@ I'@ I'@, i @ VI. Questions and Answers A. What would be the impact of -Dhasina out R@IP grants in terms of projects and funding at sponsoring institutions, staff employed on operational projects, and staff employed on the RMP program (core) staffs? B. Has any consideration been given to modifying @iP so that the mechanism which has been established may be used in a different way? C. What is TUIP doing in terms of Training and Manpower Utilization activities? D. What is PYP doing in the area of kidney disease programs and regionalization? E. What types of planning and feasibility studies cAre being done by the RI@ program staffs? F. What is the situation in terms of the use of State boundaries by the Ri',i?ls in defining their area of influence? G. To what extent have the Rlels been successful in attracting other funds? H. To what extent have the RIIP's been able to assure continuation funding for operational projects without a continued reliance on Federal funds? I. In the past there was some indication that the medical schools and providers dominated RIIP. Is this still true? J. Based on recent budgets, what percentage of RY-P funds support activities of a categorical disease nature? How are these funds allocated among the various major diseases? A. Q. What would be the impa ct of phasing out RMP grants in terms of projects and funding at sponsoring institutions, staff e loyed on operational projects, and staff em loyed on the MP p Pd4P proaram (core) staffs? A. Sponsoring Institutions of Operational Projects As of June 30, 1972,, some 1,007 operational projects were being carried out by the Regional Medical Programs at a level of $76,540,,ooo. The phasing out of these projects would affect the following types of sponsoring institutions in terms of numbers of projects and grant funds: No. of Funding Level - FY 72 Sponsor Operational Projects (in thousands) Medical School 327 $ 27$772 University Health School 52 35227 Other Educational Institution 61 3,561 University-Affiliated Hospital 52 3,,670 Community or other Hospital 132 59699 Voluntary Health Agency 49 3@044 Public Health Agency 74 55049 Health Professional Society 18 213 919 Other 195 155696 Multiple 47 5,902 TOTAL 1,007 $ 765540 Staff'EmDloyed on ODerational Projects As of August 1972, staff employed on operational projects totaled 2,292 persons (full-time equivalents). This included: Professional and Technical 1,654 FTE Secretarial and Clerical '638 FTE 25 292 FTE This amounts to an average of 41 persons per Region, with a high in California of 184 operational project staff, and two to three Regions in the lower range of 7-10 operational staff. Program (Core Staff) Program staff in the RMP's for FY72 included 1,374 full-time equivalents. This includes: Professional and Technical 805 FTE Secretarial/Clerical 569 FTE 1,374 FTE Given 56 RMP'S, this represents an average size staff of 24.5 full-time equivalents. Size of staff varies greatly with both the size of the region and its maturity. California$ for example, with nine sub-regions, has a total staff of 206 FTE, while the Delaware RMP, which is a newly formed region, is just in the process of hiring staff. B. Q. Has any consideration been given to modifying RMP so that the mechanism which has been established may be used in a different way? A. A variety of options for Modifying @IP were considered by the Office of the Assistant Secretary for Health before the final decision was made. Among these: 1. implementation of Quality Control/ Assurance Mechanisms -- It is possible to look at qua lity assessment efforts comprised of three basic components: (1) development of the quality assess- ment system itself, including technical assistance to start it at the State or local level; (2) the actual operation of a quality monitoring system; and (3) corrective action which is taken as a result of areas of deficiency pointed out by the monitoring system. To date, M has been mostly involved in corrective action to meet obvious problem areas. This has centered on patient care demon- strations involving new techniques and innovations in health care patterns, and educational efforts aimed at correcting identified areas of deficiency. During late FY72, RNT started to work in the area of raising the level of health care provider understanding and experience of the objectives and techniques of quality monitoring as rapidly as possible. R..IPS plans development this year of an inter-regional program for development of quality of care consul- tative services. There has been little consideration so far in RMP of moving beyond the developmental and technical assistance role to having a direct monitoring responsibility for quality of care. 2. Local Implementation of CHP Plans and Priorities --Depending on the nature of decisions made about the future role of the CHP agencies, there will probably be the need for some sort of implementing agency or agencies to take those actions and promote those activities necessary to accomplish projects and agreed upon plans. Such an implementing body would need to be responsive to the priorities and plans which had been developed by the CHP agencies. Regional Medical Programs tend to fit rather naturally into the implementor role, although this has not been in conjunction with CHP plans or priorities in particular. Reasons for looking toward RMPs as implementina agencies include the linkaae with the provider@ co ity, which will eventually be responsible for actual imple- mentation; their current existence as viable, functioning organiza- tions coverinu the entire country; and their past experience in this role in terms of patient care demonstration projects, emergency medical service systems, and program staff activities in promoting a range of new initiatives such as H'vlOls and quality assurance efforts. 