Summary Regional Medical Programs have made an impressive beginning. But it is only a beginning. Much is yet to be done. Many problems and is- sues are yet to be resolved. How- ever, if the future is marked by the same enthusiasm and cooperation and our national commitment is sus- tained, a major change may well be wrought in the workings of Ameri- can medicine. This change will benefit the health professions and bring great benefits to the American people. SECTION ONE Summarv / In October 1965 President Johnson signed Public Law 89-239; the Heart Disease, Cancer and Stroke Amend- ments to the Public Health Service Act, authorizing grants to help es- tablish Regional Medical Programs to combat heart disease, cancer, stroke, and related diseases. This program had its origin in the recommendations of the President's Commission on Heart Disease, Can- cer and Stroke, presented in Decem- ber 1964. Its ultimate goal, like that of the Commission itself, is to help make the best in modem medical sci- ence readily available to all people who suffer or are threatened by these major diseases. To accomplish this purpose, Public Law 89-239 proposes the establish- ment of direct and continuous link- ages between the patient, his physi- cian, his community hospital, and the Nation's centers of scientific and academic medicine. It seeks to unite the health resources of the Nation, region by region, in close working relationships which will speed the transmission of scientific knowledge and methods to the people whose lives depend upon them. The first stages in the development of the Regional Medical Programs are now well underway. As of June 30, 1967, planning is moving forward in 47 Regions with the support of planning grants; the 47 first year awards total about $20 million, and 10 second year awards about $4 mil- lion. (Exhibit III) The geographic Regions encompassed in these awards contain about 90 percent of the Na- tion's population. The beginning stages of program operations have be- gun in 4 Regions with the support of grants totaling $6.7 million. (Exhibit IV) Additional applications for grants to support planning covering the remainder of the country are now under review or development. On this record, progress in the development of Regional Medical Programs is substantial. It is partic- ularly impressive when viewed in the context of the initial tasks that had to be performed. These included the creation within the Public Health Service of a new administering orga- nization and the assembling of staff. Program guidelines had to be devel- oped and promulgated; criteria and mechanisms for review of grant ap- plications had to be established. The many issues and problems presented by this new departure in Federal health action were widely and in- tensively discussed with individuals from all parts of the country. In each Region, initial tasks included working out the bases for developing regional cooperation among major health in- terests, designing the planning pro- gram, appointing and convening the Regional Advisory Group, and re- cruiting staff. The initial experience described in this Report demonstrates the pro- gram's potential for improving the `health of the American people. To fulfill this potential, the following recommendations are clearly indi- cated : 0 The program should be estab- lished on a continuing basis. There is every indication that the approach authorized by Public Law 89-239 is valid and promising. Extension of the program, building upon the initial planning and pilot projects, will lead to realization of its potential and will contribute significantly to the attack on these major diseases. 0 Adequate means should be found to meet the needs for construction of such facilities as are essential to the purposes of Regional Medical Pro- grams. A limited amount of new con- struction has been found to be es- sential to achieve the purposes of the Programs ; priority needs are educa- tional facilities, particularly in com- munity hospitals. Authority to assist the construction of new facilities, which was requested in the initial bill in 1965, was set aside during the con- sideration af the bill in the Congress. This modification should be carefully designed, in amount and administra- tion, to meet the special requirements of Regional Medical Programs and to enhance cooperation with related programs. c] An effective mechanism should be found to assist interregional and other supporting activities necessary to the development of Regional Medical Programs. This assistance will facili- tate the work and implementation of individual Regional Medical Pro- grams. 0 Patients referred by practicinp dentists should be included in the r-e- search, training and demonstration activities carried out as necessary parts of Regional Medical Programs. O Federal hospitals should be con- sidered and assisted in the same way as community hospitals in planning and carrying out Regional Medical Programs. Underlying this program and the recommendation for its extension is the broad national concern over the extent to which new medical knowl- edge and technology is brought rap- * idly and effectively into use in health services and medical care throughout the Nation. The legislation proposes regional frameworks for accelerating this transfer. It envisions two-way flows of useful science and technology `; between academic and scientific cen- ters and agencies and individuals who 3 deliver medical care in the local communities of the country. To accomplish these purposes, the Law authorizes the award of grants for the planning and then for the operation of regional arrangements, designed to stimulate new patterns of cooperative action among physi- cians, hospitals, university medical centers, public and voluntary health agencies. Each regional arrangement should help to create a coordinated program encompassing research, training and continuing education, patient care demonstrations and re- lated activities. Its goal is to advance the accessibility and the quality of health services available throughout the region for heart disease, cancer, stroke and related diseases. The emphasis in this program, re- flecting the legislative background from which it emerged,. is on local initiative and local planning. This approach is intended to sustain the essentially private and voluntary character of American medicine. At the same time, it permits the use of Federal funds to stimulate and sup- port innovative approaches to com- mon problems under local leadership. An advisory group, representing the regional health interests in each Region, including those of the con- sumers of service, is required by law as an essential step in the develop- ment of a Regional Program. Thus the character of the individual pro- grams will vary as they reflect the differing needs, resources, and pat- terns of relationships. The experience gained in the year since the first grant was made has provided considerable evidence that new cooperative arrangements can be developed among institutions and in- dividuals involved in health and medical affairs. Regional groups rep- resenting a wide variety of interests and functions have come together in an unprecedented