administrative offices of an institution re- budget categories to the extent that no or renewal project. In exceptional instances of Regional Medical Programs grant as ceiving grants, and other expenses of a category is increased or decreased by more the grantee may, at its own risk, prior to the direct costs, the similar type of expenses than 20% of the approved budget. Increases a c general character which do not relate solely beginning date of antinuation award, in- applicable to other activities of the institu. to any specific unit in the institution, or to or decreases in a budget category in excess cur expenditures which exceed existing Divi. tion must, through separate cost groupings, any specific project in the institution; of 20% must be approved by the Division of sion of Regional Medical Programs authoriza- be excluded from the indirect costs allowable 0 Program administration expenses 'which Regional Medical Programs. tion but which are considered essential to the conduct of the project. The Division of to a Division of Regional Medical Programs apply to program activities administered in 6. Refunds-During the program period, re. Regional Medical grant. whole or in part by a separate organization Programs may allow reim. funds and rebates should be credited to the bursement of such expenditures from the The indirect cost rate will then be co or an identifiable administrative unit. Ex- account. Credits received after the termina- continuation grant. .Mpute@ amples of work relating to grant programs tion of the program period shall be returned by dividing the total direct salaries anci which is sometimes performed under such to the Public Health Service. Checks should 9. Accounting Records and Audit- wages paid by the institution into the total organizational arrangement are: grant ad-, be made payable to National Institutes of 0 Accounting adjusted indirect cost incurred by the institu- tion. ministration, purchasing, personnel, account- Health, PHS, DHEW, Bethesda, Maryland, Accounting for the grant funds will be in ing, etc.; 20014. accordance with the grantee and/or coop- When, under an operational grant, the coop- 0 Operation and maintenance expenses In- 0 Interest and other income erating institution accounting practices con- erating Institutions are preparing their budg- curred for operating and maintaining an Interest or other income earned on grant sistently applied regardless of the source of ets for submission to the grantee, the lnstitution's physical plant, Including ex- funds must be returned to the Public Health funds. Itemization of all supporting expendi- institutions' Indirect cost rates, @ased on penses normally Incurred for administration Service. tures must be recorded in sufficient detail salaries and wages, should be stated In the or supervision of the physical plant; jani- 0 Royalties and Profits to show the exact nature of expenditures. budget. To substantiate this rate, the co- torial service; utilities, including telephone When the costs of publishing material are Each recipient of grant funds shall keep operating institutions should supply the installation and maintenance costs; and provided from Public Health Service grants, such records as the Surgeon General may grantee with adequate substantiating data, other expenses customarily associated with any royalties or profits up to the amount prescribe, including records which fully dis- such as documents certifying that the over- the operation, maintenance, p reservation, charged to the grant for publishing the close the amount and disposition by such 120 recipient of the proceeds of such grant, the in determining that there is a proper ac- supplemental grant forms a part of the ini- J. Change of Grantee total cost of the program or undertaking in counting in use of grant funds. Failure of a tial award and only one report of expendi- If the grantee expects to relinquish active connection with which such grant is made grantee to appeal a proposed audit disallow- tures is required. direction of the program, the Division of or used, and the amount of that portion of ance within thirty days after receipt of a Supplemental applications are processed in Regional Medical Programs must be notified the cost of the program or undertaking sup- written notification will make the action of the same manner as new applications and --- ediately. The grantee may request that plied by other sources, and to make such the Division of Regional Medical Programs must compete for available funds, except grant be terminated, in which case a records available as will facilitate an effec- conclusive. those applications to meet increased ad- ine tive audit by authorized personnel. Such a ministrative costs, such as fringe benefits terminal progress report, an expenditures system must meet the following criteria: 10. Equipment (Title and Accountability) or salary increases, may be administratively report, and invention statement (PHS-3945) - A special grant account must be estab- must be submitted. The grantee may request lished for each Regional Medical Program Title to equipment purchased with grant approved. iod-if that the program be continued under the grant and be maintained at the grantee in- funds resides in the grantee institution and 3. Support beyond the Program Per rogram direction of another institution. stitution designated on the application. Re- accountability may be waived at the termina- additional support beyond the p sponsibility for expenditure of funds b tion of the grant by the Division of Regional period is required, a new application must If the grantee terminates its responsibility participating institutions must be assume-@ Medical Programs as long as the equipment be submitted. This application will go for the program, the new institution may u is used to further the objectives of the through the normal review process and will-. submit a new grant application for the re- by the named grantee institution. Public Health Service. The Division of Re- compete with other applications for availa- - The accounting records at the grantee in- gional Medical Programs, however, reserves ble funds. If approved, an initial grant for mainder of the program period. The applica- stitution shall provide the in rmat