EXCERPTS OF TESTINIONY AND MATERIALS Presented On MARCH 26 and 27, 1968 Re: Sections Of H.R. 157S8* Relative To REGIONAL MEDICAL PRO@ Before The SUBCOMMITTEE ON PUBLIC HEALTH AND WELFARE Of The COMMITTEE ON INTERSTATE AND FOREIGN CONERCE HOUSE OF REPRESENTATIVES NINETIETH CONGRESS SECOND SESSION *A Bill to amend the Public Health Service Act so as to extend and improve the provisions relating to Regional Medical Prograrns... EXCERPTS OF TESTINIONY' AND MATERIALS Presented On MARCH 26 and 27, 1968 Re: Sections Of H.R. 15758* Relative To REGIONAL @4EDICAL PROGWE Before The SUBCOMMITTEE ON PUBLIC HEALTH AND WELFARE Of The COMTTEE ON INTERSTATE AND FOREIGN COMMERCE HOUSE OF REPRESENTATIVES NINETIETH CONGRESS SECOND SESSION *A Bill to ainend the Public Health Service Act so as to extend and improve the provisions relating to Regional Medical Programs... CONTENTS Page Hearings held on- 1 0 26, 1968 ------- ------------------------------------- ,re m h --- ------------- 131 March 2f, 1968 ---------------------------------- 2 Text of H.R. 15758 ------------------------------------------------ Report of- 2 Health, EdLicaiioii, and Welfare Department ---------------------- Statement of- Bmtrude, Dr. Amos, %Vashingtoii (Stite) Medical Association and Assoei'ation of General Practitioii;;rs ---------------------------- 197 Breslow, Dr. Lester, president-elect, American Public Health Asso- ciation ----------------------------------------------------- 16S Cannon, Dr. Bland W., member, Council on Medical Education, American Medical Association ------------------------------- 147,148 Chambers, Dr. J. W., representing the Medical Association of Georgia-,)- -,-, --------------------------- 208 ri@@ ic@ - - i-@ - - - Chapman, r. see tion of American Medical Colleges- 12", De Bakey., Dr. Michael, chairman, Department of Surgery, Baylor Llniver-sity College of Medicine, Housion, Tex ------------------- 133 Elarn, Dr. Lloyd, Association of American Medical Colleges --------- 123 Farber, Dr. Sidney, director of research, Children's Cancer Research Foundation, Boston, Mass -------- --------------------------- 139 Lee, Dr. Philip R., Assistant Secretary for Health and Scientific Affairs, Department of Health, Education, and Welfare --------9 Likoff, ]Jr. William, immediate past president, American College of Cardiology -------------- 7- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -161 Marston., Dr. Robe of e nal Medical Pro- Departm( d ........0 Disease, m Dr. Clarl Cere American Heart ------------------------------- 163 NeHigan, William D., executive director, American College of Cardi- ology ----- -------------------------------------------------- 161 Ruhe. Dr. William, director, Division of Medical Education, American Me ,dical Association ------------------------------------------- 147 Siberv, D. Eugene, executive director, Greater Detroit Area Hospital C(;,,,ncil 218 Stark, Nathan J., chairman, Missouri regional medical program ----- 193 Additioiidi information submitted for the record b@ Amei ciation, letter from John B.Wilson, chairman, coi on ---------------- i ---- -------- 303 AMC Association, letter rom illiamson, 299 -i;@ asi c@ --- a- if(;;, fn s ent of Judith G. Whitaker, Am( ------------ 296 executive irec or ---------------------------- California Committee on Regional Medical Programs, statement of Dr. Lester Breslow ------------------ 171 Grc ter Detroit ( ich.@ Area Hospital ii Hospital Association, December 1967i el gional Medical Programs: A Plea for c ----------- 222 Hai : ------- 304 Hw Windsor C. ----------------- 30:3 ---------------------------- Additional information submitted for the record by-Continued Health, Rducation, and Welfare, De artment of: I p ams, state- Criteria for the evaluation of regional medical progr 86 ----------------------------- statement on 84 d under 119 pating-iii regional medical Pro- 62 ----------------------------- General Hospital in the Missouri medical program, s ment oil --------------------- 85 Operational Projects affec@ing rural areas, statement on ---------- 76 Patient care costs supported with regional medical program grant funds --------------------------------------------------- 65 Professional involvement in regional medical programs, statement --- 64 report on 12 operating reg-@@l on - i medical Publi:c- lie-a-l-t-h- -S-c-r-v-ic-c 46 programs - ----- ------------------------- continuing Television, radio, and telephon(-, networks for -- 61 education --------------------------- fl;r-we-aiE-d-i-s-ca-sc, progress report, 13 diseases ------------ --- efforts directed again;@-@@-@@alth statement on -------------------- 73 medical programs, statement on -------------- 66-72 in regional medical programs by in- 33 ions ------------------------------- Table II .- R ical progrtms, total obligation of funds, fiscal Years ------------------------------- aga, Hon. a Representative in Congress from the Matsun ------ 29@ll ,state , of ITawnii, Pt r ----------------------- 195 Missouri regional medical program, organization and goals ---------- losts and Respiratory Disease As@ociation, letter National Tubereu ging director ---------------------- :30 1 from James E. Perkins, mana REGIONAL MEDICA L PROGRAMS; ALCOHOLICS AND NARCOTICS ADDICTS FACILITIES; HEALTH SERV- ICES FOR DOMESTIC AGRICULTURAL MIGRATORY WORKERS TUESDAY, XARCH 26, 1968 HOUSF, OF RFPRFSFNTATIVES, SUBCOMMIMME ON PuBLic HEALTH AND WELPARF. COMXI=E ON INTFRSTATE AND FOREIGN COM31ERCEI Was7tington, D.C. The subcommittee met at 10 a.m., pursuant to notice, in room 2322, Rayburn House Ofrice Building, Hoii.- Paul G. Rogers presiding (Hoii. Jofin Jarman, chairman Mr. KYROS'(P subconu-nittee will ijlease be in order. The hearingi H.R. 15758, introduced by Chairman StaffLrers at the r( ministration. @ bill woul and the existing authorizations for yegional medical programs, w extend the program of heilth serv- ices for domestic and would provide mat@-a QTaiits for prei?eii- tion of @l@holisin of ics and iiar- cotic addicts. REGIOINAL 31EDICAL PROC.RAMS Ili 1965) the Congress considered legislation proposing the establish- -ment of ieoional desio,,lied to improve the hintltli care of the Ameri( fi, ds ofheart disease, cancer, stroke and related disea., ress made substantial revisions in the proposed program ii general for a maximum of deceii- trarizat.ion of the process and eiicouraoiiig the inaxi- miun feasible cooperate( i I i public and prii-.ite groups interested in the health of the Amer can peop e. It is impossible to (,rive a simple description of a regional medical proLyram since every program eit,,tblislied-is different, with each pro- tailored specifically to the needs of the region served. rr;ver 90 percent of the population of the IJiiited States is or will be "' in ' covered biregional medical progrims established on the local level either on an operational @b,,tsii today or throiicrli programs currently in the Dlannini stage. Eventually, iOO percent of our population will be cov@ b-v these programs. Many fears ,tiid reservations were expressed at the time the Coii- ress was considering the initial le(_rislafioii. It is my understanding, @owever, that many of.the -roups @vhicli had reservations about the initial proposals have since modified their positions, in large i-ne-,istire (1) 2 Ise of the modifications @at ,vere made ill the pro,(,7am by tb@ becal- im l@,,ts been administered Congress and the minner in,%vilich the pro4r, to date. rnctjor ch,,tn-aes ,ire pro- As I understand the bill presented to us, no . pal purpose of the legislation is to extend the pro- posed. The Princi e lo this year. Witli g@,,im beyond its scheduled expiration date of Jul' de- minor improvements that experience has Show" to be necessary or sira,ble. workers, In regard to the section on domestic tgricultural migratory . .. ,also proposes to extend for two t@ditional years the existin 19 the bilf igrictiltur,%, Yr,,tm of Feder, p@oL tl grants for health services to domestic migratory %vorkerg. 0 this year, Yr,,im is ,ilso scheduled to expire Juii@ 3 The existing I)roL al ,,.t this time if these workers wil? tre among so extension is- receive, the services they need. the Ileeffi@ tod,,ty) tre, to continue to DEP.KRTIEENT OF HEALTH, FDUCATION, AND WELFARE, TVas7tiitgtoti, D.C., marelt 18,1968. 11011. HARLEY 0. STAGGERS, Cha',.pilall, co?itiitittcc on i)itci,8tatc and Foi-rign CO)itl)lC?'CC. Ifoii,Sc of Repi-cscntativcs, IVashingtOji@, D.C. --ponse o yo,,ir request of .Niireli 6. t DF-tp. %IR. This letter is in re the Public ]Eieilth Service W. for ,i rep t oil H.R. 15758, t bill "To aiiiend 1 . . -, relating to regional medical Act so as to e ove the provi,4ion f migratory agri- izatioii of grant-, for health o programs, to e t for ,iicoiioiics and narcotic cultural worker qpecialize(i f,,lcili ie,; addicts, and foi ntiiiied in a draft bill submitted] tive proposal c This bill emi nient the reconi- by this Depart gress oil %Iarct c,,Il lirograiiis con- ndations on extension an me e bill also includes ta,ned in the President'@ @\larch, temporary exten- the legislative proDOsal coiitaiiicl e rini of grants healt SE tory ral Sion of th =,tud tio AVO ers. In Pardodgi n, H.R. 15758 ( odies the legislative propoqi apartment to the Congress on February 8, th( itted by tbi ntioii ,tnd treatment of alco- 194 the reconiiiieii February 7, 1968 h6 IC addiction cc lenge of crime ill '.\I( IC E ill H.R. 1.@)281, oil on oned propos@ WI you !,-;Iation. E I iuent of t f tbil; proposed legislation fl Budget , iiient o W( rd with the pr( si(lelit. gincer WILUUR J. COHEN, Acting Secretai,y. [H,R.15 758, 90th Cong., second sess.) .... d Impr ove the tons Health 8 prov': A BILL T a fgrants fr h Rith relating facilities for alcoholics and in rs, of 'gr ther purposes narcotic Bc it cnactcd by tltc ScnOtc and llolis(' of Rcpr(ly(.ntatit-c8 of tit(. rlnitc(l statc8 of Ainerica in coitgi-cs8 as8emblcd, TITR,F, I-REGIONAL -%IEDICAL PROGRA.%IS EXTENSION OF REGIONAL MEDICAL rEOGRAIIS ion 901(a) of the Public Health Service Act (42 U.S.C. 299a) SEC. 101. sect Inserting after is amended by striking out "and!' before "$200,000,000" and by 3 "June 30, 1968,". the following: "$65,000,000 for the fiscal year ending June 30, 19W, and such sums as may be necessary for the next four fiscal years,". EVALUATION OF REGIONAL MEDICAL PROGRAMS SEC. 102. Section 901(a) of the Public Health Service Act is further amended by Inserting at the end thereof the following new sentence: "For any fiscal year ending after June 30, 1960, such portion of the il)propriatioiis pursuant to this section as the Secretary may determine, but not exceeding 1 per ceiituiii thereof, shall be available to the Secretarv for evaluation (directly or by griiits or contracts) of the program authorized by this title." I'%-CLUSION' OF TERRITORIES SEC. 103. Section 902 (a) (1) of the Public Health Service Act (42 U.S.C. 299b) is amended by inserting after "State,," the following: "(which for pur- poses of this title includes the District of Columbia, the Commonwealth of Puerto Rico, the Virgin Islands, Guam, American 3aiiloti, and the Trust Ter- ritory of the Pacific Islands) COlfBI'TATIONS OF REGIONAL MEDICAL PROGRABI AGENCIES SEC. 104. Section 903(a) and section 904(a) of the Public Health Service Act (4'-> U.S.C. 299c, 299d) are each amended by inserting after "other public or nonprofit private agencies and institutions" the following: ", and combina- tions thereof,". ADVISORY COU.NCIL lfE',IBERS SEC. 105. (a) Section 905(a) of the Public Health Service Act (42 U.S.C. 299e) is amended by striking out "twelve" and inserting in lieu thereof sixteen". (b) Section 905(b) of such Act is amended by striking but "and four at the end of the third year" and inserting in lieu thereof "four at the end of the third year, and four at the end of the fourth year". .%IULTIPROGRA.%f SERVICES SEC. 106. Title IX of the Public Health Service Act is further amended by adding at the end thereof the following new section: "PROJECT GRANTS FOR NIULTIPROGRA'.kf SERVICES SEC. 910. Funds appropriated under this title ,chall also be available for nts to any public or nonprofit private agency or institution for services ded by or which will be of.-tibstiiitial use to, qny two or more regional medi- programs." CLARIFYING OR TEOIINICAL A'-%IE@ND.IfENTS SEC. 107. (a) Section 901 (e) of the Public Health Service Act is amended by inserting before the period at the end thereof "or, where appropriate, i prac- ticing dentist". (b) Section 901 of such Act is further imeiided by adding It the end thereof the following new subsection: "(d) Grants under this title to iiiy ageilev or institution for a regional medical program may be used by it to assist in meeting the cost of participa- tion in such program by any TWeral hospital." 9 ill be Dr. Mr. Ki-Ros. I understand our first -witness this morning w sistant Secretary for I-lealtli and Scientific Affairs Philip R. Lee, As in the- Department of Health, Ed@cation, ,tnd Welfare. Dr. Lee. STATEMENT OF DR. PHILIP R. LEE, ASSISTANT SECRETARY FOR HEALTH AND SCIENTIFIC AFFAIRS, DEPARTMENT OF HEALTH, EDUCATION, AND WELFARE; ACCOMPANIED BY RALPH K. HUITT, ASSISTANT SECRETARY FOR LEGISLATION; DR. RALPH Q. MAR- STON, DIRECTOR, DIVISION OF REGIONAL MEDICAL PROGRAMS; DR. STANLEY F. YOLLES, DIRECTOR, NATIONAL INSTITUTE OF MENTAL HEALTH; AND HELEN JOHNSTON, CHIEF, MIGRANT HEALTH BRANCH, BUREAU OF HEALTH SERVICES Dr. LEE. Thank you, Mr. Chairman. Mr. RO(;ERS (preiidiiig). I might say that the committee is pleased to have you with us, and particularly since your new duties have been stated b@ the Secret'ary to-be coordinator for health, and "Mr. Health" for the Government. We ,ire delighted to have you with us in this capacity today, and we are pleasedto have your 'associates. We will be glad to hear your statement. Dr. LEE. Thank you, sir. Accompanying m-e are Miss Johnston, Dr. Marston, and Dr. Yolles, Mr. R-,ili;li Huitt is with us this morning also. Mr. @ERs. We are glad to see Mr.-Huitt here. Dr. LEE. Mr. Chairman ind members of the Subcommittee on Health ,ind Welfare, it gives me great pleasure to appear before @oi-i today in support of,the Health 8ervici;s Act of 1969,-whicli contains an extension and improvements to the Heart, Cancer, and Stroke Amendments of 1965, ,tii extension of the Mi Health Act of 1962, ,cis qmeiided in 1965, the transfer of -,iutliorigeire"-,1311i'iow in section 402 of the Narcotic Addict Rehabilitation Act of 1966 to the Community Mental Health Centers Act, ,iiid the establishment of a assist communities to improve treatment services to i latter two programs to be known -,is the Alcoholic .iiid N Rehabilitation Amendments of 1968. These programs are all designed to carry forward our commitment to make the best health services ,tvailabl@ to all Americans. In his special message to Congress on health in 1965, President Johnson stated: Our first concern must be to assure that the advance of medical knowledge leaves none behind. We can-and must-strive now to assure- the availability and accessibility of the best health care for all Americans, regardless of age or geography or economic status. -A.Ithougli much has been -,iccoml)lislied in the last 3 ye@rs, much remains to be done. We must remove the barriers of discrimination that have so long barred the alcoliolic and the nircotic addict from receiving truly Comprehensive care-,,t discrimination based on di,,tg- iiosis, wfiieh is iust @s intolerable -,is discrimination based on race. The migrant worker suffers from not only the disadvantages of language, poverty, and geography, but often the even mom difficult 10 prloblem@ of ignorance and inexperience in the use of modem medi- c a services. The removal of a different kind of barrier-the time lag between discovery and effective application of new knowledge-is a ijual of the regionaf medical programs In his health message this year,-Presideiit iolnson stated: Its purpose is to translate research into action, so that all of the people of our nation can benefit as rapidly as po@ible from the achievement of modern medicine. Title I 'of H.R. 15758 extends the re .onal medical program through 91 fiscal year 1973 and clarifies ai-id improves certain a-spects of tTie program. Y'ou will recall from your consideration of this l@slation in the summer of 1965 that it -was introduced as a result of -the findings of the Presideiit's Commission on Heart..Disease, Cancer, and Sf-roke. The Comniissioii found that i-nedical science has created the -poten- tia,l to reducA the heavy tolls of these diseases but that this potential was not being realized Tor many of our citizens. The Interstate and Foreign Commerce Conunittee played a major role in clarifying both the nature of the program alia the direc- tion in which it was to go. The basic objective of this program is to assure that the -people of this Nation, wherever they may be, .vill benefit from the ad-va@s of medical science against the threats of heart disease, cancer, stroke, and related diseases. . As an additional dividend, this progrtni will have an impact extend- inly far beyond the control of specific diseaz@. The physicians and other h@lth workers involved in the regional medical @rograms will be applying their new knowledge and new techniques to pitieli,ts being treated under tl edi@,ire. and other health programs. 'ne lessons learn iial medicil programs cannot help but @iance the qual ey of there other activities. The orozr@ his justified our expectation that this progr@ Nv-ould improve the effectiveness and quality of medical care fo ose wl suiffer from the major killer diseases. The program is already briii@in together diverse groups in the g - health helcY in an unprecedente fashion and in a m,@iiiier that re- sults in t consideration of the unfilled health needs of the region, rather than those of the individual institutions. Despite the present shortage of manpower, the program litiz, been successful in recruiting throng out the lqatioii tal@iitect persons ii-illin(-r to make firm career co@tments to acliievinc-, the zoals of tlic, i,)-ro-arain. The Drozrams leave efrriied the support of t-fie major lieilth re- 'professional and voluntary, at the national and regional levels. sour@' The y have helped overcome hostilities and divisions wliie@liai-e existed in some cases for generations. Indeed, there -has been a positiN-e re.,:I)on-@e to this comiiiittee@s man- date in the original legislat -oii that this program would be community I based-4-liat the respoiisibil ty.for plaiiiiln ' id organizing the opera- tion of the program woul( belong to tli@@r'el'gioii, not to the Federal Government. As evidence of this response almost 1.000 medical institutions are participating in the regional medical proo,,raiiis, including every med- I 11 ical school and hundreds of hospitals. This involvement of medical schools ,iiid other teacliiiig and research institutions helps develop close tnd continuous contact between medical advances and their ap- plicatioii in the community. Almost 800 health organizations are participating, including every State medical society, State health department, State heart associa- tion, and State cancer society. Over 7,000 non-Federtf-connected individuals Ire now actively enLya-aed in the programs, including 1,800 employed either full- or p@rt@time by the regional programs, over 1,900 members of the ired by the law who must advise on the s and approve ,tll operational activities and members of various subcommittees, , who are contributing their time. s an iiivolv not only of the experts in the region but als tli personnel at the arassroots level, tnd this is irlus- tr,,tted (p. 33) which is submitted with the testimony. Tlie,q institutions. and or--anizatioiis -,ire the forces which with your support, will carry to :Fulfillment the high expectations for this program. The e of the -program is eiiabling the regional groups to ,tssess SWP tliorouLyli1v the needs ,ind opportunities within their reiion and to implement the steps that can- be realistically undertaken to improve thi diagnosis and treatment of the major disease.-,. Bv coi)inLr with these lems ii a regional scale, the groups are ,tl;le t@ pfa'li for the mops@tobefficieiiot use of specialized resources for service or training from the largest medical center to the isolated rural physician. The regions have found that many different types of activities can contribute to objectives such as demonstrations of advanced diagnos- tic and patient-care techniq'ues, training -and continuing education of health personnel, development of communication and patient date networks, application of computer and other modern teehnolozv to Ilealtli care, and r@reli into better means for organizing and d@f@ver- I ILY improvements in -lieilth care. "ilie hrst planninL), Loraiit was -twarded less than 2 years -,igo. Today there are 53 have received planning grants and include the entire p, Puerto Rico, and an application from that Commoi reviewed. Eleven on have receive ts to support initial operational re I s -i other re activities, , !d 13 -- E-e submitfea tpplicatiods to @n the operational phase of programs. To fiiianc4b these activities p th there has been a rapid ine in e obligation of funds, tnd this is illustrated on table ll,,%vliieh is attached. The involvement i'n the regional medical programs by local insti- tutions and individuals has been enthusiastic. IVitliin the next year ,ill of the programs expect to enter the operational phase of their pro-aram. They are eager tD continue the work- they have @ii. l@ additioli@to exte@din the -basic ,tuthorities of -the regio@al med- ical program, the bill ains ,tmeiidmeiits to those an- thorfti@ that would li tccomplisli their goals more effectively. It contains %vould assure proper evaltia- tion of the accomplishi rim by provicfing-that up to 12 1 percent of the apprqpriatiQn for any fiscal vear be6nninz with 1970 mav be used bv the -8 ry for the evaluation. - The bill malies clear that @onal medical grants can be awarded to a combination of regional medical program agencies for carrying on a regional medical pro Also, a new authoatyis added which would permit the anvardln_& of zmnts to anv public, or private nonprofit @gefi-cy or institution services which @ill be of substantial value and use to any two or more rewonal medical programs. Such services might incliide producing education materials, developing evaluati uni- d othe. which efficient s of the needs to authorize the use of regional medical ,grant. funds to permit the full participation of Federal gorsop.%alms in regional medial programs as the iml56@nt community resources whiejethiky in fact are. Another aanen@ent claTffies that a Dracticin-a dentist as well as to a facility c es which a-re E can play an ii oral cancer, dment peZt such referrals. in the original act ivhich does not incre-w in the Advisory Council membership, from 12 mem-. bers to 16, is provided in the-bill, an expansion made n ar-v -by the increasing workload of the Council in- ' ' icationi and rev ingr.%oapvdiversity of the desirability of having members who reflZa interests. - The bill also extends the provisions of the programs to Guam, American Samoa, and the Trust Territory of the-PaEific Islands. The Ha,waii re@onal medical pro-aram has indicated that it would be inter- ested in i@ciudipg these a-r These provisions will s al medical programs and will provide the flexibilit) in making the most efficient use of all the health elements of the community in-the pro-aram. The committee has received copies of the Surgeon Gen@ral's report on regional medical programs, which dewribes- in detail the initial prozress. I would like to-submit for the record material which adds io t@at report and which will bring you up to date on the accomplish- ments of the regional medical programs. May I submi-t that for the record, Mr. Chairman? Mr. RorFRs. Without objection, it will be received. (The document referred io follows:) 13 PROGRESS REPORT 0 U.S. DEPARTNIENT OF HEALTH, EDUCATION, AND WELFARE Public Health Service 4 14 nal Medical Programs have been awarded ing grants*... 0 to develop operational proposals through . . . surveys of needs and resources feasibility studies organization and staffing Regional Medical Program is currently under development 15 042 Re@ional Medical Programs have received opera- ti.nal grants*... 0 to improve patient care through research. con- tinning education, training, and demonstration projects 0 to ievelop better methods for the exchange of information amon@ medical schools, medical centers, community hospitals, practicing phy- sicians, and other health institutions, or,,ani- zations, and personnel 0 to continue to develop new and expanded plans for further improvement of patient care *As of February 29, 1968 16 REGIONS AND PROGRAM COORDINATORS OR DIRECTORS I ALABAMA 10 FLORIDA 19 LOUISIANA B. B. Wells, M.D. S. P. Martin' MJ). J. A. Sabatier, M.D. U. of Ala. Med. Ctr. Provost, J' Hillis Claiborne Towers Roof 1919 7th Ave. S. Miller Med. Ctr. 119 S. Claiborne Ave. Birmingham, Ala. 35233 U. of Florida New Orleans, La. 70112 Gainesville, Fla. 32601 2 ALBANY, N.Y. 11 GEORGIA 20 MAINE F. M. Woolsey, Jr., M.D. M. Chatterjee, M.D. Assoc. Dean J. G. Barrow, MJ). 295 Water St. Albany Med. Coll. Med. Assoc. of Ga. Augusta, Me. 04332 47 New Scotland Ave. 938 Peachtree SL N.E. Albany, N.Y. 12208 Atlanta, Ga. 30309 21 MARYLAND 12 GREATER W. S. Spicer, Jr., M.D. 3 ARIZONA 550 N. Broadway DELAWARE Baltimore, Nld. 21205 M. K. DuVal, M.D. VALLEY Dean, Coll. of Med. W. C- Spring, Jr., M.D. 22 MEMPHIS U. of Arizona Wynnewood House MEDICAL Tucson, Ariz. 85721 300 E. Lancaster Ave. REGION 4 ARKANSAS Wynnewood, Pa. 19096 J. W. Culbertson, M.D. W. K. Shorey, M.D. 13 HAWAII Coll. of Nied. U. of Tennessee Dean, Sch. of Med. W. C. Cutting, M.D. 858 Madison Ave. U. of Arkansas Dean, Sch. of Nied. Memphis, Tenn. 38103 4301 W. Markham St. U. of Hawaii Little Rock, Ark. 72201 2538'Ibe Mall 23 METROPOLITAN 5 BI-STATE Honolulu, Ha. 96822 WASHINGTON, D.C. T. W. Mattingly, M.D. W. H. Danforth, M. D.. 14 ILLINOIS D.C. Medical Society V. Chan. for Med. Affairs Wright Adams, M.D. 2007 Eye St. N.W. Washington U. 112 S. Michigan Ave. Washington, D.C. 20006 660 S. Euclid Ave. Chicago, 111. 60603 St. Louis, Mo. 63110 15 INDIA-NA 24 MICHIGAN A. E. Heustis, M.D. 6 CALIFORNIA G. T. Lukemeyer, M.D. 1111 Michigan A . Paul D. Ward Assoc. Dean East Lansin-g, Mich. 48823 655 Sutter St. #302 Indiana U. Sch. of Med. San Francisco, Calif. 94102 1100 W. Micbig@ SL 25 MISSISSIPPI Indianapolis, Ind. 46207 G. D. Campbell, M.D. 7 CENTRAL 16 INTER-$I@UNTAIN U 2, of Nliss. Med. Ctr. NEW YORK 00 N. State Ct. B. H. Lyons, M.D. C. H. Castle, Mm. Jackson, Miss. 39216 State U.-of N.Y. Assoc. Dean 750 E. Adams SL U. of Utah 26 MISSOURI Syracuse, N.Y. 13210 Salt Lake City, UL 84112 V. E. Wilson, M.D. 17 IOWA Executive Director 8 COLORADO- W. A. Krehl, NI.D., Ph.D. for Health Affairs WYOMING 308 Melrose Am U. of Missouri P. R. Hildebrand, M.D. U.ofIowa Columbia, Mo. 65201 U. of Col. Med. Ctr. Iowa City, la. 59940 4200 E. 9th Ave. 27 1$IOUNTAIN STATES Denver, Col. 80220 18 KANSAS K. P. Bunnell, Ed.D. C. E. Lewis, M.D. Assoc. Director 9 CONNECTICUT Chairman Western Interstate H. T. Clark, Jr., M.D. Dept. of Preventive Med. Comm. for Higher Ed. 272 George St. U. of Kansas Univ. E. Campus New Haven, Conn. 06510 Kansas City, Kan. 66103 Boulder, Col. 80302 17 28 NEBRASKA- 37 NORTHWESTERN 46 TENNESSEE SOUTH DAKOTA OHIO MID-SOUTH H. Morgan, M.D. C. R. Tittle, Jr., M.D. S. W. Olson, M.D. 1408 Sharp Bldg. Medical College of Ohio 110 Baker Bldg. Lincoln, Neb. 68508 at Toledo 110 21st Ave. S. 29 NEW JERSEY 38 OHIO STATE Nashville, Tenn. 37203 A. A. Florin, rA.D. R. L Meiling, M.D. 47 TEXAS N. J. State DepL of lUth. Dean, Coll. of Med. *S. G. Thompson, M.D. 88 Ross SL Ohio State U. Suite 724 E Orange, N.J. 07018 410 W. 10th Ave. Sealy-Smith Prof. Bldg. Columbus, Ohio 43210 Galveston, Tex. 77550 30 NEW MEXICO Reginald Fitz, M.D. 39 OHIO VALLEY 48 THI-STATE Dean, Sch. of Med. W. H. McBeath, M.D. N. Stearns, M.D. U. of New Mexico 1718 Alexandria Dr. 22 The Fenway Albuquerque, N.M. 87106 Lexington, Ky. 40504 Boston, Mass. 02115 31 NEW YORK 40 OKLAHOMA METR.AREA K. M. West, M.D. 49 VIRGINIA V. deP. lArkin, M.D. U. of Ok. Med. Ctr. E. R. Perez, M.D. N.Y. Academy of Med. 800 N.E. 13th St. Richmond Acad. of Med. 2 E. 103d SL Oklahoma City, Ok. 7310.4 1200 F. Clay SL New York, N.Y. 10029 Richmond, Va. 23219 41 OREGON 32 NORTH CAROLINA -- 50 WASHINGTON- M. R. Grover, M.D. ALASKA IVL J. Musser, M.D. Director, Cont. Med. Ed. Teer House Sch. of Med. D. R. Sparkman, M.D. 4019 N. Roxboro Rd. U. of Oregon Sch. of Med. Durham, N. C- 27704 3181 S.W. Sam Jackson U. of Washington 33 NORTH DAKOTA Portland, Ore. 97201 Seattle, Wash. 98105 T. H. Harwood, M.D. 42 PUERTO RICO 51 WEST VIRGINIA Dean, Sch. of '.kied. U. of North Dakota A. Nigaglioni, M.D. C. L Wilbar, Jr., M.D. Grand Forks, N.D. 58202 Chancellor, Sch. of Med. W. Va. Univ. Med. Ctr. U. of Puerto Rico Morgantown, W. Va. 26506 34 NORTHEASTERN San Juan, P.R. 00905 OHIO 52 WESTERN F. C. Robbins, M.D. 43 ROCHESTER, N.Y. NEW YORK Dean, Sch. of Nied. R. C. Parker, Jr., M.D. J. R. F. Ingall, M.D. Western Reserve U. Sch. of Med. and DenL Sch. of Med. 2107 Adelbert Rd. U. of Rochester State U. of N.Y. at Buffalo Cleveland, Ohio 44106 Rochester, N.Y. 14620 Buffalo, N.Y. 14214 35 NORTHERN 44 SOUTH CAROLINA 53 WESTERN NEW ENGLAND C. P. Summerall, 111, MD PENNSYLVANIA Dept. of Med. F. S. Cheever, M.D. J. E. Wennberg, M:D. Med. Coll. Hospital Dean, Sch. of Med. U. of Vt. Coll. of Mea. 55 Doughty St. U. of Pittsburgh 25 Colchester Ave. Charleston, S.C. 29403 3530 Forbes Ave. Burlington, Vt. 05401 Pittsburgh, Pa. 15213 45 SUSQUEHANNA 36 NORTHLANDS VALLEY 54 WISCONSIN J. M. Stick-ney, M.D. R. B. McKenzie J. S. Hirschboeck, M.D. iNfinn. State Nfed. Assoc. 3608 Market St. Wisconsin RMP, Inc. 200 lst SL S.W. P.O. Box 451 110 E. Wisconsin Ave. Rochester, -N@. 55901 Camp Hill, Pa.'17011 Milwaukee, Wisc. 53202 'Associate Coordinator 309-653 0-68-2 18 NATIONAL ADVISORY COUNCEL E. L. CROSBY, M.D. J. R. HOGNESS, M.D. E. D. PELLEGRINO, M.D. Director Dean, School of Med. Director of the Med. Ctr. American Hosp. Assoc. U. of Washington State U. of New York Chicago, DI. Seattle, Wash. Stony Brook, N.Y. M. E. DEBAKEY, M.D. J. T. HOWELL, M.D. A. M. POPAIA, M.D. Prof. and Chairman Executive Director Regional Director Dept. of Surgery Henry Ford Hosp. Mountain States Regional Baylor U. Detroit, Mich. Medical Program Houston, Tex. C. H. MILLIKAN, M.D. Boise, Idaho H. G. EDMONDS, Ph.D Consultant in Nettrology M. I. SHANHOLTZ, M.D. Dean, Graduate Sch. Mayo Clinic State Hlth. Comm. No. Carolina College Rochester, Minn. State Dept. of Hlth. Durham, N.C. G. E. MOORE, M.D. Richmond, Va. B. W. EVERIST, JR., M.D. Director, Roswell Park W. H. STEWART, M.D. Chief of Pediatrics Memorial Institute (Chairman) Green Clinic Buffalo, N.Y. Surgeon General Ruston, U Public Health Service HISTORY AND PURPOSES OF REGIONAL MEDICAL PROGRAMS On October 6, 1965, the President signed Public Law 89-239. It authorizes the establishment and maintenance of Regional Medical Programs to assist the Nation's health resources in making available the best possible patient care for heart disease, cancer, strcike and related diseases. This legislation, which will be referred to in this publication as The Act, was shaped by the interaction of at least four antecedents: the historical thrust toward regionalization of health resources; the development of a national biomedical research community of unprecedented size and productivity; the changing needs of society; and finally, the particular legislative process leading to The Act itself. The concept of regionalization as a means to meet health needs effectively and economically is not new. During the 1930's, Assistant Surgeon General Joseph W. Mountin was one of the earliest pioneers urging this approach for the delivery of health services. Tle na. tional Committee on the Costs of Medical Care also focused attention in 1932 on the potential benefits of regionalization. In that same year, the Bingham Associates Fund initiated the first comprehensive regional effort to improve patient care in the United States. This program linked the hospitals and programs for continuing education of physicians in the State of Maine with the university centers of Boston. Advocates of regionalization next gained national attention more than a decade later in the report of the Commission on Hospital Care and in the Hospital Survey and Construction (Hill-Burton) Act of 1946. Other proposals and attempts to introduce regionaliza- tion of health resources can be chronicled, but a strong national movement toward regionalization had to await the convergence of 19 other factors which occurred in 1964 and 1965. One of these factors was the creation of a national biomedical research effort unprecedented in history and unequalled anywhere else in the world. The effect of this activity was and continues to be intensified by the swiftness of its creation and expansion: at the beginning of World War II the national expenditure for medical re- search totaled $45 million; by 1947 it was $87 million; and in 1967 the'total was $2.257 billion-a 5,000 percent increase in 27 years. The most significant characteristic of this research effort is the tre- mendous rate at which it is producing new knowledge in the medical sciences, an outpouring which only recently began and which shows no signs of decline. As a result, changes in health care have been dramatic. Today, there are cures where none existed before, a number of diseases have all but disappeared with the application of new vaccines, and patient care generally is far more effective than even a decade ago. It has become apparent in the last few years, however, (despite substantial achievements), that new and better means must also be found to convey the ever-increasing volume of research results to the practicing physician and to meet growing complexities in medical and hospital care, including specialization, increasingly intricate and expensive types of diagnosis and treat- ment, and the distribution of scarce manpower, facilities, and other resources. The degree of urgency attached to the need to cope with these issues is heightened by an increasing public demand that the latest and best health care be made available to everyone. This public demand, in turn, is largely an expression of expectations aroused by awareness of the results and promise of biomedical research. In a sense, the national commitment to biomedical investigation is one manifestation of the third factor which contributed to the creation of Regional Medical Programs: the changing needs of society-in this case, health needs. The decisions by various private and public institutions to support biomedical research were responses to this societal nee4 perceived and interpreted by these institutions. In addition to the support of research, the same interpretive process led the Federal Government to develop a broad range of other pro- grams to improve the quality and availability of health care in the Nation. The Hill-Burton Program which began with the passage of the previously mentioned Hospital Survey and Construction Act of 1946, together with the National Mental Health Act of 1946, was the first in a series of post-World War 11 legislative actions having major impact on health affairs. When the 89th Congress adjourned in 1966, 25 health-related bills had been enacted into law. Among these were Medicare and Medicaid to pay for hospital and physician services for the Nation's aged and poor; the Comprehensive Health Planning Act to provide funds to each state for non-categorical health planning and to support services rendered through state and other health activities; and Public Law 89-239 authorizing Regional Medi- cal Programs. 20 The report of the President's Commission on Heart Disease, Cancer, and Stroke, issued in December 1964, focused attention on societal needs and led directly to introduction of the legislation au- thorizing Regional Medical Programs. Many of the Commission's recommendations were significantly altered by the Congress in the legislative process but 'Me Act was clearly passed to meet needs and problems identified and given national recognition in the Corn- mission's report and in the Congressional hearings preceding pas- sage in The Act. Some of these needs and problems were expressed as follows: *A program is needed to focus the Nation's health resources for research, teaching and patient care on heart disease, cancer, stroke and related diseases, because together they cause 70 per. cent of the deaths in the United States. 0A significant number of Americans with these diseases die or are disabled because the benefits of present knowledge in the medical sciences are not uniformly available throughout the country. 0There is not enough trained manpower to meet the health needs of the American people within the present system for the delivery of health services. 0Pressures threatening the Nation's health resources'are building because demands for health services are rapidly increasing at a time when increasing costs are posing obstacles for many who require these preventive, diagnostic, therapeutic and rehabilitative services. 0A creative partnership must be forged among the Nation's medi- cal scientists, practicing physicians, and all of the Nation's other health resources so that new knowledge can be translated more rapidly into better patient care. This partnership should make it possible for every community's practicing physicians to share in the diagnostic, therapeutic and consultative resources of major medical institutions. They should similarly Ire provided the op- portunity to participate in the academic environment of research, teaching and patient care which stimulates and supports riiedical practice of the highest quality. 0Institutions with high quality research programs in heart disease, cancer, stroke, and related diseases are too few, given the magni- tude of the problems, and are not uniformly distributed through. out the country. 0There is a need to educate the public regarding health affairs. Education in many cases will permit people to extend their own lives by changing personal habits to prevent heart disease, cancer, stroke and related diseases. Such education will enable indi- viduals to recognize the need for diagnostic, therapeutic or re- habilitative services, and to know where to,find these services, and it will motivate them to seek such services when needed. 21 During the Congressional hearings on this bill, representatives of major groups and institutions with an interest in the American health system were heard, particularly spokesmen for practicing physicians and community hospitals of the Nation. The Act which emerged turned away from the idea of a detailed Federal blueprint for action. Specifically, the network of "regional centers" recommended earlier by the President's Commission 'was replaced by a concept of "re,-ional cooperative arrangements" among existing health resources. The Act'establishes a system of grants to enable representatives of health resources to exercise initiative to identify and meet local needs within the area of the categorical diseases through a broadly defined process. Recognition of geographical and societal diversities 'Aithin the United States was the main reason for this approach, and spokes- men for the Nation's health resources who testified durin@ the hearings strengthened the case for local initiative. Thus the degree to which the various Regional Medical Programs meet the objectives of Ile Act will provide a measure of how well local health resources can take the initiative and work together to improve patient care for heart disease, cancer, stroke and related diseases at the local level. The Act is intended to provide the means for conveying to the medical institutions and professions of the Nation the latest advances in medical science for diagnosis, treatment, and rehabilitation of patients afflicted twith heart disease, cancer, stroke, or related di- seases-and to prevent these diseases. Tle grants authorized bv Tle Act are to encourage and assist in the establishment of regional cooperative arrangements among medical schools, research institu- tions, hospitals, and other medical institutions and agencies to achieve these ends by research, education, and demonstrations of patient care. Through these means, the programs authorized bv Tle Act are also intended to improve generally the health manpower and facilities of the Nation. In the two years since the President signed The Act, broadly representative groups have organized themselves to conduct Re@ional Medical Programs in more than 50 Regions which they them-,elves have defined. These Regions encompass the Nation's population. They have been formed by the organizing groups using functional as well as geographic criteria. These Regions include combinations of entire states (e.g. the Washington-Alaska Region), portions of sev. eral states (e.g. the Intermountain Region includes Utah and -@- tions of Colorado, Idaho, Montana, Nevada and Wyoming), sin-le states'(e.g. Georgia), and portions of states around a metropolitan center (e.g. the Rochester Region which includes the city and 11 surrounding counties). Within these Regional Programs, a A-ide variety of organization structures have been developed, includin@ executive and planning committees, categorical disease task forces, and community and other types of sub.regional advisory committees. Regions first may receive planning grants from the Division of Regional Medical Programs, and then may be awarded operational grants to fund activities planned with initial and subsequent plannin@ C, 22 grants. These operational programs are the direct means for Re- gional Medical Programs to accomplish their objectives. Planning moves a Region toward operational activity and is a continuing means for assuring the relevancy and appropriateness of operational activity. It is the effects of the operational activities, however, which will produce results by which Regional.Medical Programs will be judged. On November 9, 1967, the President sent the Congress the Report on Regional Medical Programs prepared by the Surgeon General of the Public Health Service, and submitted to the President through the Secretary of Health, Education, and Welfare, in compliance with The Act. The Report details the progress of Regional Medical Programs and recommends continuation of the Programs beyond the June 30, 1968, limit set forth in The Act. The President's letter transmitting the Report to the Con-ress was at once encouraging and exhortative when it said, in part: "Because the law and the idea behind it are new, and the problem is so vast, the program is just emerging from the planning state. But this report gives encouraging evidence of progress-and it promises great advances in speeding research knowledge to the patient's bedside." Thus in the final seven words of the President's message, the objective of Regional Medical Pro. grams is clearly emphasized. THE NATURE AND POTENTIAL OF REGIONAL MEDICAL PROGRAMS GOAL-IMPROVED PATIENT CARE The Goal is described in the Surgeon General's Report as . . clear and unequivocal. 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 disease, cancer, stroke, and related diseases to be available to all." MEANS-THE PROCESS OF REGIONALIZATION Note: Regionalization can connote more than a regional cooperative arrange. ment, but for the purpose of this publication, the two terms will he used interchangeably. The Act uses "regional cooperative arrangement,' but .1regionalization" has become a more convenient synonym. A regional cooperative arrangement among the full array of available health resources is a necessary step in bringing the benefits of scientific advances in medicine to people wherever they live in a Region they themselves have defined. It enables patients to benefit from the inevitable specialization and division of labor which ac- company the expansion of medical knowledge because it provides a system of working relationships among health personnel and the institutions and organizations in which they work. This requires 23 a commitment of individual and institutional spirit and resources which must be worked out by each Regional Medical Program. It is facilitated by voluntary agreements to serve, systematically, the needs of the public as regards the categorical diseases on a regional rather than some more narrow basis. Regionalization, or a regional cooperative arrangement, within the context of Regional Medical Programs has several other impor- tant facets: 0- It is both functional and geographic in character. Functionally, regionalization is the mechanism for linking patient care with health research and education within the entire region to provide a mutually beneficial interaction. This interaction should occur within the operational activities as well as in the total program. The geographic boundaries of a region serve to define the popula- tion for which each Regional Program will be concerned and responsible. This concern and responsibility should be matched by responsiveness, which is effected by providing the population with a significant voice in the Regional Program's decision- making process. 0 It provides a means for sharing limited health manpower and facilities to maximize the quality and quantity of care and service available to the Region's population, and to do this as eco- nomically as possible. In some instances, this may require inter- regional cooperation between two or among several Regional Programs. 0 Finally, it also constitutes a mechanism for coordinating its categorical program with other health programs in the Region so that their combined effect may be increased and so that they contribute to the creation and maintenance of a system of comprehensive health care within the entire Region. Because the advance of knowledge changes the nature of medical care, regio@ization can best be viewed as a continuous process rather than a plan which it t@y developed and then implemented. This process of regionalization, or cooperative arrangements, con- sists of at least the following elements: involvement, identification of needs and opportunities, assessment of resources, definition of ob- jectives, setting of priorities, implementation, and evaluation. While these seven elements in the process will be described and discussed separately, in practice they are interrelated, continuous and often occur simultaneously. Involvement-The involvement and commitment of individuals, organizations and institutions which will engage in the activity of a Regional Medical Program, as well as those which will be affected by this activity, underlie a Regional Program. By involving in the steps of study and decision all those in a region who are essential to implementation and ultimate success, better solutions may be found, the opportunity for wider acceptance of decisions is improved, and implementation of decisions is achieved more rapidly. Other 24 attempts to organize health resources on a regional basis have ex- perienced difficulty or have been diverted from their objectives because there was not this voluntary involvement and commitment by the necessary individuals, institutions and organizations. The Act is quite specific to assure this necessary involvement in Regional Medical Programs: it defines, for example, the minimum composi- tion of Regional Advisory Groups. The Act states these Regional Advisory Groups must include "practicing physicians, medical center officials, hospital administra- tors, representatives from appropriate medical societies, voluntary health agencies, and representatives of other organizations, institu- tions and agencies concerned with activities of the kind to be carried on under the pro-ram and members of the public familiar with the need for the services provided under the program." To ensure a maximum opportunity for success, the composition of the Regional Advisory Group also should be reflective of the total spectrum of health interests and resources of the entire Region. And it should be broadly representative of the geographic areas and all of the socioeconomic groups which will be served by the Re-ional Program. The Regional Advisory Group does not have direct administrative responsibility for the Regional Program, but the clear intent of the Congress was that the Advisory Group would ensure that the Regional Medical Program is planned and developed with the continuing advice and assistance of a group which is broadly representative of the health interests of the Region. The Advisory Group must approve all proposals for operational activities within the Regional Program, and it prepares an annual statement giving its evaluation of the effectiveness of the regional cooperative arrangements established under the Regional Medical Program. Identification of Needs and Opportuni@s-A Regional Medical Program identifies the needs as regards heart disease, cancer, stroke and related diseases within the entire Region. These needs are stated in terms which offer opportunities for solution. This process of identification of needs and opportunities for solu- tion requires a continuing analysis of the problems in delivering the best medical care for the target diseases on a regional basis, and it goes beyond a generalized statement to definitions which can be translated into operational activity. Particular opportunities may be defined by: ideas and approaches generated within the Region, ex- tension of activities already present within the Region, and ap- proaches and activities developed elsewhere which might be applied within the Region. Among various identified needs there also are often relationships which, when perceived, offer even greater opportunities.for solutions. In examining the problem of coronary care units throughout its Region, for example, a Regional Program may recognize that the more effective approach would be to consider the total problem of the treatment of myocardial infarction patients within the Region. This broadened approach on a regional basis enables the Regional 25 Program to consider the total array of resources within its Region in relationship to a comprehensive program for the care of the myo- cardial infarction patient. Thus, what was a concern of individual hospitals about how to introduce coronary care units has been trans- formed into a project or group of related projects with much greater potential for effective and efficient utilization of the Region's re. sources to improve patient care. Assessment ol Resources-As part of the process of re-ionalization, a Region continuously updates its inventory of existing resources and capabilities in terms of function, size, number and quality. Every effort is made to identify and use existing inventories, filling in the gaps as needed, rather than setting out on a long, expensive process of creating an entirely new inventory. Information sources include state Hill-Burton agencies, hospital and medical associations, and voluntary agencies. The inventory provides a basis for informed judgments and priority setting on activities proposed for develop- ment under the Regional Program. It can also be used to identify missing resources-voids requiring new investment-and to develop new configurations of resources to meet needs. Definition of Objectives-A Regional Program is continuously involved in the process of setting operational objectives to meet identified needs and opportunities. Objectives are interim steps toward the Goal defined at the beginning of this section, and achieve. ment of these objectives should have an effect in the Region felt far beyond the focal points of the individual activities. This can be one of the greatest contributions of Regional Medical Programs. The completion of a new project to train nurses to care for cancer patients undergoing new combinations of drug and radiation therapy, for example, should benefit cancer patients and should provide additional trained manpower for many hospitals in the Region. But the project also should have challenged the Region's nursing and hospital communities to improve @enerally the continuing and in. service education opportunities for nurses within the Region. Setting ol Priorities-Because of limited manpower, facilities, financing and other resources, a Region assigns some order of priority to its objectives and to the steps to achieve them. Besides the limitations on resources, factors include: 1) balance between what should be done first to meet the Region's needs, in absolute terms, and what can be done using existing resources and compe. tence; 2) the potentials for rapid and/or substantial progress toward the Goal of Regional Medical Programs and progress toward re- gionalization of health resources and services; and 3) Program balance in terms of disease categories and in terms of emphasis on patient care, education and research. Implemerdation-The purpose of the preceding steps is to provide a base and imperative for action. In the creation of an initial op- erational program, no Region can attempt to determine all of the program objectives possible, design appropriate projects to meet all the objectives and then assign priorities before seeking a grant to 26 implement an operational pr6@ram which encompasses all or even most of the projects. Implementation can occur with an initial operational pro-ram encompassin- even a small number of well- designed projects which will move the Region toward the attainment of valid pro-ram objectives. Because rationalization is a continuous process. a Re-ion is expected to continue to submit supplemental and additional operational proposals as they are developed._ Evalu@on-Each planning and operational activity of a Re-ion, as well a.:, the overall Re-ional Pro-ram, receives continuous, quan. 0 r3 titative and qualitative evaluation wherever possible. Evaluation is in terms of attainment of interim objectives, the process of regionali- zation, and the Goal of Re-ional Medical Pro@rams. Objective evaluation is simply a reasonable basis upon which to determine whether an activity should be continued or altered, and, ultimately, whether it achieved its purposes. Also, the evaluation of one activity may suggest modifications of another activity which would increase its effectiveness. Any attempt at evaluation implies doing whatever is feasible within the state of the art and appropriate for the activity being evaluated. Thus, evaluation can ran@e in complexity from simply counting num. hers of people at meetings to the most involved determination of behavioral changes in patient management. As a first step, however, evaluation entails a realistic attempt to design activities so that, as they are implemented and finally con. cluded, some data will result which will be useful in determining the degree of success attained by the activity. RFVIIEW COMMMEE K. P. BU-,NELL, Ed.D. G. E. MILLER, M.D. D. E. ROGERS, M.D. Assoc. Director Director, Off. of Research Prof. and Chairman Western Interstate ComnL in Med. Educ. Dept. of Med. for Hi er Ed. Coll. of Med., U. of rU. School of Med. Boulder,,L,.. Chicago, M. Vanderbilt U. G. JAi@, M.D. P. M. MORSE, Ph.D. Nashvflle, Tenn. (Cbairmai3) Director, Operations C. H. W. RUHE, M.D. Dean, Mount Sinai Research Ctr. Assistant Secretary School of Med. Mass. Inst. of Tech. Council on Med. Ed. New York, N.Y. Cambridge, Mass. American Med. Assoc. H. W. KE.NNEY, M.D. A. PASCASIO, Ph.D. Chicago, Ill. Medical Director Assoc. Research Prof. R. J. SLATER, M.D. John A. Andrew Memorial Nursing School, U. of Executive Director Hosp. Pittsburgh The Assoc. for the Aid of Tuskegee Institute Pittsburgh, Pa. Crippled Children Tuskegee, Ala. S. H. PROGER, M.D. New York, N.Y. E.J.