*QTET003* I' A l@ 'i@' M I," N 'I' 0 F11 I,: A 1, 'f@ 11, E 1) UAI 0 N A N D W E L F A R E Ilealth Services and Mental Ilealth Administration Division of Regional Medical Programs National Advisory Council on Regional Medical Programs Minutes of the Meeting February 2-3, 1971 Parklawn Building Conference Room G/H OF lil,'AI,Tli, EI)L'CA'1'10,\' AND Wl:,I,FARI-- PUi3l,IC S@,PVIC@, National Advisory Council on Regional Medical Programs Minutes of the Twenty-8econd Meeting I/ 2/ February 2-3, 1971 The National Advisory Council on Regional. Medical Programs convened for its twenty-second meeting at 8:30 a.m., Tuesday, February 2, 1971, in Conference Room C/H of the Parklawn Buildinf,,, Rockville, Maryland. Dr. Harold Margulies, Acting Director, Regional Medical Programs Service, presided over the meeting. The Council members present were: Dr. -Michael. J. Brennan (2/2 only) Dr. William R. liuiit Dr. Bland W. Gannon Dr. Alexander M.'Mcllhr-@dran .Dr. Edwit-i I,. Crosby Dr. Clark If. Millikan Dr. Michael E. Dellakey (2/3 only) Dr. Alton Oclisner Dr. Bruce W. Everist Mrs. Florence R. Wyckoff Mr. Harold H. Hi.iies, Jr. (2/3 only) Dr. Marc J. Musser (2/2 only) A listing of RI-T staff members, and others attending is appended. 1. CALI. TO ORDER AND OPLLQING RI-I@IARYS The meeting was called to order at 8:45 a.m. on February 2 by Dr. Harold Margulies. II. INTRODUCTIOI@I OF NEW COUNCIL @IBI-"RS AND EX OFFICIO @li-,Mr)ER FROM THE VETERANS AD,\IINISTRKFION Dr. Margulies introduced Dr. Herbert B. Pahl, the new Acting Deputy Director for Regional Medical Programs Service. Dr. Pahl will have responsibility for work with the Council. It is hoped that future Council meetings can be held in smaller more convenient quarters with staff services planned to help the members make optimum use of their sessions. Dr. Margulies welcomed Dr. Alton Ochsrip-r as a new Council member, and Dr. Marc J. Musser, the new Ex Officio member from the Veterans Administration. Another new member, Mr. Harold It. [lines, Jr. was introduced the following day on February 3. I/ Proceedin-,s of meetings are restricted util,ess cleared by the Office of the Administrator, 1-1,SMilA. The restriction relates to all Material submitted for discussion at the meetings, the supplemental material., and all other official documents, including the, agenda. 21 For the record, it is noted that members absent themselves from the me etiii_g, when the Council is discussing, @ipplication's: (a) from their respective institutions. or (b) in which a conflict of interest Tniglit III. ANNOUNCI-."%IENTS Dr. Margulies made general announcements, and called attention to the statement on, "Conflict of Interest,@' in the information folder. He reported that Mr. Curtis Treen has resigned from the Coun cil and that we are working on the appointment of new Council members to increase the membership to twenty, not including the Ex Officio member from the Veterans Administration, in accordance with Public Law 91--515. IV. CONFIRMATION OF FUTURE MEETING DATES 'nic Council reaffirmed the following dates for future meetings: May 1.1-1.2, 1971 November 9-10, 1971 August 3-4, 1971 February 8-9, 1972 V. CONSII)ERATI,ON OF MINUTES OF THE NOVEMBER 9-10, 1970, MEETI With the addition of Dr. Hunt to the list of Council members present, the Council unanimously recommended approval of the Minutes of the November 9-10, 1970, meeting as written. Dr. Brennan, Chairman of a Council subcommittee on automated multi- phasic screening, announced that the subcommittee had met the day before for six hours and that they are developing a working conference to be held in April 1971. The mer@ibers of the subcommittee are: Dr. Michael J. Brennan, Chairman; Dr. Alexander M.:McPhe ran, Dr. Clark H. llillikan, and Dr. John E. Kralewski o'L' the Review Committee. The working conference in April will be held in Detroit and will report its findings to the Council at the May meet ng. VI. LEGISLATION, APPROPRIATIONS PMPS BUDGET A. Termination of RMP Support for Projects At the November 1970 meeting, Council discussed project renewal and termination of RMP funding for those that seek such support beyond the dates at which they originally proposed to terminate or become self-sustaining. At this meeting Mt. Roland Peterson, Assistant Director for Planning and Evaluation, presented salient findings from experience in six regions with 90 projected, that became operational three or more years ago. In most of these projects, three or more years of RMP support was requested initially. Thirty percent of the group terminated RMP support on schedule. In some regions this happened with 60-70% of the. projects. On the other hand, many individual projects expanded their bttdf-yc-tq. IT) '7 r-.T@ll- f T' @, t -in s T)roic@ct-, feerried to from 3 listings, but the activities continued to receive @IP support through the budgets of core or other project activities. RIV support tended to persist longer for medical school than for community projects. This kind of analysis will continue to be reported. Additional regions will be included as they reach appropriate ages. B. Overview of Adaptation to Requirements of New Legislation The ongoing process of adaptation to the "program review" and triennial cycle must be- integrated with adjustment to features added to the legislative base by P.L. 91-515. Rcgul.ations and guidelines are being re-examined for this purpose. It is hoped that the formal..regulations can be kept simple and straight-forward. Publication of guidelines should take a form that will facilitate both their development by Council and their application to RMP operations. New legislation features of particular interest include: 1. Review of RMP plans by CHP "b" agencies that have pl.ans in being: @,IPS is hopeful of broadening the RMP-CHP working relation- ships beyond the letter of the law, to improve the combined effect of the agencies' planning -on health services. 2. DHEW recommendations for changes in the scope of the program: Modification of the disease-categorical targeting of the legislation might be one such proposal that IWS and Council should examine. Council may wish to express its opinions on any proposals concerning the scope of R14P or CHP legislation that go to the Secretary. 