fashion to plan and work cooperatively on common needs and goals. Over 1,600 individ- uals, including physicians, medical educators, hospital administrators, public health officials and members of the general public are serving on Regional Advisory Groups. They are performing an important role in the planning and develapment of the in- dividual Regional Medical Program. It seems reasonable to anticipate that workable mechanisms for accomplish- ing the goals of the Heart Disease, Cancer and Stroke Amendments of 1965 will progressively emerge based on these initial cooperative efforts. There are, however, uncertainties and problems still to be resolved in the further evolution of this program. In part these questions arise out of the diversity and complexity of forces that characterize the American health scene. Some of the questions are generated by the particular terms of the legislation under which the program operates. Still others emerge from certain broad changes which are inherent in the further development of these programs. Significant among these questions are the following : 0 Can the character, quality and availability of health and medical care services in the area of heart disease, cancer, stroke and related diseases be significantly and meas- urably modified? 0 Are the regional administrative entities developed for these programs viable and durable over a long period of time? 0 Can voluntary professional and institutional compliance be obtained in the efficient disposition and use of critical manpower, facilities and other resources on a regional basis? 0 How will the activities generated under Regional Medical Programs af- fect medical care costs and influence the extent to which such costs can be met by normal financing methods versus direct support through Re- gional Medical Programs? 0 What long-term relationships should be established to assure that Regional Medical Programs comple- ment other Federal health programs, particularly the Comprehensive Health Planning Program initiated under Public Law 89-749? c] How can local programs over- come lack of space to carry ,out cer- tain of the activities and functions being engendered by Regional Med- ical Programs, particularly space for training and continuing education? In addition, it has been difficult thus far to obtain more than a tenta- tive commitment from many insti- tutions and individuals because of un- certainties'over the national intention- and the limited duration of authoriza- tion for grants for Regional Medical Programs. Assurances of longer sup- port are essential to maintaining the vigor and achieving the objectives of this program. Many of these issues and prob- lems will be resolved in the future conduct of the program. Others will require either executive or legislative action. Regional Medical Programs have made an impressive beginning. But it is only a beginning. Much is yet to be done. The Essential Nature "The objective of this legislation is to build from strength and to pro- vide those mechanisms which can link the source of strength with the needs of the community . . . We wauld hope that the proposed new program could have its greatest in- novative effect . . . as a significant new extension of the capability of existing progmms in bringing to bear on patient needs the benefits of sci- entific medicine." Excerpt from the Report of the Senate Committee on Labor and Public Welfare on S. 596 (P.L. 89- 239). SECTION TWO The Essential Nature BACKGROUND The Report of the President's Com- mission on Heart Disease, Cancer and Stroke in 1964 was the imme- diate stimulus for the legislation that became Public Law 89-239. That report, issued in December of 1964, made a series of recommendations aimed at the development across the nation of regional complexes of med- ical facilities and resources. These would function as coordinated sys- tems to provide specialized services for the benefits of physicians and pa- tients in the several geographic areas. In the longer perspective, however, the Regional Medical Program con- cept is the result of many ideas and trends that have evolved over a pe- riod of years. These include some of the social, economic, and scientific changes affecting all of modern soci- ety, as well as developments in the de- livery of medical and health services. The progress of science has exerted a powerful force for change. Since World War II great strides have been made in extending the frontier of medical knowledge and capability through research. This advance has greatly strengthened the armamen- tarium of medicine available to con- tend with the problems of health and disease. It is providing a fundamen- tal impetus for progress in health, stimulating intensified efforts to bring the benefits of science to all the people. Along with great benefits, these advances have brought new prob- lems. Increasing specialization has be- come necessary for mastery of rapidly advancing knowledge and technol- ogy. While specialization has raised levels of expertise, it has also increased the fragmentation of services, thereby complicating the process of delivering medical care. At the same time the advance of science threatens the heavily burdened physician with rapid obsolescence of knowledge. This threat in turn raises new prob- lems in communication and educa- tion. New patterns of relationships, systems of service, and mechanisms are critically needed in medicine, as in other fields, to cope with and ex- ploit advances of science for the well- being of the people of the Nation. Other important forces have also contributed to the conditions and needs which set the stage for Regional Medical Programs. Many factors have raised the public's expectation for health : the rising economic capa- bility of the Nation, the higher gen- eral level of education of the public, the record of success in the control of the major communicable diseases, and other social progress. In addi- tion, national concern has focused on the special problems of disadvantaged groups and areas not sharing fully in the overall progress. Efforts to meet these demands for services have been complicated by manpower and fa- cility shortages and increases in costs of medical care. More efficient and effective use of health services has been sought through regionalization for many years. It has also been viewed as a means to broaden the availability of high quality health services. In 1932, the Committee on the Costs of Medi- cal Care focused attention on this approach. In the same year, the Bingham Associates Program of the Tufts University-New England Medi- cal Center initiated the first compre- hensive regional medical effort in the United States. About 15 years later, similar ideas were included in the Report of the Commission on Hospi- tal Care and were, in turn, reflected in the Hospital Survey and Construc- tion Act of 1946 (Hill-Burton Pro- gram). While other regionalization plans have been advocated and at- tempted from time to time, these ef- forts were largely isolated and limited. Efforts to achieve regional organi- zation of private and voluntary health services have nat been notably suc- cessful. The reasons vary, but in general they reflect