I w I -A I a w - B&B INFoRmikriom & lm^=E MAKNAMEMENT 300 @loecc M=Rucon SOULCVARD Ulapacm M,%$tL=OftMv MAIW@040 Z077Z 0 US^ 0 taol) 24"1 I a DEPARTYir-'N-T OF TiE7jTil, EDUCATION, AND @-,L-LrAIZF, PUBLIC IIEALTII SET@Z@RICE National Advisory Council on Regional Medical Programs Minutes of the Ti,,entv-eighth Meeting 1/ 2/ October 16-17, 1974@ The National Advisory Council on Regional Medical Programs convened for its twenty-eighth meetina at 8:30 a.m. on Monday, October 16, 1972, in Conference Room G/H of the Parklavm Building, Rockville, Maryland. Dr. Harold Margulies, Director, Regional Medical Progra--ns service, presid- ed over the meeting. The Council Members present were: Michael J. Brennan, M.D. Clark H. Millikan, M.D. Bland lq. Cannon, M.D. Mr. Sewall 0. Milliken Mrs. Susan L. Curry Mrs. Mariel S. Morgan Michael E. D--Bakey, M.D. Marc J. Musser, M.D. Mr. Edwin C. Hiroto Alton Ochsner, V,.D. Anthony L. Ko.@roff, M.D. Mr. C. Robert Ogden Mrs. Audrey M. Mars Russell B. Roth, M.D. Alexander 14. 14cPhedran, M.D. Georae E. Schreiner, M.D. John P. Merrill, I-I.D. Benjamin 1-7. T@atlzins, D.P.M. Gerhard A. Meyer, M.D. Mrs. Florence P. XYyckoff Drs. DeBakey, Millikan, Musser, and Roth were present on October 16 only. Dr. DeBakey was present only during the afternoon session. Dr. Merrill was present on October 17 only. A listing of RMPS staff members and others attending is appended. 1/ Meetinqs are conducted in accordance with Executive order 11671 and the Determination of the Secretary of Hea'Lth, Education, and llelfare, thereunder, dated Senteniber 27, 1972. Procep-dinas of the closed portions of meetings, and r,,a---erials submitted for discussion during such closed portions are restricted unless cleared by the Office of the Administrator, HSMHA. 2/ For the record, it is noted that members absent themselves from the meeting when the Council is discussing applications: (a) from their respective institutions, or (b) in which a conflict of interest might occur. This procedure does not, of course, apply to en bloc actions--only when the application is under individual discussion. -2- .I. CALL TO ORDER AND OPENING PM@S The meeting was called to order at 8:30 a.m. on October 16, 1972, by Dr. Harola Margulies. Dr. Margulies called attention to the conflict of interest and confidentiality of meetings statements in the Council books. Dr. Margulie@ specifically pointed out that the confidentiality statement applies only to the closed portion of the meeting ifivolved with the review of applications. He also called attention to Executive Order 11671 and its requirements for announcement of meetings and provision for pub- lic attendance and observation. II. REPORT BY DR. MARGTJLIES Completion of Council Terms Dr. I-largulies noted that Dr. ilillikan and Dr. DeBakey were both completing their maxim= feasible terms on the Council. Both have served since the beginning of the Program. 2. Quality of Care Conference A Quality of Care Conference has been set for St. Louis during the week of January 22. The meeting will deal with quality of care and quality assurance from a professional standpoint. It will consist of major presentations and panels, rather than a series of workshops. The meeting is designed to develop a common base of understanding on quality of care issues. Attendance will be kept limited to facilitate moving through the agenda effectively. 3. R.BG/GP-zCI.TEE Policy Statement The Regional Advisory Group/Grantee Relationships Policy, which the Council considered and endorsed at its June meeting, has been sent out to all Coordinators, RAG Chairmen and Grantees. Vlhile this has stimulated some further questions where grantees had not appreciated limitations on their actions, the policy has been generally accepted as reasonable. A 1-tarch 1 target date has been set for Regions to make adjustments in accord- ance with the new policy. RMPS will provide advice as needed, but does not exnect to approve interim drafts generated by the Regions. 4. Discretionary Funding Policv Another policy statement which has been distributed is that on discretionary funding-,which describes the freedoms with which MiPs can develop new activities without formalized review and indicates when R:.IPS approval is recuired. The Discretionary Funding Policy involves a transfer of responsi- bility and of judgment which is consistent with the -3- decentralization of RMP functions. Under the policy a Regional Medical Program, which has set out what it pro- poses to do, is given a degree of,flexibility during the course o-f the year and the course of the triennium to 'ts interest without having to stop in everv stage pursue 1 of the process for a pro forma endorsement of activities which have already been endorsed Sy a previous review. In actual operation, the Discretionary Funding Policy will require discretion both on the part of @IPS and the individ-, ual Regional Medical Programs. At this point one Council.nember suggested that discretionary funding authority possibly should be limited to a specific dollar amount.- In response, Dr. Margulies indicated that the new policy provides adequate control over the kind of rebudget- ing that occurs. He further indicated that any amounts rebudgeted inappropriately would be brought to the Councills attention. At a future meeting of the Council, there will be a report on how the Discretionary Funding Policy is being carried out, and the Council can decide then whether shifts being made under the policy are reasonable. 