I EL U& B&B ImFoRmikiriom & ImAa3E M^m^=EMENy 300 @lotce M=Stnz*n UOULXVMM UPPOWER M,&RLACSltc2t MA 040 Z077Z I USA 11 CZC 1) 394@ 1 1 0 February 15, 1968 THE SPECIFICATIONS FOR THE HEALTH POLICY RESEARCH CONTRACT The purpose of the Health Policy Research Study of Regional Medical Programs is to determine, through an evaluation of the present regional programs, its actual and potential impact on the nation's health care system. Insights into the relationship betweer health policy'as expressed in P.L. 89-239 and the health delivery system at the regional level will provide valuable guides to future policy determination. In looking at Regional Medical Programs, the following specific topics should be explored: (1) Regional Medical Programs as an Instrument for Regionalization of Health Care; (2) Evaluation of RMP in terms of the Accomplishment of the Purposes of P.L. 89-239; (3) Evaluating TM in terms of the Ultimate Coal; (4) the Economics of Regional Medical Programs; and (5) Division of Regional Medical Programs-Regional Relationships. These topics are-not stated in necessary sequential order and are not mutually exclusive in their content. In addition they are not t as the definitive boundaries of the study but are the core to the development of the study. This study is to be carried out by the contractor under a basic caveat; namely, that the said contractor in requesting data from the regions, does not attempt to influence, steer or shape the policies or decisions of any of the regions in any mamer. The Division of Regional Medical Programs also reserves the right to supervise the selection of those regions from whom data shall be collected. 1. Regional Medical Programs as an Instrument for Regionalization of Health Care This involves study of the nature and potential of Regional Medical Programs as a now societal instrument for the development of linkages among the health resources in a given area for the attaiment of the purposes of P.L. 89-239. A. The History of Regionalization Efforts: This comparative study will involve extensive research in the literature and experience of regionalization (including RNP) as it has occurred in the health field and other areas. Implicit in this general survey are the following specific studies: (1) An identification of the factors behind the development and utilization of the regional approach; (2) An identification of the components involved in these regional efforts, and the extent of such involvement; (3) An identification of the organizational patterns developed under these regional efforts--this would involve an investigation of whv the particular organizational structures @,tere chosen and how they operated. (4) A measurement of the degree to which these regional efforts stimulated the adoption of new practices and procedures. it is anticipated that the foregoing studies will provide the Division with insights into: (1) The development of criteria and indices for regional4 ization, taking into account the origins of the regional plane and how they determined their criteria for achievement; (2) The elements co=on to RMP which influenced their levels' of accomplishment; (3) The types of activities that can be undertaken itL a regional setting--the potentialities and the limitations. B. The Components and Operations of R@ional Medical Pmgrams: These studies will be largely descriptive in nature and will involve extensive multi-disciplinary investigations into the components and the operations of the various regional programs and their potential for the achievement of the Program goals. The following represents some of the areas of interest to the Division: (1) The establishment of cooperative arrangements: An identification of all the participants involved in the program; their capabilities; the reasons for their involvement; the extent of their involvement; and their relationships to one another. Among the areas to be considered is the relationship of institutional commit- ment to and involvement in Regional Medical Programs to the goals of that institution. Attitudinal studies to compare the perception of RMP from the standpoint of various professional, public and institutional interests might be of some use here. (2) Organizational frameworks--this would include studies of: (a) the types and the characteristics of or @ national frameworks adopted by the regions and the reasons for the adoption of a particular pattern, including the regional power structures and decision-making processes and the identification of key movers in the dftplopment of goals and objectives and the formulation of plans for the carrying out of these goals and ob- jectives. -3- (b) the nature of the mandate of PJIP to plan and coordinate the health activities for a given region through the development of creative and' cooperative interrelations among Federal, State, and local government programs and the relation- ship of this mandate to existing governmental and constitutional mandates. (e) the "comunity of solution"--The magnitude and the complexity of the i@sues requiring decisions by Regional Medical Programs ranges from such highly technical subjects as high energy radiation therapy and coronary care units to the less technical, but equally complex, issues of primary patient care. Effective solutions to these problems require the active involvement and interplay of all the forces vitally necessary to or affected by the solution of them. The contractor should try to idefitify the mix of involvement--the "community of solution"---- necessary for effective solutions. Particular attention should be paid to the RMP subregional structure as it relates to the RMP covenant to plan, organize and coordinate for the delivery of quality health care and the interrelationships of RMP with other programs concerned with the organization of a system for the delivery of health care and other regionalized programs. (3) An identification of the potential benefits' of RMP regionalizati,,t-, to society and medicine including the obstacles to the full development of a regional structure and the requirements for chaL2ges in the RMP role of fostering the development of a system for the delivery of comprehensive health care. In this regard, the contractor should develop appropriate models for regionalization for health taking into account current trends in the provision of health care and the various settings of the regional programs. 2. Evaluation of RNP in terms of the Accomplishment of the Purposes of P.L. 89-239 In view of the relatively primitive state of the techniques of evaluation of Health Programs and the lack of available substantive data due to the newness of the program, this study may be largely descriptive in its approach. Perhaps the most to be accomplished by this evaluation study is an assessment of current activities, which can serve as baseline data for subsequent evaluation in two or more years. The contractor will undertake the following: -4- (1) A description of the evaluation process undertaker. by individual regional medical programs, the procedures and techniques employed by the regions; and the findings to daLe. (2) A description of the accomplishments as perceived by the regions, and of their opinion as to the effectiveness of the accomplishment @r s@. (3) A description of the degree to which projects move these regions toward the accomplishment of their goals and the goals of the Division. (4) Survey of current evaluation techniques and their functions including a description of the circ,-mstances under which they are used and their limitations. It is expected that the end,product of this study will be thq development of various criteria which would: (1) Give the Division insight into the ways in which it should be looking at the work of the regions; and (2) Give the regions insights into evaluating their own programs. 