the difficulties of inducing common action among sep- arate and independent components of the health enterprise, and the lack of financial resources in sufficient amounts and duration to assure con- tinuing stability. The present day circumstances of the practice of medicine and the de- livery of health services may provide more suitable conditions for the growth of the regional approach. The physician is the part of a com- plex system involving closely related facilities and ancillary services. The hospital has become the central in- stitution in the community medical scene. Prepayment plans and group health programs contribute to coordi- nation and common action. Federal programs committed to social prog- ress provide a pervasive force for action. Thus the regional concept emerged again in a new form, in the major recommendations of the President's Commission on Heart Disease, Can- cer and Stroke which proposed the development and support of "region- al medical complexes". This proposal called for substantial and sustained Federal support as an essential con- dition of success. THE ESSENTIAIA NATURE President Johnson, at the signing of Public Law 89-239 on October 26, 7 1965, said, "Our goal is simple: to speed miracles of medical research from the laboratory to the bedside." The bill he signed into Law on that occasion, the Heart Disease, Cancer and Stroke Amendments of 1965, stated the same goal in slightly differ- ent terms: ". . . to afford to the medical profession and the medical institutions of the Nation . . . the opportunity of making available to their patients the latest advances in the diagnosis and treatment of [heart disease, cancer, stroke and related diseases] . . ." To accomplish these goals, P.L. 89-239 authorized a J-year, $340 mil- lion program of grants for the plan- ning and establishment of Regional Medical Programs. These grants pro- vide support for cooperative ar- rangements which would link major medical centers-usually consisting of a medical school and affiliated teaching hospitals-with clinical re- search centers, local community hos- pitals, and practicing physicians of the Nation. Grants arc authorized for planning and feasibility studies, as well as pilot projects, to demonstrate the value of these cooperative re- gional arrangements and to provide a base of experience for further devel- opment of the program. The objectives of the legislation are to be carried out by, and in co- operation with, practicing physicians, medical center officials, hospital ad- ministrators and other health work- ers, representatives from appropriate voluntary health agencies and mem- bers of the public. The law specifies that there shall be no interference with patterns or the methods of fi- nancing of patient care, or profes- sional practice, or with the adminis- tration of hospitals. Because this broad range of CO- operation is the central concept of Regional Medical Programs, each program is required to establish an advisory group representing the vari- ous health resources of the region and including consumer participation. This group has the important func- tion of assuring full collaboration and advising all the participating insti- tutions in planning and carrying out the program. The ultimate objective of Regional Medical Programs is clear and un- equivocal. The focus is on the patient. The object is to influence the present arrangements for health services in a manner that will permit the best in modern medical care for heart dis- ease, cancer, stroke and related dis- eases ta be available to all. The scope of the program is nationwide, encom- passing the great cities, suburbia, and rural areas. The program design inherent in Public Law 89-239 derives from a series of basic concepts: O The best in modern diagnostic and treatment methods is not readily accessible to many Americans suffer- ing from or threatened by heart dis- ease, cancer, stroke, and related diseases. O There is need for increasing inter- action between the diagnostic and therapeutic capability in the major medical centers, where an eflective interplay between research, teaching, and patient care can bring rapid and eflective application of new medical knowledge, and the medical capabil- ity in many community settings. 0 The progress of science will con- tinue to increase the complexity of making available to all the potential benefits of modern medicine. 0 The complete realization of these potential benefits requires the co- operative involvement of the full range of each region's medical and related resources. 0 The diversity of local health needs and resources calls for the as- sumption of responsibility by each region for the design of a pattern of collaborative action best suited to its own special circumstances. The role of the Public Health Serv- ice in developing this broad program design is defined in the Congressional declaration of purpose : "Through grants, to encourage and assist in the establishment of regional cooperative arrangements among medical schools, research institutions, and hospitals for research and train- ing (including continuing educa- tion) and for related demonstrations of patient care in the fields of heart disease, cancer, stroke, and related diseases . , ." Thus, Public Law 89-239 repre- sents a Federal investment in regional initiative. It invites and supports the creation of new patterns of coopera- tive action among physicians, allied health workers, hospitals, medical centers, universities and research in- stitutions, public and voluntary health agencies, and the consumers of health services. THE CONDITIONS AND QUALITIES EMPHASIZED Regional Medical Programs put into practice the principle that essential responsibility and power for the im- provement of health services should be exercised locally. The basic policy of the program is designed to en- courage innovation, adaptation and action at the regional level. Freedom and flexibility to do those things necessary to achieve the goals of each program has been provided. The achievement of any one objective of a Region may require a combina- tion of activities, such as research, specialized training of allied health personnel, continuing education of physicians, experimentation to find the best methods to achieve desired results, and demonstration of the most effective patient care. The Law does not allow support of isolated projects, however meritorious, whether they be in continuing education, research, patient care demonstrations, cooper- ative arrangements or training. Thus the success of a Regional Program will depend upon how effectively the Re- gion brings to bear its unique combi- nation of institutions, agencies and organizations to define and meet its own needs and opportunities. Critical to future progress is the willingness of members of the medi- cal profession to accept their full share of leadership in this effort. Equally important is the willingness of university schools of medicine to become involved in cooperative ef- forts to apply the fruits of research efforts. Similar challenges and new responsibilities are presented to hos- pital administrators, health officers, voluntary health agencies, schools of public health, and