3. Annual report on RMP effectiveness: The first report, already prepared by RMPS, was essentially a status, or baseline report. Council may wish to contribute to these reports regularly. The schedule for such reports suggests that Council's input should be presented in the fall of the year. C. Budgetary Outlook Plans for the fiscal year 1972 budget will have a considerable impact on the final apportionment of funds for the remainder of fiscal year 1971. At present the outlook is for level funding of RMP grants at. $70 mill-ion for each of L@le two years. This would be accomplished by reserving a large part of the 1971 appropriation to be carried over for obligation in 1972. This presents two kinds of problems. First, because it requires a major reduction in current commitments to Regional. Medical Programs for both years, f--he planning and persuasive aspects of the Regional Medical Programs becomes more important, with less emphasis on their capabilities to support projects.. Secondly, it presents a very low appropriation base for the 1.973 budget, so that maintaining the sime 4 $70 million level through that fiscal year iqill. require a significant appropriation increase. The 1973 budget presentation is.essentially a technical problem that must be solved by RNP,S within the DHEW structure. The adjustment of @'@T aijards to the proposed reduction would affect everyone and requires Council's attention. One possible route would be to find the necessary reduction by cutting awards to the less effective regions, and retaining levels cl.oser to-existing commitments in the more effective regions. This and alternative policies will be the subjects of intensive study over the next few weeks. D. Progress in Administrative AdiListnient to Legislation, the Triennial Cycle and National Empliisis on Pro@ ammirlg Council.'s policy statements are being examined for possible review and updatini@. Review criteria have been update(], but @,ire-subject to n)o(lifi- cation and refinement as necessary. Cotincil.'s participation will be sought as pl.ans and drafts.become avail-able. When completed, these materials will be given not only to Council and staff, but also to the Regional Medical Programs as well, as aids to program development. system integrated Meanwhile this RMPS is developing a comprehensive review with a new Management Information System. The objectives of these de- velopments are to effect economies in time, integrate @T activities with the total IIS4n program surveillance, and improve RMP per formance. These developments are intended to potentiate the formation and implementation of our human judgments. 1. The current status of the RMPS Management Information System was presented by Mr. Frank Ichniowski, Acting Chief, Office of SystenLs Management, RMPS. During Iii-s presentation he highliglited.some of i7.lie most recent actomplisliments of the MIS team and then proceeded to ti-e-in these current activities with the MIS implementation plans. In line with these plans, fie announced a planned reorganization of the Office of Systems Management to better reflect the demands of the Management Information System and to more optimally utilize available personnel. This reorganization provides for separate branch activities within OSM dealing with: MIS Design and Analysis, Programming and MIS Data Base Control. It was pointed out that at least five major sources will be providing inputs to the MIS. These inputs include the Anniversary Review Application, the Regional Reporting System, Site Visits, and other reports on contact, R:4PS Staff and the Regional Office. Certain other efforts currently underway by the MIS team were identified, namely: Development of an MIS liaison team, use of MIS consultant, and MIS t@ 1.@ Iiit (@ti (It, (I LIiit t Iic!.,i(! exLr.,.i car ar (-LIVF tw i strengthen inti more accurately guide the plan I)ei,nL, developed. Mr. Iclinio@@!ski then linked these var:L.ous ongoing activities to a series of proposed outputs which could reflect the needs and demands of the system users. This output plan categorized outputs as emanating from combinations of four major groupings: Financial Information, Regional Characteristics, Performance Records and Control, and Historical Records. ultimately, the MIS wilL provide usage, via remote teletype or video display units, to RMPS, Review Conmitteel National Advisory Council, fIS@fHA, the Regional Office and the Regions themselves. The Review Cycle and its Tools. Mr. Ken 13num presented a description of the purposes, pliases and tools of CI)c proposed Triennial cycle of review and survctill.ance. a. Council I)isctl,;sion ... On efficiency of operation: Development of such systems always risks over-elaboration of the Management Information System; the manualizing of procedures, ritualization of site visits and of application reviews can result in ever-increasing demands on staff and advisors' time. ... Danger of over-simplifying a complex multi-disciplinary operation like the management of RMP; observance of rigid pro- cedural specifications may conceal real problems and forestall application of important professional judgments. Council-staff responsibilities: Need full understanding of Council s responsibility for program and financial judgments. In some research programs councils have concerned themselves with content, left funding to staff discretion. Some councils control initial funding and commitments; others concern them- selves with other funding decisions. Staff discretion in approving program changes without Council review also needs definition. ... Regional Medical Program development and progress4 Council needs to observe conformance with guides, quality of project designs and operations, not only to maintain program direction, but also to evaluate its own guidelines and policies. 6 I)ev(,I.c)pnients in regions do not always present on fixed ai-iniversir or Lri(-@nnJil. dates; som(-,tim(!@ it is highly y desirable to review and a(,LivAte new departures as soon is their virtues become apparent. Cross communication between regions could be impeded at considerable loss In effectiveness if concepts had to await fixed dates of Council- review. Council.'s job is primarily policy determination, but both' cyclic-.1 and interim reviews of operating and proposed changes contribute to Council's 'udgments. Perhaps Council and staff action responsibilities could be enumerated, with staff pre- senting a list of its actions for discussion at each Council meeting.. I'he posit!