i I * TABLE OF CONTENTS QUESTION AND ANSWER 'PAG- WHAT SPECIFICALLY IS A REGIONAL COOPERATIVE . . . . . . . ARRANGEMENT? HOW LONG WILL IT TAKE TO MAKE THESE LATEST . . . 2 ADVANCES AVAILABLE TO ALL OUR PEOPLE AND WHAT WOULD THE COST BE? HOW LONG WILL THE REGIONAL PROGRAMS CONTINUE AND WHAT IS THE PROJECTED FEDERAL ROLE? HOW IS LOCAL CONTROL OF A REGIONAL MEDICAL . . . . . . . 4 PROGRAM INSURED? ISN'T P.L. 85-239 PRINCIPALLY A CONTINUING . . . . . . . 5 EDUCATION PROGRAM? ISN'T THE PRINCIPAL PURPOSE OF THIS PROGRAM RESEARCH? - - 6 WOULDN'T IT BE BETTER IF THERE WERE NO LIMITATION BY . . 7 DISEASE CATEGORIES IN@THESE PROGRAMS? HOW MANY AND WHICH RELATED DISEASES ARE SUPPORTED AS . . 8 A PART OF REGIONAL MEDICAL PROGRAMS? WOULDN'T IT BE BETTER IF FUNDS UNDER P.L. 89-239 . . . . 9 WERE DISTRIBUTED ON A FORMULA GRANT BASIS7 WHY HAS THE PROGRAM DEVELOPED SO SLOWLY? . . . 10 WHY HAVE THE ADMINISTRATION.APPROPRIATION . . . . . . . . 11 REQUESTS BEEN SUBSTANTIALLY LESS THAN THE AUTHORIZATION LEVELS? WHAT IS THE STATUS OF THE FUNDS WHICH WERE . . . . . . . 12 EARMARKED BY THE CONGRESS LAST YEAR? HOW MANY LIVES HAVE BEEN SAVED BY REGIONAL. . # . . . . 14 MEDICAL PROGRAMS? WHY ARE THE REGIONS SO DIFFERENT IN SIZE . . . . . . . . 15 AND POPULATION? HOW MANY PERSONS ARE EMPLOYED IN THE AVERAGE . . . . . # 16 REGIONAL MEDICAL PROGRAM? WHAT HAS BEEN THE INVOLVEMENT OF THE GENERAL . # 0 0 0 . 17 PRACTITIONER IN REGIONAL.MEDICAL PROGRAMS? -- QUESTION AND ANSWER PAGE WHAT VOICE DOES THE CONSUMER HAVE IN THE . . . . . . . . 18 DEVELOPMENT OF A REGIONAL MEDICAL PROGRAM? HOW DOES THIS PROGRAM AFFECT THE INCREASING o . . 19 COST OF MEDICAL CARE? HOW MUCH-WI-LL REGIONAL MEDICAL PROGRAMS COST . . . 20 DURING THE OPERATIONAL STAGE? WHAT IS THE RELATIONSHIP OF OTHER PRIVATE AND - 21 PUBLIC FUNDING TO FUNDS AVAILABLE UNDER P.L. 89-239? HOW HAVE YOU KEPT FROM INTERFERING WITH THE . . . . . 6 22 PRACTICE OF MEDICINE? WHAT ACTION HAS BEEN TAKEN TO IMPLEMENT . ... . . . . . 23 SECTION 907 OF P.L. 89-239? @HOW HAVE YOU IMPROVED THE.HEALTH FACILITIES . . . . 25 OF THE NATION? HOW HAS THE HEALTH MANPOWER OF THE NATION 27 BEEN IMPROVED? HOW DO YOU INSURE THAT FUNDS AWARDED UNDER 28 P.L. 89-239 DO NOT SUPPLANT OTHER AVAIIABLE SOURCES OF FUND8? UNDER WHAT CIRCUMSTANCES ARE PATIENT CARE@ . . . . . . . . 29 COSTS PAID UNDER P.L. 89-239? TO WHAT EXTENT HAVE THE MEDICAL SCHOOLS DOMINATED 30 THE REGIONAL MEDICAL PROGRAMS? HOW MUCH MONEY HAVE YOU GIVEN TO MEDICAL SCHOOLS? . . . 3 WON'T THE LIMITATIONS OF PROFESSIONAL AND TECHNICAL . . 32 MANPOWER PREVENT THE PROGRAM FROM DEVELOPING AS RAPIDLY AS YOU HAVE PROJECTED? THE SURGEON GENERAL'S REPORT ON REGIONAL MEDICAL,. 33 PROGRAMS CALLS FOR CONSTRUCTION AUTHORITY TO MEET SPECIALIZED REGIONAL NEEDS. WHY IS NO SUCH AUTHORITY REQUESTED IN THIS BILL? TO WHAT EXTENT HAS REGIONAL MEDICAL.PROGRAMS,PAID . . . 34 DISPROPORTIONATELY HIGH SALARIES? TO WHAT EXTENT HAVE HOSPITALS BEEN INVOLVED IN . . . . . 3.5 REGIONAL MEDICAL PROGRAMS? QUESTION AND ANSWER PAGE i@'ukS THE DEVELOPMENT OF REGIONAL MEDICAL .. . . . . . . 37 ,,OGRAMS AFFECTED THE AVAILABILITY OF PHYSICIANS IN THE RURAL AREAS OF THE UNITED STATES? WHY HAVEN'T,REGIONAL PROGRAMS DESIGNED TO SERVE 38 THE MAJOR URBAN AREAS DEVELOPED MORE RAPIDLY? WHAT IS THE RELATIONSHIP BETWEEN REGIONAL MEDICAL.o,. 39 PROGRAMS AND NEIGHBORHOOD HEALTH CENTERS UNDER THE OFFICE OF ECONOMIC OPPORTUNITY? DO YOU PLAN TO TREAT CIVILIANS IN VETERANS @ . . . . . . . 41 ADMINISTRATION HOSPITALS-IF THIS AMENDMENT IS MADE PART OF THE ACT? WHAT IS THE RELATIONSHIP BETWEEN PUBLIC LAW 89"239 45 AND PUBLIC LAW 90-174? WHAT SPECIFICALLY IS A REGIONAL COOPERATIVE ARRANGEMENT? A Regional Cooperative Arrangement or regionalization is the process whereby the benefits of scientific advance can be efficiently and effectively brought to those in need by the full array, of health resources. Such a process can only be successful if it is based upon the commitment of individual, professional, institutional, and governmental resources which is voluntarily given. There is no longer any question that Regional Medical Programs is a mechanism which can engender this voluntary commitment across the entire spectrum of health resources. 