I' A It 'I' M I-,' N 'I' 0 FI I I,' A 1, 'I' 11, E 1) TJ A 'I' IN A N D W E L F A R E Health Services,and Mental Health Administration Division of Regional Medical Programs' National Advisory Council on Regional Medical Programs Minutes of the Meeting February 2-3, 1971 Parklawn Building Conference Room G/H DEPARTMENT OF l@@EALTII, EDliCATION AN[) W,:,I,FARi;' PUBI,IC ifEALTI-i SI--IPVICE National Advisory Council on Regional Medical Programs Minutes of the Twenty-second Meeting 1/ Z/ February 2-3, 1971 The.National Advisory Council on Regional Medical Programs convened for its twenty-second meeting at 8:30 a.m., Tuesday, February 2, 1971, in Conference Room G/H of the Parklawh Building, Rockville, Maryland. Dr. Harold Margulies, Acting Director, Regional Medical Programs Service, presided over the meeting. The Council members present were-. Dr. -Michael J. Brennan (2/2 only) Dr. William R. liunt Dr. Bland W. Cannon Dr. Alexander M.'McPhedran Dr. Edwin L. Crosby Dr. Clark II. Millikan Dr. Michael E. DeBakey (2/3 only) Dr. Alton Orhsner Dr. Bruce W. Everist Mrs. Florence R. Wyckoff Mr. Harold H. Hiiiesl Jr. (2/3 only) Dr. Marc J. Musser (2/2 only)@@@ A listing of RMP staff members, and others attending is appended. 1. CALL TO ORDER AND OPEiiING REMARKS The meeting was called to order at 8:45 a.m. on February 2 by Dr. Harold Margulies. II. INTRODUCTION OF NEW COUNCIL MEMBERS AND EX OFVICIO MEMBER FROM THE VETERANS ADMINISTRATION Dr. Margulies introduced Dr. Herbert B. Pahl, the new Acting Deputy Director for Regional Medical Programs Service. Dr. Pahl will have responsibility for work with the Council. It'is hoped that future Council meetings can be held in smaller more convenient quarters with staff services planned to help the members make optimum use of their sessions. Dr. Margulies welcomed Dr. Alton Ochsner as a new Council member, and Dr. Marc J. Musser, the new Ex Officio member from the Veterans Administration. Another new member, lir. ilarold It. [lines, @ir,. was introduced the following day on February I/ Proceedings of meetings are restricted unless cleared by LltL- Offi e o the Administrator, HSPIIIA. The restriction relates to all r&-iteri 1 stibiti@ tt for discussion at the meetings, the supplemental material, and all.otlie official documents, including th@ agenda. 2/ For the record, it is noted that members absent themselves from he meeting when the Council is discussing applications: (a) from th ir re soective institutions, or (b) in which a conflict of interest T-light III. ANNOUNCI,"MENTS Dr. Margulies made general announcements, and called attention to "Conflict of Interest," in the information folder.. the statement on, He reported that Mr. Curtis Treen has resigned from the Coun cil and th'at'we are working on the appointment of new Council members to increase the membership to twenty, not including the Ex Officio member from the Veterans Administration, in accordance with Public Law 91-515. IV. CONFI@IATION OF FUTURI,- MEETING'DATES 'flie Council reaffirmed the following dates for future meetings: May II.-I.2. 1971 November 9-10, 1971 August 3-4, 1971 February 8-9, 1972 V. CONSIDERATION OF MINUTES OF THE NOVEMBER 9-10, 1970, MEETING With the addition of Dr. Hunt to the list of Council members present, the Council unanimously recommended approval of the Minutes of the November 9-10, 1970, meeting as written. Dr. Brennan, Chairman of a Council subcommittee on automated multi- phasic screening, announced that the subcommittee had met the day before for six hours and that they are developing a working conference to be held in April 1971. The members of the subcommittee are: Dr. Michael J. Brennan, Chairman; Dr. Alexander M.:McPhedtan, Dr. Clark H. Millikanl and Dr. John E. Kralewski of the Review Committee. The working conference in April will be held in Detroit and will report its findings to the Council At the May meeting. VI. LEGISLATION, APPROPRIATIONS PMPS BUDGET A. Termination of RMP Support for Projects At the November 1970 meeting, Council discussed project renewal and termination of RMP funding for those that seek such support beyond the dates at which they originally proposed to terminate or become self-sustaining. At this meeting Mr. Roland Peterson, Assistant Director fbr'Planning and Evaluation, presented salient findings from experience in six regions with 90 projects that became operational three or more year,% ago. In most of these projects, three or mote years of RMP §uppor was requested initially. Thirty percent of the group terminated@RM support on schedule. In some regions this happened with 60-70% of tile. projects. On the other hand, many individual projects expandc-d@ @oTn@ their budgets. In sor@-,,- instances projects seemed to diRappe.