-on of,the Regional Advisory Group needs very clear specification in documentation of the review process and the assignment of responsibilities. b. Staff Response ... Efficiency of operation.: Staff projections for the niodes of operation in the management information and review procedures now envisioned indicate that the new approach will save time on routine basic processes and leave more time available for sub- stantive tasks. ... Over-simplification: The general aim of the plan is to emphasize human professional judgments at all points of decision., ... Council-staff responsibilities: Council's responsibilities for grant decisions are fixed by law; the purpose of this pro- cedural development is to give Council a choice of ways in which its responsibilities can be carried out efficiently. Staff will prepare a list of Council-staff responsibilities and Council choices for next meeting. ... Regional Medical Program development and progress4 Cross- communication between regions occurs naturally through direct region-to-region exchange and through region-staff-region'routes. Staff plans to br4@ng Council a report on cross-communication at the next meeting. Council action: Staff was requested to circulate for con- sideration at the next meeting a description of the proposed review process aiid the types of judgments that would be reserved to the Council. 7 VIT. RE@IARKS BY DR. VEIINO'Q E. WILSO',i, AD,@IINI-STRATOR, HEALTH SERVICES AND. .IIEN'FAT, lit,"Al,'rll Al)@ITNIS'I'RA'I.'ION A. @llp@,@tt@nL_@D r@cctor: I)r. Ilarold Margulies has been confirmed is Director, RMIIS; only the paper work remains to be completed. 11. Reconimendati.ons of the Willard Task Force: Completion of the task force report is expected soon. Unfortunately a draft could not be developed in time for this session. C. Health Maintenance Organization: The Health Maintenance Organization (HMO) concept is a broad flexible one that has strong HEW support. The term now refers to organizations providing comprehensive health care to enrolled populations and financed by capitation. Prepayment and carefully defined packages of services to represent comprehensive dare are important elements in current considerations. HEW is very active in implementing the concept and in stimulating the formation of HMO'S. Late in Nover@ber the Secretary appointed the following four task forces to examine important aspects of IIEW posture toward the concept: Policy Relationships wi-th non-Ill-',W agencies Financing Technical Assistance The Administrator, HSMHA, heads tile technical assistance group. However, head-, and members of the groups were selected, not to represent their constituent agencies, but to explore concepts of the Department's in- volvement. Ultimate assignments for implementation of HEW policies and responsibilities for W40's are by no means obvious and certainly are not decided. There is a high probability that HSMI-IA as the Department's technical agent in heal-th care delivery will have an important role in technical assistance for IL'40 propagation. CliP agencies undoubtedly will tiavc, review and comment responsibilities concerning proposed IlYiO Lctivatioa. RMP as a channel for provider expression will be fully involved. It seems clear that lil,'.W will acti.vely support promotion of HMO activation. The Dc@pirtn,.erkt will offer technical assistance and the planning and coordinating capabilities of its field arms and associated agencies. There is no pl.an to replace existing forms of Health care with the HMO; the objective is to open access to health care as broadly as possible and Funding of IIEW activities is as yet unresolved. $2.25 mill-'on may be available from YICIISPD 1971 appropriation; some amount might be taken from reserved @IT' funds; other amounts may yet be found elsewhere. Technical assistance funding might well become a HSMI@ responsibility. Whatever is decided for fisc@il- year 1971- activities will. affect planning for 197@ appropriations for other programs as well as for the IISMHA tota D. Questions and Answers: Q. What are the characteristics of a desirable ILMO? A. It has taken from September to January to arrive at the fo low ng list of characteristics: An organized system of contractually related healthcare facili- ties; an organized multi-disciplinary group of health care pro- fessionals; an enrolled group of clients; a so und insurance plan. No rigid prescriptions have been adopted for accommodation to the insurance plan or for minimum enrollments. Q. What is the Departmentis view on coverage of enrollment? A. Broad. If access to health care is to be extended through the HMO device, some groups will. require assistance. SSA and SRS are looking at this. A Family Ilealth Iiisurance Plan might be a vehicle for extending coverage. Q. Looking beyond the problems of initiation and establishment, what will provide long-term support? A. A soundly planned HMO should be supported by the revenues from its operations. Q. Will- Federal contributions on behalf of Federal beneficiaries be uniform? A. It seems logical to believe that Federal IDIO's will expect uniform or at least minimum packages of individual or family care, but will regionalize the prices of the standardized packages. Q. Could a large employer set up a "house" 'HMO'? A. Some are already studying the idea. It seems likely that three or four will appear soon. Labor organizations also are interested. 9 Q. Is legislation expected? A. Proposals on financing loans and insurance are being considered. Nothing new is needed for program administration. Q . I%That rate of pro-ress does the 111'@W visualize - how many fli@10 projects might be established in a year? A., Many questions must be investigated in order to organize an li@fO, establish the necessary contractual relationships, specify and price servi.ce packages, and work out enrollment principles. About fifty groups are known to be interested. Q. 14hat is the outlook for action l.n the field of quality of medical care? A. Models for operations in this fi-el,d are needed. SSA, SRS, and HSMHA are studying the possibilities. Agency responsibilities are not yet clear. The RMP as a provider organization might logically be a vehicle for administration, but lacks credibility because performance has been uneven. This is one of the multi- program topics on which Council may expect to be asked for advice, in line with last nieeting's discussion. VIII. STATUS REPORT ON GUIDELINES, CONTRTCTS AND PLANS FOR THE FUTURE A. Ileart Disease, Cancer and Stroke Guidelines Dr. Margaret Sloan reported on the status of the heart isease, cancer and stroke guidelines. Preparation of the guidelines has been going forward under three contracts. qliese have enabled multidisciplinary groups of health professionals representing all the professional organizations interested in a particular disease area to obtain the consensus of experts. Agreement has been reached on the criteria which would have to be met by medical institutions in the country in regard to personnel, organization, and facilities if they were to be capable of providing the highest quality of care for patients with heart disease, cancer, or stroke. In the original concept, these groups were expected to develop criteria for a list or lists of 10-20 