5. Kidney Guidelines At the June 1972, meeting of the Council concern was ex- pressed about the language in the P14PS Kidney Guidelines, specifically with respect to what it meant by a "full-time transplant surgeon." The Council directed PIIPS to clarify the point by indicating that we were talking about a kind of commitment on the part of transplant surgeons, rather than something very tiahtly defined as@"full-time." A clarifi- cation has been developed and sent to all the Regions. 6. San Francisco Kidney Meeting At the June Council meeting some concern was also expressed over how kidney consultants were to be made available. The Review Committee had expressed some doubts about the use of a National Panel. m@hese were not shared by the Council. The Council did, however, exnress a view that there should be a good level of understanding among the consultants as to how they were going to carry out their review functions--both from the technical point of view, and with respect to the overall principles of a network of dialysis and transplant centers to which RMP and the Council are committed. A two-day meeting was held early in September for over 70 kidney ,specialists who are on the @IPS Consultant list. The Conference -4- was also attended by Dr. Schreiner and Dr. Merrill, representing the Council. Dr. Schreiner indicated that a significant group of specialists attended the meeting and that it provided an opportunity for then to anall;,ze the guidelines and get a common base of information at one time. 7. Ilational lddney Foundation Award The Regional Medical Programs Service has been selected by the National rddney Foundation to receive that group's Annual Health Achievements Award. The award will be presented in New Orleans on November 18. 8. Review Cornittee Functions For the last several months the RLMPS Review Committee has had extensive discussions about its functions, vis-a-vis the Council and Staff Anniversary Review Panel. These kinds of questions arise naturally in all review groups as changes occur both in their membership and the patterns of program operation. In order to clarify the situation, RTPS staff has developed a paper on the role of the Review Group with respect to the other R!@IPS review bodies. The paper was discussed with the Review Committee, e7hich found it acceptable. (hie Committee member felt that a chart of the PNIPS Review Process would be 4elpful, but that is a mechanical feature rather than a sub- stantive comment on the functions of the Committee. The Comittee does analyze applications in great depth and spends conside @ le time on site visits and subsequent discussions. In addition to the nex7 functional statement, R!IPS has done other things to make them feel more secure in their role. Cormuni- cations has been improved markedly, for example, by feeding back actions of the Council to the Review Committee. This enables the members to know when there are differences, and understand why those differences occur. 9. Status of R!.IPS Policv ilanual It has been reported to the Council in the past that PIIPS is. in the process of preparing a looseleaf, cross-indexed Dolicv manual. This has proven to be a rather arduous, time-consuming task, which has been frequently interrupted by the exigencies of day-to-day operations. The manual has now been completed. It.will be circulated for comment to Coordinators, RAG Chairmen, grantees, members of the Council, and members of the Review Committee. It will also be announced as available for comment in the Federal Register. Revised regulations for the program are under consideration. They will be redrafted, but they have been held back until the manual could be completed. One of the items that will be included in the manual is a full discussion of section 910 which, among other things, provides for activities of a National or interregional interest and otherwise broadens the scope of Regional Medical Programs in the fields of health manpower education delivery svstems, etc V,'e have not developed a policy statement on Section 910, largelv because this might create,the illusion that t-,ere is a separate pot of money available for carrying out the authorized activi- ties, which is not the case. 10. Progress on S@tion 907 Section 907 is that part of the Act which requires the Secretary to prepare a list of hospitals having the most advanced capacity for dealing.with the categorical diseases. RIIPS is now in the process of developing a list of such hospitals through a contract with the Joint Commission on Accreditation of Hospitals. Under the' contract a list of questions and a questionnaire has been developed by a groun of experts. The questionnaire covers equipment, Personnel, teaching programs and volines of service dee,-.ied to he needed to assure quality of care. No final decision has been made on the nature of the list or its distribution when complete. The final list will not be one that depends upon minimum standards, and this will make it unique. The nature of the final list, ho@7eier, has not yet been determined. It conceivably could be restricted to an "unique" group of institutions. It could be a more extensive list associated with professional requirements for patient referral, or it could be a much larger list shovying the characteristics of institutions. It is anticipated that information in the questionnaire will also be useful for planning, allocation of resources, and attempts to achieve regionalizat'ion. The list, as put together, should be maintained, modified as needed, and made broadly available. As a consequence, r-!,IPS exnects to be workinc! with other appropriate HSMHA offices to develop arrangements for the monitoring and continuity of the list. There was considerable discussion bv the Council with respect to the need for judgmental input by Rcaional Advisory Groups in the Section 907 activity. -6- It was moved, seconded and carried that: "After the list is received by this Council, it be distributed to the local Regional Advisory Groups for review and comment, and modification, and returned to this Council before the final list is p@sed on to the Secretary." (Transcript Vol. 1, page 34.) In subsequent discussion it was made clear that the above action of the Council referred only to the list of facilities and not to the raw data from the questionnaires. 