CONFERENCE ON REGIONAL MEDICAL PROGRAMS Washington Hilton Hotel, Washington, D.C. January 15-17, 1967 THE ISSUE: SURGEON GENERAL'S REPORT TO THE PRESIDENT AND THE CONGRESS Prepared by Staff of the Planning and Evaluation Branch of the Division of Regional Medical Programs This paper is provided as background to the TUESDAY, JANUARY 17, 1967 General and Discussion Sessions t! PREFACE The Report to the President and the Congress is set forth as a specific requirement in Section 908 of the Act authorizing support for Regional Medical Programs, as follows: "On or bef ore June 30, 1967, the Surgeon General, after consultation with the Council, shall submit to the Secretary for transmission to the President and then to the Congress, a report of the activities under this title together with (1) a statement of the relationship between Federal financing and financing from other sources of the activities undertaken pursuant to this title, (2) an appraisal of the activities assisted under this title in the light of their effectiveness in carrying out the purposes of this title, and (3) recommenda- tions with respect to extension or modification of this title in the light thereof." The purpose and importance of this provision was clearly stated in the following excerpt from the related Report of the Senate Committee on Labor and Public Welfare: "The bill calls for reevaluation of the program and the submission of a report to the Congress by June 30, 1967. The Committee views this requirement for accomplishments and recommendations of further development as an important and integral part of this legislation. This program provides the opportunities for major innovations. It is impossible to say with any precision at this time what the nature, extent and diversity of these medical complexes will be in the future. We do know that these developments will be closely watched by the Congress and by the American people. The Committee does expect that, as experience is gained, the various aspects of the program may alter to deal with new problems and opportunities and to extend the coverage of the complexes into new communities and situations. The impressive endorsements of the concept of give a basis for launching the program as soon as possible, but the final form in all its particulars is not, and cannot be clear at this time. Therefore, the need for careful and continuous reevaluation assumes a special importance for this program. The Committee urges that the program be administered at all times with a view toward the identification of productive modifications for submission to the Congress when the extension is considered in the future." INITIAL APPROACH The Report is a staff responsibility of the Division of Regional Medical Programs. A special Ad Hoc Committee of leaders in the fields of health, education and community affairs was established to furnish expert advice*. The Committee held three meetings between September and November of 1966 to help shape the approach to the Report and identify issues which require consideration. In addition, it was considered important to obtain the experience and insight of a wide variety of people concerned with Regional Medical Programs through a national conference. One of the major objectives of the Conference is to provide a forum for this purpose and a common frame of reference out of which an additional input of ideas can be secured before drafting the report. -'-Members of the National Advi@oEZ Council: Dr. Michae I DeBakey, Dr. Bruce Everist and Dr. James T. Howell. Other members: Mr. Ray E. Brown, Dr. George James, Mr. Boisfeuillet Jones, Dr. Charles Odegaard, Dr. Edmund Pellegrino, Dr. William Ruhe, Dr. Clark K. Sleeth, Dr. Ray E. Trussell, Dr. Burton Weisbrod, Dr' Robert Westlake, and Dr. Paul N. Ylvisaker. Special Consultants: Dr. Norman Beckman, Dr. Ward Darley, Dr. Edward Dempsey, Dr. Kermit Gordon, Dr. Charles Kidd, Dr. Jack Masur, and Dr. Howard Rusk. 2 IDENTIFIED ISSUES Divisional Staff and the Ad Hoc Committee have identified certain items and issues. These points are set forth on the following pages for discussion during the meeting on January 17. In addition conference participants are encouraged to identify and discuss issues and topics not included in this paper. 1. Background of t e ort There will be brief discussion of broad trends in science, medicine and education, and social and economic aspects leading to the enactment of Public Law 89-239. The legislative history will be siffmarized including the Administration's proposal (S. 590 and HR. 3140), the Senate and House Hearings and Reports. 11. The Nature ur o se of Public Law 89-239 a. urpose Primary objective is to ensure that persons through- out the country have the benefits of medical scientific advances in heart, cancer, stroke and related disease. Attainment of this objective is impeded by the gap that exists between scientific advance and day-to-day practice in parts of the Nation. The fundamental purpose of the Act as formally stated in Section 900 (b) is: ".. .to afford to the medical professions and medical institutions of the nation ... the opportunity of making available to their patients the latest advances in the diagnosis and treatment of these diseases." 3 b. Prescribed Mechanism for Attainment of Objective The prescribed methodology is regional cooperative arrangements among medical schools, research institutions, and hospitals, with broad based advisory committees to insure commitment to broad regional needs and guard against the domination of any individual institution or group. III. Progress Report In accordance with the specifications in Section 908, this Section will report on (1) activities supported under the program, (2) the relationship between Federal financing and financing from other sources of the activities undertaken, and (3) an appraisal of activities assisted in the light of their effectiveness. A. Activities Under the Program 1. Chronology of implementation a. Bill signed into Law October, 1965. b. First Council meeting December, 1965. c. Division of Regional Medical Programs established at NIH - February, 1966. d. First applications for planning grants received - April, 1966. e. First awards for planning grants - June, 1966. f. First applications for operational grants received October, 1966. g. First national conference on Regional Medical Programs January, 1967. 