the allied health professions. New systems are being sought amid diverse geographic and social circum- stances that will make available to all the people medical services for heart disease, cancer and stroke and related diseases that are excellent in quality and adequate in quantity, while preserving the diversity and largely private character of our med- ical care process. The responsibility of achieving these desirable ends does not devolve upon Regional Medical Programs alone. They must operate in conjunction with other programs having related objectives. But Re- gional Medical Programs, properly developed, can serve as a keystone of a structure which will permit the de- livery of the type of medical care serv- ices desired by all. In accomplishing this goal, it is essential to find ways to harmonize the values of personal and scien- tific freedom with the demands for efficient use of resources and nation- wide availability of services. Re- gional Medical Programs offer the private and public institutions and the health professions of the country opportunities to demonstrate that, on a voluntary cooperative basis, given adequate resources and flexibility to use them, it is possible to work out effective regional and local systems to bring the benefits of scientific prog- ress to all. When the Regional Medical Pro- grams are fully developed across the nation, they will help to assure every individual, wherever he lives, that: O His physician has readily avail- able the knowledge, skills and techni- cal support that permit early diag- nosis of these diseases and prompt initiation and appropriate follow through for the most effective known preventive or curative action. fl His community hospital is equip- ped and staffed to provide the full range of services his condition re- quires, or is part of a system which makes this range of services available to him. In short, every person whose life and well-being may be in jeopardy from one of these diseases should have the full strength of modern medical science available to him through the cooperative efforts of the medical and related resources of the region in which he lives. These are the goals to which Regional Medical Programs are dedicated. Activities and Progress Activities and Progress " . , . the Surgeon General . , . shall submit . . . a report of the activities . . . together with (1) a statement of the relationship between Federal fi- nancing and financing from other sources . . . (2) an appraisal of the activities assisted . . , in the light of their effectiveness. . . ." " . , . the Surgeon General . , . shall submit . . . a report of the activities . . . together with (1) a statement of the relationship between Federal fi- nancing and financing from other sources . . . (2) an appraisal of the activities assisted . . , in the light of their effectiveness. . . ." Public Law 89-239 Public Law 89-239 Section 908 Section 908 SECTION THREE Activities and Progress REPORT OF ACTIVITIES During the 21 months from the time Public Law 89-239 came into being until June 30, 1967, 47 Regions re- ceived grant funds to aid their plan- ning activities and 4 of these Regions also initiated the operational phase of their Regional Medical Programs. (Exhibits III, IV) These programs received awards of about $24 million for planning and $6.7 million for operations. (Table 1) The regional areas to which the awards far plan- ning relate contain about 90 percent of the Nation's population. Additional applications for grants to support the planning of Regional Medical Programs covering the re- mainder of the country are under review or development. Overall, a total of about 54 Regional Medical Programs are anticipated. It is likely that by the late summer or early fall of 1967 Regional Medical Programs covering the entire country will be either in the initial planning or initial operational stages. Progress in the development of Regional Medical Programs thus far must be measured against the tasks involved in launching a new and innovative venture dependent tb a very high degree upon local enter- prise. The establishment of many new relationships and activities has been required. Moreover, this devel- opment has taken place in a time of widespread manpower shortages and in conjunction with parallel demands from many other health programs, such as Medicare and Medicaid. In this context the progress reflected by the present state of activity represents a considerable achievement in a rela- tively short time. How this was ac- complished provides a gauge of the direction and potential for the future. The Initiating Actions Shortly after the Law was signed by President Johnson on October 6, 1965, the Division of Regional Medi- cal Programs was established at the National Institutes of Health. To direct its activities, Dr. Robert Q. Marston accepted the invitation to leave his post as Dean of Medicine and Vice Chancellor of the Univer- sity of Mississippi and become Asso- ciate Director of the National Insti- tutes of Health. Prior to the arrival of Dr. Marston, Dr. Stuart Sessams, Deputy Director of the National In- stitutes of Health, was responsible for the development of plans and policies for the new program. The Supplemental Appropriation Act of 1966 provided initial funding for the program, making available $24 million for grants and $1 millian for the Division for fiscal year 1966. The Department of Health, Educa- tion, and Welfare Appropriation Act of 1967 provided $43 million for grants and $2 million for the Division for fiscal year 1967. The National Advisory Council on Regional Medical Programs, estab- lished by the Law, was named from outstanding experts in heart disease, cancer and stroke, plus top leadership in medical practice, hospital and health care administration and pub- lic affairs. (Exhibits V, VI) It met for the first time in December 1965 to advise on plans and policies. In early February 1966, the Council met again to review and approve the prelimi- nary issue of the Program Guidelines. Quickly printed, this publication was given its initial distribution in March. During the spring of 1966, about 20 applications for planning grants were received and reviewed by the initial review groups and the Na- tional Advisory Council. By July 1, 10 grants were recommended for ap- proval and awarded. Between July and December 1966, approximately 40 applications were reviewed. Many were returned for revision or addi- tional information. Twenty-four were approved and funded. As a result, 1966 ended with a total of 34 Re- gional Medical Programs receiving awards for planning programs, rep- resenting areas that included some 60 percent of the population of the country. The first applications fox operational grants had also been submitted. Subsequently, in February 1967, the first four operational and 10 ad- ditional planning applications were recommended for approval by the National Advisory Council. At the Council meeting in May, five addi- tional planning applications were recommended for approval. In June, continuation grants were awarded to 10 Regions for the second year of planning. Broad Participation in Planning The promptness and manner with which program proposals were de- veloped reflect the interest this new program has generated in the nation- al health scene and give heartening evidence of the willingness of diverse interests in the health field to coop- erate in this new framework. The in- terest and enthusiasm generated throughout the country is the result of a number of factors, not the least of which was widespread participation of many individuals and groups, both in the formulation of policies at the national level and in setting up and planning their own Regional Medical Programs. 