IIIM!Illllllllll!@l!l 4@l* CONFERENCE ON REGIONAL NEDICAL PROGRAMS Washington Hilton Hotel, Washington, D.C. January 15-17, 1967 THE ISSUE: THE DEVELOPMENT OF COOPERATIVE ARRANGEMENTS Prepared as a cooperative effort by the staff of the Division of Regional Medical Programs This paper is provided as background to the MONDAY, JANUARY 16, 1967 Morning Discussion Session In an editorial in the November 23* 1962 issue of Science#' DAel Wolfle pointed out that honesty and objectivity, reliance on the evidence rather than upon bias, wish, authority, or personal advantage, is one of the greatest gifts that science has given to society. A goal of the groups applying for Regional Medical Programs is to work toward meaningful relations which will be based on objective data and real needs. There has been concern for some years because health resources and organizations with nonidentical but related and overlapping goals have often not been able to work together effectively or to seek joint solutions to new problems. Many have defined the problem and have offered a logical solution. A fine example is given in the following statement by Dr. Charles L. Hudson at the 1962 Teaching Institute of the Association of American Medical Colleges: "A restoration of harmony among the elements involved could be effected by a sincere collaboration among physicians as physicians, in teaching and research, in training of interns and residents, and in patient care in the hospital and in the office. This, an education and practice complex, could be formed if physicians were willing, if necessary, to surrender some prerogatives in the interest of creating an effective private medical care system that would be recognized by the public for its superiority over systems established by government and welfare. "Evaluations could be made of the needs of the public for medical care, of the kinds of services required, and of the numbers and kinds of physicians and institutions needed to provide these services Based on these evaluations, educators could construct curricula to deliver graduates consistent with modern requirements. Community hospitals could continue to employ directors of medical education required to provide excellent training programs of perhaps a diff6rent character but of quality equal to those in the university centers. Differences between university hospitals and community hospitals would disappear in the collaborative efforts to train interns and residents through an interchange of teachers and trainees, the sites to be deter-mined by the competence of the hospitals to satisfy the fu- ture service requirements of the trainees. "The inevitable centralization of knowledge and techniques with stratification according to levels of knowledge and competence would continue, but equally important would be the areas manned by the physician with broad training. His primary contributions to the system would be in medicine, with occasional exceptional additions where circumstances required them. "The key to success of an integrated medical' practice would be the proper identification of the physician now sometimes referred to as the general practitioner, personal physician, family physician, first-contact physician, internist- pediatrician-psychiatrist, and other mixtures. if the profession fulfills its promises, there will be new and increased efforts to keep people well, an emphasis on health rather than disease, an augmentation and an enhancement of the field of preventive medicine. "The greatest challenge of the present is inherent in the job description of this physician, x-h o must feel the significance and importance of his practice and must believe in his ufiique ability as a true specialist to perform duties that others in the more narrow specialties might find impossible. Under no other circumstance will there be effective competition to careers in subspecialism. The divisive forces in the profession of medicine themselves point up the interdependence of its parts and the real need 2 ative effort. With such a sincere effort I would for cooper predict that our intraprofessional differences would disappear. "Numerous unilateral attempts at adjustment of medical practice have failed, because any undertaking that seeks to alter the position of one element, without regard to the effect on the integrated system, causes unhappiness and strife in the whole professional complex and will increase its susceptibility to outside interference and even domination. "As to the medical practice of tomorrow--if inte igence, good will, and technological advances exert their potent force--the changes should hopefully go in the direction of better care for the sick and greater fulfillment of the hopes and aspirations of physicians. (Epilogue) "As I finish this chapter after six months. of struggle and interrupted effort, I am at my desk, having just returned from seeing a patient with disseminated lupus erythematosus who is alive and at the moment well because of the miracle of medical progress. In recalling her happiness and the look of fondness and gratitude she gave me, I cannot help reaching out in appreciation to those persons, some known to me and many unknown, whose efforts have permitted me this,, the supreme reward of