outstanding centers in the country as required by Section 907 of PL 89-239. As the work progressed, it was redirected to the present focus on quality care in all types of medi.cal installations which will be more broadly useful. The Cancer Guidelines, prepared under a contract with the American College of Surgeons, are about to be published by the College at their own expense. The final document will still not be entirely satisfactory to the Council, but should prove useful in setting a goal. for development of resources for the t,,rr@:-itment nf The Heart Di,sease Guidelines, being prepared by the Inter-Society Commission on Heart Disease Resources under a contract with the American Heart Association, are being published in preliminary form as a series of reports in the Journal Circulation. These deal separately with each major form of cardiovascular disease excluding stroke, and cover the areas of prevention, diagnosis, treatment, and 'hen the last report has appeared in Circulation, rehabilitation. Iv they-will all be reviewed again in the light of comments and criticism received, revised as necessary, and printed in monograph form by the G.11.0. Initial response to these reports has been most enthusiastic. RMPS is now working on problems of publicity, distribution, and gaining the attention of physicians, hospital personnel, and health planners to their contents. Implementation will be stimulated by the l@I)s and the affiliates of the AIIA. The Stroke Guidelines are being developed by the Joint Committee for Stroke Facilities under a contract with the American Neurological Association but have not yet reached the publication stage. There was agreement that the Guidelines would be of value only as long as they are kept up-to-date and, therefore, that a mechanism should be established for periodic updating and.revision. In the case of the Heart Disease Guidelines and in an attempt to preserve continuity in the effort, it was proposed that a new contract be negotiated with the AIIA to continue the ICHD for one more year during which that organization would carry out an evaluation of the acceptance and applicability of the Guidelines. At the end of that period, it was anticipated that the ARA and the American College of Cardiology would jointly assume responsibility for revision and maintaining the currency of the Guidelines. A similar arrangement will eventually be considered for the Stroke Guidelines. In the case of the Cancer Guidelines, which are organized according to the specialty groups involved in diagnosis and treatment, the Council considered the possibility of a different approach which might be mounted to consider all the resources of 'personnel, organization, and facilities needed to deal with each major type of cancer. The Board of Regents of the American College of Surgeons was considering the establishment of a Task Force which might under- take the development of cancer guidelines dealing more specifically with the major types of cai.cer. Dr. Brennan proposed that RIMPS negotiate a contract to develop a model for the comprehensive, multidisciplinary treatment of cancer patients on a regional basis using a systems analysis approach. The concept proposed involved: per Itiu 0YL@,;A i,-s 2. Measuring the cancer control resource s an d capability of the region to provide the quality of control envisioned In the Guide- I. ill C..-, ; 3. Determining the i.ip@provemc@nts needed to make the region's cancer capabilities equal to its requirements; and 4. PrograiTmiing steps the providers of health care could take to achieve this goal. Dr. Brennan indicated that Detroit might be an appropriate locality in which to develop the proposed model. Dr. Margulies agreed that RMPS would revi.ew the pilot model'proposed and-report on the plan at its next Ece-ti@. The Council expressed approval of the guideline contracts as a,mode of obtaining expert opinion and consensus of the medical profession in the complicated fields of preventive and clinical medicine. Since the Guidelines were prepared by the profession for the profession, it was felt that they would be far better received than any Federal guide- lines or standards. It was suggested-that the Heart Disease Guidelines be considered a model which could be used by HEW for other target disease areas. The Council was warned that such guidelines would not always be accepted without dissent and could provoke controversy. For example, the National Heart and Lung Institute had expressed the opinion that the dietary recommendations in the report on the Prevention of Atherosclerosis, reviewed at the preceding meeting of this Council, were premature. IX. STATUS REPORT ON @IP AND CHP CONTRACTS Mr. Ileterson reported on progress made on the contract, Hsm 116-@-62(l), "Information Support System (ISS) for Management Control and Eval.uation." This contract is to assist the administrators of Regional Medical Programs in solving I)roblems'in management control and program evaluation y providing them with certain types of information which are not usually available. The system is designed to develop information for Program Coordinators on the character and extent of the interaction of the RMP with the various segments of the medical community, as well as with its, level of involvement with various types of medical problems. Informatil)n collected through the analysis of documents as grant applications, news- papers, and newsletters will form the basis of individual reports to each Regional Medical Program, and a summary report to the Regional Medical Programs Service. 12 The contract to study, "Comprehensive Health Planning," made with the Organization for Social and Teclknol-ogical Innovation, Inc. (OSTI), and Arthur D. Little, Inc., to assess the character and progress of Comprehensive Health Planning is now getting underway. X. COUNCIL POLICY ON LONG TERM TRAINING AND TRAINING IN SPI,"CIALTY AREAS Council continues to receive inquires about specialized long-term training as an RM, activity. Individual inquiries sometimes relate to support of professional pre-doctoral. training and sometime to post-doctoral or post-residency training. At the present meeting, requests urging RMP support of polst-resi(lent training in nephrology for physicians and of training for occupational, physical and speech therapists were received from the Southeastern Coordinators'. -Council took note of the need for trained personnel in these and other categories and urged the Regional Medical Programs to take steps to identify the needs and stimulate action, such as listing existing vacancies and publicizing them. Council also noted that RMP funds are insufficient to finance a significant