the right under unusual circumstances to a new program period will be awarde tion should include the reasons for trans- needed to identify the receipt and expe transfer title of equipment to the Division of ferring the program and the probable effect lure of all program funds separately Regional Medical Programs or to another H. Program Evaluation of the move on the program. Administrative each grant. Expenditures shall be recoi approval may be given by the Division of by the component program and budget ( ost grantee. The grantee should make a special effort to Regional Medical Programs to continue the categories shown in the approved budget. Excess materials and supplies retained by incorporate into all aspects of the planning program at the new institution. Applications, - Each entry in the accounting records at the the grantee upon termination of the pro. and operational activities appropriate mecha- however, that reflect major changes will be grantee or cooperatinglnstitution shall refer gram hiay be accounted for under the same nisms for evaluating the effectiveness of all referred to the National Advisory Council on to the documentation which supports the terms as equipment. as pacts of the Regional Medical Program. Regional Medical Programs for recommenda- entry and the documentation shall be filed The concern with the evaluation should be- tion. in such a way that it can be readily located. G. Additional Funds gin in the planning process so that the - The accounting records shall-provide ac- planning process may include planning for K. Change of Program Coordinator curate and current financial reporting in. To obtain additional funds for support of a evaluation mechanisms. The exploratory na- formation. program, the procedures vary according to ture of the Regional Medical Programs The program coordinator named in the ap- - The accounting system shall possess an the need as follows: makes the need for the realistic evaluation plication shall be responsible for coordina- adequate means of internal control to safe- mechanisms especially important. Particular tion of the program during the period for 1. For continued support-An application attention to the evaluation process will pro- which the grant was awarded. guard the assets, check the accuracy and form requesting support for the next budget vide the means for the grantee to assess his A change of program coordinator or other reliability of the accounting data, promote period of the program period (continuation progress and accomplishments and will also key official directing the program requires operational efficiency, and encourage ad- grant) will be mailed to the grantee institu- provide the basis for the preparation of approval by the Division of Regional Medi- herence to prescribed management policies. tion about 4 months before the beginning progress reports which can be used by the cal Programs. The grantee is required to 0 Records date of the next budget period. It is the Division of Regional Medical Programs in notify the Division of Regional Medical Pro- ments to support entries on the accounting The financial records, including all docu- responsibility of the grantee to request this evaluating the accomplishments of the total grams if such a change is necessary. application form if it is not received. The national program. records, mus't be kept readily available for application should be submitted in accord- examination by authorized personnel. No ance with the instructions accompanying the 1. Changes In Approved Program L. Change in Program Period such records shall be destroyed or other- form. The program period may be extended up to wise disposed of within three years after The Division of Regional Medical Programs the termination of the program. Unless writ- 2. For supplemental funds-if additional does not intend to interfere with administra- 12 months (but not beyond June 30, 1969) ten approval is obtained from the Public funds to conduct the program are required tive or program flexibility which @erves the without additional funds, if requested by the within any portion of the program period objectives of the Regional Medical Frograms. grantee before the end of the program Health Service to dispose of the records, they must be retained until the audit has over those budgeted and approved, and such If, however, a change is determined by the period. n the institution grantee to be desirable, and if that c@an been completed and all questions about the funds are not available withi @e expenditures are resolved. receiving support for the program, a supple- would constitute a substantial change in ine M. Early Termination of Grant 0 Audit mental application may be submitted. A nature of the program originally approved, 1. By the Grantee-A grant may be termi- The Division of Regional Medical Programs face sheet, budget page, and justification the grantee should consult with the Division nated or cancelled at any time by the follows generally accepted auditing practices are required for a supplemental award. A of Regional Medical Programs staff. grantee upon written notification to the 1 2 1 Appendix 7-Publ'c Law 89-239 Division of Regional Medical Programs stat- submitted by the named grantee on behalf Public Law 89-239 professional practice, or with the adminis- ing the reasons for termination. of all cooperating institutions to the Division 89th Congress, S. 596 tration of hospitals, and in cooperation with 2. By the Public Health -A grant of Regional Medical Programs for each October 6, 1965 practicing physicians, medical center Service officials, hospital administrators, and repre- may be revoked or terminated by the Sur- budget period of the program period. If the geon General, in whole or in part, in any grantee fails to submit an expenditures re- AN ACT sentat.ives from appropriate voluntary health time within the program period whenever it port within 120 days after the end of each To amend the Public Health Service Act to agencies. is determined that the grantee has failed budget period, future awards for that project assist in combating heart disease, cancer, "Authorization of Appropriations in a material respect to comply with the may be withheld. stroke, and related diseases. terms and conditions