2 HOW LONG WILL IT TAKE TO MAKE TEESE LATE, Sr ADVANCES AVAILABLE TO ALL OUR PEOPLE AND WHAT WOUID TEE- COST BE? The full development of Regional Medical Programs to accomplish this objective will probably take many years. The mechanism being developed will be utilized continuously to translate into improved health services the continuing advances of medical knowledge. While we can make some projections of costs for the next five years, a more accurate understanding of what proportion of our health resources should be devoted to this purpose will emerge from the initial experience now just beginning. It is the intent of the Regional Medical Programs to stimulate these improvements in health care, but the ongoing costs of the improved services will continue to be paid for out of the normal mechanisms for financing h6alth-dare costs after the improved capabilities have been integrated into the broader health-care system. It is not the purpose of Regional Medical Programs to pay for certain health-care services on a permanent basis. 3 HOW LONG WILL THE REGIONAL PROGRAMS CONTINUE AND WHAT IS THE PROJECTED FEDERAL ROLE? The goal of each Regional Medical Program is to make available to everyone within the Region the best possible patient care for heart disease, cancer, stroke and related diseases. This goal can be achieved only over a process of many-years, perhaps decades. It is reasonable to expect that the role the Federal Government is now playing would have to continue in order to assure the viability of Regional Medical Programs, although the specific activities which are funded under P.L* 89-239 would alter as the needs of the Regions change over time. HOW IS LOCAL CONTROL OF A REGIONAL MEDICAL PROGRAM INSURED? Each Regional Advisory Group provides overall advice and guidance in the planning and operation of the Program. It is actively involved in the development of regional objectives. And it by law must review and approve any operational proposal before it can be submitted to the Federal Government for possible funding. Each Regional Advisory Group is broadly based including physicians, medical center officials, hospital administrators, medical society members, other health professionals, and voluntary health agency repre- sentatives, as well as members of the public. (If the Committee is interested, I can provide more detailed information on the membership'of the Regional Advisory Groups or t e Record). 5 ISN'T PUBLIC IAW 89-239 PRINCIPALLY A CONTINUING EDUCATION PROGRAM? The object of Regional Medical Programs is to influence the present arrangements for health services in a manner that will permit the best in modern medical care for heart disease, cancer, stroke and related diseases to be available to all. To reach this goal, a multifaceted program is necessary. Continuing education of the practicing physicians, members of the allied health professions and members of the public, is certainly an important facet. Other aspects of the program--health services research, demonstrations and training, and the care of patients-- are other equally important facets. Since the ultimate objective of Regional Medical Programs is improved care for patients with Heart Disease, Cancer, Stroke and Related Diseases, this objective cannot be reached by any one single approach. 