contribution to solve this problem. ACTION: Council reaffirmed the position taken at its last two meetings and did not make an exception for the requests presented at this meeting. XI. CO'JNCIL POLICY ON IIUBLIC SERVICE IIROGRM Council was asked to consider enunciation of a policy governing content of broadcast or other public service utterances of Regional Medical Programs. One incident was reported to illustrate,the need for a stated policy. Council noted that a Regional Medical Program, through an unguarded issuance can embroil itself in counter productive controversy. It was noted, a]-so, that such incidents have been few in number, an local in effect. There is some danger of exaggerating the significance of such events by making a formal pronouncement of what, in general, is a matter of common sense. ACTION: The Acting Director, @IPS, was asked to discuss the specific circumstances with the coordinator of the region in which it occurred. XII. IIYPERTEN!')1014 RESOLUTION A representative of the National Heart and Lung Institute presented resolutions of the. Councils of that Institute and the National mended by all three was a program of community projects for appli- cation of drugs to control- of hypertension. VA studies utilizing 1-3 experimental- placebo groups have slioi-in such dramatic effects with both severe and moderate hypertensives that medical ethics dictated discontinuance of the placebo control groups. The NHLI has prepared request for proposals for clinical trials in the general population. All three of the advisory bodies mentioned above have commended this need and effort to the attention of the Regional. Medical rograms, in hope that they will find ways to initiate and assist in such trials. ACI.'ION: Council requested RMI'L; to alert al.l. IZegi,oiiil Medical Programs to these opportunities and to distribute the NIILI requests for pro- posals as well as reports of the VA experience to all regions. XIII. REPORT OF THE AD HOC REVIEW COMMITTEE ON KIDNEY DISEASE At the request of Dr. Harold Margulies, this Ad Hoc Committee was convened on January 27-28, 1971, to review the applications submitted to RNPS related to renal disease projects. It was the unanimous opinion of the committee that there is a need to define the mechanism of evaluation of these projects. It is clear that there is a significant gap between the existence of proven lifesaving techniques in kidney disease control and their application on a broad scale. In reviewing the submitted proposals on renal disease, it became obvious that there was inadequate screening at the local level. This is a result of the lack of an established advisory group in renal disease in most areas and the difficulty in finding local expertise not involved with the submitted projects. This Committee recognizes the need for the development of kidney disease projects at the local level, based upon the unique needs of a given region. However, based upon our present review experience, we would recommend that t'nese projects undergo more intensive peer revi@w and applicants be encouraged to submit the proposal to a panel of reviewers in the field. These reviewers could be from within or outside of the region. Local_Regional Medical Programs intending to submit proposals could receive aid in the preparation and technical review of their project from the Kidney Disease Control Program. It would, therefore, be possible for a region to submit a realistic proposal which best suits its particular area and has undergone extensive review. In vi(@w of the fact that the total amount of funds and manpower which will be available for kidney disease projects will not fulfill the total national needs for these. projects, we believe that the existence 14 of a categorical re@iew body at the Federal. level may have distinct advantages. A Kidney Disease Review Committee would be capabl.e of examining all projects in this area and determining a priority assignment based upon a proper national distribution of facilities with emphasis on sharing of facilities and the promotion of inter- regional. cooperation. In collaboration with the Kidney Disease Control Program, the Committee would therefore be capable of providing an overall perspective witic]7, would be geared to avoiding wasteful duplication of effort and expense in this area and stimulating activity where needs exist. Ultimately, we are confident that advances in the state of the art and in the development of new funding mechanisms will evolve to the point where there will be no advantage to the consideration of kidney disease projects separately A non-categorical approach to evaluation of these projects will be more appropriate at that time. For the present, however, we feel that the establishment of a categorical peer review group, which is capable of comparing the numerous i ney disease projects submitted by the various Regional @ledical Programs, would be an effective way of ensuring the development of kidney disease activities that embody local needs as wel-1 as a broader national or inter-regional overview. XIV. RECOMENDATIONS F(@'@-ACTION - REVIEW OF APPLICATIONS 1 ALABAMA REGIONAL MEDICAL PROGRAM - @l 00028 2/71 Total direct cost levels for continuation. New, renewal, and develop- mental activities for the next three years are as follows: 03 $1,765,557 04 - $1.,654,245 05 - $1,373,606 Request for developmental funding is approved as requested. Council did not believe another site visit was needed to appraise the capacity of the Region to utilize this type of funding. This Council actic-. i'@ffers from Review Committee in that approval for developmental component and additional funds for this purpose are recommended. This Council action-also reflects consideration of the policy is sues raised by the Continuing Education and Training Branch regarding Project li37 - Taking the Lid Off the LPN and Project #4R - Ilealth Manpower in Junior Coll.eges. Council believes tbp Region's priorities should be the determining factor concerning t .-@!;e education activities since present policy does not preclude their..