11 TABLE 1 TABLE 2 AWARDS FOR PLANNING AND OPERATIONS OF REGIONAL MEDICAL PROGRAMS, JUNE 30, 1967 --__~ ~-~~ - Number Amount TOTAL..........,........................... 61 $30,946,907 = MEMBERSHIP OF ADVISORY GROUPS FOR REGIONAL MEDICAL PRO- GRAMS, JUNE 30, 1967 1 ~.. ~~~ ~. Planning Awards. . . . . . . 57 $24,277, 174 - -_----- For 1st Year Activities. . . . . 47 19,822, 153 For 2d Year Activities. . . . . . . 10 4,455,021 Operational Awards. . . . . . . . . . 4 $6,669, 733 - Category Num- Per- ber cent- age TOTAL. . . . . . . For 1st Year Activities. . . . . . . . . . 4 6,669,733 Practicing Physi- cians . . . . . . . Medical Center Officials. . . . . . . Members of Public. . Voluntary Health Agency Represent- atives. . . . . Hospital Admin- istrators . . . . , . Other Health Workers. . . . . . . Public Health Officials. . . . . . . . Other. . . . . . . About one hundred consultants aided the new Division by providing advice and counsel on various as- pects of the Program during the ini- tial period. These advisors repre- sented a broad cross-section of the leaders in American medicine and health fields. They devoted intensive efforts to the review of Program pro- posals and grant applications. Some of these people sat on technical re- view groups. Others dontributed their thinking to the development of such specialized activities as continu- ing education, community health planning, systems analysis, data col- lection, communications, evaluation, and the preparation of this Report. (Exhibit VII) Activities in the Region Similarly, in the Regions, the wide- spread participation of concerned in- dividuals as members of Regional Ad- visory Groups and as Coordinators and staff is infusing the Programs with vitality and character. Over 1600 individuals are participating as members of Regional Advisory Groups. Membership in these groups ranges from 12 to 111, averaging 32. The members include a variety of pro- fessional backgrounds and representa- tion of a broad cross-section of insti- tutions and organizations. (Table 2.) In fulfillment of the intent of the program, the major health agencies of the regions have been involved in 1634 100 -- 356 22 281 17 260 16 196 170 142 122 I07 12 10 9 7 7 -. 1 Zncludes 51 Regions, of which 47 had received planning grants and 4 had applications under review. the development of these Regional Medical Programs. All of the Na- tion's existing medical schools and their affiliated hospitals and most of the schools under development have participated. In virtually every pro- gram, representatives of State medi- cal societies, health departments, can- cer societies, heart associations, hos- pital associations or hospital planning agencies have taken part. In addition, many programs have already developed links with univer- sity resources outside the medical schools and with other State and local private and public agencies having related interests. Examples of these are Schools of Dentistry, Nursing, Social Work, Business Administra- tion, Education and Public Health and Departments of Vocational Re- habilitation, Welfare, Education, and Hospitals. Community Councils, planning councils, Blue Cross and similar groups are also being involved in many instances. Representatives of Veterans Administration and Public Health Service Hospitals are also frequent participants. Regional Organizations Several kinds of institutions have assumed responsibilities as coordi- nating headquarters for Regional Medical Programs. Since the legisla- 12 tion does not designate these agencies, they must be decided upon by the various institutions and interests par- ticipating in the development of the Programs. The agency so selected acts for all involved in these cooperative programs. Among the 47 Regions receiving planning grants, 28 university medi- cal schools have assumed responsi- bilities as coordinating headquarters. Seventeen are private nonprofit agen- cies, 10 of which were newly orga- nized for this purpose, 5 are medical societies, and 2 are multi-institutional agencies. One State and one inter- state agency have also undertaken this task. (Table 3) Program Coordinators and Staff The Program Coordinators and Directors holding key leadership po- sitions in the administration of the Regional Medical Programs come from a variety of backgrounds. About half previously held important posi- tions in medical education, such as university vice-presidents, medical school deans and professors. Others have come from private practice of medicine and from positions of administrative leadership in hospitals. The rest previously held key roles in voluntary health and governmental agencies. (Exhibit VIII) TABLE 3 COORDINATING HEADQUARTERS AND GRANTEES FOR REGIONAL MEDICA L PROGRAMS, JUNE 30, 1967 Type of Agency Coordi- ;:`d"I: Grant- quarters ees 1 TOTAL. . . . . . 47 47 - ___ Universities. . . . 28 33 State. . 23 25 Private. . . . 5 8 m - Nonprofit Agencies. . . 17 12 Medical Societies. . 5 6 Newly Organized Agencies. . 10 3 Other Agencies. . 2 3 ~ ___ State and Interstate Agencies. . . . 2 2 ___ ~ 1 The grantee &Ters from the coordinat- ing headquarters when the Region re- quested this arrangement or the latter agency did not have the capability to assume formal&al responsibility. -.~__ -. These coordinators are building staffs with a wide range of com- petencies. As of June 30, 1967, there were some 600 staff people working in these programs. These include over 300 professional workers with train- ing in medicine, hospital administra- tion, and other health disciplines as well as in related fields such as sta- tistics, economics, sociology, systems analysis, education, communications and public relations. Special coordi- nators ar consultants for heart dis- ease, cancer and stroke are commonly included. Nature of Preliminary Planning Regions The applications for Regional Medi- cal Programs planning grants have defined the geographic areas in which the initial planning efforts will be focused. It has been recognized that these definitions are preliminary and will be refined during the plan- ning process and by operating experience. The individual Regions have ranged in population from less than 1 million to over 18 million. (Table `4) The median is 2.6 million persons. Collectively, the preliminary plan- ning regions encompassed in pro- grams now in being or proposed cover the entire country. Gaps in geographi- cal coverage, which was an early con- cern, have not materialized in the initial planning proposals. TABLE 4 NUMBER OF PERSONS IN PRELIMINARY PLANNING REGIONS FOR REGIONAL MEDICAL PROGRAMS Population range Regions 1 -___~ ~~~~ TOTAL . . . . . . . . . . . 51 Less than 1 ,OOO,OOO. . . . . . 