3. Evaluating Regional Medical Pro&rams in Terms of the Ultimate Health Goal: The ultimate goal of Regional Medical Programs is clear: it 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. The means of accomplishment given to Regional Medical Programs are research, training, (including continuing education) and demonstrations of patient care. It is obvious that a great number of diverse approaches to these means of accomplishment will be taken by the various regions. The study of the effectiveness of these diverse approaches is discussed above. In addition to that study, another must be made of the possible ways of Measuring, in as precise terms as possible, the impact of the sum of the regioni' activities on the care of the patient with heart disease, cancer, stroke or related diseases, and ultimately on the health status of the nation. It would seem that the above stated goal suggests at least two areas of study: (1) The beat in modern medical care; and (2) The availability of such medical care to all persons. This study must basically be directed toward the establishment cfz (1) Criteria by which a change in medical care and/or a change in the numbers receiving this care could be detected and related to Regional Medical Programa'activities; or (2) Criteria by which a change in the health of the population of this nation could be detected and related to Regional Medical Programs' activities; and (3) Methods by which these criteria could be applied Region by Region and/or nationwide. Traditional criteria and evaluation procedures could be investigated for effectiveness and applicability to this particular problem, but new criteria and techniques may have to be developed and applied. Obvious beginning points would be the appropriateness of criteria such as morbidity or mortality figures, hospital utilization data, estimates of disability, days lost from work, earning capacity, social restrictions, prolongation of life, increase in quality of life, complication rates, etc. Hopefully, other more appropriate criteria would be developed. A tendency might exist to judge the quality of medical care. While attention must be paid to determining methods of judging the quality of medical care, the judgment of care per se is not the purpose. 4. The Economics of Regional Medical Programs This study in general should address itself to a determination of: the means of achieving the purpose of Regional Medical Programs at the least cost to the taxpayer; the economic benefits of regioualization; and the economic implications of Regional Medical Programs. In pursuing the above, the contractor will undertake the following: A. The possible application of program planning, budgeting techniques to Regional Medical Programs at both the national and local levels, which would include: (1) the development of output data relating to the major objectives of Regional Medical Programs; (2) the development of input data relating to the cost experience of *T. B. The development of cost projections, including such models as may be applicable for Regional Medical Programs. For the purpose of developing insights into the relative alternatives available for obtaining the objectives of RNP, the estimated cost of such alternatives, and the estimated benefits to be derived from the alternatives. This endeavor would include: (1) short (5 years) and medium (10 years) projections of costs and benefits for MT; (2) long-range forecasting, taking into account the current -6- trends in health activities, future demographic expansion and future technological change. C. An estimate of the potential economic benefits of regionalization in terms of efficiency in the allocation of facilities, manpower and money. D. An analysis of RMP with respect tb its effect-, interaction and potential regarding health care costs and financing. E. An examination of the applicability of present Federal and regional fiscal control policies to RMP, including the suitability of existing fiscal auditing techniques in a program involving decentralized, multi-institutional funding; and the development of possible,new techniques as may be appropriate. 5. Division of Regional Medical Programs--Regional Relationships: This study will provide the Division of Regional Medical Programs with insights into its proper role in relation to the regions. These relationships divide principally into three major areas. The first is the role of the Division as a resource and consultation center for the regions. Second, is the Division's role in developing interregional resources. Finally, there is the role of the Division for ensuring, through the Regulations, the Guidelines and the review process, the attainment of the purposes of the Law. The role of the Division as a resource for the regions has several major facets. The major areas of the study must include at least a description of the proper consultative services the Division should supply, and a study of the alternative mechanisms for supplying such services to the regions. Next is the proper role of the Division in relationship to Congress and the private health agencies, such as the categoric societies. The responsibilities of the Division for the development of scarce resources need special study. Included in this area of concern would be an evaluation of the areas most in need of development and guidelines for 'Optimal methods of funding. Another area requiring special study is responsibility of the Division of Regional Medical Programs' attainment of the purposes of the Law. The keystone, in this regard, is the grant application dual review process using non-Federal peer judgement. To the extent possible this review process should be studied to determine the applicability of quantitative measures. Further emphasis should be placed on the special characteristics of W grant applications such as the diversity of project proposals and the relationship of the individual projects to overall programscontinuity. The relationship of DRN? staff to the non-Federal review process should be investigated. Attention should also be given to the analysis of RMP as an experiment in "creative federalism," i.e., an approach based upon definition of purpose and incentive funding by the Federal government while preserving local integrity and initiative in the planning and the control of the action program. 34 APPENDIX A Charge to Subcommittee Task Force on Stroke Registries February 24, 1967 The intent of the Task Force on Stroke Registries. would be to examine the question of the need for stroke registries as they may relate to research, community planning, and service; examine the various techniques utilized in the past and at the present time for regis- tries in other disease areas; and make recommendations about the need for 'stroke registries and what their scientific and administrative characteristics would be. It is expected that the Task Force's report will be useful to not only the Joint Council Subcommittee on Cerebrovascular Disease in its program planning activities, but also to the Regional Medical Programs in consideration of planning and operational grants for the development of stroke registries.