-KOWALEWSKI,M.D. ProL and Chairman J. D. THOMPSON Chairman, Dept. of Med. and Prof. of Public Hltb. Committee of Environ. Med. Physician-in-Chief School of Public Hltb. Acad. of Gen. Practice Tuits N.E. Med. Ctr. Yale U. ' Akron, Pa. Pres., Bingham Assoc. Fund New Haven, Conn. Boston, Mas& 27 N as I II EVENTS AC77ON 1964 DECEMBER Report of the President's Commis ion on Heart Di@, a] Cancer, and Stroke 196S FEBRUARY TO CongressionaJ bearings JULY OCTOBER Enactment of P.L 89-239 DECEMBER National Advisory Council meeting Initial policies and pre- liminary Guidelines reviewed 1966 FEBRUARY Establishment of Division Publication of preliminary Guidelines National Advisory Council meeting Policy for review proc- en and Division activities set APRIL Review Committee meeting National Advisory Council meeting 7 planning grants awarded JUNE Review Committee meeting National Advisory Council meeting 3 planning grants awarded JULY Publication of Guidelines Review Committee meeting AUGUST National Advisory Council meeting 8 planning grants awarded SEPTEMBER First of 5 meetings of 4d Hoc Report material Committee for Report to the discussed President and Congress OCTOBER Review Committee meeting NOVEMBER National Advisory Council meeting 16 planning grants awarded 1967 JANUARY Review Committee meeting National Conference National views on Programs & information for Report provided FEBRUARY National Advisory Council meeting 10 planning and 4 opera- tional grants awarded APRIL Review Committee meeting MAY National Advisory Council meeting 5 planning and I opera. tional grant awarded JUNE Report to the President & Congress JULY Review Committee meeting AUGUST National Advisory Council meeting 2 planning grants awarded OCTOBER Review Committee meeting NOVEMBER National Advisory Council meeting 2 planning and3opera- tional grants awarded 1968 JANUARY Conference-Workshop Regional activities and ideas presented 28 PUBLIC LAW 89-239 'hro h rants, to afford to the medical profession and the medical institu- . the diagnosis T ug g tions of the Nation the opportunity of planning and Implementing programs to make available to the American peo@le the latest advances in and treatment of heart disease, cancer, stroke, and related diseases by estall- lisbing voluntary regional cooperative arrangements among . . . o Physicians 0 Voluntary Health Agencies 0 Hospitals 0 Federal, State, and Local Health Agencies 0 Medical Schools 0 Research Institutions 0 Civic Organizations -nu L%. & njuGIONAL ADVISO.R'V COUNCILS T'he activities of Regiona@ Medical Programs are directed by fulltime Co, ordinators working tog@ther with Regional Advisory Groups which are broadly representative ot the medical and health resources of the Regions. Membership on these groups nationally is: Hospital A@trat Practicing ans Public He Officials Other Health Workers 17 Voluntary ical Center Health Agenc ool OfficiaL- Other Members of the Public 33 Dr. LEE. I would like to insert in the record two tables, shoNNin participation 9 . in the regional medical program, and total obligation of funds. (The eo-cuments referred to follow:) TABrz I.-Participation in regional medical programs by indi@duals and organizations Individuals ------------------------------------------------------- 7,200 S@,s of 54 programs ------------------------------------------ I, 800 Members of regional advisory groups ---------------------------- 1,900 Subcommittee members ----------------------------------------- 2,500 Local action group members ------------------------------------ 1,000 Institutions ------------------------------------------------------- 934 Hospitals ----------------------------------------------------- 800 Medical schools ------------------------------------------------ '103 Dental schools ------------------------------------------------- 18 Schools of public health ----------------------------- L ---------- 13 Organizaltions ----------------------------------------------------- 779 State medical societies ----------------------------------------- 152 County medical societies ---------------------------------------- 90 State health departments --------------------------------------- '52 State cancer societies ------------------------------------------ 151 State heart association ----------------------------------------- 152 State hospital association -------------------------------------- 40 Area@vide health facility planning agencies -------------------- .30 State dental association ---------------------------------------- 29 Other prof@- ional ,societies, local voluntary agencies, etc --------- 383 100 percent participation. 34 TABLE II.-Regional nwdical progrant3, total obligation of funds Fiscal year: IVA ------------------------------------------------------ $2,500,000 1967 ------------------------------------------------------ 28,900,000 1968 ------------------------------------------------------ 153,800,000 1969 ------------------------------------------------------ 299,800,000 Projected, Preildent's budget. Dr. LEE. Thank you, Mr. Chairman, for this opportunity to explain to this subcomii-iittee our vieivs on H.R. 15758. Mr. Huitt, Di,. infarstoii, Dr. Yolles, and Miss Johnston will be happy to answer any questions you may have. Mr. ROGERS. Thank You very much, Dr. Lee, for your statement covering the proposed fegislati;n. I think we will start our questions by Mr. Kyros. Mr. KYROS. Thank you, Mr. Chairman. It very excellent statement and I want to commend you, Dr. Lee, on I to welcome you here. I would like to start with the last thing you said on page 18 ol your statement. How will community mental health center completioiis, -%vliere you will have facilities for treatment of alcoholism an(f narcotic addic- tion, make ,t vital contribution toward preservation of such problems?, Dr. LEE. I .vould like to ask Dr. Yolles to comment on tbac, ,tiid then I will comment also. Dr. YOLLES. The prevention referred to in terms of these programs, which are primarily pointed to treatment of alcoholics and Iddicts, re- fers to @ondary prevention. The secondary prevention ,tpproach is, in effect, early intervention to prevent further pathology from occur- ring. We would hope that the preventive aspects-education, consulta- tion with other agencies, Would be handled under other legislation, Public Law 89-749, the Partnership for Hetltli Act, ivhicli also will deal with these problems. Mr. KYROS. Will these centers be similar to some of the mental health centers in Massachusetts? Will they treat people as outpatients? Dr. YoLLFs. Depending on the type of case, you may have a varia- tion in types of treatment. If someoi-ie came in in an acute state, he would be- -hospitalized, generally in a general hospital, and then go on to perhaps -transitional day care or night care and then outpatient care, and foflowup thereafter. Mr. KyRos. Let me ask a question generally about the regional medi- cal program. As funderstand it, it has been in operation nearly 2 years, is that right 2 Dr. LEE. That is correct. Mr. KyRos. Have you been able to make qualitative analysis on whether this program has made knowledge of medical science avail- able to practitioners in rural areas? Dr. tEF,. Yes; I think we can cite examples. I would like to emphasize that the efforts until now, of course, have been primarily brin@ing the various groups together, building the f ound,,itio-n on which the opera- tional programs will be moving forward rapidly- 35 Dr. Marston? Dr. MARSTON. This is not an easy question to answer at this early stage in the program. We do have Operational grants awarded which include more- than 100 projects that are unde n e regions. t" 'lv y Perhaps the best way I could answer this might be to take the ex- ample of one region anal how it has moved in the area of heart disease, cancer and stroke. I would like to use, from time to time, some of the words of the ap- plicant, because this is a program that is occurring in the region. The North Carolina r aid decided 1-n the late summer of 1967, a er nt, that it had attained re erati IC strategy to achieve the go@ onal medical r een de- veloped. A uniifec' ve leadership ol e prin- cipal health inter on, had been orl e stimu- l@tion of producti- ati t forguid ination of program develc and nization structured for effective dec'isi6nmaking base on need region had been developed and adequately tested. During 1966 and 1967, North Carolina had had a small project in the area of heart disease. This development was described in the re- gion s progress report as follows: Since cooperative arrangements in- volving such a wide assortment of people and institutions in one proj- ect was a novel departure for us, the experience has been invaluable. We quickl@ learned that the original protect contained seriously inade- quat@ provisions f?r manpower.- Thus, in our operational grant appli- cation submitted in O@ber 1967, an expansi@on of the project was proposed, and as time p , further modffieation is anticipated. Con- fere-nces with staffs of -small community hospitals and observations of patients with acut4Bmyocardial infarcts-I)einitreated therein convinced us tl-lat an effort had to be made to determine the feasibility of an ap- propriatelv designed coronary care unit for these small h;spitals. The rp-gion's @port goes on later to describe the availability of cor- onary care units, and particularly the ability in these units to do some- !Iiing as far as the rhythm or the electrical disturbances in the heart is concerned, which is not possible without the specialized equipment and trained people in these units. The growing interest and availability of coronary care units in this region also has generated the need to provide a cardiopulmonary and resuscitation training program to expand on an e, lier, limited pro- gram of the North Carolina Heart Association. Additional projects in the heart area, which are in v,,tiious stages of implementation or planning, include the diagnosis and treatment of hypertension, the use of specialty equipped tmbulances, pediatric car&iological screening, and so f ortli. In the cancer trea, the North Caroliiii program ivorked with exist- ilig.grotip@ who have worked in the cancer field before, and they state an increasing number of community hospitals and their staffs are at- tempting to meet the standard of the American Colleae of Surgeons for the approval of their cancer programs. In this r@gion there are only seven hospital programs that currently are approved, and they would hope to-inere-ase this through the regional medical programs. 36 The North Carolina regional medical program nonv enjoys, accord ing to ,t report of progress, an tiiiiistiall.@y active cooperative arrange ment with- all of the major groups concerned with planning an( implementing cancer activities. The cancer subcommittee of the regional advisol@v group provide @t mechanism ,vhereby efforts can be better coordinated and tasks iiioi@, rapidly and effectively accomplished. They are about to iiiitiate central cancer registry ,tnd a central cancer information service. Tllei goal is to establish ,t well-coordinated, compreliensii-e caiicei, pi-ograii ate ,igeiicies, academic aLreiicies, coiii onal tnd voluntary organ,i'zatioiis. '.riii s also includes ,t special cancer commissio some years ago, before the advent of tli regional med ca M. The North CE program reports that much less has been a( complished in the ,tre,,t of stroke than in the other disease categories but there is an emphasis in this statement that there is an intent t brin into balance. K cient to launel-i and maintain a meaningful stro@- prok rban and rural North Carolina communities is ,tvai able ve an application before us for development of com program. I -%vould I ke to jua mention one other thing, not in t categories area about a particular problem that this region has ideiitifie throu iate director for hospitals. In the -,vestern part of tl St gh its assoc, ate there are seven hospitals in as many communities that are f acii, manpower problems-that are facing t@e problem of keepipg up. Dr. Amos Tobnson, who is a pist president of the American Aca( emy of General Practice, told the lA8 Washington conference worl shop on regional medical programs_tli-,it these seven hospitals wi' ordinated program by the pe(;ple in t] epared to go so far as to a ply as a grot p der the Joint Commission on Accredit in the midst of testing the concept of ,tnizatioii where no one liospital-is ab @ssary capabilities. the last 3 years-and we want to make or this with respect to the regional medic programme% ecliiie in deaths from hi(,rli bood pressui it is about a decline over the past 3 -years. I think there no question tb eLrional health proLyram@ develop activity ai the kiiowled eirly detection of hypertension, and early treatme becomes moi ilable, we will see iii acceleration of this very sign] cant decline, which, of course, will affect particularly the stroke prc lem and, to a lesser extent, the deiths from coronary disease. Mr. KYROS. Dr Lee, pursi-iiiig tlie.questioii of the effectiveness of t program, let's think for,% moment a boiit costs. X-s I understand it from your table II, "Regional Medical Program -,t total obliattion of fund-S for the fiscal years 1966 through 1968, v show approximately $85 million, either in planning or oper,,ttioi grant obligations. 37 Now, as measured against that $85 million, have you made any kind of an analysis or evaluation which shows that, for that kind of money, we have achieved some significant advance through the regional medical program ? Dr. LEE. The program to date primarily has been one of planning and developing the mecl-ianisms which then can be evaluated. For example, we were developing the data base which in many areas is seriously lacking. After we develop such a data base in th@ yegions,.7e will carr forward the evaluations for which we are asking specinc earmarke@ funds. I think it is really too early to be able to state with any degree of certainty a cost-to-benefit effect. I think that we should also recognize what I think is going to be one of the most significant contributions of the ram. That is the spin pro off of benefits, well beyond the program itsel@, not only in terms of people ivhose care is paid for through Medicare or Medicaid. For example, as improvement takes place in community hospitals the way Dr. Marston described it, as Physicians are able to participate in these programs in community hos@itals, the program is bound to have a si ificant impact on improvin@quality. gn I think the best buy in-medicalcare is good care, high-quality, and this, to me, is going to be one of fhe mo@t important long-term con- tributions of the D@o@am. And I think this is one of the reasons that we see the kind of enthusiastic support among practicing physicians in many parts of the country -%vbo were at first really very suspicious of the program. As ih " have seen it develop, as they have participated, they have @y become increasingly enthusiastic. We will be developing for -this spin- off some tecluiiques for measurement so that Nve can determine the additional conditions of the program. Mr. KyRos. Dr. Lee, in this Will as it is proposed, I understand that $65 million is sought for the fiscal yetr ending June 30,1969. Dr. LEE. That is correct. Mr. KyRos. What carr'yover of funds will we have for this program? Dr. LEE. The carryover is $30 million. Mr. K-iRos. So of the approximately $95 million we ,tre talking about, you have $30 million uiiobligated -as yet. Dr. LEE. Yes. That is held in reserie,,actu,,tlly, by the Bureau of the Budget.. Mr. KYROS. My next question is -,t general one about your program. Has the American Medical Associ,,tiCloii now endorsed this program ,Ls it is being carried out? Dr. '.NIARSTO.N-. I think the best answer to that is a paper that Dr. Dwight Wilbur gave at a conference workshop-,%vhicli has been ptib- lished in the current issue of JAMA. It is very supportive of the program. Mr. KYROS. What does this proar,-tiii do for a general practitioner, say, in,,t rural area like in my own State of Maine? Dr. LEE. I Might add one thiiiLy. If the -@@MA has endorsed it, these ,ire actions that would li-,t\-e to ,be tftkeii by the house of delegates. The ivould have to vote on a resolution s, - ing they endorse iC, and y Ity tm not sure, that action has bekii t akeli. 309-653 0-63-3 38 If i-. Ki-Ros. But, the President has put in a statement that lie support.,; you tell its specific@illy 110N%- lieral practitioner in ,t ),ioll,tl iei-e is et, program ill Street (yets iii@,ol%-ed ii ;t I)t'oL,,@aiii ? Siv ti the ire,,t ill ,vlil(.]l lie I)i,,ict'i-ces, but li@ is in ,t small toivii that doesii t hospital. A iitimbel- of exa)i-il)les come to mind. There was t I)roblem-,,tgain in Nortli Carolina, to ttke up where I left off- of ,t community that was about, to be NN-itliotit t physician, and the I)eo- 1)16 Ill the community turned to the regioiial-i-nedic-,ii program foi- tssistaiice. The regionii program was able to examine what the problems ivei-e in attracting I)Ii@sici,,Liis to that, community tli-cl LrrowiiiLy out of that, there htscien-eloped a ritlier niijor study for th,,t@ regiol7 in the prob' lems of the rural am-i. The principal example, I thii-ik, is ail easy one: The tradition of the Birmingham Associates which, as you -%vill recall from testimony lead- ilig to passage of this legislation, was held up ,ts,,t model of how various health institutions tiid resources can lia-%7e t relationship through ail oraanizatioii such as the associates. The tctivities of the Birmingham A@sociates ,tre being expanded and carried further by the regional medical programs. There are a vtriety of other things being done to assist the physician in rural areas where no hospital @xists. There are opporti-inities for physicians from one part 6f WashinRtoii State to come into and ltdually spend time in larger hospitals. This includes an exchange so that someone arranges to take over their practice for ,t period of fime. There are the usual continuing education programs, but I thinkkvitli t different emphasis-with the emphasis on doing those things that meet the needs of the physician rather than offering t course that is pre- selected for him. The difference has been that the physician is involved in decisions and in planning in terms of his needs rather than coming in at t later stage,. There are also other facilities or services in L number of the regions that are planned and will be implemented for the physician. Dr. LEE. I -,vould just add another comment on that, and this relates to ,t personal experience I had N-isitiiia Vinel Haven Island, where there is one physician in general practice. fle has been able to ,ittract occa- sioii,,illy third- and fourth-@e-,ir medicil students to come and spend part of the sumnier with him, ,tnd this has been a tremendous stimulus to him. It has provided him the best possible opportunity to keep up. Itbas,,t@ been --i unique educational experience forthestiideilts,be- cause people have lived there for many,, many generations, and certain disease pttterns there -,ire somewhat unique. 1-te has developed relation- ships with, for example, diabetic experts ,tt Harvard, who liaN-e been interested in diabetes in this particular population group. He has been able to keep up far more effectively t@,,tii the -tverage ]-)ractitioiier, and one of tlie things that is being explored in the pro- gram is the'participation of third- ,tnd fourth-year- medical students in these community hospital teaching progrLms. The development. of reaching programs in comii-iuiiity.liosl)itals, the extension of teaching programs, will attract young physicians to areas 39 that would otherwise not have been attractive to them. They have been used to active teaching programs in the university centers, and they have tended not to -%vant to go too far from these. But I think the opportunity to keep up professionally, to interact with other people and with students on a continuing bas'i's, will be an added benefit. Maine is a verv zood example of the needs of the country to attract physicians to ar@a@ other than the---e urban areas where most of them lia@ settled, or the suburban areas. I think that the regional medical programs are making and can con- tinue to make a s nicant contribution to this. Afr. KyRos. I ifave one last que-qion, Mr. Chairman. That is this: You have seen the program in o' eration for a couple of years now. p lVhat can you say about the fact that this is Federal money, that there is ,t possibility, ,tlwa,@s, when using Federal funds, that the Fed- er,tl Government gets some kind of control over the medicine ai-id i-nedi- cal practice. You know, -%ve hear this all the time, and we are concerned ,ibout it and I -,vouldn't want to see Federal roiitrol over medicine. How can you say sir as administrator of this progrtm, that Federal control is not an encroachment on medical -practice through this program? Dr. AftRSTO-,-. I think this coiyuiiittee took a very important step when it gave essentially veto power to the regional advisory groups This means that we cannot establish on the national level any reoioiiai operational activity that has not had priortpproval of thetl)propr@ate Regional Advisory Group. And thi-- is perhaps the stroii-oest point. The other point is that again, the @urzeoii C)reiieral is limited b the I y fact that every application must be recoi-nmeiided for approval by the iioli-Federal, Nail'oiiil Advisory Council on regional medical pro- graiiis. I think basically these are the two sharpest assurances that the control will remain at the regional level. A third assurance is that the programs are working with the control rei-n,,tiniiig at the regional lei-el. This is recognized, I think, at. the Federal level s well ,is throualiout the country. Mr. KYRO,-,. You have ha(f-iio feedback of any I)robleiiis concerning c()mpl,,tij-it,:7. of Federal control like we have hid in programs, such as OEO and others? Dr. TEF. I think there was a great deal of speculation that this would i)o tii(3 rho fict that, it has not been the case, the fact that there liaf,, been increasing participation I)v practicing physicians in the I)],,iiiiiiiiz of the programs and as the operational programs develol), the extent. of i),i lei r;,it' 'Pation, the fact that there are 800 hospitals with their staffs I)a ripaiiilg are indications that this, in the planning and early operation stage, really has gra@ro-ots support. I ivoiild add one other thiiiLy to ivliat Dr. Mirstoii said. I think the ii(,tioiis of this committee- aiid-tlie periodic oversiulit of the program I)y the Congress is iiiotlier assurance to physicians, with the law as itiswi,itteii,'tliattlierewilljiotbeFederalcoiitrol. Certainly, the way in which the prozraiii has been administered has been 'list in the opposite direction, to simulate to the maximum extent possible, local initiative. Those who participate have to solve their local differences, which have beeiicoiisider,,ible in some of the regions. 40 Some people have felt that the prooTam -%vas movilia too slowlv, but it. takes time to work out differen@ which have long existed. l@iit as -,ve view it, the way Nve,,ire proceeding gives the bec;t, I)ossil)le fouiidatiol-L for the program, because it is stimulating local initiative -ill over the countrv. Mr. l@yRos. I a@ delighted to hear you sty that, Dr. Lee. I know f roiii my experience f royi-i talking ivith docto@s in the Stite of '.LNiaiiie, that tli@y tliiiik the program is an outstanding one, t@at it doesn't encroach on them, an7d I think this is a credit to your administration. eople who have to do a hard iob, iiid I want to coiii- You ,ire the iiieiid yoi ministering ,i program like this, ivbich is coiii- plicatecl- rly because Of the important rel,@itionsliip be- tweeii doi S. You have do: e an outstanding job, and I am proud of you. Mr. RoGEi6. Mr. Carter 2 Mr. CARTER. I notice that the new bill %vill include an -,authorization for funds for treatment of alcoholics, and it will also include funds for treatment of addicts, too. Dr. LEE. Yes, sir. Mr. CARTER. How much will that be this year and next year, Your -additional authorization? ,Dr. LEE. The ,tmount that -,ve li,%ve requested is, for the alcoholics, $7 million, and for the narcotic ,iddict rehabilitation, $8 million, and in fiscal 1970, $15 million for the alcoholics and $10 million for the addicts. Most of that money will be for the development of services rather than construction. It-is about 30 percent for construction or renova- tion of facilities. Mr. CARTER. Will these treatment centers for alcoholics and narcotic ,,iddicts be an integral part of the inent,,tl health centers, or will the-, be separate?, Dr. LEE. I would like to -,isk Dr. Yolles to further elaborate on that Dr. YoLTFs. These treatment facilities, Dr. Carter, would be built into tlip, community health center ,iiid would be ,tii intezral part of it 11'e would even relate the special facilities for home@ss alcoholics t( this coiitiiiiii-ini of set-vices. This is the key point ill the leaislatioii t, relate these services for treatment of ,tlco@olics -,tnd narcotic ,id(licts t the total panol)lv of services in the community health center. Tli i-nay be physically separated, but there would be adeqtiat P-Y transfer of -patients ,tiid records between the services, just as in tli basic program. Mr. CARTER. I think that it is good that it is so. It ivill be less di- fictilt, as I see it. I notice that in your regional health development, 11 regions liaN been funded. Is that riLylit ?, Dr. LEE. Yes, 11 operational graiits have been funded, and 53 pl,,ii iiing grants. .Mr. CARTER. This is in its infancy ,it the present time?, Dr. TFF. That is correct, sir. Mr. CARTER. Of course, there has been a decrease in the number -i@ 3 ve,,trs, strokes in the p, . but you really Nvouldn't ,ittribute all tli decre setotheest,,t-bli;hmen'toftliesellregions2 'I Dr. LEE. No, not at all, Dr. Carter. 41 I think we would not want to imply that either these programs or some of the other programs that have been initiated in the last 3 years that -have been milking good progress would in any way have done so. They @inay h'ave contributed, but certainly, as far as the national figure is concerned, it would be a slight contribution to date. Mr. CARTER. Actually, there are improved methods of treatment, really, different medicines used in treatment of strokes thatlitve been maiily responsible for this. Dr. LEE. Yes, sir. I think the improved drugs and the earlier dia-ajiosis-of the hypertensive association that thev zet under treatment ,it trii earlier stage Of the disease have contributed @o this. Mr. CARTER. I would like to know how the specific or anization of .1 regionis. Could you give us a plan, who is fiead of it@ and how it branches down? Dr. MARSTON. I think what one needs, Dr. Carter, is the organization of more than one region to achieve what you want.. The one thing that has to be established in each reLrion is a broadly representative regional advisory group. It is a requirement of the law that this?oe established. In every region, so far as I can remember, there are task forces in the areas of heart disease, cancer, and stroke, Nvhich include people with special knowledge in these areas. In each region there is also a core administrative unit, a, staff that varies in size- But on the average in the regions funded for planning only, it is about 20 to 26 peopre, and in the operational regions, the stafT that is actually paid on- an average number -about 90. Operation of the progra fferently in different regions. In Connecticut there are I In Kansas there are 10 sub- regions. In Georgia, there region for each county, with representatives from every e State, and -%vith representa- tiv-es from eve These local-level LyrouDs ,ire active in deter local nee . n some instanm i.@@ units are called loca oups. Now, to corn re@ion, in Kansas these local action groups i-nay either respond to ii rmatioii that has come from studies carried ouC by the re-gional staff or, indeed, other zroui)s in the State. Or the local -,action propose proje@ts that they themselves identify as being needed in thit area. In desizninLy these projects, the loca s can work with the staff of ific regional medical program, cal ng on exTerts from outside of the region, if necessary. Kansas ]list substantive review committee, that is, a committee that reviews, oii the basis of scientific and I')rofessioiial nierit, the proposals. Finally, with the results of this review available, tli! application, which may have been stimulated either at the local lei-e or m,,ty-have been stimulated as the result of data that his been gathe -ed elsewhere, comes before the regional advisory group, which must approve all operational project proposals. A recent example - Of this process in Kansas resulted in about half of the proposals that came to the regional advisory grou d@ being returned to the originators for one reason or another for itiolial work before final approval at the regional level. After regional ad- 42 roval is 9',Iille )OS.,II for fiiiidii-ig Pro- visory grpil@ ',Ipp in activities cOlIles to tile Di site. \-isits -,I,, this point, we II-,ive tile OPI operational Tt",@, I the AVa@ We did ill the case of ere I)i,ol - is case we act ,tpplicl,ltioll. Ill tll d, and made ,report o our review (,ol ttee @ill(l, ce,ts were T)ropose C fin,ilIv, to oui- Nt@ioiial AdN,ls, "Y 'Oliiicil. Do@ this help?, .-s, sir; that is helpful. Mr. CARTER. Yp iiiiig education to get to tllt' What procedures do you h,,tN-e for contiii . res-areli'? general practitioner and cornn-iuiiities.,votir ad@,aiiees in e Dr. MAItSTO--,-. ALYlil-1, this has vari@d. There have been some ill- st,,incp-s in which -,t community took the lead. Great Beiid, Kaiis. for Educational subeeiiter, if -voti want: for example, has established all tile immediately surroundiiilr Great Bend. education and to focus care as The purpose liere is to trv to focus I close to the patient's home as possible. And in the instance of Kansas, oved out aw,,Lv from The iiiiivel-sitv to @6,Lt- find this focus has been in @ii@eiitprs. 1. In other %reas, preexistin d facilities have been iiti- '@@zed-Alb-,iiiy N.Y., for exi ay radio system -,vliicli I (Ylaiicl provides iii-llosl)it',Il educati, I of the New Fii,. s' Albany re(yioiial medical ,area. This ha been ,iugm, proLrr,,tm. earn and the iC-%vould say continuing.educ,,ttioii related to the physi tient's needs, ,is opposed to cc>ntinuing.educ,,itioil that somehow ha-, 'I a very major focus of the drifte(I away from the ctre of patients, is program. gr. CARTER. Do you h,,t@@'regional seminars oil newer concepts in medicine ,vttended by practitioners from the, subregions?, -Rs,ro-,-. There wts , I)er of Dr. MA i major one in Oregon that a iiiem my staff attended not long 1190, Mr. CARTER. The PUrP?Se of this bill is to dimiiiisli deaths from heart disease, cancer, ,ind s roke. Do you hav available to ers in the subregions close liaisoii with @l as so that tliev Call get ill- formation qui tment?, Dr. MARSTO iscoiisin of a 24-hour-,,t-day telephone sere ans ii-i t e -,ire . There is ,i specialty tei@ ill foNv,,t that to ,Ictliqlly Ly-o out to the scene aii(t I)hy '@ his stroke patients. provid ion to thi sici,,iii ,iii Mr. That is pirt of your regional system at the present time? Dr. MARSTON. Yes. M*. CARTER. I want to congratulate you on that. I.thilik that is very good. I certainly feel that t@ese ideas, or these questions which I have, asked you should be further implemented, if possible. Th,,tnk you, Mr. Chairman. Mr. ROGERS. Mr. Sklibitz? Mr. SKU-BITZ. Tli,,ink you, Mr. Chairman. Doctor, I ,tm ,t new 1'nellnber oil tliiF, conii-nittee, ,iiid @ am f i-oiii the great State of K,,ti-is,,ts that vou have been praising so Iiiahly. Doctor, I ,tm interested int number of things. 43 First, I want to say I appreciate the fact that you are interested in Kansas. I hope %ve can get some money to keep this show on the road. How much money -,vas authorized, Doctor, for these regional medical proarams in 1966? ffr. Af,,RSTON. The authorization was $50 million. Mr. SIKUBITZ. How much was,,tppropriated? Dr. AFARSTON. $25 million, including $24 million for graiits-$25 million total. Mr. SKUBITZ. In 1967, how much -%vas authorized? Dr. @AFARSTON. The authorization -,v,,ts $90 million. The appropria- tion iv-,is $43 million for grants ,tnd $2 million for direct operations. Mr. SIKUBITZ. You have a total of how much? Dr. lkfARSTON. $45 million was appropriated for 1967, $25 million appropriated for 1966, so that would be ,t total of $70 million. Mr.-SKUBITZ. In 1968, how much -%vas authorized? Dr. 3fARsroN. $200 millioi-i. We have received $53.9 million in ap- propriations for grants and $4,900,000 for direct operations, for a total of $58.8 million. Mr. SKuBiTz. Out of this total amount of appropriations, how much do you have available to you now? Dr. AFARSTO.N. $53.8 millioii-iiicludiiig $4.9 million for direct opert- tions. This total is coml')rised of $27.9 million of our 1968 appropria- tion-$30.9 million was put in reserve-plus $25.9 million in carry- over funds. Mr. SKUBITZ. The thing that botliers i-ne, Doctor, is that you come here with an excellent program. It looks fine on paper. But, unless this Congress gives vou ii-ioney we ,iccoi-nplisli nothing. So far as I am concerned, I want t@ be as helpful as I can to assist you in this impor- tant work. Thank you, Mr. Chairman. Dr. LEE. I would like to make all additional coi-nmeiit on that, Mr. Chairman. As the progrtin has developed, of course, with the en,olutioli of the planning, the ,iiitliorizatioiis were well i@bove those required, and as we li'love into the operational phase, we feel that, of course, sig- ilificalitly more funds will be re( uired with the operating programs. Plaiiiiiii@ is one thin , but operating programs 9 is quite another. -NI would the gentleman @ield? Mr. CARTER. @ i-. Chairman, ,Tust, how has this money @ii spent, Doctor, most of it?, Dr. 1,EE. The money, primarily, goes, of course, for the lliirinly of staff and for the activities of the st,,iff, in some cases for the purc@ase of equipment., the development of coronary care unit, or for long- distance transmission of cardiograms, whi-cli is being tested on all experimental basis. This kind of thing, staff and equipment, which would be related to the educational efforts- Mr. CARTER. Do voii have a central place in each region, to which place cardiograms may be, traiisiiiittedbv phone? Dr. LEE. Not in each region. I think-- that flie experimental pro- grain is going Oil in Missouri. 44 Di-. '-\f.@rSTON. That is a iiialoi- one, -,vliicli has been supported 13i '-;Itloiitil Centel I iiti-ol on-ei- the ]@ist @) N.eill's. tll(, -\ - for Cli oiiic Disease ('o It 1,.-, I)eiiia field tested iii'@\lissout-i at the present. All.. (' ii have such- In one i-e@rioiiyo Dr, -11.@rs,roN,. Yes. if,.. C.@r,-i-Fi,. Do you eiix-isioii in the future the use of such ceii- ti-,tllzed diaoiiostic aids? Di-. I,,FE. If iN-P, find the experiii-ieiit in Ali@ouri is F;ticcessftil, Ill(l t iF. demonstrated fliit you call iiiipro\-e patient care, iiid that it is -i cost stand oiiit that other regions will then Nvlllt feilsil)le from . p I to (le\-elop similir programs. It may be that t computer ivould sei-\-e perliap-,- more than one region. These ai-P, expensive, depeiidiiig,oii the kinds of pi-o(,Yrams that are developed, such as iutomated iiiulti- pli,qsic -@reeiiing. '.\fr. SKUBITZ Or example, to det4?,ct some of the diseases early, cancer and car ioN@,iscul,,ir diseases p,,trticul arlv, the development of the ,tutom,,ited long-distance cardiograms-as other advances take place. stiv, in the area of radiology, it may be that those Nvould also be ap )Iiid oil a regional basis. I think it is \vise to test tlieii-i out first in ,L single area, as is now I)eliiL), done in ',\Iis,.3otiri, to find out ]low feasible it is at the level of the community hospital, and in the coi-nmunities where the patients are aiid the p ysic ,ins ,ire in I')ractice, to see if it is prtp-tical. '\fr. CARTER. Many of our community hospitals have lines to these places to interpret their cardi i n-, that way. ogr' s ill Dr. -\[.@IISTON. Dr. Ctrter, this goes a bit beyond that. The reason thev wanted to try this advanced system is that, in addition to the iistial telephone lines for the transmission of EKG, this new system doesn't take the place of interpretation by the physician, but does save time in supplying the attending physician with ,tii in,,ilysis of the c,lectrocardio situated computer. lVh,,Lt this that we ,ire not goin_a to elioti,-Ii train o EKG analyses, we have to de%-elol) highl skilled m,,iiipowei- y required ill t tfiaii It telephone line. -All'. SKUB sk one more question? .\fr. ROGERS. Yes. .\fr. SKUBITZ. Did you say @200 million was aithorized in 1968? Dr. '-\fARSTo.N. Yes, Sir. '.\Il'.SKU-BITZ. HOWMUC]ididCoiigressttppropriate2 Dr. AIARSTON. $53,900,000 for gr,-tnts -end $4,914,000 for direct operations. \fr. SKUBITZ. Thank you. '.\fr. ROGERS. What do you think of combining the comprehensive and the regional program? What -,vould yoti health planning program , ,Lms think- ol combining these two progr, Dr. LEE. The two proaram-s have t different purpose. ks we move tli ,tiid a - t t' programs develop, they-will be obviously gr,,tted. But I don't believe they should be am. el that ,t coi-nprelieiisive health plan for a State should include ,it we -,ire doin - in this regional program? 9 45 Dr. 1,EE. Yes) I think as ive develop our capabilities at the State level for plaiiiiina and a capability in the areECivide planning, it will encompass concerns with mi - ' s- with other kinds 6f disadvantaged grant ) groups, and it will also include considerations of regional medical programs. .Nfr. ROGERS. In the comprehensive plan, don"t we give, money for treatment of heart disease to a city? Dr. LEE. In the partnership f6r health, a formula grant goes to the State, and project grants for the development of comprehensive health services, ,tiid thes@ may include services for people who have heart disease or other diseases. The focus of tl-ie regional medical programs, and I think this is fundamental to an underaandiiig of the program, is that they have - imply developed ,t foundation for cooperative ,trr,,ingements that s didn't -exist before. We did not li-ave this-in some areas, there were programs of continuation of education, such as in Kansas, or Ave had the @ingliam Associates in New England, but we had not seen the kind of -arassroots participation focusing on improving patient care. The comprehensive health plan has to encompass manpower, en- vironmental health problems-tlie full spectrum-and the project grants c,,Lii relate to a variety of these things. Alr. ROGERS. I realize we are getting tl-Cis prograin'started now, and it is in ,t beginning st@g@,.but'l would think your plinliers should be givin-a thought to comniiiing these programs where there will not be ,,in oir@rlap, @ecause I would iiiiiik that there would be some areas where there would be rather considerable overlap -%vitbin ,t State plan, partic- ula,rly for heart, cancer, and stroke. Dr. TIEE. IVe are concerned not only ,tbout the relationship of the regional programs with the partnership for health, but also the better and more efficient use of all of the programs, @ych ts OEO proarams. and %ve htve seen in the Wttts area an excellent example of cYose cooperation between t regional medical program, the develop- iiieiit of ,i co)nmuiiity hospital, iiid the neighborhood health center program funded by OEO. We are concerned at the national level with stimulating at the State and local level the close integration of these progrims so that we can make most efficient use of manpower, which is our scarcest resource, but also tjie funds available. 'Nf r. ROGERS. Yes. I hope to see some of these OEO progr ai-ns under your department. I feel strongly On this. I reilize this was an iniiova- tin-e approicb, but I think it sl@oiild be tied in more closely. @t me ask a few questions that voti may ivaiit to give answers for the record, tliit you may not bai-e wi'tli you. How ii-iaiiy regions are,,ictiialiv operating -,is of January 1968? 'Dr. -.NfARSTO.@. There are now .1--) with funded o])eratioiial progriii'ls. .Nfr. ROGERS. I know funds. I am talking about operating. Are they really operating now? r, Dr. -,LNIARSTO-N. Yes, Sir; tlie@- are beginning. This will -,-ary from one I si,iied yesterday, which is obi-ioiisly not doing much, to ones that have been operitiiily, a ve,,Lr. r. ROGERS. Wo@ld' .you just give us for the record a rundown of each of these 12, the personnel, how tliev are iiivoIN-ed, how ii-itich money they are getting, and I would like t'o know ivliere that moiipy is beiiio- ?I 46 h oii television' tie-ills, ,,,(I how lll,,Illv hospitals are tie(i SI)ellt, hoiv niuc -Nvli,,it, i III pro N-emeiits ,ire iii IS. ]II, ide iii liosl)ita Ili other words, when -,ve passed this bill, the idea of the thrust of this 1)rograni -%v,,is to ii-iake sure tile iienv methods of treitiiieiit \\,ei,e 0.0i 11,@ to get t?.tlle people. '-\'ow, I realize if is N-ei-y early aiid too sooii for iii to iiiake -,I critical id(-,iiieiit, probably, but I (,e@tlie feeliii(p that this iiiav be stopple,,-, iii tile deaii's office at the ii-iedical colleges. Well, I just -,VItllt to filed this out. "'Ig"ter.] Dr. LEE. It had better iiot be. (The following iiiform,,ttioii -,vas received by the coiiiiiiittee:) DEPAP.T3,iE-TT OF HEALTH, EDUCATION, A-.ND WELFARE (PUBLIC HFKLTH SERVICE) REPORT ON 12 OPERATING REGIONAL INIEDICAL PROGBi.q.6 ALBANY REGIONAL MEDICAL PROGRAM The Albany Regional Nledical Program Nvas one of the first regions to receiv( an operational award on April 1. 1967. Currently funded vitli $755,605, tbi region has appitximately 43 operational -taff nieml>ers, including approximately 14 physicians, 17 nurses, 5 ot@er allied health personnel, and 6 general supl)or@ personnel. Over two-thirds of the staff are from the comniuliity hospitals, an( they are working closely -,vith the local medical center and R.\IP staff to increase the capabilities for quality care at the local hospitals. Approximately 60 hospitals from the Albany Region are participating in tli, program. Approximately 30 of these hospitals are directly participating in tli operational projects outlined belonv. Two hospitals are represented on the AO. visory Committee, and the remaining are involved in oil-going planning activitie- Operational Projects 1. Tico-icay radio communication systems direct cost-4144,100 existing two-way radio network to include will provide continuing education for physician will also provide information and education pi,. s of boards of trustee, voluntary health -.igei d selected civic groups. 2. Co)iit)tttnity information coordinators, direct cost-$73,800 Former pharmaceutical representatives will be used to contact local phy,@ clans to tell them about Regional Ikledical Programs and to evaluate their att tiides towards R'I%lP. .'I. Postgraditate In8trtiction Developiiieitt Pa)tel, direct cost-$102,600 This pro-gram proposes to have experimental and control groups of doctors determine their educational needs. These doctors will then participate in I structional programs. After%vards they will be tested to determine the effectii ness of the instruction. 4. CoiiinzitnitV hospital learning centers, direct cost-$75,800 This project will establish learning centers at coiiiinuwty hospitals using "S( Instruction Units" and audio-visual equipment for rapid di--semiiia@tion of n( medical knowledge. Eventually, the directors of this project hope to evaltig physician progress. Initially, 8 hospitals will be involved. 5. Albany Medical Center coronary care training and demonstration pi-ograi direct cost-$125,200 .k coronary care unit will be established at Albany %Iedical College to @i as a model and trainiii,- unit for training physicians and iinrses who will tl) be able to establish similar units at community hospitals. This project will al ment the existing Coronary Intensive Care Unit at the Albany Medical Cent 47 6A and 6B. Conimunity hospital coronary care training and denton8tration pro- grat?z., direct cost-$55,400 This will complement project #5 by establishing coronary care units of three each it three (-oiiiiiiiiiiitv hospitals: Pitt.-4field General, St. Lukes, and Vassar Brotl)ers. These will serve as demonstration iii(I educational projects for other hospitals in the region. A continuing educational program will serve the perma- nent Unit Staff and staffs from smaller hospitals. 7. Training and demonstration project, intensive cardiac care unit Herkimer 3feiizorial Hospital, direct cost@,500 The initial I)hise of this project is to train 6 or 8 nurses from small community hospitals iii-(-ardia(, anatomy and physiology, coronary disease, the principals and Staffing of a car(iiic intensive care unit, and in handling the complex equipment. Th @. nurses will a@ be sent to Albany '.Nfedical Center for active training with specialized equipment. . I.NTERMOUNTAI'; REGIONAL MEDICAL PROGRAM The Intermountain Regional -.Nfedical Program received its first operational grant award on April 1, 1967 and its current operational award totals $1,832,800. Approximately 80 staff members are serving in the operational projects, about one-third of whom are from community hospitals working together with the Re- gional '.\Iedical Program ,taff from the medical center, they are bringing to local li(-alth practitioners and hospitals throi-igliotit the region modem techniques for treating patient.,; with the categorical diseases. Approxiniatel.i- thirty hospitals are currently participating in the Program. Three hospitals are represented on the Regionil Advisory Group, and almost every major ho!,I)ital in the region has established a local planning group to study local need,, and to -krve as liaison with the Central IR.NIP staff. Seventeen hospitals participating in the operational projects outlined below, and as the program continues to gro,%i-, it is anticipated that additional hospital,, will become involved. Operational Projects 1. Regional faculty and core-staff seminars direct co8t-$12,600 The l,'ziiversity of I'tali Ale(lical School will hold a ;eries of quarterly seminars ciii (-oiiil)reheiisive health care, continuing education, contemporary learning the- or3-, behavioral science principles, and iii(@,istireiiieiit technology. The faculty, ex- I)erts from across the country, will addre.,A.,;,iii audience of health professionals in- %-oli-ecl in IR'@NII). 2. -Yetio@ for continuing education in heart disease, cancer, stroke, and related diseases, direct cost-$243,000 The objectives of this program are to develop t communications network be- tweeii I)atieiit-(-are and re@areli institutions to encourage liaison between health (-,,ire personnel in the arei. The currently existing 2-wav radio system, including 11 lio.,41)itals in 7 communities in or near Stlt l,ake City, will be extended to re- iiiote hospitals to serve as one link. Closed circuit TV and use of KVED (Uni- versity of I'tth education Tl') is also I)Itiiiied. Tbi@ may establish the community hospital as the locus of continuing education. 3. Itiforiiiatio)t and cotiztiziinicatio)zs excha?igc set-,vice, direct cost-440,000 The GIES is a region-wide clearing house for information about IRAIP. Staff will be put in local communities to act as public relations representatives and also to distribute information to medical personnel and the public. The community @t,iff Nvill also gather information on community needs Ind resources and re- sources and serve as a station for collecting economic, social, and medical data. Cai-diopliltizonary rcsitscitatio)@ training pi-ograt)i, direct cost-463,1100 The University of Utah will give a 3-(Iay course in resuscitative techniques to selected physicians from small communities. Each physician will then be responsi- ble for teaching the techniques to health personnel in his community. This "rt-stis(-ititioii (consultant" will also collect data about the number of times resuscitation is employed and the results. 