11. MIS and Evaluation Committees Dr. Margulies Zalled on Dr. Pahl.to discuss two newly established internal @LDS staff corimittees--one concerned with Management Information and the other concerned with RI-IPS Evaluation activi- ties. Both of these groups are composed of I*IPS senior staff. The establishment of the two steering committees indicates the very real interest of P.LMPS in setting a high priority on the better employment of the Management Information System and in improving the usefulness of RMPS Evaluation activities. The MIS group will look closely at the data being collected and its usefulness to site visitors, the Review Committee and the Council. With respect to evaluation, the Council has from time to time been advised of evaluation contracts that have been let and has periodically been informed of results. As the program matures, however, it becomes more and more important to develop an understanding of the accomplishments both of headquarters staff and the individual Regional Medical Programs. The establishment of the evaluation committee is desianed 'to give the evaluation function a considerably higher priority in the future than it has had in the past. It is hoped that increased emphasis on the evaluation function will enable R:4PS to involve both the Review Committee and the Council more fully in the formulation of plans. The stepped uv evaluation effort is expected to improve the understanding of the program within the Department, and HSMHA, and among the general public. 12. Review Committee Member@l Dr. Margulies also called upon Dr. Pahl to discuss changes in the composition of the Review Committee. 'Three new members have been appointed to the RMP Review Committee. They are: Dr. William Luginbuhl, Mrs. Maria Flood, and -Dr. Grace James. In addition, there have been three recent resignations from the Review Coqmittee: Mr. Jeanus Parks, Sister Ann Josephine and Dr. Edmund Lewis. At this point there was considerable discussion by various members of the Council, princinallv Dr.-Brennan, with respect to the need for greater representation of the categorical disciplines on the Review Committee. As a result of the discussion it was moved, seconded and carried that: "The Council expresses, through the Administrator, its conviction that authoritative scholars, auali- fied in neurology, oncology, and cardiology be included in the members'Aiin of the Review Corimittee." (Transcript Vol. 1, pages 55 and 57.) STATF-@IENT BY DR. STOIT.F, Pr. Margulies introduced Dr. Frederick L. Stone, Interim Deputy Administrator, HS14liA, who read a statement for the Administrator. The statement primarily concerned two subjects: (a) develonn.-ents relating to categorical disease control programs within the De-oart- ment, and (b) the desirability of continued funding by RIIPS of certain types of activities. A copy of Dr. Stone's statement is attached. Dr. Margulies asked Mr. Peterson, Director, Office of Program Planning and Evaluation, ITIPS, to discuss recently developed statistical data relating to the matters discussed by Dr. Stone. Mr. Peterson stated that roughlv @7o-thirds of the Project activi- ties for which R:.IP suDoort has been discontinued are being picked un at a reduced level by other local funding sources. in addition, many discontinued 'orojects have been phased out for thoroughly valid reasons. Such projects (1) nav have been time limited,. (2) may have proved to be undesirable, or (3) may have been determined to be of low prioritv in relation to available funds. lvlith respect to the funding of categorical activities, there has been a marked Percentage decrease in single categorical disease activities and a slight increase in dollars devoted to these, largely as a result of the increase of total funds available to PL@IPS from 1971 to 1972. In addition, manv activities related to the categorical diseases in general are s@omerged in the "multi- categorical' classification. There was extensive discussion of Dr. Stonets remarks bv various members of the Council. The following key points were brouaht out: -8- 1. Fixmness in phasing out MIPS funding for particular activities has largely resulted from limitation on the amounts of funds available. 2. RMP staffs need to develop capabilities for economic planning, argument, and presentation to funding bodies. 3. If NIII controlled programs do not work along with the RMP structures new organization similar to RMP will have to be invented. 