2 3. Mochanism(s) for conducting pilot experiments, demonstrations, and reforms within the system. This includes conmunity-based test beds for valid R&D efforts. --There has not been a particularly great emphasis on designing the products of health services research and development for widespread implementation at the local level. Much of what is locally developed does not take advantage of experiences else- where in the country. This area of widespread introduction of innovations into the health care delivery system is one in which RW is already somewhat involved, but which could be expanded upon and made more explicit. This would be in keeping with one facet of the original P.NIP mandate which was to promote the latest advances, and it would also provide a needed compliment or tioutlet" to HS' research and development efforts. 4. Promotion ot/assistance to new Federal initiatives (e.g., M's, Emergency Medical Service Systems). --As new Federal initiatives are decided upon, their success depends a great deal on having agencies at the local level which can -respond quickly and effectively to initiate new program activities. For a variety of reasons, including their linkage to the provider community, their operating experience, and the flexibility allowed by a grant structure which incorporates both operational project activity and program staff activities, the RWs are able to function well in responding to a variety of new Federal initiatives. S. Vehicle for large-scale implementation of community-based disease control rocrams, such as hypertension and end-stage renal P C, disease. --Given recerit Congressional action in terms of the National Car-cer Act and the National Heart, Blood Vessel, Lung and Blood act of 1.972, one possible area of focus was on community-based disease coptrol programs. In part because of its legislative background, there are some proponents of having R@ dlive empI-iasis to largb-scale implementation and support of disease control programs. Such disease control programs might best be carried out by a mechanism which has close ties to co,.,@ity health institutions, rather than by one of the national research institutes. Use of the RMP mechanism would help ensure that the disease control activities undertaken would be more nearly integrated with or linked to the larger health care delivery system and private provider sector at the local level, rather than leading to further fragmentation of the system. 3 6. Feedback loop from the service to the educational sector,, and those institutions responsible for the production/training of health manpower. --There is currently a vary tenuous connection between the educational sector, more specifically the medical schools and other health personnel schools, and the patient services sector in the form of community hospitals and the practicing physicians The educational sector tends to on the ba is oi ,project its plans s shortages of specific personnel; the patient services sector, on the other hand, tends to look at gaps in health services, either in terms of specific population groups or geography. There is not a well-formed attempt to relate education to the health services delivery nee s o an area. Regional Medical Programs in conjunction with the CHP agencies, would play a part in this effort by developing an improved feed- back loop_from the patient service sector to the educational sector, so that the focus of the latter is concentrated on gaps in health services, many of which might be filled by existing manpower. 7. Stimulation and support of greater sharing of resources and services among health institutions aimed at moderating cost increases. --There is a continuing need for the development of improved institutional linkages to increase the productivity of each of the participating institutions . Such linkages extend their capacity where limited services already exist, and provide for increased availability and accessibility where such services do not exist. Regionalization and new organizational arrangements are major themes of Regional'i%ledical Programs. TA'orkina, relationships and linkages among co . ity hospitals and between such hospitals and medical centers are among the primary concerns of the program. The linking of less specialized health resources and facilities such as small co ity hospitals with more specialized ones is an important way of overcoming the maldistribution of certain resources, and thereby increasing their availability and enhancing their accessibility. Kidney-disease is one area in particular in which the development of integrated regional systems can prevent the duplication which has so frequently wasted our limited resources. C. Q. What is RMP doing in terms of Training and'Manpower utilization activities? A. RMP support for training and manpower utilization activities is generally divided into three categories: FY 1971 FY 1972 Percent of Percent ol No. of Amount (in operational No. of Amount (in operation Activity Projects thousands) funds Projects thousands) funds Training Existing Health personnel in New Skills 144 $105,154 22 200 $13,266 17 Training Now Categories of Personnel. 