4S 5. A training program in fitteitsivc cardiac care. direct cost-$118,600 A (-,@re f@iciilty of in using Cardiac Care t'nits and diagnosing and treit- itig heart (lis(@ase Nvill teiich short courses in their subjects. The student., 1)(, iiitt,reste(I physicians iii(I iitirse,; from comnitinity hospitals building coroiiar@- care units. 6. I'r-(ii)zing for nurses i?i c(t)-(Ii(te care and cardiopiilt)ionary resuscitation, (lit-c(-t cost-434,000 Thi.- i@ an intogril part of both the cardiac care and cardiopulmonary resus- (-itzition programs for physicians (#4. #5). Ntirs" trained in Salt 1,@ik(, City @vill return to their communities to serve ,is a core factilty for reaching tli(, techniques at the local level, The iitirses will work closely with the siiiiilarl@- trained physicians. 7. Cli)iical trainee program in cardiology, direct cost-$65,700 This program has two emphases- (1) To provide general practitioners, internists and cardiologists with training programs in heart disease techniques tailor made to their individ- tial situations. (2) To increase the number of formally trained clinical cardiologist,, through a training period (3 months to one year) at the existing cardiology school at the university of Utah. 8. l'isiting consultants and teacher program for small community hospitals, direct cost-414,800 Small communities will be given the option of requesting one or two-day clinic.q. -k minimum number of four cardiac patients will be required. These clinics will upgrade the level of care to victims of heart disease living in remote areas. Visiting physicians will assist the local physician in a precise diagnosis in a precise diagnosis of his patients. 9. A regional computer-ba8ed system for nionitoring physiologic data on-Iiite from remote hospitals in the )-cgionalntedical program, direct cost-$6,37,100 This project's purpose is to test the feasibility of using a central computer to process a variety of physiological signals generated by patients in remote hos- I)it,ils, feeding the results of calculations from these signals back to station,, within the hospitals, and using the information for diagnosis. 10.Cancerteachingproject,direetcost-494, 0 This project attempts to upgrade the level of care available to local coiiimuiii- ties. The coordinator will direct a program of physician education to create trained cancer' specialists who in turn, will becoiliL, centers of cancer information in their local communities. The physicians will receive a small stipend for reaching and obtaining information. k region-wide tuiiior registry will be started, ,is will i training program in new techniques for pathologists. 11. Stroke and related neurological diseases, direct cost-$9 7 This project will establish clinics to bring expert consultation service in stroke iiid related neurological diseases to local communities; will provide continuing education to local physicians and Niirses; will collect data about stroke patients .,wen iii(I the problems they present to the, practitioner. A 24-hour telephone con- ,,ult,,itioii service and information library service will be maintained at the Utah ',Nledical Center to provide community phy:4!cians with immediate advice. In a(ldi- tioii, practicing physicians will be trained at the medical center in the latest diagnostic and treatment techniques. The courses will last from 4 weeks to one year. 12. Editcational'pi,ograt)t in respiratory therapy for physicians and nurses, direct rost-$25,300 To train physicians and nurses to utilize the special te cbniques and eqtiij)- iiient in respiratory therapy. Five (lay;seminars and follow-up 2 day refresher courses will train participants to administer therapy and to teach others. 13. Regional c)ielocrinc metabolic labot-ato?-y, direct cost-$237,900 To provide ,ervice facilities where practicing physicians can obtain laboritor) data essential to the diagnosis ind treatment; to create awareness iiiiotig cians of the possible presence of metabolic and endocrine abnormalities; to 49 derive statistical information. Three laboratories will be established: an immuno- assay laboratory, a chemical laboratory to measure steroid hormones, and a developmental laboratory to reflue t@hniques. Seminars will be held both inside and outside of the laboratories. Abnormal findings will be reported to the refer- ring Physician by telephone by a physician who is competent to offer consultation. i KANSAS RMIONAL MEDICAL PITOGRAM The operational activities of the Kansas Regional Medical Program began on June 1, 1967, and are currently funded at the level of $699,852. Approximately 80 individuals with varied backgrounds, comprise the current staff, of which about one-sixth are physicians, one-fifth are nurses, and an additional one-fifth are other types of allied health personnel. The remaining staff includes related health personnel, such as communications specialists and social scientists, and general support personnel. About half the staff are from the medical center and the other half are from community hospitals. Together they are working on programs to improve community capabilities for treating the categorical diseases. Approximately 20 community hospitals are currently involved in the Kansas Program, and it is anticipated that additional hospitals will becoi-ne involved as expansion takes place during the next few years. Ten of these hospitals are directly involved in operational projects, two are represented on the Advisory Committee, and eight are involved in on-going planning activities. Operational Projects 1. Educational progratm-Great Bend, Kans.-4261,000 (&ireot cost) To develop a model educational program in this small community a full-time faculty, which will be affiliated with the Kansas Medical Center, will be in residence. Included in this comprehensive program are plans for continuing phy- sician and nurse education and clinical traineeships for heath-related personnel, Studies will be made of community needs, resources, etc. 2. Health, Sciences Conintunication and, Inforniation Center-477,900 (direct cost) This project is engaged in conducting studies to determine the feasibility of establishing communication linkages vital to education, service, and re@rch -programs. Specific studies to be undertaken are a physician communication sys- tem, TV teaching, electronic linkages, and Mediars search capacity. 3. Stzidy of the quality and availability of ntedical care-$149,000 (direct cost) To determine unmet needs of patients, locations, professional education, and -Nvorking arrangements of physicians and those in the health related disciplines. 4. Hospital information sy8teitt and data facilitic8-$67,500 (direct cost) To conduct studies within the region concerning various aspects of community resources and needs, epidemiologic data and participation of health care per- sonnel in continuing educational programs. A co))ipitter systeiib will be used. 5. CardioraReiiiar nurse trai?tiizg-$98,500 (direct cost) To develop an in-service training program to prepare nurses, who are the main- stay of coronary care units in community hospitals, with basic physiological knowledge of coronary care, ability to use instrurdeiits and equipment in coronary care units, experience in home care, and familiarity with social agencies that can aid in the rehabilitation of patients. 6. Ca)icer detectioi?, prograi)t-Providenco Hospital-425,000 (direct cost) To evaluate the strengths and weaknesses of the Cancer Detection Center now operating as an area referral center in Providence Hospital in Kansas City, Kansas. The records of patients will be studied to show effectiveness and yield of test results, type of personnel who have used the clinic and their source of referral, and effectiveness of follow-up. 7. Cardiovascular work evaluation-$21,100 (direct ro8t) This project will demonstrate the Cardiac Work Evaluation Unit and show its usefulness for the evaluation and rehabilitation of the patient. It is developing an effective technique for showing physicians and the community at large the ability of patients to return to work after receiving the appropriate rehaibilita. tion. 50 DISTP-ICT OF COL@-IBIA REGIONAL @[EI)ICAL ,%IETROPOLITA PRO-GRA3,f 11 its operational activities on -,%larch 1, 1968, ,vith an award of This region bega S, seven other ,$41,0,,318. A staff 047, including about 11 physicians, two nurse type,,, of stipportin'e niiel sti(-h i-, I)erso] @illied health I)ers, and secretari vil I ivork together to coiiir)uter I)rograili "e@'; h' @e staff is frolli ijill)@ove esotirces. Ab , ,If of t . local iiie(t the- medical ceiitei half is from community hospitals ai-i(I other local health ageiic atioii of medical center-colilllliinity personnel helps assure a qual rieiited prograii will increase Seven hospitals articipating, a to the entire I t next few yea ,is reg f directly partic oiects outlined bel al hospi on the Regionf p, and two are ser 9 ,b,, ittees. I-lowever, se hospital- Nvill bei programs as they send their trained in the pr( below. Operational Projects 1. Free man's Hosj)ital Strok6 statiozt for th@ Diag)tosis, Treatment, and II?- d vestigation of Cerebral T'ascular Disease, direct cost-$181,889 This project is a c stroke, from diagnosis and treat urban '.\egro area. Based in tht iiieiit to home care in the region, tnp stroke statil)i Free(inian's HosPita physic ans and medical students. Relat@ will serve as a teaeb epidemiological and ies -,vil be undertaken. 2. The 'VVa8hington, D.C. Regi@ol Cerebrovascular Disease Folloicitp a)td Siit- veilla,nce SYstei)i, direct cost-$94,200 Under the sponsorship of G@orgetowii UniN-ersity, @s project is attempting to establish a uniform system ter measuring a@d evaii are give t. s in the area, in order to tacilitat follow-II s ion helpful in detem y medici ing out epidem ographi f the var hospital s ater continuity i p at E ii and therefore gr care. 3. A training Progran@ for cardiovascular teeltiticians, direct Cos t-$7JI,707 sDital Center i Oualified students are being trained at the Washington Ho .. Washington, D.C. in sliecific areas of medicalobservation and I)rocedures to coii I)Iement nurse,.,' activities. In addition to training personnel for Nvork in ho I)Itals throughout the region, this project hopes to produce a malitial for trainii@ these technicians in the other regional hospitals. iiissouRl REGIONAL MEDICAL PROGRA3,1 0 r=l activities be an,,in Nli--otiri on April 1, 1967, @nd current 0I)e@ g r tiorr .1 I amount to 2, OW. An @-tiiiiated 160 operilif nal staff i)eopi with diverse backgrounds, are serving on the Program, including approximate 15 ph urses, LG allied health personnel, three social scielitisi their supporting personnel. T and a computer specialist,, -Ind remai de overall support, such as research .and staff a&@ist,,iii and a, d clerical personnel. Th4 api)roa(-I; being employed by tlii., region :111(l outlined ns below suggests that hospital involvement will inerei l@roject (I SI)i -- rapidly 0 next t@vo,years. Ci@irreiitly, nine he tals tire iiivoli-ed in t program, II ng two hospitals Nvni(.Ii are represented on the Regional A vi,,ory Committee. Operational Projects SIIitltville community liealtit service progratit-(Iit'cct, co,'4t $200,957 i,ity health @erl, The pur@,l of thi, Ilea 3e project is to establish i model Cellular -I id training programs ,iii(i program ding continuing education e and restorative care fti(-iliti@ education for the public; emergency ilitelis v home care programs; public health, prevent ve iiiedi(-iiie, and whool health; @ voluntary health agencies. I rogr@iiii centered around Sliiithv ordiiiated wit VW 51 and to include about 50,000 persons in county (Clay). Activities are centered around Smithville Community Hospital and the group practice clinic as a nucleus. 2. Mitltiphasic testing of an ambulant popiilation-direct cost $421,471 This project is designed to establish centers for performing series of diagnostic laboratory tests to identify the most useful tests feasible for screening large rural population groups; determine the different patterns for ill and healthy populations as an aid in detection of heart disease, cancer and stroke in pre- clinical stages. '.Nlodel test centers will be established at the University Medical Center, Columbia, Nlissouri, and the State -.Nfental Hospital in Missouri. A third is planned for the Smithville complex. 3. Conipzitcr fact bank-direct cost $279,365 This project is designed to develop and apply techniques for delivering latest information on diagnosis and care of patients with stroke and allied diseases to the local physicians. Electronic data information storage and retrieval system will be developed at the University Medical Center (Columbia, Missouri) and later extend to include Smithville and other communities in the region. 4. Mass scree)zing-radiologV-direct cost $54,814 This project will help improve the accuracy of radiologic diagnosis of heart disease, cancer and stroke through electronic communications media. Three small rural hospitals will be hooked into the University of Missouri computer and Department of Radiology to evaluate diagnostic efficiency and determine applic- ability of ultra-sound and thermography in diagnosis and therapy. 5. Conigrehensive cardiovascular care units-Springfield, Mo., direct cost $69,347 A comprehensive care unit for grouping patients with heart disease or other circulatory system illness or who have been admitted for other purposes but require close cardiac observation is being developed. The project is to be under- taken at hospitals without a house staff, where it is hoped that grouping of patients will relieve the workload for nurses on general medical and surgical wards. St. John's Hospital medical staff and Greene County Medical Society are coordinating activities with 3 local hospitals in Springfield. 6. Conintunicatioit research ii?iit-direct cost $61,743 Supporting research unit for program to identify public attitudes and knowl. edge about heart disease, cancer, and stroke; to understand motivations for seek- ing health care and to determine and develop effective methods for communicat- ing with public and lead them to seek medical care. 7. Data evaluation, coinpitte@- simulation and systetiz8 de8ig;z-dii-cct cost $329,712 This program will help to determine data needed from the public Ind physicians for early detection of heart disease, cancer and stroke through studies on the form of data, mechanisms for classifying, storing and retrieving data most effectively. 8. Bioengi?zeering project-$229,129 The aim of this activity is wider distribution in rural areas of sensor trans- ducers, for early detection of heart disease, cancer and stroke and to generate more information on physiological patterns of these diseases. 9. Pi-ograt)t cvalitation centcr-direct cost $103,899 Through a multidisciplinary research approach accumulate data in two S4Bp- arate communities about health care, needs and attitudes as a base for developing instruments for measuring quality of care and levels of health in terms of an individual's function in his community. 10. Aitto?izated patient hi8tory-direct cost $77,561 This project is testing the feasibility of ail automated system for obtaining patient history and analyze complaints prior to examination by physicians, as an aid in early disease detection. 11. Aiitoiiiated electrocardiography in a rio-al ai-ea-dit,cct cost $369,000 To provide hospitals and physicians in rural areas with automated facilities for transmitting electrocardiograms and an automated system for analys" of ECG'S; to demonstrate the feasibility of such systems where this service is limited or non-existent, and to develop, test and implement the use of bioengi- neering signals as aid in diagnosis,. 52 12. Operations research and systems design-(Iirect cost $39,055 This activity will help develop systems concer ed -,i-ith testiliL, "early detee- n tion''hypothesis-develop operational methods of early detection t@-ts for -,I large rural population. 1.3. population study group survey-ttit-ect cost $65,200 using National H@ith Survey questionnaire study factors contributing to II,(' of health services in small towns, with emphasis on the influence of an,ailal)ility of care. 111. AutotiLatcd hospital record systcrit-dircct cost $52,100 This activity is testing the automation of hospital record data through use of computer systems to organize a.ready reference service and easy acec-@ it) llos- pital data as a base for measuring effectiveness of changes. 15. Computer Assembled Ott-Going Ma)tual of 3Icdical and Pai,a)ttcdic(il ices-direct cost $26,842 16, Central core administration, planning and coordination-direct cost $238,805 i'TJniversitY of Missouri Medical Center, Columbia, Missouri) @Nlissouri Re- gion@ I ',Nledical Program. MO'UNTAIN-STATES REGIONAL 'JEDICAL PFtOGRA.%l This four-state region (Ida s operational activities on Marc 3 to include one activity in core y eleven will serve in the project ve physicians an e hospitals involved will includE hospital in whi s !II send their sto r taking place as well as those training. The Regional Adv@r udes two bospitf Operational Projects 1. Intensive coronary care in small hospitals iit the region--direct cost $206,913 Hospitals in the @on will send Registered Nurses into St. Patrick's Hospital, Montana for coronary 3 week course will be offered three times a y a or 21 nurses,, folionv-ups at the home hospi- r f r dditi ng program espe tals four times ea yea I- a cially designed for small town pbyi an, will I iversity of %Iontann lour times a year. NORTH CAROLINA REGIONAL AIEDICAL PROGRA3.1 On '.%larch 1, 1968, the Nor Carolina Regi ogram recei@ed i combined planning and opera t The operational component of this award toti . The operational staff includes approximately i -eight physicians, one nurse, six other aiiied her niiel. North Carolina has alread: the Pro- grain. The Advisory Group I plaiiiiiii,, subcommittees include an additiona eil iiiately t%veiitN,-on(@ lio.,41)ital,,4 are participating in the operational ed below: Operational Projects nd researclt in community )ttcdical care, direct coit-$209,200 1. Editcatioi,@ a To develop resources for training more medical and allied medical student., to provide new tvl@ of educational experiences which will maker family I)ra(-ti(.i mo're attractive; to have a post-graduate education I)rograiii.at the medi(-@i school; to strengthen ties between the medical school faculty anct practicing 1)hy sieians; and to have the medical school become involved in community I)laiiiiin@ for improving the quality an-availability of medical care. Affectepr6ximation y has worried, and this is commented on in the grant aplilfeations that come in to us. I think there will be changes over time, but I think many areas are findinLr thev want the advantages of the I,,trg@r regions It'iid yet the .opportunity of breaking down ii-ito subregioiial groups, and ",e have nor discouraged this. Mr. ROGERS. What has happened in Florida? I don't think they have gotten off the around there; have they ? Dr-lkfARSTI)-N. TYie-v have a planning grant that was ii-iade this year, Mr. ROGER-,. So yo@ would anticipate a year- NIARSTON. Ye Dr. S. I take that back, partially. We liai-e had an ap- placation from Florida since that plaiii)ing graiit,,iskiiig for funds for c,, ,t feasibility study,,%vliich the Nitioiial Advisory Coun allows under aiiiiiiig grant' This application arrived on mv desk vesterda)-. PI Mr. ROGERS. I Would like the status, if you cot@ld aive'it to us -of all r5 1 the regions, the 5,3, what States their are in, -,Y.Iieii We ciii expect to see sol"letliijig get doivn to the local hospitals and into the medical Pro- fessioii there. 66 (The following iliformatio", was rP-CBivIecl by tle comlnittp'p':) STATEMENT ON TIIF STATUS 01' DFPARTMENT 0, JIFALTH, EDUC MS ,ATION, AND W@ARE REGIONAL @IEDICAL PROGRA t Puerto Rico hive enibarled en enga,ed s indicated in the table below, a p A es have In' iipo 41 of the 54 RI ionals (e.g , in I ists, allied ions and Vol, phy bea org ad isorY CO'nm ofli of vsuch indivi( vie grams as i"ol@eme,t of community sei other health bo pr tb ational th Pi n( requ re b( t( ated. bee, awarded to 12 Regional P d initial operational grant re( t become mo c an priva pr wi sprea nd i STATUS OF REGIONAL MEDICAL PROGRAMS (AS OF MAR. 30, 1968 Beginning date Funding Regional medical program rrently available Cumulative awards Operational status Planning Operational Planning Operational Planning Operational 1, 1967 -------------- $393,788 -------------- $661,756 -------------- initial operational grant request anticipated in fiscal Alabama-State of Alabama ------------- ------- .- Jan. year 1969. Albany-Northeastern New York, portions of southern July 1, 1966 Apr. 1, 1967 384, 244 $921,510 707,033 $921,510 Vermont and western Massachusetts. Arizoria-State of Arizona -------------------------- Apr. 1, 1967 -------------- 119, 045 -------------- 119 045 -------------- Do Arkansas-State of Arkansas ---- _ do ............ -------- 360, 174 -------------- 360: 174 -------------- Do: Bi-State-Eastern Missouri, ------ do ..................... 603, 965 -------------- 603-,965 -------------- Do. and southern Illinois. California-State of California ----------------------- Nov. 1, 1966 .............. 3, 226, 225 -------------- 4,079 593 -------------- Initial operational grant request under review. Central New York-Syracuse, New York and 15 sur- Jan. 1, 1967 -------------- 268, 634 -------------- 434:156 .............. Do. rounding counties. Colorado-Wyoming-States of Colorado and Wyoming ------- do --------------------- 339,605 -------------- 488,359 -------------- Initial operational grant request anticipated in fiscal year 1969. Connecticut-State of Connecticut ------------------- July 1 1966 .............. 33 513 -------------- 419,932 -------------- Initial operational r,,nt requestunder review. Florida-State of Florida --------------------------- Nov. 1: 1967 .............. 24d, 000 -------------- 240,000 -------------- Initial operational gr. nt request anticipated in fiscal year 1969. grant request der review. GeOTgia-state of Georgia. ----------------- Jan. 1, 1967 ------------- 341,824 -------------- 694 427 -------------- Initial operational Grea oulia;f@ r. 1, 1967 ------------- ------- 1, : -------- Initial o grant requestua'lnticipated in fiscal ter Delaware Valley hia-Camden (N.J.) Ap 1534, 494 ------- 534 494 ...... l@erabonal metropolitan area and adjacent areas of eastern year 69. Pennsylvania, southern New Jersey, and State of Delaware. Hawaii-State of Hawaii ---------------------------- July 1, 1966 -------------- 194, 771 -------------- 'I" 781 -------------- Do. llinois-State of Illinois ------------------------ ------------- 336,366 -------------- 336,366 -------------- Do. illdiana-State of Indiana- 496@013 -------------- 889 -------------- Do. Intermountain-Utah and p-o-r-ti-a-n-s--o.f-C-o-l-o-r-a-d-o-,-I-daho, July 1,1966 363;524 2,038,123 608,615 2,038,123 Montana, Nevada, and Wyoming. Iowa-State of Iowa ------------------------------- Dec. 1 1966 -------------- 290..591 -------------- 55 ------- Initial operational grant request under review. Kansas-State at Kansas --------------------------- July 1:1966 June 1,1967 281,627 699,852 3721',923490 ------ @99,852 Louisiana-State of Louisiana ----------------------- Jan. 1,1967 -------------- 454,445 -------------- 710,290 -------------- nitial operational grant request anticipated in fiscal Year 1969. Maine-State of Maine ----------------------------- May 1 "67 -------------- 193 909 -------------- 193,909 -------------- :niiial operational grant reques t under review. Maryland-State of Maryland ----------------------- Jan. 1:1967 .............. 770:230 .............. 967,459 -------------- Initial o@gerationa rant request anticipated in fiscal yea r 69. See footnotes at end of table. STATUS OF REGIONAL MEDICAL PROGRAMS (AS OF MAR. 30, 1968Y4ontinued Beginning date Funding Regional medical program Currently available Cumulative awards Operational status Planning Operational Planning Operational Planning Operational $173,119 -------------- Initial operational grant request under review. memDhis-Western Tennes pi Apr. 1, 1967 -------------- $173,119 -------------- and Dortions of Arkansas 00 Metro @olitan Washington, I aJan. 1, 1967 Apr. 1, 1968 527, 089 $418,318 651, 171 $418,318 and surrounding suburbai nd v rlinia, cl !go._ - ------- Do. Mi h State f Michign ----------------------- June 1,1967 -------------- 1, 294, 449 ------ --- 1, 294, 449 ------- "si"i at. 0 i is MIS p ------- JU 1967 322, 845 -------------- 322, 845 ----------- Do. W@f@ '!it 324, 254 2, 887, 903 635, 967 2, 887, 903 a @ opolitan --- ------- p r.. Mis ilale of Missouripelxclu ing St. Louis. Mountain States--States of Idaho, Montana, Nevada, Nov. 1, 1966 Mar. 1, 1968 1, 082, 107 206,913 1, 747, 370 206. 913 and ing. Mebra=uth Dakota-States of Nebraska and Jan. 1, 1967 -------------- 349, 367 -------------- 597, 609 -------------- Do. w Jersey ------- ------ I]1 7- - -------- 297,466 -------------- 297 -- ----------- Do' 80i,466 Mexico- ------ Oc@ 1'. 11 9966 6---------------- 553,270 ----------- 866 -------------- Inlt I-rational -rant request ugder review. -New-Yo -Nassau, --- .......... tj - op @k et ii, June 111967- --------- 967,010 --------------- 967,010 --- at oprtio net grant request anticipated in fisni r Cou n ties. year 1969. North Carolina .... ------- July 1 1966 Mar. 1, 1968 773,674 1,652,164 1,000,374 1,652,164 North Dakota--. -------- iuly 1:1967 ------------ 188,010 -------------- 188 010 ---------- --- Do. land and surrounding n. 1,1968 -------------- ve Ja 285,783 -------------- 385 783 ---- -- I ----- Do. counties. Northern New England-State of Vermont and 3July 1,1966 -------------- 723,920 -------- ----- 883,695 -------------- Do. cou nties in northeastern New York. Northiands-State of Minnesota ------------ -------- Jan. 1,1967 -------------- 629,887 -------------- 1, 000, 791 -------------- De. 0, Jan. 1. 1969 ----------- 309,180 ---- --------- 309, 180 -------------- Do. counties in northwestern Ohi 136,771 ------------- 136,771 ---------- --- Do. s uthern % of Ohio (61 Apr. 1, 1967 -------------- i und Columbus, excluding Do. area. 472,096 --------- a n-Cincinnati, Ohio, areas Jan. 1,1967 -------------- 346,797 --------- 0 nd part of Kentucky. Se,,. 1: 1,9,6,, 282.100 330.318 -------------- D perational pending. in -------- - ............ 353'760 ----------- A-. 'it o@' .1 grant re gea@"tanticipated in fiscal u all a ---------------------- Apr, 1 7:::::: -------- 231, 125 -------------- ------------------ I at opertllla q ------- , 1969 ----- ------------------------------------- I------- yea Puerto ;-f-@u' 'er-t-o--Ric'o ---------- (1) surrounding Oct 1, 1966 Mar. 1, 1968 318,286 255,487 500,425 255,497 Rochester-Rochester. N.Y., and 11 ----- Initial Operational "BrIt request under review. Jan. 1 1967 -------------- 379 246 ------------- 502,773 -------------- I rlitia operational giant request anticipated in fiscal So line ---------- - 263:530 ------------------------------------- yealr 1969. centered 3rOu-na- June 1"1967 -------------- St nsylvania. Ti ce@rtral Tennessee 2 1,630,304 review. rn Kentucky and 1, 1966 Feb. 1, 1968 523,738 1,630,304 673 4 1.... _Initial operational grant request under -------------------------- July -. 1,260,181 -------------- 1,667:194 --------- - ------------- do ------------------- tional grant request anticipated in Ti -mpsh' 439,037 ---------- --- ------ fiscaol year 1969. T c a ire, Dec. 1,1967 -------------- 439,037 -------- Initial pera co -------------------------------- 2 00 ---- 545,454 ---- Jan. 1.1967 '5' 0 a37,948 Virg 05,.148 SepL 1 1966 68 0 1 wa! Jan. 1 2 1------ 2 2, 663 W a----- Dec. 11 1996676 ar ---------- 2a3@717 31,033 we surrouwdl-n-g-wi@- W' . 1, 1968 ei ------ Do. wy urgh, Pa., and 28 sur- Jan. 1,1967 -------------- 340,556 -------------- 340,556 -------- e: ----- 2 630, 149 344,418 630,149 sin ---------------------- Sept. 1, 1966 Sept 1, 1967 --------- WI! IInitial planning grant application has been received and is under review. 2 Combined planning and operational grant; includes some $340,000 for planning. 70 ILLUSTRATIVE E-,A3,iPLFS OF CURITE-NT STATUS In qd(litiL)n to this li@stilig of grant awards and the projected initiation Of operational activities by the 54 regioiis, some specific examples of activities can serve to illustrate the status of activities in the Regional Medical Program and how these activities relate to acliiei,ing some of the major objectives of the program. P.L. 89-239 makes clear that activities under it are to be considered part of, and coi)tributors to the evolution of a system which establishes and strengthens, On a regional basis, functional relationships among the elements of the health system. The, law assumes that only through such regional arrangements can the health status of the patient benefit fully from the accomplishments of medical science. The following eximples show how these mechanisms have been effective or give promise of being effective in influencing the quality of health care under the following headings: 1) Cool)erative Arrangements; 2) The Relationship of Science to ',-ervice; 3) Education and Training; 4) Demonstrations of Patient Care; and 5) Experimental Projects. 1. Cor)l@ei-ative A?-raitgenient8 Regional Medical Programs are based upon voluntary cooperative arrange- ineiits f,,illoiig all the health resources in each Region. These cooperative ar- rangements characterize the type of regionalization with which this program is concerned. The word "regionalization" in the context of Regional Medical Pro- granis does not refer to the development of a rigid plan which has been imposed from above. Rather, it stresses the process whereby local resources are joined together to identify needs and opportunities, to assess resources, to define objec- tives, to set priorities, and then finally to implement a program and to establish methods of self-evaluatioia. Here are some specific examples of how such arrange@ ments ciii be expected to affect patient services directly. Four hospitals in Lafayette, Louisiana, are pooling resources in cooperation with the State Heart Association and one of the medical schools, to improve the care of patients with myocardial infarction in that area of the Region through the establishment of a coronary care demonstration and training unit. The local decision was made to concentrate on developing a high quality coronary care unit in a single hospital. These varied institutions joined with the public to raise private funds, recruit and train staff, and equip the unit. Although the invest- ment of Regional Medical Program funds was limited, the cooperation engendered by the program not only 'accomplished much, but also has served as a model of cooperative action to the Region. The community of Anchorage, Alaska, in response to the needs identified by the Washington-Alaska Regional Medical Program for a high energy radiation source closer than Seattle, Washington, is now conducting ta fund raising cam- paign Solicited private funds will be used to construct housing for the equip- meiit, which will be purchased by the Regional Medical Program. The treatment center will be operated as a regional resource by the Providence Hospital, as planned and approved by local and regional advisory groups. The decision to support this activity involves cooperative arrangements at another level also, for the National Cancer Institute conducted the on-site visit ivhich gave assur- ance of the son d scientific and professional basis of this project. The Anchorage Building and ades Council, comprising some 14 unions have taken on the.c e building as a project, thus contributing more than one half this one source. One of the ii associations sponsored by Regional Medical Pro- gralus is betweei Vanderbilt niversity Medical School and Meharry Medical College on the one hand, and the Neighborhood Health Center supported by the Office of Economic Opportunity, located near Meharry on the other. Consultants from Vanderbilt are working with the faculty of Meharry and the staff of the Health Center to provide comprehensive health care for impoverished comniu- nities formerly without adequate care. In many other Regions similar collabo- rations between institutions of varying maturity and strength have resulted in achievements heretofore difficult, if not impossible. 2. Tite Re7ationship of Science to Service The complex problem of relating the more sophisticated and advanced ac- tivities avallabl@ in only a few institutions within a Region to the broader needs of people of the Region is a significant mandate for the programs. This task Is being carried out In a variety of ways. 71 The computer expertise and facilities of the University of Missouri and the previous work of the Public Health Services' National Center for Chronic Dis- ease Control, are being used by local physicians to test the effect of the avail- ability of computer-assisted and semlautomated interpretation of electrocardio- grams on the care of patients. The Intermountain Region has an outstanding multidisciplinary research group investigating computer application to clinical problems. Automated Illy- siological monitoring has been extended from the Latter-day Saints Hospital in Salt Lake City to four other hospitals in the Region, through the use of remote computer consoles, allowing a more sophisticated level of treatment in these hospitals. In this case, as in many others, the developluental work wts sup- ported by the National Heart Institute, which now is jointly funding with Re- gional Medical Programs the application of the technologic Idvances. The latest and best in medical science exists also in institutions other than universities and research Institutes. Wisconsin has a death rate from pulmonary embolism higher than the nation's average, and in Wisconsin, the -)farsbfield Clinic has a group es@. ially knowledgeable about thromboeiiibolle disease. The Wisconsin Regional Medical Program is supporting a unit at the -Alar@litield Clinic for the demonstration of the best techniques for diagnosis and lion-sii,.,gical management of patients with pulmonary embolism. The '.Nlarchfield Clinic has established referral routes from five hospitals in the Region for emergency care of patients suspected of having pulmonary embolism. The effect of this unit haA already been made apparent by the increased demand from physicians through- out the Region for educational services there. The unit already his treated more than 30 patients, with results better than the national average-a distinct Improvement In patient care. Research Institutions are anxious that medical lyractice benefit from research efforts. For several years, tlye Memorial Sloan-Kettering Cancer Center has ex- tened Its consultation and teaching programs out to the practicing community in six hospitals. Now, through the New York Metropolitan Regional -%Iedical Program it Is able to expand its coverage to surrounding areas, and is planning to include 28 additional hospitals s<) that the knoivledge and talent of the ifenio- rial Sloan-Ketering Cancer Center can be made available to practitioners throli@@h- out the area. In many similar projects, Regional Medical Programs serves as a vehicle for transmission of the latest scientific advances to the bedside. S. Education and Training Education and Training have been traditional methods of inil)rovin_z (,iizilitv in all fields. The emphasis in Regional Medical Programs has been to Airport education and training, not as separate isolated Ictivities, but rather ill terms of recognized needs for the Improvement of patient care service..-, and as all in- tegral part of other activities. An example of the development of this type of training incl educational FI.o- gram arose in the Rochester Region,,where 29 hospitals were faced %vitli the problem of establishing coronary care units. Through their Regloiiil Ifed@"(-,Il Program, they have been able to focus instead on the problems of givi:!g tile? best diagnosis and treatment to all pttients with myocardial inflection ill tile Region. A recently awarded operational grant will stiliport training 111(i coli- tinuing educational programs for physicians and niir.,e,,4 to staff the finite. the development of evaluation techniques, and the establishment of a resource lnt community hospital. The California Region plan.,; to anticipate the neeflq for e(Iiieqtion -).i,(] training in a neiv community h @ital to be @mpleted within the next three years in the Watts area of Los Angeles. A Post-(3r-,adiiate facility will be reei-tilt(@(i no"- ind -gmil,-zore(I jointly by the Chtrles Drew Medical Socipt3,. tlip T.Iiiii-ersity of Cili- fornia in Los Angeles, and,the University of Southern Citliforiiil. Once built, the hospital itself will support the faculty, but Regional Me(licil Program funds are being sought for interim assistance. ' Numerous programs are seeking to provide expert consultation on request. These Include making consultation available by telephone or two-wav radio oil a 24-hotir basis, a dial access telephone-audio tape system in Wisconsin. and a medical jukebox in Albany which will show a variety of single concept filmq on demand.. @l 2 4. Demomtrat@ of Patient Care Demonstrations of patient care are proving to be effective in serving the -goals ,of the program, and have been a major expression of cooperative arrangements for the betterment of a particular situation. Resources in Mississippi for the management of stroke patients are limited. Four intensive care beds for the demonstration of latest advances and modern potential of @ke care have been established under Regional Medical Program& 'The usual hospital costs are -be-Ing -su from other sources but with this 'newly funded demonstration unit, physicians, nu@, and all allied health pro. f@onals have access to excellent training. The result of such training and "oil line" experience is already leading to improved care for stroke patients. In Iowa, a different demonstration pattern Is being used. Through the Iowa Regional Medical Program, a stroke team with physicians and allied health competence is available for on@ite consultation. This unit taken to the patient provides specific e<)nsiiltation and comprehensive education for those responsible for continuing care. In Smitbville, Missouri, an entire community has enthusiastically @me a ''demonstration project." With the funding of a much needed rehabilitation unit in that town of 2,500, which serves a population of 50,000. the imagination of the community was captured. Impr@ by the potential of Regional Medical Programs, the town leaders sought and became a "demon-4ration subregion" for the Missouri program. Thus, over a dozen regional projects are now being tested in Smithville. There are many examples of -units demdnstratingcare of patients with -acute myocardial infarction. The units are varied. Some are in small and some in large hospitals. Some represent joint efforts between "Medical C-enters" and outlying hospitals. Some -are administered by physicians while others are administered by nurses. These models recognize the realities of manpower shortages, and of the significant differences in the locales where patients are treated. 5. Bxperimentat Projects Regional Medical Programs are offering an excellent opportunity for the use of information coming out of research into better methods for making available the advances of medical science. North Carolina Is paying considerable attention to the special problems of an area in the western part of the state known as the "State of Franklin." For example, seven hospitals in as many different communities are testing the fea- sibility of a common Board of Trustees and a coordinated program to the extent that they will request accreditation as one hospital by the Joint Commission on Aecredi@tion of Hospitals. Separately these hospitals, plagued with manpower and facility shortages, face not only an uncertain future, but the knowledge that they will have increasing difficulty in maintaining quality patient care. As a result of the Regional Medical Program, these hospitals are now testing the concept of a unique regional hospital organization which will make possible the implementation of improved care in heart disease, cancer, and stroke. The University of Michigan School of Engineering is cooperating with the Intermountain Regional Medical Program In a systems and operations study of coronary care. Here we see recognition of the need for the health system to In- crease tbLe effectiveness and efficiency of care modalities. In this era when na- tional attention la direted to rising medical care costs, many resources and types of expertise will be needed to minimize needless expense. Vermont is In- volved in a modified cost benefit analysis of several health activities being ini-; tiated. The data collected should provide not only the Vermont Regional Medical Program, but the health industry In general with Information upon which deci- sions can be made on substantive rather than Intuitive bases. Mr. RoGms. Is there any particular emnhasis given in the regional programs to the core cit@ @roblem I @r. MAnsToN. Yes, sir. -The program has tended to go more slowly in the very large, complex urban areas, I think, pro@ l@ for the same ,reason some other programs there have gone more slowly. But there are some kev examples-of our activities in urban areas. In the Califomia- region, the Watts zroup is workinz on a pro@am with UCLA, the local chapter of the-Nat@ional @fedi@al Asioc@tion, and USC. 73 The Temi -Midsouth region, in Nashville, is suprrting a pro- gram in combination with OEO-I could give vou a list of these. Mr. RoGFits. Let us have a list of these, a-ndwhat hospitals in these areas are involved and the personnel involved. (The following information was received by the committee:) DEPARTMENT OF HEALTH, EDUCATIO@-T, AND WELFARE STATEMENT ON REGIONAL MEDICAL PROGRAM FFFORTs DIRECTED AGAINST THE HEALTH PROBLEMS OF THE INNEP. CITY In August 1967, the National Advisory Council on Regional Medical Programs Issued a statement which gave consideration to the health problems of metro- politan areas and their iniaer cities. While recognizing the complexities of the urban environment, the Council stressed the responsibility of Regional Medical Programs to contribute to the solution of health problems there. In addition, it recommended.that an appropriate group of national leaders be named and called together to consider honv the attention of Regional Medical Programs could best be focused on the issue. In response to the statement and to the Surgeon General's memorandum of October 9, 1967 "Improving the Health Status of the Urban Poor," a meeting was held on November 16, 1967 to consider the problem. Among those persons invited to attend were hospital representatives, RMP coordinators from urban areas, health planners, representatives from OEO, medical school officials and physicians with responsibility for the provision of care to the urban poor. The discussion concerned the need for immediate action to reduce the health status differential which now exists, the need for experimentation in the methods of delivering health care, and the need for coordinating the activities of diverse groups which provide health care services in the inner city as well as specific approaches and projects which might be undertaken. .At the local level, Regional @ledical Programs which include major metro- I)olitan ,ireas have developed varied approaches to solving these problems. These efforts include cooperative arrangements between hospitals, health departments, medical schools, voluntary agencies and practicing physicians to meet the health needs of the poor. Examples of these approaches now under development or in operation can be summarized as follows: California Regional Medical Program has established a subregion covering the Watts-Willowbrook area of Los kngeles which will facilitate the develop, ment of activities aimed at meeting the specific needs of the people there. Through the Regional '-Nfedical Program, the University of Southern California School of Aledicine and the UCLA School of Medicine are cooperating with the local Charles R. Drew 'Nledical Society (an affiliate of the National Medical Associa- tion) in establishing a post-graduate medical school at the Southeast General Hospital now under construction in Watts. This school will provide back-up services to the OEO neighborhood health center in the area, develop training programs for allied health personnel, provide stimulus for additional physicians to enter the practice within the community and will develop training programs for physicians already there. California Regional Aledical Program has requested funds for partial support of the school in the early stages of development. In addition, work is now underway at the University of Southern California School of I%Iedi4eine on the application of cancer case finding methodology to poverty groups. New Jersey Regional Medical Program has organized an urban health unit within their office and has established a Task Force on Urban Health Services under the chairmanship of Mrs. Anne Sonlers, a member of their Regional Advisory Group. Membership on the Task Force includes representatives of the New Jersey Hospital Association, the New Jersey State Department of Com- munity Affairs, county medical societies, local OEO CAP programs and other groups. The function of the group will be to stinitilite and review projects for improving the availability of health services to persons living in urban direas of the state, particularly low income groups. The group currently is working on the development of hospital based group practices at %Iiddlesex Geiieril hospital in New Brunswick and at West Jersey Hospital in Camden, as demonstrations of improved ,Tstems for patient care for heart disease, cancer and stroke. The New Jersey Regional Medical Program will assign a coordinator/planner to the Model Cities offices in Trenton, Newark, and Hoboken. The function of 74 these persons will be to gather data on services and the facilities available for people suffering from heart disease, cancer and stroke; to provide liaison be- ms and the Nlodel Cities Programs; and to assist tween Regional Medical Progra of health services for the com, the Alodel Cities offices in developing a program mullity which will be consistent Nvith the overall goals and objectives of the Regional Medical Program. Tennessee-midsouth Regional Medical Program has developed a number of projects which affect the health care of the Door in Nashville. Coronary care shed at Nashville i@letropl;litan General Hospital and Hub- units will be establi t population. bard Hospital, which serve patients largely drawn from an indigen s for Negro onduct continuing education program @Nleharry Medical College will c radiation unit to improve cancer =eiyans and will establish a supervoltage der-graduate radiology p in the community and improve graduate and un training. In addition, there is a project to test the effectiveness of multiphasic screening examinations in the early diagnosis of heart disease, cancer and stroke. Meharry will establish a screening center which will operate in support Of i comprehensive neighborhood health center funded by OEO and will serve a pop- ulation of 18,000 people. The test population and a control grouD will be evaluated and compared with reference to changes in morbidity, patter@s of utilization of health services. health attitudes and cost per patient diagnosed. Tri-State Re'gioiaal ',LNIedical Program received a planning grant in late 1967 and is only now becoming completely organized. Since that time Dr. Norman Stearnes, Program Coordinator, has been involved in a number of meetings ii'liere he has made known Regional Medical Program's interest in working to improve the availability of health services to the urban poor. He also is serving on an ad hoe committee formed in Boston by Blue Shield to discuss the planning of home services and will sit on the Health Services Advisory Commitfee to the Boston City Department of Health and Hospitals. At this time, there are two projects for earmarked funds under development in the Boston area, a stroke project at the New England Medical Center which will have a tie-in with the Columbia point Neighborhood Health Center and a hypertension project being developed by D Ei dward Kass of the Channing LaboriCtory, Boston Department of Health nd @osp, a tals. Illinois Regional Medical Program has established a number of formal and informal contacts with persons in the Chicago area responsible for providing health services to the inner city including Dr. David Greeley, Associate Direc- tor, Chicago Board of Health and Dr. Mark Lei)i)er, Vice President, Presbyterian- St. Luke's Hospital which operates an OEO A-nanced neighborhood health cen- ter.'Now in the planning stage at Presbyterian-St. Luke's Hospital is a com- munity hypertension detection program which will be focused on the Mile Square area of Chicago. Included would be evaluation of case finding methodology, ef- fectiveness of treatment, nurse interviews with patients and an analysis of the interaction of the program to the community. Michigan Regiona]CMedical Program: At its recent February meeting the Re' gional Advisory Group of this program formally adopted a statement for prior. ities for Regional Medical Program iLetion which reads in part "the first priority for Regiorial'Aledical Program support will be given to those projects which are concerned with the improvement of the delivery system of health care including such aspects as (a) improvement of the delivery system of health care to low income groups; and (b) innovations and improvements in the utilization of manpower . Underway is a planning project supported jointly by Regional 'I\le(lictl Programs and the State Health Department (Project ECHO) for gather- ing data on the health needs in depressed areas of Wayne County, Michigan. Wayne County General Hospital has submitted a project to study the use of subprofessional workers to assist the phy,;iciin in patient care and will design and establish training for such persons recruited from the local community. Wayne County General Hospital serves the indigent population of Wayne County and Is located adjacent to a large indigent group in western and southern Wayne County, Michigan. In addition, ilegloiial'inledical Program staff at Wayne State University School is working to establish liaison with urban health programs in of Medicine Detroit including OEO and 'Alodel Cities. The Executive Director of the Detroit Urban @ague has been named to the Wayne State Advisory Group. Indiana Regional Ale(lical Program is working with Flanner House, a volun- tary community agency in Indianapolis to develop a multiphasic health sereeiiin, program for low income population groups. With State and local support the 75 Regional Medical Program is conducting planning and feasibility studies to determine the types of screening procedures which will most effectively reach target population groups and which can in part be administered by I)rei,lou.