4 1,000,000-2,000,000. . . . 10 2,000,000-3,000,OOO. . . 14 3,000,000-4,000,000. . . 5 4,000,000-5,000,OOO. . . . . . 8 More than 5,000,OOO. . . . . 10 ~~_ ~~ __--- .~--___ ~~~- l Includes 51 Regions, of which 47 had received planning grants and 4 had appli- cations under review. ~~-~~ In 30 cases, the preliminary plan- ning regions approximate State lines, due principally to the existing respon- sibilities of many of the key groups participating in the preparation of the initial planning grant application. Inasmuch as none of the Regions is bound by State lines, many of these preliminary definitions are likely to be modified on the basis of criteria more specific to health needs. In 11 Regions, the initial Region includes parts of 2 or more States 13 and in 10 it is part of a single State. Some regions primarily cover urban metropolitan areas. Others follow lines previously established for plan- ning health facilities. Planning Activities The planning activities of each Re- gional Medical Program are directed at the design of operating programs and the steps for their establishment. Initial planning activities have gen- erally been of four major types: 0 Organization and stafing for planning and coordination j-J Strengthening relationships and liaison among institutions and indi- viduals throughout the Region 0 Development of planning data /J Preparation of designs for pilot operational programs A principal effort in the planning of Regional Medical Programs is the careful study and analysis of many relevant factors : demographic and biostatistical characteristics of the Region, the manpower and facilities resources, the adequacy of and needs for specialized clinical facilities and problems of manpower supply and distribution. Surveys of training and library resources, on-going con- tinuing education programs and un- met educational needs are also re- ceiving widespread attention. The patterns of occurrence of heart disease, cancer, stroke and re- lated diseases are also being studied by many regions. Most are analyzing patient referral patterns and existing methods of providing diagnostic, treatment and laboratory services. Present and possible communication and transportation patterns relating to these services are also receiving widespread attention. These planning studies have, in most instances, been based on previous data collection ef- forts and have, in turn, contributed to the development of cooperative arrangements among the partici- pating organizations. About one-half of the planning ap- plications proposed the undertaking of specific feasibility studies aimed at assessing the workability and utility of particular program elements. Many are exploring better ways of advanc- ing educational and training activi- ties. Particular attention is being given to improvements in continuing education programs for both practic- ing physicians and allied health per- sonnel. The effectiveness of tele- phone, radio and television networks in linking community hospitals to uni- versity medical centers is being in- vestigated under differing local con- ditions. Methods of carrying out demonstrations of patient care and applying evaluation procedures are also being tested. In addition to analytical activity, planning for Regional Medical Pro- grams involves major efforts directed toward the strengthening of the rela- tionships and communications among health and related agencies within the Region. Various approaches are being used to further these coopera- tive relationships. The establishment of working task forces and commit- tees, the conduct of conferences and workshops, and the employment of liaison personnel are common. Nu- merous programs are scheduling con- ferences at community hospitals and with other local groups to explain and discuss the purposes and nature of the prospective Regional Program. Working together in planning and initiating planning and feasibility studies has been found to be one of the most effective methods of estab- lishing and implementing common objectives. Although each Regional Medical Program is in many ways unique, some flavor of what Public Law 89- 239 means in action is revealed by reports of certain programs that are -- 1 As reported by individual Regional Medi- cal Programs. TABLE 5 MAJOR PLANNING STUDIES UNDER WAY OR PROJECTED BY 44 REGION- AL MEDICAL PROGRAMS, ~&ARCH 1, 1967 Subject Under Study Patient care Regions Specialized Clinical Facili- ties. . . . . . . 30 Disease Patterns. . . . . . . . . 28 Patient Referral Patterns 28 Patterns of Services.. . . . 25 Laboratory Services. . , : 25 Transportation Patterns. . 21 Manpower Physician Manpower Nursing Manpower.. . . Dental Manpower.. . . . . . . . . Other Allied Health Man- power.. . . . . . . . Training and education 30 29 25 26 Continuing Education Pro- grams. . . Training Resources. Medical Library Resources. Communications Patterns and Resources . . . . 28 28 26 26 14 presented as a supplement to this Re- port. What is happening in six Re- gions is discussed against a back- ground of previous activities. In addi- tion, excerpts from the first annual reports submitted by ten Regions that received grants as of July 1, 1966 are also presented. - -__ Operational Activities -~-------- _ -.~- The four grants that have been made for operational programs are based largely on planning activities started prior to the passage of Public Law 89-239 (Exhibit IV). During the consideration of the legislation, it was recognized that there were several areas of the country where consid- erable effort had already been di- rected toward improved regional rela- tionships among health resources. In these places sufficient planning had already been accomplished so that operational activities could be initi- ated early. In the beginning stages these oper- ational programs will encompass four principal types of activities: 0 Application of the latest knowl- edge and technology to improve capabilities for diagnosis and treat- ment. O Specialized training and continu- ing education to enable health prac- titioners to use these capabilities most eflectively in treating patients. 0 Use of modern communication technology. 0 Research on and exploratory de- velopment of new methods for the organization and delivery of high quality services for patients with heart disease, cancer, stroke and related diseases. cation systems joining medical cen- ters and community hospitals. 0 The development and demonstra- tion of improved methods and ar- rangements for providing detection, diagnostic, treatment and rehabilita- tion services including such activities as: Each Region will have differing requirements and approaches toward upgrading its capabilities for the diagnosis and treatment of heart disease, cancer, stroke and related diseases. In general, the designs of the initial Regional Medical Pro- grams provide for the following spe- cific kinds of activities as examples of the basic ingredients of comprehen- sive operating programs: 0 The exchange of personnel be- tween medical centers and commu- nity hospitals and the provision of consultation and other assistance to practicing physicians by medical cen- ter and other specialized personnel. 