BRIEEFING BOOK MSTORY OF REGIONAL MEDICAL PROGRAMS NATIONAL LIBRARY OF MEDICINE BETHESDA, MARYLAND 1991 July 24, 1991 RMEP BRIEEFING BOOK CONTENIS TAB I Introductory Statement TAB II Chronology of Regional Medical Programs TAB III RMP Enabling Legislation TAB IV Useful Summary Articles TAB V Biographical Sketches of Directors of Regional Medical Program TAB VI Budget History TAB VII Summaries of Key Reports and Hearings TAB VIII List and Map of RMPs INTRODUCTORY STATEMENT This briefing book is designed to provide those being interviewed in connection with NLM's history of Regional Medical Programs project, and their interviewers, with basic background information about RMPS. The book will also be useful to journalists, historians and others interested in the hsitory of RMPS. The book was prepared by NLM's History of Medicine Division with assistance from others both inside and outside the Library. This version of the briefing book is a first draft, and comments and corrections are most welcome. Please address these to John Parascandola, Chief, History of Medicine Division, National Library of Medicine, 8600 Rockville Pike, Bethesda, MD 2 08 94 11 -M I CHRONOLOGY OF REGIONAL MEDICAL PROGRAMS February 1964 President Johnson delivered his "Health Message" to Congress in which he announced the establishment of a Commission on Heart Disease, Cancer and Stroke. December 1964 The Report of the President's Commission on Heart Disease, Cancer and Stroke was issued, presenting 35 recommendations including the development of regional complexes, medical facilities and resources. January 18, 1965 Companion bills--S. 596 and H.R. 3140--were introduced in the Senate by Senator Lister Hill (Ala.) , and in the House by Rep. Oren Harris (Ark.), giving concrete legislative form to the recommendations of the DeBakey commission. August 1965 Anthony Celebrezze was replaced by John Gardner as Secretary of HEW. October 1965 P.L. 89-239, the Heart Disease, Cancer and Stroke Amendments of 1965, was signed. The Commission concepts of "regional medical complexes" and "coordinated arrangements" were replaced by "regional medical programs" (RMP) and "cooperative arrangements," thus emphasizing voluntary linkages. December 1965 National Advisory Council on RMPs met for the first time to advise on initial plans and policies. February 1966 Dr. Robert Q. Marston appointed first Director of the Division of RMPs under NIH. He also served as Associate Director of NIH. April 1966 First planning grants approved by National Advisory Council. original emphasis of RMps placed on continuing education, patient-care demonstration projects, and development of new manpower resources. February 1967 First operational grants approved by National Advisory Council. June 1967 The Surgeon General submitted the Report on Recfional Medical Programs to the President and the Congress, summarizing progress made and recommending extension of the program. only f our were December 1967 61 RMPs designated; operational. March 1968 Companion bills to extend RMPs were introduced in the House by Harley 0. Staggers (W.Va.) as H.R. 15758 and in the Senate by Senator Lister Hill (Ala.) as S. 3094. March 1968 Wilbur J. Cohen takes over as new Secretary of HEW. Reorganization of the Public Health Service announced. July 1968 The Health Services and Mental Health Administration (HSMHA) is created; RMPs transferred from NIH to HSMHA. RMPs combined with eight programs of the National Center for Chronic Disease Control to form, within HSMHA, the Regional Medical Program Service. The chronic disease programs included the Cancer Program; Chronic Respiratory Disease Program; Diabetes and Arthritis Program; Heart Disease and Stroke Program; Kidney Disease Program; smoking and Health Program; Neurological and Sensory Disease Program; and Nutrition Program. September 1968 Meeting of all RMP program coordinators in Alexandria, VA. Five regional groups established: Northeast, Southeast, Midwest, Southwest and West. October 1968 P.L. 90-574, extending RMPs for two years, was signed. Changes included -- expansion outside the 50 states; funding interregional activities; permission of dentists to refer patients; permission of Federal hospital participation. January 1969 Robert H. Finch appointed Secretary of HEW in the Nixon administration. September 1969 National meeting of coordinators of RMPs and chairmen of Regional Advisory Groups in Warrenton, VA. FY 1969 44 RMPs were operational. Membership in various Regional Advisory Groups exceeds 2000. Over 400 operational projects were under way. Jan-Oct 1970 Bills extending RMPs introduced; hearings held. June 1970 Elliot L. Richardson appointed Secretary of HEW. October 1970 P.L. 90-515 was signed into law. New provisions: emphasis on primary care and regionalization of health care resources; added prevention and rehabilitation; added kidney disease; added authority for new construction; required review of RMP applications by Areawide Comprehensive Planning agencies; emphasized health services delivery and manpower utlilization. New manpower included "physician extenders" such as nurse practitioners. FY 1970 Of the nine original chronic disease programs, the following five were phased out: Cancer, Diabetes and Arthritis, Chronic Respiratory Disease, Heart Disease and and Neurological and Sensory disease. The RMP Service consisted now only of RMPS, Kidney Disease Program, and National Clearinghouse for Smoking and Health. 54 RMPs were operational. Membership in various Regional Advisory Groups was 2,400. November 1972 Caspar Weinberger appointed Secretary of HEW by Nixon. FY1973 Peak year of funding of RMPS, with $140 million appropriated. Emergency medical services were playing an increasing role, receiving larger share of funding. Nixon administration proposes health spending cuts, including zero funding for RMPs in FY1974. Bureaucratic and local support gains a one- year extension. July 1973 HSMHA is split into the Health Services Administration, the Health Resources Administration, and the Alcohol, Drug Abuse, and Mental Health Administration. RMPs placed in the Health Resources Administration. 1974 The National Health Planning and Resource Development Act of 1974, P.L. 93-641, consolidated RMPs with the Hill-Burton and Comprehensive Health Planning Federal programs. February 7, 1974 In response to a law suit filed by the National Association of Regional Medical Programs, the court ordered the Secretary of HEW to release the $126 million in impounded fiscal year 1973 and 1974 funds to the nation's RMPS. 1976 After a transitional period, independent RMP operations ceased. III 4 1 i SYNOPSIS OF PL 89-239 (RMP ENABLING LEGISLATION) "Heart Disease, Cancer, and Stroke Amendments of 196511 This act amended the Public Health Service Act by adding on to it the following: "Title IX, -EDUCATION, RESEARCH, TRAINING, AND DEMONSTRATIONS IN THE FIELDS OF HEART DISEASE, CANCER, STROKE, AND RELATED DISEASES" Section 900. "Purposes" a. To establish regional cooperative arrangements of medical schools, research institutions and hospitals, for the purposes of research, training, and demonstrations of patient care. b. To rake the latest advances available to the public, through such cooperative arrangements. C. To do so without impinging upon the private health care system. Section 901. "Appropriations" a. $50 million for fiscal 1965. Those funds to be used for grants for universities and institutions for the purposes as outlined in 900 a. b. These grants cover up to 90% of construction costs. C. The funds are not to be used directly for patient care. Section 902. "Definitions" Regional Medical Program: a cooperative arrangement among a group of public or private non- profit institutions 1. . . .in a geographic area to be determined by the Surgeon General. 2. . . . that includes one or more research centers and one or more diagnostic/treatment centers. 3. . . . that includes coordination arrangements of its various components. Section 903. "Grants for Planning and Development" a. The Surgeon General in consult with the National Advisory Council authorizes all grants. b. Fiscal accountability is required of all grant recipients. The applicants must provide an advisory group of experienced members in the health care fields. Section 904. "Grants for Establishment and Operation of Regional Medical Programs" This section is essentially a repetition of those regulations in 903, applied here to the formation of a new Regional Medical Program. Section 905. "National Advisory Council on Regional Medical Programs" a. The Surgeon General appoints all 12 of its members, subject to approval by the Secretary of HEW, of this council and serves as its chairman. Two members must be practicing physicians, and there must be one each who is outstanding in the f ields of heart disease, cancer and stroke. b. Members serve four year terms and may not serve more than two continuous terms. C. The council advises the Surgeon General in the preparation of regulations and of policy matters. Section 906. "Regulations" The Surgeon General is responsible for setting regulations covering grant applications, and covering the coordination of this with other programs relating to the same diseases. Section 907. "Information on Special Treatment and Training Centers" A list of facilities that provide the most advanced methods and techniques is to be made available by the Surgeon General to practicing physicians. Section 908. "Report" This section requires that the Surgeon General submit a report by June 30, 1967, to the President and then to Congress on the following: 1. A statement of financing sources, both Federal and non- Federal. 2. An appraisal of activities after the first year. 3. Recommendations for modification or extension of this title. Section 909. "Records and Auditif a. This section requires that fiscal accountability be maintained. available to the Nation, and to accomplish EXHIBIT XII these ends without Interfering with the pat- terns, or the methods of financing, of pa- tient care or professional practice, or with Public Lai@- 89-239 the administration of Hospitals, and in co- operation with practicing physicians, medi. 89tla Congress, S. 596 cal center officials, hospital administrators, October 6, 196,'D and representatives from appropriate volun- tary health agencies. An Act "Atit7tori@@ation of Appropriations Heart Disease, "SEC. 901. (a) There are authorized to Cancer, and be appropriated $50,000,0-00 for tlic- fiscal Stroke Amend- year ending June 30, 1966, $90,000,@O for ments of 19,65. the fiscal year ending June 30, 1967, and $200,000,000, for the fiscal yeir endin- June 30, 1968, for grants to assist public or non- To amend the Public Health Service Act to profit private universities, medical schools, assist in combatin- heart disease, cancer, research institutions, and other public or stroke, and related diseases. nonprofit private institutions and agencies Be it enacted by the Senate an-d Ilou8e of in plannin,-,, in conducting feasibility studies, Representatives) of the United States of and in operating pilot projects for the estab- America in Congress a8sembled, That this lisbment of regional medical programs of Act may be cited as the "Heart Disease, research, training, and demonstration activ- Cancer, and Stroke Amendments of 1965". lties for carrying out the purposes of this title. Sums appropriated under this section SEC. 2. The Public Health Service Act (42 for any fiscal year shall remain available for U.S.C., ch. 6A) is amended by adding at the making such grants until the end of the fiscal end thereof the following new title: year following the fiscal year for which the "TITLE IX-EDUCATION, RESEARCH, appropriation Is made. TRAINING, AND DEMONSTRATIONS IN "(b) A grant under this title shall be for THE FIELDS OF HEART DISEASE, part or all of the cost of the planning or CANCER, STROKE, AND RELATED other activities with respect to which the DISEASES application Is made, except that ,iny such grant with respect to construction of, or "Purposes provision of built-in (as determined in ac- cordance with regulations) equipment for, "SEC. 900. The purposes of this title are any facility may not exceed 90 per centum of "(a) Through grants, to encourage and the cost of such construction or equipment. assist In the establishment of regional co- "(c) Funds appropriated pursuant to this operative arrangements among medical schools, research Institutions, and hospitals title shall not be available to pay the cost for research and training (including COn- of hospital, medical, or other care of patients tinning education) and for related demon- except to the extent It Is, as determined In strations of patient care in the fields of accordance with regulations, incident to heart disease, cancer, stroke, and related those research, training, or demonstration diseases activities which are encompassed by the " (b) To aff'ord to the medical profession purposes of this title. No patient rball be and the medical Institutions of the Nation, furnished hospital, medical, or other care through such cooperative arrangements, the at any facility incident to research, training, opportunity of making available to their pa- or demonstration activities carried out with tients the latest advances In the diagnosis and treatment of these diseases ; and funds appropriated pursuant to this title, "(c) By these means, to Improve gen- unless be has been referred to such facilit@, crall.v the health manpower and facilities by a practicing physician. i leDefinition-8 11(f) The term 'construction' includes alteration, major repair (to the extent per- "6EC. 902. For the purposes of this title- mitted by regulations), remodeling and "(a) The term 'regional medical pro ram' 9 renovation of existing buildings (including means a cooperative arrangement among a initial equipment thereof), and replacement group of public or nonprofit private institu- of obsolete, built-in (as determined in ac- tions or agencies engaged in research, train- cordance with regulations) equipment of ing, diagnosis, and treatment relating to existing buildings. heart disease, cancer, or stroke, and, at the option of the applicant, related disease or "Grant8 for Plan?tfng diseases; but only if such group- "SEC. 903. (a) The Surgeon General, upon "(1) is situated within 'a geographic the recommendation of the National Ad- area, composed of any part or parts of visory Council on Regional Medical Pro- any one or more States, which the Surgeon grams established by section 905 (hereafter General determines, in accordance with In this title referred to as the 'Council,), is regulations, to be appropriate for carry- authorized to make grants to public or non- Ing out the purposes of this title ; profit private universities, medical schools, "(2) consists of one or more medical research institutions, and other public or centers, one or more clinical research cen- nonprofit private agencies and Institutions ters, and one or more hospitals; and to assist them in planning the development "(3) has in effect cooperative arrange- of regional medical programs. ments among its component units which "(b) Grants under this section may be the Surgeon General finds will be adequate made only upon application therefor ap- for effectively carrying out the purposes of proved by the Surgeon General. Any such this title. application may be approved only if It con- "(b) The term 'medical center' means a tains or Is supported by- medical school or other medical institution "(1) reasonable assurances that Fed- involved in