@ly untrained persons from the community who have received on-the-job training. New York Metropolitan Regional Medical Program has made specific assign- ments to members of their core staff for maintaining liaison with community mental health programs, OEO and Model Cities. Particular effort has been made Society, the inov- Ing force behind an OEO health center in Brooklyn and as a result the president to develop a working relationship with the Provident Clinical of this organization has recently been appointed to the Regional Advisory Group. In upper Manhattan, the Regional Medical Program is practicing with representatives of the National Medical Association, Columbia University Col- lege of Physicians and Surgeons, Aloiint Sinai School of Medicine and St. Luke's Hospital in the development of continuing education programs for unaffiliated physicians. The Regional Medical Program is also taking leadership in co-spoii- soring a conference on health careers for the underprivileged to bring together all interested forces in the area to develop a coordinated program. Also in the developmental stage, are several projects for earmarked funds including a pediatric pulmonary disease center at Babies Hospital, a feasibility study for the development of screening and treatment of stroke patients at Harleni Hospita I, and a mobile coronary care unit to operate out of St. Vincent's Hospitil ill Greenwich Village. Metropolitan Washington, D.C., Regional Medical Program will establish a stroke station at Preedman's Hospital, the teaching hospital of Howard Uili- versity Iledical School. The project will improve the care'of patients from a predominantly Negro population group by setting up an intensive care stroke unit in the hospital and by developing extensive follow-up services for stroke patients. The unit will be used for training medical students, area physicians, nurses and paramedical personnel in the latest techniques of stroke management. There will be research studies undertaken on diagnostic methods, epidemiology and the cultural, behavioral and socioeconomic consequences of stroke. Also submitted for review are stroke projects to be operated at George lilasbington University Hospital, D.C. General Hospital and Glenn Dale Hospital wl)ieh would combine university and D.C. Department of Public Health efforts. .L%Iissouri Regional ',Nledical Program win establish at Kansas City General Hospital a special diagnostic and treatment unit for patients with cerebrovas- etilar disease. Approximately 500 patients a year will be referred from the emergency roon), outpatient department, clinical services of the hospital and from physicians in the surrounding communities. Kansas City General Hospital serves the majority of indigent patients in the Kansis City, Alissouri area and will provide the back-tip to an OEO neighborhood healtli center now under develop- iiient in the community. '@Nlissouri Regional Medical Program ,izid Kansas Re- gional Medical Program have also established a greater Kansas City liaison coiii- niittee to review and coordinate the activities of both programs in the metropoli- tan area. Gc,orgia Regional '.Nledicil Program has submitted for rev!eN-,, a project for the development of a community hypertensive, control program, to determine tl)e most effective methods to identify symptomatic hypertension in an urban 1-aciillv mixed community in Atlanta. The project which would be conducted by the Georgia Stite Health Department would assess the most effective methods to achieve good blood pressure control in these hypertensives, train lay blood pre-s- sure aid@, in(I (icterniiie Nvhether a community program in hypertension control is econoin;cilly feasible using public health methods. ,Afi-. RoGrR.@. 117liat about the rural areas ? Di-. I tliiiik things have tended to 1-nove moi-e rapidlv ii) the rural treas. .Afr. RocFRi. Let us liave,,t breakdown there, too, please. (The follo@ving ii)fonnation ivas received 6y the committee:) 76 DF,PAP.TNIFNT OF HEALTH, @UCATIO-@i, AND WELFARE 8T,TFUENT 0-@i OP@TIONA.L PROJECTS AFFECTING RURAL AR@B @,&NY RFGION,&L MEDICAL P@RAM i serve to.enhance the CaPabili- Many of the Albany operational activities wil - . fessionals from . the rural areas. By c ties of health professionals In , and by i-- small communities into the medical center for contir ties they ications between the medical center ing proj- proving com@ll level of patient care in those Comm hope to raise tne ects involve rural areas: operational Projects Two-way Radio Communication System: Direct Cost, $144 00 7 existing two-way radio ne@, s will provide continuing educat 0- also provide information i boards of trustees, volul n- tion classes, an eted civic groups. 2. Community Iormation Coordinators: Direct Cost, $73,800 ocal physicians a e 'cal rep@e:rltatives will be used to contact I Former ph rmac ut i,.,l 1, nd to evaluate their attitudes to tell them about R@ al Programs a towards R'LDP. 9 Centers: Direct Cost, $75,800 S. co?)ti?zzinitY Hospital Learnin ers at community hospitals using learning cent - ds@iliation This project will establl$@ for rapid on Units" ancL audio-visual equipment of this project hope to self Instructi FventuallY, the directors Of new medical knowledge. _ ., !aUy, 8 hospitals will be involved. evaluate PhYsiciaia progress. IMT, 4. Community Hospital Coronary Care Training and Demon4tration Program: Direct Cost, $55,400 ree coronary Care units of three cThis project General, St. Lukes, and Vas" the ommuiaity 110 nd-educational Droje@ts for oil taff will serve as i program will serve the pe region. A coni and staffs fror e Tjltit Herk-imcr project, Intenqive Cardiac Car 5. Training and Demonstrati Memorial Hospital: Direi Cost, $3,500 iect is to train 6 or 8 nurses from, small community The initial ase of this pr ogy, coronary disease, the principals and hospitals in c and in handling the complex equipment. staiffing of EL ( Medical Center for active training with Tbecie nurses specialized equipment INTERMO'UNTAIN REGIONAL MEDICAL P@R-&M The Inte ountaiu P-egiO@al Medical ProLram ha a essentially three types of ities. Several Pi tional involving the projects fo ther training of aid projects se C( use local PhYs! from of electron g of patients in remote area these projects follows- Operational Projects Education in Heart Disease, Cancer, Strok6 and Re- 1. Nettvork for Continuing Zated Diseases: Direct Cost, $243,000 elop a comme@inications network be- The objectives Of this Pro-zram are to dev laison between health care and resear x a radi ty tended to t,,,, patient ch instit @tiol3s to egnc2ouvrag uding y The currently e ' tl o systems, i]3cl 15 ci Vill be ex ne, in the area. r Salt Lake Ca communities in or nea it TV arih use of KVED (Uni- 11 serve as one link. Closed eireu establish the community re ation TV) Is also planned. Thi may ve of continuing education, h( 77 2. Information and Coin@nzinications Bxchange Service: Direct Cost, $110,300 The CIES is a region-wide clearing house for information about IRMP. Staff will be put in local communities to act as public relations representatives and also to distribute information to medical personnel and the public. The community staff will also gather information on community needs and resources and serve as a station for collecting economic, social, and medical, data. 3. Cardiopulmonary Resuscitation Training Program: Direct Cost, $63,1100 The University of Utah will give a 3-day course in resuscitative techniques to selected physicians from small communities. Each physician will then be resj)onsi- ble for teaching the techniques to health personnel in his community. This re- suscitation consultant will also collect data about the number of times resuscita- tion is employed and the results. 4. A Training Program in Intensive Cardiac Care: Direct Cost, $118,600 A core faculty of experts in Lising Cardiac Care Units and diagnosing and treat- ing heart disease will teach short courses in their subjects. The students will be interested physicians and nurses from community hospitals building coronary care units. 5. Training for Nurses in Cardiac Care and Cardiopulmonary Restiscitation.,Direct Cost, $34,000 This is an integral part of both the cardiac care and cardiopulmonary resuscita- tion programs for physicians (#3, #4). Nurses trained in Salt Lake City will re- turn to their communities to serve as a core faculty for teaching the techniques at the local level. The nurses will work closely with the similarly trained physicians. 6. Visiting Consultants and Teacher Program for Small Coinntunity Hospitals: Direct Cost, $14,800 Small communities will be given the option of requesting one or tvo-day clinics. A minimum number of four cardiac patients will be required. These clinics will upgrade the level of care of victims of heart disease living in a remote area. Visit- iiig physicians will assist the local physician in a precise diagnosis of his patients. 7. A Regional Computer-Based System for Monitoring Physiologic Data on-line from Remote Hospitals in the Regional Medical Program: Direct Cost, $637,100 This project's purpose is to test the feasibility of using a central computer to process a variety of physiological signals generated by patients in remote hos- pitals, feeding the results of calculations from these signals back to stations with- in the hospitals, and using the information for diagnosis. 8. Cancer Teaching Project: Direct Cost, $94,300 This project attempts to upgrade the level of care available to local communi- ties. The coordinator will direct a program of physician education to create trained cancer specialists who, in turn, will become centers of cancer informa- tion in their local communities. The physicians will receive a small stipend for teaching and obtaining information. A region-wide tumor registry will be started as will a training program in new techniques for pathologists. 9. Stroke and Belated Neurological Diseases: Direct Cost, $98,700 This project will establish clinics to bring expert consultation service in stroke and related neurological diseases to local communities; will provide continuing education to local physicians and nurses; will collect data about stroke patients seen and the problems they present to the practitioner. A 24-hour telephone consultation service and information library service will be maintained at the Utah Medical Center to provide community physicians with immediate advice. In addition, practicing physicians will be trained at the medical center in the latest diagnostic and treatment techniques. The courses will last from 4 weeks to one year. KA,NSAS REGIONAL MEDICAL PROGRA-.U Kansas Region Is emphasizing cardiovascular care in its rural programs. In addition It Is setting up a comprehensive model training program in a small community. The project descriptions follow: 78 operational ilrojects 1,@clid, Kansas: Di-ect cost, $261,000 1, E(Izicatioii p)-ogi-at)is-Gi,cat linity a ftill-tilll( model educational I)rogram in this small Coll")' To develoi) I sas medical Center, will be it which will be affiliated with the Kan ire plans for continuing faculty, residence. ded in this comprehensive pro,-rani Iltli-related I,(-" Inclu p y sure c@ducatioll and clinical tra:lleeships for Ile 1 h. siciail and Iill be made of country needs, resources, etc. sonnel. Studies w-Viii Cost, $98,500 2,. Cardovascular I -se Ti-ai@ii?tg: Direct e ses, who are ill To develop all iii-servic@ training program to pr pare iiur niain@y of corollary care units in comn-iunity hospitals, with basic 1)liysiologict l,nowledge of corollary care, ability to use instruments and equiPllent in cor(, nary care units, experience in home care, and familiarity with ,3ocial ageiici(, that can aid in the rehabilitation of patients. S. Cat-diovascitiar IVork Evaltiatioi@: Direct Cost, $21,100 This project will demonstrate the Cardiac AVorl@ Evaluation U-ilit and show it usefulness for the evaluation and rehabilitation of the patient. It is develoijili: an effective technique for showing physicians and the coluliiunity at large tli ability of patients to return to work after receiving the appropriate rehabilitation 'blISSOURI REGIONAL MEDICAL PROGRAM The Missouri Regional Medical Program operational activities involve project ,directed toward improved screening techniques, early disease detection all rapid diagnosis, and more effective delivery of services. These are coordinate with automated systems for transmission of information and health data to a; physicians and community hospitals in the treatment of patients with heat disease, cancer, stroke and related diseases. Six projects focus on the bealt needs, the care of patients, and training of staff for rural communities. Operational Projects 1. Smithville Comnitt)tity Health Service Program: Direct Cost, $200,957 To establish a model community health service program including continuum education and training pro.-rams and health education for the public; einergen( intensive and restorative care facilities; home care programs; public healt' preventive medicine, and school health; coordinated with voluntary health age: d Smithville (population of 3,500) and to inclu( cies. Program centered aroun about 50,000 persons in Clay County. Activities are centered around Stizitltz;il Conz?iLtinity Hospital (75 beds), and the group practice clinic as a nucleus. 2. Uttltiphasic Testing of air At)tbula?tt Populatio?t: Direct Cost, $J@-1,1171 To establish centers for performing series of diagnostic laboratory tests i identify the most useful tests feasible for screening large rural populiti( e the different patterns for ill and healthy populations as groups; determin aid in detection of heart disease, cancer, and stroke in precl!Dical sttges. NIod test centers will @ established at the University Medical Center, Columbia, tl State Mental Hospital and a third is planned for the Sntithville complex, S. Mass Screening-Radiology: Direct Cost, $54,814 To iuiprove the accuracy of radiologic diagnosis of heart disease, cancer al stroke through electronic comniunicatioiis media. Three siuall rural hospitals NN- be hook-ed into the University of Missouri computer and Department of Rii( ology to evaluate d a@stic efficiency and determine applicability of ulti- sound and thermography in diagnosis and therapy. 4. Comprehensive Cardiovascular Care Unit8-Springfield, Missouri: Di@-t Cost, $69,347 To develop a comprehensive care unit for grouping patients with heart (I ease or other circulatory system illness or who have been admitted for otli purposes but require close cardiac observation. The project is to be undertake at hospitals without a house staff, where it is hoped that grouping of patien will relieve the workload for nurses on general medical and surgical war( Springfield (a community of over 100,000) has 4 general community hospit.9 79 ranging in size from .34 to 511 (a total of about 1,200 beds). St. John's Hospital medical staff and Greene County Medical Society are coordinating activities with 3 local hospitals in Springfield. .5. Automated Electrocardiography in a Rural Area: Direct Cost, $369,000 To provide hospitals and physicians in rural areas with automated facilities for transmitting electrocardiograms and an automated system for analyses of ECG'S; to demonstrate the feasibility of such systems where this service is limited or nonexistent, and to develop, test and implement the use of bioengi- neering signals as an aid In diagnosis. 6. Ope)-ation8 Research and Systems Design: Direct Cost, $39,055 arly detection" hypothesis- To develop systems concerned with testing "e develop operational methods of early detection tests for a large rural population, MOUNTAIN STATES REGIONAL MEDICAL PROGRAM Operational activity in the Mountain States Region is specifically designed to benefit small hospitals In rural areas and to train health professionals from rural areas. Operational Projects 1. Intensive Coronary Care in Small Hospitals in the Region: Direct Cost, $206,913 Hospitals in the region will send registered nurses onto St. Patrick's Hospital, Mis.@ula, Montana, for coronary care training. This three-week course will be offered three times a year for 21 nurses, and there will be follow-ups at the home hospitals four times a year. In addition, a 4@y training program especially designed for small town physicians will be held at the University of Montana four times a year. NORTH CAROLINA REGIONAL MEDICAL PROGRAM In North Carolina there are 10 funded operational projects all of which have a direct effect upon hospitals, health professionals, and patients in rur areas. Some are concerned with education and training of physicians and allie health personnel, and others with patient care. All of them are designed to bring the latest scientific advances down to the community level. The projects are listed as follows: Operational Projects 1. Education and research in c-mnmunity medical care-direct cost, $209,200 To develop resources for training more medical and allied medical students; to provide new types of educational experiences which will make family practice more attractive; to have a postgraduate education program at the medical school; to strengthen ties between the medical school faculty and practicing physicians; and to have the medical school become involved in community plan- ning for improving the quality and availability of medical care. Affected by this project are the following groups: the University Community; the Caswell County Rural Health Services Project; the Regional Health Council of Eastern Appa- lachia, Inc. ; the State of Franklin Health Council, Inc.; the Charlotte Memorial Hospital; the Moses Cone Memorial Hospital, Greensboro; Ind the Dorothea Dix .Neuromedical Service. 2. Coronary care training and develop-ment-direct cost, $55,938 To use the project as a medium for developing cooperative arrangements among the various elements in the health care comniunity. Initial and continuing educa- tion will be provided to nurses and physicians in community hospitals, consulta- tion will be available to hospitals in establishing CCU'S, and a coniputer-based system of medical record keeping will be developed. This project has led to new working arrangements: (1) between the university medical centers; (2) be- tni-een medical and nurse educators; (3) between doctors and nurses in commn- nity hospitals; (4) between university medical centers and community hospitals. S. Diabetic consultation and educational services-direct cost, $132,081 To establish three medical teams to deliver services throughout the state; to assist in expansion of diabetic consultations and teaching clinics; to provide so patients; to assist urses and minars for physicians and teaching sessions for chaptr" to test tech se zation of a State Diabetes Association an nes in many communi- In organi different s niaues If data collection. Many people of tie-s are involved in this project. ct cost, $66,615 4. DeveloP@nic?lt Of a central cancer -registry-dire rated with th@ To devise a uniform region-wide cancer reporting ,,e a broaC er-stored data rom which can b p@s, tile comput nal, research, oi ra ge of educat@ pi hospitals are I)arti !Dating in the cal Center, North , teniori c charlotte i' in Jude all O',- tal, Hanover @\lem Ilospital. In subs( on. pitals and phvsici e-direct cost, $25,839 iltc, the. dtilY 5. 3ledical library extension sel'@'ic e medical schools ties of the thre rsonnel Nvill be To bring medical library fac@,@ Local hospital Pe aged in medical practice. into a functional unit work of those eng if; libraries will be organized . will be trained to assist medical sta vices. Bibliographic request service for responding to requests for ser established. tl,, reter-direct Cost, $41,716 6. Cancer inforrt?a , vith immediate consultat e To Drovide practicing physicia ical schools w e f@llow-up literature. Each Of t@e three ,d mg of this and grai)nic locale. The ai for providing s@rviee in Its 9CO - st physicians in providing optimum care of pati fold: 11) to ass@ - ricians by giving and (2) to continue the education of the PnY -centered experience. in a patient I niedicine-dirct cost, $SS,313 7. Continuing education in int6r" Medical Center To bring practicing internists from all o@er the share respon- to-date trainip-2 in their suDsPecif dents, staff, I clans and make wari University, I should enhance the a edical center I d els, for the expand I care in the commlnity- t, $67,508 8. Continuing education in denti-8try-direct Cos ow edge of mutual concern whi@h sici,,Iiis and d@ntistr, with the kn ive members ai ai dental care as ted disease r I therapi8ts-direct Cost, $27,838 a] 9. Continuing education for Physica education pro all develo and establish regional continuing Ces To p b( pi't, in Order to strengtll the,, te. Subregion@w activities. part, of the sta committees will small comnz-uniti identified and 10. The establishment of a "t' 019. Itospitals in Appalachia, I hospitals in thi ospi This is a PI Will a ysi la es ar rural, mOuntai en adequi ill be n ill tRi provides st course I ill b whe available. An 9 edUCS geographic rel necessary. TENI-;E:SSEF, ,IID-Sol-Tff BEGIONAL. _,IEf)l(.1,L PROGP.A@F Ile@e Due to the geographical .diversity Of the health problln Regional Medical Program n,.,s been concern rural areas. TI w 11 as the health Prr regional progra]3 of the urban poor as e , t solutions to i ram has sougll Tennessee prog 81 through a system of linkages between the medical centers and the rural areas. In addition to providing programs to allow medical personnel and practicing phyL4i- clans from rural community hospitals to come to the medical center for training courses, the Tennessee program has endeavored, through the use of modern com. munication techniques, to create medical education resources in the rural areas. The Hopkinsville Education Center and the deployment of coronary care units are two examples of such projects. Operational Projects 1 and 2. Hopkinsville Ed@tion Center and Chattanooga Education Center- direct Cost, $73,700 These are the first of the local continuing education centers specified in the Vanderbilt plan. At each hospital, a full-time Director with an appointment at Vanderbilt and an assistant director will supervise resident and physician educa- tion in their area. Their services will be available to physicians at smaller com, munity hospitals in each area, as will the enlarged hospital library facilities. The Chattanooga and Hopkinsville locations provide the basis for looking at problems in continuing education in urbanand rural settings. 3. Franklin Coronary Care Unit-Williamson County Hospital-Frankliii- direct cost, $81,400 T'his-is one of the subsidiary units mentioned in the Vanderbilt proposal. This is prim@ly a pilot project to study the feasibility and usefulness of establishing a center in a small community hospital. 4. Clark-8@lle Coronary Care Unit-Clark8@le Mentorial Hospital-direct Cost, $19,000 As the Franklin program, this project is a subsidiary of the Vanderbilt pro- posal. Since this hospital has been operating a unit, the plan calls for its expan- sion, continuing education and a phone hook-up to Vanderbilt. 5. Murray Coronary Care Unit-Murra-y-Calloway (Ky.) Co-unty Hospital. Direct Cost, $38,800 Murray-Calloway County Hospital, the training center for Murray State Uni- versity school of nursing, will serve as a demonstration center for the sub-region. Direct phone communication will be established with Vanderbilt, which will send consultants from its: school of continuing education. This project has the ' dual objective of relating the Murray State Nursing program to an established medi- cal center and providing regional training resources to a remote area. 6. Crossville Coronary Care Unit-Upland8 Cumberland MedicaZ Center Cross- dlle: Direct Cost, $28,300 This project has two purposes: (1) -to establish a two-bed coronary care unit in the hospital; and (2) to determine the feasibility of operating acute coronary care units in rural areas. The hospital will cooperate with Mid-State Baptist Hospital and Vanderbilt. 7. Tvllah.ot)ia Co?-ovary Care Unit-IIarton Memorial Hospital, Tii7lahoina, Tenn.: Direct Cost, $28,800 See Baptist Hospital Program. S. Project to Improve Patient Care in a Remote Mottiztain Conii)iiiizity by Recruit- ing and. Training Health Aides for a Neiv Extended Care FacilitV-Scott Coiznty Ho.@pital-Oneida, Tenn.: Direct Cost, $10,300 '.Nlanpower shortage in this isolated mountain hospital is critical. Personnel to man an extended care facility now under construction -will be obtained by two methods: (1) In-service training for hospital personnel; (2) an educational di- rector (an RN) to serve as ,t liaison to the high schools to encourage young peo- ple to enter the medical fleld and come back home to practice. In addition a training program leading to the LPN would be initiated. Clinicil training will be sul@rvised by the Educational Director while local high schools provide basic training. Hop7@-i?iscille Coronary Care Unit@eiiiiie Sttiai-t Memorial Hospital-Hop- I,-i?zsville, Ky,: Direct Cost, $49,500 This plan is ,;imilar to the Franklin plan, except that it mentions establishing links to :smaller conimunitv hospitals by belPiDg set up smaller care units in them, 82 thus providing for the grouping of rural community hospitals for more efficient use of existing resources. WASHINGTON-ALASKA REGIONAL IFEDICAL PRoGRA@i -,Nledical Program operational projects Coll- The Washington-Alaska Regional ' - activities to en- cern themselves largely with continuing education and training mmunications hance the medical and paramedical capability. They foc@s. on co teebi)iques and instruction materials and method re adaptable to the far flung and remote communities in the vast and the many scattered rural communities in Washington State. are being con- (lucted to improve the health manpower resources c(ymmu it i s with limited or no specialty health services, -Which are distant froi major medical center. Operational Projects 1. Central Washington-Communication System for Continuing Education for Physicians: Direct Cost, $18,181 To bring the medical resources of the University of Washington to physicians and community hospitals in Yakima, who in turn will act as consultants to sur- rounding smaller communities through seminars and conferences. educational TV, other audio-visual instruction; and exchange of teachers and practitioners. To eonnect internists in Central Washington to Yakima cardiologi via EKG tele- phone bot-line, to permit quick analysis (starting with 5 comn Yakima is a community of about 45,000. The total population !I ington counties exceeds 300,000. in addition to three general ima-St. Elizabeth, Yakima Valley Memorial, and New Valley 1 e other community hospitals to be reached initially are located ii miinities of Ellensburg, Moses ake, Othello, T@ppenisb, Pross e, (population ranges from 500 in Moses City -to some 8,600 in Ellensburg.) 2. Southeast Ala8ka-PO8tgraduate'Editcation: Direct Cost, $27,062 To improve communication between Seattle Medical Community and the uni- versity to alleviate problems of the isolated physicians in southeast Alaska cities and communities: Juneau, Sitka, Ketc-bikan (3 largest). As in Central Washing- ton ethoodds will be used such as telelectures, consultant services, semi- t'vera'm E' " nar h tline to hospitals in June EKG ad the 0 au, Sitka and KL-tchikan. The popu- lotion I. thee 3 cities totals about 17,000. S. Postgraduate Preceptor8hip for PhVsician8-Coro*arV Care: Direct Cost, $17,610 A pilot project to provide opportunity for practitioners from remote and ISO- I-,ited communities to spend a week or more under a preceptor major medical centers to studv advances in care of coronary heart disease ar se practices in their communities. The 4 major medical centers in I- r, dence Hospital. Swedish Hospital, Virginia Mason Hogpi and University Hospital and Medical Center and -two In ne are Deaconess Hospital and Sacred Heart Hospital. 4. Cariliac Pulmonary Technician Training: Direct Cost, $41,554 Develop a formal program for training cardiopulmonary technicians to per- form non-crit cal function in coronary care units and free physicians for other duties. Four r general hospitals in Spokane-Deaconess, Holy Family, Sacred Heart St Lukels-will participate in this training program with Spokane Corn y College. 5. Tico-ivay Radio Conference and Slide Presentation: Direct Cost, $8,445 Six pilot programs on heart, cancer and stroke topics to be transmitted via two-way radio-telephone slide conference to p spital staffs on topics selected by panel of physicians, starting i in Washington. To explore potential for continuing network seri remote regions. 6. Alaska 3ledical Library Facilities: Direct Cost, $21,754 Todevelo acommunity edicallibraryforAlaskaatthePHSAlaska'Native Medical Cei for Alaska physicians and health related staffs and agencies; t( with community aL-encies, Arctic Health Research, University nd to supplement Continuing education project for SoutbeastA chorage cancer project. 83 WESTERN NEW YOP.X REGIONAL MEDICAL PROGRAM programs in the Western New York region have a direct effect upon Both of the is, and patients in the rural areas. Particular empha. hospitals, health professions ving community hospitals and on training nurses sis will be placed upon invol from community hospitals in rural areas. The projects are listed as follows: Operational Projects 1. Tw-)-IVay Comn@unication8 Network: Direct Cost, $170,519 A two-way communication network will link hospitals of Western New York and Brie County' Pennsylvania to the Continuing Education Departments of the State University of New York at Buffalo and the Roswell Park @lemori,,il Insti- tute. The network will serve several purposes, such as continiiidg education for physicians and the health-related professions, public education, administrative communication, consultation with experts, and contacts among banks. It will assist both the physician and community hospital in either the rural or urban environment in having at their fingertips the latest advances in the (lia,-nosis and treatment of heart disease, stroke, and cancer. Particular emphasis will be placed upon involving rural hospitals in this program thereby improving both their didactic and restorative function. 2. Coronary Care Program: Direct Cost, $127,544 This project will test a training technique for providing qualified nur es Who will be required to staff developing coronary care units in the Region. Approxi- mately 80 nurses will be selected from all parts of the Region for a combined academic and clinical course. It is planned that the nurses receiving this train- ing will return to both rural and urban hospitals for the purpose of providing a diagnostic and didactic function. While the program,will be housed at the medi- cal center, the community hospitals of this iegion will be the benefactors of the project. Since there are few nurses trained to work in coronary care units. par- ticularly in the rural environmeiat, special attention will be paid to attracting nurses who will return to the community hospital. WISCONSIN REGIONAL MEDICAL PROGRAM Four of the Wisconsin projects have relevance to the inaprovement of health care in a rural setting, through the provision of education and infor- mation. Physicians and allied health personnel in community hospitals will benefit from the following projects: Operational Projects 1. A pilot deinOn8tratiOn program for puliiio)tary thromboet)ibolis?@i,: direct cost, $84,600 In this project a center is being established at Marshfield Hospital in Marsh- field, Wisconsin, for demonstration diagnostic techniques and the available therapy for pulmonary thromboembolisni. The project has a continuing edu- cation component which will reach physicians from many hospitals in the Re- gion. This will involve a 24-hour consultation service, the preparation of a movie on the topic, and special training sessions for groups of physicians. The pr ect will de@?nrtrate a comprehensive program which will encom- nti.ve, therapeutic, and rehabilitation procedures for pa- pass diag@ tients, p4x ucation, a rapid transportation system for patients from Northern the state, and cooperation between the clinic and other hospitals; nd medical schools in the State. 2. Teleplio?ie dial access tape recording library in the areas of heart disease, ca-n-cer, stroke, attd related diseases: direct cost, $18,950 This feasibility study will be carried out by the Universitv of Wisconsin which will record and store short, 4-6 minute, tapes on various aspects of treating patients with the three diseases. Any physician anywhere In the Region can dial the library at any time and request a tape relevant to a problem in which he is interested. S. Yvrsing tclepho,?ie dial access tape recording Tibi-ary i-i the areas of lie(i?-t di,iease, cancer, stroke. and related diseases: direct cost, SIIZ,800 This feasibility study, similar to the one above, will establish a central tape library with information recorded on nursing care In emergencies, new pro. 84 cedures and equipment, and recent developments In nursing. Nurses from any hospital in the region will be able to call at any time to have a tape played to them. Development of medicaZ and h@altlt related slitgle concept fit)@@ p)-ogi,ant in comntunity hospitals: direct co8t, $33,250 This education feasibility project involves ten community hospitals in its first phase. Fifteen films on procedures and techniques used in treating heart, cancer, and stroke, will be developed. Projectors and the films will be installed in the hospitals for use by physicians and other health personnel at their con- venience as a continuing education device. After four to six months the ma- terials will be relocated in ten additional hospitals. Mr. RoGERs. When do you expect to have your first evaluation of a regional medical program? 'NIARSTON. @Ve have evaluations each time a Dr. i region applies for a supplement, and we require an annual progress report. In one of the eg as the funding was beginning @o get up to a r e ionsdtl-iat in additi@n to these normal sizable level, we d cide revienvs that we should mount a special site visit and evaluate the reaion's status from the standpoint of the iyrogram. We now are doini this all of the time, picking out times of @rogram movement, particularly the shift fro@ planning to an operational grant and upon receipt of a supplemental request for an enlarged activity. We go back and re- vie@ the entire hiitory of the grant. Mr. ROGERS. )"at is the oldest region? Dr. MARSTON. The first four operational programs were funded at approximately the same time, Intermountain, Kansas, Missouri, and Slb,iii . N.Y. Mr. @OGERS. Could you let us have your evaluation of how effective these have been, for the record. (The following information was received by the committee:) DEPARTMENT OF HEALTH, EDUOATION, AND WEIFARE STATEME@NT ON EFFECTIVEINESS OF REGIONAL MEDICAL PROGRAMS The effectiveness of Regional Medical Programs is determined in the following ways: Evaluation of the effectiveness of each Regional Medical Program is a con- tinuous process which involves review by the Federal Government, its non- Federal advisors, and the grantee itself. These review activities are specifically intended to determine the extent to which the region has implemented the proc- ess of regionalization which includes seven essential elements: involvement, identification of needs and opportunities, assessment of resources, definition of objectives,, setting of priorities, implementation of program activities, and self- evaluation. This process of regioliilization is the means by which the region moves toward its ultimate objective-the assurance of easily accessible improved patient care for heart disease, cancer, stroke, and related diseases. A svsteniatic and comprehensive review of the scientific and administrative aspects of each Regional Medical Program has been designed in order to deter- mine the extent to which each Regional Medical Program implements this I)roe- ess of regionalizatioil for the purpose of achievin, its goal of iniproi@ed patient care. This review process includes surveillance at the regional and Federal level, and is conducted by both iion-Federal and Federal experts. By law each opert- tional activity must be approved by the Regional Advisory Group prior to its submission to the Federal Government for review and approval. Frequently the regions themselves have elaborated on this requirement by establishing local, in addition to regional, advisory bodies and/or scientific review bodies which also carefully examine proposed activities. 85 d the National Advisory A site visit by members of the Review Committee an integral Council on Regional medical Programs to the region is included as an or a region. As the operational pro- part of approving an OU site visits are made. Finally each nd is c submit an annual progress report program. am direction by the grantee must be justified se review procedures. ssible to deter- prehensiv, review process it is PO 1 system program is in fact evolving a regiona n York, and Intermountain Regional Medical e Miss tional phase of development. The Pr'ograms I ti first a result of the review determination of their re the National Ad- process described above, Regional Medical visory Council and mem evaluated during Programs. The progress received from EL11 the review of supplemen /or staff to review the four regional progr just been car are Scheduled for the first yea these reviews to date indicate that immedia ical Programs are naking substantial progress toivard the these R( goals set forth a year aLo as the basis for the Operational grant award. The major problems encountered have been difficulties In recruiting personnel and slowness in the delivery of important equipment. These factors have caused some delays In implementing I)articular projects. In addition to this evaluation at the national level, the regional programs are ,developing their own capabilities for self-evaluation. Special staff has been added to the central @ff of the regional programs with specific competence in evaluation techniques. These techniques are being further developed and ap- plied to the operational activities. ',Nfr. ROGERS. In Kansas, is l@aiisas City General Hospital involved in that? Dr. MARSTON. In Kansas Citv, there is a joint committee from Kansas and 'infissouri to ivork together in the Kansas City area, ,tiid the Kansas City Generil Hospital has been involved; yes. '.%fr. ROGERS. Could you let us know to what extent? Dr. AIAPSTO.@. Yes, Sir. (The following iiif oriii,,itioii wis received by the comniittee:) DEPARTMENT OF HEALTH, EDTJOATION, AND WELFARE STATEMENT ON THE INVOLVE- 3iENT OF THE KANSAS CITY GENERAL HOSPITAL IN THE MISSOURI REGIONAL IIEDICAL PROCRAM The Kansas City General Hospital Is directly involved in the planning for and lissouri Regional development of the Missouri Regional Medical Program The '.\ Medical Program has allocated $82,920 for planning in Kansas City with head- quarters located at the Kansas City General Hospital. Several staff -hare respon- gibilities for Kansas City General Hos-pital operations and Missouri Regional Medical Program planning, including the Executive Director of the Kansas City General Hospital. Several proposals related to the Kansas Citv General I-lospiti] have been submitted by the %Iissourl Regional Medical Program to the Federal Government for review. A project to develop programmed comprehensive cardio- vascular care at Kansas City General Hospital is pending final review by the Review Committee and the National Advisory Council on Regional Medical Programs. Planning studies are underway on manpower training and post- graduate medical education in heart disease, cancer, and stroke. '.Nir. ROGERS. How do you evaluate your regional medical progr,,iinq Could vou let us know the criteria used for evaluation? I think tl-io eoll,lmii'tee would be interested in that.. Dr.'-NfARSTON. Yes, Sir. (The f ollowiricr ii is received by the committee:) n if orii-iation w. 309 -653 0-68-6 86 DEPARTMENT OF IIEALTH, EDUCATION, AND WELFARE STATEMENT ON TIIE CRITERIA FOP THE EVALUATION OF REGIONAL MEDICAL PROGRAMS Each planning and operational activity of a Region, as well as the overall Regional Program, receives continuous, quantitative and qualitative evolution wherever possible. Evaluation is.in terms of attainment of interim objectives, the process of regionalization, and the Goal of Regional Medical Programs, easily accessible in3proved patient care for heart disease, cancer, stroke, and related diseases. The criterion for judging the success of a region in implementing the process of regionalization is the degree to which it can be demonstrated that the Regional Program has implemented the seven essential elements of that process: involvement, identification of needs and opportunities, assessment of resources, definition of objectives, setting of priorities, implementation, and evaluation, Ultimately, the success of any Regional Medical Program must be Judged by the e-Ktent to which it can be demonstrated that the Regional Program has assisted the providers of health services in developing a system which makes available to everyone in the Region improved care for heart disease, cancer, stroke, and related diseases. It is also important to note that each Regional Medical Program is encouraged to build self-evaluation methodologies into its ongoing program. These evalua- tion methodologies then form an integral part of the total evaluation of the Region's program. ,i fuller description of the process of regionalization Is contained in the Progres8 Report o)t Regional Aledical P?-ogi-ams (see p. 13) which was submitted for the Record during the hearings on R.R. 15758 and is the process upon which interim evaluations of each program are based. .L fr. ROGErs. I 'know on page 2, section 103, it is simp]3, t correction to allow the District of Coluni6ia, Commonwealth of Puerto Rico, ,and so f ortli, ill. This ameiids the public health law its.-I f. Doesn't this go to the entire act? Dr. LEE. Yes. Mr. ROGFRS. So that this -,vould ,tffect every progradl of the Pul)lic Health Service, would it? Well, perhaps you can give us the information. Mr. KARL YoRby (Deputy Director, Regional Medical Programs, HEW). Actuall-v, there is a general definition in the Public Health Act which does @o't include these -td(litions. These additions have been made to certain other prograi-ns in the act. This is briiioiiilr the regional medical programs into line oi-i that. Mr. R@ERS. Thank you. I ,im dellolitec to see the Del.)artmeiit siip- th port this program for migrant hear ,which I have been interested in and helped to write the original law. And I took ,t very actii-e part since then- in following this program. I have been verv -pleased with -it. Miss Johnston. I think year have done a good job it is v@ry essential that we recognize this t@ 'third I think is a program. s ould be contin e- h u d rather than lettiiig it get into the partnership as yet, because I don't think this has been well planned for in manv of the States. Dr. LEE."111e would agree with that, Mr. Rogers, ,tncl also at the time the partnership for Ee-,tltlicomes up for revienv again, this would come up for review at the same time. And we would be able to then recommend, and you would be able to decide whether it should coii- tinue as a separate special prootam or whether it could, in fact, be incorporated within the fabric @ the partnprship-for-health program. 'iNIr- RoGERs. When vou look over a partnership plan froi-n a State, will the Department @ that this plan has in it the necessary guide- lines to carry out this type of health prograni2 87 Dr. LFE. As we develop, and as the States develop the capability for planning, tile purpose, of course, of the partnership for healt 1 will continue to be to create a i-nechaaiism in -the States- and permit the States to set their own n 'orities. IVe then review tl-iat in relation to the priorities that have @n set within the States; and certainly in terms of national needs and national priorities, those are also looked at as they relate to these State plans. But we want to have the States make these determinations. And this, of.course, presents un' ue -problems with the mi--rants. because they do move from State to @tat-e and it is difficult to @ncom'ass that p within any single State plan. REQUIRED U14DER ".R. 15759 FOR FISCAL YEARS 1969-77 IGATIoti AUTHORITY ar Fiscal @ear ESTIMATEI) NEW OBL Fiscal ye 197 EDUCATION, AND WELFARE Br Fiscal Ye 1 1976 T OF IJEALTH, Fiscal year Fis 1975 DEPARTMEN ar fit year Fiscal year 1973 Fisr I(I .at ye r Fiscal i972 197te ................... tiew obligation authority 1969 ... .................... ......... $350 000,000 ----------------------- - ----------- 000,000 $ ------- -------------------- Ao,000,0 ------ -- , lo $200 $65,000 00 .... ------ ---- --------------- ............. .................... .... -- ---- 9. 000: Lo $115,000 ----- ----------- ---------------------------------------- --- efs. --------- - : ---------- ----------------------- R ri ------------- ---- --- ------ ----- ra ---------- -- ---------------- II.S 15 000,000 25,000,000 --------------------------- ---- -------------- P.c,-, ........ ooo,000) Ill. Al- "I ooo,000) -------------- ---------- 176, (7 A. --------------- (i, ooo,000) (16,ooo,ooo) --------------- 11 242, 877, n @if ------- 675, 0- (7, 299, pe n, and ................. (3,567, ................ ----- -- .............. lo,17E itation ---------------------------- 1,242, ersonnet requirements tion lehabilita ------------ requirements. P 2, N@ 89 ion position on the Total tiOA required ----------------- pre ictiOn n r, his table I thi time be full con i,ed Note: The prol m 1, ents and I will be dependent 0 122 -Ili of Mr. RoGE-Rs. Our next witness is Dr. Carletorl socia- the Dartmouth Medical School, who will be ap'pear ecl by tion of American medical.Colleges, and he Nvill Tenn. Dr. Liovd Elam, of the Mpharrv Medical Collef your Doctir, it is,,t pleasure to have both of you here. our testi- giving your time so that the committee tiny benefit from, mony. 123 STATEMENT OF DR. CARLETON B. CHA2MAX, REPRESENTING THE ASSOCIATION OF AMERICAN MEDICAL COLLEGES; ACCOM- PANIED BY DR. LLOYD ELAM Dr. C.UAIPMAN. Thank you, Mr. Chairman. I am Carleton B. Chap- L man, dean of Dartmouth Medical School, and on my right is Dr. LI -i, who is president of Meliarry Medical Colleg -W oyd Elan e. e are on this occasion spokesman for the Association of American Medical Colleges. Our association represents the 88 medical schools in the United States as institutions, a large proportion of the Nation's medical educators as individuals, and 330 @aj(;r teaching hospitals. Mr. Chairman, I would like to point out that we would like to speak to the regional medical programs, because medical schools are 'inti- li'lately il@volved in these prozrams , and while we favor in Lfeneral the other provisions of the bill,-we can claim special expertise in these areas. We spoke before this group in favor of the adoption of the heart diseases cancer, and stroke amendments in February 1965, but em- pliasized that the Nation did not then possess enough trained personnel to carry out the provisions of the proposal. At the time, our spokesman noted fhat our m- edical schools, ?iiginal@y set up solely to train physi- ciaiis, were already developing into mectical service centers with con- staiitly expanding responsibilities in the health field. He went on to say: This experience makes it clear that the professional and institutional relations are complex and delicate. It also makes it clear that it is painfully difficult to procure and maintain an adequate supply of trained manpower. A functioning regional complex . . . would make the efforts of the practicing physician more effective, but the development and operation . . . will require a marked in crease in trained manpower. He also noted that the success of a rezional complex is heavil dependent on the continued and growing @ffectiveness-of the medica@ sc@ool and the medical center. At this time, 3 years later, we consider these observations still highly pertinent. But, in general, we believe the discernible effects of Public Law 80-239 to date liaN@e been salutary. It has created a mechanism by means of which the Nation's medical schools have be--un to relate to comi-niinity and consumer health needs, and to work with man lav and professional @oups in designing iie%v methods of coping wit tli'e.@ needs. It has i@iitiafe(i the organization of the Nation into re- (,Yioiis, for the purpose of de]iN-er-v (;I health services, very effectively. And ,ilthough this orL_Yanizatioiitl process has not yet proceeded to completion, the results to date more than justify the passage of the law. IVe i.re well ,tware that efforts to implement the legislation have been associated with many problems. Regional orgt ii@atioiitl strtic- ttires ,tnd, for tl-iat matter, the definitions of regioiia boundaries, ,ire in some instances iiiidtily complex iiid clums@ Son o health 1)1-of es- sioiials complain that they do not understand the i itent of the law qiid some are suspicious of it. Lay and T)rofessioii,,tl zroul-)s wliicl-i, in C;oi)ie regions, are attempting @'reacl@ joint decisi@ns !or the first 12,4 occasionally one hears the ultie,s. And til-np,, are havinLy some- diffic ' ff to use the law as a means view't.h,it the in aictl schools are,,ittemptill, of gaininLy control of the Nation's healtl-l care, system. reclict,,tble ,tiid But in our view5 these difficulties were to all extBnt P important Point is that the lanv, by mobilizill@ local inevitable. The Ilicil, is effecting t cooperative attack on health problems N@- initiative, had not been operative before. III Our although hiLIllv r@SELr'.Vl -Illy favorable view the gp-n-p-ril roiisensi-is lay and profes-;,on,,tl is hio tn to the la-%v. schools themselves have had difficulties ill (lischal,,xiiig The medical the ]aNN- II-,ts their obligations under the law. Many of them, when tn ministrative personnel that 'was capable of dealing assed, had no ad In some instances programs clen-elop- Pw'itli these new responsibilities. d commitment, of I)rc>f@ioiial pei-soiuiel inLy under the law involve ttecl. Far from attempting to take over that is already fully cOrll1li am niaiiv, ,tnd perhaps most, medical schools control of the progr, liortaoe of i@i'olved lircr Iv owing to S tn have been slow to become v e . personnel. 