0 Continuing education programs for medical practitioners and allied health workers, at both local facilities and medical centers including the development of learning centers at community hospitals and communi- Demonstrations of coronary care in teaching and community hospitals. Expansion of cerebral vascular diag- nostic resources. Demonstrations of improved methods of utilizing computeis in monitoring physiologic data and in providing data for the use of practicing physi- cians and hospitals. I'J Development of inform'ation pro- grams to further communications, understanding, and cooperation among the institutions, organizations and individuals of the Region. The Review Process ~___ .~___ ~~ The review of applications for opera- tional grants has been designed to en- sure careful consideration of the strategy and soundness of the pro- posal for a Regional Program. Many Regional Advisory Groups have es- tablished subcommittees to analyze the validity and significance of pro- posals prior to their review and rec- ommendation ; these committees drav upon both community and academic resources. In line with the specifica. tions of the Law, the Regional Ad- visory Group itself must approve all applications for operational funds. The review process at the National Institutes of Health involves technical review by both expert nonfederal con- sultants and the staff of the Division and other offices with relevant ex- pertise prior to action by the National Advisory Council. This process is focused on evaluating the organiza- tion and conceptual strategy of the Regional Programs and making avail- able the benefits of expert professional analysis of project proposals. It seeks to preserve for each Region a large measure of the responsibilities and opportunities for deciding on prior- ities for action. A detailed statement of the review process is contained in Exhibit IX. SUPPORTING ACTIVITIES OF THE DIVISION OF REGIONAL MEDICAL PROGRAMS As support for Regional Programs, a number of activities have been under- taken by the Division of Regional Medical Programs to develop needed information and resources which can facilitate regional program develop- ment. (Exhibit X) 15 Continuing Education A conference in September 1966 of 16 leaders in the continuing education of physicians and allied health person- nel identified needs critical to the de- velopment of more effective activ- ities in this field. The meeting documented a national shortage of professional health workers capable of conducting and evaluating pro- grams in continuing education. To help meet this need, a contract was developed with the Center for the Study of Medical Education at the College of Medicine of the University of Illinois to study the feasibility of expanding graduate programs lead- ing to a degree of Master of Educa- tion and also short term training pro- grams in the area of continuing education. In addition, other univer- sisty groups have submitted proposals for assistance to extend their pro- grams in these fields. In January and May 1967 representatives from six universities, including staff from schools of medicine and education, met to examine possibilities of ex- panding programs to train educa- tional manpower. The Division staff has also worked closely with national organizations to broaden resources in continuing edu- cation. They include committees of the American Medical Association, the National Board of Medical Ex- aminers, the Association of American Medical Colleges, American Public Health Association, American Physi- cal Therapy Association, Association of Hospital Directors of Medical Ed- ucation, Inter-University Communi- cations Council (EDUCOM) and other professional and public groups. Systems Analysis The use of systems analysis has been encouraged in Regional Medical Program activities as an integral component of program development. Exploratory efforts have been under- taken to make broader use of systems analysis skills in studying specific problems of improving medical serv- ice. As part of this effort, the Divi- sion has entered into a contract with the Department of Industrial En- gineering of the University of Michi- gan to study how to apply operations research and systems analysis meth- ods to problems of regional medicine. Data Collection Conferences of specialists met in March and May of 1967 to identify and discuss data available for plan- ning and evaluation of Regional Medical Programs and problems of data collection. By taking advantage of available data, Programs can avoid duplication of effort and there- by concentrate on studies of coopera- tive arrangements and other issues and needs unique to Regional Programs. Listing Facilities __---- Section 908 of Public Law 89-239 re- quires the Division to ". . . estab- lish and maintain a list or lists of facilities . . . equipped and staffed to provide the most advanced meth- ods and techniques in the diagnosis and treatment of heart disease, can- cer or stroke. . . ." As a first step to fulfill this requirement, the Divi- sion has contracted with the Ameri- can College. of Surgeons for its Com- mission on Cancer to undertake a study of appropriate standards to provide the highest level of diagnosis and treatment of cancer patients. Such standards may then be useful as measures by which medical care in- stitutions of the country can evaluate their own capabilities, and by which the individual Regional Medical Pro- grams can estimate where additional support may be needed. Disseminating Information A device for sending periodic reports to the Regions has been established to disseminate to Program Coordina- tors and other interested persons in- formation and data affecting the development of Regional Programs. This medium will also help speed the exchange of reports of significant progress and problems among the Regions. FINANCING FROM OTHER SOURCES Substantial contributions have been made to the development of Regional Medical Programs by hundreds of individuals and institutions through- out the country. Leading officials of medical schools, hospitals, research institutions, voluntary health agencies and members of the public have de- voted effort and resources to plan for these new programs. In many areas, local funds have been made available specifically to aid in the initial plan- ning. For example, in Vermont, the State legislature appropriated $lO,- 000 to help defray planning expenses. In Oregon the University Medical School, the State Medical Associa- tion, and the members of the Re- gional Advisory Group donated $6,000. The Mountain States Re- gional Medical Program received a grant of $13,700 from a private foundation. Altogether, it is estimated that through March 1, 1967, more than $1.5 million in cash and services has been contributed to the planning -~ .-..__. _._._.~_ -- .~~. ~~ __ .~~. ~_~ . ~~ ..~_~. --.. .-. .- _ -...- TABLE 6 I ESTIMATED AMOUNT OF FUNDS FROM NON-FEDERAL SOURCES FOR PLANNING REGIONAL MEDICAL PROGRAMS, THROUGH MARCH I,1967 r I Region TOTAL ................... Alabama ....................... Albany,N.Y.. ................. Arizona. ........................ Arkansas. ...................... Bi-State ........................ California. ...................... Central New York. .............. Colorado-Wyoming. ............. Connecticut. .................... Florida ......................... Georgia. ....................... Greater Delaware Valley .......... Hawaii. ........................ Illinois. ........................ Indiana ........................ Intermountain. ................. Iowa ........................... Kansas ......................... Louisiana. ...................... Maine .......................... Maryland. ...................... Memphis. ...................... Metropolitan Washington, D.C .... Michigan ....................... Mississippi. ..................... - .- - Total Cash Services $1,497,300 $287,800 $1) 209,500 21,200 96,800 2, 800 5,100 13,200 3,800 24,500 100 600 1,500 ("1 17,400 72,300 2,700 4,500 11,700 . . . ...*.... 12,000 . . . . . . . . . . . 33,800 7,500 2, 300 174,500 6, 900 48, 000 76,900 53,500 19,500 125,000 6,000 ("1 . . . . . . . . . . . 6, ooo . . . . . . . . , . . . . . . . 900 70, 100 . . . . . . . . . 3,000 4,500 5, ooo 11,100 . . . . . . . . . ("1 1,500 . . . . . . . . 9, 700 300 . . . . . . 9,000 .**.*...... 33,800 7,500 1,400 104,400 6, 900 45,000 72,400 48,500 8,400 125,000 . . . . . . . . . . . 16,200 7,000 20,000 2,000 4,500 15,000 . . . . . . . . . . . 14,700 7,000 10,300 1,700 4,500 6,000 1 As refiortcd by individual Regional Medical Programs. 2 .Not reported. Region Total Missouri. ...................... Mountain States. ............... Nebraska-South Dakota. ......... New Jersey. ................... New Mexico. .................. New York Metropolitan Area. .... North Carolina. ................ North Dakota. ................. Northern New England. ......... Northlands. .................... Ohio State. ................... Ohio Valley. ................... Oklahoma. ................... Oregon ......................... Rochester, N.Y. ................. South Carolina. ................. Susequehanna Valley. ............ Tennessee-Mid South ............. Texas .......................... Tri-State ....................... Virginia. ....................... Washington-Alaska. .............. West Virginia. .................. Western New York ............... Western Pennsylvania. ........... Wisconsin. ...................... $48,900 15,000 9,000 17,800 25, 200 11,000 38, 100 . . . . . . . . . . 134, 200 30, 900 37, 200 10,600 50,000 18, 000 53, 500 3, 000 6, ooo 20, 400 82, 000 . . . . . . 25, 000 4, ooo 11,000 38, 300 7, 000 37, 500 - -- I - Cash Services $3,90( 13, 70( 1,4oc 12, ooc 5, 7oc 1, ooc . . . . . . . ("1 10,ooa 5, 4oa 6,600 2,100 $45,000 1,300 7,600 5,800 19,500 10,000 38, 100 . . . . , . . . 6, 000 40,900 1,500 . . . . 3,400 10,000 (`1 , . . . . . . . . . . 124,200 25,500 30, 600 8, 500 50,000 12,000 12,600 1,500 6,000 17,000 72,000 . . . . . . . . . . . l,ooo 2, 100 1,000 8,500 . . . . . . . . . . . 25,000 4, 000 10,000 36,200 6,000 ' 29,000 17 development of Regional Medical Programs from non-Federal sources. A listing of these amounts, by Region, is set forth in Table 6. Procedures are being developed and implemented in the Regions so that these cooperative programs are financed from a variety of sources. In some areas, total responsibility for the support of the activities will be assumed by local funds after an ini- tial period of study, testing and dem- onstration. In many Regions, voiun- tary agencies and foundation funds are being enlisted. At this stage in the development of Regional Medical Programs, it is not possible to ascertain the longer term relationships of Federal and non- Federal funding of the activities un- der this program or to assess the nature of their impact upon medical service costs. If this program is suc- cessful in developing needed addi- tional elements in the community health scene that are parts of im- proved services, the extent to which these services can be financed through regular cost and payment processes or other local funding mechanisms and the extent to which permanent or temporary Federal assistance will be required are issues that will call for critical examination as the program progresses. AN APPRAISAL OF THE ACTIVITIES ASSISTED IN THE LIGHT OF THEIR EFFECTIVENESS Only a tentative appraisal of the effectiveness of Regional Medical Programs in carrying out any of the established objectives is possible this soon after enactment of the legisla- tion. On the basis of this limited period of observation there seems to be clear evidence that overall prog- ress has been substantial. The pros- pects for the future are positive and auspicious. The first objective of the Regional Medical Programs is "the establish- ment of regional cooperative arrange- ments." Accomplishment in respect to this objective has been outstand- ing. As noted above, the health in- terests of the Regions as well as re- lated agencies and members of the public have come together in an un- precedented fashion to consider the most appropriate local ways of meet- ing identified needs under this pro- gram. Maintaining the continued commitment of these groups with di- verse goals and interests to continue to work together in establishing and implementing Regional Medical Pro- grams will be crucial. The second purpose of Regional Medical Programs specified in the legislation is "to afford the medical profession and the medical institu- tions of the Nation, through such cooperative arrangements, the op- portunity of making available to their patients the latest advances in the diagnosis and treatment of these diseases." Much of the planning effort is focused on identifying the types of "opportunities" that are most appropriate and practical to provide and strengthen capabilities. As re- ported above, a broad spectrum of potential approaches to this objec- tive are being explored in planning, feasibility studies and pilot projects. Progress to date indicates that the basic concept of looking to regional groups for ideas and initiative is well founded. The third purpose specified in the Law is "to improve generally the health manpower and facilities avail- able to the Nation. . . ." Regional planning holds the potentiality of ac- complishing this objective also. Better ways of utilizing and training health manpower, including many types of allied personnel, are also being ex- plored. More efficient methods of extending the effectiveness of exist- ing and new facilities, through shar- ing and cooperation, are being initiated. Most importantly, Regional Medi- cal Programs themselves are develop- ing resources and procedures for continuing evaluation. A principal strength of these programs is the op- portunity to build up resources for continuous evaluation; this is par- ticularly appropriate and necessary in light of the concentration on in- novation and experimentation. Eval- uation mechanisms are generally being established as part of the planning process so that essential baseline data will be accumulated and capabilities developed to assess continuing progress and problems. In this way, the Regional Programs will be better able to modify their direc- tion and speed, on the basis of actual experience, and progressively im- prove their effectiveness. The long-term effectiveness of Re-