postgraduate medical trainin eral funds paid pursuant to any such grant 9 will be usbd only for the purposes for and one or more hospitals affiliated there- with for teaching, research, and demon- which paid and In accordance with the stration purposes. applicable provisions of this title and the regulations thereunder "(e) The term 'clinical research center, means an institution (or part of an institu- 11(2) reasonable assurances that the tion) the primary function Of which is re- applicant will provide for such fiscal con- search, training of specialists, and demon- trol and fund accounting proce'dures as are strations and which, in connection therewith, required by the Surgeon General to assure provides specialized, high-quality diagnostic proper disbursement of and accounting for and treatment services for inpatients and such Federal funds ; outpatients. "(3) reasonable assurances that the ap- "(d) The term 'hospital' means a hospi- plicant will make such reports, in such tal as defined in section 925(c) or other form and containing such Information as health facility In which local capability for the Surgeon General may from time to diagnosis and treatment Is supported and time reasonably require, and will keep augmented by the program established un- such records and afford such access there- der this title. to as the Surgeon General may find neces- "(e) The term 'nonprofit' as applied to sary to assure the correctness and verlflca- any institution or agency means an Institu- tion of such reports ; and tion or agency which Is owned and operated 11(4) a satisfactory 'showing that the by one or more nonprofit corporations or as- applicant has designated an advisory sociations no part of the net earnings of group, to 'advise the applicant (and the which inures, or may lawfully Inure, to the Institutions and agencies participating In benefit of any private shareholder or the resulting regional medical program) individual. in formulating and carrying out the for the establishment and operation of will keep such records and afford such such regional medical program, which access thereto as the Surgeon General advisory group includes practicing physi- may find necessary to assure the cor- cians, medical center officials, hospital ad- rectness and verification of such reports; ministrators, representatives from appro- and prlate medical societies, voluntary health "(4) any laborer or mechanic employed agencies, and representatives of other by any contractor or subcontractor in the organizations, institutions, and agencies performance of work on any construction concerned with activities of the kind to be aided by payments pursuant to any grant carried on under the program and mem- under this section will be paid wages at bers of the public familiar with the need rates not less than those prevailing on for the services provided -under the similar construction In the locality as program. determined by the Secretary of Labor in ',Grants for Establishment and Operation of accordance with the Davis-Bacon Act, as Regional Medical Program-8 amended (40 U.S.C. 276a-276a-5) ; and the Secretary of Labor shall have, with IISF,C. 904. (a) The Surgeon General, upon respect to the labor standards specified in the recommendation of the Council, Is au- this paragraph, the authority and func- thorized to make grants to public or non- tions set forth in Reorganization Plan profit private -universities, medical schools, Numbered 14 of 1950 (15 F.R. 3176; 5 research institutions,. and other public or U.S.C. 133z-15) and section 2 of the Act nonprofit private agencies and institutions to of June 13, 1934, as amended (40 U.S..C. assist in establishment and operation of 276c). regional medical programs, including con- struction and equipment of facilities In con- "National Advisory Council on Regional nection therewith. Medical Programs "(b) Grants under this section may be made only upon application therefor ap- Appointment of proved by the Surgeon General. Any such members. application may be approved only if it is rec- IISFC. 905. (a) The Surgeon General, with ommended by the advisory group described the approval of the Secretary, may appoint, In section 903(b) (4) and contains or is sup- without regard to the civil service laws, a ported by reasonable assurances that- "(1) Federal funds paid pursuant to National Advisory Council on Regional Me-di- any such grant (A) vnll be used only for cal Programs. The Council shall consist of the purposes for which paid and In ac- the Surgeon General, who shall be the chair- man, and twelve members, not otherwise In cordance with the applicable provisions of the regular full-time employ of the United this title and the regulations thereunder, States, who are leaders In the fields of the and (B) will not supplant funds that are fundamental sciences, the medical sciences, otherwise available for establishment or or public affairs. At least two of the ap- operation of the regional medical program pointed members shall be practicing physi- with respect to which the grant Is made; clans, one shall be outstanding in the study, "(2) theappll'cantwillprovideforsuch diagnosis, or treatment of heart disease, one fiscal control and fund accounting proce- shall be outstanding in the study, diagnosis, dures as are required by the Surgeon or treatment of cancer, and one shall be out- General to assure proper disbursement of standing in the study, diagnosis, or treat- and accounting for such Federal funds; ment of stroke. Records. Term of office. "(3) the applicant will make such re- " (b) Each appointed member of the Coun- ports, In such form and containing such cil shall hold office for a term of four years, Information as the Surgeon General may except that any member appointed to fill a from-time to time reasonably require, and vacancy prior to the expiration of the term for which his predecessor was appointed "Information on Special Treatment and shall be appointed for the remainder of such Training Centers term, and except that the terms of office "SEC. 907. The Surgeon General shall es- of the members first taking office -shall expire, tablish, and maintain on a current basis, a -Ls designated by the Surgeon General at the list or lists of facilities in the United States time of appointment, four at the end of the equipped and staffed to provide the most ad- f2rst year, four at the end of the second year, vanced methods and techniques in the diag- and four at the end of the third year after nosis and treatment of heartdisease, cancer, the date of appointment. An appointed mem- or stroke, together with such related infor- ber shall not be eligible to serve continuously mation, including the availability of ad- for more than two terms. vanced specialty training In such facilities, Compensation. as he deems useful, and shall make such list or lists and related information readily 11(c) Appointed members of the Council, available to licensed practitioners and other ivhile attending meetings or conferences persons requiring such information. To the thereof or otherwise serving on business of end of making such list or lists and other the Council, shall be entitled to receive com- information most useful, the Sur-eon Gen- pensation at rates fixed by the Secretary, eral shall from time to time consult with in- but not exceeding $100 per day, including terested national professional organizations. traveltime, and while so serving away from their homes or regular places of business they Report to President and Cong)-cs8 may be allowed travel expenses, including "SEC. 908. On or before June @0, 1967, per them in lieu of subsistence, as authorized 'j by section 5 of the Administrative Expenses the Surgeon General after consultation with Act of 1946 (5 U.S.C. 7,3b-2) for per- the Council, shall submit to the Secretary sons in the Government service employed for transmission to the President and then intermittently. to the Congress, a report of the activities under this title together %vith (1) a state- Applications for ment bf the relationship between Federal grants, recom- financing and financing from other sources mendations. of the activities undertaken pursuant to this " (d) The Council shall advise and assist title, (2) an appraisal of the activities as- the Surgeon General in the preparation of sisted under this title in the light of their regulations for, and as to policy matters effectiveness in carrying out the purposes of arising with respect to, the administration this title, and (3) recommendations %vitli Of this title. The Council shall consider all respect to extension or modification of this applications for grants under this title and title in the light thereof. shall make recommendations to the Surgeon General with respect to approval of applica- "'Records and Atidit tions for ,ind the amounts of grants under "SEC. 909. (a) Each recipient of a grant this title. under this title shall keep such records as the "Regulatioiis Surgeon General may prescribe, includin.- records which fully disclose the amount and "SEC. 906. The Sur,-,eon General, after disposition by such recipient of the proceeds consultation iN-itli the Council, shall pre- of such grant, the total cost of the project or scribe general regulations coverng the terms undertaking !n connection with which such and conditions for approving applications for grant Is made or used, and the amount of grants 'under this title and the coordination that portion of the cost of the project or of programs assisted under this title with undertaking supplied by other sources, and programs for training, research, and demon- such records as will facilitate an effective strations relating to the same diseases audit. assisted or authorized under other titles of "(b) The Secretary of Health, Education, this Act or other Acts of Congress. and Welfare and the Comptroller General of IV i i 4,11 USEFUL S Y ARTICLES Robert Q. Marston and Karl Yordy, "A Nation Starts a Program: Regional Medical Programs, 1965-1966,11 J. Med. Educ., 42 (1967): 17-27. Paul D. Ward, "The Curious Odyssey of Regional Medical Programs," West. Med., 120 (1974): 425-429. Caspar W. Weinberger, "The Guideposts in the RMP Odyssey," West. J. Med., 121 (1974): 158-160. A Nation Starts a Program: Regional Medical Programs, 1965-1966* ROBERT Q. MARSTON, M.D.t AND KARL YORDY$ National Institutes of Health, Bethesda, Maryland This month [October, 19661 marks the lems being encountered in implementing first anniversary of P. L. 89-239, the this legislation are influenced by large Heart Disease, Cancer and Stroke Amend- issues and historical trends which can be ments signed by President Johnson on seen only incompletely at any one time one place. October 6, 1965. The legislation was and f rom any hailed by some as a landmark in the While the historian of the future will history of American medicine. It was f ocus on forces that we ran perceive only strongly criticized by others, both for dimly at present, reflection on the possi- what it said and what it did not say. ble impact of the programs brings to Even some of those who supported the mind a view of history presented by Rob- legislation in principle still maintained ert Bolt (1) in A Man For All Sea-sons. a wary curiosity concerning the imple- His theme is that an examination of the mentation of such general legislative trends and forces will illuminate only a language. The philosophical hopes and portion of any historical event. What is fears of a year ago have been replaced of interest is the way it happened, the by actual events, real problems, and iden- way it was lived. "'Religion' and 'econ- tifiable progress. It is appropriate at omy' are abstractions which describe the this time to report on the extent to which way men live. Because men w 6rk we the Regional Medical Programs legisla- may speak of an economy, not the other tion has been implemented. way round. Because men worship we It is estimated that there will be 48 may speak of religion, not the other way or 49 programs: 45 planning grant ap- round. plications or declarations of intent have BACKGROUND been submitted to date. These programs will actually be defined in large measure There are a number of long-range fac- through the activity of those people who tors and trends which constitute a com- will make them operative. It is this mon heritage for the Regional Medical characteristic of the Regional Medical Programs and which set the scene for Programs that makes them a fascinating the passage of the authorizing legislation. experiment in federal health policy. The most important of these factors is Obviously, experience with the devel- the impact of science on the nature of opment of these programs is still quite medicine and medical practice. The dy- limited, and many of the difficult prob- namic growth of medical research in this country during the past twenty years and Presented at the 77th Annual Meeting the resulting advances in knowledge form of the Association of American Medical Col- leges, San Francisco, October 22, 1966. the scientific base which is the beginning f Associate Director; Director, Division of point for the program. Following are Regional Medical Programs. some of the factors which contributed . * Assistant Director, Division of Regional - - Medical Programs. to the development of the legislation: 7. 