the physician. "A moment's reflection will show us what we all must know: we are not self-sufficient; even as an individual one does not practice alone." Congress and others involved in the development of Regional Medical Programs were convinced with Dr. Hudson that individuals and even institutions cannot cope with the complexities of modern medicine in isolation. Public Law 89-239, which authorizes grants for the planning and establishment of Regional Medical Programs, begins with the following two statements of purpose: a To encourage and assist in the establishment of regional cooperative arrangements among medical schools, 3 research institutions and hospitals for research and training (including continuing education) and for related demonstrations of patient care in the fieltis of heart disease, cancer, stroke, and related diseases. To afford to the medical profession and medical institutions of the Nation, through such cooperative arrangements, the opportunity of making available to their patients the latest advances in the diagnosis and trbat- ment of these diseases. Other sections of the law and the legislative IiisLory that led to its enactment indicate that all organizations and groups concerned with realizing these purposes are to be included as an integral part of the cooperative arrangements. These 4@ncltide, in addition to those identified above, medical societies, healtl. departments, voluntary agencies, other health professions and individuals concerned with health. Section 903 specifically provides that the Regional Advisory Groups must be "broadly representative" and must approve applications for operational grants. The Program Guidelines emphasize the essential importance of regional cooperative arrangements among these @roups tlirough- out the planning and operational phast-s of the Regior.,i.1 Medical Programs. 14hile it is recognized ttia-, the IA,il. deve.i.opiti;-.,nt of 4 such arrangements involves all medical institutions, organizations and individuals within a Region, and may take considerable time, the initiation of this effort is a critical aspect of the planning process for a Regional Medical Program. "Cooperative arrangements" are intended to facilitate effective exchange of information and ideas and working relationships among centers of advanced capabilities, private practitioners, community hospitals, and other interested private and public agencies through- out a Region. Through such channels, information and assistance can be moved out to upgrade and maintain daily practice at the highest possible level. The same local groups can feed back information on needs as a basis for further research and training. In this way, science and service may be linked in systems of mutual support and benefit. In the development of the program, emphasis has been continuously placed upon its cooperative and centrifugal features. It is believed that the extension of excellence in health care to all parts of a Region can be facilitated by bringing together all the major insti- tutions and interests for planning and action. The product of the efforts of organizations working together can be much greater than the sum of the separate efforts. As the President's Commission on Heart Disease, Cancer, and Stroke pointed out: "A creative partnership among all our health resources ... is the true path to the conquest of heart disease, cancer, and stroke." 5 During the first year of the program, a great deal of emphasis was placed on the term "cooperative arrangements" both by the applicants and by the reviewing groups. One applicant, who was also a consultant to the program, stated that in the strictest sense, justification of the program would rest on the ability to demonstrate the development of cooperative arrangements where they had not existed previously. All have agreed that the documentation of this aspect of the program is an appropriate accomplishment to report to the President and Congress. The requirement for.the development of regional cooperative arrangements was the major factor in determining@the sizes and shapes of Regions as various parts of the country probed for what seemed to be the best workable conditions. A part of the planning process will be to reexamine the factors that lead to the conclusion that a given Region offers the best opportunities for effective utilization of resources. In some instances, political considerations may have deserved a relatively higher priority in the establishment of an application for a planning grant than will be the case with regard to operational grants. In others, deficiencies of resources may require the development of cooperative arrangements across great distances, at least for interim purposes. Almost surely, close relationships between adjacent Regions will prove beneficial. An editorial in the 6 August 12 issue of The Journal of the American Medical A sociation comments that cooperative arrangements within Regions seem assured and that the next question is whether such cooperation can exist between Regions. The development of cooperative arrangements requires organiza- tion and communication, sharing of resources, ability to reach joint decisions, and the development of the capability to evolve new and creative