@l 3 F-MP listings, but the activities continued to receive support through the budgets of core or other project activities. @ support tended to persist longer for medical school than for community projects.@ This kind of analysis will continue to be reported. Additional regions will be included as they reach appropriate ages. B. Overview of Adaptation to Requirements of New Legislation The ongoing process of adaptation to the "program review" and triennial cycle must be integrated with adjustment to features added to the legislative base by P.L. 91-515. Regulations and guidelines are being re-examined for this purpose. It is hoped that the formal.regulations can be ke tsimple and straight-forward. Publication of guidelines p should take a form that will facilitate both their development by -Council and their application to RMP operations. New-legi8lation features of particular interest include: 1. Review of RMP plans by CHP "b" agencies that have plans in being: @IPS is hopeful of broadening the RMP-CIIP working relation ships beyond the letter of the law, to improve the combined effect of the agencies' planning-on health services. 2. DHEW recommendations for changes in the scope of the program. Modification of the disease-categorical targeting of the legislation might be one such Proposal that RMPS and Council should examine. Council may wish to express its opinions on any proposals concerning the scope of R14P or CHP legislation that go to the Secretary.@ 3. Annual report on RMP effectiveness: The first report, alre@idv prepared by MIS, was essentially a status, or baseline report. Council may wish to contribute to these reports regularly. The schedule for such reports suggests that Council's input should e presented in the fall of the year. C. Budgetary Outlook Plans for the fiscal year 1972 budget will have a considerable impact on the final apportionment of-funds for the remainder of fiscal year 1971. At present the outlook is for level funding of RMP grants at $70 million for each of the two years. this would be accomplished by reserving a largo part of the 1971 appropriation to be carried ovet@fo obligation in 1972. This presents two kinds of problems. First, b&cAO.Se@ it requires a major reduction in current commitments to Regional Medic Programs for both years, the planning and persuasive aspects of the Regional Medical Programs becomes more important with less emphasis 0 their capabilities to support projects., Secondly, it presents a very low appropriation base for the 1973 budgeti so that maintaining the s 4 $70 million level through that fiscal year will require a ignifica s nt appropriation increase. The 1973 budget presentation is.essentially a technical Droblem that must be solved by MVS within the DHEW structure. The adjustment of RMP awards to the proposed reduction would affect everyone and requires Council.'s attention. One possible route would be to find the necessary reduction by cutting awards to th@e less effective regions, and retaining levels closer to-existiilg commitments in tire more effective regions. This and alternative policies will be the subjects of intensive study over the next few weeks. D. Progress in Administrative Adjustment to Legislation, the Triennial Cycl e and National Emphasis on Programming Council's policy statements are being examined for possible' review and up dating. Review criteria have been updated, but are subject to modlfl-@ cation and refinement as necessary. Council's Oartl.clpition will be sought as plans and drafts become available. When completed, these materials will be given not only to Council and staff, but also to the Regional Medical Programs as well, as aids to program development. Meanwhile the RNPS,,--l',-,, developing a comprehensive review system integrated with a new Management Information System. The objectives of these de- velopments are to effect economies in time, integrate RMP activities wt the total HSMHA program surveillance, and improve RMP per forman6e. These developments are intended to potentiate the formation and implementation of our human judgments. 1. I'he current staltus of the RNPS Management Information System was presented by Mr. Frank Ichniowski, Acting Chief Office of Systems Management, RMPS. During his presentation lie highlighted.,96me of fire most recent accomplishments of the MIS t6,am and then proceeded to tie-in these current activities with the MIS implementation plans .In line with those plans, lie announced a planned reorganization ot Office of--',,,-f;,L-ems Management to better reflect the demands of the Management Infi-'-rma'. tion System and to more optimally utilize availabl personnel. This reorganization provides@for separate brantli I activ.ties within OSM dealing with: MIS Design and Analysis, Pro ramming. and IS 9 Data Base Control. It was pointed out that at least five major sources will be providing inputs to the MIS.. These inputs include the Anniversary Review Application, tl-,@.I-!