16 921 2 55 3,566 5 Continuing Education 149 9,578 21 186 12,031 16 Training Existing Health Personnel in New Skills - aimed at enabling the person trained to assume new responsibilities in his already chosen career field. The emphasis is on increasing the productivity of personnel and includes expand- ing the functions of registered nurses and career mobility for licensed practical nurses. New Categories of Personnel - the establishment of training programs for new categories of personnel such as physicians' assistants, nurse practitioners, and communit health y workers. The primary objective here is to expand the man- power health pool through the development of these new categories of health and allied health professionals who can become part of an expanded health services delivery team. *Total current funding level, which includes some funds obligated in prior years. Continuing Education --courses aimed at maintaining OX, improving-the level of practice of the health professional. Most RMP training activities operate outside the general education process, and are of short-term duration. In FY71, through on-the-job training (involving release time)5 85% of the training provided was five days or less, with 60% of that involving one day or less. In RMP's approach to resolving manpower problem s, the emphasis is on evelodina programs that more closely relate education to the health service delivery needs of an area. In terms of health professionals already recognized (e.g., MD's, nurses), the emphasis is on increasing their capabilities, knowledge and skills, and not on increasing the numbers of such recognized health professionals. Training is not supported which leads to licensure or registration. On the other hand, training for new categories of personnel is devoted to creating new types of health paraprofessionals not yet recognized by the health care system as health pro- fessionals. The present curriculum structure of the health professional schools is not designed to create these new types of manpower (e.g., physician aide, home health aide). In terms of the course registrations for each of the three major categories of training, the attached chart shows 3 naturally that the highest registration is in the shortest- term courses (i.e.,, continuing education, and new skills for existing personnel) while the training for new categories of personnel, which takes a lonaer period, shows a lower level of registrations. COURSE REGISTRATIONS IN RMP-SPTLZSORED EDUCATION ACTIVITIES FY 72 (Listed by Type of Training Received and Discipline of Recipient) CONTINUING NE14 SKILLS FOR NEW TOTAL DISCIPLINE EDUCATION EXISTING PERSONNEL b/ PERSONNEL c/ No. Percent Physicians (@/DO) .46,328 10,140 56,468 29% Dentists 1,442 197 1,639 1 Nursing Personnel 36,301 25,072 146 61,519 32 Allied Health Personnel 23,011 12,362 1,205 36,578 18 Hospital/Nursing Home Personnel 10,414 694 11,108 6 Medical, Dental and Nursing 6,106 1,139 7,245 4 Students Other 8,582 9,579 1,064 -19,225 10 TOTALS 132,184 59,183 2,415 193,782 100% a/ Continuing Education - courses aimed at maintaining or improving the level of tice of the health professional. b/ New Skills for Existing Personnel - training aimed at enabling the person trained to assume new responsibilities in the already chosen career field or adding skills in a different but related health field (e.g., coronary care training for nurses, career mobility for licensed practical nurses).. C/ New Personnel - development of,training programs for such new categories of personnel as physicians' assistants, nurse practitioners, and community health workers. D. Q. What is RMP doing in the area of I collection activities carried out during 1970 and 1971, in order to determine the extent of regional problems and the resources available for use in their solutions. 2 Area of Planning Study of Number of Studies Data Collection Manpower distribution and availability . . . . . . . . . . . . . . . . . . . so Services and facilities . . . . . . . . . . . . . . 98 Health conditions . . . . . . . . . . . . . . . . . 95 Categorical diseases . . . . . . . . . . . o . . . . 29 Screening . . . . . . . . . . . . . . . . . . . . . 23 Continuing education . . . . . . . . . . . . .. . . . 42 Data Banks . . . . . . . . . . . . . . . . . . . . . 38 TOTAL 375 In addition, the Regional Medical Programs are involved in a variety of joint planning and data system efforts which involve cooperation with other agencies, particularly the Comprehensive Health Planning agencies. According to a program analysis memo- randum completed in 1971 on @IP relationships with CHP agencies, some 45 State CFIP agencies cooperated with R@,IP's on joint surveys., studies, or exchange of services in data collection or analysis. Of the 50 Regional Medical Programs having Federally-funded Areawide CHP agencies in their region, 46 reported having data sharing or other types of joint data activity with at least one Areawide agency in their region. In Arkansas, for example, Areawide CHP agency staff and committees are utilized to provide subregional data to RMP in the develop- ment of subregional plans. The Arkansas RMP and the State CHP agency are also cooperating on the development of a regional hospital plan for health service delivery, and both were closely involved in the planning for the Experimental Health Services Delivery System. RMP, with its strong linkage to the provuer community, has served as an important technical, professional and data resource for the State and Areawide CHP agencies. The RMP'S. in turn, have looked to the plannina agencies for expression of broad-based community health needs and priorities. Although the amount of funds being used for planning activities was large in the early years of the program, it has declined recently as most of the l@rograms have become operational, and has ranged from approximately $4-5 million in the past two years. 3 Feasibility studies.