of the grant. The "Sec. 901. (a) There are authorized to be grantee will be promptly advised of the rea- A supplemental grant forms a part of the Heart Disease, appropriated $50,000,000 for the fiscal year sons for termination of the grant in writing. existing grant and only one expenditure re- Cancer, and ending June 30, 1966, $90,000,000 for the port need be submitted on the combined Stroko Am,n,i- fiscal year ending June 30, 1967, and N, Reports grants. ments of 1965. $200,000,000 for the fiscal year ending June All repdrts required to be submitted to the 4. Time or Effort Report-Charges for sala- 30, 1968, for grants to assist public or Public Health Service should be sent to the ries and wages of individuals other than Be it enacted by the Senate and House Of nonprofit private universities, medical Division of Regional Medical Programs, Pub- members of the professional staff will be Representatives of the United States of schools, research institutions, and other America in Congress assembled, That this public or nonprofit private institutions and lic Health Service, Bethesda, Maryland, supported by time and attendance and pay. Act may be cited as the "Heart Disease, agencies in planning, in conducting feasibili- 20014. roll distribution records. For members of the Cancer, and Stroke Amendments of 1965". ty studies, and in operating pilot projects 1. Progress Reports-The grantee is re- professional staff, quarterly estimates of the for the establishment, of regional medical quired to submit an annual progress report. percentage distribution of their total effort Sec. 2. The Public Health Service Act (42 rograms of research, training, and demon- This report should contain sufficient detail must be used as support in the absence of U.S.C., ch. 6A) is amended by adding at the P end thereof the following new title: stration activities for carrying out the pur- to inform the reader of the accomplishments actual time records. Time and effort reports poses of this title. Sums appropriated under with particular respect to the objectives are not to be sent to the Division of Re- "TITLE IX-EDUCATION, RESEARCH, TRAIN- this section for any fiscal year shall remain originally set forth. These progress reports gional Medical Programs but must be re- ING, AND DEMONSTRATIONS IN THE available for making such grants until the must be submitted with the application for tained by the grantee and must be made FIELDS OF HEART DISEASE, CANCER, end of the fiscal year following the fiscal a continued support. In addition, grantees available for inspection by the Public Health STROKE, AND RELATED DISEASES year for which the appropriation is made. may be required to supply other information Service staff. "(b) A grant under this title shall be for needed for guidance and development of the "Purposes part or all of the cost of the planning or national program and are encouraged to re- 5. Invention Report-Immediate and full re- "Sec. 900. The purposes of this title are- other activities with respect to which the port significant developments promptly at porting of all inventions to the Public Health ,(a) Through grants, to encourage and as- application is made, except that any such any time. A terminal progress report must Service is required. be submitted to the Division of Regional sist in the establishment of regional cooper- grant with respect to construction of, or Medical Programs within three months of 0. Miscellaneous ative arrangements among medical schools, provision of built-in (as determined in ac- the termination of the program period. research institutions, and hospitals for re- cordance with regulations) equipment for, 1. Safety Precautions-The Public Health c any facility may not exceed 90 per centum search and training (including ontinuing 2. Regional Advisory Group-The Regional Service assumes no responsibility wit re- Or the cost of such construction or equip- Advisory Group is expected to prepare an spect to accident, claims or illness ari !ng education) ani for related demonstrations of ment. annual statement on the effectiveness of the out of any work undertaken with the assist- patient care in the fields of heart disease, "(c) Funds appropriated pursuant to this ti- regional cooperative arrangements estab- ance of a Public Health Service Grant. The cancer, stroke, and related diseases; tle shall not be available to pay the cost of lished under the Regional Medical Program. grantee institution is expected to take neces- "(b) To afford to the medical profession and hospital, medical, or other care of patients The report should be submitted to the Divi- e Nation, except to the extent it isi as determined in sion of Regional Medical Programs b the sary steps to insure or protect itself and its the medical institutions of th ts, the accordance with regulations, incident to y through such cooperative arrangemen grantee along with the annual progress re, personnel. opportunity of making available to their pa- those research, training, or demonstration port. Periodic reviews of grants by the staff 2. Federal Income Tax-Determination of a of the Division and the Advisory Council will tients the latest advances in the diagnosis activities which are encompassed by the include consideration of the effectiveness of tax status of an individual receiving com- and treatment of these diseases; and purposes of this title. No patient shall be pensation in any form from the Public furnished hospital, medical, or other care at the Advisory Group in serving its essential Health Service grant is the responsibility of "(c) By these means, to improve generally any facility incident to research, training, or purpose. the internal Revenue Service. the health manpower and facilities available demonstration activities carried out with 3. Expenditures Report (Form NIH-925-3)- 3. Military Service-The Public Health Serv. to the Nation, and to accomplish these ends funds appropriated pursuant to this title, A single expenditures report and a single ice will not intercede on behalf of an indi- without interfering with the patterns, or the unless he has been referred to such facility narrative progress report is required to be vidual in relation to military status. methods of financing, of patient care or by a practicing physician. 