6 ISN'T THE PRINCIPAL PURPOSE OF THIS PROGRAM RE@SEARCH? The principal purpose of this program is to influence health services in a manner that will permit the best in modern medical care for heart disease, cancer, stroke, and related diseases to be available to all. In order to reach this objective without undue interference in the patterns of medical practice into better means for making the advances of medical science more widely available, research becomes one effective tool for Regional Medical Programs. Other effective tools include demonstrations, programs for continuing education and training programs. Research and specifically health services research will be a powerful instrument for Regional Medical Programs but the total effect o these research activities will be increased by integrating them into the program so that research can interact with the other activities. 7 WOULDN'T IT BE BETTER IF THERE WERE, NO LIMITATION BY DISEASE CATEGORIES IN THESE PROG@? These disease problems,which cause more than 70 percent of all deaths in the United States and afflict millions more, constitute an appropriate nucleus for the development of an effective broadly based regional cooperative arrangement among the health-care resources. Because of the tremendous scope of these disease problems, they have a major impact upon the total range of personal health services; and in order to plan effectively for these diseases, it is often necessary to consider the entire spectrum of resources available for personal health services. However, these major disease areas have served as useful action objectives for the cooperative arrangments and relation- ships being established in the Regional Medical Programs. As these initial actions prove the effectiveness of these regional arrangements for these disease problems,.the experience can also be useful in accomplishing other heal th purposes. At that time it may be appropriate to consider an expansion of the scope of this legislation, but at this time the focus on these major diseases is appropriate and effective. HOW MANY AND WHICH RELATED DISEASES ARE SUPPORTED AS A PART OF REGIONAL MEDICAL PROGRAMS? Several related diseases were specifically mentioned in the legislative history of P.L. 89-239, such as hypertension, kidney disease and diabetes. The relationship of other diseases, such as emphysema, to heart disease can be'established. We have required, however, that all grant applications requesting support for activities in the area of related diseases make the case for why the proposed activities relate to heart disease, cancer., or stroke. For example, support would not be provided for. kidney disease activities which sound professional judgment could not relate to problems of the cardiovascular system. 9 WOULDN'T IT BE BETTER IF FUNDS UNDER P.L. 89-239 WERE DISTRIBUTED ON A FOIL%IULA GRANT BASIS? It would not be at all feasible to administer this legislation on a formula @asis. Regions and their programs are developing at different rates and in different ways. Accordingly, it would be difficult if not impossible to develop a formula which would be flexible enough to take these varying rates of progress into account on an equitable basis. This is especially important when one takes into account the fact that the boundaries of each region are not determined here in Washington, but by the regions themselves. Consequently, there is great diversity in their size, popu- lation, and complexity. Furthermore, the flexibility inherent in t is process of self-det ermination makes it likely that regional boundaries may be modified as the program develops. A formula distribution of funds would have the effect of stultifying Reaional Medical Programs. 10 Why has the program developed so slowly? The rate of increase of obligations for RMP grants has been rapid--$2.5 million in fiscal year 1966, $29 million in fiscal year 1967, and $54 million in the current fiscal year--and, obligations of nearly $100 million are projected for fiscal year 1969. The delay has been in the initial,". to the Regional Medical Programs. This delay is the result of the difficulties involved in organizing diverse interests in the health field into a workable cooperative arrangement that calls for new relationships and new perceptions among the participants. The staff of the Division and the National Advisory Council felt that it was important to avoid the pressures of a crash effort. Instead,, they sought assurance that the Regional Medical Programs had worked out its initial organizational problems before a planning grant was awarded. In most instances development of the RMP has been rapid once the planning phase has been launched and effective leadership recruited. 