@f-,,inding. to a i2-itiolIL511 P@-C.LOU. The designation 01 02, etc. relates to the first, second, etc., budget 9- periods for the subject application, not necessarily the budget periods that will actuall@ b-@ sup@1e-@fciFt d@, -- 15 ARKANSAS RI?GIONA], MEDICAL PROGRAM - M4 00052 2 ent) Additional funding is recommended at a @ninirium of $111,925, $113,734, $122,884 with the maximum to be determined by staff after receiving technical site visit tea-ni's recommendations regarding funding for Project it37 - Co,-P.I)rehensive Program for Kidnev Disease Control. CALIFORNIA REGIONAL MEDICAL PROGRAM - RM 00019 2/71 & llL70 (Su lement) Approval of developmental component funding for California RMP. Approval of increasing level of funding for current 03 year by $407,768 of which $200,000 is for developmental funding. Approval of future funding for California RMP for both corei projects and developmental funding at following levels: 04 - $8,363,994 05 - $8,363,994 06 $8,3.63,994 Subject to following conditions: I-) overall RMPS funding restrictions; and 2) satisfactory program priorities to be included in May 1 application. Delegation to California RAG decisions regarding allocation for all projects included in both November 1970 and February 1971 applications except for Project #65 - Comprehensive Renal Detection, Diagnosis and Treatment Program (Area VIII) and #74, Blood Bankin This action differs from Review Committee recommendations in the number of years of funding recommended. Council concurred with site visit team that this Region needed guidance from Council regarding overall level of funding to be anticipated before sub- mitting application for three-year funding of operational projects in May 1971. COLOPADO/WYOMING REGIONAL MEDICAL PROGRAM - RM 00040 2/7 u lement No additional funding is recommended. Developmental- funding is disapproved. Region may rebudget available funds into Project #22 and Project #24 if the RAG determines that they: a) respond to a recognized need for local region,-.ilization an6 improvement; and b) demonstrate integration into the Region's health care system in a way that will permit dis- engagement of RMP funding within a short time. Because of Council policy regarding use of RMP funds for basic education, P.roject #23 is ineligible. and staff interpreta,--iL;ii o-L poi-i.(-y regarding Project #23. 16 (',ONNI-"C'FICU'r RE(;101,,'Al, MI@'])ICAI, I'l@OGI@AM 1,U4 00008 2/71 (Sti )lc@mc!nt Additional funding at a reduced amount of $70,496 is recommended for the.cuirent 03 year. This Council action is the same as recommended by the Review Committee. FLORIDA REGIONAL MEDICAL PROGR@'Q RM 00024 2/71 Additional funding at a reduced level of $200,000 - 03 year; $160,000 04 year; $145,000 - 05 year is recommended. Action on Project #38, The Florida Statewide System of Patients With End Sta'sz'e Kicdine Disease, was deferred to provide time for advice revision and resubmission as recommended by the Ad Hoc.Panel on Renal Disease. This Council action concurs with the combined recommendations of the Review Committee, and Ad Hoc Panel on Renal Disease and staff with regard to renewal of Project #15. GRIATER DELA14ARE VAI,LEY REGIONAL MEDICAL PROGRAM - PM 00026 2/71 No additional funding is recommended for activities presented in this application. Region has option to rebudget available funds into new Project #27 Director of @ledical. Education - as well as for previously approved Projects #6, #8, #10, #14, and #15. RMPS funding is precluded for the training of lay personnel proposed in Project #28, First Care Cardiopulmonary Resuscitation Training ram (Deceml3er 1969 Council). Projects #25, r@ alysis Training Crozer-Chester Medical Center and #26 - Demonstration and Evaluation of a Dialysis Train - Thomas Jefferson Diversity are disapproved. Council agrees with Review Committee and Ad Hoc Panel on Renal Disease that two dialysis training projects in same area raise serious questions about cooperative planaing and review procedures in the Region. This Council action differs from Review Committee recommendations in respect to funding recommended. 17 HAWAII REGIONAL MEDICALIPROGRAM 00001 2/71. (Supplement) Additional funds are recommended for three years: 05 - $285,119 03 - $366,300 04 - $285,182 Request for one year developmental funding is approved. Because of Council policy, Project #23, Mobile Coronary Care, is not recommended for support. This Council action concurs with Review Committee recommendations. INDIANA REGIONAL MEDICAL PROGRAM - @l 00043 ement) Additional funding of $150,000 for one year j.§ recommended for this Region. Request for developmental funding is disapproved. This Council action coincides with Review Committee recommendations. ILLINOIS REGIONAL MEDICAL PROGRAM - RM 00061 2/71 Increase in support for one year only to a total level of $2 million is recommended for the Illinois RMP. Developmental funding request is disapproved at this time. This Council act!-on coincides with Review Committee recommendations. INTERMOUNTAIN REGIONAL MEDICAL PROGRAM - RM 00015 2/71 Additional funding of $225,000 recommended for this Region for one year. Request for developmental funding is approved as requested. Region may rebudget funds into any projects included in this application or for continued cooperative plannink for Project #29, Plivsician's Assistants Training; (Ili'70 application). However, Council would like to advise Region that decision to continue funding of Project #16R Endocrine ProRram - would raise doubts about Regional priorities. This Council action coincides with Review Committee recommendations. 18 LOUISIANA REGIONAL MEDICAL PROG@L - ICl 00033 2/71 Additional funding of $400,000 for one year is recommended. Request for developmental funding is disapproved. Region may rebudgc-t available funds into supplemental, core, planning and feasibility studies or projects included in this application. Project #9, Th n Bank, is approved with advice to Region about the budget and the educational program plans, as noted by the Ad Hoc Panel on Renal Disease. This Council action coincides with recommendations of the Review Committee and incorporates the advice of the Ad Hoc Panel on Renal Disease. ',IIARYLAND REGIONAL MEDICAL PROGRAM - P14 00044 2/71 No additional funding is recommended for activities proposed in this application. The request for developmental funding is disapproved. Project #33, A ion and Therapy for Chi ommended by the Ad lloc Panel on Renal Disease. Advice to Region should convey Council's specific desire that in- formation about program concerns should not be interpreted as criticism of the new coordinator, rather as hope that lie can mobilize MRMP resources for coordinated action. This Council action coincides with recommendations of both Review Committee and Ad Hoc Panel on Renal Disease. METROPOLITAN WASHINGTON REGIONAL MEDICAL PROGRAM - RM 00031. 