17 i@ 18 Journal of Medical Education VOL. 42, JANUARY, 1967 the forty-year discussion on reg-ionaliza- Admiiiistration's proposal. Many changes tion of medical services; the evolution were made in the original bill, primarily of the medical schools with the accom- as the result of hearings before the pan3ing development of great medical House Interstate and Foreign Commerce centers; and underlying social factors Committee, chaired by Congressman relevant to health concerns, including the Oren Harris. By its action, Congress rising expectations of the consumer of made it clear that this program would health services who is increasingly com- be built upon cooperation among existing ing to expect that modern medical science institutions and that local initiative will have the solutions to his health would play a determining part in the de- problems. velopment of the Regional Medical Pro- The legislation was directly influenced grams. The law emphasized the role of by such publications as the Coggeshall the required regional advisory group and Report, Planning for Medical Progress the intent that this group be broadly through Education (2) ; the Dryer Re- representative of all health interests and port, "Lifetime Learning for Physicians" include practicing physicians and repre- (3) ; and the Reports of the Association's sentatives of the interested public. Eighth and Tenth Teaching Institutes The House Committee was impressed "Medical Education and Medical Care: with the potential contribution that the Interactions and Prospects" and "Medi- Regional Medical Programs could make cal Education and Practice: Relationships to the more effective utilization of man- and Responsibilities in a Changing So- power. Therefore, it stressed the role ciety" (4, 5). However, the actual im- of continuing education and training petus for the introduction of the bill in accomplishing the purposes of the was the publication of the Report of the legislation. President's Commission on Heart Dis- Although the bill as originally written ease, Cancer and Stroke (6), which provided authority for new construction, focused on the relationship between sci- this section was eliminated before the ence and service in medicine. The man- legislation was passed. date of the President's Commission did Finally, Congress aut orized the'pro- not include the drafting of legislation; gram for three year,-$ and made clear its that task was performed under the intent that this initial period be an ex- leadership of Dr. Edward Dempsey, then ploratory phase which would constitute Special Assistant to the Secretary of the the learning experience on which future Department of Health, Education, - and extension and modification of the legis- Welfare for Health and Medical Affairs, lation could be based. and Dr. Dempsey's Assistant, Dr. Wil- Preceding the signing of the legisla- liam Stewart, now Surgeon General. The tion, the administrative decision was bill that was sent to the Congress by the made that this new responsibility of the Administration contained the elements Public Health Service would be adminis- which have proved to b e most important tered by the National Institutes of to the development of the program over Health. This action emphasized the the past year, including the emphasis on fact that the Regional Medical Programs the relationship of academic medicine to concept focused on the relationship and medical practice, the creation of work- interaction between the development of able cooperative arrangements among new knowledge and the provision of bet- health resources, and the use of competi- ter medical care. In the period preceding tive grants rather than formula grants. and following the final approval of the Congress did not rubber stamp the legislation, Dr. Stuart Sessoms, Deputy A N7ation Starts a ProgramIMarsto7i and Yordy 19 a r FIGURE Director of NIH, was the focal point for fact that the flexibility of this legislation NIH concern with this legislation, as- was deliberate public policy and that this sisted by Mr. Karl Yordy. Much of the flexibility is central to the concept of a early implementation which will be de- regional medical program. scribed later in this paper occurred under The legislation clearly prescribed that the leadership of Dr. Sessoms, who bore the program be carried out on a regional the major responsibilities until February, rather than a national basis. The law 1966. represents a vote of confidence in the On October 6, 1965 there were no ex- willingness of the regions to accept the perts on regional medical programs, no basic responsibility for devising the pro- master blueprints of how a regional grams to accomplish the purposes of the medical program would work. During law. The flexibility of the legislative this period, questions from prospective provisions highlights this transference of applicants and other interested parties responsibility to the regional level. A attempted to probe the flexibility of the clearly defined national medical program legislation in order to determine whether would have led to fewer questions. How- or not there was a specific blueprint for ever, even if workable, it would have implementation (Figure 1). How do meant less opportunity for creativity, you define a region? How many regions fewer opportunities to develop diverse will there be? Who ran apply? What answers appropriate to diverse problems, will be the responsibilities of the appli- and less assumption of responsibility at r-ant? What is the exact nature and role the local level. of the regional advisory group? Tell me After one year of experience, there is in specific terms what a regional medical considerable evidence justifying this program will do and how it will function. law's almost -naive trust and faith in the The answers, or some would say lack of ability of formerly divergent medical answers, to these questions reflected the interests to cooperate on a voluntary 20 Journal of Afedical Education VOL. 42, JANUARY, 1967 RANIS (Pu ic LaW 8 EGIOIAL MEDICAL. PROG CHRON OF@ R October, 19 FEB FMM@T DWM OF p ww. PO FIGURE 2 basis in accomplishing important health of the medical school faculty and admin- objectives. istrators feared that their medical centers D@LOPMENT were being asked to assume the total re- sponsibility in their regions for medical R&4,SSURANCE AND DEFINITION care in the :fields of heart disease, cancer, Experience with the program divides and stroke. Nonaffiliated hospitals feared naturally into several phases (Figure 2). that they would have no role to play in The first spans the period from the sign- the program (Figure 3). ing of the legislation in October until However, along with the fears and anx- about February, 1966. During this time, ieties, there was a ground swell of in- much of the effort of Dr. Sessoms, the terest in the Regional Medical Programs authors, and others was spent in pro- expressed by a very wide variety of viding reassurance to various medical health organizations, institutions, and in- groups concerning the 'nature of this dividuals. Meetings were held in regions program as defined in the law. For some throughout the country to discuss imple- still feared that the program would be mentation of the program. The staff at a federal medical system which would di- NIH was contacted by literally hundreds vert patients to distant medical centers of medical organizations and groups ex- with no concern for the role of the local pressing interest and support. The Re- practicing physician or hospital. Some gional Medical Programs appeared as a 21 A Nation Starts a Program/Marston and Yordy m@ iec -f FiGur,E 3 topic for discussion in the programs of Council as required by the law. Members a number of major medical professional of the Council and the ad hoc consultants organizations. became increasingly articulate in inter- In December the Division of Regional preting and defining the program in Medical Programs was established and its speeches, in their own professional or- National Advisory Council held its first ganizations, and in the development of meeting. individual regional plans. REGULATIONS, GUIDELINES, AND OUTLINES RECEIPT AND REV-IEW OF APPLICATIONS The second phase of the program ex- The period from April through June tended from February until April. Spe- constituted the third program phase. cial groups of consultants with expertise During this time, the emphasis changed in such relevant fields as continuing edu- from reassurance, definition, and prep- c-ation, community health planning, and aration to the receipt of applications for hospital administration were called to- planning grants and the review of those gether to advise the Division on the applications (Figure 4). No deadlines implementation of the program. Regula- for the receipt of applications were pub- tions were drafted and proposed. Pre- licized. Instead, it was the Division's liminary guidelines for applications and stated intention to hold frequent review the application forms themselves were meetings so that applications could be developed and widely distributed. Another nsidered without undue delay and with- meeting of the National Advisory Coun- co cil was held and a process for the review out the development of a crash program. of applications was developed, consisting Therefore, the National Advisory Coun- of a preliminary review by staff and by cil met to consider applications in April, a group of ad hoc consultants prior to June, and August, preceded each time the review by the National Advisory by a meeting of an ad hoc initial review 22 Jourwl of Medical Educatio7z VOL. 42, JANUARY, 1967 ,'t Inc, @e /,V, FIGURE 4 group representing a variety of back- in the actual review of planning-grant grounds in health affairs. These groups applications. were able to consider applications with NEGOTIATIONS AND ANTICIPATION varying approaches to the planning of a regional medical program and reach a During the final phase of the first year consensus on the merits of the proposals of the program, lasting from June until in terms of the purposes of the law. Dur- October, concern was with (a) contin- ing this phase, 39 planning-grant appli- ued review of applications for planning cations were received@verwhelming evi- grants; (b) a rapid buildup of activities dence of the willingness of regional in continuing education; (c) preparation groups throughout the country to accept for the required Report to Congress in responsibility for the development of a June, 1967; and (d) anticipation of ap- planning program. lir-ations for operational grants. In reviewing the :6rst applications, the In considering the applications, the re- Division was able to identify certain view groups found that a straight "yes" areas of emphasis and problems, which or "no" answer was seldom sufficient to were then reflected in the organization communicate the intent of their actions. of the Division's staff and development Therefore, the National Advisory Council of Division policies. Examples are the requested that the Division staff dis- consideration given to continuing educa- cuss with each applicant the action that tion as a major function of the Regional was taken and the reasons for that Medical Programs and the proposed action. It was felt that this interchange large-scale use of systems analysis tech- and discussion between the applicant niques in the planning of specific regional group and the staff of the Division -would medical programs. As a result, the guide- contribute to a better understanding on lines document (7) issued by the Divi- both sides of the nature of the proposal. sion on July I was based not only on the On many applications the National Ad- intent of the Congress and the judgment visory Council required that additional- of the National Advisory Council and information be obtained from the appli- other advisors but also on experience cant before the application could be A Nation Starts a ProgramIMarston and Yordy 23 recommended for approval and a grant pated in the development of applications. awarded. When the additional informa- Actually, many have now given in their tion requested would not affect the basic regions the same type of talks staff mem- soundness of the proposal, the Council bers were giving a few short months ded approval, conditional upon a go. recommen receipt by the Division of clarifying in- formation. If the information to be pro- PLANNING-GRANT APPLICATIONS vided was more substantial, the Council One of the most productive sources of deferred action on the application until information at this relatively early stage it could consider the additional informa- of the program has been the grant appli- tion supplied by the applicant. On other cations themselves. They provide pre- applications the Council did not feel that liminary insights into the types of ac- it could recommend approval of the ap n behalf of the tivities to be carried out o placation until substantial revisions bad Regional Medical Programs as well as been made in the proposal. In recommend - a rough gauge of the extent to which "re- ing revisions, the Council emphasized the i gional cooperative arrangements" among fact that it expected to see the rev sed medical schools, research institutions, hos- application at its next review meeting pitals, and other health agencies and in- and that in negotiating these revisions, stitutions have developed to date. the staff of the Division would not re- Forty-three applications have been rec- quire that applications conform to a ommendl-d for approval or are currently standard pattern. The Council wanted under consideration. They cover regions these applications to retain their unique which contain about 80 per cent of the characteristics; but it felt a strong sense nation's population. Certain of the major of responsibility that the award of fed- metropolitan centers account for most of eral grant funds could only be recom- mended after satisfactory evidence had the remainder of the population. As might have been expected, rnulti-medical- been presented that the proposal, what- center urban areas have had particularly ever its proposed approach, could reason- ably be expected to result in a plan f or difficult problems in developing the coop- a regional medical program that acc erative arrangements essential to the Re- iom- on. Fional Medical Programs. However, pend plished the objectives of the legislat ing applications and discussions with This phase of the program saw the groups in New York, Philadelphia, Chi- appointment of a blue ribbon ad hoc com- cago, and Boston, for instance, have led mittee, which has now had 2 meetings to focus on the Surgeon General's Report to the conviction that effective ways will to the President and Congress, due June be found of bringing together the many health interests that 'exist in these urban 30, 1967. Also during this phase, ini- tial plans were made for a national meet- areas. ing to be held January 16-17, 1967 in The applications which have been re- response to a number of requests for ceived indicate that the initial planning such a meeting and also because of the of the Regional Medical Programs will need to get grass-roots opinion for the generally include 4 major types of activi- Report to Congress. ties: (a) organization and staffing; (b) At this time, a change in the types of studies to collect and analyze data on re- questions which medical groups asked sources, problems, and needs; (c) devel- staff representatives became apparent, opment of ways to strengthen communica- primarily because increasingly large pro- tions and relationships among the health portions of audiences had actively partici- institutions and agencies of the region; 24 Jourwl of Medical Education VC)L. 42, JANUARY, 1967 and (d) preparation of proposals for health manl>ower, facilities, and special- operational projects. ized capabilities. Most of the applica- The approaches to the organization tions include proposed studies of the dis- and staffing of the programs vary widely. tribution of and needs for medical and In a majority of cases (26), the formal nursing manpower. They also give high applicant-the institution acting as the priority to problems associated with the "programming headquarters" or "agent,, shortages of laboratory and other allied for the region-has been a medical health personnel. school; this situation is particularly Most of the applications include plans likely when there is only one medical for continuing education activities for school in the region and that institution allied health personnel as well as for phy- is part of a state university system. sicians, dentists, and nurses. There have been 4 applications from The strengthening of communications medical societies, 2 from existing private and relationships among the existing and nonprofit agencies, and one from a state -potential participants in the Regional agency. In 10 of the 43 regions new Medical Programs through a variety of corporations have been established to be devices is planned. the applicant. It has been suggested that In view of the critical importance of these new organizations may be of con- cooperative arrangements in the pro- siderable significance for the develop- grams, the following delineation of the ment of more effective cooperation among membership of the regional advisory major health resources. groups may provide an initial measure of In addition to the applicants them- how effective the programs are likely to selves, well over 400 other cooperating be in engendering these arrangements: agencies or institutions are represented 1. Practicing physicians and medical in the applications, with hospitals, both center officials each make up about 20 affiliated and nonaffiliated, constituting per cent of these advisory groups. the largest group. Among the