14HY IIAVE TIIE ADLvi :,..@'.;"'@@OPRIATION RL,:QUESTS BEEN SUBSTANTIALLY LESS 'irILAN TIM AUTHORIZAT-@C)ii LEVELS? This program did not begin to really function until the latter part of the first year of its authorization. Therefore, it was appropriate to request only partial funding at the start of the program. Subsequent funding has been sufficient to sustain the early development of the program. Indeed the actual rate of increase in the obligation of funds and the projected increase in the President's Budget for fiscal year 1969 represents a sizable and consistent growth in program activities. Much of the initial time was spent within the regions in establishing the organizational and planning base for the programs. Now that this time-consuming process has been accomplished in most areas, the programs are moving forward morerapidly. 12 W@.T IS '."EIE STATUS OF TI-IE FUNDS WI-IICH WERE EAR,4AIaED LY TEIE CONGRESS LAST YEAR? In the last session of Congress, the Appropriations Committee directed Regional Medical Programs to support proarams in coronary care, community hypertension programs, community detection and treatment pro- grams in stroke, chronic pediatric pulmonary disease centers and chronic pulmonary disease programs for adults (emphysema) to the extent possible. The appropriation included one million dollars for each, except chronic pulmonary disease centers, $750,000, and emphysema programs, two million dollars. The regions were advised of Congress' intent in a special coimmuni- cation forwarded to each region in December. The Regional Advisory Council made special plans so that programs submitted for these earmarked funds could receive prompt and critical reviews. Although significant interest was generated in many regions, each expressed concern to insure the mechanism for local initiative and local review. As a result the Division has considered only programs which have had the endorsement of the Regional Advisory Groups. The congressional intent was largely anticipated in most regions. Therefore, regions were able to respond promptly because of planning which by and large had predated the earmarked funding. In fact the program had previously funded activities in coronary care units in small hospitals an coronary..care unit manager training programs, but had not funded activities in the areas of mobile units or pre-coronary care. Three reaions had undertaken planning in the area of mobile units and were able to develop proposals. No regions, however, had significant planninc, in the area of C, pre-coronary care and we have thus far been unable to support activities 13 in this area. We anticipate, however, that in the very near future we w-;-"l be in receipt of proposals in this important area. Similar experience has occurred in the area of stroke detection and treatment programs and community hypertension treatment programs. Plannin- in each case was catalyzed by the region's awareness of congressional,interests in these specizic areas. The National Advisory Council for Regional Medical Programs has met once since the receipt of the earmarked funds. In that meeting, programs in stroke and coronary care obligations totaling $2.8 million were made. The Council has scheduled a second and final meeting for April 8, when commitments in all areas will be made. On the basis of proposals now available the.program anticipates expenditure of funds for Regional Medi- cal Programs in the area of earmarks in excess of the amounts designated by Congress. 