2/71 Total direct cost funding for three-year levels ate recommended for continuation, new or renewal activities as follows: 04 - $1,658,351; 05 - $1,359,906; 06 - $1,116,353. Request for developmental funding is disapproved. Additional funding for continuation of Project #12, Mobile Cor r Care tJnit, is not recommended, but Region may rebudget funds for completing two full. years of activity, as originally proposed, provided 19 METROPOLITAN M"T CONT. All kidney disease projects are disapproved. Project. #16 - @'obi.1-c Dialysis (',enter, Project #47 A Reg on@al "lull I @h o@1- r@ raiTi, and Project ii3l - @a @itol He odial s@is Training are disapproved as recommended by the site visit team and the Ad Hoc Panel on Renal Disease. Region should be advised of Council's interest in further review only of a comprehensive proposal for renal disease, rather than project-by-project proposals. Region may rebudget funds into projects included in this application if RAG determines that they are of high priority and within RMPS policy. Project #17, National Career Council, Project #23, Iiihalati6n a Traini and Project #43, Cervical Cancer Detection raise policy -issues. One year funding only is recommended for Proj.ect #2R. This Council action differs from Review Committee recommendations only in level of funding recommended for each of three years, coincides with recommendations of Ad Hoc Panel on Renal.. Disease and incorporates advice from the December 7-8, 1970 site visit team. MICHIGAN REGIONAL MEDICAL PROGRAM PM 00053 2/71 Additional three-year funding at a reduced level is recommended for two new projects as follows: 01 - $368,073 02 - $366,098 03 - $388,274 This Council action coincides with Review Committee recommendations. NEW JERSEY REGIONAL @IEDICAL PROGR,*L RM 00042 2/71 Total direct cost levels for continuation, new and renewal activities recommended for the next three years as follows: 01 - $2,989,501 02 - $1,454,750 03 - $1,276,466 The second and third year levels do not reflect core support which was not requested at this time. Request for developmental funding is approved as requested. Request for one additional year of support for Project #3R, onal Training Center for Cardiac Nursing, is approved. This Council action coincides with Review Committee and incorporates advice and recommendations from December 1970 site visit team. 20 - NEW MEXICO REGIONA@L MEDICAL PROGRAM - @l 00034 2/71 (Su ent) Additional funding is recommended as requested for Project #16, Heart-, Sound. and @lurrr.@-ur Screen for Neiq Mexico School Children, as follows: 03 - $45,188 04 - $55,558 05 - $57,069 This Council action coincides with Review Conmiittee recommendations. NEW YORK METROPOLII'AN REGIONAL MEDICAL PROGRAM - @l 00058 2/71 (Supplement) Additional funding of $200,000 for developmental component.is recommended for one year. No additi.oial funding is recommended for new Projectg #25, #26, #27, And #28; however, Region has option to rebudget available funds into these activities, provided RAG determines they are of high priority for present goals and objectives of Region. This Council action coincides with Review Committee recommendations. NORTH DAKOTA REGIONAL MEDICAL PROGRAM - RM 00060 2/71 Additional funding of $30,000 is recommended for one year. Request for developmental funding is disapproved. Region may rebudget available funds for increased core or approved projects in line with its own priority. rllis Council action coincides with Review Committee recommendations and incorporates advice from the December 1970 site visit team. '14 - RM 0002 NORTfll,ANI)S REG10NAL MEDICAL PROGRIV 1 2/71 Approval of level'of fundi g for three years for all activities, including continuation, new activities and developmental funding as follows: 03 - $1,954,400 04 - $1,511,600 05 - $1 378 700 Approval of developmental. funding as requested for three years. Region may rebudget available funds into any of activities proposed in this application, if RAG determines they are of high priority for Regional objectives and in line with RMPS policies. Attention to RMP policy is particularly pertinent in regard to Project #20, Diabetes I.-or, iT, -1 Congeni.til. 14part R(.-5,,istrv. Region !'rojcCL ii -L Ad ii ia id ior Project #14, as noted by the Review Committee. 21 NORTTILANDS FJ4P CI)NT. This Council action coincides with Review Committee recommendations and incorporates advice from the site visit team. OREGON REGTONAL ML,"DICAL PROGR@vi - RM 00012 2/71 04 year A total direct cost level of $1,064,291 for the 15-inonth is recommended for this region. Region may rebticiget available 04 year funds into core, continuation projects, renewal projects and new projects in line with its priorities and objectives. Approval for'the renewal projects is for one year only with the exception of Project #4R, Comprehensive Stroke Care with Regional Education, which is approved for the 05 and 06 years as requested. O@ - $54,s444 06 - $56,617 Council takes exception to its general policy regarding phase-out of RMP projects because of Project 4R's outstanding demonstration qualities. This Council action differs from Review Committee recommendations in the level of funding recommended for the 04 year. Project #21 was withdrawn by the Region and Council concurred with staff's recommendation that $91,580 additional funding was needed to support on-going projects. SOUTII DAKOTA RI,"GIONAL MEDICAL PROGRAM - l@ 00067 2/71 Approval of South Dakota Regional Medical Program as a separate Region. Three-year funding for core and one year continued funding for.coronary care activities in three South Dakota hospitals is recommended as follows: 01 - $379,500 02 - $313,000 03 - $376,000 This Council action coincides with Review Committee recommendations. SUSQUEH,KN'NA VALLEY REGIOIN'AL MEDICAL PROGRAM - RM 00059 2/71 (SPECIAL ACTIO,li) Approval of two yearst additional funding for Project #6R, nar Care Nurses' Traini oram, G6isinger Medical Center and one year funding for Project #25, i.-Itoona Coronary Care Training, in following amounts: 01 - $88,425 02 $31,553. 