other key 2. Hospital administrators, representa- participants are medical societies and tives of the voluntary health agencies, state or municipal health agencies. other health professionals, and public It is clear from the applications that health officials each account for about 13 utilization of existing health personnel is per cent of the total. planned; experienced senior health ad- 3. "Public" members, including law- ministrators and educators are being yers, industrialists, labor leaders, and sought and found to fill major positions. housewives, account for the remaining 8 It is also evident that many of the per cent. grantees will be looking to other disci- 4. The state governors have been in- plines and to other university faculties volved, in one way or another, in about for assistance. For example, there have one-half of the cases. been a number of proposals for the par- 5. The state health officer or a member ticipation of such individuals as sociol- of the state board of health from the ogists, economists, and communication specialists. In addition, applicants will staff of related health departments is a seek advice and assistance in areas such member of the regional advisory group as computer technology and operations in almost every case. research on a contractual basis, either 6. Staff members of area-ivide hospital from universities or from private firms. planning agencies are members of about The surveys which are most commonly one-half of the groups. In all other mentioned in the applications are con- cases a representative of the appropriate cerned with the collection of data on hospital association is named. A 1\7atio-n Starts a PrograrnIMarston and Yordy 25 FIGURE 5 7. The groups have representation from negotiations with applicants represent heart associations and cancer societies. beginnings in the development of these OPMATIONAL GRANTS relationships. The creation of a branch for consultation and assistance under the The purpose of the planning grants is direction of Dr. Margaret Sloan resulted to develop operational programs (Figure from a recognition of this need. Further, 5). While continued planning is a cru- ai)i)licants are being advised to make cial part of the programs, it is antici- f-- pated that only a few new planning ree use of supplemental applications so grants will be submitted and that in that their programs can more easily be - developed by incremental steps. creasingly the focus will be on the need 2. It @is necessary to develop flexible but for supplemental support for planning specific involvement of other federal and and for the initiation of operational com- nonfederal sources of support, including Ponents. A number of applications for their review and approval processes. It operational grants have been submitted is recognized that just as the program or are in preparation. I I calls for an integrating and synthesizing The Division has been deeply invoivea activity on the regional level, the Divi- in the development and clarification of sion has a synthesizing and integrating the review and approval processes which responsibility to the grantees. In some will be required for these applications' instances it is clear that specific proce- As a result of this study, it has become - apparent that this process must estab_ clures must await the opportunity to lish 3 new types of relationships: work with concrete examples. 1. There must be a continuing and st)e- S. The review and approval process developed on the national level must be cific relationship between the Division staff, the review committee (now ap- related to the review and approval mech- Pointed on a permanent basis), the Na- anisms which exist in the various re- tional Advisory Council, and the grantees. gions. Basic to the goal of establishing The frequent meetings of both the review the decision-making mechanisms on the committees and the National Advisory local level is the assumption that differ- Council as well as the extensive staff ent priorities exist in different parts of 26 Journot of Medical Education VOL. 42, JANUKRY, 1967 the country. However, neither the Na- law anticipates the use of research and ex- tional Advisory Council nor the Public periments, and the initiation of activities Health Service can delegate its funda- which, when evaluated, can be modified mental responsibility and accountability as indicated. (c) Criteria for specific for the wise expenditure of federal f unds. projects must be developed. The scope w The mechanisms of the review process and flexibility of this legislation is such can be simply described. The regular that there is no difficulty in listing great process will be a familiar one: grants numbers of meritorious and needed proj- will be received and reviewed by the ini- ects which could be supported. Suggested tial review committee; additional infor- criteria for setting priorities are as mation will be gained by site visits, follows: which in many instances will be con- 1. The degree to which the project ducted by members of both the committee would assist in the wise utilization of and the Council; and then there will be manpower. As one applicant noted, the a recommendation by the Council and the regional group is not interested in tying final action involving administrative de- up resources with fine projects for which cisions by the Public Health Service. the necessary manpower is not readily In addition to this regular process the available. staff will custom-tailor the review proc- 2. The degree to which proposed proj- ess to meet the particular needs of indi- ects involve multiple institutions and vidual grants. In many instances this types of institutions and, therefore, will mean obtaining additional informa- would lead to more effective development tion on scientific merit or other aspects of cooperative arrangements, particularly from the existing expertise in other in- in the initial steps. stitutes or bureaus of the Public Health S. The degree to which the proposed Service or other agencies in the govern- project relates science to service. ment to insure that acceptable standards 4. The degree to which the project will are maintained; and it will also involve contribute to continuing education and exploring the potentialities for support. training for physicians and other health The development of a decision-making personnel. process in each region is a prerogative 5. The degree to which latent talent or of that region, and much time and effort unique regional resources nugbt be uti- have already been devoted to this area by lized more effectively. the Division and by applicants through- 6. The degree to which the proposed out the nation. Some factors relevant project represents a critical area which, to evolving effective processes seem to be if supported, will beneficially affect a either easily identifiable or particularly larger program. A regional medical pro- pertinent: (a) The initiation of the first gram offers the opportunity to bridge steps in the operational program along gaps and to support new and innovative with continued planning should represent approaches which of themselves may be movements toward the fuller development only a small portion of much more ex- of the regional program. (b) On the one tensive activities. hand there will be a need to determine Finally, of course, the fact that this is the appropriate balance between depend- a broadly categorical program in the ence on retrospective data, opinions, and area of heart disease, cancer, and stroke the experiences of others, and on -the must be taken into consideration. other band there will be the need to ini- The Division has been convinced that tiate activities which will themselves pr@ as the programs proceed into the opera- vide the basis for future decisions. The tional phase, grantees will be well ad- A Nation Starts a Program/Marston and Yordy 27 vised to select those activities which they that did not previously seem connected, can see clearly, rather than depending on sketches a more embracing frameworl,, the development of some master plan in moves toward larger, more inclusive under- vague and unexplored areas. Therefore, standing. it is anticipated that many will choose The beneficial changes which have been those initial steps which will contribute effected by the program twenty years to further refinement of the basic deci- from now will depend upon the extent sion-@ng processes which they have to which it has stimulated creative per- established. formances which have contributed to con- stant improvement in As those who are involved in the pro- the quality of gram move along this not uncomplicated medical service in the nation. path, it is worth remembering the way a REFERENCES dean once described the problem of the vice president for health affairs in bring- 1. BOLT, R. A Man for All Seasons. London: Heinemann, 1961. ing together groups with nonidentical 2. CO@ESH@, L. T. Planning for Medi- goals. After speaking to the value of Cal Progress Through Education. Evan- such activities, he raised a word of cau- ston, Illinois: Association of American tion in the following wav: Medical Colleges, April, 1965. What do they do? In short they try to 3. DRYER, B. V. Lifetime Learning for hitch mules and cows to the same plow and Physicians: Principles, Practices and then drive the rig. What do they try to do? Proposals. J. Ned. Educ., 37: June, They try to assemble the team, work to- Part 2, 1962. gether, combine assets, etc. To continue to 4. SnEps, C. G., WOLF, G. A., JR., and enlarge upon our metaphor of hitching two JACOBSEN, C.(Eds.)."Medical Education thousa-nd-pound beasts together without rec- and Medical Care: Interactions and ognizing that the objective of one is to pull Prospects." Report of th e Eighth Teach- and the other to be milked could end with ing Institute of the Association of one going unmilked and the other sitting American Medical Colleges. J. Ned. down. Both have highly and equally com- Educ., 36: December, Part 2, 1961. rnendable objectives, but working together 5. WOLF, G. W., JR., and D , W. as a team neutralizes the effectiveness of "Medical Education and Practice: Rela- each. tionsmps and Responsibilities in a The goal of the Regional Medical Pro- Changing Society." Report of the Tenth grams, like that of the vice president for Teaching Institute of the Association health affairs, is to make the activities of American Medical Colleges. J. Ned. Educ., 40: January, Part 2, 1965. of its members more effective in their 6. President's Commission on Heart Dis- pursuit of their own goals. ease, Cancer and Stroke. Report to the President. A National Program to Con- CONCLUSION The success of the Regional Medical quer Heart Disease, Cancer and Stroke. Programs requires that medical schools (Volume I.) Washington, D.C.: U.S. Government Printing Office, 1964. as well as all other participants share 7. Guidelines-Regional Medical Programs. authority as well as responsibility. Gard- U.S. Department of Health, Education, ner (8) made the following statement in and Welfare, Public Health Service, National Institutes of Health, ivision his monograph, Self-"newal: The Indi- vidual and the Innovative Society: of Regional Medical Programs, July, Every great creative performance since 1966. the initial one has been in some measure a 8. GARDNER, J. W. Self-Renewal: The bringing of order out of @os. It brings Individual and the Innovative Society. about a new relatedness, connects things New York: Harper & Row, 1965, P. 39. Refer to: Ward PD: The curious odyssey of Regional Ntedical Government and Medicine Programs (Government and Nied;cint). West J IIcd 120:425429, May 1974 -fol- The Curious Odyssey of Regional Medical Programs PAUL D. WARD, Oakland to DL:RING ITS EIGHT @-FARS of existence, Re-ional poses of the program. If we could end the stor@ on i@ledical Pro2rams (R.NIP) has developed a histor%l that note, it would be like the classical novel plot: marked b%, man@, chan,2es of fortune. iNo social the beoinnin-, the problems faced in the middle, program enacted after World War 11 has exper- and the happy ending. But in real life, there is ienc,-d the ups and downs, the changes in direc- probably more trauma to come. tion, or the praise and vilification that have be- In the beginning, the intent of the legislation fallen R.NIP. Some pro!zrams like ,Model Cities and was to create a partnership consistino, of major the Office of Economic Opportunity (oEo) have segments of health providers, educators, public peaked and then fallen from grace, but none have and voluntary health agencies and other health had the spectacular roller-coaster ride Of RNIP. resources. Whfle these new "cooperative arrance- Those involved in the program believe R@Nlp has ments" were to be carried out with an emphasis proven its worth and provided many improve- on heart disease, cancer, stroke and related dis- ments in the health care system, but it has also eases, there was an implicit, though unstated, ac- served to test the stamina of those directly in- kno@ledgement that the potentially confming re- volved in the program, for it has been like riding straints of a purely categorical approach to good the rouer-coaster through a wind tunnel with the health care left room for other experimental wind direction changinc, every few minutes. activities. In any case, the overall objective was The changes of fortune have resulted mostly to make high quality medical care more uniformly from an unusual number of changes in philosophy available to every American. For more than three at the top level of the Department of Health, Edu- years this view of Regional Medical Programs ca6on and Welfare, the multitude of quarrels held sway: Par.tnerships were developing among REw has had with Congress, and the intrusion of medical centers, the health professions and facili- the Office of Management and Budget into pro- ties designed to provide a single quality of medical gram decisions (which omB is iU-equipped to care largely of a categoricauy-linked nature enter, especially in the health care field where its through voluntary cooperative arrangements; and, expertise barely equals zero). Finally, the courts without interfering with established patterns of have entered the scene, With a ruling that the medical practice, to disseminate new knowledge program should be returned to the course charted to doctors, nurses and other health professionals by Congress and that the funds appropriated by through programs of continuing education. Congress should be made available for the pur- In the spring of 1970 there were stirrings in The author is Executive Director of the CaUfo@ Regional the high-reaches of the Department of Health, Medical Program. Education and Welfare. The department issued a Subrrifttcd February 22, 1974. RFprint requests to: P. D. Ward. Executive Director, Califoraia set of recommended national priorities for health. Regional Medical Program, 77DO Edgewater Drive, OaMand, CA 94621. Emphasis was placed on the quantity side of med- THE WESTERN JOURNAL OF MEDICINE 425 REGIONAL MEDICAL PROGRAMS way to reduce the productivity and momentum ical care, with quality relegated to a secondary role. Special eflort was to be made to serve the of any program, if that is the intent. tep shortly needs of the poor, including particularly the The Administration took the next s American Indians, urban and rural poor, migrant thereafter by introducing its proposed budget for farm fa@es, children under five and women of fiscal 1972, in which the language called for a