122 "Definitions 11(f) The term 'Construction' includes altera- lishment and operation of such regional find necessary to assure the correctness tion, major repair (to the extent permitted medical program, which advisory group and verification of such reports; and "Sec. 902. For the purposes of this title- by regulations), remodeling and renovation includes practicing physicians, medical "(4) any laborer or mechanic employed by "(a) The term 'regional medical program' of existing buildings (including initial equip- center officials, hospital administrators, any contractor or subcontractor in the means a cooperative arrangement among a ment thereof), and replacement of obsolete, representatives from appropriate medical performance of work on any construction group of public or nonprofit private institu- built-in (as determined in accordance with societies, voluntary health agencies, and aided by payments pursuant to any grant tions or agencies engaged in research, train- regulations) equipment of existing buildings. representatives of other organizations, in- under this section will be paid wages at ing, diagnosis, and treatment relating to stitutions, and agencies concerned with rates not less than those prevailing on heart disease, cancer, or stroke, and, at the "Grants for Planning activities of the kind to be carried on similar construction in the locality as de- option of the applicant, related disease or "Sec. 903. (a) The Surgeon General, upon under the program and members of the termined by the Secretary of Labor in ac- diseases; but only if such group- the recommendation of the National Advi- public familiar with the need for the serv. cordance with the Davis-Bacon Act, as ices provided under the program. amended (40 U.S.C. 276a-276a-5); and "(1) is'situated within a geographic area, sory Council on Regional Medical Programs the Secretary of Labor shall have, with composed of any part or parts of any one established by section 905 (hereafter in this or more States, which the Surgeon Gener- title referred to as the 'Council'), is author. "Grants for Establishment and Operation of respect to the labor standards specified in al determines, in accordance with regula- Regional Medical Programs this paragraph, the authority and func- ized to make grants to public or nonprofit tions set forth in Reorganization Plan tions, to be appropriate for carrying out private universities, medical schools, re- "Sec. 904. (a) The Surgeon General, upon the purposes of this title; Numbered 14 of 1950 (15 F.R. 3176; 5 search institutions, and other public or the recommendation of the Council, is au- U.S.C. 133z-15) and section 2 of the Act "(2) consists of one or more medical nonprofit private agencies nnd Institutions thorized to make grants to public or of Juno 13, 1934, as amended (40 U.S.C. centers, one or more clinical research to assist them In planning the development nonprofit private universities, medical 276c). centers, and one or more hospitals; and of regional medical programs. schools, research Institutions, and other "(3) has in effect cooperative arrange- 11(b) Grants under this section may be made public or nonprofit private agencies and in- ments among its component units which only placation therefor approved by stitutions to assist in establishment and "National Advisory Council on Regional the Surgeon General finds will be ade- _upon ap quate for effectively carrying out the pur- the Surgeon General. Any such application operation of regional medical programs, in- Medical Programs may be approved only if it contains or is cluding construction and equipment of facil- poses of this title. supported by- ities in connection therewith. "Sec. 905. (a) The Surgeon General, with "(b) The term 'medical center' means a "(1) reasonable assurances that Federal "(b) Grants under this section may be made the approval of the Secretary, may appoint, medical school or other medical institution funds paid pursuant to any such grant only upon application therefor approved by without regard to the civil service laws, a involved in postgraduate medical tra g be used only for the purposes for the Surgeon General. Any such application National Advisory Council on Regional Medi- t inin '!c accordance with the and one or more hospitals affiliated hee- wih h paid and in may be approved only if it is recommended cal Programs. The Council shall consist of with for teaching, research, and demon- applicable provisions of this title and the by the advisory group described in section the Surgeon General, who shall be the stration purposes. regulations thereunder; 903(b)(4) and contains or is supported by chairman, and twelve members, not other- "(c) The term @clinical research center' wise in the regular full-time employ of the means an institution (or part of an institu- "(2) reasonable assurances that the appli- reasonable assurances that- United States, who are leaders in the fields tion) the primary function of which is re- cant will provide for such fiscal control "(1) Federal funds paid pursuant to any of the fundamental sciences, the medical and fund accounting procedures as are such grant (A) will be used only for the search, training of specialists, and demon- required by the Surgeon General to as- purposes for which paid and in accord- sciences, or public affairs. At least two of strations and which, In connection sure proper disbursement of and account- ance with the applicable provisions of the appointed members shall be practicing therewith, provides specialized, high-quality ing for such Federal funds; this title and the regulations thereunder, physicians, one shall be outstanding in the diagnostic and treatment services for inpa- "(3) reasonable assurances that the appli- and (B) will not supplant funds that are study, diagnosis, or treatment of heart dis- tients and outpatients. cant will make such reports, in such form otherwise available for establishrpent or ease, one shall be outstanding in the study, "(d) The term 'hospital' means a hospital and containing such information as the operation of the regional medical program diagnosis, or treatment of cancer, and one as defined in section 625(c) or other health Surgeon General may from time to time with respect to which the grant