22 Su VAL1,LY FIIP CONT. Deferral of remainder of application for new funding, pendin,, a site s, plans for priorities for the visit to study the program progres future. This Council action differs from Review Committee recommendations. Council considered as a special action the Region's third proposal for CCU Training at the Altoona Hospital and recommended funding for one year. TL',U6 RLGlUi4AL @,DICAL PROGRAM ItM 00007 2/71 (SUPT'I,EMI,'Ij@'I & SPI,"C AL ACTIO,N) Additional funds are recommended as follows: 03 - $26,900 04@- $26,500 Region may rebudget available funds into any of the other activities included in the supplemental application in line with Region's priorities. Council wishes to advise the Texas RAG that any RMP funding for both Project #53, Choriocarcinoma and Related Troplioblastic Diseases and #50 Control of Hypertension and Chronic Renal Disease, h@ou d@e transitional only to pernl-fc-p-roject directors time to locate other sources of funding. Council recognizes that long-range support is necessary to accomplish the aims of Project #50, but does not believe @IP should be the source. The previous restriction on expenditure of funds for Project #14R, Stroke Demonstration Pr@@anLIL@r Punitive. Patient Care, should be lifted. This Council action incorporates recommendations from both Review Committee and the Ad floc Panel on Renal Disease. VIRGINIA RLGIONAL 14,DICAL PROGRAM - RM 00049 2/71 @, @p@lenienq No additional funding is recommended for the Virginia Regional @ledical Program. The request for developmental funding is disapproved. Council will reconsider request for additional fundinp, for Project 1710, Multiphasic Screening Program, in May when special Council subcommittee reports its recorwnendations. Action on Project #12, Procurement of Cadaver Kidneys for rransnlaiitation, is deferred, pending Region's response to advice from Ad tioc Panel on R(-n 2 3 VIRGINIA P-@,IP CONT. Region should be advised of Council policy regarding support of new mobile units in relation to Project #11. This Council action incorporates recommendations from Review Committee and Ad Hoc Panel on Renal Disease. WASIIINGTON-ALASKA REGIOI@,AL MEDICAL PROGI@i4 - RM 00038 2/71.1 & 2/71.2 Additional funds are recommended as follows' 04 - $289,778 05 - $268,129 06 $30$700 Developmental funding is approved as requested. Additional funding is recommended for Project #9R - Alaska Medical Library, and #38R - Medical Computer Service, as requested. Additional funding is recommended for the Regional Kidney Program, as noted by the Ad Hoc Panel on Renal Disease. Region should be advised, however, that despite the Panel's concerns about specifics of the Regional Education Program, Region may incorporate continuing education on renal disease into overall continuing education program when appro- priate. This Council action coincides with recommendations of Review Committee and the Ad Hoc Panel on Renal Disease. WESTEP"N NEW YORK REGIONAL MEDICAL PROGRAM - RM 00013 2/71 Additional funding is recommended for Western New York as follows: 04 - $359,424 05 - $374,827 06 - $113,265 The request for developmental funding is disapproved. Region has option to rebudget funds into projects included in this application, but should be advised on Council's concerns about lack of priorities for the overall program. Funding for Project #21, Choriocarcinoni@t and Relal--ed Trophoblasti.c Disease, should be considered as transitional. and short-term only to provide time to develop other sources of funding. Ccu-,icil cites Project #lR, Telephone Lecture Network, for special consideration in funding- This Council action coincides with Review Committee recommendations. 24 WEST VIRGINIA U,,GIONAL MEDICAL PROGRfi@l 101 00045 2/71 Additional. funds are recommended as follows: 02 - $260,000 03 - $260,000 04 $@60,000 Region may rebudget available funds into any activities included in this application if RAG determines they are of high priority and in line with RMPS policy. Attention is called specifically to Council policy on registries rel.@ited to Project #12, Cancer Education and Service. Region should be advised of Council's special interest in Project #8, Medical Self-Audit, This Council action coincides with Review Committee recommendations. WISCONSIN REGIO.NAL MEDICAL Pl@OGRAI.4 - l@ 00037 2/71 (Supplement Action on this request for developmental funding i!3 deferred pending Council consideration of Region's triennial application in August 1971.1 Council suggests that Region incorporate plans for developmental funding in Triennial application. This Council action coincides with Review Committee recommendations. XV. ADJOURNMENT The meeting was adjourned at 12:30 p.m. on February 3, 1971. I hereby certify that, to the best of my knowledge, the foregoing minutes and attachments are accurate and complete. Harold Margulies, @ir' Director Re-gional Medical Programs Service April 26, 1971 ATTENDANCE AT THE NATIONAL ADVIsoRy COUNCIL MEETING FFBRUARY 2-3, 1971. RMPS REPRESENTATIVES IN RMPS STAFF REGIONAL OFFICES Mr. William A. McKenna Region I Mr. Ken Baum Mr. T. H.. Griffith Region IV Dr. Edward T. Blomquist Mr. Maurice C. Ryan Region V Mr. Cleveland Chambliss Mr. Spencer Colburn Mr. C. Ray Maddox Region VII Miss Cecilia Conrath Mr. Daniel P. Webster Region VIII Mr. Tom Croft Mr. Ronald S. Cutrie Region IX Mr. Herbert Dunning Mr. Hugh S. Campbell Region X Mt. Gerald T. Gardell Mr. Terrance T. Genz OTHERS ATTENDING Mr. Samuel 0. Gilmer, Jr. Mrs. Eva Handal Dr. Vernon E. Wilson, Administrator, usmi Mr. Charles I-lilsenroth Dr. Margaret 11. Edwards,'NCI, NIH Miss Dona Houseal Mrs. Frances H. Howard, NLM, NIH Mr. Frank Ichniowski Dr. William J. Zukel, NHLI, NIH Dr. Philip A. Klieger Dr. Alan Kaplan Dr. Marshall J. Keyes Mr. John M. Korn, Jr. Dr. Harold Margulies Mr. Frank Nash Dr. Herbert B. Pahl Mr. Ronald L. Peterson Mr. Eugene S. Piatek Mr. Michael J. Posta Miss Leah Resnick Mr. Abraham Ringel Mr. Dale Robertson Mr. Morton Robins Mrs. Jacki Rosenthal Mr. Richard L. Russell Mrs. Pat Schoeni Mr. R. Shaw Silsbee Mrs. Sarah J. Mr. Thomas H. Simonds Dr. Margaret H. Sloan Mr. James A. Smith Mr. Dan Spain Mr. Lee E. Van Winkle Mr. David Lovenvirth, RMPS Consultant NATIONAL ADVISORY COUNCIL ON REGIONAL @IFDICAL PROGRAMS BRENNAN, Michael J., M.D. (72) licPHEDRAN, Alexander M., M.D. (73) President, Michigan (cancer Foundation Emory University Clinic 4811 John R Street 1365 Clifton Road, Ni E. Detroit, Michigan 48201 Atlanta, Georgia 30322 CANNON, Bland W., M.D. (73) MILLIKAN Clark H., M.D. (72) 910 Madison Avenue Consultant in Neurology Memphis, Tennessee 38103 Mayo Clinic Rochester, Minnesota 55902 CROSBY, Edwin L., M.D. (71) Executive President OCHSNER, Alton, M.D. (73) American Hospital Association Ochsner.Clinic Chicago, Illinois 60611 1514 Jefferson Highway New Orleans, Louisana 70121 DEBAKEY, Michael E., M.D. (72) President and Chief Executive Officer ROTH, Russell B., M.D. (73) Baylor College of Medicine 240 West 41st Street Houston, Texas 77025 Erie, Pennsylvania 16508 EVERIST, Bruce W., M.D. (71) WYCKOFF, Mrs. Florence R. (72) Chief of Pediatrics 243 Corralitos Road Green Clinic Watsonville, California 95076 Ruston, Louisiana 71270 HINES, Mr. Harold H., Jr. (74) EX OFFICIO MEMBER Senior Vice President Marsh & Y@cLennan, Inc. MUSSER, Marc J., M.D. 231 South LaSalle Street Chief Medical Officer Chicago, Illinois 60604 Veterans Administration Washington, D. C. 20420 HUNT, William R., M.D. (71) Commissioner County of Allegheny 101 Courthouse Pittsburgh, Pennsylvania 15219 CHAIRMAN Vernon E. Wilson, M.D. ,Administrator Health Services and Mental Healt Administration 5600 Fishers Lane Rockville, Maryland 20852