5 Grants for Regional Medical Programs Increase or 1968 Estimate 1969 Estimate Decrease Grants for regional medical programs .......... $48,900,338 $93,800,000 +$44,899,662 Introduction Grants are awarded to assist in the planning, establishment and operation of Regional Medical Programs for research and training (including continuing education) and for demonstrations of patient care in the fields of heart disease, cancer, stroke and related diseases. In the two and one-half years since the President signed the Act, broadly representative groups have organized themselves to conduct Regional Medical Programs in 54 Regions using functional as well as geographic criteria. These Regions encompass all of the Nation's population and include combinations of entire states (e.g. the Washington-Alaska Region), portions of several states (e.g. the Intermountain Region which includes Utah and sections of Colorado, Idaho, Montana, Nevada and Wyoming), single states (e.g. the Georgia Region and portions of states around metropolitan centers (e.g. the Rochester Region which includes the city of Rochester, N. Y. and 11 surrounding counties). Within these Regional Programs, a wide variety of organization structures have been developed in addition to the Regional Advisory Group required by the Law. These include executive and planning committees, categorical disease task forces, and community and other types of sub-regional advisory committees to coordinate cooperative arrangements among the Regions' health resources. These regional cooperative arrangements, among representative health resources are a necessary step in bringing the benefits of scientific advances in medicine to people wherever they live in a Region. It enables patients to benefit from the inevitable specialization and division of labor which accompany the expansion of medical knowledge because it provides a system of working relationships among health personnel and the institutions and organiza- tions in which they work. This requires a commitment of individual and institutional spirit and resources which must be worked out by each Regional Medical Program. It is facilitated by voluntary agreements to serve, systematically, the needs of the public as regards the categorical diseases on a regional rather than more narrow basis. Regions first receive planning grants from the Division of Regional Medical Programs, and then may be awarded operational grants to und activities planned with initial and subsequent planning grants. These operational programs are the direct means for Regional Medical Programs to accomplish their objectives. Planning moves a Region toward operational activity and in concert with evaluation, is a continuing means for assuring the relevancy and appropriateness of operational activity. It is the effects of the operational 86 activities, however, which will produce results by which Regional Medical Programs will be judged. - on November 9, 1967, the President sent the Congress the Surgeon General's Report on Regional Medical Programs submitted to the President through the Secretary in compliance with the Act. In preparation for this Report suggestions were sought from the 600 participants in a National Conference on Regional Medical Programs held in January 1967. Proceedings of this Conference were published recently. The Report details the progress of Regional Medical Programs and recommends continuation of the Programs beyond the June 30, 1968 limit set forth in the Act. The President's letter trans- mitting the Report to the Congress said, in part: "Because the law and the idea behind it are new, and the problem is so vast, the program is just emerging from the planning state. But this report gives encouraging evidence of progress--and it promises great advances in speeding research knowledge to the patient's bedside." Thus, in the final seven words of the President's message, the objective of Regional Medical Programs is clearly emphasized. Program for 1968 and 1969 Two types of grants are authorized by the enabling legislation - planning and operational grants. The achievement of any one objective of a Region may require a combination of activities, such as research, specialized training of allied health personnel, continuing education of physicians, experimentation to find the best methods to achieve desired results, and demonstration of the most efficient patient care. The law does not allow support of isolated projects, however meritorious, whether they be in continuing education, research, patient care demonstrations or training. As a result, a Regional Medical Program is not a collection of individual projects and represents far more than the sum of the parts. It is the linking together of these activities to accomplish the objectives of the Act through cooperative arrangements and interrelationships intended to improve care within a Region of all suffering from heart disease, cancer,, stroke and related diseases. Acceptance of the challenges posed by Regional Medical Programs is well demonstrated by the activities of Regions. One Region, faced with the not uncommon situation of a large number of hospitals wanting to establish coronary care un ts, was initially concerned with the mechanics of building and equipping such units. Their attention shifted, however, to a consideration of how the Region might give the best diagnosis and treatment to all patients with myocardial infarction. What started as an emphasis on hardware in hospitals developed the potential of bringing the best talent in a Region together to consider a number of critical problems, including the need for trained manpower, the need for specialized resources in a community hospital, and the need to document for evaluation purposes what emerges from a possible dramatic change in the care of patients within a Region. Another Region, finding itself with a number of small hospitals already having established coronary care units, has turned to the difficult but necessary task of studying the effectiveness of these small units, and the cost/benefit realities of,such units in small hospitals. 