4. Earmarking of funds for specific categories of activi- ties can be detrimental to the administration of the total progra,-,i of an. IU4P. Dr. John R. F. lagall, Chairman of the National Steering Committee ,of Regional Medical Program Coordinators, was recognized by the chairman. Dr. Ingall endorsed the Councills comments concerning the need for assistance of RAG and R@lPs in the development of control programs. He also stated that Regional Advisory Groups had strong categorical protection built in, and indicated that the nroblem of many Pi.lPs is relating categorical interests to the general deliverv of health care. He stated that many projects have been continued by other agencies and requested (re: E:,IS) that liSMHA keep Rmps informed on relevant contracts. In closing, Dr. Stone indicated that he would advise.the Administrator of the Councills and others' comments. He also stated that NTH clearly would not try to stimulate another set 'of netiiorks--that the creation of "control" programs would be a FSMIiA-wide activity in which the Council could expect to take the principal load. Finally, he pointed out that other HS@lTiA programs have a certain experience in dealing with the third party payment problem and can furnish technical assistance to P-IlPs and other organizations where required. IV. SPECIAL REPORTS 1. R,@IP RelationshiT)s with Health Care Institutions Dr. Margulies called on Mr. Sam 0. Gilmer, Jr. to discuss @IP Relationships with Health Care Institutions. Mr. Gilmer pointed out that recently a n @ er of small and informal conferences have been held with hospital oriented RMP/program staff and with individual hospital administrators. These indicate, as in the past, that there is little institutional commitment to R:.!P on the part of hospitals. There are exceptions, however. There is a real need to strengthen RMP and MIPS relation- ships with hospitals. Hospital governing bodies generally have not adopted policies clearly statina the relationship. of the hospitals service program to the activities of the MiP serving the area. Likewise, there is no commitment -9- on the part of hospital administrators, as a whole, with respect to the importance of RMP or commitment to working with P-1@lPs even though a number of hospital administrators are involved with the programs as individuals. In addition to the informal conferences, a survey of hospital administrative competence within Rr-lPs is now 'being conducted. Returns indicate that about tvio-thirds of the P,%IPs have designated a staff person to handle hospital liaison functions. In closing, Mr. Gilmer cited a n@er, of activities in which hospitals and Regional 1-tedical Pro- grams could profitably participate and particularly called attention to the TAP program of the Joint Cormission on the Accreditation of Hospitals. 2. Management Survey Activities Dr. Margulies called on Mr. Thomas Simonds, of the RMPS Grants Management Branch, to discuss Management Survey activities. Mr. Simonds stated that the Management Survey Program was first organized in 1969. At that time survevs were only conducted at the request of the Coordinator or with his agreement. Anproxinately two years ago the Management Survey ProqraA-n was reorganized so that all Reqions are surveyed by staff on a regular basis. Management surveys cover such items as the adequacy of a Region's written policies, payroll and leave procedures, the adequacy of financial management and records procure- ment and inventory control, as well as personnel policies and procedures. On completion of each survey, preliminary findings are discussed orally with the Region and the final written report includes only material which has been discussed in advance. survey reports are distributed internally to appropriate units of RIIPS, HSLNIHA and HET-1, including the M,VT Audit Acrency. Copies are furnished to the coordinator, RAG Chairman and grantee institutions. Recommendations of Management Survey reports are used to correct identified deficiences, to assist the operations desk and the Director, and to provide information for con- sideration by site visitors and other reviewers. By the end of November- 1972, management survey visits will have been conducted in 35 Regions. Eighteen additional surveys have been scheduled for the 1973 calendar year. IOIPS has considerable information in the Management Information System as well as extensive institutional memorv on the part of staff and older Committee and Council members. Membership in these groups changes, however, and the visual materials were developed in an attempt to bring background information to reviewers in a matter that can be quickly grasped without slowing down the review process. After viewing the visual charts at the September 1972, Committee meeting, Committee members expressed the view that the presenta- tion had been helpful. They suggested, however, that the information in the charts would he even more useful if made available to site visit team members prior to site visits. Committee members also expressed the opinion that canned visuals could be misleading. and that information should be tailored to individual applications to bring out the salient-points. Council discussion following,Mrs. Silsbee's presentation likewise sounded a note of caution. The Council members expressed the opinion that such material might be presented in a capsulated form which could be misinterpreted by the uninitiated. Several examples were cited of holy data accumu- lated in broad categories could mask important details. Program staff functions, for example, include both administrative activities and activities of a professional and program nature. IX. REPORT ON f-IOLRTTAIII STATES, IITTER@IOUTTTAIN Al-115 COLO-PADO Dr. Margulies called on Dr. Milliken, who had participated in a site visit addressed to the question of territorial overlap between the Mountain States, Intermountain and Colorado/1,7yom- ing PlIPs. Dr. Milliken stated that the purpose of the site visit was to decrease the friction that had apparently developed between the RMPS. The three Regions decided to create an-interregional Executive Council-designed to reach joint decisions regarding programming in overlanned areas. In addition, a policy and procedures document has been developed for coordinating the activities of the three programs. X, REPORT ON DPVELOPi.