child-bearing a-c who might not otherwise be able "stronger discriminatory policy which will be to receive appropriate contraceptive counseling. applied in awarding grants to individual regional "Primary care" was described b5, national leaders medical programs." "As a resWt," the budget in favorable terms, and was to be developed for language continued, "a sharp retrenchment in those Americans who, for a variety of reasons, grant awards will be made for those regional were not able to seek or find necessary medical medical programs which have been the least pro- care in their own communities. ductive in order to support selected increases for ,Regional Medical Programs had been enacted those regional medical programs which have as Title IX of the Public Health Service Act. N@lith shown the greatest innovative potential for mov- the exception of Medicare, Medicaid and Mater- ing the local health care system toward improved nal and Child Health, most federal health pro- accessibility and quality of care. grams are a part of the Public Health Service Act "The major shift in emphasis by the regional and are subject to extension by Congress at least medical programs will b.e directed t oward ira- every three years. When the Administration in- proved and expanded service by existing physi- troduced its bill in 1969 to extend Regional Medi- cians, nurses and other allied health personnel; cal Programs, the emphasis on categorical pro- new and specific mechanisms that provide quality grams was gone. Primary care and creation of control and improved standards and decreased new kinds of health care services were in the costs of care in hospitals; early detection of dis- 4i ascendancy, and the proscription against inter- ease; implementation of the most efficient use of fering with traditional patient care patterns had all phases of health care technology; and support- been deleted. Congress modified the Admiaist-ra- 'ing the necessary catalytic role to help initiate tion's desires, keeping the categoricaU3@-related necessary consolidation or reorganization of activities, adding kidney disease, and retaining the health care activities to achieve maximum effi- restriction against interfering with established ciency."' Thus, it was a new direction, with the medical care practice patterns. Notwithstanding emphasis on health care economics in place of this sentiment, -Administration spokesmen con- the legislated purposes of quaEty and regionali- tinued to speak favorably Of RMP's as the proper zation. vehicle for promoting new patterns of medical Regardless of the advisability of Regional Med- care and new forms of health manpower. ical Programs taking on these responsibilities (several of which were new and, many observers thought, inappropriate for Rmp), even if they About this time, however, the practice of were to have been carried out the budget man- "forced carryover" of funds began. "Forced carry- agers were willing to provide only $52.4 million over" is federalese meaning that OMB or the fiscal in new money, about half what had been avail- people in the department embargo a part of the able in 1971. It became more apparent that the money Congress has appropriated for a program Administration expected Regional Medical Pro- and carry it over to the following year, usually for grams to concentrate on dehvery of primary the purpose of reducing the next year's appropn'- care, emergency medical services, health man- ation. It is a means of whipping a program into power development and cost contai=ent, with line@f warning it to revamp its behavior and categorical and continuing education program purposes, or perish. This revamping always proves activities held to a minimum. In fact, the term dif5cult for some if it violates the intent of the law, and disturbing to others as they see their continuing education was to become one not to be politely used. commitments to l@ people who are cooperating voluntarily with the program upset by the change The authorization for new money as proposed in purl>ose. Also, it is a sure way to throw conster- in the President's budget message to Congress nation, confusion, distrust and depression into the carried with it the assumption that the carryover working ranks of a program. There is no surer funds, an unprecedented $34.5 million, would 426 MAY 1974 120 5 REGIONAL MEDICAL PROGRAMS make a total rf $86.9 minio' ublished, with Regional Medical Programs n available for RMP was p fiscal 1972 activities. Yet it had been increasingly slated for oblivion by June 30, 1973. difficult as the year passed to persuade the HEW Arguments were heard like drum-fire from Ad- budget managers, and, later, the OfEce of Man- ministration spokesmen that Rmp's bad been too agement and Budget, to release these carryover closely linked to categorical disease activities and funds. The proposed $86.9 million funding level had not reaII3, served the needs of people (whereas for all of the 56 Rmp regions represented a cut of an early 1973 HEW document covering the pre- $20 million in one year. As the early months of vious year showed that more than half of the 9.6 1971 passed, the Administration reduced Rmp million people directly served through RMP aus- funding levels and it became increasingly proba- pices bad been in primary and emergency care ble (if the views of the then-Secretary Of HEW settings), and that RMP projects "have not been Elliott Richardson and his colleagues were as carried out according to any consistent theme or pessimistic as they seemed) that the $34.5 mil- set of authorities." No one in authority bothered lion would not be awarded for Regional Medical to add that it was because of the Administration's Programs, but would be retained at year's end to various mandates for change in the program's be carried over to fiscal 1972. purposes and direction that "any consistent theme" failed to exist. As Director of the OMB, Mr. Weinberger de- Coordinators of the 56 Rmp regions felt that clared that (1 ) "It is not an appropriate use of some effort should be made directly with the Sec- federal funds to finance continuing education for retary's office to argue for the release of more professionals generally capable of financing their money. Seven representatives of the RMP'S, the own education to improve professional compe- American Medical Association, the Association tence"; (2) "Originally established to upgra e of American Medical Colleges, and the Kidney health care of persons threatened by heart dis- Foundation met with Secretary Richardson and ease, cancer, stroke, kidney disease and related several of his colleagues in May. The meeting diseases, the RMP'S in recent years sought more began with a decidedly negative cast, but ended to improve access to and generally strengthen the with a renewed interest on the Secretary's part in health care delivery system"; and (3) "Dis- the accomplishments Of RMP's and an unstated mantling the superstructure of the RMP'S will also pledge to seek further responsibilities for Regional reduce the competition for the limited staff avail- Medical Programs. There was no agreement on able with the skills needed to make a contribution the release of the $34.5 million, but RMP'S were to improving the health service system in the U.S." charged that spring with helping to define "health He added that after an expenditure of nearly $500 maintenance," to set criteria for quality in health million during the life of the program "there is maintenance organizations and to develop and little evidence that, on a nationwide basis, the set in motion quality control activities. It seemed RMP's have materially affected the health care de- to the RMP'S then, if not in later perspective, that livery system.112 Yet Administration spokesmen they had won their point and the Administration had called Rmp the best link government had with did not, after all, intend to phase out the program. health providers. A $10 million supplemental appropriation for RMPS in fiscal 1971 was heavily endorsed by Congress to help restore some of the momentum Congress was yet to be beard from but on Feb- lost to the programs through the Administration ruary 1, 1973, the Administration sent telegrams cutbacks, and the Administration adopted a con- to all RMP coordinators, requiring that plans for cept of level funding for Regional Medical Pro- phasing out operations by mid-year be submitted grams for fiscal 1972. Toward the end of that by March 15. The Administration began im- election year, however, when it became apparent pounding funds for a wide range of programs, that Caspar W. Weinberger was to move from many of them, including Rmp, in heart 2. e his position as Director of the Office of Manage- RMPs began dismantling their operational and ment and Budget to Secretary of HEW, RMP Co- program staffs, and many patients who bad been ordinators began to feel apprehensive about the helped by the specialized services brought into be- program. Their gravest concerns were realized ing through RMP training and demonstration pro- when the President's health budget for fiscal 1974 jects no longer could receive the individualized THE WESTERN JOURNAL OF MEDICINE 427 REGIONAL MEDICAL PROGRAMS and often highly technical aid. Although RMP'S comprehensive health planning agencies in carry- nationally represented in dollars a very small ing out the provisions of Section 1122 of the So- part of the programs that Mr. Weinberger indi- cial Security Admendments of 1972. Again, this cated he would cut or discontinue, he probably represented a sigafficant change in the program. mentioned RMP More often than any other pro- As the law suit progressed, it became apparent gram in his early 1973 public discussions of the that the RMP's had more than a good chance of need to reduce federal spending. During this pe- winning their case. Finally 'on February 7, 1974, riod Congressional leaders reiterated their intent the court ordered Secretary Weinberger to pay the to keep RMP and other health programs alive. $126 million in impounded fiscal 1973 and 1974 Congress had before it the extension of the 16 funds to the nation's Regional Medical Programs. programs contained in the Public Health Service While the Administration could appeal the ver- Act, the legislative authorization for which ended dict, the court required that the orders be carried on June 30, 1973. It was generally agreed that out immediately, regardless of appeal. many provisions of the PHs Act needed to be re- vised and the stratagem to renew the Act for one year in order to allow sufficient time for reflection On the second major point in the suit, namely on the revamping of the code was ad ted with that the Pmp's be relieved of the mandatory termi- OP overwhelming support. The Administration did nation date of June 30, 1974, the court found as not favor the blanket one-year extension and Mr. a "conclusion of law" that "operational activities" Weinberger took th e unusual step of lobbying of Rmp's "should be permitted to proceed un- Congress personally to argue against the bill; but hindered" by HEW or the Office of Management it was passed unanimously in the Senate, by a vote and Budget, "and this should be done until Con- of 94-0, and had an overwhelming 372-1 tally in gress indicates a contrary intention." The conclu- the House of Representatives. Mr. Nixon signed sion apparently allows the possibility of keeping the measure and it became law in late June. selected RMP projects operating through fiscal Then began some additional confusions and 1975. uncertainties as various levels of the Administra- In addition to the order on release of funds tion argued that funds could or could not or would and a relaxation of the June 30, 1974, termina- or would not be released before June 30. Some tion date for Pmp's, the court lifted the program $6.9 miWon in funds was released to the regions restrictions imposed by the HEW Secretary in the on the last day of the fiscal year with the stipula- September 7, 1973, directive containing the "pri- ti tion that they could not be spent and the remain- orities and options" section @ting RMP activity ing impounded funds were incorporated in the law to the five major areas. The court found that HEW suit filed against the government by the National may legitimately be faced with time and funding Association of Regional Medical Programs. constraints because of reduced Rmp activity, and The one-year extension of the Public Health that its managers must be allowed to find ways to Service Act had become law, but since the Ad- make the program as effective as possible. "How- ministration had expected that Regional Medical ever, they must do so in a manner consistent with congressional, not self-imposed, time and budg- Programs would expire by June 30, except for the necessary tidying up that might carry through un- etary @tations." In addition, the court found, til February 15 at the latest, there were no plans "The defendant administrators may not refuse to pt applications for programs in subject areas for the program once fiscal 1974 began on July 1. arce_ _ _ Consequently there were no directions for several that are wi@ the purposes outlined by the weeks about what was expected. Three of the 56 statute." The court also ordered the defendants to regions were closed down because the Adminis- "rescind in writing all directives inconsistent" with tration believed them to have been demonstrably its order and notify recipients of such directives" inadequate. Finally, on September 7, a new mis- that they are no longer applicable. The February sion statement was issued outlining five program 7 order became effective immediately and the areas, to which Rmp's were to be restricted: court ordered the government to pay the costs of quality care assurance, emergency medical serv- the suit. ices, hypertension, kidney disease and develop- If the court order, preva-Us and its intent is ment of new and more effective manpower utili- obeyed, the RMP'S programmatically can return zation and training programs and assistance to to their earlier purposes, at least until, Congress 428 MAY 1974 120 - 5 REGIONAL MEDICAL PROGRAMS acts on any extension of the Public Health Service health needs-that is, a graphic indication of the Act. deficits and excesses that exist in terms of health In a short span of time, the program's purposes care services. Regulation, to the extent that we give major consideration to th have been bent and twisted from improving the have it, should e qualit), of care to creating new care, to controlling plan when decisions about the health care system the cost of care, and now supposedly back to the are made. But the same people should not per- intent of the law. And those same forces which form both functions if objectivity and justice are caused the twisting and turning cried the loudest a desired result. Nor are regulators and planners about the lack of "any consistent theme." the best implementers of services. Implementation The future for the nation's health programs is requires the skills of those who have had the ex- in the hands of Congress. The expiration date of perience of providing service. Quality detern-dna- June 30, 1974, for most of the Public Health Serv- tions should be based on provider research and ice Act is rapidly approaching and it is doubtful experience. To mix the three functions in one if there is time to revamp all of the programs be- staff and organization is tantamount to placing the fore that date. Some or most will probably be legislative, judicial and administrative function in extended for one more year to allow time for one unit. Equitable conclusions would be hard to hearings and debate. achieve. RMP has proven itself to be the best During early 1974 there have been moves to implementer of services in terms of access and combine the functions of planning, regulation, quality based upon provider experience. This re- improvement and implementation of care into one source should not be wasted. organization at the local level. It is to be hoped REFERENCES we can avoid this pitfall. Planners are not regu- 1. The Budget of the United States Government: Fiscal Year lators by nature or training, and should not be 1972-Appendix. Executive Office of the President. Office of Management and Budget, 1971, p 398 assigned regulatory functions. 