@egional Reporting System, Site Visits, and other reports on contact, R'JIPS Staff and the ReR!6nai Office. Certain oh efforts currently uii@'erway by the MIS team were identified, namely 'Development of an MIS liaison team, use of MIS;@consultant, and MIS Lli.-it Lliesc! exLrzi curricular acLJvltl.c!s will strengthen and more accurately guide tbc, plan being developed. Mr. Icliniowski then linked these various ongoing activities to alseries of proposed outputs which could reflect the needs and demands of the system users. This output.plan categorized outputs as emanating from combinations of four major:gtoupings: Financial Information, Re ional Characteristics, Performance Records and 9 Control, and Historical Records. ultimately, the MIS willprovide usage, viA remote teletype or video display units7, t:o RMPS, Review Committee, National Advisory Council, HSMHA, the Regional Office and the Regions themselves. The Review Cycle and its Tools. Mr. Kon Baum presented a description of the purposes, phases and tool.s of the proposed triennial cycle of review and surveillance.: a. Council Discussion On efficiency of operation: Development of such systems always risks over-elaboration of the Management InfotmAtiOn System; the manualizing of procedures, titualization of sit6 visits and of application reviews can r6sult in ever increasing demands on staff and advisots' time. Danger of over-simplifying a complex multi-distiplinary operation like the management of RMP; observance of rigid pro- cedural specifications may conceal real problems and foresta1 application of important professional judgments. ... Council-staff responsibilities: Need full understanding of Council's responsibility for program and financial judgments. In some research programs councils have concerned themselves ls with content, left funding to staff discretion. Some cbuhti control initial funding and commitments;,ottlers concern them- selves with other funding decisions. Staff discretion in approving program changes without Council t6view also needs definition. ... Regional Medical Program development and progress: Council needs to observe conformance with guide,s, quality of Project designs and operations not only to maintain program direc@ @o but also to evaluate its own guidelines and policies.@ 6 I)cvcl.opmeiits rc@i.,,ioiis do not always present -tflem-;elv(!.q on fixed annive@- or triennial- clites; sometimes it is highly desirable to review and activate new departures as soon as their virtues become apparent. Cross communication between regions could be impeded,at considerable loss in effectiveness if concepts had to await fixed dates of Council- review. Council's job is primarily policy determination, but both' cyclic@-I and interim reviews of operating and proposed changes contribute to judgments. Perhaps Council and staff action respon.,:'.-,-i@-i-'-ities could be enumerated, with staff pre- sonting a list of its actions for discussion at each Council meeting.. The position of.the Regional Advisory Group needs very clear specification in documentation of the review process and the assignment of responsibilities. b. Staff Response ... Efficiency of operation: Staff projections for the tiodes of operation in the management information and review procedures now envisionf.,,"@ -@@.@ldicate that the new approach will save time on routine basi-"r.@rocesses and leave more time available for sub- stantive tar'ks. ... Over-simplification: The general aim of the plan is to emphasize human professional judgments at all points of decision. Coundil-staff responsibilities: Council Is responsibilit es for grant decisions are fixed by law.- the purpose of this Pr cedural development is to give Council a choice of ways in wh,ch its responsibilities can be carried but efficiently. Staff will prepare a list of Council-stAff responsibilities and Council chbi@@7.@': for next meeting. ... Regional'@iedical Program development and progress: Cross- communication between regions occurs naturally through direct region-to-region exchange and through region-staff-regioh'route@-. Staff plans to bring Council a report on cross-cotmunication at the next meeting. ... Council artion: Staff was requ68ted to circulate for'con sideration at-"I. next meeting a description of the proposed review process and.tlie types of judgments that would be roserved;@ to the Council. 