11 especially ,Lcute ,ts the schools move to begin to meet This has bee ortage of physicians. Yet there is no doubt in our rninds the growing@1-1.,l Schools -wisl-i to be involved as effectively as possible, that our me(tic in keeping 7@th the intent of the law, to make not to gain control but@ ore readily available to all who need them. their talents and facilities in d the eq@ally vital matter of improving But this vital matter, an ll,,tl function, together constitute "Ali obli- and expanding our educatio allv in a few,months, or even perhaps gation that cannot be met optim s. The medical scho@is seel,- no special privilege uiidei, in 2 or 3 year co the reaional mecucal program law but wish, on the ntrary, to as- Sist maerially in its successful Implementation. has operated exceedingly smoothly, We believe that the original law considering the nature of the planning procedure it has initiated. We also believe, however, that enough experience has been or soon will be ga@thered to justify a few minor procedural ,ilterations. When the law rst began to @ -implemented, there ivere no generally appli@b@e anizations of the ge al types specinecl. ototypes for regional org ner Vnumber of different patterns have now emerged, some more eff@tive than others. It mav, in our view, soon be prostrate for more defini- ap, tive o nizational' delines to be provided I;y the Division or Re- r@edic-al Pr,09@IMC, -aional s. It will als-0 be appropriate in the future to reconsider critically the structure of the various reoions. The responsibility and a of which are too farge to function c @sehtitinoyn. And the main thrust of the legisli r view , to be restated and clarified. It has been f recluently noted that its central focus of the law is the patient and his n-eeds. This is unquestionably true. But a more rele- vant -%va@ of saying the same thing is to indicate that the law proposes to afford to the medical profession and the medical institutions of the N,-ttioii, through coolDeroCtive arrangements. the opportunity of making available to their patients the latest advances in-f-he diagnosis and treatment of the diseases named in the l@,tw." In other words, the law provides us with the means and authority to find ways of assisting physicians and other health workers to pro- 125 vide American citizens. wlierever they may be, with @tter health vide that @are more efficiently, ucli care and to Pro -,veen I,,ty and professional has CooL)eralCion bet impressive methods has, in geneyai, been most tli and u between ,lot invariably be@ ideal. Good fii, t, but o striking T)s cannot m created oveinigh , such ginul . inal law is that it has se the stage for the accompli mentS Of the orig cooperation between these groups, developn con-iplishing !what i@ set out to do but the The -a elopmellts can procew must be viewed real- pace at that the P@ n agreei-nent with those who say has th rate ',it Nvliieh pl',Illlll ist sfactory; on the contrary, 0 119 nall is ssive, owing In no sl procp,ecled has, to date, bp-eii very impre which have characterized to tl widerst and wisdom measure I the administr done The next stthen age, as will have to be elicourt%ge medici t Will in the pla render ate for the Wel airman, the law should continue to oper roclucing prez,en- tantive change but that the results it is P Nation's ritic,,Illy evaluated and scrutinized. The must Si w'involved, for.tlie most part, to the extent of medicE not in ,iii effort to gain control, but rather to help to their et provide critical service. And as we go ,Iboi-it meetin2: our iII "L obligations under the law. we seek the understanding of our critics; inL dominance, no less than those those who feel that we are reach x for , gh on the other. whofeeltliatweareiiotmovingfastorvigorousl enou - -nize We,,tre Mr. Cliairma ely i ve recog I i is vital to the that the essence of th( ical I s which we welfare of the Natior ever@ must discharge. 'iNir.ROGER Thalikvou,Dr.CbaT)niailiforanexcelleiitstatement. S. , , I miaht say, too, that I recall tfiat many of Y@u@ suggestions were ,accept( his committee in the writing of the original Itw. Y ou were most h to the committee. Before qi estioniiigi if we could have a statement from Dr. Lloyd Elam. Dr. LA-,Nf. Mr. Chairmai-i, my name is Lloyd Elam. I ai-n president of Ateliai in Nashville. Tenn. Before assiii-nino, that positil of the Del),,Irtment of Ps.yehi@itry at.LNicharry and f( dean of the SC ool of -i%fedicine. I seak tod, v is @in official representative of the Association of p Anierican'.Nfedic,,il Colleaes ,ind wish to comment specifically on rel,,i- tionsliips between regional medical programs and medical schools. I coll-le before you today as one who has had direct experience withi regional medical program, a proar,,ti-n which is already entering the after having made remarkable prog@ss.in briiio-iiig operational phase, t, t@getlier various heiltli re@oui,ces in tlie,Nlidsoutli area diirinz its 1)1,.tn- iiinz phase. I have a deep concern about the availability and of heattfi care amon, the poor, P-,3peciilly ill our cities; I am p,,trticiii,,irly 126 interested in what regional medical prograi-ns can do ill this critical area. titution, '.L%l arrv Medical college, The regrettable f act that II-'Y ins the point I and resources allows nl programs has limicecl pers?,nne me under Memo n ties we ass@, we that the resl)ollsll)ili latices or out "I must lot become a drain on our ri 0 our -ients Avi'til other liealt resoul enter into cooperative arranged heart disease, cancer, dia,,,nOsis.,@@d treatme,@ Of ry edtica- region, to impro,l cr our prlrna and sioke, we 11-lu t do so witnout, jeoparclizin, schools tional str,,iints, Al-,Iiarry and the for the Avi trong sense 0 ,of th t ) P-xpress a.@ jes that surro I i-nedi- he@ilt' the commLlil-1 we see n OP@rtuTilt@ Out cl,ii ptle -poss it@-for str, rbvel- hi fil their urliclue obligation ill cO@'111 and in'- opin( t of better wavs to aPP' or al i-nedictl prov eiin in the next at we, expect ouLyi-i the co- pro,o es few of ere-s groups in Ten- ope souther ollege, Vgn@ rbilt Ulli- nes ealth planninj The d scuss'Ons versit,,v School Of mdica.1 smietl' opolitan N z,,ttions. A regi, of '-,Vietr @cies, ar healtli 0 funds %verp, r( bellilt'l-I "Igeln E nd plan so P, bringing the country, th 0 a-s in manX oses has re ited in an ell- interests 10 of the regi Of ti t of our pro s yc that ill u ut each yn,,tde f or o n sce W: widely in heart re on. TI arti h care prof NV conce Sol ified during the plan- disease) c' , trolce h,, n and allows "le to -ning T)r@. on@ projec@ whi P,(Idr@ing, is the cui -term evtluatlon ST)e,,tk to a P@t' . an urban al p persons in atu a-, 'health, I I-Onjull-"Orl Pi groill I these 'Person,- tl a to @d out r medical -What it SE if it is ,IC ,Ily arhiev ng 127 ith the coopeya- i)rograni is asic screening tioll- of Var center. The co-- laboratory as an E computer serv,- operation with Vi and iecorclk@p- ices needed for the autDir uncover heart al medical earliest stages,' POI e disorders, as-' e ine ce treatr evaluating the the n ealth center. -00 itive arr a, multiphasic ' L identificat Df need for medical e,,tre screeiiin rI,-iborata through early di of a, n ocl healthcentor for meet- ed is ve This o culd have been difficult. if to I help of regional medical.pro- of the es tant elements of regional ams are p project: The bringing to- iously dispa,@ate elemen the medical rare system- ct funds to get thinas done-and the 6omiiig Dower an gr)p@ w the rea ly significant h@altli i@ of our rpaion. The inv ement in re-aional medical proLnams of V,,inderbili medical sch(>of-s and of many ot@e@ n-lediral country, is far from superficial. Indeed, in many area school was iiist@rumelital-in the establishment of the, reg program and these institutions have lent their expert ill'y this major new program. They are ameptl'ng responsibilities launch , edical students and conduct- beyond the traditional on@s of teaching in i-anslate more iiig research. They have be@ now prograli,s to t promptly the fruits of medical research into improi@ed care for the people Within the regions that they serve. shall like to --lose simply by, serving MY Ptrnest and enthusiastic y hope @tipport to the legislation exteiiclin this program. I sincerel 19 ts that you will agr wi mv estimation of i great importance. eaking before you today- Tlia@ you for I @Nfr, R@Erts. ThELiiky Are t]iL,,reany. quest io us. -Afr. KyRos. I have on to welcome you here and thank Dr. Chapman and D you for your statements. ,I-,,,tpman, on page 2 of your stateiyient you include in your re- Di-. (' . rs the view that the medical schools marks that occasionally one hea ,,ire gtte the reoional medical program for the purpose of @y,,Oini e N-,ition's health care stem. pand on that a little S@it? What is the problem nroblem existed. there? I ely begun to dis- Dr. ( so has larg _ e law was first appear heard the medical passed. In addition, we bav nder this law schools might simply take @l SCS. and use them for stan I can state Of coursel this is n( with assurance that r scll( iE Most of us have 12,8 nts, relatively small amounts of @ds il order attaine,d small amo personnel to enable to find the personne think, Mr. us to @ ii-ivolved el prograir ro that these or: moment etors that "Y ine, I have 1 @lr@l'CYROS..111 tb tate where one of the valu,,tbl program e are you don't have a ml cal scho in Maine- other States in the clon't hai our- you serve an educf dissemin rent information t( ally woul at kind of informa-t@ioii. Dr CIiAP31AN. Ves, Sir; and manv of us -,vho are degns regard many of th' Most important aspects of @his activi to be the colitinuatiO@ e ty education feature for physicians, and in our own northern tier of s, Mr. Kyro@of course, we represent three regons there, Alaiiie State s tie in -%vi@h New and Veriuont are separate regions, and Alaine i (I Hampshire. Maine a d the Vermont regional We are meeting r( n meclie,,ii program ofl the main things is this: the con- tinuation of medical P5, in the act Mr. KYROS. On PE about the desire, per@a ' consider to obtain a more de: gui@eline and to re critically the geozraphic st@uctu@ i various regions. What sPe- cific ally are you ting? is a good case in -point. As you well Dr. CHAP@LA@ , .ng itself as a l@iioiv, Sir, New been Nyorki y p@rposes g for man re on with the rnd-Albany as -%veii. on%oston, and to SOM, ex Our 1)resent ional struci modification. li The northern t@. a r geogra pr weeli lay and Air. KYROS. ( of get@@g the professional gr action for latest ,Idvancps in an the i),,ttielit have impressive, the balan e has not been iliv@iably ideal.' es that mean? Dr. CIIAP:NIAN. it is a matter of ffroups that have never real- ly worked together before, are ii@w having to d(;so, and as I said earlier, I thinl,-, in the State, some suen difficulty was inevitable and indeed predictable. cely, as I @ee In our own area, the balance is coming @round very ni .ch has brought togetii@r til operating in the advisory grOuPg wl" 0 Is Pe T)IB -who had certainly never approached any serious proposa toi testimony this morning to be on- derstan vour prograTr 'that is set forth in the act before us tirely toddy 2 MAN d consider it very distressing in- Dr. CHAP - 'y at the -Doint now -where we will deed if it were not we need in order to bring p-in to obtain th( early carry out bf oeTth ao@am tb do t job, and will r pr f the intent the original act. 129 Mr. KyRos. Are you ,,tisfied -with the $65 million provided for fiscal 1969? 1 believe FMAN. I am really in no position to Speak to that' Dr. CHA the next step. it,Will take us circumstances tipl-iasic s@reening underthe tand your @ul Mr. KyRos. Dr. Elam, I unders that would not otherwise have turned up uterine cancer in patients been fou@d. Will that be continued! of the screening vvill be sent to d the results Dr. EiAm. yes, @i@ - o," ing up such things. a doctor in the anticipation of turn Mr. KyRos. Thank you. Mr. ROGERS. Dr. Carter? Dr. CArm No question -vour testimony, -OLn4 we Mr. R( the committee. I l'OPO appreciat g yo for any improvement that that y Particularly I am con, you the progra SI think maybe this cenie(i about biingin in I people. I program, along balance that you 9-rB more people, with the medical peo 9 ci it that to us, on and I would likO to 91 cc b( most helpful to the vour examination pr( Committees Dr. CHAPMAN. Thank you, Mr. Chairman. Mr. RoG@. Thank you The committee stands adjourned. journed, to reconvene (Whereupon9 at l@:30 p.m., the committee ad at 10 a.m., Wednesday, March 27, 1968.) OLICs AND REGIONAL MEDICAL PROGRA31S; ALCOH NARCOTICS ADDICTS FACILITIES; HEALTH SERV- ICES FOR DOMESTIC AGRICULTURAL MIGRATORY WOR-KERS WF,DNESDAY, XARCH 27, 1968 Ho-usE OF REPRFSFNTATIVES) SUBCOMI,IITTEF oN PuBLic HFALTH AND WFLFARF@ Commi,rrFp, 01-T IIMRSTATE AND FoREiGiq COMMERCF,' -Wa,3hington, D.C. The subcommittee met at 10 a.m., pursuant to -notice' in room 2322, Rayburn House Office Building, Hon. Paul G. Rogers presiding (Hon. John Jarman, chairman). 131 133 Mr.-RoGERS. an old friend of tl"is '.'Ommittee, Dr. Alieliael Our next witness Is , B' lor Uiiiver- De Bakey, chairman Of the Department of Surgery, ay sity of Afedicine, Houston, Tex. on the President's ColillnissiOrl I was really the guidiiig force for Proaraln. for with u,, I@nd-we are pleased to receive I you CHAIRMAN, DEPARTME'XT STATEMENT OF DR. MICHAEL De 13AKEY or MEDICINE, OF SjRGFRy, 13AYLOR 'UNIVERSITY COLLEGE HOUSTON, TFX- Ile OPP Dr. Dr BAYry. Thank you. I am ar,,tteful ortuiiity to for t ee, ,i-s I did o Julv 7, in s ip- again n Olt n their pi ogress. and to rep . 0 ort o Ms imit'ee 'III(, the for what this subcol - t e to won d Foreign Conimerce.have doll entire whiel-i is ,ilready setting ,i pattern devel( e Nation. for en ,ineec i-ne rt of title I-of H.R. 15758.;lltro- I collie b ou III stroi , ir. Stagger@. ,,in of y committee, N t 1 Advisory Council ducecl by he c 't@i'm er of the Nationt oil Re- I hive been 9, menib ssinceitScreatioii,,,tndI herefore@htvehad Lyioll, see ,tl I%Ieklical Program, . program The opPortullitY to see tells it dev-6loP throughout the country cis but There I-,,,Ive 'Deen times when I hai7( the f act is that this progrtm has deve and in t very sound way. to see t@lie first oinf where I tbii-ik we -will beol i P . i t@ Noiv -We're at c e INe, which was to fruits of this program 1-11 terms of its 0 els'of our E-O'-ietY, Provide the best possible, care for the pa s was It need we and to extend this kind of care to eve the past. ,il)le full- t',Iillly have recognized but were not , cer @p, this program 'Vill ,Lcl-iieve an b ily in ill I belie (,,Id stroke, in the fields of heart dise,(ise, cancer, the related ,Lrea-9. Icl like 'lil-I , 'Is ts of the leaislatioil.I%vO'l At this time there ,t Pee to discuss in more specific terms. You -,vill recall, --Nlr. Chairman, in the in the original bill there -%T.,is much discussion original testimony, and of construction authority. I think the committee was svise in pointinL), out that -witl-ioiit this .ztrtiction-tliere -,v," ,tutlioriz',Ition type of authorization for ne-%v coi-i., 134 t be jeopardized in the for rei,ON@,ttiOn-tliat the pro(yi,zim would 1-10 n pl,,iiinin phase. e in the area of ,tetual operation) ,Ind already '-\'ow,@owever, vve ar tioiiiiig. I WO next several there, .I"e 11 proyrams fulic in some t-I tils, perhaps 40 or 50 percent of the pr( Ilion . 91 you se@) ( of opertiiio". So we are iliovin onsti-Lictio, come ilicre',Ls- As we Move into this area is need. ent, and ELI, limited ill ino-lv more aPP9,r s f,,tirl3 etion needs This construction i existin u scope. It is not On the same sc whic I enters,,tlre,,tdy within the medical the money. have the authorizf for the regional medical the consty oritv we need '-N'o iv I itv hospitals and to the sprimarily to the comniull proar,,i,i-ns apPlie n'lts where the pas efion has not inticip,,tted more -peripheral u I . t coiistrii this t@-PP, -Of proL,,ram. I)ort there is documentation and oiitliii- 11, f.@e Surgeon-Generalls re_ various types of construction needed. tltize your time ilig of tle should like to do, Mr. Chairm@tn@ rather than 'IV. 1-i at I it p. formal st,%temeiit for the record within the -next now. is to .;ubm it I oot few'( ty,,3. I bad hoped to have this ready for voli today, b in of emergencies over the,%vee@-end. involved in a series our formal e. understand, and NN-itllout objections v -_Nlr. ROGFRS. IV of the record following your testimony. statement will be, made a Dart - need for new Dr. DEBAKEY. This is'the limited but Nvell-(Iefined ONv this best construction. I leiN,e to the cOniTyiittee@s judgment as to h should be met. oillt, out ti@l,,It it is essential for the future of the pro- Allow me to p -nitnitv hospitals. am to find meals of mectin(y these ieeds of the comi particular even needs include construction, space for classrooms; . ind s@ic facilities, laboratory Sp-,ice of special.tvl)es; , e out- ti@I)e..s of cliigno t ind stroke@ TI" t' -,,Itlllellt units i-el,,itiiiefy to heart disease, cancer, , 1,e ailable, ,tnd Ivill@ hospital,,; siii-iply do n@t this type of space ,tv MP-"Iris of fiiidinu the ttind-,- to- provide this kind fre(@tieii:tlY ll"ye "10 zn of (,Oll,,;truction. Chairman, I would emphasize that we have reached the Finally, Mr. stage in this program where we must look to the :ftindinz levels over the next 3 to 5 years. As -%Yp, move more,,ind mo ink the, cost of these programs will reach the fio@t. n our original concepts and the original proposals ii the Pi-c--ident's Com- '@ioii's report. iiiis Yo,,i will recall that we expect this to reach authorization levels of well over $150 million by the end of 5 years. Now we are, beyond that po;iii- in our @thinkiiig, and -,ve now liaN-e better evidence of what the need:, are going to be. I would say they -%Vill approximate $5 or $10 million in e4acli re,ioii -%vitliin the next 5 years. TI-lirefore, I would hope the coi-arnittee -%vill contemplate authorization levels of some $500 rnil- lioii -,vithin the 5--ve,,tr period. This level will not-be reached Soon, of course. However, I would thin to the $300 million level. I opportunities to provide fundin(y at this available than ,it, this moment. in 135 I will be slid to aiisiver aiiv citiestiolis you have. -,Nlr. Cliairiiiaii9 n ch, Dr. b,;Bakey, for giving US Mr. RoGERs. Tll,,tlik you very n-i@ its importance. your viewpoints on this progra!n ai@cL u may be aware Could you give us an exartiple o-f one reason that yo would want -to do this in your statement. of i-naybe you or E BAKEY rather t@liaii take your tii-ne about it, let my D d lik t Di-. Well, e to discuss an are, st,tteincii provide this information. I woul cel)t of the prozrLl", nl3r ,Lceeptp-d the totil cOn where tlie@ liaA,e i-iot o ovic@ the but ,ire utilizing the prograii-i in ,t iiioc-:t efficient,way to I)r i- t I think are esseiititl: re@-earcli, edue, I)articulitr three elements tlia i,ion, ,tiid patient c,,irp-. These three elements must be coTiibliied at the iich the physician iiieets the patient. level at ivl 11cel.il with the Pl'O.!Yi,aiii, ilici I Air. ROGERS. This his been my CO to a@t. f@dbacks that realize it is still very young. But I ,iiii beginning similar yet. it is not tile pro@ani is not rell@ellili@ the practicing phy level, at the cleaii's little higher down t,;the hospital. It li as stopped ,it a offi(-R. F BAKEY. This is understandable at the plaiiiiin(,, @tage. Only Dr. D r- " ,,it the operating stag_ae will they begin to feel the i)rograi-ii. The, i-Ciost important thing to me is the fact thtt tbiiproo;ra,.ii is be- coii-iing better understood by the practicing I)I-iysiciaii, and there is develo an enthusiasm for the 1)@Lyrtiii at, the grassi-oots level that reallv Pi,, ign strikilily contrast to some of the earlier experiences. M@. ROGERS. Th@t is right. I remember very vividly. I t-Iiii-ik it might be liefi)ful to point out some of these areas where vou feel the I)roara@ is beiiiieffective in Lrettiii@ to the community bospftal, and wh@re ihe people in the coii-imuiiity ,t.@e really beginning to receive the benefits. This would be helpful to the committee, laid also to spread it Upon the record so that other areas can see what is beiilff done. in the most successful programs. Dr. DE BAKEY. I %vill be very pleased to do this and include it in the statement I will file with you. Mr. ROGERz.;. Th,,ti-ik you. Air. Kvros? Mr. K@os. We are happy to have you here, Sir. These proo_-rams of construction that you ,tre talking ibotit, Nvoul(l still have- to be initiated ,it the local level and passed -On I)v the Ad- visory Council. Dr. DE BAKFY. Yes; and they would also have to slioiv justification .is being within certain ui(lelines, as being essential to the efficwy of this proLyr,-iiii. Ther@,tre all kinds of construction needs, but we have N-ai-ioiis types of construction .ttitliorities, ,iiid I would think the important thing is iisti,iietioii to . ti t that we limit the CO the needs of this program , i, t is, lvliei-e it call 1)(3 deiiioli-,ti@zttc@(I unequivocally tliqt without the coi-istrue- t@ion space the program couldn't be effective, couldn't be implemented. AIr.-Kypos. I don't know how familiar you are, Sir, with the moi-iey requirei-nents of the I)rogra,,ii; but the figures vesterd,,iv -,vere that it ivoiild be about $30 million (-;iri-yoil-er from tire last @scal -vear, and the, bill tl-iis @,ir carries $65 million. Do vou think $95 iiii],lioii Ivan be eiioii,h for this kind of planning this co'miiicr veqr? 136 Dr. DF, BAYXY. Well, if I read the situation. within th@ @ext year correctly. I would sav we would come close to that, cert@t""Y ; and I don't thi@ it is going to j copardi@e the program. What I am concerned at>out is when we Let into t@@ gDerational phase within the next-well, say by lcg7l. I w@uld say wit'llA this 2- to 3-vear period we are going to see areal escalation in activity and, there- fo're, 1 -funding needs. Mr.lllr,yRos. I understand, thank you very much. Mr. Ro-G@. Mr. Nelsen? Air. N@@. I have no questions. Ml-. RoG@. Dr. C Mr. CA@R. It is B e B,,tkey, to have you here. You are so well Imown to ma g absolutely dedicated to the serv- ice of umanity. We to be I w Is? for sc to siv e at way. Dr. es. Well, some rooram. For example, let us take the cOmrD . zn They need and can us@, and in ,t ive care ' built in such v can't even reno- unit; but the hospital is v,,ite space. experience, r own YOU are f a-miliar from vour own . I am sure, in you area of l@entucky2 where liospitdls, even those built with Hill-Burton funds, are -now so lammed that it would be denying the use of the space for some very e.-,Sen al purpose. So they need additional space. To build this, they have to have mall sum. It ma-v amount to a hundred monev. It maybe a relatively s thous'and dollars, but it is @till money that is hard to find f or this purpose. unit would be.oi-io wing. Another would hope An intensive care my colleague @ill -point this out in his @timonY to you-in terms. of ae,u@ strokp, units. There will be diagnostic facilities of certain specific character. . I eneralls report. which the Council had We -point out in the Surgeon G the review, the tvpes of space @eeded. They will need clas This is the land of space that is essential to carry- ut the program. 'VI. CA.@R.-CertainlY we ha@ seen that inan-v of our hospitals in the smaller areas, and I am surp-.it is true in cities-, that in the past few years building has taken plant but still it is inadequate. Dr. Dn BARDY. completely inadequate, and also'lt doesn't take into consideration these @ds of needs. They diqnlt even visualize these needs in the early plans. Their concern was with immediate needs that thZ had to meet. r. C@R. I see the need of these things. Dr. DF, BAKEY. Ma-v I.say to ou, Dr. Carter. that it was part of your understanding that helped @yroA.m this pro'grarni and I want to thank you again for your In-si into this whole program. . gllt Mr. CARTM Thank you, sir. Dr. Dr, B@y. It w@@ a tremendous -help to us. Mr. ROG@. Mr. Skubitz? Mr. Chairman. Mr. S-Ku-B"rz. Thank you, 137 I have no questions, Dr. De B akey, but I want to join my @@lleagues in ,velcoming you here today. I am looking forward to receiving your recommendations. Dr. DE BAKBY. I want to express my appreciation to the commit- ,tee for the wisdom and kindness and generosity thev have shown, and it is @ood to know there are public servants like yourselves. ,Nlr. ROGERS. Thank you. (Dr. De Bakey's prepared statement follows:) STATF.NfE',T OF @)fICHAFL E. DE BAKEY, M.D., PROFESSOP. AND CI-IAIP.-,fAN, DEPART- 3fENT OF SURGERY, BAYLOR U.V@RSITY COLLEGE OF MEDICI'QE, IIUUSTO-@N, TEx. Mr. Chairman and members of the subcommittee, I am Michael E. De Bakey, Professor and Chairman of the Department of Surgery, Baylor University Col- lege of Iledicine, in Houston, Texas. I had the honor of being named by President Johnson as the Chairman of the Commission on Heart Disease, Cancer, and Stroke, whose report led to the initial recommendation of the Regional Nledical Programs legislation which this committee developed and passed in 1965. Since .its creation, I have been a member of the National Advisory Council on Regional -Aledical Programs and am also a member of the Regional Advisory Group of the Texas Regional Medical ProgranL I testify today in strong support of Title I of H.R. 15758 introduced by the distinguished Chairman of your full coinloittee, '.%fr. Staggers. If enacted, Title I would extend the authorizing legislation for Regional Medical Programs for an additional five years as well as clarify certain technical aspects of P.L. 89-239. I would like briefly to reiterate the basic concept of the Regional Medical Pro,-rains, the future of which this subcommittee is presently considering. The Regional Medical Programs comprise a group of units added-wherever possib@to already existing medical centers in regions throughout the country. The units are part of the overall research, teaching, and medical care going on within the medical centers in regard to heart disease, cancer, and stroke. These units together make up a national network for research, for teaching new developments to doctors and nurses, and for care of patients under investi- gation. Thus each physician served by this network has, readily accessible to him for his patients, the full range of up-to-date knowledge and skills developed through nation-wide research. At the same time the doctor contributes to re- search, for his observations add to the total knowledge. Each of these units we are discussing has its own facilities and staff, though .they function as part of the existing medical work force, to ptill together and strengthen the medical resources now in existence. The Regional Medical Programs as initially authorized, placed principal em- phasis on regional voluntarism, as the means by which their goal might be achieved. Today I can report that your confidence in this approach has been well placed. Within the last three years 54 Regional Medical Programs have been brought into being. By this summer approximately one-half of these will have entered the operational phase. The remaining regional programs will shortly thereafter begin operation. With its emphasis on voluntary cooperation the Regional '.Nledical Program mechanism has managed to harness the creative energies of practicing physicians, hospitals, medical schools, voluntary, state and local health agencies. All too frequently in the past these creative energies have been isolated from one another or, even worse, in competition. Regional Medical Programs male it possible for all providers of health services to combine their strengths to improve the care of patients with heart disease, cancer, or stroke. Thus our aspirations of 1965 today are working entities. One of the most iml>ortant developments is the large and increasing involve- nient of the medical profession. In a recent speech the President-elect of the American ',Nledical Association said, "As a whole, the medical profession at the beginning of the year 1968 is probably more deeply involved in the planning process to determine the nature of the Regional Medical Progrinis than it has been in the planning of any previous Federal program." Now in considering the future of these Progrims, Air. Chairman, I would like to discuss the legislation before your comnlittee. I was disappointed to 138 the bill does no den the constFuetioil authority find that Title I of the iiiter- for Regional Medical Programs. s in 1965, state and Foreign Commerce Con ecessary if there was much testimony that construction ax) committee in the requirements of the legislation were fully n its report on modify-Ing the bill deleted the authority for nev by th bill the committee reasoned that the progra the th authority in its initial plan red co those instances in which new be fo ical Programs, other Federal fill lew EC e committee in its report ind te tb time of the legislation's extension. mmittee,s wisdom on this to commend the co Medical Programs have not been jeopardized in in fac , ized themselves, di these past during which they I ave organ pi d their programs and begun to enter the operati( nal phase. the 54 Regional However, this situation is rapidly changing. Alre idy 12 of them will have Programs are operational and within the next year )r so all of idly begun operations. Accordingly, their needs for addit oiial facilities will rap increase. al'sreport to the President and The Congress on Regional The Surgeo@i Geller edical Program documents the case for limited Regional M ,L%.'edical Programs - It is extremely important to understand that these construction authority munity hospitals, not our medical facilities would principally be located in corn schools. ruction described in the report ng education programs, Example, of needed community hospital c(>iist include class ar conference rooms for regional continue ,,pace for spec ns of community patient care, and expanded diagnostic labor These needs der existing Federal construction pro- grams. There ai for-this'. (1) The funds for the construction of health facilities has groNN,ii eiiorni result of an overnvhelliiiiig demand for such facilities. (2) By definition, the nature of Regional Aledical Program construction needs goes beyoii('l 'the needs of a single institution to the needs of the region. tutioii would Accordingly. it is unreasonable to assume that any Single iiisti be Nvilling t@ divert its scarce funds for matc-hilig purposes when the bezic@tits of the facilitv are intended for -iiiany ii@titutions. Since it is essential that there be no substantial distortion of the concel@t of Regional Al@lical Programs, I concur that rather strict limitations should be placed on tills vitally needed @?nstruction authority. The kinds of limitations one finds in the Surgeon General's report, having to do with the amount of funds -poses, -em entirely reasonable to me. available for construction pui sL im I)i-oje(,t.@ Having considered the limitations what kind of Regional Progr, are we working to generate? How does such a project work? An example of the effective implementation of the program ini,olviiig comniunity hospitals is pro- vi(led by the Rochester (New York) Regional ';Nledi inaugurated all initial five-part )mratiolial progr cal Program which lig.,; am in the area of cardioi-,,isculir dis ase. Each part is specifleal y designed to meet observed or expressed needs in zed n edical care to the heart patient. One project will pr( ining n cardiology for general 1))-actitioiier-, and iiitei-- iliE ne in the tell counties which ir,,tkc, up this region. @ei-- eri iiig programs will be offered so as to best meet the iii(Iii-!(Iuql iiel cians who will participate. This program is being persente(I se to the request-, @f physicians for this type of assistance. Ole in direct re.@poi DhasL, of this r visitations to peripheral hospitals by the cardi- ;Iogists who wl Certain audio-visual equipment will be placed in theSE ontinued use by the local physician. A parallel p ive month long courses to prepare pro- fessional nurs( in the man ment of coronary care units. he growth in the number of cor ary care uni which provide essential Illedic I care during the acute phases of cardiac illness has created an urgent need for an increased nulii- her of well trained nurses; tbE latest advances in nursing techniques and modern life-saving equipment deman( s Realized instruction In the nursing skills re- 139 quired. Hospitals in the region have already expressed their intent to have nurs@, participate in this program as soon as it is activated. The objectives of thi4-z program go beyond that of supplying specially trained nurses for coronary ca,-c units in general hospitals; every effort will be made to train coronary care u,@;t nurses from the smaller community hospitals as well , even though they may not as yet have such a unit. Three additional activities will also be pursued under this initial operational prograra. A regional laboratory will be established for education and traiiiii)6, of medical personnel in the care of patients wnth tlironibotic and liemorrlii,-'e disorders. This is the first such facility in the region and ivill be based in one of the general hospitals participating in the Rochester Regional Medical Pro- gram. A region-wide registry of patients with myocardial infarction will b@ implemented which will gather uniform information from the coronary care units of participating hospitals and provide immediate as well as longitudinal data for analysis. A relatively small amount of funds has been made available to the region to develop the first learning center in the region where ,*Die oi the educational programs in heart disease, cancer, and stroke may be presented to physicians and nurses. The first year award for this multifaceted program in cardiology is $343,T'@. Having described an example of what we are building, Mr. Chairman, I should like finally to say a word or two about the level of funding I believe essenti@,l if Regional Medical Programs are to have a fair chance to achieve their goal. We all realize that the maintenance of health is assuming an Increasingly important role in our socioeconomic area of concern and activities. The health industry today accounts for an expenditure of $50 billion but it is scheduled soon to increase to an expenditure of $75 billion. If the Regional Medical Program is to fulfill its function as the interface be- tween the moving parts of this health care mechanism, it must continue to be able to influence that increasingly expensive device We would be short-sighted engineers, indeed, to derive authorization ceilings for the next five years of this program by looking backward at the cost of these programs at the time they were being planned. The cautious development of those programs has unleased a chain reaction of operational activity which will necessitate substantially increased funding levels. It is already clear that on the average these programs will be operating at a level of between $5 million and $10 million each within the next five years. It is, therefore, necessary that an authorization level of roughly $500 million be used as the yardstick with which one measures the funding levels of the program contemplated by this extension. Alr. Chairman, I am indeed privileged to again have the opporttiiiitv to present my views to the committee which has done so much to shape health legisl-,I- tion in general and the Regional Medical Programs In particular. Air. ROGERS. Our next witness is Sidney Farber, director of research, Cliildren's Cancer Research Foundation, Boston, @Nfass. Dr. Farber is also an old friend of the conu-nitte@, and he ivas helpful in the formulation of the original le-aislation, haviiig.served as cliair- man of the Cancer Panel of the Pres'ident's CommisSion. Welcome back, Dr. Farber. STATEMENT OF DR. SIDNEY FARBER, DIRECTOR OF RESEARCH. CHILDREN'S CANCER RESEARCH FOUNDATION, BOSTON, MASS. Dr. FARBER. Thank you. It is a great honor to be once more before this committee, where my memories are as lieql,tnvariiiiiig as any iiieiii- ories I have in my entire professional career. I join Dr. DeBil@e 'N and all our colleagues in expressing gra@itude to this committee ,ind Con t important program tfress for starfinly what I regard as the mos ill e field of medicine in the @story of our country that is applied directl_y to the care of the patient. I sp@ak strongly in favor of H.R. 15758, the purpose of which icz' among other things, to amend the Public Healfh Service Act so LA- 140 to extend and approve the provisions relating to regional medical health programs. I join my coHeague,_@r- DeBakey, in strong recommendation for construction funds, and L will give one examp@e of this later, which will illustrate the great need for construction-funds in this program. What we are asOing today is authorization for the next 5 years for these funds with the hope that funds will be available, released from other sources, which will make the support of this program and so many other worf efore tlWConzress possible. I would like to words about these --programs. There has beef beginning already. I want to give evidence that the s excellent under Dr. Marston in the division of regional medical programs, and that the Council and advisory boards are composed of wise and courageous men who are not afraid to say no, nor are thev not afraid to say yes, in -theapproval of pro ramsthatdeserveapproval. ;as a member of the National Advisory Council t e cil to the Regional Medical Programs Council; atching and listening with great -appre- am asked for help, in the deliberations of these advisor The regional in represents the first time in the history of American med here all searnents of society concerned with the health of our people have come together to achieve a common oil of better health, preservation of lives 'and the prolongation of ple ,who suffer from these dread diseases. This -is a itself, and would be worthy of the entire cost of tl-iis s were the onlv spin-o:ff of ltvhat has been done. I medical pro'gra-ms,,q@ite cerned with bringing to every man, woman ancL ciiild these dread disea-ses,,and eventually, I hope, from 9,11 that is known today that might save lives or prolong go( accomplished in the simplest terms in two waTs. We beiin with the community hospital and the doctor in practice. We give7added strength first in manpower in trained personnel in those community hospitals, and, second, technical facilities for what is lacking. And we -link -these community hospitals with so-called iceenters.1) These centers are not buildings in one place. They are not in one building, but tliev re-present a p@ion of a given region -where there is a concentration of expertise in medical schools, teaching hospitals and research institutions where there are f acuities and manpower and expertise that cannot be duplicated endlessly. The countrv iust can't afford that. If we can b@ing these two seo-ments of the medical community to- -aether, the community hospitals and these medical complexes, and icatioii in the modern idiom for rendering advice, we will achieve some- otl-ier fields, will bring great I want to in, ntio at I had the privilege of mentionii-ig once before before this ee. 141 In cancer, if we could bring to every man, ivoinaii and child every- thing. that is known in diagnosis and .therapy today, there would be a saving of 100,000 to 300,000 who are destined to die of cancer this year. In the field of heart disea-@ and the field of stroke, thi@ can be iiiultil')lied as evidences of what this.l-)rogram can accomplish. For the remaining 200,000 of the 300,000 for -whom we have nothing available today and who ivill die of cancer, e require research. T@ Iv great research programs of the National Cancer Institute and the Ainerican'Caii@r Society tiid the many private institutions of the ;country will provide the research in the course of time which will bring .answers to the problems which cannot be answered today. But if we can focus our attention on those who can- be saved with l@iiowledge presently available, this goal is worthy enough. I want to point out one example in regard to construction. You ,tre familiar with the great returns from the priitae sector to the Hill- Burton Act and to the Health Facilities Construction Act, and so on. In those there has been an outpouring of private money. That will hap- pen here, too, in those parts of the country where the private sector can aid. In those where the private sector is unable, this program should shoulder the entire burden, because human life is precious wherever it is. There is one example that I learned about just before coming here. The community of Anchorage. Alaska, in response to th@needs identified by the Washiiigton-Alaska regional medical program, for hig@-en@rgy radiation facilities closer than Seattle, Wash., is now conclucting a campaign to build the facility. Solicit@d private funds will be us@d to col-istruct the liou;-:ing for the equipment, which is very expensive. The eq'uipmeiit will be purcliaz-zed by the regional medical program. The tr@tmeiit center will be operated as a. regional res-ou@e by the Providen@ hospital, as planned and approved by the local iiid and regional advisory groups. The decision to support tle ictivit-,y inv)lvps cooperative ,trrange- iiients at another level also, and of this I ,tm very proud. The National Cancer Institute conducted the -c:-,te. visit, which gave assurance of the sound scientific and professional basis of this project. Here is a beau- tiful example of two segmented of the National Institutes of Health 'Cooperating. I have just heard that the -kiichorage Construction Trades Council, comprising 14 unions, have tal,-en on the construction of the building' .contributing ii-iore than one-half of the total cost from this one source alone. This-is heart-warming, indeed, to see a community as a whole ,joining with a Federal program in aiding people sufferi-nz from can- cer by providing a form of treatment that Yiad b-een lacking'i'n that part of the country. The time has come now to recommend greater support for this pro- gram on the basis of the fine proo,,re-@ whic@ has been made. You have already heard from Dr. DeBake_v in response to questions for the amount which is recommended for Chis year. iNfay I mention two other figures? By 1971 this program should be supported by in amount no less :than $300 million, not cotiiitiiiz construction. And we should reach 142 the figure of $500 million -,,vithiii 5 years' time if we are to utilize to the full the strength of what has been mobilized in the varioii@- i-e,,ff ions of the country in behalf of the health of our own people. I close these reii-iLrks, '.LNIr. Chairman and geiitleniel' , confident III the belief that the leadership to the Conzre@s offered bv your coiii- iiiittee will permit these regional medical programs to i@-ia6 i ti-iii.N great contribution to the health of all of us. Thank you. ( DI-. Farber's prepared statement follows:) ST,ILTFNtE-,T OF DR. SID',EY FARBER, DIRECTOR OF RESEARCH, CIIILDREN'S CA-,'CFP RESEARCH FOU@NDATION, BOSTON, MASS. '@Nlr. Chairniin and members of the Subcommittee on Public Hf,,Iltliind 11'elfir it is Nvith gratitude that I ,icknowledge this opportunity to appear before you ill strong support of II.R. 15758, the purpose of which is, among other things. '@t,l aiiieii(I the public health service act.qo as to extend and approve the provisioii!4 relating to Regional'i%ledical Programs." Aly name is Sidney Farber. I a ii) founder and Director of the Cliildren's Ciiii(,er Research Foundation in B@,toii, and Chairman of the Staff of the affiliated Ciiil- dren's Hospital Medical Center. For almost 44 years I have been associated ii-itli Harvard Aledical School is a student and member of the Faculty, where I aiii -il, research, and noiv the S. Burt Wolbach Professor of Pathology. @Nly iiiedic, ing activities have been devoted to children and to the field of cancer. i@t the present time I am President-elect of the American Cancer Society which derii-t@@ its great strength in its struggle to control cancer, from more than 2 million volunteers in all parts of the country. Presently I am a member of the National Advisory Cancer Council of the National Institutes of Health, and represent tlipt Council to the National Advisory Council on Regional Medical Programs. It was my privilege to serve as a Member of the President's Comniission on ]Eleart I)is- ease, Cancer and Stroke, as Chairman of the Panel on Cancer. It was this (''ojii- mission ivhich produced the renowned DeBal@ey Report which culiuinited in this enactment of P.L. 89-239, the Heart Diseise, Cancer and Stroke Amendment (if 1965. It was my privilege, too, to te@tifv before this Committee in support of the original eiiabling legislation. Today I come before you in support of the extension of this program which represents one of the greatest opportunities in the history of medicine to prevent death from these dread diseases. ind to prolong good and useful life for our people. Alay I qiimmarize briefly a few points concerning the program as a %N-li6lp. and that portion dealing with cancer in particular: (1) A magnificent beginning in planning, and to a smaller extent in operations hai already been made in this very short period of time. The Regional '%I(-(iical Programs already ;how convincing evidence that for the first time in Aiii('riciii history the various components of a given region of the country concerned -,N-itli the health of our people can and will work together toward the achievement of a goal which has never been -go broad r defined. (2) The goal of the Regional '.N (lical Programs, in a few words, is the pro- and child suffering from any of these. dread and vision for every man, woman related diseases, of all that is known as well as all Qophisticated technical liroce- dures for the prevention of death iiid the prolongation of good life. Ftiii(l:itii(-iital to the achievement of these goals are development.% in data collection and tli(@ I)el.- fection of better methods of delivery of medical care, as well as inil)ro%-eitieiit, In continuing education for the physician and education of the public. ';%Iakiii,-, use of these invaluable tools, then, the Regional I%Iedical Programs, in the c age of cancer, are beginning to create meaningful relationships between comnitinity hospitals and those parts of the region where are located the medical school@, teaching hospitals, and research institutions concerned with cancer. The colii- inniiity hospitals must be strengthened by increasing the number of members of their ,,taffs, specially trained In the various aspects of diagnosis and treit- m t of t e many different diseases we call cancer, and the,addition to their tee iiicil arinaiiientarilim of such qpeeial technical devices as radiotherapy units. and other dii,-nostic and therapeutic equipment. In the medical school complex there will be concentrations of specialists in tilp many phases of cancer research, din,-nosis and treatment to give expert assistance 143 to any doctor in the region in behalf of his patient. In such complexes where a critical mass of expertise is to be found, primary responsibilities will include continuing education with the help of technical equipment in the modern idiom, demonstrations of new techniques for diagnosis of treatment, and consultation services to the community hospitals and all doctors in the region, in addition to the conduct of research designed to provide, solutions for problems In cancer which can not be satisfactorily handled on the basis of present knowledge. (3-) It has been estimated by experts that if we could make available to every patient with cancer in the country today all that is known concerning diagnosis and treatment, we could save 100,0-00 of the more than 300,000 who will die of cancer this year. This is without new knowledge emanating from research labora- tories. It is a goal that can be achieved by the full development of these Regional -Ifedical Pro,-rams in the field of cancer alone. (4) As was the case with the Hill-Burton program, and also the Health Fa- ,eilities Research Construction Program of the National Institutes of Health, in- vestment of Federal money will be sure to call forth investment from the private sector. You will be interested I am sure in one exljerience In a part of our Country which has serious need for improvements in the field of cancer. The commodity of Anchorage, Alaska, in response to the needs identified by the Al'ashington-Alaska Regional Ifedical Program for high energy radiation treat- nient facility closer than Seattle, Washington, is now conducting a fund raising campaign. Solicited private funds will be used to construct housing for the ,equipment, which will be purchased by the Regional Nfedical Program. The treat- nient center will be operated as a regional resource by the Providence Hospital, as planned and approved by local qnd regional advisory groups. The decision to support the activity involves cooperative arrangements at another level also, for the Nationil Cancer Institute conducted a site visit which gave assurance of the -sound scientiflc and professional basis of this project. I heard just before coming here that the Anchorage Building and Construction Trades Council, com- I)ris:ing some 14 unions have taken on the construction of the building as a I)i-oject. contributing more than on(- half of the total cost from this one source alone. RECO1,13fE@NDATION' The time for increasing the supj)ort for these Regional Programs in Heart Disease, Cancer and Stroke has come on the basis of the truly splendid start that has been made. The upward trend of needs-almost double each year- is ipparent as more programs reach the stage of actual operation. In fiscal 1967 (inly 4 programs were operating; in 1968, 20 more will reach that stage. Even to make possible the universal application of such a simple and established technique for detection of cancer of the uterus at the Papanicolaou smear, Is an expensive procedure, but one that will be followed by the saving of thoii- ,qands of lives of women each year. We should emphasize, too, that many seg- iiients of our svstem-in ghettos, rural areas, or old-age homes among others, have little or no access to modern scientific health techuolo-,ies. We are aware that particularly at this time priorities must be established and that (-boiceq must be made. It is our purpose today merely to point out the great good that will come if there is suprort of programs which have already demon- sti-ated their ability to achieve the goals defined by the Presideut's Commission (in Heart Disease, Cancer and Stroke and put Into law by the Congress of our Country on the recommendation of this Committee. From the time of the iden- tification of these goals in P.L. 89-230, the Regional Medical Programs have captured the imagination and raised the expectations of the general public and the health provisions alike. Those who have studied the needs of this progralia most carefully recommend that the ceiling for the national program as a whole .zhould reach the level of more than 500 million dollars within 5 years, and should certainly not be lower than 300 million dollars for 1971 if we ire to utilize to tbt, full the strength which has been niobilized in the varous regions of the (it-)untry in bebftlf of the health of our own people. I close these remarks confident in the belief thit tli(, leader-hip to the Con- I-res@ offered by votir Committee will permit these Regional Medical Programs to make a truly great contribution to the health of all of us. .Afr. ROGFRS. Thank voii i-ei,v mtich, Dr. Farber. We tre indebted to youforbein2liereandgivingusvouropiniononthisprogr,,ii-n. 144 ancer Research with the Children's C Let me ask you, for instance, -ole where a new treatments Foundation, can you give us anv exam. perhaps, hasbeen disse@inatedth@ough aiegionalmedical.program? Dr.