@-l-ITAL COMPONENT Mrs. Silsbee was called upon to report the results of a staff study concerning the developmental component and proposed action. At the present time, 35 Regions have been approved for a developmental component twenty-one have not been approved. -12- Of the latter group, eight Regions have not applied. Two of these are still in the planning stage. Thirteen Regions have applied and have been diskpproved--eight of them twice. The Developmental Component was initiated at a time when PI.IPS was shifting from a focus on "project" to emphasis on "program." Among other things, the developmental component appears to have been useful in helping many @@gions to strengthen the RAG, program staff activities, forward planning, budget control, and the project monitoring function. At the same time, there my have been a detrimental effecl- upon those regions that were not approved. Some disa'Pproved applicants misinterpreted the denial of a developmental c@,.Donent as sianifving disenchant- ment with speaific activities proposed, rather than with their goals or processes. In addition, and most important, those Regions that needed the developmental component most were those that did not meet the standards for approval. Since the developmental component was initiated, PITPS has decentralized oroject review,.in3'-tiated the triennial system, introduced the review criteria and rating system, and announced the discretionary funding policy. These changes provide Regions with flexibility and recognition, and do other things that the developmental component was originally designed to accomplish. R%IPS is currently thinking about phasing out the developmental component in an orderlv manner and will be seeking the Councills advice on this at the next meeting. Xi. MISSOURI SITE VISIT Dr. McPhedran reported on a special site visit to the 14issouri PT.IP which took place on Sente,,@er 18, 1972. The site visit had been recommended previously, bv Council, to relav Council concerns relating to the value of some expensive computer projects and the organization of both the program staff and Regional Advi- sory Group. Dr. McPhedran reported the following: 1. Program staff is beginning to seek solutions to problems in the Region, rather than waiting for nroject proposals to be initiated by other groups. 2. Program staff is beginning to work on priorities, goals and objectives. 3. The Director of t@e program has assumed another rest)onsi- bility, on a part-time basis, and is spending currently only 54% of his time with the P-IIP. -13- 4. The Regional Advisory Group needs to add Veterans Adninistration, C.HP and minority representation. 5'. The Region needs to create an evaluation section and simplify its review Process, At the conclusion of Dr. I.IcPhedran's report there was some discussion of the relationship between the Missouri @IP and the Bi-State PIIP in St. Louis. The consensus was that while there were unsettled jurisdictional issues between Bi-State and Illinois, there is no problem betv7een BiTState and Missouri. XII, REVIEW OF APPLICAT107iqS A. Albanv Moved: Dr. Ochsner Seconded: Mr. Ogden Accept the Review Comittee's recommendations for three- year funding in the amounts of $1,618,000; $1,783,090; and $1,940,723. (Transcript, Vol. 1, Page 165.) B. Bi-State Moved: Dr. McPhedran Seconded: Mrs. Curry Award triennial status, but no developmental co-.nnonent in the amount of $1, 150, 000 for the 04 -,-ear t@7ith 7% increases for the 05 and 06 vears, and conduct a site visit after the next year of operation to review BAr, effectiveness, staff relationships, and boundary nroblens with Illinois. Pmounts approved include $50,000 in discretionary funds to make it possible to hire a Deputy Coordinator. (Transcript, Volume'l, Page 171.) C. Wisconsin Moved: Dr. Millikan Seconded: Mrs. Wyckoff Accept the recommendation of the Staff Anniversary Peview Panel to increase the approved level for the 06 year to $2,153,624, including $312,881 for kidney activities and a $177,907 developmental component. (Transcript, Vol. 1, Page 173.) -14- D. West Virginia Moved: Dr. Cannon Seconded: Dr. Roth Accept the Committee's recommendation for $1.5, $1.6, and $1.7 million for the first,.second and third years. (Transcript, Vol. 1, Page 178.) E. Central New York Moved: Dr. Schreiner Seconded: Dr. Musser Approval in the amount of $889,000. (Transcript, Vol. 1, Page 18@) P. Michigan Moved: Dr. DeBak-ey Seconded: Dr. McPhedran Approval in the amount of $2.25 million. (Transcript, Vol. 1, Page 189.) G. Hawaii Moved: Mr. Hiroto Seconded: Dr. Komaroff Accept the recommendations of the Review Committee in the amounts of $1,805,488, $1,839,213, and $1,820,577 for the 05,06, and 07 years, respectively, including kidney and earmarked funds for the Pacific Basin. Kidney funds are subject to satisfactory definition of relationships between Kuikini and St. Francis Hospitals. The request for a developmental component was not approved. (Transcript, Vol. 1, Page 194.) H. New Mexico* Moved: Dr. Yoaaroff Seconded: Dr. Watkins Approve for triennial status in the amounts of $1.25, $1.30, and $1.35 million for the 05, 06, and 07 years, respectively. A site visit is to be conducted next year, and no funds are to be allowed for basic training in allied health professions. (Transbript, Vol. 1, Page 206.) Co-@c!il t-c- fit recommended by the Review committee Decause of the izegion's success in obtaining alternative funding for six of thirteen projects. Mrs. Morgan not present in meeting room. I. Northern New