- Pilot projects which frequently provide necessary seed money. if the initial results warrant, imple- mentation on a larger scale, either as a R@,IP-supported oper- ational project or with funds from other sources, can generally proceed. A project to screen Pittsburgh students for sickle cell anemia was initiated last year,by the Western Pennsylvania RMP. Testing will provide an indication of the problem in school age groups, with the data to be analyzed by the Allegheny County Health DepartmOnt and the University of Pittsburgh Health Center. The American Indian Free Clinic opened this spring in a re- modeled wing of the Grace Baptist Church in Compton, Cali- fornia, which is part of the greater Los Angeles area. With seed money from the California RMP, an OEO grant, and much volunteer help, the Clinic handles 35-40 patients every Tuesday and Thrusday evening. All equipment for the clinic was donated and almost all the volunteer help are Indians. F. Q. What is the situation in terms of the use of State boundaries by the RMP's in defining their area of influence? A. Geographic boundaries: Number of program which primarily: Encompass single States 34 Encompass two or more States 4 (e.g., Washington-Alaska RMP) Are arts of single States 11 p (mainly in N.Y., Pa., Ohio) Are parts of two or more States 7 (e.g., Bi-S@te: St. Louis and southern Tilinois) There are both pluses and minuses to the use of State boundaries by the majority of the Regional Medical Programs. Points Favoring the Use of State Boundaries There is a greater congruency with State CHP agencies, allowing greater consistency of RMP priorities to community and State established priorities. The increasing politicalization of health at the State level i@@more consistent with those RMP's that match State boundaries. Many emerging and important practical issues are or will he dealt with in a State frame of reference, including production of manpower licens-ure, HMO regulation, and other tax-supported activities. 2 Points Auainst the Use of State'Boundaries In those cases in which the RYP does not match a State -boundary; there is generally strong justification in terms of the natural medical trade area. These include the metropolitan areas of St. Louis (and southern Illinois), Memphis, and Metropolitan Washington, D.C., with others in Ohio Valley (Kentucky plus Cincinatti and other parts of southern Ohio) and Intermountain R@IP (Utah, and portions of surrounding States). State boundaries could harm making maximum use of these natural trade patterns. State boundaries can lead to creation of unnecessary or redundant specialized services and facilities, such as kidney disease and specialized heart disease resources. There might be less incentive to make optimum use of nearby resources of another State through regional planning and patient referrals. Use of a State boundary for an FIIP should in no way inhibit it from reaching beyond State boundaries in its activities where the logic of the situation has so dictated. Most regions have followed this logic in developing their programs and activities. G. Q. To what extent have the He's been successful in attracting other funds? A. With a small initial input of program staff time or opera- tional project funds, the FJYT's have often been able to generate health care activities on a larger scale which brought in funds from a multiplicity of sources. In FY72, for example, approximately $8.4 million in other sources of funds was coNbined with $76.5 million in He funds to carry out operational projects. Other sources of funding included: State funds: $1.33M Local funds: 3.51 Other Federal: 2.20 Other non-Federal: 1.4o $8.44M Among e@les: Maine's Regional Medical Program has been primarily respon- sible for $4oo.000 of additional financial support from other agencies and organizations during this past year. This includes: * $75,000 from the Maine State Legislature and $40,000 from the New England Regional Cormdssion working toward development of a College of Physicians * $29,000 from various voluntary health agencies for public education in health * $4,300 from a variety of drug corporations for a coronary care project * $4o.,OOO from the Veterans Adrdnistration for Area Health Education Planning * $9,500 from the Comonwealth Fund for evaluation of the Inter-active Television Project * $43,000 from OEO - New England Regional Co@ssion for a healthmobile project. 2. New Jersey JUTls four-year old Urban Health Corrponent, funded at $160,000, provides health planners to that state's eight Federally-designated Model Cities Progranis. Begun in 1968 vihen urban health coordinators were assigned to New Jerseyts first three lqodel Cities, it proved so successful that in AT)ril 1970 this project was expanded to include the other Model Cities in the state. To date, the staff has secured more than $8.4 Billion from sources other than @ to fund health program in these cities. (This Urban Health Corrponent was expanded again in 1971 when the New Jersey @ signed a contract with the New Jersey Depart- mnt of Comunity Affairs to provide health planning assistance to the 16 cities in the state's ten Comunity Development Programs.) Q. To what extert have the He's been able to assure continua- tion funding for operational projects without a continued reliance on Federal funds? A. The concept of time-limited support has always been central to Regional Medical Programs. Furthermore, incorporation within the regular health care financing system of RMP- funded operational projects and activities has been an LTortant measure of their success (or failure). This con- cept of t@-@ted support initially was given explicit policy expression several years ago. The National Advisory Council in Noventer 1970 considered and approved a