-F'ARB@. Yes, Air. Chairman. The Children's Cancer Research Foundation, if I may speak of something with which I have been concerned for the last 21 years, is really tot-vpe of the Regional is a prihvateqorlolndifion, assisted from ]Nfedical Center proKram..It se, funds from the in- the private sector and receives re %re National C, cer Institute and help from the American Cancer Society. It is stip- ported by the entire Mew Enaland community. treatment for children It provides expert care Wnd diagnosis and with leukemia a@d all forms of cancer, for any child sent by a doctor in the entire region. The doctor takes care of fhe patient at home land Ives the tremendous moral and medical support required by i amily which has a seriously ill child at home. The foundation proviies the techniques and equipment which are much too expensive to be in a doctor's @ffice. It carries- out all these expensive --erv-ices without professional charge to the patient; at home the patient is the pri@, te atient of hi-s private doctor. p In 21 years, Mr. Chai@ian, I have never bad a complaint from a single doctor in this region. We have had remarkable cooperation, an(! the community as a whole has cooperated to support something which they considered absolutely necessary for the co@fort, the -,vell- be, nd the mental peace of the family, as well as for the health of the c%ild Mr. RoGERs. Have we had any real breakthroughs in this area, ill the treatment of leukemia in children? Dr. F@,,RBER. lkfr. Chairman, there has been very great roo-,ress. it was 20 -vears ago last November when the first chemica?th@t could control leukemia, at least temporarily, was administered to a child for acute leukemia. There is no cure for acute leukemia, but patients live good lives f or several years, instead of a few weeks or a few months. And ther@ are alive a few hundred patients, adults and children, about I percent, I estimate of all the patients with leukemia treated, who leave lived good lives for 10 to 15 -vears without evidence of the disease. This is not a cure, in my opinion, but this is verv heartwarming evi- dence that we are @ the riiht direction in the use of chemicals, and many suppoqive pro ranis, such as platelet transfusions and so forth. o'd lif@ in -he next forward step If we can keep t in research 91 may come in time fo'r that ehi@'lodl We have other tumors in adults as well as children, which have re- sponded to surgery, radio therapy, and chemotherapy. In one case of cancer of the kidney in children, we are now above 80 percent, in long- term survivals because of the addition of chemical, in this case an anti- biotic, to modalities of surgery, and radio therapy. We have accom- plished whit seemed impossible 20 years ago. Once spread to the lungs E,,td occurred in this kind of tumor, there was a matter of 3 to 6 months of life ahead. We are now able, in about 60 percent of the children who have had spread of this cancer to the lungs, we are able to have complete destruction of the tumor using small -amounts of radio ther- apy -anq an antibiotic,. Life has'continued in the longest patient for 13 years with no evidence of the return of the tumor. 145 There are many examples that could be given from the splendid in- stitutions in the country and in other parts of the world wliere great- est advances have been made. The word "cancer" does not apply to a, single disease. It includes many different diseases, which may be un- relwted, all of which are called cancer, so we may have to answer your question instance by instance as we record su Mr. P%,oGFRs. I think that is encouraging, and I think it is well for us to spread on the record some of these examples, so where you have a tecli,nii,que that is successful, this can be spread ,quickly through a re- hat it can get to giollal 1-nedical program-at least that is the theo'ry-t the local doctors and hospitals. And although we may not have the necessary treatment there, it can be arranged for and the treatment prescribed. Dr. FARBER. We hope these regional programs will provide for the community hospital the expertise and the eq will take care of the vast majorit@ ?@ patients with cai r the cen- ters the new problems wiiicii require far gre@ equipment and manpower. Mr. ROGMS. Thank you. Are there any questions? Mr. KyRos. I want to join with you in welcoming Dr. Farber here. Mr. NELSEN. I was interested in your statement that many patients have as long as 13 years wit@ no evidence of recurrence. Is = an .fie number of years that the medical profession -y specl assumes to be @st the danger point in radiation treatment of a tumor? Dr. FARBER.-This varies from tumor to tumor. In the ctse of the kidney tumor I mentioned, I have experience for more than 40 years with this kind of tumor. If there is no recurrence or evidence of tiunor 2 years after initiation of therapy, -,ve may as- sume with a high degree of certainty that the patient will remain in -aoocl health. In the case of other tumors, canee@ of the breast, for ex- @mple, although most patients will remain well if they have been well for 10 vears, Wil of u@Dr. Carter, too, I am sure-h,,ti,e seen patients who ha7ve had recurrences 18 to 20 years later. So we must give a different answer for each kind of tumor. Mr. I\TELSEN. I had in mind a case tl-iat I am ivell aivare of, that litp- pens to be my son who had a brain tumor. It is now 5 Nears since the radiation treatment was given and he has been in ve good health I ry since this operation was performed. I am always wa@hini of course. This was 5 years,,tgo, and it,,vould seem he is in very good g@alth at this time. Dr. FARBER. I am sorry to learn you have this personal experience, Mr. Ne@n. I would say the story you give is encouralyiiia. If there is no evidence of tumor after 5 years, this looks very h@pe:rtll. Mr. RoGERs. Dr. Carter? Mr. CARTER. I want to say thank you for an iiiterestiiigind informa- tive-,ind I started to say "persuasive" presentation, but instead of that, I am going to sav that so far as I am concerned, I ,iin a believer tnd am fully, persuad@d in what you sty. Thank you. Dr. FARBER. Thank you very much, Dr. Carter. Mr. Sik-uBiTz. Doctor, I litve one statement. 146 You made the statement, I believe, that if we could niakp, avail- womanan .d child the'evidence that we have oil cancer, able to every man) ar. is this correct 100,000 lives would be saved this year or ,tny ye Dr. FARB@. That is correct. Mr. SKUBITZ. Of courser I recognize the task we have in trying to get to every individuals but don'@we have a central clearing agency of some sort where information is collected ? Dr. FARBFR. Yes ,we, do, through the National Cancer iTtitute ,tnd the merican Calic,&r Society, but the problem is cOmpiex. May I men on a few of th complexities? F we must be come to his doctor early. This is No. 1. The erican Can v has had a great educational I)rogran'l for maii@ E @to have patients come mucli applv the cytologic dia@nos- eariip,r than is no@ otild save thousands ot tic test, for example, to @ver@ ii today, we c lives, literally thousands, DI here is 9, form Of cancer of the uterus which can be cured by su ery. or radiotherapy. r But if we can't -et the patiery xamined properly and regularly, we cannot save lives. tshould be made. It is that there is a There is a furi e comi-niinitv hospitals of the country lack of facilities well trained men-and devoted doctors, where there are and without all of the supportive but without exp !or the therapy that is extremely costly@ one.cannot do as much I)atie-nf@ as we hope, to do when these regional medical programs bring stil,)port to every community hospital that is connected with every Center, and every center connected with every other center. There are man-v reasons of this kind, but if this countrv decided toda,V that it was worthwhile saying these 100,000 lives by br@nginIZ the fin,ii@cial support and the administrative relationships that wovircl be required, these li '-Xfr. SR-CBITZ. I thought you -,vere say- iiiz that one of to bring ,tbout an aware- als are- and if they could Items in the in(liv I - recognize them, place for proper medictl ,attention. theyv Dr. F-,,"]@.ER. 9 O. 1. rt o it is %i,hat the individual I-,atie,iit will do, is what the doctor will do. But if these patients criiie t@ cli do not have facilities, the doctor, ivlio is ,tlre,@tdy overburdened with the tremendous l.Illioiiiit of good ral practice, will be unable to give the optimal treatment, bi facilities are lacking, be@,,tuse of the expense of stipportiye.therapy, because of the -number of ex- perts in n-iany fields of medicine, surgery, and laboratory science, are, iiot,ivailable for the patient. But if ,L patient should receive everything that is known today, lie -,vill stand a far, far better chance in such a place @than he can otherwise. Mr. SYUBITZ. Thank you, Doctor. Mr. RO(;FRS. Thank you very much, Dr. Farber, for your excellent testimony. 147 Our distiii_uuish6d colleague, Congr6ssjiian Kuykendall, will iii- troduce the niWxt witness. We are pleased to have our colleague with us at the committee here and are delighted that you will introduce our next witness. STATEMENT OF HON. DAN KUYKFNDALL, A REPRESENTATIVE IN CONGRESS FROM THE STATE OF TENNESSEE Air. KuyiiENDArL. Thank you, Air. Chairman. It is a real privilege to be with the subcommittee for a few moment@ and a particular privilege to introduce a man who for several reasons, I thinki is peculiarly qualified to testify on this particular bit of legislation. I thinli h@ is qualified for -several dffferent reasons. First, if not foremost, is the fact that our city and area of Afemphis is very much a regional city, probably more so than any in city ajoirn 125 outside of the crowded area of the eastern seaboard, where with miles of our city we have five States. And we have run into problems of Hill-Burton- because of implications of not getting ben@fits from a regional concept. We proudly announce that Memphis is a major medical center aroun& our @ university. And Dr. Cannon himself is one of the outstanding surgeons and maybe more particularly pertinent to this hearine. one of -the major contributors to medical education in the whole'Ration, having been one of the leaders in the field of medical education for quite some years. So it is a privilege to introduce my fellow'@Nfemp)iiaii, a good friend and a leading educator, Dr. Bland Cannon, of Memphis. Reluctantly, I have to leave now, tnd go to my committee. -Mr. RoGERs. We understand. Dr. Cannon, we are pleased to have you and welcome you to the committee. I understand you have an associate, Dr. Henry Brill. Dr. CANNON.YES. I would like to 'ask Dr. Riihe, Dr. Brill, and Mr. Harrison to accompany me to the witness table. .Air. RoGFRs. Wi;welcome all of you to the comniittee and will be pleased to receive your testimony. It is my understanding. Dr. Can- non, that you are representing the American Medical As7s@ciation in giving your testimony. n i STATEMENTS OF DR. BLAND W. CANNON, MEMBER OF COUNCIL ON MEDICAL EDUCATION, AND DR. HENRY BRILL, MEM13ER OF COM- MITTEE ON ALCOHOLISM AND DRLUG DEPENDENCE, AMERICAN MEDICAL ASSOCIATION; ACCOMPANIED BY BERNARD HARRISON, DIRECTOR, LEGISLATIVE DEPARTMENT, AND DR. WILLIAM RUHE, DIRECTOR, DIVISION OF MEDICAL EDUCATION Dr. CANNow. That is correct, Mr. Chairman. I am a practicing neurological surgeon and ,t member of the Ameri- can A@fedical Association's Council o@Afedical Education. With me to present the views of the American Medical Association on H.R. 15758 is Dr. Henry Brill, of Brentwood, N.Y. Dr. Brill is chair- man of the AMA's Comniittee oii Alcoholism'and Drug Dependence. 148 Mr. Bernard Harrison is director of AMA's Leaislative DP-partmeiit, and Dr. William Ruhe is director of AMA's Division oi -,Nfedical Education. rts of H.R. 15758 affect' thr e programs of special The three pa e interest to the American Medical Association. I -will comment on the first ptrt which relates to the extension of the regional medical pro- m. The second part proposes an extension of the program for ariLlits for1r, health services- for migratory workers. The third part proposes a new program for alcoholic and narcotic addict rehabilitation. Dr. Brill provide th i's views on the I,,itter will e subcommittee with the associatioi subject, two s. STATEMENT OF DR. BLAND W. CANNON Dr. CAN-., ON. One hundred and twenty-one years ago,,as a result of the concern of the profession with problems relating toIthe quality of medical education -andhealth care, the A-AIA was founded. since that day, in 18-!7, organized medicine has encouraged methodologies of ea are which it believes will best provid -ilth care h th el e improved hez for .,ill PFtients. The increased longevity winch the American people enjoy today is a tribute to medical advances and their -application to the health care of the American people. The American @llysio-i,,tn today is prepared to reiider the best MeZlical care in the -%voild because he is @a, product of a constantly improving pattern of the finest medical education ,tnd r@,,trch; because, his opportunities for -post--radtiate education are un- excelled a@ywhere; arid because Ihe has b@n armed with matchless and ever-advancini diagnostic and therapeutic techniques. I have made the previous statement, Mr. Chairman, because it should be clear that while we constantly strive for improvement so that what we have today will be better than yesterday, @nd what we obtain to- n'lorrow will still be better than today, we @ust not lose siglit, of the remarkable accomplishments that ha-vebeen made inhp-alth cire bv our medical educators, medical researchers, and practicing phys;cians. In July 1965, when'Dr. James Z. Appel, who was th f the association, appeared before the f -11 Interstate ind merce Committe,;fo testify on the bill to establish the ri program concept, he voic6d the assoeiation's concern w visions of the bill then before the committee. Because ment,-, made bytlie committee, much of our concern was qyietaul. R-.,NIP began auspiciously and, since that time, continues to promise a hopeful future. But,there are still some -who would like to see the recional medical proamm as an instrument by which the oraanizaticn and derivery of hearth care to the American people could -];e changed in some revolu- tion,-Lrv manner. Importanti -, this does iiot,appeir to be the vieiv of those in tl-ie, ,,idministrat-ion c ed with the im- -plement,,ttion of Public Law 89-239. Dr. Dwight L. Wilbur, president-elect of the AMA. in ,iddrec@ino' I in the conference-workshop on regional medical pro-arams on January 18, 1968. noted that on an earlier @easion Dr. R. -infarston, dire@or of the @eoional medical programs, had said tl-i,,tt RMP faces the challenge of influencing the quality of health services without exercisiiio- Federal 149 or State -aoverrimeiital control over current patterns of health activ- itie.s. Dr. VVilbur then said: If the program in fact is clearly one designed to catalyze and to facilitate the development of better programs than now exist to serve patients and their physi- cians, it will undoubtedly receive enthusiastic cooperation from the medical pro- fession and related groups. Such support is evidenced by the participation in RMP by some of our outstanding physicians and bv constituent medical societies of the A.LAIA. In five of the 51 regions, a@State medical society is the program grantee. Tlieseare Georgi-a, t@lie' District of Columbia; Nebra-4ka, LMin- iiesota and Pennsylvania. In mtny of the other regional programs, the stateine(lictil society istii,activ@paitioi])alit. Ave ivitli,fav(w tiie e rly progress 6f R.NIP, its ability to build on existing patterns of medical care Sometimes addiiiLy iie@v features or cha@ old ones as local demands and resources rqake possible) and the local flexibility which ,tllows the program to make a real con- trib-Lition to @ulie healthcare of our nation. -A-t the same time we recognize that the concept of the regional medi- c,,il program is still in its very early stage of existence and that it is dif- ficu"t to ,tppraise the, program. We do not kii-Ow. for exatni)] e, how ii-i-Licli this program 'idas to the sti-e&,3 on an already.., ovekt-axe@l s@l')Ply of available medical. manpower. There is some concern that tlie@ipro- lifei-@tioii of !F-@deral!health programs subst@a-iitiallAT contributes to the rise in.health care costs. For this,reason, we are pleased that H.R. 15758 provides for an,e-v-.Lltiation of the program. "re'would .81ILxaest, I,.nii-eN@e- that -t,,he evaluation begin, Julv 1. -1968. rather than J-ul-y l' 1970 sineIe ei,,@lu' atioii,@lioiild boom iii't'.'e@g"rl@i the @nning.'INTO also su zL),e--t that the subcommittee consider further ii-ceiicliiaL), section 102 to i@rovide that the evaluation shall be made b ment a noiig ,qgeiiev. ?vern Se 104 clions 103 iiid 106 contain provisions which ive believe to be .salutary. Section 103 ])roviles for the inclusion of the territories under RALIP; section lQ4 mikes coi-nbinatioii of re@ional medical program agencies eligible for planning and ol)eratioiiar zranfs -, an(l.@ec-tion 106 ,adds a iieiv provision under which ariiit.,3 coul-d be n@@d6 to public or ' i)ri'@t institutions for. sWvices i ceded by,. for Iii@li ' ill be noiii)ofit. v c I w of substantial use- to, ,iiiy two or more regional medical pro rains. We 9 recommend the,,tdol@tioii of all three changes.. As to other amendments, we recommend that the subcommittee delete the open-eiid'authoriz,,it;on for funds for the 4 fiscal years end- 'ill dealing after June 30, 1969. In view of the fict that we are st l'IC, il,li-t,li -a relatively untried pro(yrai-n, we believe it ivoilld be wise to limit the "l-itliorization to such silill-, is this subcommittee m,,tv defei-i-nine to be reasonable, rather than t<) provide for "such suii-is is; m@y be necessary for the next 4 fiscil veers. " Further, )vitli the same coicerii, we tirae the subcomniittee to @tend the program for t total of 3 years ratlie-r-tjian the 5-year extension provided in the bill. Both of the @re- vious witnesses have mentioned 16'71 as ,t landmark in the activation of the proQ:ram. rill a,l-l-we note that section 105 provides for ,iii increase in the ]lumber @f, Advisory Council members froi-n 13 to 17. As this change is made I)v the subcomi-nittee, we -would @;iiggest the further Inien(l- 309-653 0-68-8 150 provide that four members of the council shall be practiciig ment;to es that only two be practicing P@Y- physicians. The current law requir sie,,,ans. In view of mediciiie's involvement with pMP, we believe that f four practicing physicians would be helpful havin 'a minimum 0 P program. and to the RM ,clvisory Council, to -they e say -that RW has stimulated Mr. Chairman, in conclusion, let in from the medical profession. Some of @ur distin favorable reaction regiona,@ pr@gram guished medical leaders are p-a@tici ;ating in the county me(iica .soc@ties are cooperating in the rw, @ms hold plann@ ity. On the who el we feel that the progr much-I I would nowask Dr. Brill wit] Mr. Chairman, to co s statement with comments on the remain- inlg of H. 1,5758. Thai you, Dr. Cannon. 154 Mr. RoGms. Mr. Skubitz? Mr. SKU-Birz. Dr. Carter raised a question that I had intended to ask. I am wondering whether we shouldn't limit these authorizations to 1 Year. lVhen we authorize for nts do not li@,.,e to appear before us and j I us what they have done. They are throu ose 1-year authorizations? Dr. CANNON. I think that 1-year commiti-nents could create dif - ficulties. Mr. SKu-Brrz. This doesn't stop the agencies from plannin-a for 4 or 5 vears. It means they are to co-me back and report to us andtell us ivb,ii they are doing. Dr. C@NNON. There may be difficulties in effecting the program, in hiring personnel, and many other things, but we @ouldn't be op- posed to your annual evaluations and appropriations. I mean, that is ,i decision for -your committee. Mr. SKUBrrz. I don't think the committee wants to abandon the pro- gram. But this is the committee that listens to the testimony. n I think it is important for the agencies to come back and tell us what thev have done and justify tge money they need for the next vea,r. Otl;er-wise, the departments are on their own' -We have no control. . Dr. CANN@ON.'We are tremendously pleased and have commended this committee for its perceptivity i@oi-aaniz n into a it@ this a have lat co progr m meaningful piece of legislation. *e stilf nfidence in your judgment. .%fr. SK@ITZ. I notice, for example, in this particular bill there was an authorization for $160 million-in'1967. T@is makes it appear that the program is starting to level off at this time. It doesn't make sense to me. Thank you, Mr. Chairman. Afr. ROGFRS. Thank you very much. Dr. Cannon, I notice you still express some concern that . pro- gram might be used to bring about some change in a revol nary iii,inner i-n health care of the Xmerican people. Is this widely felt in the medical com@uftity? Dr. CANNON. I think that there still exisfs an aura of concern, be- cause some niig]4t interpret the legislation to mean that it can effect tile, standardization of health care. 155 Mr. ROGERS. I thought -we had dispelled that in writing the bill. no made every attempt to in this committee. I recall the concern when the bill came out of the. Senate. It would have put up medical com- I)Iexes where patients could be referred, and so fortli. But we changed the concept of the program in this committee, as you may recall, and, I hope, dispelled this idea. And I would hope the American Medical Association could dispel that viewpoint. Dr. CAN.NO.N. I think the ai-nendments have been very gratifying, but the shock wave initially was rather jzreat. And, as you know, this is soinethino, that -we have had to gradually overcome. Mr. IIA=so,-T. May I comment, .81r. Cliairiyian, that as indicated by Dr. Cannon in his statement, that because, of the amendments made by this committee at flie time it passed on this bill, the fears ,iiid concerti of the , iation were somewhat quieted. And while tlierc@, still remains some concern, 'we have seen much hopeful promise. We have be-en very much appreciative of the work done by this committee in the ado@tion of the- initial program. Mr. RoG@. Thank you. I notice you express concern oli paae 3-yoii don't know yet how return this program may add to the @tr@--,s of tiiilretdy overtaxed stip- ply of available medical minpo,.Ner. it was my concept in the iiial legislation, and from lieariii(y testimoney, that rather than IcIripo-,i burden to manpoiver, t, tclc this would perhaps serve as an easiiig of manpower, because the theory ivis that you could quickly get to the doctor in his own locality the latest treatments, the infon-n,,ition of the latest treatments, anZI so fortli. And teams could be brought in from the uiiiversit-v centers to ivoi-k ii-itli them in a cooperative spirit, where it didiit take the time of the local man to have to go someplace for 2 weels in the sui-nmer to do the continuing education tliqt we carry oii iioNv. ('Communications ivoulcl be improved, ind this was, I tliouolit, ,i hopeful %vav of helping to ease the anpower problem rather than putt burden on it. )?gat is your feelin@ oii that? Dr. CAN-NO-N. I think voiii, point is well taken. The average practic- iiig -physician is somew@at in -t box for time. He, bouiiees around and c,,tn'i ;eall- v break away from an educational experience. However, many men, as you know-I would say most of tlieii-i- ,ire dedicat@ to continuing self-eclucation. What I had reference io here was the number of personnel, the demands on an already scarce commodity has been iiiereise(l, and the utilization of those people -who are trai@d in medical care to idiniii- ister i)ro--rams, to p-arcicitape in them, to teach, to set up units. We don't'lia@e any specific figures, but we ire coiieerIiied. '.LNIr. ROG--Rs. I airl interested in having infori-n,,ition iloiiol this line, because I would see it operatiiio, just the opposite, iiid I would lioi)e it i,.-oiild. zn I Dr. CAN.NO.N. May I ask Dr. Rtilie, who is director of our Division on Medical Education, to comment? Mr. ROGERS. Yes. Dr. RunE. I believe what you said will ultimately be the else. In the plinnin;z and early operational stages, however, it has been iieces- s.iri for -,ill of the regions to accumulate rather large staffs of pi-ofes- sio)i,il people to administer the program iiid to direct it. 156 As I recall, and I am not certain this is the exact number, but I recall one of the large@ regiops estimated that it would need approxi- matelv 90 professional people. Mr. ROGEM. All doctors! Dr. RUHF,. Not necessarily M.D.'s, but persons at that comparable deLyree level, in order to carry on the administrative work and the di@ection of ,the program. Thus, one of the immediate effects has been a rather considerable increase in the competition for-that isn't per- haps the rigl@t word-but in the available opportunities for employ- ment (3f professional people at the administrative level. We have noticed this @lready. I think it has been noticed in the medical schools which have been actively involved in the regional activities. It has been n arv for them to add additional faculty and administrative personnel ill order to discharge their responsibili- ties under the program. These people have to come from somewhere. They were not in great su@plibefore. A number of them have col-ne out of practice, and while we feel ultimately this may result in more efficienC utiliz,,t- tion of health care services, we think there is an immediate effect here in providing some competition for manpower in the health field. This is, I think, the basis for this statement. Mr. ROGERS. Well, now, I wondered Nvas this: For instance, I envisioned the fact that you would carry On a continuing education program, perhaps t-l-irough television, where you have an expert in t medical center L)-lvinir instruction to your local hospitals in ,t certain treatment that ma ve just come out; so that you don't have to send y or have each doctor come in and tike instructors out to eac hospital, that time to con-le to the medical center. But the communication is one of the means that you are going to cut do,%vii On the useof iiiiii- power, I would hope. Is this envisioned? Dr. R-ui-iE. Yes; it is. Mr. ROGERS. So there are so many things where I think you ivould be savinZ the time of the local doctor; so you don't have to have fi@-e doctors @ihere one doctor may do the work of two doctom-for in- st,ii-i,ce, where hie performs his exam and wants a reading On an X-ray, and 1-to @ something that is "-ronz, but he can get it -in the medical center where it comes back immediately with a c@nunic,,ttioii on the diagnosis. I'4n't that going to save him time and enable him to see more patients? Dr. RUHE. I think in time it will. Mr. ROGEM. Right, and this is what we are concerned with, getting the licralt,h -to the peo,@le, ,tnd this is the reason this program was eii- visioiied,,ind ado fed, I think. Nfr @ . C,.XRTER. Ay r. Cli,,tinyian, will the gentleman yield? 'iNf r. ROGERS. Yes. Mr. CARTER. I want to say something in behalf of the zeiieral 1)ric- titioiiei- in this case, if you pla-@. I (Toll't think -%ve -Ii(Yuld self him too short. Ile is a man who is known by the fruits of his labor. If Ile doesn't produce, certainly his practice is going to fall off, and lie does take pa-rt in schools. ITe goes as a member @f the -kc,,ideiny of Gen- era] ractice. IT,- is required i-ecqilarly to go to school. 157 Our universities. too, in cooperation with the medical association I visiting Physicians who come to our hospitals (lo provide aid and i throu out rural America to teach us, and we are glad for -this. itioner in most c-,is@ if he is efficient and effective, Tli( 2 he hg annels of communication with universities, and surge ticians who can be of help to him. IN7fost of our community hospitals, I would say, have % qualified radiologist who read their films from time to time. So we have mozzt of these pro, dy been developed bv @ams already. They have alrea private initiative, forced by the n ity of doing the best type of work. And I should sav that most general practitioners do these tbincs. This prog@m, a; I see it is to complement the program wliich@i-; already P-xistinol,. Mr. ROGERS. I am not trying to run down the general practitioner. I think he has done a grand job. IVe want to hef@ him to do a better job for the American J)eople. I agree with you. f think be has done a great job. We want to help it' this program. This is t llv. him do a better job w ii program, @ea for the doctors, so I ivould understand whv the American i%ledical I -early bll-; Association would support it. It is i @l'@ly for the doctor@ tobehelpfultotlielii;,,,@@ii,inggoodtre,itiiie-.-.1. Dr. C'ANNo,@. Mr. ('Iia-irmtn, niav I comiyieiit on your statement? ROGER-,. Ye-- Dr. CA.NNON. T.i!s is, in essence, wl-iy we believe in the expan;-zioii of the Advisoiy C,)uii'cil. AVe believe- it is -,vise ',,@ ,-ke tivo new i-nembei-:-t from . @--, practicing I)rofession. Mr. I'%oGFRs. I think it is a good suggestion .'..Ik we -l.0'@ d have practicing people, and I don't think we ire iig enough hospital I)eople in there, either, Dr. C,,tnnoii. I think t c are getting too many v' c@,Licators. This is natural at first .ind we need them. But we have overlooked in this to date, I think, bringing in a more active participation by p@,i@',ici@g physicians and bv hospital administrators, and some of the people wiio are actually invilved -with providing some of these services and where the critical units should be. We n@d a more practical approach in tjie implementation of what is a good program in theory, and I think your suggestion is -aocd I might state that I think the only grou that requires cor;t-inuing education is your gr!)up of. general does it not2 Your specialties don't require continuing e aps they will. This will be good. Dr. @ANNON. By our negative reward system, they require it. Mr. ROGERS. I am sure all the doctors try to keep up as best tbev can,It is not easy. I can assure -vou this conunittee is not going to go for op6h-ended funding. We have made it a practic@ as bas:been expresied by mv colle'l@es here. We will set a certain sum to be authorized, and oi;r norm@l procedure has been a 3-year program. 159 -If r. RoG@s. e from Illinois, who may know We have a distinguished colleagii er is here, our dis- ,,tl@iit the Chicago problem. Congr@, man Spring he may have soll'IE', tiiigiiislied minority leader on tl'P- committee, and question-,. -NAr. Chairman. .Air. SPIIINGER. Just one or two, eture at the time we were you an-v 1)art of the A,NLK stn' Doctor, , -cancer bill'@ passed the heart, stroke, rni, I certainly was. Dr. CANNON- If "Structure,, is an all-inclusive te of the But I was not one of the spokesmen at that time. I am aware statements that were made. accept the testimony of anyone who -Nir. SPRI--\-GER. Well, never will I comes before this committee as an expert on ,t program until I am more than satisfied. The 'entlenian from Florida and I kept this thing, within what we 9 tlioll-aht were r@, soiiable boundaries -at that time. It came over here from the Senate with one and a half days of hearing at $970 millions almost a billion dollars to start a, rogram, and I have never seen such an arrav lined up for that bill, anS I ,-tlmost swallowed it, until I -%,vp-llt Yd home an lt about it. Then I just began to make some investig,,t- to fi tllou;@ tiolis nd out h And said about the distin- guishe,( during that time, that we wer t out .it $320 9 body that they would pass our bill. if correct, -we are almost at the end of 3 ve-,irs, and out of w' a piddly little $320 million, they have been able to spent date. to this for one reason only,,,iii(I that is that you are I g N 1101$'V .5 million for tile fiscal year 1969, qiid nothing has been ',\fr. Chairman, with reference to any possible re- iiiaininLr 2 years. -\fr. YROGFRS. It has been said, ,ind they are submitting the fiL-, Iii-es. -Afr.SPRI-,GFR. 1,i-figla.(Itoseetliat. I come back agi ii to my colleagIle in saying that. at the time you were speakiiiLy on t iis before, your people doubted that this program could be und@rtake i. They went on-aiid pointed out why, in terms of pei-soiiiiel,,tv,,til,,tble and so on. I ,iii-i -ala(l that what you said and wl@-it I said and i\ir. Rogers said, \v others o his come n tl@is conin liq-, come true. Only it .Vt,tee even more true than we anticilpatei. This is about the only time we li,qv-e overexalii,,tted 11 pro--ram. ,ii-n ti@,,it'I supported energetically, once I thought This was ,t progr, it was within some reasonable means. But, I nierel point this out, that Yf@re us with figures I am extremely skeptical of anyone who comes be unless they can bejustified. 'deredtol)etbebesttestillioll intlie, This was, may I sav, what I consi ,it ter ro country. But you oti(ylit to ao back and see tli, @-tillioliv, f m Dr. it before this coi-niiiitt@, to justify Dc,Ba.@v'on down. " was presented ,,t program for ,t billion dollars, which turned out 3 years later to ]rate spent $85 million. 160 I just want to put, that on the record, because I think it ought to be brought out herp,-tliat what we get in the way of landslide te-stimody here'is a selling job and snow job el-,timing that something Ctn be done immediately. Mr. SIKUBITZ. Air. Chairman, will my colleague yield? Air. SPRINGER. Yes. Mr. SKUBITZ. Was $S20 million authorized and $320 million appro- pri,,tted? Mr. SPRINGER. Fifty-nine and 200. Mr. SKu-BiTz. But how much money was appropriated? Mr. SPRINGER. $85,200,000. Mr. SKUBITZ. That is all they spent. How could they spend any more if more wasn't authorized? Air. SPRINGER. The fact is they didn't spend all that was ,tppro- pri,tt,e,d. They appropriated more than $85 millions Thank you, Ali. Chairman. Mr. ROGERS'. Thank you. I do think it might be brought out at this point that I would com- mend the administration of the program in the fact that they haven't just gone out ,ind spent money. So I think this is rather com- ii,iondable, that they have held up some 8 million on last year because they felt they were not at a stage to spend it. So this is-cornmendable, ana I would want to put that on the record, too, that we don't want them, just because -,ve in - authorize something ay on it in, tnd spend it ,t-v be appropriated, that expect them to go out , unless they are at that point -%vliere it could be done effectively. So I thik whether we reach goals that we may have set is not neces- stiriiv the determination oil the spending of tl@e money. We want to make sure that it is appropriately spent a--id even though the goals may have been set above that. go I think the administration of it has not been in error in that regard. @r. RUHE. May I comment. on that? I think- we would support this fact. We have been reassured tiid Encouraged by the way this program has been administered. I think in defense of the program, one thing call be said, that in the early stages, very careful attention has been given to the planning and the preparation for the operational stage of the program. This has been one of the things whijli has kept thwexpenditures doivii at the present time. But as the program gets mov, ing into the operational plia@, I think it is reasonal;le to expect that the costs wou-Id increase greatly. IVe feel that the program has been administered very -well, and with restraint and good judgment. Air. RoGERs. Thank you. Mr. SKUBITZ. That- brings me back to the question I raised a few iTioineiits ago, the necessity of limiting these authorizations and havin 9 the igenci es come back ai@d present tiieir case and prove their point. If we al-itliorize for 3 years, they don't have t6 come back. From that moment oil they go before the Appropriations Committee Mr. RoG@s. -T@is is right. Dr. RUHF,. There is one problem in that, if I M@LY. 'Biat is, from tile standpoint of the region which is attempting to recruit personnel, if 161 there is gnv quest' n wl-lether th iiig to be continued 10 e program is zo for the in(fefiiiite fubu@ it would ibe extremel@ difficult to get good people to change their careers and come into this program. Mr. SKUBITZ. Doctor, you sound like a Government bureaucrat. We hear the same slttenieiit time a-lid again we must have a, 3- or 4-yetr program, or we can't get the peoples But for some r n,the Gov- erniiielit has no trouble Iiirin g Air. RoGEm. It may @ tli d@optloer is looking @t what happened to the C<)iizress on only a, 2-year contract, and he is disappointed. [La@lit,er.] Mr. HARRiso@N. I would like to comment on Mr. Skubitz' question, 1 The a@iation would generally siippoq, i@ it was the committee's good judgment, ,tn authorization for a single year which would re- quire the program people to come back and ive the comi-nittee an o@rt-untiy to examine the program ,tgaui. iftliat wis your judge- iiaeiit, and we would support that movement. Mr. SKUBrrz. You -had better stay with the chairman. I am the low man on the totem pole. [Laughter.] Af r. RoGPRs. As ,t matter of fact, Mr. Skubitz, you might be inter- e@ to know that we did a special'study on HEW and recoi-nmeiided ye,,triv authorizations. Ikl@ SKuBrrz. I am glad to hear that. .Af r. ROGERS. We haven't @ii uble to move it ill C4Dnlnlit@ Yet. Thank you very much. Your testimony has been most helpful. Dr. CA.NNON. Thank vou, Mr. Chairman. 'tness is Dr. William Likoff, immediate put Mr. R@ERS. Our next wi president,, American Colleze of Cardiolozv. from @tliesda,, Md. We are very pleased to line you with us) f)@:Likoff. STATEMENT OF WILLIAM LIKOFF, M.D., IMMEDIATE PAST PRESI- DENT, AMERICAN COLLEGE OF CARDIOLOGY; ACCOMPANIED BY WILLIAM D. NELLIGAN, EXECUTIVE DIRECTOR Dr. LiyoFF. I am pleased to iiitr<)duee William Nellicmn, executive director of the colleae. I appreciate the-privilege of ap ariiig before this committee to present the views of the Aiiiericaii@ollege of Cardiology regarding bill H.R. 15758. The L,-o,,tls and Iiilosopliy of Public Law 89-239, the progress record edical program duri ig its short life and the future in this-eiideavor ,ir( pertinent to your cur- rent c and, therefore, p@ompt,t ils testimony. Medical science in this country is tavorect )y superb talent, coiii- ce and abundant resources. This committee, however, is par- e- te'l7 ticular y tivare that the distribution of these assets, specifically in terms ol patient care, is shamefully uneven. The basic goal of Public Law 89-@39, the authority for the regional medical program, is to bridLye this unequal gap between science and service and to provide an efriel@lit health care s@steiii which will assure the transmission of the best ill scientific knowledge to all people of this country suffering from heart disease, cai-icer, @iid stroke, or struggling to avoid these catastropliies. 162 Tile concept regulating the regional medical program is reiiial@k- abl -y simple @nd in the best tradition of this country's genius for e:ffec- tive acti-oi). It holds that modern medical advances can t)e made available to all -people when needs ,tre identified ,it a regional level by individuals i-nv(;Ived in regional affaiIrs ,ind when available re- sources and manpower are properly exploited through cooperative arrangeniel-its liliL-iiia discovery with learniii,@ and application. Critical analvsis of the activities of the rediolial medical program uncovers an iiii@isual record of accomplishment toward thvt goal over a relatively short period of time. Feaeral funds have stimulated the planning for a health care system in approximately 50 regions encoiii- passinly about 90 percent of this country@s population. Operational pro-ar@ins have been activated in 1 1 additional reziolls. Solicitations for planning and operational a@ants for areas not yet involved are beiii4z constantly prepared and re-viewed. The speed with -%vliicli Public L,,t@, 89-239 li@s exercised its impact and the -wide area of its maturiii(y influence is most impressive ,tliiiost denying the complexities of zn establishing i new administering organization ,tiid staff within the Public Heal@li Service and the difficulties in assembliii<), for planning and tction representatives of diverse scientific and coli- sumer L-roups in a mvriad of local communities. The Tirst clynaniic'eiigztgei-neiits with the problem-, of organization, defi'lil'g regional needs in health care ,tnd interrelating local resources for their correction have revealed ,t nuii-lber of specific facts. Those who ]rate worked in the field deN-elopii,9 a program for a specific region, ,]]most -%vitliolit exception sense that institutions and men representing medical, pai@aniedical, and consumer interests welcome the challenge and opl@(;rtiiiiity to serve. They are tpplyiiig themselves unstintingly to the search for sound idiiiiiiistritive structures and for effectiie voluntary cooperative arraiiaeiiieiits which will assure the success of the program. They share @ positive view about the likelihood of obliterating the i-oid now separating the conversion of knowledge to service. They ,tpl)reciate locaf needs and they are creative in their @]aDS to meet tliei-n. From early experience it ilso appears that the fuiidin(, provisions of tlie,,ict,,ire ai:leqtiate and that tlievublic Health Service is awarding these funds judiciously ,iiid in keeping with the needs and sophistication of the a - lications front the petitioniiio- regions. pp zn However, and in contrast to some of the statements made to this point, the community is extremely sensitive to the limitations imposed 1) the fact that the program has not been establi--Iied oii a coiitiiiuin<-, y n basis. The paradox of contestiii Nvith long-term needs and long-range ob .etives under the ui-nbrella of a short-term act is uncomprehensible. .1 e it ill-ip,,tirs the liarnessijily- of niqiipower; it constricts programs to the c,, a ]mine te; dedication is diminished; promise is aborted; potential threatened. In t frank ackiiowledgemoiii of clear fact, Public L,,t-%v 89- 239 has evolved the ty, Pe of robust response tlitt deserves the assurance of coiitiniiiiic, support and inclusion of logical ireas of involvement not heretofore eml)rae-ed. At least a portion of these are reco(,rnized in H.R. 1,5758. Certainly the provisions to involve areas outside of the 50 States is consistent with our traditional obligatibi-is: those improviiiz iml)le- cr ineiitatioii through interregional cooperative, those seekin, involve- iiielit of Federal hospitals ,ind providing for construction funds Ire 163 The American College of Cardiology e@ithusiastieally endorses the of the regional medical program because d need and seek to use forces which require on. 11're support the planning ,tnd opera- grain where we possess manpower and resources. The college is certain the program will elevate the health of the Nation. It pYe,,tds for a favorable action oli bill H.R. 15758. This amend- ment to tlie Public Health Service Act extends and expands the medical regional proo-ram to a new and amplified potential and hope- fully to the status @f the most distinguished medical program con- ceived in our time. I am o_ratef ul for the opportunity of expressiiia these vieivs Mr. @ERs. Thank you very 'Much, Doctor- We appreciate your testimony. Did your associate have any statement?. Air. NELLIGAN. No, sir. Air. PwGERs. Doctor Carter. Air. CAP.TER. No questions. Air. RoGERs. Mr. @kubitz? Mr. SKuBiTz. No questions. Mr. ROGERS. I mi@lit sav that the committee, in adopting ,t 3-ye,,ir program rather th,,i@PL 5- or 10-year progr@in, feels that this is one way for this committee to carry out its responsibilities to the Congress an(] the American people, because otherwise we have no review of the proo,rai-n. Dr. LIKOFF. I understand thtt philosophy, Mr. Chairman, but I do wish to tell the committee, and particularly Air. Sktibitz, that we in the field have found it difficult to construct loiio,-raiize. vital orcya- iiiz,,ttiojial programs and planning in view of the uii@el4aintv fi@Oill time to time of the funding required to support these ventures. Something we plan for a, decade ahead cannot be accoml.)Iislied oii 2-y,,r ,ppro ri,,ttions. How you get Government workers under these conditions, I @on't know. We are ]@aving difficulty. Air. @FRs. I am siLire it would be desirable to set prograii-is for as much time as we ivanted with as much money as was ivaiited, but we have to equate the economy of the Nation. But this is the coii-iiiiittee's f auction, and that is what we will do. We are grateful for your testimony in support of this legislation. Itwillbe@elpfultousiiioiircoiisidera7tion. - tn Our next witness is Dr. Clark- Millikan, of the'@Nfavo Clinic, who will appear and give testimony for the Ai-nericaii Heart Association, Inc. Dr. Millik@an, we are delighted to litve you here. tiid will be pleased to have vourtestimony. if yo@ would like to put your statement in the record and just stiin up for us, it would be acceptable, or if you prefer, reid it. STATEMENT OF DR. CLARK MILLIKAN, CHAIRMAN ., COUNCIL ON CEREBROVASCULAR DISEASE, AMERICAN HEART ASSOCIATION Dr. M@IKAN. Air. Rogers and members of the subcommittee, it is not only an lionor, but a responsibility, to talze part in the coiist,i,lic- 164 tion of the continuing legislation. I would prefer, actually, to just make some comments. '.L%lr. RoGms. That will be done. Without objection, Dr. Millikaii's statement will be placed as part of the record lollowinLy his remarks. Dr. LNfILLIKA--,. I i-epr@nt the American Heart Association, beiii(y chairman of t-lie @soci,,ttioii's council on cerebrov-,iscular disease. Z, This proo,,rim his turned out to be 'It unique opportunity and t practical recognizable entitv for cooperative and collaborative ar- ranzeme,nts, not. only ,between the university centers and practicing ph@-,ici,,tns but, between government and noiigovei-nment agencies and personnel. The Heart Association, for instance, has taken an extraordinarily active part all over the N,,Ltion, not only at the level of rezioiial ,idi-i- sor'y conuiiitte(-s but in smaller community aIT-,iir-s. L,@@weelc there was ,t meet ina in @-eNv York .,it which over 400 volunteers were present, and one of the irrived at at. that meetiiiz was to eii- firm decisions , coura@e further the participation of Heiit -A-ssoci,,Lti@@i personnel, wliie,l@caii briiio- ,t c-,-reat deal to the implementation and the purposes of the past bill and @fie new bill. This exemplifies the kind of feeliiig.aiid tl)e loyalty, for instance, that is being generated by the very wise provisions of this act, and we heartily endorse the continuation of fliesp, basic principles, ill- cluding tli@ haziness of oi-iginatina ideis it the local level ,tiid liaA-ill(y ,idmini-st,ritioii remain -.it the local Yevel. t, Commentino, about the matter of the finances, $65 million is a su(y- estioii for fiscal 1969 tiid as is broti(,rlit out, there is to be some 9 holdover. You @ire a.Nvare that there are now actually about 1 1 operttioiial pro- gr,,ims, ',Llld within the next few months there will be a total of 30 to 35 operational programs. It is extraordinarily important to consider tli,,t,Cwe are thinking in terms of a gripli of continuity here. And as this program develops effectively, gaining momentum, it is mandatory that we not put a fence in front of it -,It ',Illy point in time with the attendant loss, in possible instances, of personnel. oram relates to people, whet-her at tl-ie administra- This whole -pro- tive end or the pr@ticing -physicifcii end, or at the patient end. And if we do something Nvhich caits-baek the momentum in the year 1968 to 1969, we have lost more than 1 year of progress, and so I would emplimize the need for the continuity of fiscal support for this whole business. Now, on the matter of construction money, that has come up in reference to the new bil . It would seem hi(,rlily important that there be authorization for this. As Dr. DeBakey mention@ ,tnd Dr. Farber added, there ,tre areas of ,tctivity for which new construction funds will undoubtedly be n@ss,,iry -,it the level of 2, 3, or 4 years from now, -,vhich should be evaluated at that point in time. It does not need to be done now in terms of @'gning ,in amount of money. But it should be lool@ed at precisely later on. But the cardiac iiitelisive care unit, or ,t stroke unit, or ,t matrix which requires space--t-bat is not the issue -it the moment. But for adequate planning in the future there sl-iould be the authorization 165 for the tential of including new construction somewhere ill the course optoiMe. Now, a comment in the area of stroke, because this is the area of my particular interest. The American Heart Association has been much interested in stroke and has formed a council on cerebrovascular disease and has been active in promoting teaching and spreading the word in communities. I believe that RAIP offers us all opportunity to produce It greater matrix where we are really going to -(fo sometfiing ,-tbout stroke. You.are aware of the need for treatment in terms of aciite facilities for rehabilitation, reentry of the atieiit into the community, but we are pow beginning to accumulate Nat,,t which, if we can get the iiifor- matlon to the population and to tl-ie physici,,tiis,,%Vill significantly afTect stroke prevention. And this is the kin(f of thing that IRMP is desi(rned to do, among other tliinas. One of the most interesting items that is coming on the aaeiida now is the word "hypertension," or hic-,h blood pressure, and we now have definite epidemiological evidence@ihrougli @rogram's which lian-e been supported and orikiiiated by you people that livperteiisioli is as ii-n- p?rtant in stroke as it is in heart disease, certafi@eitegories of heart disease in particular, and that via the detection and treatment of ilypel@nsion, we may cut significantly down oil the incidence of stroke. TI-ie, Heart Associ@tion is designing pr@gralns to interrelate to R.NIP and provide screening and detection mechanisms to find these people. Some 20 percent of Rypertensives are not even detected at this point in time. In relationship to the very important subject of hypertension, the al medical programs offer an excellent matrix for the evaluation programs for screening, detection, and are constructed, funds should be ,ti,ail- arative trials of drug a@@ts; including ose which will come out of developmental These are simply summaries of some of the comments that are in the formal record. I don't want to belabor these issues, but to i-ne, we ,ire dealinL, with the national resource, the hetlth of our people, and we could@tbedise,ussinLy'amoreim ortantsubject. p I congratulate ancY commend you on all of the things that you have done, aid in this particular frame of reference your wisdom in guiding 1 R.NIP has been unique. (Dr. Millikan's prepared statement follows:) @STATFNIE.NT oF DR. CLARK '@%IILLIKAN, CIIAIRMA-Q, C<)U-,%CIL Oiq CEREBROVASCULAR Dis@sE, AMERICA@-Z HEART ASSGCIATION I am Dr. Clark'.Nfillikan, Chairman of the American Heart Association's Coun- cil on Cerebrovascular Disease. Representing the Association I welcome the op- portunity of testifying in support of H.R. 15758, the five-year extension of the Regional Medical Program (P. L. 89-239). As one of the organizations instru- mental in promoting the original Regional Medical Program in 1965, we are pleased with the significant contribution it has made to the application of new medical knowledge to the diagnosis and treatment of heart disease and stroke. We are particularly Pleased that the Regional Medical Program has provided, as intended, an effective vehicle for governmental and non-governmental co- operation in combatting the three diseases taking the greatest toll of life in 166 American society. Alaximum responsibility has been on local leadership and regional cooperative arrangements. Heart Associations across the country have been active on almost all Regional Advisory Committees planning programs, gathering data on health iualal)ower requirements and analyzing available health facilities and services. We expect continued participation during the five years of the proposed renewal as the ein- I)hasis of the program shifts from the planning to the operational phase. Last week in New York City 400 American I-Ieart Association volunteers and st,,iff from across the nation planned ways in which we can improve our Pro- grain. One entire discussion group was devoted to the interrelationship of the Regional medical Program and the American Heart Association.,We discussed the ways in ivhich the relationships between Heart Associations n the various states and the governmental agencies in their areas could be reinforced. It was decided at this national meeting that part of our future program would be to encourage our membership to take every available advantage of Regional Medical Programs, so that Heart Associations would be playing their maximum role to the maximum beneflt of their communities. The original law provided over a three-ye,,ir period increasing grants of from .