England Moved: Mrs. Ilyckoff Seconded: Dr. @IcPhedran .Approved in the amount of $850,000 for the 04 and 05 years, including a developmental component and $ 37,500 and $25,400, respectively, for continuation of kidnev activities. Triennial status is denied, but should be granted if the Region seems ready for this after a site visit at the end of the 04 year. (Transcript, Vol. 1, Pages 209 and 213.) J. Virginia* Moved: Dr. 1,7atkins Seconded-L Dr. DeBakey Triennial status approved in the amount of $1.8 million, including Developmental component for each of three years. (Transcript, Vol. 1, Page 218.) K. Indiana Moved: Dr. Brennan Seconded: Dr. Ochsner Approve the Review Committee's recommendation for $1.2 million for one year. (Transcript, Vol. 1, Page 220.) L. Rochester Moved: Mr. Milliken Seconded: Dr. Brennan Accept the Review Co-,nittee's recommendation for $935,000, including $35,000 for kidney, and noting specifically the Conriittee's requirement that the bylaws be completed. It was also recommended that the Region be revisited in within six to nine months. (Transcript, Vol. 1, Pages 225-226.) M. Texas** Moved : Mrs. -'4organ Seconded: Dr. Schreiner Accept the Peview Cornittee's recommendation for $1,900,000, .$2,100,ooo and $2,300,000, including the following amounts for kidney: $337,157, $309,640, and $294,640, for the next three years (with the funding for the second and third years contingent upon greater minority involvement in staff and RAG as determined farth-:!r -- -ie@.7 in n4--- ---nths. (--ranscr4-nt, Vol. 2, Page 6.) Mrs. Mars'not present in rqeeting room. Dr. Meyer not present in meeting room. Dr. DeBakey absent. -17- There were no council comments with respect to these continuation applications, or the proposed actions by the Director. (Transcript. Vol. 2, Page 80.) I hereby certify that, to the best of my knowledge, the foregoing minutes and attachments are accurate and complete. Ilarold Margulies, iI.D. Director Regional Medical Programs Service ATTENDANCE AT THE NATIONAL ADVISORY COMICIL MEETING October 16-17, 1972 PJ4PS STAFF Mr. Norman Anderson Mr. Roland Peterson Mr. Waddell Avery Mr. Michael Posta Mr. Charles Barnes Mr. Laurence Pullen Mr. Kenneth Baum Dr. Richard M. Reese Ms. Marilyn Buell Mr. William Reist Mr. Richard Clanton !Is. @-ah Resniclc Mr. Spencer Colburn Mr. Abraham Ringel Ms. Cecilia Conrath Dr. Jimmy L. Roberts Mr. Joseph De La Puente Mr. Richard Russell Ms. Annie Dicks Ms. Rebecca Sadin Mr. Alex Dobson Mr. Luther Says Ms. Eileen Faatz Ms. Patricia Q, Schoeni Ms. Myrtle Flythe Dr. Richard Schrot Mr. Gerald Gardell Ms. Kathryn PI. Sievers Mr. Sam 0. Gilmer, Jr. Ms. Sarah J. Silsbee Ms. Eva PI. Handal Ms. Shirley Simon Mr. Charles Henson Mr. Thomas Simonds Mr. Charles Hilsenroth Dr. Margaret Sloan Mr. George Hinkle Mr. James Smith Dr. Edward J. Hinman Mr. Mathew Spear Ms. Dona Houseal Ms. Doris Staton Mr. Francis C. J. Ichniowski Mr. Jerome Stolov Mr. Joseph Jewell Mr. Calvin Sullivan Mr. A. Burt Kline Mr. William Torbert Its. Lorraine Kyttle Dr. Clarence Washington Mr. Walter Levi Mr. Lee Van Winkle Dr. 'Joseph Linehan Ms. Glenna Ililcon Dr. Harold Margulies Its. Constance 1-7oody Mr. Rodney blercker Mr. Frank Zizlavsky Dr. Bruce Miller Mr. Roger Miller OTHERS ATTENDlt7G Mr. Ted Moore Mr. Bob Morales Mr.-Edward Bridgforth, Public, Ms. Marjorie Morrill Jackson, Mississippi Ms. Mary E. %Iurphy Dr. Margaret H. Edwards, NCI-NIH tir. Frank Ilash Dr. John R. F. Inaall, Public, Mr. Eugene Nelson Lakes Area P4kiP, Buffalo, New York Ms. Peggy Noble Ms. Frances Howard, IILM-NIH Mr. Harold O'Flaherty Dr. Frederick L. Stone, OA-HSMHA Mr. Joseph Ott Mr. Donald N. Young, OGC-HSZIHA Mr. Chris Ottenweller Dr. William J. Zukel, NHLI-141H Dr. Herbert B. Pahl .Ms. Jeannie L. Parks 10-16-'12 Presentation by Dr. r. L. Stone to National Advisory Council, RMPS- Dr. WiJ-son has asked me to express his sincere regret that he is unable to meet with you this morning, but this is his day to defend the HSMHA budget before the OMB, and I am sure you will understand and wish him well. Before proceeding @her, I would like to emphasize those specific attributes of the Regional Medical Programs that signalize its progress: 1. Its-decision-making powers have been decentralized to the final level in most cases; i.e.., to the states or sub-reaions of states. 2. In a special sense it demonstrates revenue-sharing at its best. 3. It has evolved, nationally speaking, into the only reliable tool vm have which relates to the professional at the community level. 4. In these Programs we have, regionally disbursed, the largest- pool of talent addressed to health care in otii., Nation, There are several things he has asked me to discuss with you--and I:iie :t@t is I. Priorities: Wearewell aware of the many pressures w.@ic'Li have bt Lffet-ed tlit-- Medical Programs ever since they became a part of IIS@HIA in 1968--and n@.,,,c,r has the strain been greater than in the last two years. tji-ider voiLr gu:; they have made the best of very difficult ,3itu,.itiorts, iii-id their contrilj;ttioii to solving the problems of access to priiiary coiiil)relic-ii,,-!.,,,c health been remarkable. 