is made: shall be outstanding in the study, diagnosis facility in which local capability for diagno- reasonably require, and will keep such "(2) the applicant will provide for such or treatment of stroke. sis and treatment is supported and aug- records and afford such access thereto 'as fiscal control and fund accounting proce- "(b) Each appointed member of the Council mented by the program established under the Surgeon General may find necessary dures as are required by the Surgeon shall hold office for a term of four years, this title. to assure the correctness and verification General to assure proper disbursement of except that any member appointed to fill a "(a) The term 'nonprofit' as applied to any of such reports; and and accounting for such Federal funds; vacancy prior to the expiration of the term institution or agency means an institution or "(4) a satisfactory showing that the appli- "(3) the applicant will make such reports, for which his predecessor was appointed agency which is owned and operated by one cant has designated an advisory group, to in such form and Records containing such shall be appointed for the remainder of or more nonprofit corporations or associa- advise the applicant (and the institutions information as the Surgeon General may such term, and except that the terms of tions no part of the net earnings of which and agencies participating in the resulting from time to time reasonably require, and office of the members first taking office inures, or may lawfully inure, to the benefit regional medical program) in formulating will keep such records and afford such ac- shall expire, as designated by the Surgeon of any private shareholder or individual. and carrying out the plan for the estab- cess thereto as the Surgeon General may General at the time of appointment, four at 123 the end of the first year, four at the end of vanced specialty training in such facilities, "Section 1. Titles I to IX, inclusive, of this the second year, and four at the end of the as he deems useful, and shall make such Act may be cited as the 'Public Health Serv- third year after the date of appointment. An list or lists and related Information readily ice Act'." appointed member shall not be eligible to available to licensed practitioners and other (b) The Act of July 1, 1944 (58 stat. 682). serve continuously for more than two terms. persons requiring such Information. To the as amended, is further amended by renum- "(c) Appointed members of the Council, end of making such list or lists and other bering title IX (as In effect prior to the while attending meetings or conferences information most useful, the Surgeon Gener. enactment of this Act) as title X, and by thereof or otherwise serving on business of al shall from time to time consult with in- renumbering sections 901 through 914 (as the Council, shall be entitled to receive com- terested national professional organizations. in effect prior to the enactment of this Act), pensation at rates fixed by the Secretary, and references thereto, as sections 1001 but not exceeding $100 per day, including "Report through 1014, respectively. traveltime, and while so serving away from Approved October 6, 1965, 10:15 a.m. their homes or regular places of business "Sec. 908. On or before June 30, 1967, the they may be allowed travel expenses, includ- Surgeon General, after consultation with the Ing per them In lieu of subsistence, as au- Council, shall submit to the Secretary for LEGISLATIVE HISTORY: thorized by section 5 of the Administrative transmission to the President and then to Expenses Act of 1946 (5 U.S.C. 73b-2) for the Congress, a report of the activities HOUSE REPORT No. 963 accompanying persons In the Government service em- under this title together with (1) a state- H. R. 3140 (Comm. on Interstate & Foreign ployed intermittently. ment of the relationship between Federal Commerce). "(d) The Council shall advise and assist the financing and financing from other sources SENATE REPORT No. 368 (Comm. on Labor Surgeon General In the preparation of r U' of the activities undertaken pursuant to this & Public Welfare). lations for, and as to policy matters ari:igng title, (2) an appraisal of the activities assist- CONGRESSIONAL RECORD, Vol. 111 (1965): with respect to, the administration of this ed under this title In the light of their effec- June 25: Considered in Senate. title. The Council shall consider all applica- tiveness in carrying out the purposes of this June 28: Considered and passed Sen- tions for grants under this title and shall title, and (3) recommendations with respect ate. make recommendations to the Surgeon Gen. to extension or modification of this title in Sept. 23: H. R. 3140 considered in House. eral with respect to approval of applications the light thereof. Sept. 24: Considered and passed House, for and the amounts of grants under this amended, in lieu of H. R. 3140. title. "Records and Audit Sept. 29: Senate concurred In House "Regulations "Sec. 909. (a) Each recipient of a grant amendments. under this title shall keep such records as "See. 906. The Surgeon General, after con. the Surgeon General may prescribe, lnclud- sultatlon with the Council, shall prescribe Ing records which fully disclose the amount general regulations covering the terms and and disposition by such recipient of the conditions for approving applications for proceeds of such grant, the total cost of the grants under this title and the coordinatio2 project or undertaking In connection with of programs assisted under this title witri which such grant is made or used, and the programs for training, research, and demon- amount of that portion of the cost of the strations relating to the same diseases as- project or undertaking supplied by other sisted or authorized under other titles of sources, and such records as will facilitate this Act or other Acts of Congress. an effective audit. "Information on Special Treatment and "(b) The Secretary of Health, Education, Training Centers and Welfare and the Comptroller General of the United States, or any of their duly au- "Sec. 907. The Surgeon General shall estab- thorized representatives, shall have access lish, and maintain on a current basis, a list for the purpose of audit and examination