7 VII. REMARKS BY DR. VEIZNON E. WILSONL AILM iN@l-I'RATOR, BEAI,THTSERVICES AND 'fENTAI, IIEALTII ADiklINISTRATION A. Ai)nointmeht of Director: Dr. llarol,c] Margulies ha-, been confirmed: as Director, RMPS; only the paper work remains to be completed. B. Recommendations of the Willard Task Forc@: Completion of the task force report is expected soon. Unfortunately a draft could not be developed in time for this session. C. Health Maintenance Organization: The Health Maintenance Organizdti6n@ (HMO) concept is a broad flexible one that has strong HEW support. The term now refers to organizations providing comprehensive health care to enrolled populations and financed by capitation. Prepayment and carefully defined packages of services to represent comprehensive care are important elements in current considerations. HEW is very active in implementing the concept and in stimulating the formation of IRAO'S. Late in November the Secretary appointed the following four task forces to examine important aspects of HEW posture toward the concept: Policy Relationships with non-IIEW agencies Financing Technical Assistance The Administrator, HSMHA, heads the technical assistance group. liowever,@@ heads and members of the groups were selected, not to represent their constituent agencies,. but to explore concepts of the Depattm6nt's in volvoment. Ultimate assignments for implementation of HEW polities and@ responsibilities for HMO's are by no means obvious and certainly are@not' decided. There is a high probability that HSMIIA as the Department's technical agent in health care delivery will have an important role in technitai assistance for IR40 propagation. Clip agencies undoubtedly will have review and tomment responsibilities concerning proposed l@j'O activation. RMP as a channel for provider expression will be fully involved. It seems clear that HEW will actively support promotion of HMO at lvation. The Department will offer technical assistance and the planning an coordinating capabilities of its field arms and associated ag6n6i a 'th the@HMO.' There is no plan to replace existing forms of Health c re wi 31 tlie'ol)j(@ctive is to open access to health care as broadly as POSS DIC ana@ j I V @i,i ii) i', Funding of HEW activitii. @;'as yet unresolved. $2i25 mil.lion may be available from NCBS@RD 19 71 appropriation; some amount might be taken from reserved MiP funds; other amounts may yet be found elsewhere. Technical assistance furi(A-L-iig might well become a IISMHA responsibility. Whatever is decided for fiscal. year 1971 activities will affect planning for 1972 appropriations for other programs as well as for the liSMHA total. D. questions and Answers: Q. What are the characteristics of a desirable HMO? A. It has taken fr6@.-.@ @@eptember to January to arrive at the following list of characteristics: An organized system of contractually related health@caro facili- ties; an organized multi-disciplinary group of health care pro- fessionals; an enrolled group of clients; a sound insurance plan. N6 rigid proscriptions have been adopted for accommodation to the insurance plan or for minimum enrollments. What is the Department's view on cover ago of enrollment? A. Broad. if accel-. :o health care is to be extended through the e,' SSA and HMO device, soi@'! roups will require assistance. SRS are looking at',Lhis. A Family Health Insurance Plan might be a vehicle for extending coverage.. Q. Looking beyond the problems of initiation and establishment, what will provide long-term support? A. A soundly planned HMO should be supported by the revenues from, its operations. Will Federal contributions on behalf of Federal beneficiaries be uniform? A. It seems loigic;'@@ t,.o bel.ieve that Federal IIMO's will expect uniform or at least minimum packages of individual or family care, but will "regiotalize" the prides of the standardized packages. Could a large employer set up a "liousell HMO? A. Some are alread-@ ,@.tudying the idea. It seems likely that three or four will ap-,..,", soon. Labor organizations also are interested. 9 Is legislation expected? A. -Proposals on financing loans and insurance are being considered. Nothing new is needed for program,administration. Q. What rate of progress does the IIEW visualize - how many HMO projects might be established in a year? .A. Many questions must be investigated in order to organize an HMO, establish the necessary contractual relationships, specify and price service packages, and work out enrollment principles. About fifty groups are known to be interested. Q. What is the outlook for action in the field of quality of medical care? A. Models for operations in this field are needed. SSA, SRS, and HSMRA are studying the possibilities. Agency responsibilities are not yet clear. The RMP as a provider organization might logically be a vehicle for administration, but lacks cr6dibi ity because performance has been uneven. This is one@of@the mu ti-@ program topics on which Council may expect to be asked for advice, in line with last meeting's discussion. VIII. STATUS REPORT ON GUIDELINES, CONTRACTS AND PLANS FOR THE FUTURE A. Heart Disease, Cancer