2. Basic data concerning applications received and approved; amount of awards; population served; participating organizations; staffing; nature and variety of cooperative arrangements; feasibility and 4 other studies undertaken etc. 3. Analysis of Major Planning Activities a. Organization and staffing of planning unit. .b. Collection and analysis of data on resources, problems and needs. c. Strengthening of communications and relationships among health resources. d. Development of feasibility studies and proposals for priority operational projects. e. Arrangements for continued planning. 4. Analysis of Major Activies of Operational Programs 5. Interregional Developments a) Multi-State (New England, Mid-West, Rocky Mountain area) b) Intra-State (New York, California) B. Relationships of Federal and non. 1. Resources made available from non-federal sources for pre-planning prior to grant awards 2. Resources made available from non-federal sources for planning and operations after grant awards. 3. Estimates of tyoe,of non-federal resources likely to be made available in the future. 4. Policies and procedures for assuring diversification of support. C. f Effectiveness 'I.. Methods of evaluation being developed and applied by Regional Medical Programs. 2. Data on scope of cooperative arrangements. 3. Approaches being developed to measure changes in resources and facilities that will extend "opportunities" for applying the latest advances. 5 4. Approaches being developed to determine impact of programs on the diagnosis and treatment of heart disease, cancer and stroke. 5. Examples of "critical incidents" in the development of Regional Medical Programs. IV. Problems and Policy Issues Requiring Consideration This section is most important since recommendations for extension and modification of the law will arise.from the problems and policy issues which have been identified. Inclusion of an item for discussion in the report does not necessarily mean that a change in the law is indicated. A. Continuation of Program There is considerable and compelling,evidence of the effectiveness of the Act in bringing about cooperative regional efforts among the major health resources for the purposes specified in the Act. Attainment of the fundamental purpose of assisting all physicians and medical institutions to bring the benefits of medical research advances to their patients appears realistic on the basis of early experience. While current legislative practice makes it unlikely that a new authorization will not include a time limit, the Regional Medical Program effort should be established as a continuing program. Such a long-term commitment is particularly important in order to enlist the participation of all institutions and to provide a sound basis for recruitment of high caliber manpower. 6 B. Construction of New Facilities The original Administration proposals for authority to support Regional Medical Programs included provision for grant assistance to aid both new construction and renovation. This provision was amended in the Congress to limit the definition of "construction" su that only renovation and remodeling costs were eligible for support. The Report of the House Committee on Interstate Commerce stated that "the lack of this authority for new construction should create no serious problems during the 3 years authorized in this.legislation and when a request is made for extension of this legislation in the future, the committee will review this question again. Experience to date has identified a number of areas in which authority to assist new construction is essential to the development of Regional Medical Programs. Priority needs have been reported for space in community hospitals to conduct continuing education programs and to carry on demonstrations of patient care. Most community hospitals do not include adequate space for educati.oi:,.al programs; acute shortages of patient care and supporting facilities have required immediate attention. The same conditions generally make it impossible to meet the needs for space for continuing educatinn programs through renovation and remodeling. During the conduct of feasibility studies and pilot projects, Regional Medical Proo,-.-ams have been forced to rent space outside the hospital for the conduct of educational programs and. the use of the 7 educational staff. This approach is not only costly but-it significantly reduces the impact of these efforts. It is more difficult for many medical practitioners and allied personnel to participate. It is impossible for certain desirable programs to be organized, particularly those involving demonstrations of patient care. The issue of matching requirements for construction also needs further consideration. Reports indicate that many community hospita s have insurmountable difficulties in raising funds for the construction of facilities for continuing education. There is a danger that a rigid matching requirement in this respect will distort or impede progress toward the achievement of the program's purposes. C. Relationship of Federal and Non-Federal Funding Regional Medical Programs provide, through cooperative arrange- ments, a broad systematic framework for planning and action. It is recognized that the Federal grant funds should not finance all the needs identified in this process and should not take over total support for the application of all medical scientific a ances. Congress has evinced interest in the amount of non-Federal resources made available to these programs as an index of local commitment and support and as a reflection of budgetary realities. It has been emphasized that diversification of fund support will enhance local initiative and control. In reviewing grant requests, primary attention is given to the extent and nature of local support. Continuing consideration will be focused on the policies And procedures that are employed locally for -8- ensuring diversification of resources for Regional Medical Programs. It has been f elt that a policy placing responsibility at' the local level f or assuring balanced, diversif ied support is more ef f ective and appropriate approach than a rigid matching requirement, particularly in view of the cooperative and innovative nature of this new program. D. Inter-R Public Law 89-239 authorizes grants only for the planning and operations of individual