to or lists of facilities in the United States any books, documents, papers, and records equipped and staffed to provide the most of the recipient of any grant under this title advanced methods and techniques In the which are pertinent to any such grant." diagnosis and treatment of heart disease, cancer, or stroke, together with such related "Sec. 3. (a) Section 1 of the Public Health information, including the availability of ad- Service Act is amended to read as follows: 124 Appendix S-Regulations of Regional Medical Programs March 18, 1967 (k) "Geographic area" means any area that funds will not supplant funds otherwise funds solely for the purposes for which the the Surgeon General determines forms an available for establishment or operation of grant was made, as set forth in the ap- economic and socially related region, taking the regional medical program. proved application and award statement. In SUBPART E-GRANTS FOR REGIONAL the event any part of the amount paid a MEDICAL PROGRAMS I into consideration such factors as present (d) Advisory group; establishment; evidence. grantee is found by the Surgeon General to this Subpart E and future population trends and patterns An application for a grant under section 903 have been expended for purposes or by any Authority: The provisions of of growth; location and extent of transpor- of the Act shall contain or be supported by methods contrary to the Act, the regulations issued under sec. 215, 58 Stat. 690, sec. tation and communication facilities and sys- documentary evidence of the establishment of this subpart, or contrary to any condition 906, 79 Stat. 930; 42 U.S.C. 216, 299f. Inter. tems; presence and distribution of educe, of an advisory group to provide advice in pret or apply secs. 900, 901, 902, 903, 904, tional, medical and health facilities and formulating and carrying out the establish- to the award, then such grantee, upon being 905, 909, 79 Stat. 926, 927, 928, 929, 930, programs, and other activities which in the ment and operation of a program. notified of such finding, and in addition to 42 U.S.C. 299, 299a, 299b, 299c, 299d, 299e, opinion of the Surgeon General are appro- any other requirement, shall pay an equal 'k-e') Advisory group; membership; descrip- amount to the United States@ Changes in 299i. priate for carrying out the purposes of Title tion. The application or supporting material grant purposes may be made only in ac- 0 54.401 Applicability. ix shall describe the selection and membership cordance with procedur es established by the The provisions of this subpart apply to 0 54.403 Eligibility. of the designated advisory group, showing Surgeon General. grants for planning, establishment, and In order to be eligible for a grant, the appli- the extent of inclusion in such group of lbl Ob tion of funds. No funds may be practicing physicians, members of other 'iga operation of. regional medical programs as cant shall: health professions, medical center officials, charged against the grant for services per, authorized by Title IX of the Public Health r material or equipment delivered, Service Act, as amended by Public Law (a) Meet the requirements of section 903 or hospital administrators, representatives from formed o 89-239. 904 of the Act; appropriate medical societies, volu ntary pursuant to a contract or agreement entered (b) Be located in a State; agencies, representatives of other organiza- into by the applicant prior to the effective 0 54.402 Definitions. (c) Be situated within a geogIraphic area ap- tions, institutions and agencies concerned date of the grant. (a) All terms not defined herein -shall have propriate under the provisions of this sub- wit@ activities of the kind to be carried on (c) Inventions or discoveries. Any grant the meaning given them in the Act part for carrying out the purposes of the uncer the program, and members of the award hereunder in whole or in part for (b) "Act" means the Public Health Service public familiar with the need for the serv- research is subject to the regulations of the Act, as amended. Act. ices provided under the program. Department of Health, Education, and Wel- (c) "Title IX" means Title IX of the Public 0 54.404 Application. (f) Construction; purposes, plans, nd fare as set forth in Parts 6 and 8 of Title Health Service Act, as amended. specifications; narrative description..With re- 45, as amended. Such regulations shall ap- (d) "Related diseases" means those dis- (a) Forms. An application for a grant shall soect to an application for funds to be used ply to any program activity for which grant eases which can reasonably be considered be submitted on such forms and in @uch In whole or part for construction as defined funds are in fact used whether within the to bear a direct relationship to heart dis- manner as the Surgeon General may pre- in Title IX, the applicant shall furnish In scope of the program as approved or other- ease, cancer, or stroke. scribe. sufficient detail plans and specifications as wise. Appropriate measures shall be taken (b) Execution. The application shall be exe- well as a narrative description, to indicate by the grantee and by the Surgeon General (a) "Title IX diseases" means heart disease, cuted by an Individual authorized to act for the need, nature, and purpose of the pro- to assure that no contracts, assignments, or cancer, stroke, and related diseases. the applicant and to assume on behalf of posed construction. other arrangements inconsistent with the (f) "Program" means the regional medical grant obligation are continued or entered in- the applicant all of the obligations specified (g) Advisory group; recommendation. An ap- to and that all personnel involved in the program as defined in section 902(a) of the in the terms and conditions of the grant Act, placation for a grant under section ?