'What we need from 2. The Budgct of the United States Government: Fiscal Year 1974-Appeadix. Executive Office of the President, Office of planning is a plan which indicates community- Managcment and budget, 1973, p 383 THE WESTERN JOURNAL OF MEDICINE 429 o: W@berger CW Refer t The guideposts in the RW odyssey Government and Medicine (Govemment and Medicine). West J Med 121:158-160. Aug 1974 The Guideposts in the RMP Odyssey CASPAR W. WEINBERGER Secretary of Health, Education, and Welfare 14OLOGY of the Regional Medical P s within his pro@ty. We can expect THF CHRO, ro- resource grams extends through one of the most turbulent this period of accelerated progress in the delivery decades in the history of American health care. of health care to be capped by the enactment of From 1964-when the Report of the Presi- some type of national health insurance. dent's Commission on Heart Disease, Cancer and If this has been a period of accomplishment, it Stroke recommended the development of regional has also been one of experimentation and learn- complexes of medical facilities and resources- ing. We have learned that producing more health until today, no fewer than 38 laws directly affect- manpower and facilities is not necessarily ac- ing the nation's health care system, t including companied by improved geographic distribution appropriations legislation, have been enacted. of those resources. We have learned that improv- Federal expenditures for the nation's health have ing the quality of health care says nothing about risen from about $4 billion in fiscal 1965 to $24.6 extending that improved care to those who are billion for fiscal 1972, with $26.3 billion requested physically or financially remote from our centers by the President for existing health programs in of medical excellence. And we have learned that fiscal 1975. the price of an improved health care system is The programs which have been conducted not cheap. Last year, expenditures for health care under this legislation, supported by billions of tax amounted to 7.7 percent of the nation's gross dollars, have contributed substantially to improve- national product, compared with 5.2 percent in ments in the national availability of health faciti- 1960. ties and health manpower and in expanded access The proliferation of approaches to American to these resources. health problems attempted during the past decade The number of active physicians in this country has also shown us that a national policy of simply has increased from 280,461 in 1964 to more than inaugurating a stream of new programs, each ad- 345,000 this year. The number of American medi- dressing only a part of the total health care de- al schools has increased from 87 in 1964 to 114 livery problem, simply adds to the already great c oday. The 1964 problem of scarce hospital beds federal health bill and postpones or hampers the t has now become a problem of how to control the task of marshalling federal resources into a corn- proliferation of unneeded beds and unnecessary prehensive, coordinated effort. duplicative facilities. If we are still confronted by The fact that these lessons were learned over a roblems in the distribution of health resources, period of time, and not as of some precise date, p we are at least on the verge of providing the indi- eliminates such factors from any neat chronicle of vidual citizen with the means for paying for those the fortunes of some individual program-whether EDiToRls NOTE: r was invited to @nd to it be Regional Medical Programs, HM-Burton, or the commentm Cal P@ health manpower-but the impact is there never- hich app ur- .T.,-,;. Whis respoi in theless. Further, especially in view of the pro- broader perspective be sees it. liferation of federal program in the 1960's, a Reprint requests to: C. W. Weinberg 7be Secret@ of H@th, Fdu@tion, iLnd Welfare,Washington, @ 20201. chronicle of the twists and of one program 158 AUGUST 1974 - 121 - 2 GUIDEPOSTS IN RMP ODYSSEY should take into account the total context of fed- ease activities and comprehensive health care eral activity within which those fortunes occurred, problems. More than half a billion dollars has' whether it included increased competition for been expended via the Rmps in an effort which federal funds, the development of opportunities has neither been true to the program's initial ob- for administrative improvements, the availability jecdves nor sufficiently flexible to fulfill a more of alternative programs to carry on the work, the comprehensive mission. As a result of court ac- implementation of changed views of what con- tion, another $218 million is being directed into stitutes federal responsibility, and the Assigning, this dubious direction. of higher priorities to problems previously sub- Even with the original strong emphasis of RMP merged. on regionalization there is little evidence-and Even when these considerations are admitted only with regard to kidney disease-that the RMPS into the discussion of the history of a particular have in many areas produced the regionalized program, there is room for honest disagreement, systems of health care originally envisioned at the variations in interpretation, and shades of opinion. program's outset. The judicial system is as legitimate an avenue to resolving those important differences as direct approaches to the legislative or the executive There is no significant evidence that the RMPS branches. have achieved their goal of getting research ad- Failure to acknowledge that both problems and vances into regular large-scale practice. The train- policies can change and that not everyone will ing programs undertaken are typically of limited agree with the revised position is to present a dis- scope and duration, and there is no substantiating torted picture of seeming inconsistencies, contra- evidence that these have had a significant impact dictions, and imagined vendettas. on actual medical practice or in demonstrating The initial concept of Regional Medical Pro- improved quality care. grams was to provide a vehicle by which scientific A major problem with respect to Pmp has been knowledge could be more readily transferred to the high cost of maintaining the program, or core, the providers of health services, and by so doing, staffs in each of the 56 regions. A significant part Li improve the quality of care provided, with empha- of the overall RMP effort and funds has gone to 46 sis on heart disease, cancer, stroke, and related pay for program staff and their activities includ- diseases. That this original purpose has been ing administration, consultation, project develop- broadened or revised or that some categories have ment and management, and evaluation. been rescinded was inevitable in light of an im- Another continuing problem has been the re- proved perception of the nature of the nation's lationship Of RMPS to Comprehensive Health health care delivery problem over the past decade. Planning. In some areas, iLmps and CHPs have That the utility of the Rmp approach in coping worked closely together in a beneficial way, but with present problems and priorities has been often their individual roles have been hard to short of the mark, is neither surprising nor a re- differentiate. It is difficult to have a CHP agency flection on the integrity or competence of the in- with responsibility for the health planning for an dividual RMps. Despite'the value of the relation- area while another federally-supported program, ships established by the Rmps over the past several an Rmp, is implementing activities in that same years, the RMPS in their present form were simply area based on its own planning and priorities. What has frequently happened is that, since the never envisioned as a vehicle for addressing the comprehensive scope of health care delivery prob- RMP has had funds available to carry out opera- lems in the manner which we believe will be effec- tional acdvfies, its planning has become the de- tive and is required today. ciding force of what is done in a given area. fills has not always been consistent with broader corn- munity and consumer health needs and interests. From the outset, the Rmp has had great dif5- The opportunity for such conflict may be seen culty in defining a clear role for itself in con- from the fact that of the 56 Rmp regions, 34 are centrating its efforts and resources on even a few, exactly coterminous with state boundaries 'and well-selected target areas. At the same time, it served by CHP agencies. has been unsuccessful in reconciling the conflicting A solution to this problem has been advanced and changing emphasis between categorical dis- by the Administration in the form of the proposed THE WESTERN JOURNAL OF MEDICINE 159 GUIDEPOSTS IN RMP ODYSSEY Health Resources Planning Act (S. 3166), which able elements of existing agencies and programs would replace the present RMP and CHP authori- involved in the present fragmented health plan- ties, which expired June 30. The bill has two ning process, the proposal provides for an orderly major purposes: First, to assist the nation's health transition to bring those agencies into a new align- care system to plan more effectively to provide the ment of Health Systems Agencies envisioned in resources necessary to meet the nation's health the bill. Hill-Burton, CHP, and RMP programs care needs; and second, to grant assistance to would be eligible to receive technical assistance states to pay part of their costs in regulating from the Department of Health, Education, and proposed capital expenditures and rate increases Welfare to enable them to qualify for provisional for health care. certification as a Health Systems Agency under The provision of that assistance This proposal provides for a clear distinction be- the proposal. tween planning and development activities on the could be conditioned upon a reorganization of the recipient entity or its merger with another efitity. one hand and regulatory functions on the other. We believe that the planning function should rest Of the health planning biLls currently being con- at the local level. It is at this level at which local sidered by the Congress, with few exceptions, an be characterized by their similarities to problems are best understood and can best be most c solved. On the other band, we feel that regulatory the Administration bill rather than their differ- fun tions should be placed at the state level, rec- ences. It appears that somewhere in the chron- c ognizing that regulation is more clearly a govern- ology of RMP fortunes, the issue has become not ment function. We plan, however, that the state whether RMP should remain or be terminated, but regulatory bodies will rely heavily on the local whether RMP is willing to shed its present nomen- planning bodies for advice in carrying out their clature and limitations and participate in the more functions. comprehensive approach to improving health care Moreover, far from total abandonment of us- which is being developed today. 160 AUGUST 1974 121 2 BIOGRAPHICAL SKETCHES OF DIRECTORS OF REGIONAL MEDICAL PROGRAM 1966-68 Robert Q. Marston, M.D. 1968-70 Stanley W. Olson, M.D. 1970-73 Harold Marcjulies, M.D. 1973-75 Herbert B. Pahl, Ph.D. Biographical Sketches of RMP Directors Robert Q. Marston, M.D. Robert Q. Marston was born in Toana, Virginia on February 12, 1923. After graduating from Virginia Military Academy in 1943, he attended the Medical College of Virginia, where he obtained his M.D. degree in 1947. Selected as a Rhodes Scholar, Dr. Marston then spent the next two years studying at Oxford University in England with Professor Howard Florey, a Nobel Prize recipient for his work with penicillin. After returning to the United States in 1949, he took an internship at Johns Hopkins Hospital, then spent the next year in a residency at Vanderbilt University Hospital. From 1951 to 1953, Dr. Marston served in the American Forces Special Weapons Project at the National Institutes of Health (NIH) , studying the role of infection following whole body radiation. After army service, he took another year of residency at the Medical College of Virginia. Having received a four year Markle Fellowship, Dr. Marston was appointed Assistant Professor of Medicine at the Medical College of Virginia and then Assistant Professor of Bacteriology and Immunology at the University of Minnesota. He returned to Medical College of Virginia in 1959 to assume an Associate Professorship in Medicine, at the same time serving as Assistant Dean. In 1961, Dr. Marston was named Director of the University of Mississippi Medical Center and Dean of its School of Medicine. In 1965 he was appointed Vice Chancellor of the University, while continuing on as Dean. From 1961 to 1966, Dr. Marston served on a consultative review committee for the Division of Hospital and .m Medical Facilities within the Department of Health education and Welfare (HEW). On February 1, 1966, Dr. Marston was appointed as the first Director of Regional Medical Programs, which was originally located in NIH. He also served as an Associate Director of NIH. Dr. Marston's tenure as Director of Regional Medical Programs lasted until 1968. On April 1, 1968, Dr. Marston was named Administrator of the Health Services and Mental Health Administration, under the reorganization of the Department of HEW. But in September of that year he resigned that position to accept the directorship of NIH, which he held until 1973. On Tanuary 21, 1973, he became Acting Director of the National Institute of Neurological Diseases and Stroke, but left in April of the same year to become a scholar-in-residence at the University of Virginia. Dr. Marston was named president of the University of Florida at Gainesville in January, 1974, holding the presidency for 10 years, until 1984. He remained at the University of Florida as Emeritus President, Emeritus Professor of Medicine and Joint Professor of Fisheries and Aquaculture. Among distinctions bestowed upon him, Dr. Marston was named the first distinguished fellow of the Institute of Medicine, National Academy of Sciences. He has served as a member of many health and medical organizations: member of council of the Institute of Medicine, National Academy of Sciences; member of the board of directors of Johnson and Johnson; member of the National Association of State Universities and Land Grant Colleges; fellow of the American Public Health Association; honorary member of the National Medical Association; honorary member of the American Hospital Association. Stanley W. Olson, M.D. Stanley Olson was born February 10, 1914 in Chicago. He earned his B.S. from Wheaton College in 1934 and then went on to study medicine at the University of Illinois, where he took hls M.D. degree in 1938. Dr. Olson took an Internship at Cook County Hospital