87 Even the problems surrounding continuing education and training of health manpower forces Regional Medical Programs to consider other major issues. One Region has within it an expensive and excellent facility for the production of audio-visual materials, such as color motion picture films and television tapes. Because of the need for such materials by that Region, the production facility and the Region are working cooperatively. But attention has shifted from the mechanics of the production and distribution of teaching aids to the need for the determination of the proper content and use of such materials in teaching programs. The Region and the producer have jointly begun to study these problems in the specific terms of educational needs. In addition, they have recognized their unique ability to conduct such a study, which promises benefits to all regions. On theother side of the country, a Region unable to produce its own audio-visual aids has decided to define carefully its need for program materials, and only then to secure them from a neighboring region. In these ways, inter-regional cooperative arrangements are being structured in order to solve elaborate hardware problems. The point to be made, however, is the switch from primarily a hardware problem to the larger issue of the proper use of educational aids within a program. Many additional activities with great promise for achieving the objectives of the program were described at a Conference-Workshop held in January 1968. Over 700 persons involved iq Regional Medical Programs attended and exchanged ideas and reports of progress through over 60 papers and numerous exhibits. The proceedings of the Conference-Workshop have just been made available. Fiscal Year 1969 will be the first year of this program under new legislation, following an initial two and one-half years under the original "Heart Disease, Cancer, and Stroke Amendments of 1965". During the initial period, this appropriation has supported the establishment of 54 regionally- based programs devoted to planning activities. Of these, 24 will have initiated or will have qualified for operational programs based on cooperative efforts, to reduce the illness,, disability, And premature deaths caused by these and related diseases. These programs already involve nearly every medical school in the country, research centers, hospitals, physicians, voluntary and public health organizations, allied health personnel and their representative societies, and others. In 1969, in addition to planning activities in 54 Regions and operational programs in 24 Regions, it is expected that an additional 30 Regions will have initiated or qualified for operational activities. The specific activities now supported under Regional Medical Programs grants are as varied as the Regions themselves, and bear the stamp of imaginative response to local health needs that can only emerge through regional fact- finding, planning and decision-making. As substantial as this beginning is, it is only a beginning. As the foundation for action has been established, the extent of the challenge has also emerged more clearly. Since this program was first proposed three years 83 ago, the threats of heart disease and stroke have remained strong and still resistant to human skill and inventiveness. In these two and one-half years it has also become more apparent that the solution of these and other major health problems will require significant improvements in the organization and delivery of health services. Therefore, the great promise of Regional Medical Programs for the coming years lies in their demonstrating how medical capabilities can be more effectively organized to help solve these problems through new patterns of collaboration of all available health resources. Ultimately, the overall success of any Regional Medical Program must be judged by the extent to which it can be demonstrated that the Regional Program has assisted the providers of health services in developing a system which makes available to everyone in the Region the best care,for heart disease, cancer, stroke and related diseases. Of the $93,800,000 available in 1969, $62,900,000 represents new bbligational authority. An amount of $24,000,000 is needed to meet continuation requirements for grants awarded prior to the February 1968 Council. Applications totalling $14,500,000 will be presented to the February Council for review. Approximately $8,000,000 in new comm tments for 1969 is anticipated as a result of Council action. We have in hand and have been informed by the Regions that applications in the amount of $28,900,000 will be presented to the May Council and it is anticipated that an additional continuation commitment will result in the amount of $15,000,000. In summary, total continuation commitments are $47,000,000, leaving $46,800,000 available for support of 30 new operational awards as well as supplemental support of the initial 24 operational grants expected to be awarded by June 30, 1968. it should be noted that the initial operational award repres ents the first step of operational activities designed to accomplish the objective of P.L. 89-239. April 24, 1968 Division of Regional Medical Programs Status of Grant Funds (In thousands) Funds available: FY 1967/68 funds ...................... $25,900 FY 1968/69 funds ...................... 