approaches to complex problems which cannot be met by individual institutions or organizations. In the early stages, it is inevitable that most decisions will be made on a basis of the wisdom and experience of the participants and the advisory groups. A primary goal should be, as Wolfie suggests, to begin by establishing mechanisms which will allow the substitution of objectivity for bias, and data for wish or authority. Some insight into the problems to be anticipated in the future can be gained from a study of the issues which have arisen in the review of the early operational applications. A primary goal of Public Law 89-239 is the establishment of decision-making mechanisms on the local level which assumes that different priorities exist in different parts of the country. On @the other hand, neither the National Advisory Council nor the Public Health Service can delegate their basic responsibility and accountability that Federal funds will be expended wisely. 7 gional Medical Programs have submitted A number of Re ently being applications for operational grants which are curr . These applicants the Review Committeeg t@e council, review6d and staff have id entified issues in the process of working with these applications. The following list is not meant to be complete, for future grant requests will bring out additional issues, and one could speculate that still ot@ers will arise: 1. Characteristics of early operational proposals A. Many projects contained in each complex proposal quests B. Sizable budget requests, including large hardware re C. Commitment of effort by individuals, organizations and institutions II. Regional Medical Program vs. collection of projects A. Relevant characteristics of Regional Medical Program on which this judgment can be made 1. OvIerall leadership and guiding philosophy a. is there a unifying conceptual strategy which will be the basis for initial priorities of action, evaluation, and future decision making? Are there sufficient feedback loops in the strategy9 b. Is there an administrative mechanism which can: 1) make decisions (2) relate to regional needs (3) stimulate cooperative effort among major health interests .dentified? Can c. Are the key leadership persons i they work with the major health interests? Do they have experience and skills appropriate for providing leadership to a complex endeavor? 8 d Is there involvement and commitment of the major health interests such as: (1) Medical schools (2) Practicing physicians (3) Hospitals (4) Public health agencies e. Will the ongoing plannirg process interact with the first operational steps in the development of a program that meets the broader needs of the entire region? nterrelationship of specific proposed 2. Nature and i activities in regard to the goals of PL 89-239.' B. Evidence that priorities have been set at the regional leve III.,Quality standards A. Regional vs. National standards B. Emphasis on grantees) own evaluation mechanisms as quality uplifting factor at regional lev6i IV. Criteria for judging appropriateness of support A. Scope and limitations of Regional Medical Programs legislative authority, including categorical focus B. Availability of other sources of support C. Priority on innovative and leverage effects V. Criteria for judging level of support A. Geographic distribution - Should consideration of availability of funds for later proposals be a pIart of decision on amount awarded to first applicants B. Partial or phased support as mechanism for: 1. Allowing fuller development of plans before proceeding to fuller implementation 9 2. Permitting better decisions on distribution of funds 3. Early review of progress C. Need to support "critical mass" of activity which will have a sufficient impact to permit evaluation of results D. Support of costly activities as national or interregional resources when justified by the involvement of unique capabilities in a specific Regional Medical Program E. Extent of need for support of operational activities as necessary for further development, extension, and solidification of regional cooperative arrangements VI. Length of commitment A. Degree of emphasis to be placed on self-limiting nature of projects B. Need for long range commitment for "core" activities which are essential investment for conduct of specific projects VII. Relationship of operational proposals to ongoing planning activities A. Need for documentation of relationship B. Extent of prior planning and its relationship to proposed operations and continued planning C. Extent to which needs of periphery of the region need to be documented as basis for undertaking operational activities VIII. Need to spell out relationship with adjacent regions and to justify the proposed region IX. Adequacy of administrative arrangements, including fiscal accountability of grantee Examples such as these from early operational grant reques s, and others yet to come, will continue to test the workability of developing cooperative arrangements over a wide range of activities. The first Conference discussion session is directed at reviewing experiences in the development of these regional cooperative arrangements and considering plans for extending and modifying these arrangements in the future.