in Chicago in 1938 and remained there until 1940. He was awarded a fellowship from the Mayo Foundation and earned an M.S. in Medicine from the University of Minnesota in 1943. Dr. Olson then served as an Assistant Director of the Mayo Clinic and for the sane period, 1947-1950, held a position as Instructor in Medicine at the Graduate School of the University of Minnesota. From 1950-1953, Dr. Olson was Dean of the College of Medicine at the University of Illinois, and Medical Director of the University's Research and Educational Hospitals. He became Dean of the College of Medicine at Baylor University where he remained in that capacity until 1966. From Baylor he moved to Vanderbilt University, and until 1968, held a Professorship in Medicine along with a clinical Professorship at Meharry Medical College. Dr. Olson was a member of the National Advisory Council for Health Research Facilities within NIH from 1963 to 1967. He served from 1964 to 1965 on a review panel of the Public Health Service which oversaw the construction of medical schools. Dr. Olson was named Director of the Tennessee Mid-South Regional Medical Program in 1967. In 1968 he was appointed as Director of the Division of Regional Medical Programs and continued in this position until 1970. He left this post to take up an appointment as President of the Southwest Foundation for Research and Education from 1970 to 1973. Dr. Olson then joined the College of Medicine Northeastern Ohio University as Provost until 1979, when he became Professor of Medicine and Emeritus Provost. Positions held concurrently by Dr. Olson during his career include: consultant for the State University of New York; member of the Medical Advisory Panel of the U.S. Office of Vocational Rehabilitation Administration, 1960-1965; member of the committee on medical school-Veterans Administration Relations, 1962-1966; member of the National Advisory Commission on Health Manpower, 1966; and consultant on Medical Education, 1979. He has also been Vice-president of the American Association of Medical Colleges, 1960-1961, and is a Fellow of the American College of Physicians. Harold Margulies, N.D. Dr. Margulies was born in Sioux Falls, South Dakota on February 13, 1918. He earned an A.B. from the University of Minnesota in 1938 and a B.S. from the University of South Dakota in 1940. He studied medicine at the University of Tennessee and was granted his M.D. there in 1942. Later, in 1948, he acquired an M.S. through his work in the Mayo Foundation. Dr. Margulies served his internship at Iowa Methodist Hospital in Des Moines, from 1943-1944. He was a Fellow in internal medicine at the Mayo Clinic from 1944-1945 and also during 1946-1949. Dr. Margulies practiced medicine, having specialized in internal medicine and cardiology, in Des Moines from 1949-1961. He then became professor of medicine at Indiana University. He served overseas in the AID (Agency for International Development) Contract at the Postgraduate Medical Center in Karachi, Pakistan, 1961-1964. He then relocated to Alexandria, Egypt, to be an advisor on Medical Education in the World Health Organization, 1965-1966. Dr. Marcjulies's service abroad also included a role as Associate Director of the Division of International Medical Education of the Association of American Medical Colleges and as Director of the AID Contract project from 1965-1967. Dr. Margulies returned to the U.S. and was appointed Associate Director of Socio-Economic Activities of the AMA in Washington, from 1967-1968. He then took the position of Secretary of the Council on Health Manpower for the years 1968-1969. He transferred to the Health Services and Mental Health Administration to be Deputy Assistant Administrator for Program Planning and Evaluation from 1969-1970. It was in 1970 that Dr. Margulies was appointed Director of the Regional Medical Programs Service, a post which he held until 1973. Concurrent positions that Dr. Margulies has held throughout his career include that of consultant in internal medicine for the Veterans Administration, 1949-1961, White House Office of Science and Technology, 1966-1967, and Diplomat of the American Board of Internal Medicine. Among his many distinctions, he is a Fellow of the American College of Physicians and of the American Public Health Association. Herbert B. Pahl, Ph.D. Dr. Pahl was born in Camden, New Jersey, on August 14, 1927. He was educated at Swarthmore College, graduating with a B.A. in 1950. At the University of Michigan he did his graduate work in biochemistry, earning an M.S. in 1952 and a Ph.D. in 1955. He began his post-graduate career as a Fellow of the National Cancer Institute, and of the Sloan-Kettering Institute, from 1955- 1957. Dr. Pahl then took an assistant professorship at Vanderbilt University in biochemisty in 1957 and remained there until 1960. He entered the National Institutes of Health in 1960 and until 1962 his service there was as the Executive Secretary of the Graduate Research Training Grant Program. He moved to the Special Research Resources Branch and was first its assistant chief and then its chief during 1962-1964. Dr. Pahl continued as chief of the General Research Support Branch from 1964-1966. From 1966-1969 he was the Executive Secretary of the Committee on Research of Life Sciences of the National Academy of Sciences-National Research Council. Returning to NIH, he was appointed deputy associate director of science programs of the National Institute of General Medical Science in 1969. His involvement in the Regional Medical Programs Service began in 1971, at which time he was appointed its Deputy Director. In 1973 he was promoted to the Directorship of the Regional Medical Programs Service and continued in this position until 1975. From 1975 until 1982 Dr. Pahl was staff director of the Committee to Study National Needs for Biomedical and Behavioral Science Research Personnel, which operated within the National Research Council of the National Academy of Sciences. His latest appointment was to the Program Directorship of the Cancer Center Branch of the National Cancer Institute at NIH. He assumed this role in 1984. Dr. Pahl is a member of the American Association for the Advancement of Science. VI BUDGET HISTORY The budget figures in the table and graph that follow have been taken from Regional Medical Programs Fact Book (published by the Regional Medical Programs Service in November, 1972). Further research is now in progress to try to confirm and expand upon these figures. We do not yet have data for the period after 1972, when RMPs were being phased out. NW Mw WAM APPROPRIATIONS AND BUDGETARY HISTORY (dollars in thousands) Fiscal Fiscal Fiscal Fiscal Fiscal Fiscal Fiscal Year year year year year year year 1966 1967 1968 1969 1970 1971 1972 ---------------------------------------------------------------------------------------------------------- Authorization $5OrOOO $9OgOOO !%200,000 $65tOOO $120,000 $125,000 $150,000 Amount appropriated for grants $24iOOO $43,000 $53,900 $56l2OO $73,500 $99,500 $90,500 Actually available for grants, $24,000 $43,934 $48,900 $72g365 $78,500 $70,298 $135,000 Amount actually awarded for grants $2,066 $27,052 $430635 $72l365 $78s2O2 $70,298 $111,400 Appropriations and Budgetary History 210 200 190 - 180 - 170 - 160 - ISO - 140 - 130 - 120 - 110 - 100 - 90 - x x 0 so - x TO - 60 - x x 50 - x x x x x x 40 - x x 30 - x x x 20 - x x x lo - 0 1966 1967 1968 1969 1970 19TI l9T2 Fiscal Year Authorization Eo Anmni appropriated for grants Actually available for grants @ Amount actually awarded for grants Vil S IES OF KEY REPORTS AND HEARINGS Report of the President's Commission on Heart Disease, Cancer, and Stroke, December, 1964. Heart Disease, Cancer, and Stroke Amendments of 1965, Report of the Senate Committee on Labor and Public Welfare, Subcommittee on Health, June 24, 1965. Heart Disease, Cancer, and Stroke Amendments of 1965, Report of the [House] Committee on Interstate and Foreign Commerce, September 8, 1965. Report of Regional Medical Programs to the President and the Congress, Submitted by William H. Stewart, M.D., Surgeon General, U.S.P.H.S., June, 1967. Hearing before the Subcommittee on Public Health and Environment of the Committee on Interstate and Foreign Commerce, House of Representatives, ...on ... Oversight... of...Regional Medical Programs, May 8, 1973. Report of the President's Commission on Heart Disease, Cancer, and Stroke December, 1964 This commission, chaired by Michael DeBakey, M.D. , was charged with responding to President Johnson's Health Message of February, 1964. The Report was the result of nine months of testimony from 166 health care experts and consultation with 60 health organizations and associations. The report was organized in two parts. Part I identified the national scope of the problem of the three leading causes of death of the time: heart disease, cancer and stroke. Part II was in the form of a list of 35 recommendations, which basically advised that a national network be established to conquer these diseases. Part I This section of the report included data about the magnitude of the problems resulting from these three diseases. They accounted for 71% of all deaths for the year 1963. Each disease was presented separately. The scope of each disease was analyzed in terms of nu-mber of-deaths, disability caused, economic impact, and progress made to date. Part II This section proposed 35 recommendations for establishing a national network to conquer the diseases. Of those 35, the salient proposals were as follows: That the Federal Goverrment has a responsibility toward every citizen, to protect their health against these three killers, and to support research to combat these diseases. That a program of grant support be undertaken to support medical complexes of hospitals, medical schools and other institutions; and that there be growth in the number of "centers of excellence" in education and research. That the Vocational Rehabilitation Administration launch a 5-year program for rehabilitation of patients with these diseases. That national programs be established for the detection of cervical cancer; for continuing education; for prevention; for 25 non-categorical research institutes; for categorical research centers in the area of the three diseases; for clinical fellowships; for recruitment and training of personnel in all pertinent areas; for the training of specialists in health communications; for review of manpower requirements; for support of the National Library of Medicine; for improved methods of statistical collection and study; for establishing a National Drug Information Clearinghouse to be affiliated with the National Library of Medicine; and that research of a collaborative nature be supported outside of the U.S. Heart Disease, Cancer, and Stroke Amendments of 1965 Report of the Senate Committee on Labor and Public Welfare, Subcommittee on Health June 24, 1965 Presented by Senator Hill of Alabama, this report, in connection with Senate Bill 596, included a review of the Report of the President's Commission. The Senate subcommittee report suggested that Regional Medical Complexes be established to address the recommendations of the Report of the President's Commission. Endorsements from the American Heart Association, American cancer Society, American Hospital Association and American Public Health Association were included. The Regional Medical Complexes were designed to link medical centers, research centers, and diagnostic and treatment stations of community hospitals. The intention was to widen the availability of the best medical care. The other provisions of Senate Bill 596 were described: grants were to be authorized for the planning and development of complexes, for research, for training, for prevention, and for demonstration of patient care in connection with each of the three leading diseases. The bill was drafted to provide flexibility for existing local experience. The subcommittee advised that the early emphasis of the program be on planning, so as to benefit best from local initiative. The role of the advisory group and the emphasis on patient care were mentioned. The report included the Surgeon Generalls recommendation that the proposed programs be placed in the National Institutes of Health. A National Advisory council was expected to foster coordination of the complexes. The expected advantages to be derived from such complexes were new opportunities for clinicians to avail themselves of the latest advances, better training, cooperation between research centers and hospitals, and optimum use of expensive facilities. These advantages hopefully would lead to a new degree of access for those afflicted with the leading three diseases. The report ended with a summary of explanations of each part of the bill, S.596. Heart Disease, Cancer, and Stroke Amendments of 1965 Report of the [House] Committee on Interstate and Foreign commerce September 8, 1965 Companion bills, H.R. 3140 and S. 596, were introduced into the House and Senate to fulfill the recommendations of the President's Commission headed by Michael DeBakey, M.D. This report accompanied the House version of the bill (H.R. 3140). As a Congressional committee report, it was of the same format as the report of the Senate subcommittee on the companion bill. The report reviews the House bill, which was similar to the Senate version. A statement from the president of the AMA, Dr. James. Z. Appel, was included in this report. Appel raised the AMA I s objections to the bill, which concerned the fear of a federally sanctioned program impinging upon the free, private system of hospitals and physicians. Because the intent of the bill, as explained by Secretary of HEW Anthony Celebrezze, was to make use of existing facilities and to limit new construction, the phrase "regional medical complexes" was changed to "regional medical programs." The report also explained the following changes: a reduction in the time period of effectiveness of this bill from five years to three years, after which point new legislation would be required to continue the program; patients could be referred only by a private physician to a program and only for the purposes of research or training. Also, the requirement for diagnostic and treatment centers was replaced by simply requiring participation by local hospitals. The report indicated the need for extensive funding of planning before implementation of a vast program. The priorities of continuing education and the extension of the latest advances in medical care to rural and suburban communities were indicated. A section by section description of the bill follows at the en o the report. Report on Regional Medical Programs to the President and the Congress Submitted by William H. Stewart, M.D. Surgeon General, U.S.P.H.S. June, 1967 This report fulfilled a requirement of P.L. 89-239 that the Surgeon General give an evaluation of Regional Medical Programs by June, 1967. The report discusses activities, progress, issues and problems of RMPs to date. It provides information on the planning grants and operational grants awarded to date. It also lists the members of the National Advisory Council and the RMP Review Committee, as well as the consultants to the Division of RMPS. Excerpts from the annual progress reports of the various RMPs are also included. Other materials included in the report are the procedures for review and approval of operational grants, basic data such as lists of staff, a copy of the law 89-239, and the RMP regulations. At this point, 47 planning