Regional Medical Programs. No consideration was given during the development of the legislation to other types of grant support. Reports have indicated that certain resources and activities to facilitate and support the development of Regional Medical Programs m in some instances, best be developed on an inter-regional basis, e.g., training of continuing education and other leadership staff, preparation of teaching materials, standardization of data collection, refinement of evaluation procedures. The available methods of financing of these needed services are often awkward and inadequate. It has been suggested that modification of the Act to permit grants directly for these support activities may be desirable in order to facilitate the development of individual Regional Medical Programs. Proposals for such support would have to be directly related to the achievement of the basic purposes of Public Law 89-239 and would be made only after review and approval by the Nationa Advisory Council on Regional Medical Programs. f. 9 E. Interpretation of Act A keynote of Public Law 89-239, in both its legislative and adminis- trative aspects, has been flexibility of approach. The primary purpose of this approach is to place maximum responsibility on local leadership to develop apprbpriate-mechanisms, plans and programs. Administrative guidelines and policies have encouraged local initiative while, at the same time, ensuring the established statutory purposes are pursued. Instead of rigid national directives, heavy reliance has been placed upon the review and evaluation of local p'rogram proposals by non-Federal consultant groups, both at the regional level through the Regional Advisory Group and at the Federal level by an expert review Committee and the National Advisory Council on Regional Medical Programs. Specific examples of flexibility of approach are: 1) The fundamental recognition that attention must be given to developing and maintaining a sound foundation of clinical capability upon which more sophisticated programs can be built. For example, it is recognized that increased accessibility to the most recent advances n cancer treatment is ineffective if there are serious gaps in basic diagnostic and treatment capabilities. Similarly, it is recognized that "improved diagnostic and treatment capability" must necessarily include preventive and rehabilitation activities. -10- 2) The establishment of new organizational mechanisms to reflect the cooperative relationships required in the program. One expression of this development is the organization of new non-profit agencies to serve as the coordinating agency for the Regional Program. These new arrangements can involve a spectrum of new administrative and fiscal problems that require innovation and inventiveness for their solution. On the basis of experiences to date, it appears that flexibility of approach has facilitated progress toward accomplishment of the aims of the program. However, reports have indicated that, in some instances, unreasonably rigid or lax interpretations of the Act and the Guidelines have complicated understanding and action. The question at issue is whether portions of the Act or Guidelines need to be clarified or amplified to insure needed flexibility. F. Categorical Emphasis The legislative history of Public Law 89-239 indicates that the original Administration proposal requested authority to make grants to encourage programs of regional cooperation among the major health resources for heart disease, cancer, stroke and other major diseases. The law as enacted provided for grants to encourage programs of regional cooperation among the major health resources for heart disease, cancer, stroke and related diseases. The categorical emphasis of the program has been widely discussed. Some have felt that it is not rudent or practical to develop Regional p Programs on a categorical basis. Others have argued that the efforts of the program shoulc be exclusively focused on immediate measures to reduce losses from the three "killer diseases"; they have pointed out that the highly complex skills and facilities required to apply the recent scientific gains against these categorical diseases makes it particularly desirable to organize such efforts on a regional basis. Others have suggested that the scope of the three diseases and related diseases is so broad that their control necessarily requires attention to fundamental questions of manpower and facilities. The initial period of program development has provided opportunities to test these viewpoints through a variety of experiences. During the planning phase the major activities undertaken by Regional Medical Programs have involved the establishment of a planning staff, the initiation of studies to obtain the basic data concerning pertinent health needs and resources and the development of cooperative relationships among the major health resources in the region. These activities are generally generic by nature and consequently have not significantly involved problems of categorical definition. In most cases, in order to plan effectively for heart disease, cancer, and stroke, it has been found necessary to consider at times the entire spectrum of resources available for personal health services. However, the emergence of the operational phase of the program will put a more intensive focus on its categorical purposes. Only projects -12- that can be shown to have direct significance for combating heart disease, cancer, stroke and related diseases can be assisted with Regional Medical Program grant funds. The experiences of the Regional Medical Programs will be especially important in determining what modifications, if any, are necessary or desirable on this issue in the legislative authorization. The impact of the categorical limitations on the potential of the Regional Medical Programs to contribute most effectively to improved health of the people and the best use of available manpower and facilities needs to be determined Similarly, the best ways of facilitating the diffusion of knowledge concerning the diagnosis and treatment of heart disease, cancer, stroke and related diseases needs to be identified. These discussions must take into account the fact that the legislative proposal for extension of Public Law 89-239 will probably request authorization for the program through 1973. -13-