'nieix f-.Lexibi.lity, iiiiagl'li.,ition, zi)-id re,-,oiircofii]-ness leave been most impressive. Tliqv have found it possible I..o tidjtist to iiew prioriti.cs identified by liS@IIIA wlien these came -tloncr--tlie medic,-tily Uliderserved, Tnrliins, la migrant workers, urban and rural poor., young children, and the elderly-- and they have been able to place emphasis on ambulant care facilities and the more effective,use of allied health personnel. Their ability to enlist the cooperation of the providers and all concerned groups in the regions was most notably displayed in the recent crash prorram to set up emergency medical 2 services, and I believe no other organizations in the country could possibly have done this so rapidly and so well. However, our priorities are also set by the Congress, which in. neral reflects the will of the people, and it has been inescapably ge clear that many members of Congress are just as interested today in improving the care of patients with heart disease, cancer, stroke, and kidney disease as they were when the R@IP legislation passed in 1965. As a matter of fnct the Nnt.ioiiil Canc(!r A(,t of 11)71 pi,'4tt@d lii part bric.-auti c,- L@lk(,- It@ll'ti liii(I not. ftilfi..tlc,tl Llit! of t.liutit-, %vitc) PIL-(L for the RMP legislation in '65 and those meynl)ers of Congress who over- whelmingly supported it;'Yo they decided to try again. Those members of the health professions concerned with heart disease were not quite so frustrated because they had been deeply involved in the RMPS effort to develop guidelines for optimal care through the Inter-Society Commission for Heart Disease Resources. Nevertheless, they also wer@ deeply distressed as the RMPs withdrew sharply from support in the I field of heart disease and urged ecual time with cancer on the Hill. Congress expressed its continuing commitment to improviiia the lot o: .people with cardiovascular, respiratory and blood diseases by passii,-,, the National Heart, Respiratory and Blood Disease Bill of 1972. no accident that increasing imounts of $d'O, 30, and 40 M were authorized in both bills for control activities iii.cooperati-on with other Govei7nment agencies. 3 When Appropriation Hearings came around last spring, members of Congress were hearing bitter complaints from their constituents--doctors and patients concerned about heart disease, cancer, and stroke--uho found that many RMP programs in these disease areas were being terminated., The pointed out that the legislation on the books stilj makes heart y disease, cancer, stroke, and kidney disease the major responsibility of the RMP'S. And they it- does! Of course@ itis perfectly true that if people do not have access to health care at all, they will not have access to care.@-or heart disease, cancer, stroke, and kidney disease either, and therefore the recent emphasis on access to primary care is totally commendable. Miat the R@IP's have been able to accomplish in that direction has served to strengthen the base for all medica@ care across the country. Now., however, Congress has made it crystal clear that it wants the national effort in the control of heart disease, cancer, stroke, and kidney disease greatly intensified and that it will no longer tolerate diversion of funds appropriated for those purposes. This time it has authorized special funding for control effo:cts in tlic,@ 1)u(l,;(-,ts L)f the NCI and NHLI and in both cases it has directed that tb(,se activities bf. 4. ............... ........... carried out'ih'thd!'dl66List'06s.§ible codperat±6ii'irith'6thdt'Gov@rnment agencies. The appropriation committees have been generous with the contro I portion of the NCI and NHLI.budgets, but at this point we cannot tell what funds will eventually be released. Partly as a result of Congressional pressure, partly because of the need to achieve better coordination betiqeen the various parts of I - 15HEW,, and because of the crushing magnitude of the problems of heart disease, ca.ncer, stroke, and kidney diseases which constitute at least @O percent of the content of comprehensive health care, the Secretary has agreed that IIS',KJIIA will work closely With the Institutes in the area of disease control--and specifically in the fields of heart disease, cancer, stroke, and kidney disease. As a forerunner of the kind of intense cooperative effort which will henceforth be coordinated by the Institutes, the I;ccreta-ry launched the National Hypertension Program on July 25. Aimed initially at pro- fessional education in the field of liypcrtcnsion, it will later move on to public education and to the prepar,-tti.on of the iicaltli services delivery system to respond to an increased demand for screening, dia,@- nosis, treatment, and follow-u . This'activity is being served by'-- .P National Advisory Committee, an Inter-A-ency Working Group, and four task forces made up of members of the Natio:ial kdvisory Committee and@ representatives of the NHLI, Vk, FDA, and HS.MIIA. The first will deter- mine the content of the educational. proprini, define the level above which treatment is indicated, and recommend what that treatment should be; the second will plan the professional educational program; the third will plan the public education program; and the fourth, chaired by HS@IRA, will evaluate the impact on the health services delivery system and determine the resources-needed to respond to the professional and public education programs. Dr. W. McFate Smith, Regional Health Director for Region IX, is serving as the chairman of Task Force IV. This has been a very intensive effort'tsince July, and has engaged a large amount of the time of Dr. Margulies, and of Drs. Hinman, Sloan, and Greenfield. Eventually, it must engage the time and attention of this Council and of all the Regional lledical Programs. Dr. Wilson has made a firm commitment that every IISMIIA program which can increase its attention to measures affecting the control of heart disease, cancer, and stroke within the limits of present fuiidirA and personnel will do so. Depending on the level of funds eventually released, additional contributions will. be