grants had been awarded, totaling about $24 million; 4 operational grants had been approved for a total of $6.7 million. Among the recommendations made in the report were the following: referrals by dentists should be included in RMP activities; Federal hospitals should receive assistance in the manner that community hospitals received aid; that a means of meeting the space needs of the program should be found; a five year extension of the original commitment should be enacted, and the program should ultimately be established on a continuing basis. Construction of essential facilities was called for, especially in the area of continuing education. Also mentioned was the need for creating integrated data banks and communications systems. Hearing before the Subcommittee on Public Health and Enviro=ent of the Committee on Interstate and Foreign Commerce House of Representatives . . . on . . . Oversight . . . of . . . Regional Medical Programs May 8, 1973 These hearings determined the fate of Regional Medical Programs. It was decided that RMPs were to be phased out. No grant funds were to be included in the President's budget request for fiscal year 1974. The hearings gave the rationale for this decision. Dr. John S. Zapp, D.D.S., Deputy Assistant Secretary for Legislation, Department of HEW, testified that the Regional Medical Program Service (successor of the Regional Medical Programs Division) was ineffective. Zapp's testimony highlighted perceived RMP weaknesses. He mentioned a lack of a clearly defined role, a lack of reconciliation between categorical disease activities and comprehensive health care problems. He claimed that for fiscal year 1972, 40% of RMP funding went toward administrative purposes. RMPs were seen as impinging on the territory of Comprehensive Health Planning (CHP). Dr. Zapp foresaw CHP overtaking RMPs in areas such as data systems. He considered other RMP functions to be redundant since similar functions were carried out in other areas of HEW. Rep. Richardson Preyer (NC) countered by noting that physicians who made volunteer efforts in RMPs would lose trust in future government programs when they saw the fate of RMPS. Dr. Harold Margulies, M.D., the Director of the Regional Medical Programs Service, testified that he believed continuing education efforts were not effective. But he did credit RMPs with establishing coronary care units "in a great range of hospitals around the country." He estimated that, as Dr. Zapp charged, 40% of funding was going toward administrative purposes. Dr. Margulies in general agreed with the assessment that the RMPs had "so little direction that the program has sort of lost its way." Rep. James Hastings (NY) suggested that the best aspects of RMPs be continued and enjoined to CHP so as to "try to develop some national health policy, which I think we are lacking today. . . .11 Rep. Hastings also asked for a possible one year extension for RMPs to work on such a proposal. Testimony from various other individuals was heard. For example, a group of leaders from five of the RMPs testified in favor of continuation of the program. They pointed out such accomplishments of RMPs as promoting cooperative ventures between private and government agencies, attracting high quality staff, catalyzing innovation, and educating health professionals in new skills. Dr. Faxon Payne, advisory chairman for the Tennessee-Midsouth RMP, identified the constructive accomplishments of that RMp. Among those accomplishments were, a new, cost-reducing, cooperative venture among area hospitals in supplies; the building of two coronary care units; and a toll-free telephone line for physician consultation. The grassroots aspect of the program meant that local officials were able to determine funding according to their specific needs, and thus waste was minimal. This assertion contradicted Dr. Zapp's testimony of the supposed excess under which this program operated. one of the criticisms of the detractors of RMPs was that physicians did not need to be provided with continuing education services, because those resources existed. In addition, the income of the average physician was so high that they should be expected to pay for their own continuing education courses through existing agencies or institutions. Dr. William J. Hagood, Jr., M.D., speaker of the House of Delegates, Virginia Medical Society, member of the regional advisory group of the Virginia RMP, addressed this criticism. First, Dr. Hagood mentioned that other health care personnel (e.g., nurses, nurse practitioners, technicians) of lower income than the physician were receiving the majority of continuing education in his RMP. Second, he pointed out that the Virginia RMP provided consultants to physicians in the field, so that the education could be applied directly to practice. Such education indeed was deemed more useful to improving health care directly, without the physician having to close his practice for days to attend seminars or lectures at some other location. As for administrative waste, Dr. Hagood pointed to the central office of the Regional Medical Programs Service, under HEW, as the root of many problems. The inefficiency of the main office was to blame, and not the 56 individual RMPS. Another issue raised was the supposed ambiguity and hence overlap of RMPs with the Comprehensive Health Planning Service. The latter, as a so called "Section 314 (b) 11 agency -- a designation that was enacted under Public Law 91-515 -- had as its mission, the decentralization of planning, so that each area agency would plan according to its own priorities. The emphasis was on underserved areas, minorities, and problems of nursing homes. Thus, Rep. Ancher Nelsen (MN) charged "Could it be that the two programs [RMPS and CHPS] would run better as one, and that they should be merged?" To which a fellow Minnesotan, Dr. Robert E. Carter, M.D., Dean of the University of Minnesota Medical School, responded that the one, RMPS, was geared toward implementation, while the other, CHPS, had its emphasis on planning. The testimony of Dr. R. Ingall, M.D., executive director of the Lakes Area Regional Medical Program was an eloquent polemic against the arguments of the detractors. He stated that 'IRMP is governed by the people and for the people. . . . RMP's recognized that authority handed up was much greater than authority handed down . . . . It This was the mission of decentralization. In his testimony, Dr. H. Phillip Hampton, director of the Florida Regional Medical Program, pointed out that the recently established Professional Standards Review Organization (PSRO) was one organization that was dependent on RMP services in technical support for its proper functioning. Dr. William McBeath, M.D., Director of the Ohio Valley Rmp, addressed the issue of the categorical mandate of RMPS. He related that the Ohio Valley RMP was burdened by a change in its priorities from on high, and that to receive funding from 1969 onward, it had to place greater emphasis on ambulatory care. The ever changing mandate was a reason for lack of focus and the discontinuity in projects. Because of funding cuts, projects could be undermined before they got off the ground. Vacillation in RMP goals came as a result of the so-called "Finch Report," a white paper that came out of the Secretary of HEW's office. Robert Finch served as Nixon's first appointed Secretary of DHEW until June, 1970. This was a period of intense flux in HEW. The "Finch Report" of this period stressed the need to serve low-income groups, single mothers with children under five, Indians, migrant workers, and other disadvantaged groups. As a result, Dr. Paul Ward, Director of the California RMP, related in his statement that coordinators of the various RMPs met in Atlanta to redirect RMPs according to the Finch priorities. The Finch Report therefore was the impetus that moved RMPs further off its categorical track. Reference was made by Dr. Ward to a meeting with Secretary Finch, in which a course was set by which RMPs were to proceed along these new priorities. Dr. Ward outlined the guidelines by which funding was allocated. The first step in the allocation process was to seek the involvement of the existing local institutions and affiliates. The second step was to make an "assessment of need", something, which Paul Ward argued, should have been taken care of by a 314b agency (Comprehensive Health Planning.) The third step was to catalog resources of the region already in existence. The fourth was for the Regional Advisory Group to establish the priorities to be followed for funding in the region. The fifth step was to implement the funding for its operational purposes. This was followed by the evaluation process. Dr. Ward also attacked John Zapp's assertion that 40% of RMP funding went to administration. Dr. Ward asserted that according to the "accepted classical definition of administration, it comes much more close to 7 percent than it does to the 40 percent (that Dr. Zapp claimed]." Dr. Hampton, director of the Florida RMP, also responded to the charge of uncontrolled administrative costs, and related that his program was spending less than 5% on such costs, by the federal definition. He continued that "If you take [into account] the entire core staff, all the expenses of the core staff which is far beyond administrative in their activities, it is only 14 percent." J' Determined to give the RMPs their due, Dr. Ward credited them for developing 11 . . . more E24S (Emergency Medical Service] programs than any other single source in the United States . . . 11 and for extending care of some nature to more than 9 million persons in 197 2 . The hearings also contained letters of support for Regional Medical Programs from organizations, including the American Nurses' Association and affiliated community hospitals, and also from individual physicians. Supplements on the budget, number of people served, evaluation procedures, and reports from individual programs were also included in the testimony. Vill A I LIST OF REGIONAL MEDICAL PROGRAMS RMP Geoizraphic Area 1. Alabama RMP Covered the state of Alabama. 2. Albany RMP Included 21 northeastern New York counties centered on Albany, with contiguous portions of southern Vermont and Berkshire County in western Massachusetts. Overlapped Tri-State and Northern New England RMPS. 3. Arizona RMP Covered the state of Arizona. 4. Arkansas RMP Covered the state of Arkansas. Overlapped in the northeast portion with Memphis RMP. 5. Bi-State RMP Included southern Illinois and eastern Missouri counties centered on the St. Louis metropolitan area. Overlapped Illinois RMP. 6. California RMP Covered the state of California. Overlapped Mountain States @ in sections of Nevada. 7. Central New York RMP Included 15 central New York counties centered on Syracuse, and the Pennsylvania counties of Bradford and Susquehanna. 8. Colorado-Wyoming RMP Covered the states of Colorado and Wyoming. Overlapped Mountain States and Intermountain RMPS. 9. Connecticut RMP Covered the state of Connecticut. 10. Delaware RMP Covered the state of Delaware. II. Florida RMP Covered the state of Florida. 12. Georgia RMP Covered the state of Georgia. 13. Greater Delaware Valley RMP Included southeastern Pennsylvania (Philadelphia- Camden), northeastern Pennsylvania (Wilkes Bar-re-Scranton) and southern New Jersey counties. Overlapped New Jersey RMP. 14. Hawaii RMP Included the state of Hawaii, American Samoa, Guam, and the Trust Territory of the Pacific Islands. 15. Illinois RMP Covered the state of Illinois. Overlapped Bi-State RMP in the southern portion of the state. 16. Indiana RMP Covered the state of Indiana. Overlapped Ohio Valley RMP. 17. Intermountain RMP Included the state of Utah, portions of Wyoming, Montana, Colorado and Nevada. Overlapped Colorado-Wyoming and Mountain States RMPS. 18. lo@ a RMP Covered the state of Iowa. 19. Kansas RMP Covered the state of Kansas. 20. Lakes Area RMP Included seven western New York counties centered on Buffalo, and the Pennsylvania counties of Erie and McKean. 21. Lou@isiana RMP Covered the state of Louisiana. 22. Maine RMP Covered the state of Maine. 23. Maryland RMP Covered the state of Maryland and York County, Pennsylvania. Overlapped in southern central Maryland with the Metropolitan Washington DC RMP. 24. Memphis RMP Included the western Tennessee area centered on Memphis; northern Mississippi; northeastern Arkansas; portions of southwestern Kentucky; and three counties in southwestern Missouri. Overlapped Mississippi, Arkansas and Ohio Valley @s. 25. Metropolitan Washington DC Included the District of Columbia and contiguous RMP counties in Maryland and Virginia. Overlapped Maryland and Virginia @s. 26. Michigan RMP Covered the state of Michigan. 27. Mississippi RMp Covered the state of Mississippi. Overlapped Memphis and Virginia RMPS. 28. Missouri RMP Covered the state of Missouri, exclusive of the St. Louis metropolitan area. 29. Mountain States RMP Included portions of Idaho, Montana, Nevada and Wyoming. Overlapped California, Intermountain and Colorado-Wyoming RMPS. 30. Nass-au-Suffolk RMP Included the counties of Nassau and Suffolk (Long Island) of the state of New York. 31. Nebraska RN.@'P Covered the state of Nebraska. 32. New Jersey RMP Covered the state of New Jersey. Overlapped in seven southern counties with Greater Delaware Valley RMP. 33. New Mexico RMP Covered the state of New Mexico. 34. New York Metropolitan RMP Included New York City and Westchester, Rockland, Orange and Putnam counties. 35. North Carolina RMP Covered the state of North Carolina. 36. North Dakota RMP Covered the state of North Dakota. 37. Northeast Ohio RMP Included 12 counties in northeast Ohio centered on Cleveland. 38. Northern New England RMP Included the state of Vermont and three contiguous counties in northeastern New York. Overlapped Albany @. 39. Northlands RMP Covered the state of Minnesota. 40. Ohio RMP Covered the central corridor of the state from the northwest to the southeast. 41. Ohio Valley RMP Included most of Kentucky (101 of 120 counties), southwest Ohio (Cincinnati-Dayton and adjacent areas), contiguous parts of Indiana (21 counties) and West Virginia (2 counties). Overlapped Indiana, Memphis, Tennessee MidSouth and West Virginia RMPS. 42. Oklahoma RMP Covered the state of Oklahoma. 43. Oregon RMP Covered the state of Oregon. 44. Puerto Rico RMP Covered the Commonwealth of Puerto Rico. 45. Rochester RMP Included ten counties centered on Rochester, New York. 46. South Carolina RMP Covered the state of South Carolina. 47. South Dakota RMP Covered the state of South Dakota. 48. Susquehanna Valley RMP Included 27 counties in central Pennsylvania centered on the Harrisburg-Hershey area. 49. Tennessee Mid-South RMP Included 84 counties in central and easatem sections of Tennessee and portions of southwestern Kentucky. Overlapped Ohio Valley RMP. 50. Texas RMP Covered the state of Texas. 51. Tri-State RMP Covered the states of Massachusetts, New Hampshire and Rhode Island. Overlapped in western Massachusetts with Albany RMP. 52. Virginia RMP Covered the state of Virginia. Overlapped in northern section with Metropolitan Washington DC RMP. 53. Washington/Alaska RMP Covered the states of Washington and Alaska. 54. West Virginia RMP Covered the state of West Virginia. Overlapped in two counties with Ohio Valley RMP. 55. Western Pennsylvania RMP Included 28 counties in Pennsylvania centered on Pittsburgh. 56. Wisconsin RMP Covered the state of Wisconsin. Regional Medical Programs .............. P.R. TtIIIIII . . . . . V. 1.