and Stroke Guidelines Dr. Margaret Sloan reported on the status of the heart disease, cancer and stroke guidelines. Preparation of the guidelines has been going forward under three contracts. These have enabled multidisciplinary groups of health professionals representing all the professional organizations interested in a particular disease area to obtain the consensus of experts. Agreement has been reached on the criteria which would have to be met by medical institutions in the country in regard to personnel, organization, and facilities if they were to be capable of providing the highest quality of care for patients with heart disease,, cancer, or stroke. In the original concept, these groups were expected to develop criteria for a list or lists of 10-20 outstanding centers in the country as required by Section 507 of PL 89-239. As the work progressed, it was redirected to the present focus on quality care in all types of medicine installations which will be more broadly useful. The Cancer Guidelines prepared under a contract with the American 11 'College of Surgeons, are about to be published by the College at their own expense. The final document will still not be entirely satis f! t to the Council, but should prove useful in setting a goal for de eiopment of resources for trip nf r-irr@er patients @ @ @ !II 10 The Heart Disease Guidelines, being prepared by the Inter-Society Commission on Heart Disease Resources under a contract with the American Heart Association, are being published in preliminary form as a series of reports in the Journal Circulation. These deal separately with each major form of cardiovascular disease excluding stroke,'arid cover the areas of prevention, diagnosis, treatment, and rehabilitation. When the last report has appeared in Circulation, they.will all be reviewed again in the light of comments and criticism received, revised as necessary, and printed in monograph form by the C.P.O. Initial response to tliese;lreports has been most enthusiastic. RMPS is now working on problems of publicity, distribution, and gaining the attention of physicians, hospital personnel, and health planners to their contents. Impl.emcintation wil.1 be stimulated by the l@Ps and the affiliates of the AIIA. The Stroke Guidelines are being developed by the Joint Committee for Stroke Facilities under a contract with the American Neurological Association but have not yet reached the publication stage. There was agreement that the Guidelines would be of value only as long as they are kept up-to-date and, therefore, that a mechanism should be established for periodic updating and.revision. In the case of the Heart Disease Guidelines and in an attempt to preserve continuity in the effort, it was proposed that a new contract be negotiated with the AHA to continue the ICHD for 6nb more year during which that organization would carry out an evaluation of the acceptance and applicability of the Guidelines. At the end of that period, it.was anticipated that the AHA and the American College of Cardiology would jointly assume responsibility for revision and maintaining the currency of the Guidelines. A similar arrangement will eventually be considered for the Stroke Guidelines. In the case of the Cancer Guidelines, which are organized according to the specialty groups involved in diagnosis and treatment, the Council considered the possibility of a different approach which might be mounted to 'Consider all the resources of personnel, organization, and facilities needed to deal with each major type of cancer. The Board of Regents of the American College of Surgeons" was considering the establishment of a Task Force which might under- take the development of cancer guidelines dealing more specifitally with the major types of cancer. Dr. Brennan proposed that @S negotiate a contract to develop a model for the comprehensive, multidisciplinary treatment of cancer patients on a regional basis using a systems analysis approach. Ilie concept proposed involved: -.1 Period ui' years ahead; 2. Meastjrln- the cancer control resources and capability of tll 0 region to provide the quality of control c@nvi.sioned in the Guide lines 3. DeLermining the improvements needed to make the region',s cancer capabilities equal. to its requirements; and 4. Programming steps the providers of health care could take to achieve this goal. Dr. Brennan indicated that Detroit might be an appropriate locality in which to develop the proposed model. Dr. Margulies agreed that RMPS would review the pilot model'Rroposed and report on the plan at its next meeting. The Council expressed approval of the guideline contracts as a mode of obtaining expert opinion and consensus of the medical profession in the complicated fields of preventive and clinical medicine. Since the Guidelines