14 How many lives have been saved by Regional Medical Programs? This question clearly focuses on the purpose of the program--to improve -.he care of patients with heart disease, cancer, stroke and related diseases. The ultimate measure of the success of the program will be reflected in one measure by increased longevity. Longevity will, however, not be the only measure. Before the impact of the program can be tested, many other factors will have to be taken into account. Has care been-made more available, has care been made more acc ssible, as care become comprehensive and continuous In short, are those livina lon@er doin,- so in com'Lort? Are those living longer enjoying meaningful lives? Lon-evity that is an extensioIn of misery has little to recommend it. Ei.7ht programs are operative. On the average these have functioned @or less than 8 months.% The effect of Regional Medical Programs on mortality and i7.orbidity statistics cannot be measured in this brief period. Time will be required to answer the question. Our expectation is that the answer will justify the support that the program has received. Further, our expectation is that longevity will be achieved and the increment to life will be meaningful. 15 WHY &A"'@E THE REGIONS SO DIFFERENT IN SIZE AND POPULATION? The character, magnitude, and compl(-,x-',-ty associatc-d with heart disease, cancer, and stro'Ll-le vary across the country. Similarly, the availability of resources which can deal with these problems also is not uniformly distributed. Additionally, there was no rigid plan which would have artificially determined what area each Re-ional Pror,ram nust service. Consequently, each Region has had to fashion an area in its own way, basing its decisions on the problems it .Lace8 and the resources it can bring to bear in makin,, progr@ss aaainst them. Some were concerned that this process might result in areas of the country not being included in any Recion. T is as not occurred. In fact some Regions overlap at their respective peripheries, and we think that is fine. 1 6 HO!4 @NTY PERSONS 'ARE EM.DLOYED IN 'fl-1,E AVERAGE REGIONAL MEDICAL PROC-,-@vi'@ Based -upon experience to date, it is estimated that the average size of the sta'L.'Ls of the 54 Regional Medical Programs is 33. This figure is arrived at through the following data: Average NTOS . of Planning Size Regions .1. @,egions in 02 plannin- year 26 33 2. Re(,ions in 01 plannina year 11 15 II. Operational 92 8 Lotal Staff Planning 1023 Operational 736 1768 1 7 W,@AT FAS BEEN T@IE INVOLVL,:@NT OF TFIE GENERAL PRACTITIONER IN REGIONAL MEDICAL PR@-,ULMS? General practitioners, like practicing physicians in other specialties, have been involved in all levels of Regional Medical Programs. Since the be@i-aning of the pro-ra-,n, there has been a representative of the AAGP on the National Review ConLmittee. At the re-ional organizational level cleneral practitioners are among the 1253 physicians on Regional Advisory 0 Groups and subcommittees at least three program coordinators are general practitioners. Many of the operational pro-rams have been designed specifically for those physicians practicing in areas remote from the medical centers. ',!OICE DOI@S T'@',- CO,@@SIMP% !IAVE I'\' Tio,', DEVI]LO ',NT OF A ';Z GIONAT- N@-DI" LP'ACG@%i? A'.'L re@-'onal advisory ,roups have representation of '-he public familiar with the need for services to be provided under the as required by the law. Often these members represent specific consumer -roups, such as labor unions. The Reaiona-'- Pro@ram Guidelines specify that the program shall be developed to serve the needs of the people of the re-ion for medical care for these diseases rather than to serve the interests of the medical institutions and personnel involved in the pro-r@r,@l. A breakdown of the types o-@7 representation present on -the regional advisory -roups can be supplied for the record. Al,;-,ECT E SI C CO T Dol:s Cl, N S these The Scope Of s and the involvement of the broad spectrum of @ alth resources within the region provides health manpo,,,C,"-, tal@ing sn L ecific action to sha,@ f@IC-' 14 a-.