@,000,000 to $200,000.000 for the fiscal year ending June, 1963. We note that H. R. 1575S specifies $65,000,000 for fiscal 1969 and "such slims as may be iieces- s,iry for the next four fiscal years."We are aware that nearly $35,000,000 of unobligated funds are available in addition to the $65,000,000 provided in this bill for the next fiscal year. However, we would prefer that specific funding for fiscal years 1970 through 1973 had been included in this bill to assure the inaxi- mtilu growth of this successful program. if the $65,000,000 for fiscal 1969 is appropriated and authorized, -,ve under- stand 30 of the 54 Regional ',Nledical Programs will be receiving their initial operational -rants and 14 will be in their second or third year of operational grant activity. It is to be expected that in the following four years operational requirements will increase; yet the legislation under consideration here today leaves the program to the unknown quantity of annual Congressional appropria- tions after fiscal 1969. We have some reservations as to the wisdom of this ap- proach since long-range planning is essential to the success of this program. One final word is to fund.,;, Nve ,,tre,.4s the minimal necessity of the full $65,000,000 requested in H. R. 15758 for 1969. Among the promising developments in the Regional Medical Program of par- ticular interest to us has been the recent emphasis on extending -the development of coronary care units and the necessary trained personnel to hospitals not Dow having these lif"aving facilities. It is our understanding that the Regional '.\Iedi- cal Program has many applications for funds for this pu@qe. We thoroughly applaud the establishment of these life-,@ving facilities in every hospital cRi-ing for coronary artery problems and hope that in the future even more f Litids will be available for coronary care units. As the Chairman of the American Heart Association's Council on Cerebro- vascular Disease, I can speak with particular knowledge of the contructive pur- Po.-,es the Regional Medical Program has -and will continue to serve in mobilizing professional attention and funds for community-wicle stroke detection programs and treatment. Teaching units in many medical schools have sllied away from involvement with the stroke patient. As part of the planning and operational grants of the Regional '.Nfedical Program, nenv interest in this problem has been stimulated in a constructive way. This promising development must be eii- couraged in the next five years of the Regional Medical Program and adequate funds supplied for this purpose. Section 103 of the bill extends the Regional Medical Program to area.,, outside the United States which should be the beneficiary of this program. We -endorse tlip inclusion of Puerto Rico, the Virgin Islands, Guam, American Samoa and the Trust Territories of the Pacific Islands. Value to citizens of the states -,vith,ii the ITnited Rtates should not be hoarded but shared with areas not part of, but historically connected to the United States, Additionally, the American Heart Association endorse.,; the use of grants for tivo or more Regional Medical Programs, as proposed in Section 910. This provision will permit the economical development of teaching films, videotapes and other educational materials for use by several regions on a national basis. This Pro- vision also permits the kind of flexibility the American Heart Association has always envisioned for this program. 167 The inclusion of referals to Regional Medical Program facilities by practic- ing dentists propose d in @tion 107 is of particular importance. Dentists ciii play an important role in preventing the recurrence of rheumatic feN,er and bacterial endocarditis if aware of this opportunity. Their inclusion along with physicians in this program is therefore of significance to the alleviation of some forms of cardiovascular disease. In relationship to the very important subject of hypertension, the Regional )fedical Programs offer an excellent matrix for the evaluation of anti-hyperteii- sive drugs, As programs for screening, detection and diagnosis of high b,oo(I pressure are constructed, funds should be available for evaluation and com- parative trials of drug agents; including drugs already known and those Ni,hiell will come out of developmental laboratories. Finaliy, the American Heart Association endorses the ineluqioii of federal hospitals (Section 107) in the total operation of the Regional Medical Program. The broadest possible range of community medical facilities enlarges the scope of health services to the public contemplated in the original purpose of the program. Despite one r@rv-ation expressed at the beginning of this testimony, the Anieri- can Heart Association strongly recommends the enactment of H.R. 157@' . Mr. ROGERS. Thank you very much, Dr. Alillikan. We appreciate your testimony, and I would a re,-, -,vith you that stroke is all aret g (I wherowenp-edtodo-areatwork,an muchneedstobedonetoiilll)17ove the health of the -p@ple in this ,irea. I think it has been overlooked es ,tgreatdealfromthet timoliylh,.tveheard. Dr. Carter? Mr. CAR@. N questions. i 0 Mr. ROGERS. Mr. Skubitz? Mr. SKUBITZ. Doctor, the point I am trying to get across is, I have no objection to a. contiiiuin 'y pro -ram. But I -,vaiif-the ,tgeiie-y to come forth each year, 'Ustif-Y -,Aat they have done and prove ]low much additional money is needed. Ma-vbe $65 million is sufficient for 1969, but who is to say how Diuch we need in 1970 or 1971 without the Department coming before us and reviewing thle rogram. Afa [be we need $200 million next year, in 1970. And-inaylithe year following we may need $.300 million iii- stead of $100 million. I don't know. What I want is for the Department to come in and justify its request from year to Year. If it can't justify them, then I see no need of car ing the progrdmforw,,trd. Dr. AFILLIKAN - fay aska question? Are you addressing yourself r.@thori@zatioiis Or the amount? to just filinz the a Mr. SK@iTz. The amount. Dr. lkfILLIKA.N. I believe these ,ire different things, in. essence. It seems to me that the rd is now beinz written on the iustific@ition of th' d that we are seeing significant changes in the interi etween the laboratory and teachers. on one hand, and t physician community, on the othe@ hand, which are g( to the benefit of patic@@ all over the Natioii. Afr on't think there is much doubt about that. I am sold on the program. Dr. MILLIKAN. It seems to me that if the question is ]low much money is to be allocated per year, that is re,,tlly in the province of the com- mitt,ee, as you deliberate how you establish mechanisms to find out about this. My point is, tliou Mr. SKUBITZ. . ab, that if we authorize $200 million for 1970 and $300-million for 19@l,'the Department does -not have to 168 collie before this collillitt.ee ','nYi-nore. It goes to the Appropriations Committee. -,OGERS. '.Mr. 1,C@,ros? Mr.r ',\Iillikaii I found your testimOnv rnost.interesting, ,Mr. KI-Ros. Dr. I Iticul@rly what YOU sty not on]N in suPPOt of the progr,,tm,@b@t pa.ut OM, to Ls ConLrress III a ,,bout i oiiey. Aiid,.,,tg in, as a man who I" the last year or so, it surprises me to see doctors come before tIVis corn- i-nit,tee a-i (I ,isk for this money tncl for the continuation of progy@Ts. I usedlto think that doctors in the American Medical Association took a diff erent view. I ,tin in full agreement with your position as it is expressed here. Dr. ',NIILLIKAN-. Thank yol-i. ,,,\fr. Roc.ERs. Thanl,- You very much. it is my understanding that one of our witnesses his a 3 o'clock plane to catch back to California, ,ind if the committee would bear -,vith us, if eve could hear his testimony now, it -,vould be helpful. Dr. Lester Breslow, professor of health tdministration @nd chief of the division of health services, School of Public Health, University of California, Los Angeles. Dr. BresIoNv. we appreciate your helping the committee, and we -,vill be pleased to receive your testimony. If you would like to file your statement for the record ,vnd make appropriate comments, we %Vould be pleased to follow that procedure. STATEMENT OF DIL. LESTER BRESLOW, I?RESIDENT-ELECT, AMERICAN PUBLIC HEALTH ASSOCIATION Dr. BR@Low. Th,,tnl,- you. I am appearing before you as @i..-,esident- ublic Health Associat d lil-. ni elect of the American P ion. I woul ,ike some remarks based on the written statement which has been s:. iit,ted for the record. I\fr. ROGERS. Your statement will be made a part of the record f(,,!. lowillg_your remarks. raaiiization and -Utilization of t lie Dr. BRFSLOW. The effective o sources that \ve now have, and the unique contribution of the ori. cooperative arranaemei-its, are made i);ssible by this program. The unique contributions are to extend the excellence of the medical centers out. into the communities, and to ,tceelerate the progress that is been la(le. I tlgnnk it is unfortunate that the American people still do not realize the advances that are being made against heart disease, cancer. ,,and stroke, and the point of this program is to ,tccelerate progr When we speal&- about regional cooperative arrangements. it is im- port,,iiit to note that these are developing as a two-way street. The extension of expertise is not onlv from-the medical centers out into the community but also from the @oint of view of the practicing doctor, from the community hospitals, back to the medical centers. They then be ate the real problems physicians are tip against in the do Cal problems. arrangement and a two-way street, with Ini to say. a ew words about the progress that is being in ia. From the outset, the California program has 169 sought to effect cooperation between the hospital associations, the -the medical schools, and tfie State health depart- medical ,is,-,ociations, There has been est,,tb- itieiit, Cancer Socie@y@ and Heart Association. ications, low, tluough area colmnit- I ished ,t net-%vork of Lyood c4oinmull tees around every m@dical school and extending into every area of the State. Consequentlv, effective Nvorking bodies around many of the community liospita7is' and practic@illy in allDf the counties in ihe State ,tile tied in -,vith medical centers. A couple of advances ,vre being made. IVe are going t? submit, on @pril 1 @nd 2, for consideration bv our national site review, 14 pro- -)Os,,Ils for operating grajits in (!,,tliforiii,,t. Among these %vill be 't e-stablisli cor0l",Irv cire unit service in the coastal areas 11 1; oposal to ,t stretell of sev@rctl ,hundred miles of small communities. 0 California, If this progrii@ is approved these units will work with the University --Francisco in order to exteid this -,vhole program medical c@,iter in San I out to the periphery of the State. III the soiitbeni of the State there is a prol.)osal that would re. bring together the n-i@ical faculties of tnvo of our uiiversities the This proposed program,,ilso -%vould briiia the medicil faculties of these schools in contact with the practicing pgysiciins in the Watts-Willo'%v- brook area, in the center of Los Angeles-a ScP-iie of past violence and serious problems. The medical faculties of these -@licols ,vould work the countv ,Ind hospital adininistrator@- of the region who wou@(I then devel am ivith uate medical education progr op t post-grad coiickiitr,,itioii on l@eart disease, cancer, and stroke. I i-neiitioii these two projects merely to emphasize to the committee that. this progrctin is going to bring better care to persons not only in the medical ml-iters but ,vlso into those p,-trts of the State which litve been relatively neglected in tl-ie past, such as the alietto areas in the cities ,iiid the rural are,,is over the great stretches like in California. Thaiilz yoti,.Nlr. Chairman. (Dr. Breslow's prepared statement follows:) @STATENIF.NT OF DR. LESTER BRESLOW, PROFESSOR OF HEALTH qF-RvicEs AD@fI-,IS- TRATIO@N, SCHOOL OF PUBLIC HEALTH, U-.NIN@ERSITY OF CALLFOR-N;IA AT Los A-.\GELFS .)Ir. Chainuan and members of the Coiiiiiiit@, I aiii Les-,er Breslow, Professor of Health Servic@ Adininistratioii in the School of Piil)lic I-Iealth at I-'CLA. I have previously been the State Health Officer for the State of Ciliforiiia. I have coiiie today to sl*ak in support of H.R. 15758 and particularly that @ti'cii of the bill which would extend the authority for the R@, oizil l@i(lal Prograiii,,. In -uiy professional career I have long been concerned NN-itli the need for t iifore effective organization of our vast health endeavor, find I view the Regional i)ledic,-tl Programs as having great potential for iii@aking a very important con- tribution to this objective. In recent years this Coliiiiiittee has heard a great deal of discussion about the current difficulties of our healthcare systems For this -,\ation. These problems are not always the lack of health resources but rather the effective organization and utilization of the inany @.@-tirces with which we are 'blessed, including our resources of talent and knowledge ,is -%Yell as capital, equipment, and personnel. In passing this legislation three years ago, the Congre@-- expressed a public feel- ing that the benefits of medical science Were not being appl@l uniformly enough to all segments of our population. This expression was 1.),trt of a growing recogiii- tion i%-If-hiii the health held that the present complexity and Socialization of health care requires exploration of improved patterns of Organization. The legiii- I.ition carried through with this concern by placing ejnl)ha@is on the development through the Regional '.Nledical Progranis of "regional cooperative arraiig(?liiejits" 309-653 0-68-9 170 among the health personnel and institute ons on I regional t@asis Is prerequisite to accomplish the objectives of reducing the uiiii@s,@,iry toll these diseases. The Regional Medical Programs @me then an exciting new venture in tlit-, development of an improved health svstem-creatiiig new rel@itioil.,,Iiips arid ea- pabilities while preserving and buildin@ upon the great -tr@ln,-ths of our existing institutions, agencies. and personnel. The history of past efforts at creating a regionalized ii),,-,roaeh to health sern,- ices provides anil)le evidence that the tisk set for the R@.:,niil ll(,,clieal Prc,,-r,,iiiis will be difficult and progress at tiiiie@, will slow. There have @ii previous beginning efforts at regionalized health activities in variety, parts of the country, some of which were described by this Committee in the rt?l)ort oil the original legislation three -.vears ago. Now the pressures of an increasingly complex health enterprise and the ripid advances of medical science arid technology have i(l(lecl ,t considerable urgency to the need for regionalizatioii in the hetlth field if our people are to benefit fully from these advances. The pre,-ure:, generated by the rapid rise of health-care costs and the increasing urbaL,@-7zttioii of our society add to this urgency. The Regional Aledical Programs are beginning to show 4zciiie effectiveness in providing part of the answer to these. problems. The activities of the Re,-ionil .Nledical Programs are helping to define the opportunities for improving the excellence of the health services within each region and the contributions that each element of the region's health resources can make to that excellence. The programs are establishing a permanent framework within the regions that be- comes a two-way street whereby the expertise in the @.it medical centers becomes more readily available to the practitioner and @itution at the cotii- munity level, while at the same time the definition of community health needs and the involvement of community resources is made more relevant to the cialized capabilities of the large centers. I have seen this process at work in California where we face a more complex task than most of the regions because of the great size of the region. This is the largest region with about 20 million people, and the development of the Regional Medical Program is following a somewhat different pattern than other regions, reflecting the commendable flexibility of the legislation in allowing each regional program to develop according to the particular pattern most suitable for that re,-!on. The amount of cooperation involving all of the medical schools, the medical profession, the hospitals, the public health agencies, and interested public in California has already made an invaluable contribution to the development of the essential basis for cooperative action. Even before the Califorina Regional '.Nledical Program has received any operational funds, the progress of the program during this planning phase and the establishment of much improved lines of communication among the many elements involved constitute substantial progress. In the interest of time, I would like to submit to the Commit-tee a fuller statement of the accomplishments to date under the California Regional Medical Program. (See attachment A.) I think there is still a long way to go in developing the program in California when the progress is measured,a.@ainst the magnitude of the task. By that same measure, however, we in California are very pleased that the neces,4ary initial steps in the development of the program are now well underway. I believe that the Regional Medical Programs for heart disease, cancer, and stroke are a very important component of the development of health care on a regional basis In this country. With their emphasis on medical excellence, the involvement of medical centers, the practicing physicians, and the hospitals, the programs are a necessary part of the effort to bring the best in health care to the American people. Regional Medical Programs, however, can only make. their full contribution in concert with the many other activities devoted to that goal. The scope of the challenge is too broad to be totally -accomplished by any one program. The deyelopment of effective Interrelationships among the Regional Medical Programs, Comprehensive Health Planning, and the widevarietv of other health progr,ams-Pederal, State, and local-will be essential. I believe that the development of cooperative relationships among many diverse interests already underway through the Regional Medical Programs is a basis for hope that this cooperation can be extended to a broader level and that the effective Inter- relationships will be developed in ways appropriate to 6@e the diversities of the various areas of the country. 171 As an essential component of this broad effort, the authority for the Regional @l@cal Programs should be extended and support should be provided for their continued development. Thank you very much for this opportunity to appear before you today. [ATTACH-.NfE-.\,j! A] STATEmr.NT OF LESTER BRESLOW, '@NI.D., ON THE CALIFOR@;IA CO-NF.NIITTEE ON REGIONAL AIFDICAL PROGRA-NIS, '.%IARCH 27, 1968 The California Regional N@lical Pr(igrani has been funded for only 15 months and although it would be premature to claim tbit lives had been sa@, never- thele%ss, it can be said with confidence that the stage has been set for the pro- vision of greatly improved health care services for heart disease, cancer, stroke, and the disorders related to them. Just this week a study was launched by the California Health Data Corpora- tion to gather information on the origin of every patient admitted (luring the entire Week to every hospital in California. The study, never before undertaken on so large a scale, will show where each patient came from, what his diagnosis was when he was discharged from the hospital, and other information. II'llile these may seem little more than a set of dry statistics, the results should reveal ,kvith great accuracy the kinds of medical services needed for Californians trial others cared for in the State. Other data gathering studies, which are exl)ecte(i to lead very shortly to operational programs, will be described later. From the very beginning, planning for the California Regional Ife(llcal Pro- gram embraced all the major medical and health interests in the State. The Call- fornia Medical Association, spokesman for the State's 23,000 practicing I)h3,si- cians; the California Hospital Association, representing virtually all of the 600 short-term acute general hospitals in the region ; the California State Del@iii-t- ment of Public Health; the California Heart Associations; the California Di- vision of the American Cancer Society; the deans of all of the eight medical schools in California, and the deans of the two major schools of public health were joined by eight public representatives of the consumer. Together they con- stitute the legal advisory committee for the region and are known formally Is the California Committee on Regional Medical Programs. The Committee has met many times, has gained strength, grown gratifyingly more confident of it- self as an entity and has increasingly been able to resolve differences amicably. As for operational programs, We are looking forward to a two-day site visit in California on April 1 and 2 by a review committee of the National Advisory Council for Regional Medical Programs. They will examine the merits of 14 operational proposals generated by local comniunity interest in five of the @te's eight planning areas, and by the California Heart Association. These first ol@ eratioiial proposals are heavily weighted toward continuing education, and la- elude some promising innovative experiments. The greatest single topic of interest among these early operational lirol)os,,il., concerns coronary care units, reflecting a growing consensus throughout the Nii- tion that such units, properly equipped and with highly-skilled doctors and nurses to run them, can bring about a dramatic reduction in deaths due to myocardial infractions and other cardiac emergencies. Four of the 14 proposals deal with the training of physicians and nurses and the equipping of coronary care unit,-. One proposal would offer nurse training in several communities throughout North- Western California, stretching from the Bay Area to the Oregon border along the Pacific Coast, and would include intensive training for physicians at the San Francisco General Hospital, under the tutelage of University of California cardi- ol@@ sts. Similar proposals would be offered through several hospitals ill the highly concentrated Los Angeles basiu and include the beefing up of the ijiteii.@ive coronary care unit at the Los Angeles County General Hospitil. A joint proposal by the University of Southern California and the University of California at Los Angeles would join with the Charles R. Drew '@%ledical Society and others to establish a postgraduate medical school in the Watts-Willowbrook gliett,o area of Los Angeles. Internship and residency programs would be generated along with inservice and postgraduate training for doctors, nurses and allied health professionals, close relationships with the faculties at USC and UCLA and detailed planning to meet heart disease, cancer and stroke needs in the area. At Roseville, a community of 20,000 citizens 18 miles northeast of Sacramento, the University of California Davis '.Nledical School has encouraged local physi- 172 clans to e,@tiblish a ,'living laborato y" involving the Ni-bole collimuTlitY- COlitin- r uing education, training for licensed vocational nurses and other paraiiiedicil t)er.,oniiel, stroke treatment, handling of central iieri-ous system niali,,,nazicies, establishment of i tunior board, selected multil)hasic screening and community education programs are iilvol%-ed. The California Heart Association proposes a substantial expansion of its suc- cessfiil student research projects, bringing highly qualified science students into cardiovascular research laboratories. in l,os Angeles, special training in angiography-the visualization of the blood i,es:iel system ivith the aid of radioactive dyes-ivould be presented for practicing and qualified radiologists. Two I)rol)osals-one for the Sacramento Valley, the o-ther for the IoNver San Joaqtiiii-wotild iiiike use of videotape recording units which would be moved from one hospital to the next, covering several score hospitals. The units would be accompanied by medical television tapes, for instruction of each hospital's stiff members, iiid each local staff could record its own grand rounds, lectures ind deiiioiistr,,itionq, then, by playing the lesson back, improve its own teaching skills. The California Heart Association proposes a substantial expansion of its sue- I)itals in the State, would be expanded to other regions. The development of simple learning languages in a computer program available for uiider,-ridtiate graduate and postgraduate instruction to several regional medical program a@eas would be encouraged in another proposal. The l,oiizi Linda University @ellool of Medicine his a highly intriguing pilot project barred on a tbird-generation computer, and proposes to expand its libriry services to lpracticing physicians throughout its vast service area. The computer demonstration %N-ould test the feasibility of using a remote display, very iyitieh like a television set, on which a physician in a community hundreds of miles from the school could, by picking up the telephone, hook into the coii)ptiter and a.,(k it to analyze the electrocardiograph readings being taken on the patient lying by the phvsician's side. The computer analysis would be done in real-time, and the answer would return in 2 or 3 minutes. Such a project might provide needed services to small, remotely located hospitals and communities now lacking medical These 14 operational pro@1,3 are tinder immediate consideration. Several others, submitted in the March, 1968 quarter, will be briefly detailed in a moment. All have been developed following @lanning activity-_Nvhich began in January, 1967. The first ye,,ir's planning activity involved, among other things, the lay- ing doivn of a data base from which operational proposals are being projected. Construction of the data base has gone through two phases. In the first phase simple, readily available data were arranged in forms most useful for planning in each of the eight areas of California. De?yiographic data were acquired from the State Department of Finance. Mortality data were gathered from the State Department of Public Health. Also from the State Health Department, with added information from the California Hospital As- sociation, came material for a complete ho-spitat roster for each of the Cali- fornia Regional '.Nledical Program areas. Finally, the first phase of data acquisi- tion eiitailed analysis of less readily available types of information involving, for example, transportation and the many varieties of morbidity data. During the second half of the first planning year, six planning studies were undertaken on a region-wide scale. All were approved by a data needs subcom- mitee on which each of the California Regional Medical Program areas was represented. Each study aimed at relatively deeper I>enetration into some aspect of the data base needed for planning. At the same time each pointed clearly to the shape of o rational proposals in the making. Paticiit o?-igir, cribe(I briefly !D the opening paragraphs of this stRterLeri ant material for morbidity analysis, partic- ulary if the surN intervale. At the same time, the survey in Is first round is e3 information needed for transportation and facil- ities planning in conjunct on with the rendering of optimal care for heart disease, cancer and stroke patients. Trainiiig facilities inventorV.-',Nlany of the ideas for operational projects, which began to take shape in the first planning i)eriod, concerned manpower needs and the possibilities of training progra@a-for key health services, In addition to physician services. It was folind..tbough, that'little Information had been gathered on the simple question of ;what training facilities now exist. 173 The California Regional 'infedical Program, therefore, contracted with the Survey Research Center at UCLA to make an analytic region-wide survey of existing training facilities for health service manpower of all sorts. The survey, besides being an inventory of facilities, includes analytic details as to capacities, present enrollments, expansion possibilities, curricula and iieNir, programs. It will serve q.,4 a basis for second-generation studies and operational I)ro@als in the man- I;o-.i,er field. Physician referral patterkis.-The Stanford Research Institute, in cooperation with the California '-Nfedical Association, is completing interviews with a random sample of physicians throughout the State on the subject of referral patterns for patients with heart disease, cancer and stroke. Here, too, material never gath- ered before'is being acquired. Questionnaires already completed contain valuable material of two kinds. As a basis for improved delivery of medical service in cases of heart disease, cancer and stroke, referral pattered, troth as to physicians and facilities, are being discussed. And, the needs seen by family physicians, and other physicians of first reference, are being recorded and analvzed for the first time in this context. Registt-ies.-A cooperative undertaking involving the System Development Corp. of Santa Nlonica and the UCLA School of Public Health is doing feasibil- ity testing for possible registries in stroke and heart disease. California has al- ready had rich experience in the development of a tumor registry, covering roughly a third of the hospital beds in the State and providing cancer incidence data of unique significance. The System Development Corp. study is, therefore, moving on to a preliminary examination of regi.,itrv construction in stroke and heart disease. At the same time, the Director of the California Tumor Registry is cooperating with the California Regional Aledical Program in connection with cancer registration and follow-up. [,'se of niedical scoicty revieic niechanisms.-On a trial basis, local medical orga- nizations in three California counties are cooperating with the Regional I%fedical Program to determine the value of local medical review mechanism@generilly associated with claims review in health insurance program&-for case identifica- tion heart disease, cancer and stroke, review of prevailing community stldd- ards and practices in management of such cases, and possible development of postgraduate medical education and other programs. In each case, the county medical group has agreed to cooperate with the appropriate university medical (,Enter in the review. Specialized resovrces in 7ioipitalq.-The sixth and last of the first-generatioli California planning studies is based on questionnaires sent to III the acute, gen- eral hospitals in the State, through the cooperation of the California Hospital Association. The hospitals are reporting whether or not they have various items on a detailed roster of specialized resources or facilities needed for treatment and overall management of patients with heart disease, cancer and strole. This material, too, has not been gathered before, and is expected to highlight ma- terial lacks, oversupplies or inaldistributions. At the ,ame time, the study will bring manpower training requirements to a sharper focus as California's Re- gioiial @ledical Programs enter their operational phase. All these data gathering studies have been integrated Into the 14 operational I)ropo."Is described earlier. They have alto been incorporated into the five op- erational proposals and the two additional re(luests for funds especially e-ir- marked by Congrezs, submitted by the California Committee on Regional Medical Programs during the '.Nfarch, 1968 quarter. This second set of proposals includes the expansion of existing clinical (-,qneer diagnosis and treatment, social service consultation, radiological pliy.S!C',4, nuclear medicine and computer retrieval of pertinent data to 26 hospitals in northern California, a coordinated year-round general practice residency, intensive Coro- nary care training for physicians in small hospitals. and the establishment of a medical library and information service network. The first of the projects seeing earmarked funds involves a sixth area ill California-Orange County, the planning for which has been assigned to the University of California at Irvine-proposing a pediatric pulmonary (lemoiistr,'I- tioti center. It A-oul(I be only the fourth of its kind in the Nitiozi. The qecoll(l project would expand and improve an existing hypertension program of tile UC San Francisco Medical Center. Taken all together, these first operational proposals call be seen as the begin- niiig broad outlines in the development of a region-wi(le coiiiprelieii,,4@-e blueprint, 174 whose cohesion and effective potential for vastly improved health care services are emerging, almost on a day-by-day basis, ever more clearly. Mr. ROGERS. Let me ask this. Is your progrin-1 getting to the glietto ,,treas? Could you give us a quick rundown on that? Dr. BRESLOW. One program that is being considerecl-I perhaps should not prejudae the issue-is the proposal which has been den-el- oped by USC ana UCI,-A- faculties. It would transfer the medical expertise developed bv these two centers, in the field of heart disease, cancer, and strokp,, t(;the IVatts-Willowbrook area. It is in this -,iret that the county plans to build 9, new hospital with the aid of Hill- Burton support. The ,tim of tl-iis p@ogr,,tm.is @o build around that hospital, bringing in the practicing physicians in The community, a progr@m of postgrad- uate education, emphasizing heirt disease, cancer, ,tn(i stroke. We think this will have a remarkable effect in mobilizing the services of that portion of Los Angeles to provide I etter care. Mr. ROGERS. Thank you, and I am delighted to see you have given us a statement on the California program, which we will go into in detail. Mr. Kyros? Mr. Ir,@os. No Cluestions. Mr. RoGEm. Dr. Carter? Mr. CARTER. I am delighted tok-iiow you are making all these services available for the Watts area. I wonder what you are doing for the areas around Watts. Dr. BRESLOW. Our programs extend into the Watts area ,iiid ,tlso around the Watts area, not only throughout the metropolitan region of Los Angeles,'but in the mountainous are-as, and so forth. Other pr ts- rr. CAR@. I believe in those surrounding areas we are liable to have more heart attacks and strokes. [Latifrliter.1 Mr. ROGE@. Thank you very much, Dr. Breslow. We appreciate ve coming here. to hear one more witness here. Price, I understood, were going to ha e forward, then? We Iwill be pleased to sman, wanted to come and introduce youl kn of your work, and we are delighted to have here with us, an, Dr. Price. And you would like, Iwe will make your statements part of the record ut objection and they will appear following your re- marks if yoti-@d then stunmarize for us the points that you think be important, this would be helpful to the committee. 193 Mr. ROGERS.' The next witness, Mr. Nathan J. Stark, group vice president for operations, Hallmark Cafds, Inc., Kansas City, Mo. STATEMENT OF NATHAN T. STARK, CHAIRMAN, MISSOURI REGIONAL MEDICAL PROGRAM @Afr. STARK. My operations have nothing to do -with medicine. Mr. RoGEm. I am not so sure. Don't you give get-well cards or somethin-a? --Nf r. STZRK. I have been accused of that. I ain pleased to have this opportunity to be at this hearing on regional medical programs. I am, -as you note from the title, a non- expert in the lie-alfli 61d. A businessman interested in health programs is mv catezorv. As I listen to all these experts, many of whom I have lieardof, ai@d several of whom I have known, I asked myself the question, "'"'-h-,tt am I doing here?" But perhaps this is the new look in'the nonprofessionals vie@ of the health field. I think that the need for citizen participation has been rather iui- familiar to most of those in many pains of tfie health field, but I believe it is fast becoming consumer oriented. '@Nlv credential4- in the health field are is president of the Kansas Cit,i General Hospital and -,NIedical Center, -and as chairman of the .Alissouri regional medical program, and it is to this latter role that I wish to address in- .y remarks. '-Nly statermnt will be restricted to the Missouri proo,7aln since this i:, the one I qm most familiar with, tnd it may be typical, or may be typical of what other programs are. 194 The final focus of our program is on tile cooperative delivery and e health care to planning of the best @ibl patients suffering from heart diseasel cancer, stroke, and other related diseases) regardless of economic educational, or geographical status. The proo-ram utilizes maximum iocal plannin and initiative with re-aional empha-si rts 9,n@ review of the qual- it@of endeavors. of the public a@d professional n the region who have a bona re. Because of the stated intent of the program which was to improve care by increasing the effectiveness of present systems, attention in the @Nlissouri program was directed to early detection of disease, method- ology for systems to provide maximum economy and effectiveness, and initially ,t small number of models of delivery systems, planning for a service to a specific population of people without regard to the exact place in whi@h that -service, might 6e rendered but with empha- sis on ileliverin_a the care " close to the patient's home as is consistent iv,ith economy @nd quality. In other words, we are people oriented. Primary emphasis has been placed on the development of supportive services W-hic@utilize the newest in scientific te@ol?g. This'i eludes a variety of services which can be furnished both to the physician and to tlip, patient quickly and economically at any time anywhere in the region. The present testing of computerized interpretation of EKG's for physicians in rural areas is a precise example. For screening.p@rp@, nd for the first time in history, the private practitioner participating in the model system has consultation for Heart disease immediately available to him at every hour, 168 hours a -week, ,it an estimated cost of less than $3 per interpretation. Each interpretation can be backed up by a dial-a-phone lecture reference source, recorded on tape and also automatically available at ,ill hours at the cost of a pnone call. These backup lectures will develop on a demand basis in accord with experience.. A model of delivery systems is found in the Smithville ecl. Here building upon n existiii-a rural system, maximum effort h@isojbeen placed by tl@ 16cal advisory iroup aild the State university medical s@hool upon a'sophisticated Consultation and referral proLyram. In Smithville, the system extends into home care utilizing -all @ail- able ancillary and auxiliary personnel. Faculty members of the uni- versit_y teach and consiilt wiih-the local @ff. Financial assistance was given with a specific terminal date, at which time the system of caiTe is projected t-0 be self-supporting. The T)ro-aram provides for careful change of quality of care as a result of intensified support. It is the pfaTn of the Missouri program to establish and terminate final support for all demonstrfttioii projects in this manner in order to provide the opporti-inity for cooperative programs with a, maximum of communities in the region. Supp6-rting services And later innovations will continue to be made available on a financially self-supporting basis to these cooDeratinz communities so long as these are found to be mutually helpful. - A final fa@t of the program is the interdisciplinarv-re-search @oup in the university who are studying intensively the-delivery @Ystem 195 for health in the region, scientific devices which are needed but lack- ing at present, a, communication fwility which possibly could be ad-opted for pwwe of the program. The resea@h irou-P functions as a medical experiment station draw- iiat together the tal;nts of all university disc' lines which can con- trl tite to the definition or solution of he ems. Of the 21 bioeiigineering projects no Id like to men- tion two. One result of this research I opi@ent of a diagnostic chair, which simplifies the taking oi a he tra-eing. The cila@ir reduces the time required for an EKG from a 20 idinutes to less. Another piece of @uipment developed by the engineers and the physicians working together is an electrolytic unit -which has prove(f extremely helpful in speeding the.healing of leg ancl body ulcers for the diabetics or patients who must be in bed for long periods, and these compact units can be taken home. An added feature is ,in alinn system which reminds. the patient to keep the handle properly dam@ned. Future programs cot@ld be sumi-n,,irizecl as the design of more model delivery systems in cooperation with the public a;i-d health profe-s- sion,,tl involving finally the entire region, continued concentrated study of appropriate services designed to be self-supporting, the assistance to programs in providing for treatment of disease and rehabilitation of Pairients suderinL), from these categories of disease, and last, a translation of new Ideas into action o-n behalf of the patient or the potential patient. This is 'indeed an excitilig, though wearing, time to be involved in health affairs. The regional medical pro to mind, offers one of the beA means for -,%chieving ol)ti@,11 fieraltli formayll people, who are in effect the real beneficiaries of regional medical prpgrt@is. I would certainly urge the sup@oit tnd the continuation of this proLyram. LNow I have here an organization chart of the -,LNIissotiri regional program which I would like to offer for the record. ,Afr. ROGFRS. The committee would be very pleased to have that, and it will be made a part of the record it this point. (The document referred to follows:) .NITSS07L;Ri REGIO'QAL )IEDICAL PROGRAIF ORCA.NIZkTIOlq 1. GOAL SETTING (a) Policy is set by representatives of the public and the practicing profession upon advice from: .\Iedical schools. State departments related to health. Voluntary organization,.-. All health professional organizations. (A total of more than .50 people read and comment upon each Proposal.) (b) Planning is for a selected population of people regardless of where they may ultimately receive their care. This permits maximum use of communication mechanisms ilrea(ly established between the many involved groups. (e) Planning and operqtion,, are Icept administratively separate. 2. ORGA'.NIZATIONAL PATTER\ The Project Revi(-w Committee conists of the hL,,ad or his delegate from the schools of osteopathy tnd medicine, the Division of Health, Director of Welfare and Director of '@Nlental Di-ea-es, This committee erveQ as an advisory body to the Council on all proposals. 196 An A(li-isor@ k-otiii(4il, nominated by the Project Review Committee and ap- pointed by the Goi,eri)or, @rves as the governing body. The 12-mclubers serve ,staggered terms, no person's service to exceed six years. Members may not be drawn from University staff. The Liiiso@.i Committee is comitosed of elected or appointed representatives sent by each state-wide voluntary or professional organization Nvhicii has applied to tn(I been accepted by the Council. The 24 members serve as a reaction panel on all projects for Council. The Uiijver.-ity of '.Nli.@-oiiri serves as trustee for funds for the Missouri Regional Program. S. SPECLA.L URBAN ORGANIZATIO.N For the Kansas City area a special Metropolitan Liaison Committee has been fo rmed. Members include five local citizens and txvo representatives from each of the Advisory Councils of the two regions (Kanz@ and Alissouri) which overlap iii the Kansas City area. This comniittee also serves in an advisory capacity to the two Regional Councils for all projects which fall within the six county urban area of Kansas City. A special, local planning force has been assigned to Kan,-as City by the Mis- soiiri regional program. No matter how a re,?-ioii is described, ultimately it must interact with other regions. Modifications of the Kansas City committee have been developed with three of the other adjoining regional programs and similar plans are under dis- Clission with a nuraber of other regions which also adjoin Missouri. MU. ST.-kP@K. I submit for the record three separate publications of the Academy of Cieneral Practice ,is ei-ideiiee. of cooperative efforts between the practicing Vhy--,iciaii and the prozram. '@Nf r. ROGEIIS. IVe will receive those for the committee file. Tli,aiil@ you very much. Di-. Cai-ter9, .Air. (ARTErl. I itist want to C(,Illlplilllellt this gentleman upon the paper that, lie lias'delivered here today, iiid to sty that I thfTlIc it is ct -%-el-.y health.v sign -,vlieii men o', his evident abilitv t@vlce, part in such pi-ocrrarnsastliis.T'i-ipnkyou. -like to secon fr. IZOGE,S. I would d tlio-e :,e!itinients. I think it is excellent, -,ind -,Ye do need more ,tiid more people to involve themselves in the health field other than just the scientific conuiilinity, and I woii- der i-.1 -voii could give ii-, tii ex,,iinple-yotL q-ziv the design of more model deliverv systems. lVhtt is Your t-Iiinki@ the@e? .@TARK. Two that I h,,iv e, specifically in mind: One would be the Srilit]iN-ille project located in a rural area about 15 miles from Kansas City wfiere they are designing a prootam for the fint time to give complete cont@uity of care from the time the patient is seen in @t-he diagnostic stage through the treatment stage and tl-ten into the reli,-bi!itat@-on sta@e. Another one i@that takinLr -place in Spripoeld, Mo., at the com- munity hospital. A cardiovascular program is in force where they are treating the cardiac patient and also training nurses and doctors in the care, treatment, and rehabilitation of cardiac patient§: This is a part of the current operational arant and is working out very well. There are six or seven programs in operation, or being proposed now, in community hospitals. Mr. RorERs. T@ank -you very much. We appreciate your being here today. Our next witness who has a 4 o'clock plane, I believe, is Dr. Amos Bratrude. We appreciate your presence here today. Your Congress- 197 mail, Tom Folev, spoke to me on the floor and said he wanted to be here to persoiiafl'y introduce you to the committee and regrets he can- not be. He is in committee himself. STATEMENT OF DR. AMOS BRATRUDE, WASHINGTON MEDICAL ASSOCIATION, AND ASSOCIATION OF GE, NERAL PRACTITIONERS Dr. BRATRU@DE. I was sent here todav bv the Washington Medical Association, and I have the blessing ;f @he Association of Generil Practitioners. I am Dr. Anios P. Bratrude and am in general practice in Oiiiak, Wash. I have a common failing with all people who have moie(l,""est, ,ti)d that is our adopted home has become verv important t and 0 us) so @ou'll excuse me ii I Lyive You a few words ab-out Omak. It is a rather typical -%vesterli coinii-lu@ity ;f ibolit 4,500 people. The prime industries .,ire 109@ nLr apple orchards, and cattle. The biggest single event of the year ilrtili@'Oiii,,ik stampede, with what we consider, a -world-f,,ii-nous suicide race. It is a nice comniunitv and mv 9 years tl-iere have been very pleasurable. I aii-i ii-itrried and have fol;r children, and as a f atlier ,tiii beginning to.experience the riLyors of a teenage daughter. I was r,,iisect in the middle 11@st. Afy father was a general practi- tioiier in a small town by the name of Antioch, 111. Upon decidiii(r where to practice, there -%vere several things I was sure that I wanted. I waiited,,t community -with a hospital i@i it. I have always been i-ei-y interested in general practice but could see no reason to choose t coiii- ii-iuiiity that was lar e enough to have t well established specialist group. I iv,,inted to efO-ose a community that I felt ]lad some promise, of aroivtli 3o that I could eventually htve the type of medical etice that I ivas interested in. TI-iis: n@@'iel,7, is a Lr-roiii) of three, @orilir. or five doctors who are quite interested 11 the practice of medicine, but also -want to be free to pursue academic and recreational ictivit.ie-,. I am now the senior man of ,t foiir-maii group, Ind the reason threat I can be here todav is that I have three excellent partners tli,,it,,ire coi-er- ing for me. Those were the. practical reas,,)iis for clioosiiilp Omak. The emotional ones are that the coiuitrv iust imniedi,,ttely i@pe,,Llexl to me. I enjoy hunting and fishing -,iid outside, and all ifiese things Nvere able. We have been 13 n in ,L iie,.N, bospittl with 32 beds, iii(I a staff of seven physicians. Of course, four of these are of our groul). It is quite intercit to virjous meetings and semiiiai-s and hear people dis( s of a small hospi7tLl. Invariably these le consider i-i 100 to 150 beds to be a. small hospital. ronpsequently, t of problems that miabt occur there have no hearing at ,ill on wbi lia])peiis in a hospital of 32 beds. I had alwtys been quite interest( in ihe broader problems of medicine, and when the opportunity came to me from tli-e Wtshiiigton-Alask-,L regional medical @rogram I welcomed it. I would be the- fir-st to adniit that I bad a, rtther biased viewpoint when I ioined the IVasliiii,-toii-Alaska. regional medical program boar(]. I had been raised of fiirlv conservative parentage and ]lad ,t decidedly jaundiced opinion of the role I thought Government was pitying in medicine. If is quite surprising to find out at the first advisory com- 198 mittee meeting that most of us had the same feeling. Then it was in@r- esting to see the change in everN-one as the meeting progr@ed. it seeme7cl that most of us had verv defin@, but very erroneous icleas what the @nal medical proLram would be and how it would work. It was explained in the first @ion in M2,V of 1966 that the regionaT medical program was not LroinL), to be a vehicle to transport the patient to i4 supercenters" but ratKer @vas going to be a vehicle to transport kiio-,vljdge, technique, and assistance to the local level to imp@ve patient care in places such as Omgk. I, of course, was very suspicious that this was j@st the bait to lure us into the trap. I have now co@ plp,ted approximately 20 months on this commit@l-and I am convinced that at fe-ast the Waihington-Alaska program has not altered f rom this ideal, that is, to attem@t to improve the level of care for victims of heart'dise,ase, cancer, and stroke and related diseases into local com- munities. I was also "prejudiced in another area as I approached the Work on the regional medical program. I am in a very rural commu- nity. I think it is wonderful to have great research projects and a large amount of what we call ivory tower medicine. Btit'I ilso feel there is a tremendous amount of m@icine that has to be practiced on a day-to-day basis to help the people receive proper care. I also had manv Preconceived id7eas about physfciali education pro- grams that I felt'were fairly worthless. I have taken these pre udices ,incl conveyed them into ideas for our group, and a-i-n afraid I have helped to sidetrack certain programs I felt fi'a(l little practical value. IC do want to sty that I feel there is t definite for complicated r@ai-eli projects, and without them many of tfie idv,,tnces we enjoy today would not ,be here. But I feel, ,is the 0111@ general practitioner on tlie Advisorv Committee, that I have wasted very little time ar- ,c,,Uin-a for the aspect of medicine because many about me are. In regard to @ific prcbfems that were present in the practice of medicine in norch-contr-al Washington these axe son-le. There are ce other problems which deal with ruraJ areas, ,tnd man e citeLyorical ,ireas of the heart-, cancer, t lookillo- forward to taking advantage of t] iig prozrziiiis that are etir- reiit.lv being eE d are Fookiii- forward to many other oiiit that, I would like to so stron@ is that the 'R'-Nl as o red the first opportunity for local me& wnununities to feel tl-iat it is worthwhile to get ii-L- volved and interested in because their opinions and problems are being sought. 