made by Ilq@iHA programs to the.control of these diseases in coopeL@ti..oii -,,Ti- L'h tli(! @ICT, the the NINDS. The area of hypertension will take precedence in this cooperative effort, but the others will not be far behind. What does this mean for the @fPs? SomL-.how they will have to-be' encouraged to put a larger part of their program--, block into the fields oil heart disease, carLcer,-a-,id @troke, but to-do this a6 an int @ra@,,,rt 6 of comprehensive health care.. We wish to protect the gains tliev have made in the last two years and to reintroduce some of- the categorical disease activities in a very special way which will not adversely affect the current noncategorical program efforts. We therefore wish to see'k- your reaction to the following proposals: 1) That the RMP's be encouraged to retain or redirect a part of their regular grant program to support those activities which seem most important at the local level in relation to heart disease, cancer,. and stroke. 2) That a special fund be designated for control ac tivities--the exact amount to be determined by the level of funds finally released to RMPS by OMB and DHEtl--at least--a portion of which would be held centrally. Emphasis would remain on getting this to the RAG's as rapidly as possible but with more specific guidelines than has held for some of our past programs. 3) Some part of these central funds be awarded to the regions by contract after review by appropriate committees of expert consultants for activities which will-follow guidelines developed by PMPS in close cooperation with NCI, @ILI, and NINDS. 4) Quality assurance has been discussed-with this council before ,:tit 'Llie issue has never been more urgent. Some of these central funds may also be used to support contracts (a) with national professional organizations for 4,-'Iie devel pment of criteria for quallt 0 _y assurance in relation to heart disease, cancer, and st'r@ke; (b) with individual institutions or to groups of institutions to demonstrate various alternatives -C-or the cle'!iverv of Iiif@li g(iiLl.ty services to patients with these diseases; and (c) with ite@ion,,.tl @ff-,dical Ilrograrits or 7 national -professional organizations to promote-the.regionalizat ion of specialized facilities and services. Review mechanisms would have to be worked out; staff would have to be assigned (any additional positions possible?); and methods of communication of these changes to the regions would have to be developed. In short, RMP's have some new priorities which are really some of the ones they started with, but which now should be integrated into comprehensive health care as much as possible and represent a partnership effort with the NHLI, and 7TCI, and NINDS. II. Council P d PhasinLy diit of- 1r cts The other subject I wanted to discuss with you concerns your Council policy of decrementaj. funding and phaseout at the end of three years. We all know the dangers of getting trapped in demonstration projects for which it proves impossible to find other sources of support. Obviously, if these are alloi@-d to become fixed charaes and continue to proliferate, 0 the situation would resemble Medicare and Medicaid, soakiii,r up aii ever- increasing share of the R@IPS budget. The Program would ttic@n cease to a developmental one and lose the marvelous, innovative, catalytic role it has played so well. But it was tliis-3-year termination policy also that gave us special trouble in the Congi-ess last s ring. Programs we:@t.i p 'being terminated rigidly because they had had 3-year fundin@. In some cases little effort was made to he@. the project directors find other sources of f@a@cial support. In some, allegetily promising projects wore terminated abruptly when one or two more years at reduced funding might have enabled them to become self-stij)jjrjr-tiij,,. of tliciit., sii 8 programs or just beginning to fafill their promise, and it appeared that the,reward for success was annihilation. Whatwe should like to have you consider are some modifications of your policy which would put emphasis on the following: 1) Continue., as I know you do now, requiring new ipplicants to indicate how funding will be covered from other sources in 3-5 @,ears. 2) Make awards with decremental funding when possible. 3) Ask the PIIP's to take greater responsibility in belpin@ applicants find other sources of 4) AT)plv the policy with :Elexi.bi.li-L-y. Not all of our innovations in health care will be acceptable to the funding organizations. There may indeed be some service projects of such value that ]'%.@ll'S should continue funding them for more than three years. If no other alternative funding can be located then decremental funding should be applied gradually with a maximum of technical assistance to the local pro@riin so tli@tt i@r,3 are not in the osit.ton p of abandoning patients abruptly. 5 Particularly in programs i-il@,olviiiy children or tli(@ elderly, it would be better not- to get started on tliciii at all if -Lliere is no hope .;f other funding at the end. But the 11%@4P's will surely lay tip credit in if- they can start programs which bring h:!lp to these groups aii& eventu.-,Il,-,? make them self-sul)po2.-tiiig! It has been a keen pleasure for me to participate in your di-scussi(.)iis this morning. I tru@t you have found ii@y renj;u.,]@s i.nterestiii,r iiid tti(-pu6,lit LD t, . Their general thrust will be to it(](l initcviall.)! to this Coun(!il..',,,, prc@s(,.,,-)t responsibilities and scope of activiL@,. I I.:!.ll E)(,@ p'Le;isc@(I to,i..I..y to any quiwktdvnit' @that, e the enl3uikg - disc ussi.ons. l-rederiel, T,. St--one-OA-10--!(j-72