@4 of supported activity are aware of and comply including those contained in these regula- . the Act shall contain or be supported by a with such obligation. Laboratory notes, relat- (g) "Practicing physician" means any physi- tions. copy of the written recommendation of the ed technical data, and information pertain- cian licensed to practice medicine in ac- (c) Description of program. In addition to advisory group. ing to inventions or discoveries made cordance with applicable State laws and any other pertinent information that the through activities supported by grant funds currently engaged in the diagnosis or treat- Surgeon General may require, the applicant 0 54.405 Terms, conditions, and assurances. shall be maintained for such periods, and ment of patients. shall submit a description of the program In (h) "Major repair" Includes restoration of sufficient detail to clearly Identify the In addition to any other terms, conditions, filed with or otherwise made available to an existing building to a sound state. nature, need, purpose, plan, and methods of and assurances required by law or Imposed the Surgeon General or those he may desig- by the Surgeon General, each grant shall be nate at such times and In such manner as (1) "Built-in equipment" is equipment affixed the program, the nature and functions of determine necessary to carry out to the facility and customarily included in the participating institutions, the geographic subject to the following terms, conditions, he may the construction contract. area to be served, the cooperative arrange- and assurances to be furnished by the gran- such Department regulations. 0) "Advisory group" means the group desig- ments, in effect, or intended to be made tee. The Surgeon General may at any time (d) Rep-orts. The grantee shall maintain and nated pursuant to section 903(b)(4) of the effective, within the group, the justification approve exceptions where he finds that such file with the Surgeon General such progress, Act. supported by a budget or other d@ta, for the exceptions are not inconsistent with the Act fiscal, and other reports, including reports amount of the funds requested, and finan- and the purposes of the program. of meetings of the advisory group convened Subpart E added 1/18/67, 32 FR 571. cial or other data demonstrating that grant (a) Use of funds. The grantee will use grant before and after award of a grant under 125 section 904 of the Act, as the Surgeon Gen- ning and use of facilities, personnel, and no person in the United States shall, on the tients is payable from grant funds only to eral may prescribe. equipment, and training of manpower. ground of race, color, or national origin, be the extent that such care is incident to the (a) Records retention. All construction, (d) The population to be served by the re- excluded from participation in, be denied research, training, or demonstration activi- financial, and other records relating to the gional medical program and relationships to the benefits of, or be subjected to discrim- ties supported by a grant hereunder. Such use of grant funds shall be retained until adjacent or other regional medical pro- ination under any program or activity re- care shall be incident to such activities only the grantee has received written @notice that grams. ceiving Federal financial assistance. Regula- if reasonably associated with and required records have been audited unless a tions implementing the statute have been for the effective conduct of such activities, the (a) The extent to which all the health re- issued as Part 80 of Title 45, Code of Feder- and no such care shall be charged to such different period is permitted or required in sources of the region have been taken into al Regulations. The regional medical pro- funds unless the referral of the patient is writing by the Surgeon General. consideration in the planning and/or estab- grams provide Federal financial assistance documented with respect to the name of the (f) Responsible official. The official designat- lishment of the program. subject to the Civil Rights Act and the regu- practicing physician making the referral, the ed in the application as responsible for the (f) The extent to which the participating in- lations. Each grant is subject to the condi- name of the patient, the date of referral, coordination of the program shall continue stitutions will utilize existing resources and tion that the grantee shall comply with the and any other relevant information which to be -responsible for -the duration of the will continue to seek additional nonfederal requirements of Executive Order 11246, 30 may be prescribed by the Surgeon General. period for which grant funds are made resources for carrying out the objectives of F.R. 12319, and the applicable rules, regula- grant funds shall not be charged with the available. The grantee shall notify the Sur- the regional medical program. tions, and procedures prescribed pursuant cost of- geon General immediately if such official be- thereto. (1) Care for intercurrent conditions (except comes unavailable to discharge this respon- (g) The geographic distribution of grants sibility. The Surgeon General may terminate throughout the Nation. of an emergency nature where the intercur- the grant whenever such official shall be- 0 54.409 Expenditures by grantee. rent condition results from the care for come thus unavailable unless the grantee 0 54.407 Termination. (a) Allocation of costs. The grantee shall al- which the patient was admitted for treat- replaces such offici I with another official locate expenditures as between direct and ment) that unduly interrupt, postpone, or (a) Termination by the Surgeon General. terminate the conduct of such activities. found by the Surgeon General to be indirect costs in accordance with "ner"'Y Any grant award may be revoked or termi- in,, prac. (2) Inpatient care if other care which would qualified. nated by the Surgeon General in whole or in accepted and established account Award. part at any time whenever he finds that in tices or as otherwise prescribed by the Sur- equally effectively further the purposes of 54.406 his judiment the grantee has failed in a geon General. the grant, could be provided at a smaller Upon recommendation of the Nationa Ad. material respect to comply with require- (b) Direct costs in general. Funds granted cost. I visory Council on Regional Medical Pro- ments of Title IX and the regulations of this for direct costs may be expended by the (3) Bed and board for inpatients in excess grams, and within the limits ot avail able subpart. The grantee shall be promptly grantee for personal services, rent" of of the cost of semiprivate accommodations