'Phere certainly has been a considerable change in stance of the average physician in regard to Government in medicine. Just a, few years ago no cooperation would be offered, and if preferable no inter- fe,rence would be tolerated. Todav we find the average physician understanding that the Government will be involved in mejicine and that a cooperative venture of some kind would be most, desirable. The RMP with its emphasis on repionalization has, I bedieve, caught the fancy of the medical communities of the United St,,ites.'As ]Ftr,,ivel to various gs with colleagues who are scattered across the coun- often the,7 try, I find v have many favorable comments con- cerning tb goals of @bis programs I think that if this pro- gram were to be sig"ificaiitli, curtailed or even dropped,. you would find a considerable disillu-,ioi-imeiit ill the medical profession. I t.@iiiik most of us feel there is a strong chaii@ that the RAIP is going to offer ,,ill of us help and cooperation, not interference, from the Govermiieiit on our local me lical- problems. I think that 'if it were -Possible to establish a long )eriod, such as 5 years, the RMP could then do sia- nificant future p anning aaid the medical community would know tli7at tile program was here to stay. I have certainly enjoyed the experience of coining to Washington, D.C., an(! appeariiw b;f6re this committee. 'ni@ you very much for the opportunity. Mr. ROGERS. Thank you Very Muclil Di. Bratrude. Your testiii-iony is the tvDe I think the committee needs to hear, from a I)r,,icti(,iiig physicians We are delighted that you took time to present this t(,@ti- 0 the committee. "@r@ tCarter? Mr. CAR@. I certainly want to congratulate tl-ie gentleman Upon his presentation. He is one of the men wlio applies the 6ols which have been given him, and in addition will evalut@and use what other tools are our re .onal groups. I am impressed by his paper, and I am happy to have such a young phy ,Al You sav -vou are the only general, titi( inittee':Cor your region, or is tiiis ,t subregion? Dr. BRATRRDE. I am the onlv one for the Washinp-toii-Alaska meet- 'lg We have six practicing specialists froyi-i vari@iis disciplines: in ad@ition, of course, to many physicians in the universities. Mr. ROGERS. But there are six out of 30 whom you would classify as practicing physicians? Dr. BRATRrDr,. Seven, couiitiiily me. .Mr. ROGERS. How, inaiiv hospital administrators do you ]la Dr. BRATRUI)i@. Two. Mr. ROGERS. Do you think this is a good ratio? Dr. BRATRUDE. It is difficult to p@t ever@body there. We have six or seven lay people, we have two nurses, we liavi;a dentist; -ilid by the time you are done, we reallv ireii't heavily ladeii with the )iiedical school people. Mr. ROGERS. Would it be more of a problem getting away if you were not in partnership? Dr. BRATRUDE. I w-Ould like to speak about this a bit. I think the e t of the practicing physician is changed somewhat. As we are co'lp p trained today, we ire totally convinced that we have to stay current; and I think, as we set ourselves into practice, many of my colleagues in our county are in independent practices such as -Bill Henry, one of the doctors there. He feels it is important enough, tnd has educated his patients enough that he gets away for courses. I believe that group or no ,,roup, this i7s the way it. I'sgoing to be in the future. 'Mr. ROGERS. YOU don'f think it c"llll be brought down to the hospital level? Dr. BRATRUDE. I don't mean that. We have hospital staff meetings, and visiting professors who come for seminars, and the gentleman 200 from Missouri, some of his proo-rams sounded outstanding-- When you rniiig think ibout help that you need@it is 3 o'clock in the mo and you have a cardiac problem; you don't ne@d a seminar, you need someone to Ln,ve VOU some help. It sounded like this aspect of his program was vel7y exjiting. Mr. ROGERS. Thank you so much. We appreciate the benefit of your advice. 208 Mr. RoG@s. Our next witness is Dr. Chambers, Medical Associa- tion of Georgia, Atlanta., Ga,. -li your it, is ,t pleasure to have you bere,,tnd ve kiionv of you tlirouo, good friend, Conzressman Jael-, Flint of Georgia. Dr. CIIA--NIBERS Nvol-ild like to submit a copy @f this journal for the re-cord. Mr. P',OGFRS. Without objection, we will accept the journal for the files. (The publication referred to, "Journal, of the I\feclical Association of C-reora-ia," April 191ri, was T)Iaced in the committee files.) Mr. R'OGE'RS.You may pro@-cl. Dr. Chambers. STATEMENT OF DR. J. W. CHAMBERS, REPRESENTING THE MEDICAL ASSOCIATION OF GEORGIA Dr.CHA-.NfBERS.Mr. Chairman and ineiiil)ers of the coiiiii-iit-teE,. I am in private I?r,,Lctice of medicine in T,a Grange, Ga., associated ,i-itli a e,tv fee for serviePL)-roLiT) l,q CTraii (Tq.. is t siiiflll ).Ooo population in a county of 50,000 1)opulttioii. There is oii(,, li@I)it@ll in @ , L-, , m-,,it@ly 220 our community; il h, tpproxi beds and is an accredited hospital. I appreciate the coi-irte,.3y of this committee in liegi-ii,.g,,L voice from tile Ccgra-,sroots support" -of H.R. 15758. l@t. is illy belief that the healt@ profession,,ifs-in o-Lir region eoiisider the original leaislitioii, I)v the Public Law 89-239, as important as any t,]-i@ has been 1)azse Coiigre@ in man e feel th,,if it deserves continued support. .y Our interest in however, bep-,aii before Public Laiv 89-239 was deuced by discussion trooi@o ret)re- sent-atives ol edical Association of CTeorgl"l. rsity School of Medicine in Atlanta, the 'Aledicil 'Coll ia in Au,@ista,, the Cxeoraia, Heart Association, -,tnd the C) )I of. the American Cancer Society. These discussions wer iriiio, 1966 to include the representation from the Geor@ s:@0- cia.tion, Geor2ia Del)artii-ient of Public I-le,,,.Ith, Geo sso- ciation, Georgia D tal As,,3oci,,qtioii, Georgia Phari-ii,,iceutie,,il citi.- tion, Georgia Division of V@oc,,,ttioiial R@llibilitation,, Georgia Stite Nurses -k-@oci,,ttion. Ge<)rgii State, League for Nursing, Georgia De- p,,ti-tmeiit of Family and Children Sel-vi@, CODID-1111-iltv Council of -ktlaiita Area, ln(@., and @tlic Planning Council of '.LNleitropolit,,iii Savannah. In,,tddition.tlieGeor,-ia Nursing HomeAso@i,,itioli,,tndkiioii-led(ye- able find interested laymen were included. From such clisetis!;ioiis, 209 involving these diverse groups, a plan was developed for the orgiiiiza- tion of a regional advisory group composed of approximately 125 knowledgeable and interested persons broadly representative of our region. ilvidence of the interest of the plly-qkians of Ge<)rgi-a in the regional medical -proQTam has been shown by the fact. that the entire April 1967 iss@ oY the journal of the Medical Association of Georgia -%vas devoted to the Georgia regional medical pilograan. This is the 'ournal I -asked to be put in the record. Although the program had @olil),-officiallv beauii oil Jaiiuti-_y 1. 19C,7, the responsibility for l@ei-shi I)hvsiciaiis was already keenlv felt. @t- - P Yf in , the Medical A@ciatiol_l 0 Georo-ia ivas unanimously elected by,@he regional advisory group to @rl,e as ,tpplic-,tii@ for the Georgia region. May I quote briefl- or y from an editor'-fil entitled "A Unique Opp - tuni,ti for-leadeiship-,"' iyliieli appeared in the April journal. The regional medical program for Georgia provides the membership of the Medical Association of Georgia a unique opportunity for leadership in "pro- m<>ting the science and art of medicine and the betterment of the public health.'' However, the role of leadership etii only be effectively assumed as physicians understand the program. The legislation which established this program was the result of the report of the President's Commission on Heart Disease. Cancer, and Stroke, commonly called the DeBakey report. However, Congress gave thoughtful consideration to many medical leaders and organizations before passing Public Law 89-239 in October 1965. As a result. this law provides for local medical programs which can and will be developed by people in the areas involved for the licople in the areas to be served. This is inherent in the legislation through the lan- guage of "cooperative arrangements." and "without interfering Ni-itli the pat- terns, or the methods of financing. of patient cire of professional practices, or administration of hospitals." The regional medical program for Georgia has been planned carefully by Georgia people in a truly cooperative itiiiospliere during the pi.,t 15 months. This can best be judged by the membership of the progriiiii's Georgia advisory group. The program is practical and will provide the tools for every prnetitloner to improve not only his own medical capabilities but also to improve the quality of nier4 to the proposal, to the engagement, and finally to the marriage. Consid@riiig the divisive factors above, this is certain to be a Stormy junctions but it is ju.,it as certain that it will be consiuniiiated and liro(luctive, for it is a "shotgun weddiiig." The people of our nation are holding the shotgun. It is Icad(-d with cash-the greatest motivator in our @iety. Of 225 a moment, the disinterested and apathetic governmental father of the research ,veai-s has become the kindly, interested, but extremely firm, future father-in-law. (That he may become an Overbearing tyrant is possible, depending upon the success of the courtship.) The liliminent wedding is complicated by the fact that we are not quite certain who is the bride and who is ihe groom, If educational ability, facility, and liersoiiiiel are the measure of virility, then the medical college system must lye the groonL It is doubtful that the father will listen for long to any disclaimers of ability of the groom to effectively support the bride without further prodding or promise to. help with support. It also is doubtful that any disclaimers on the I)ait qf the bride (the medical (-are delivery system) as to her ability to a.,,stune educational or analytic duties in the household seriously will affect the future of the marriage. Similes aside for the moment, let us consider this union between medical education and research and medical care and examine the factors necessary for its ,;uecess. Three areas require close scrutiny: (1) the depth of the quality, the ability, and the personnel of our educational and research facilities; (2) the sophistication, the quality, the ability, the personnel, and the functional pattern of our medical care institutions; and (3) the question of facilities support and construction subsequent to a productive union of the educational and research institutions and the medical care institution@perhaps recognizable as the eventual arrangements for housing the family. The medical college system at present is rich in all three areas. Over the last four decades, it has built up a large cadre of educationally oriented Indi- viduals, in spite of research emphasis. The very nature and primary task of the medical college system provides it with adequate classroom, audio-visual, instructional, and other material aids to education. Its hospitals are equipped for the most sophisticated care-a significant portion of it on a research or re- search-connected basis-and are largely modern and relatively well staffed. Although the medical college certainly will need some additional support to help it in its new role as the resource of both content and some instructional ability for the transmission and validation of knowledge, it is relatively well equipped to cope with its role as educational breadwinner. The distaff side-the com- munity bo,.4p!tal, which will consume and utilize the educational payebeek-13 much less adequately prepared. INO@NUNIVERSIT'Y HOSPITALS The nonuniversity hospitals divide into those that have graduate educational programs and those that do not. A recent survey conducted by the As@lation of Hospital Directors of Medical Education shows that although graduate teaching hospitals are much smaller in number, their total bed capacity and total number of staff physicians are approximately equal to the total bed capacity and total medical staff physicians of the hospitals that do not conduct teaching programs. The same survey indicates that even among those hospitals conducting graduate programs, less than 50 per cent have mi*inwlly adequate teaching facilities and less than 10 per cent have the services of trained educators, evaluators, or sociologists available, even by consultation. There Is little difference between the two types of nonuniversity hospitals in most of the important parameters we shall measure. The major difference seems to be that those hospitals conducting graduate programs may be a little further advanced In educational philosophy. Their staffs, however, frequently are com- posed largely of physicians who do not actively participate In the teaching pro- grams, and their educational facilities, with a fe,%v notable exceptions, tend to be little different from those present in hospitals that do not conduct graduate pro- grams. Consequently, for the purposes of this discussion, the two types of non- tinin-ersity hospitals may be discussed as a common entity. The fact remains that the emerging strident necessity for the nonuniversity hospital is that it asslim-e it8 propcr role as the center of co?itiiiiiing education for the physicians and allied 7icalth personnel of it8 area. Alost nonunivei-,ity hospitals are modern, quite sophisticated, and relatively well equipped to render medical care. When one compares them with the medical college hospital, the difference in the area of medical care Is a difference between acceptable sophistication on the part of most ilonuniversity hospitals and proper xiltra.,;ophistication on the pirt of the medical college hospitals. This is a tolerable and appropriate difference. 226 INTOLERABLE DIFFERENCE The difference between the university and community hospitals in educational facility and ability, however, is so great as to be intolerable, even under present Ic,ads in continuing education in the nonuniversity hospital. These community institutions have their ultimate direction residing in the hands of boards and administrations who, in a proper and dedicated fashion, represent the voice of the community in the operation of its medical care facilities. Very few of the medical staffs and educationally oriented physicians in these hospitals have been able to impress upon their boards and administrators the overriding im- portanee of continuing education to the competence and survival of our medical practice system and its hospitals. Some of the blame for this failure to impress directive bodies must reside in the medical staffs, who have not made a coordi- nated effort to educate and thus produce a change in the attitude and behavior of their boards and administrations. Similarly, with fault re,-ting in medical staffs as well as directive bodies, non- university teaebing hospitals have tended to look upon graduate (intern and resident) education pro-franis as tolerable and interesting because they appear to raise the level of medical care, and because they provide additional hands with which to supply that medical care. However, even in relation to graduate education, it has been difficult to bring boards and administrators to spending patient care income on educational facilities, or to supply within the hospitals physicians whose base purpose is graduate or continuing education as opposed to the delivery of medical care. With the rapidly rising cost of hospitalization, and the clamor this rise has produced, one certainly must have sympathy with our hospital boards and administrators in their reluctance to utilize patient care funds for educational facilities and personnel, even though the dollars spent on education are the best purchase the patient might make. The concept is sufficiently abstract to make direct continuity of purpose and decision diffleult to achieve. PROPOSALS AND PRACRICALITIES In addition to being the subject of studies and recommendations by various commissions and individuals, our medical care and education system has been exposed to many different proposals in relation to continuing education. One hears of universities with and without walls, nationwide closed circuit television, application of the national educational television netivork to medicine, two-way radio, television tape, and a host of other novelty approaches. When one digs beneath the veneer, he is forced to the inescapable conclusion that, in spite of,all of these proposals and gimmicks, the onIV practical place to educate the P?-ac- tieing physician in a crintinitf?ig and py-oductive inanner i8 in the inilicit in lvhich he work8, treats hi8 patient8, and earns his living-his hospital. While it is true that in leading a horse to water, one may not force him to drink, the horse is a great deal more likely to drink if the -water is under his nose constantly. . While the universities and their medical centers may be the central nervous system oni continuing education and of the Regional Medical Programs' there cannot be, must doubt that the nonuniversity community hospitals will be the muscle of these programs. No portion of the knowledge produced by the billions of dollars spent in basic research in the last 40 years can be productive until it is in the hands of the individuals who care for the majority of tlit, people of our nation-the physicians of our community hospital medical staffs. The people of our nation-our consumers-in the form of Congress. have spoken in a loud and clear voice. Th@ basic purpose of the Regional Ale(lical Programs is to translate k-lioNvle(Ige into iinderstandin and thence into medical care, in a cooperative. regional, -g sic and initial form of the qctivities of the and efficient manner. Thus, the ba Regional 'inledical Pro,-rams must be reparative education in bringing physicians and other health professionals up to date. This must be followed by continuing education to maintain their competence. Once education is well under way, attention may be paid to provi(Iiii- the facilities in which the newly understood knowledge, techniques, and skills may be applied in a coordinated manner. It is senseless to build the facilities until the system of education that will assure their proper usage is established iii(I functioning, with the explicit purpose of making the billions of dollars thev have 4pent in research productive In the Care of our people. 227 HOSPITALS NEED HELP At this time, the educational muscle of the nonuniversity hospital system is so weal@ that it is difficult or impossible for it to handle its presently assigned tasks in education. If it is to become the cornerstone and functional arm of the Regional Nledieal Program, then the nonuniversity hospital needs a great deal of helli. This help must be twofold: (1) an informational campaign that stresses the ii.@il)ortance of an educational foundation to underlie all patient care ae- tii-ities so that the boards, administrators, and medical staffs of our hospitals assign proper recognition and importance to the educational activities of their institution; and (2) direct financial support to establish the slieletal fraine- Nvork of facilities and personnel necessary to support the educational functions. The first of the requirements for help to the nonunive,-,sity hospital in e(Itica- tion is well under way. The publications of the Regional -.N@ieal Program divi- sion of the National Institutes of Health place constant stress on this area. Programs within other portions of the government are des @ed to stimulate the medical colleges and organized medicine to a more active recognition of continuing education as unquestionably the most important portion of the spec- trum of u-idergraduate, graduate, and continuing health profession education. Aceeclitiiig organizations and iiistitntional groups, such -as the American Hospital Association, should play a more important role in the stimulation of interest in the educational function of hospitals; they are just beginning to evidence interest in this activity. The Association of Hospital Directors of Afedical Education, composed of key individuals in stimulating and directing continuing education, continues to increase its voice, competence, and activity. Continuation and expansion of these initial activities on the part of all the interested groups and organizations will qssure proper emphasis to a function that will produce more good patient care in the future than any other single area of endeavor. The second need, that of funding support, becomes increasingly important as more emphasis is placed Dn continuing education. The Initial direction of funding in the Regional @ledical Programs and in the comprehensive coal- inunity plannin@ programs properly has been toward the commitment of monies for integrated planning of an approach to the problem of olviiltig the Corn- munications pipeline between medical education and r@-arcli an(] iii(@ll(-til care. Once these groups have planned to communicate effectively, we still are faced with the problem of a bride niid groom who are ge@riil)lii(-tilly f;(@lrtrtite. and who, therefore, must be provided Nvith the means to communicate niii)ro- priate to their desire to do so. FACILITIES A,D EQUIP'-%IENT Funds i)iust be provided for educational faciiltic3 and cqtiipt?i(@itt i?i ,unive?-sity hospitals. Facilities include most importantly, auditorium iii(i (-On- ference room space and their accoutrements, library facilities and materials, audio-visual ulaterials and departments, and areas specificlly (le.,zigii(,(i for c(lu- @,itioii,il demonstrations in patient care. These require brick, mortar, and (,(Itlip- inent funds, which most hospitals simply cannot supply from iiloilies currently available in their communities, the Hill-Harris program, or is a result of their ies that all hospitals must lo,,itient (,are efforts. Thc--e are the very basic facilit have to adequately perform their task in educating their staffs and personnel. They are multiuse facilities and, thus, can serve for the continuing edticati4oii of allied health lirofessionals as well as physicians. Design and coi@truction of facilities may occupy a considerable period of time; thus, their funding should be of first priority. Concurrently, however, funding izqtion of these educational should be iviilable to ensure proper and complete util facilities. To make these new facilities really functional will require tivo a(ldi- tional factors: (1) investigation and measurement to assure the most I)rodue- tive content of the programs they will house; and (2) adequate numbers of educationally competent personnel to assure the productive application of the identified curriculum content and the facilities. Two of the greatest problems for individuals with practical experience in continuing education are curriculum design and content and the motivation of the practicing physician who is the student. These two factors are inextricably Interwoven with a need to know patterns Df medical care and physician fune- 228 tion. The area Nvhere Deed for information and the presence of misinformation i"" most apparent is in the field of function-the activities of physicians in the delivery of medical care and the identification of their needs and motivation in relation to continuing education. There is sore need for support within the nonuniversity setting for the measure- ment and evaluation of continuing education to assure its efficiency and i)erti- nence. Additional need relates to the measurement iii(I evaluation of the I)Iiy@i- cian's performance, so that he can be helped to become more efficient and produc- tive in the delivery of medical care. In short, we should be attempting now to identify iritat we should teach and what changes in behavioi- we are trying to bring about through continuing education. ESTABLISH RIEGIONAL UNITS It would seem of great importance that within each of the Regional Ale(licl] Programs there be one or more nonuniversity bo-,pitil granted funds to construct and staff units to measure and devaluate systemically patient care and its n continuing delivery, thus to assist in determine need, content, and motivation i education. Th@ units should be staffed by physicians, educational personnel, and sociologists. Because each region by definition is singular in quality, it i., probable that each region will have sufficiently different needs to require (lif- fereiice in approach and measurement techniques. To establish just one or two national institutions or units involved in this type of research would be inefficient and ii)sufficient. This investigative function cannot be carried On in the university setting, for we,,ire studyingi nonuniversity organism. Once identification has been begun of need, content, iiid pertinence in relation to continuing education, it will be necessary to ensure that sufficient educationally oriented, able and motivated individuals are present within each community hospital (or available to it) to ensure productive usage of the information gleiiie(I and facilities added. This assurance, in, the form of trained personnel, might Yi ry across a spectrum encompassing highly skilled, formally trained educators in the larger and more coidl)lex hospitals, to individual @ff members who b,,iN-e had the opportunity to receive additional understanding in educational pliilo.,ol)hy, ,,;kills, and techniques in smaller hospitals and cotliiuuiiities. One might regard these individuals as the "marriage couiiselors" of our simile. They are vitally important to a marriage that has little solid foundation in previously existent love or mutual respect betNNetn its partners. Only after the establishment and support of COIIIJ)eteDt and productive coii- tinning education programs should attention be turned to large-scale ,til)i)oi-t of patient care facilities. While such devotion to competence in continuing edii- cation, orientation, slid ability would somewhat delay the construction of actual physical facilities for more omplex and sophisticated patient care, the delay would serve to ensure that these facilities would be properly utilized by pby.@i- cians. Some programs could be coordinate and concurrent. Caring for pitieiit.,,- is, after all, the primary purpose for the existence of our entire medical cii-e system. A PLEA FOR ACTION in summary, this presentation is a plea for a cogent and logical progression of activity in relation to Regional '@Niedical Programs. perhaps the most inipor- tant portion of the socially oriented legislation that has arisen in recent years. By siniile, it is a request for good, sound premarital discussion and orientation by the groom and the father-in-law to ensure that the bride of our "manager' has the knowledge and. the necessary appliances and counsel to keel) holes(., properly. Community hospitals and their health professionals must be pi-operli prepared to accept and use the knowledge that will pour from the perviously sclerotic communications pipeline. The medical care system iiinst have initial funding snl)port for identification of educational need and provision of educational space and personnel. Such funding will prepare it for the proper and productive utilization of the health care system and facilities to be established in the future as the result of coordinated regional and community planning for the delivery of medical care. To paraphrase Winston Churchill, "We are Dot at the end, nor the be,-iniiiii, of the end, but perhaps we are at the end of the beginning." It is of vital inip@- tance that we be sure that this "beginning" represents a solid foundation for i productive and functional future. 229 iNfr. ROGERS. Thank you. We ,i])preciate your being here. @i-re we getting enough reT)res@iitatioii f 1-oiii hospital administrators, f roiyi local people involved -,vith the delivery of services in the couiicils?, Afr. SipF-.Ry. From my vantage point I cannot generalize. I would say that because of my American Hospitil Association responsibility, I hear some sav we d@ not have enough hospital involvement. Others sav it is fine. Hospitals are certainly welcoine to participate. Generally, I beli@ve they are eigerfy invited to participate, so I don't naive much synipltliy for t]-iose who say they have not had an op- portunitytobeaniiitegralpart. . I tliii@k that our experience in ialicliigan ii-tiglit help you to see that this is not, Just t Continuing education proaraiii for our medical schools, but in fact is ,t program that was desi(rned to develop truly cooperative regional ,irraiigeiiients, and it took us many months to develop -,a ivorkinz mechanism for the three medical schools to co- ordinate their eff@rts and communicate because they had never done this in -,t similar wa-v before. I think the ver-@ fact tliit I ,ts executive director of a hospital council was asked- to take the initiative in trying to draw together the Progra,,,,Sand develop the grant application is i good indication that in our tate at least the hospital role wis well deiitified. Thank you very much. iAfr. ROGFRS. Thank -Von. Your testimony has been most helpful. This concludes the for today. The licariiias for toiiioi-i-o,%,v will be held, I understand, i@ the m,,iiii hearing room .,Iwhich is oil the first floor, room 2123, and so the coi-ninittee will now stand adjourned until 10 o'clock tomorrow moriiina. (Wlip,reupoii, at 4:15 p.m. tli@omniittee idjoiiriied, to reconvene at 10 a.m. Thursday, -.Nl,,ircli 28, 1968.) 298 IFIOUSE OF REPRESENTATIVES, Wa8hington, 1).C., March 26,1968. Hon. JOHN JARMAN, Cliaii,i)tat?, SubCOm'"Iittee on Ptiblic Health and lVcZfare of the Committee on Inter8tate and Foreign Commerce, U.S. House of Repre8entati-ves, IVa8hing- ton, D.C. DE.kR'@NIR. CHAIRMAN: Hearings are currently being held by your Su6committee on H.R. 15758, a bill to amend the Public Health Service Act so as to extend and improve the provisions relating to regional medical programs, to extend the au- thorization of grants for health of migratory agricultural workers and to provide for specialized facilities for alcoholics and narcotic addicts, which was introduced by the distinguished Chairman of the Committee on Interstate and Foreign Com- merce, the Honorable Harley 0. Staggers. Because of the increasing involvement In medical programs In the PRC!fic by the relatively young University of Hawaii School of Medicine, I would like to take this opportunity to comment speciflcally on Section 103 of the bill, under the subtitle "Inclusion of Territories." 2W This section apparently is designed to extend the regional medical programs to Gii-iiii, American Samoa, and the Trust Territory of the Pacific Islands, as well as to other areas. The extension of such programs would promote the acquisition and (liss . emanation of medical knowledge and skills throughout U.S. territories in the Pacific. Medical research and training in which the University of Hawaii School of Medicine is presently engaged in several cooperative ventures in these Pacific areas, would be strengthened and improved. The result of all this is that the people in these areas would receive the full benefits and assistance of Ameri- can medical science and technology. For the foregoing reasons, I strongly urge that Section 103 be retained In the measure that Is reported out by your Subcommittee. It Is requested that this letter be Included in the record of hearings on H.R. 1.5758. Aloha and best wishes. Sincerely, SPARK M. MATSUNAGA, Jfeniber of Congress. AMERICAN HOSPITAL ASSOCIATION, Washington, D.C., March 26, 1968. Hoii. HARLEY 0. STAGGERS, Chaii,,nian, Interstate and Foreign Comnterce Committee, House of Representatives, Washington, D.C. DEAR CONGRESSMAN STAGGER13: This statement expresses the views of the Amerl- can Hospital Association on H.R. 15758 which amends the Public Health Service Act o as to extend and improve the provisions relating to regional medical pro. grams. to extend the authorization of grants for health of migratory agricul. tui,til workers, to provide for specialized facilities for alcoholics nnd narcotic ad(licts, and for other purposes. REGIONAL BIEDICAL P@RAIIS This Association strongly supported the development of the l(@lzllalatlon which resulted in P.L. 89-239. We were pleased that certain recommendations, which we felt were essential to the most effective development of tli(, J)romtu, were incorporated in the law. We have continued to follo%v carefully and %vith great In- terest the progress o,' the program. The past two years al)lviir to have hewn nvnt in the main in the establishment of regional programs and In their planning. 'no operating stage of the program is really only just beginning ivith it liniltt-d number of lir(@jects having been approved to date. Though good planning Is highly es"ntial it I,, to be hoped that the program will move forward rapidly la Its iil)l)licntion. We have always believed the purpose of the bill is to establish a bridge between the science of n3ediclue and its full application to the care and treatment of patients. In the coming months, therefore, it is to be hoped that the programs developed will be felt by the public in terms of a broadened application of kilowl- edge in the treatment of these diseases covered under the program. We urge the Committee to authorize the full amount requested for the program for the fiscal ,vea r ending June 30, 1969. The Association has continued to feel that implementation of the intent of the law would necessitate a full involvement on the part of hospitals and their medical staffs. This will necessitate not only the participation of the medical schools and the larger teaching and comniiinity hospitals but the smaller hospitals spread throughout the nation which provide a focal point for medical care and treatment in smaller communities. We have been disappointed at the e%teiit of involveiuent of hospitals and particularly the minimal participation of these smaller community hospitals which is so essential if the pro,-ram is to have meaning to the public at large. Therefore, the American Hospital A-gsociition will undertake a n@ber of steps which it is hoped will result in a much wider involvement of hospitals. We have also noted that very little emphasis has been given thus far to preventive care and long-term patient care and we intend to stimulate leadership on the part of the hospital fleld in fostering such a broad approach to the regional medical programs, We will continue to work closely with the administrators of the program and to work for the full(@st participation of the hospital field. 300 We recognize fully the merit of thorough planning is ii basis for the develop- ment of regional medical programs. Such plans, of course, must involve the facilities, personnel and services pertaining to the illnesses covered under the program. However, the Congress under P.T.. 89-749 initiated comprehensive be.qlth planning thereby establishing planning mechanism,.; throughout the nation to be involved in over-all health care and to specifically include health facilities, services and personnel. It is obvious therefor(,, that rather complete duplication of planning now exists between the two pro,-:rani,, and from reports %vhich we receive we are just beginning to witness the confusion resulting from this conflict and overlapping. If health planning, which We strongly al)l)roi-(-. is to be developed in an orderly niiiiiier. any overlapping an(] cozifliet must be re@olve(l. At present the existing provisions go far towards encouraging coiii- petitive activities for domination of the field. We recommend, therefore, the Congress take action to eliminate the exiqtii),- overlapping and confusion by requiring that the cooperative regional medical programs developed under P.T,. 89-239, 9Dd the results of the planning de@-EIfjl)e(I under P.T,. 89-749 be in conformity- H.R. 157.58 proposes to increase the membership of the advisory council from twelve to sixteen members. In order to facilitate further the closest l@os,,ii)le coordination between this program and the comprehensive health pro- grain, We would urge that additional representation of council meiiil)er:4 1)(, required to include individuals directly en,@azell in area and @tate wide I)Iiiiiiiiig activities. We are pleased to note that the bill, as in the or!-inal Act. does not to authorize funds to be appropriated for construction purposes. The program is of such magnitude that we believe the funds zhoul(I be expelled for the operational ph,t.@es of the hill. @rther, we feel it would be unwise to duplicate the coli:@trtic- tion authority now provided for in other acts. The bill requests clarification so that grants may be niid(-@ to agencies and institutions for services which will be useful to two or more regional medical programs. There are various services which can be developed most efficiently iii(I effectively for larger areas than would be enconil)as5ed in q single region. We believe, therefore, that the authority to iiiale grants as suggested here is desirable. '.FIGRATORY AGRICULTI:RAL WORKERS The bill proposes to extend the program of grants providing for health q-ervices to migratory agricultural workers for an additional two years. We strongly stil)- ported the original legislation and later urged iii increase in the program @o i.@ to permit payniei)t to hospitals for care provided iuigratory workers and tlie"r f,iniilie.q. Our recommendations were made after a study of the problplii of migratory worlers in considerable depth. We found that hospitals in part- of the country were providing care under emergency circumstances and ,tvitli very sizable costs for services and for which no reimbursement Was avail- able. We were, therefore, very pleased that the Congress provided funds Which could be paid to hospitals for inpatient care. The major portion of the funds which have been mi(le available go for the provision of public health services and preventive medicine with a ver3- nio(le.-,t amount being made available to pay for inpatient hospital care. We urge, there- forc,. flint the funds to be provided under the bill be increased to at least $13,000,- 000, With $5,000,000 of this amount being allocated for reimbursement of h@l)it@il.@ providing inpatient care. Because of limited funds, the administrator, of the program have necessarily restricted payments to hospitals under the program to areas which bid an over-all public health program for migrants. Therefore, no provision has been made for assistance to migratory workers in transit or in areas of the country which bad no over-all public health program for migrants. The increased an- tliorization which we have recommended.,bould enable the administrators of the pro,-ram to provide inpatient hospital care to migrants wlierever it @- needed. Further, we recommend that the program be authorized for a period of four years instead of the two years called for in the bill. We have no comment at this time on other provisions of the bill. We would appreciate your making this statement a part of the record of these hearings. Sincerely, KENNETH WILLIAMSON, Associate Director. 301 NATIO.N@AL TUBERCULOSIS AND RESPIRATORY DISEASE ASSOCIATIOV, 'Veic York, N.11.,.ilarch 20,19(;S. HOn. HARLEY 0. STAGGERS, Cilai?-Man, Interstate and Foreig?i Cotitinerce Coi)i,piittce, Hou8e of Representative8, TVaslti?igton, D.C. DEAR MR. STAGGERS: The National Tuberculosis send Re.,zj)iritoi-y Disei.,4e -is- soc-lation wishes to express its support for continuation of Itegiolial Ile(lic;il 1'1,0- granis as provided for in H.R. 157@@, Although Programs have been largelv de- velopjilent,il, reports of progress throughout the country indicate tliit the majority will shortly be iiiitiating operational activities. Rel)Ort,@,- indicate ,iii earnest desire on the part of persons concerned with this Federal program to fulfill the purposes of the legislation; namely, that the American public re(,eii-e improved uiedical services through coordinated and more efficient delii-c-ry of medical and paramedical skills and talents. Authorization for funds must be adequite to meet the groiviiig need., of the Programs in the next few years if they are to achieve their goal. The inoiii(,Iitliiii of this Federal program, which iiivolies relationships with many igencie.,,- :11)(I groups, is accelerating as operational activities are due to begin. Readizie.,;.-; to rierform will be affected by the amount of Federal funds ai-ailal)le. Tliei,efor(' the Committee should consider Ni,hether or not the authorization of $65 million for fiscal 1969 is large enough to permit implementation of the extensive plans developed over the past few years. The NTRDA is particularly eager that Regional @fedical Programs be stic- cessfully launched into operational activities because of the great need to inil)ron.e services for chronic pulmonary disease patients. At time of appropriating funds for fiscal 1968, Congress specified that between one and tin-o million dollars of the RMP appropriation for thit year be devoted to chronic respiratory di."-el.,e prograi2is. The NTRDA had requested such action by Congress because of the ei-itic@il situation in diagnosis and treatment of these diseases, particularly enil)llv.,Ciili. Incidence of emphysema has ,4o accelerated tl),it it his become the second iiiost frequent disease for which beneflts are granted to workers Ni,ho are retired for disability prior to age 65, at ail annual cost of about $90,000,000. Other diseases of pulmonary insufficiency, such as chronic broneiiiti,;, are wideql)read and resIX)II.@i- ble for much illiiess and restricted activity. Deaths from emphysema have doubling approximately every fiveyears in the recent past and along with ii.,tliiiiii and chronic bronchitis now represent the tei)th cause of death in the L'ilitt@(i States. The seriousness of the chronic reql)iritory (Ii.@.,i@e situation the Public Health Seri-lee and the Nitioiial Tuberculosis and R(@slifriltorv Association to convene a Tisk Force in the Fall (if 1966 to lio%v tile (,()III r(.) of these diseases could be improved. The critical needs III for patients @aiiie a focus for iiju(-Ii of the till(] it-(I to (-II(, (if (lie Til-k Foree's major recommendations; iiiiiiielv, that lir(i%,Isioti tx, iiin(le f(ir 1-tilaii-,tinry function laboratories, re.,41)frittori,-(,iire units. itti(i grain.-. Data indicate that the lack of Is h"pitals are even AN-itilout the ttl)lj:irtittis to take (-Arv #if -cri4ltl-I.Y- ill respiratory disease patient,;. Orgiiiiizt-(] I)rtogriiiii- eLl-I Ill 4-itl@ d small percentage of our general hospitals, ollfl&Bti("It clil;lt-0 'tillitll "h play a full role in rehabilitation and couii.@t,liiig of ri-@lilritit,ry til-Araw tvntiri@14 ,ire virtually non-existent. ,The community pra(-titioiier is 1),,irticiiinrly at 11 lo." to 13t'IP latlettle nfth chronic respiratory disease except for re(,Ollllllell(lillg Ahri3 tt,4, illness becomes critical. The average getiernl 1)rti(-titit)tit,r fit tile victiul tit I"' adequate education because of the ree(-ney ill tile rie of lilt--41 'nllt'@ the type of supervision needed to protect 1)lltit'lit-s from actitt% ltift-ellon-I mbtl It' maintain their physical condition at as optimal a lt@vcl ft-'4 call"(" 'hp provided in most communities under existing condition.,;. rr-ti,irntorjr It is obvious that direction and stipervL,;iotl of high qllalitv (-Iirot disease programs must be provided by medical -(-Ilools RII(I llle(ll('fll Demonstrations of patient diagnosis and treatment must be brought to tile munity practitioner through continuing education cotirFel-4 offered by theme institutions and facilities. The Regional '.Nledical Programs offer the, itio!,t 302 expeditious way to achieve this goaL Interest in improving programq for chronic respiratory disease patients exist in many areas and it is our belief that this interest will generate development of such programs. TB-RD associations will help stimulate interest in such programs, utilizing their background of experience in promoting better patient services. In the past, many associations have supported medical education in pulmonary disease, and li,qve demonstrated the need for screening surveys and diagnostic and treatment services. TB-RD associations were influential forces in communities for many years in promoting more adequate services for tuberculosis patients. In the same way, associations have been in a position to witness the dearth of help for emphysema and chronic bronchitis patients today and because of this, they will be good coiuniunity partners to the RMP in seeing that the urgent needs of respiratory disease patients are met. The American Thoracic Society, the medical section of the National Tubereti- lo@i.@ find Respiratory Disease Association, has provided leadership in medical standards and research in tuberculosis and other respiratory diseases. Staff of our organization will continue to work closely with the Division of Regional ,Aledical Programs to promote high standards of diagnosis, and care for chronic respiratory disease. The NTRDA is pleased with the proposal In H.R. 15758 to expand the number of Advisory Council members from twelve to sixteen. At the time Congress speci- fied that attention be paid in Regional Medical Programs to chronic respiratory disease, it also requested that one of the members of the National Advisory Council have competence in this particular medical field. Expansion of Council membership will provide more scope for ensuring representation of the various areas of medicine which are of necessity Involved in the many activities of Regional Medical Programs. We question if evaluation of Programs, as provided in Section 102 of the bill, should be performed solely by the Secretary. It would seem more satisfactory for both the Department of HEW and the public, to require that such evaluation be done by outside groups. We are certainly in support of extension of grants for health services for migratory workers and our only reservation is that these seem very minimal amo,.ints considering the high rate of disease in this segment of our population. Tuberculosis rates are high in these people because of their low economic status and beeiuse their living conditions favor spread of the disease. We support provision of funds for construction of special facilities for inpatient and outpatient treatment of alcoholism. Alcoholics have a high rate of tubercu- losis. and extensive difficulties have arisen in recent years in hospitalizing many of tlies(@ persons in community hospitals, including tuberculosis hospitals. Some of these difliculties would seem to be obviated by the provisions suggested. How- ever. recognition of the high rate of tuberculosis in alcoholics is essential in planning adequately for treatment facilities. It gives us great pleasure to record our support for extension of Regional 'Aleclical Programs. Sincerely.voiirs, JAMES E. PERICINS, M.D., Managing Director. AMERICAN DENTAL ASSOCIATION, 'Wa8hington, D.C., March 27, 196S. Ilon. JOIIN JARMAN, Chait,)iian, Subconiiiiittee on Pitblic Health and TVelfare, Committee on Inter8tate aiid Foreign Commet-ce, Hoitse of Repre8entative8, TVashington, D.C. DEAR MR. JARMAI: Pursuant to the announcement of March 18, 1968, the American Dental Association wishes to submit Its views on H.R. 15758, the Health Services Act of 1968. The Association's brief comments will be limited to those provisions of the bill which would extend and Improve the Heart Disease, Cancer and Stroke Amendments of 1965 and the Migrant Health Act of 1962, as amended. As part of its commitment to improving the total health of our people, the American Dental Association is sympathetic to the goals of H.R. 15758. The dental profession has particular and long-standing concern with respect to ol-,il cancer and some forms of heart disease. Additional research into the pre- 303 i,ejitioii and treatment of these disease niaiiifestatioi)s is needed and call and should be included in the regional medical programs authorized in H.R. 15758. lVh(,n the Heart Disease, Cancer and Stroke legislation was under consideration in l@)65, the Association submitted to this Committee details regarding the iiiei- deuce of oral cancer and the low survival rate of victims of the disease. At tl)at time, attention was directed to the need for more research into the specific causes of oral cancer and the methods of treatiueiit and rehabilitation of patients who suffer from I @. 'the Association is pleased to note that considerable progress is being made in this field and that members of the dental profession and several dental schools are participating in the prograius that are being developed. The Association also is pleased with and supports fully the amendment included in H.R.'I,5758 which makes it clear that a practicing dentist as well as a 1)liy- .@ician may refer a patient to a facility engaged in research, training or (teiiioii- stration activities which are supported by regional medical I)rogaiii fund.,;. Al'itil resl@t to the provisions of the bill extending the migrant health I)i-o- grani, the American Dental Association recognizes the need for increasing tl)e availability of dental care for migrant workers and their children. The A@@ociti- ti(i;i supports the extension of the program but agrees that i,-, soon ,is feii@itjl(,, this activity should be included in the regular public health programs of and comuluilities. The American Dental Association appreciates the opportunity to present its views on this legislation and respectfully requests that this letter be inclu(l(@(I ill the record of hearings. Sincerely yours, JOHN B. WILSON, D.D.S., Cliaii,man, Coitiicil o?z Legisl(ttir)it. UNIVEI?SITY OF HANI'All, SCHOOL OF lIfEDICI-NF. Ho?tolitlu, Hawaii, 21a)-clt 13, Re H.R. 15758. Hon. HARLEY 0. STAGGERS, I)tter8tate and Foreign Coinmerce Co?7t2kziti@e, Hoitse of Repre8entative8, TVashington, D.C. DEAR REPRESENTATIVE STAGGERS: House Resolution 15758 includes a paragraph on "inclusion of territories" which would bring Guam, American Samoa, and the Trust Territory of the Paciflc Islands within the scope of the Regional Ife(lic@il Program. The Medical School of the University of Hawaii Is involved in medical and teaching in many areas of the Pacific. We have been asked by the lie,,iltli ,administrators in American Samoa to develop an alEllation between the iic%v Lyll- (Ion B. Johnson Tropical Medicine Center and the University of Hawaii of Ifedicine. The same applies, but at a somewhat more preliniftiar3, stage, %%-It)) the health administrators of the Trust Territories, with si@fil regard to tlit, lio.,;- I)it,tl that will be built on Ponape. These programs will be mutually advantageous ,is we will provide continuation education for the medicnl and tiursitl,, ,and they will provide facilities for research and certain aspects of educitil- f r our faculty and students. I would urge your support of the parfigrapli In question I)tTqiise this facilitate the cooperative ventures described. Sincerely yours, )VINDSOR C. CuTTi,,,o, M.D., Druit. 304 TAMPA, FLA., March 20, 1968. Cougressman PAUL G. ROGERS, Holtse of Repi,e8entatives, iVa8hingto,ii, D.C. DEAR CO-IGRESSMAN ROGERS: We have Just started our Florida Regional 7%le(li- cal Program and not too many physicians tire yet aware of its great potential for improving the quality and efficiezi(-.v of medical care through improvements in communications and in continuing medical education. The Regional Medical Programs must develop into ongoing operational proj- ects and therefore the administrations bill to extend and slightly modify Regional @ledical Programs is highly desirable. This is the type of congressional legis- I.ition the physician in practice and in education will favor. Cordially yours, H. PHILLIP HAMPTON, M.D. U.S. GOVERHM[MT PRTNTING OFFICE: 1946 0-309-653