policy to the effect that RPe funding of operational projects generally should not be for more than three years. Addi- tional emphasis was given to this policy by the review criteria irfplemented in June 1971. Based on data available from recent reports from about one-third of the Regions (19 of the 56), it is estimated that IU4P support, in dollar tems, is being phased out within three years in some 75-80% of all operational projects. These same data indicate, again in terms of dollars, that roughly 60% of those projects from which RMP grant support is being orithdrawn, will be continued from other sources, albeit at a reduced level of funding. The increasing success of @s in turning over their grant funds within a reasonably short time, which in urn per- mits them to reinvest those same funds in new activities, and in attracting continuation support for activities they have helped initiate, is due to a number of factors. The rmjor one see@ to be that activities that are probl@ oriented tend to elicit community or local support. They are able to attract other sources of funds (or services in-kind) from the very outset. Another reason is that planning for decremental funding is built into many RT- initiated operational- projects. I.Q. In the past there was some indication that the medical schools and providers dominated R14P. Is this still true? A. During the initial organizational stages of Regional Medical Programs, the medical schools functioned as one of the significant resources for the RMPs' development. Commonly the center of the medical trade areas along whose boundaries the 56 regions were formed, the schools provided a natural resource for the establishment of the RMPs and for the conduct of their activities. In addition, many of the medical schools served as the initial grantee for the locally-developing RMP. As the Regional Advisory Groups began to mature, with their composition of a broad range of provider and public groups, the influence of the medical schools fell more into line with their normal influence in the community health structure. This shift is reflected in changes in the composition of the Regional Advisory Group, which is responsible for approving applications and setting overall RMP policy. Between 1967 and 1972, medical center officials have decreased from 16% to 9% of the representation while consumers have increased from 15% to 25% and practicing physicians from 23% to 27%. RMPS has also recently clarified the relationship between Regional Advisory Groups and grantees. The basic point was that the RAG, as the broadly-based group representative of community health interests, has the responsibility for setting the general direction of the RMP and formulating program policies, objectives, and priorities. With regard to the statement that Regional Medical Programs is dominated by providers, this is certainly true and is considered one of the strengths of the program. RMP provides an acceptable mechanism through which providers can work together with considerable flexibility to meet health needs that cannot be met by individual practitioners, health professionals, hospitals and other institutions acting alone. It provides one of the major links between both the Federal government an providers of care, and between consumer-oriented CHP agencies and the major provider groups. -age of PIIP funds J.Q. Based on their most recent budgets, what percent support activities of a categorical disease nature? flow are these funds allocated among the various major diseases? A. FY72 saw an acceleration of the longer-tern, trend towards the support of more cor,.orehensive and inulti-ca'L-legorical, operational activities by the RYiP's. In PY71, for examole, onlv about one-third of the nearly 600 r-,MP-supnorted operational projects were multi-categorical or compro- hensive in nature. The other two-thirds had essentially a single disease focus (e.g., heart disease, cancer, stroke). By the end of PY72, however, well over on---half of some 1,000 @,IP operational projects were of a multi- categorical or comprehensive nature. The n@, er of projects and funding levels for both categorical and comprehensive efforts is summarized below: FY71 FY72 No. of Amt. % No. of Amt. % Projects Projects Single, categorical disease focus 373 $28.5M 63 430 $29.6M 39 Multi"catcgorical or comprehensive 221 16.SM 37 574 46.7M 61 In terms of individual disease categories, there have been some significant shifts within the past year, as the summary table below shows: PY71 FY72 No. of Amt. No. of Amt. Net Projects Projects Change Heart 147 $10.SM 116 $ 6.6M -$4.2M Cancer 89 6.2M 98 6.5m + .3M Stroke & Hypertension 74 6.4M 65 5.OM - 1.4M Kidney 22 1.5M 74 6.2m + 4.7M Pulmonary disease 22 2.5M 35 2.9M + '4M Other related (e.g., i§-- 1.OM 42 2.3m + .8m diabetes) The fourfold increase in the funding of operational projects concerned with kidney disease laraely reflects the response of the R,.Ps to the Congressional priority on end-stage renal disease programs. The signifi- cant decrease, nearly 40 rercent in the funding of operational projects focused exclusively on heart disease is directly related to the continuing disengagement of P-7,:,Ps frcn coronary care demonstration and training 2 activities. This had, until recently, constituted the single largest discrete area of PD@-IP activity. In swu, there has been a large increase in the funding of comprehensive as opposed to categorical-type efforts. Among the categorical efforts themselves, there is an increasing balance among the several categorical diseases specified in title IX (i.e., heart disease, cancer, stroke, kidney disease, and other related diseases).