funds, the Surgeon General shall awa rd a notified of such finding in writing and given space, materials, and supplies, and other niess required for the effective conduct of grant to those applicants whose approved the reasons therefor. items of necessary cost as are req ui red to such activities. For the purpose of this 'r t paragraph, "semipwivate accommodations" programs will in his judgment best promote (b) Termination by the grantee. A grantee carry out the purposes of the an . The means two-bed, three-bed, and four-bed ac- the purposes of Title IX. In awarding grants, may at any time terminate or cancel its Surgeon General may issue ruIes' instruc- modations. the Surgeon General shall take into consid- conduct of an approved project by notifying tions, interpretations, or limitations supple. corn eration, among other relevant factors, the the Surgeon General in writing setting forth menting the regulations of this subpart and 0 54.410 Payments. following: the reasons for such termination. prescribing the extent to which particular (a) Generally, the extent to which the pro- types of expenditures may be charged to The Surgeon General shall, from time to posed program will carry out, through re. (c) Accounting. Upon any termination, the grant funds. time, make payments to a grantee of all or giona peration, the purposes of Title IX, grantee shall account for all expenditures (c) Direct costs; persona a portion of any grant award, either in ad- I coo and obligations charged to grant funds: Pro- I services. The vance or by way of reimbursement for ex- within a geographic area. vided, That to the extent the termination is costs of personal services are payable from penses to be incurred or incurred to the lb) The capacity of the institutions or agen- due in the judgment of the Surgeon General grant funds substantially in proportion to extent he determines such payments neces- cies within the program, Individually and to no fault of the grantee, credit shall be the time or effort the ind ividual devotes to sary to carry out the purposes of the grant. collectively, for research, training, and allowed r the amount required to settle at carrying out the purpose of the grant. In demonstration activities with respect to Title costs defmoonstrated by evidence satisfactory such proportion, such costs may include 611 0 54.411 Different use or transfer; good IX. to the Surgeon General to be minimum direct costs incident to such services, such cause for other use. settlement costs, any noncancellable obliga- as salary during vacations and retirement (a) Compliance by grantees. If, at any time, (c) The extent to which the applicant or the tions incurred prior to receipt of notice of and workmen's compensation charges,.In the Surgeon General determines that the participants in the program plan to coordi' termination. accordance with the policies and accounting are nate or have coordinated the regional medi- practices consistently applied by the grantee eligibility requirements for a program cal program with other activities supported to all its activities. no longer met, or that any facility or equip- pursuant to the authority contained in the 0 54.408 Nondiscrimination. ment the construction or procurement of Public Health Service Act and other Acts of Section 601 of Title VI of the Civil Rights (d) Direct costs; care of patients. The cost which was charged to grant funds is, during Congress including those relating to plan- Act of 1964, 42 U.S.C. 2000d, provides that of hospital, medical or other care of pa- its useful life, no longer being used for the 126 purposes for which it was constructed or a footnote acknowledging assistance from the pr cured either by the grantee or any trans- Public Health Service, and indicating that feroee, the Government shall have the right findings and conclusions do not represent to recover its proportionate share of the val- the views of the Service. ue of the facility or equipment from either the grantee or the transferee or any institu- 0 54.413 Copyrights. tion that is using the facility or equipment Whpr! the grant-supported activity results in The Government's proportionate share hali be the amount bearing the same ratio to copyrightable material, the author is free to the then value of the facility or equipme opyr'ght, but the Public Health Service re- nt, ce a royalty-free, nonexclusive, irrevoca- ., e@ as determined by the Surgeon Gener 1, as ble license for use of such material. the amount the Federal participation bare to the cost of construction or procurement. 54.414 Interest. (b) Different use or transfer; notification. The grantee shall promptly notify the Sur- Interest or other income earned on pay- geon General in writing if at any time dur- ments under this subpart shall be paid to ing its useful life the facility or equipm ant th! @nited States as such interest is re- for construction or procurement of which ceivea by the grantee. grant funds were charged is no longer to be used for the purposes for which it was con- structed or procured or is sold or otherwise transferred. (c) Forgiveness. The Surgeon General may for good cause release the grantee or other owner from the requirement of continued eligibility or from the obligation of con- tinued use of the facility or equipment for the grant purposes4 In determining whether good cause exists, the Surgeon General shall take into consideration, among other factors, the extent to which- (1) The facility or equipment will be devoted to research, training, demonstrations, or other activities related to Title IX diseases. (2) The circumstances calling for a c ange in the use of the facility were not known, or with reasonable diligence could not have been known to the applicant, at the time of the application, and are circumstances rea- sonably beyond the control of the applicant or other owner. (3) There are reasonable assurances that other facilities not previously utilized for Ti- tle IX purposes will be so utilized and are substantially the equivalent in nature and extent for such purposes. 0 54.412 Publications. U.S. GOVERNMIENT PRINTING OFFICE: 1067@ 166-753 Grantees may publish materials relating to their regional medical program without prior review provided that such publications carry 127