23,000 Total ........... I ........................... $48,900 Less: Obli ations thru 4/15/68 .............. 23,734 9 February Council approvals ............ 1,073 Anticipated 4th quarter continuations. 4,425 Anticipated May Council actions ....... 1-3,70-6- 1/ Estimated obligations ..................... 42,938 Anticipated unobligated balance As of 6/30/68 ...... 5,962 B/ Represents $1.1,506,105 favorably recommended by Review Committee to May Council, plus $2,200,000 of "Earmarked" funds, favorably recommended by Council Sub-committee. B/ Represents 1968/69 funds available for carry-over. This amount will be needed to fund hold-over business going to August Council. It is estimated that approximately $7,000,000 will be required to fund all hold-over business. April 17, 1968 Division of Regional Medical Programs Status of Grant Funds (In thousands) 1967/68 1968/69 Funds Funds Total Funds Available ............... $25,900 $23,000 $48,900 Obligations thru 4/15/68 ...... 203,294 3,440 23,734 February Council Approvals .... 1,073 ... 1,073 Anticipated Fourth Quarter Continuations ............... 4,425 ... 4,425 Subtotal, obligations .... 25,792 3,440 29,232 Available for May Council ..... 108 19,560 193,668 Applications to April Review April 17, 1968 lst-Year Total Applications Previously Reviewed: Funding Funding PlanninR - New-- Puerto Rico (65) ........ ... $246,307 $495,475 Planning Supplemental-- Syracuse (50) .............. *........ 186,886L 186,886 Subtotal, planning ...... 6.0 .... 433,193 682,361 Operational - New-- New Mexico (34) .... ......... 924,279 2,637,180 Syracuse (50) ............. 352,718 1,357,130 1,276,997 3,994,310 Operational Supplemental-- Missouri (09) ....... 0....... 0....... 1,064,654 3,399,403 Missouri (09) .................. 0.... 187,164 396,6 Utah (15) ........................... 669,558 1,515,658 1,921,376 5,311,711 Subtotal, operational .......... 3,198,373 9,306,021 Total, previously reviewed ............... 3,631,566 9,988,382 Applications, Recld to date, April Review: Planning - Supplemental-- Arizona (55) ......... $600.6 ......... 119,839 119,839 Northlands (21) ............0........ 496,928 1,216,868 Ohio State (22) ...............*..... 1,262,388 109 3,59 .Maine (54) .......................... 163,010 163,010 Oregon (12) .............. ....... 34,408 68,303 Total, planning..4 ............. 2,076,573 3,551,610 Operational - New-- Texas (07) ........................... 3,470,777 6,231,003 California (19) ..................... 3,488,098 12,213,965 1,945,913 7,215,253 South Carolina (35) ................. Michigan (53) ....................... 2,340,266 7,110,555 @1,969,837 Georgia (46) ......I ................ . 9,396,847 5,801,335 Memphis (51) ........... 1,595,179 Iowa (27) ........................... 1,173,737 6,155,657 Connecticut (08) ......... O..* ........ 3,696,657 23,936,091 Maine (54) ........... 369,761 1,464,188 Subtotal, new operational*..#.* 20,05OP225 79,524,894 Operational - Supolemdntal-- Kansas (02) .................. 0... O.. 1,531,725 7,155,073 Rochester (25) .... o..oo ..... o....... 496,214 4,171,410 North Carolina (06) .... ooo.....o .... 348,935 998,894 Oregon (12)o ....... oo ... o.6 .... o.o.. 443,060 1,228,335 Wisconsin (37)oo ..... o..ooo ...... oo. 177,249 468,269 Missouri (09).o ..... oo..o ...o.... o.. 261,615 1,415,580 California (19)o..o ........ oo ....... 805,758 2,649,920 Intermountain (15) ......... *O.** .... 616,115 1,184,112 Subtotal, operational supp*..o. 4,680,671 19,271,593 Subtotal, operationaloo.o ...... 24,730,896 98,796,487 Total, new requests for April Review..o.. 26,807,469 102,348,097 Total requests to April Review.... offooes 30,439,035 112L336,479 OPERATIONAL GRANTS AWARDED AS OF APRIL 12, 1968 Period of 01 01 02 03 Performance Awarded Pending Committed Committed Kansas (02) ........... 6-1-67/5-31-68 699,852 1,978,396 1,000,000 ... Albany (04) ........... 4-1-67/3-31-68 921,510 ... 757,500 North Carolina (06)... 3-1-68/6-30-69 1,485,341 348,935 1,347,840 1,195,134 Missouri (09) ......... 4-1-67/3-31-68 2,887,903 ... 3,385,056** ... Oregon (12) ........... 4-1-68/3-31-69 221,191 443,060 166,706 174,204 Western New York (13). 3-1-68/2-28-69 357,761 ... 177,282 180,243 Intermountain (15) .... 4-1-67/3-31-68 2 038,123 ... 1,542,272** 333,576 Tenn. Mid-South (18).. 2-1-68/1-31-69 1,630,304 ... 1,500,000 1,500,000 Rochester (25) ........ 3-1-68/2-28-69 343,749 496,214 224,963 232,566 Metro.-D. C. (31) ..... 3-1-68/2-28-69 418,318 ... 293,615 123,210 ICHE (32) ............ 3-1-68/2-28/69 206,913 ... 150,666 153,306 Wisconsin (37) ........ 9-1-67/8-31-68 630,149 25,154 163)968 55,404 Wash.-Alaska (38) ..... 2-1-68/1-31-69 1,032,003 ... 796,861 ... Awarded April 17, 1968 NATIONAL INSTITUTES OF HEALTH Regional Medica rams (In thousands) 1967 1968 1969 Actual Estimate Estimate Funds available .................. $31,952 $48,900* $93,800** Obligations .......... 4........... -27,052 48,900 93,800 Unobligated balance carried forward ........ 0 .... 4,900 ....... ....... SUMMARY OF GRANT OBLIGATIONS Cumulative Obligations FY 1966 - Planning grants 7 FY 1967 - Planning grants 41 18,053,200 02-yoar (10) 2,328,575 operational grants 4 6 669 733 27 051 508 $29,117,927 FY 1968 Planning grants 5 1,841,256 Supplements (15) 2,513,833 02-year (28) 8,121,909 Amendments (3) 126,736 Operational grants 9 6,148,752 Supplements (5) 431,380 Amendments (1) -376,748 02-year (2) 4,927,328 23,734,446 52,852,373 (4/12/68) * Includes $21,000,000 carried forward, in addition to $4,900,388. ** Includes $30,900,000 tarried forward.