were prepared by the profession for the profession, it was felt that they would be fat better received than any Federal guide lines or standards. It was suggested that the Heart Disease Guidel nes be considered a model which could be used by kEW for other target diseases areas. The Council was warned that such guidelines would not always be accepted without dissent and could provoke controversy. For example, the NAtional" Heart and Lung Institute had expressed the opinion that the dietary recommendations in the report on the Prevention of Atherostletosis, reviewed at the preceding meeting of this Council, were premature. ix. STATUS REPORT OLN @IP AND CHP CONTRACTS Mr. Peterson reported on progress made on the contract, HSM llo-RMP-6@g(l) "Information Support System (ISS) for Management Control and Evaluation." This contract is to assist the administrators of Regional Medical Progr in solving probl,ems'in management control and program evaluation by providing them with certain types of information which are not usually available. The system is designed to develop information for Program Coordinators on the character and extent of the interaction of the RMP with the various segments of the medical community, as well as with its@, level of involvement with various types of medical problems. inf:orm,atiri@ collected through the analysis of documents as grant applicatibn§9 news- papers, And newsletters will form the basis of individual repor s o ea Regional Medical Program, and a summary report@to the Regional Med cal Programs Service. 12 The contract to study, "Comprehensive Health Plan ing," made with n the Organization for Social and Technological Innovation, Inc. (OSTI and Arthur D. Little, Inc., to assess the character and progress of Comprehensive Health Planning is now getting underway. X. COLINCIL POLICY ON LONG TERM TRAINING AND TRAINING IN SPECIALTY AREAS Council continues to receive inquires about specialized long-term training as an RMP activity. Individual inquiries sometimes relate to support of professional. pre-doctoral. training and sometime to post-doctoral or post-residency training. At the present meeting, requests urging RMP support of post-resident training in nephrology for physicians and of training for occupational, physical and speech therapists were received from the Southeastern Coordinators'. Council took note of the need for trained personnel in these and other categories and urged the Regional Medical Programs to take steps to identify the needs and stimulate action, such as listing existing vacancies and publicizing them. Council also noted that RMP funds are insufficient to finance a significant contribution to solve this problem. ACTION: Council'reaffirmed the position taken at its last two meetings and did not make an exception for the requests presented at this meeting. XI. CO'UNCIL POLICY ON PUBLIC SERVICE PROGRAMS (BROADCASTS) OF RMPs Council was asked to consider enunciation of a policy governing content of broadcast or other public service utterances of Regional Medical Program . On& incident was reported to illustrate the need@ for a stated policy. Council noted that a Regional Medical Program, through an unguarded issuance can embroil itself in counter productive controversy it was noted, also, that such incidents have been few in number, and local in effect. There is some danger of exaggerating the significance of such events by making a formal pronouncement 6f,what, in genera.Lt is a matter of common sense. ACTION: The Acting Dir6ctor, RMPS, was asked to discuss the specific circumstances with the coordinator of the region in which it occurred. XII. HYPERTENSION RESOLUTION A representative of the National Heart and Lung Institute presented resolutions of the Councils of that Institute and the National r II.: c@ mended by all three was a program of community presets for apoli- cation of drugs toI control of hypertension VA studies utilizing 13 experimental placebo groups have shown such dramatic effects with both severe and moderate hypertensives that medical ethics dictated discontinuance of the placebo control groups. The NH II has prepared request for proposals for clinical trials in the general population. All three of the advisory bodies mentioned above have commended this need and effort to the attention of the Regional Medical Programs in hope that they will find ways to initiate and assist in such trials. ACTION: Council. requested RMPS to alert a].]. Regional Medital Programs to these opportunities and to distribute the NI[LI requests for pro-. posals as well as reports of the VA experience to all regions. XIII. REPORT OF THE AD HOC REVIEW COMMITTEE ON KIDNEY DISEASE. At the request of Dr. Harold Margulies, this Ad Hot Committee was, convened on January 27-28, 1971, to review the applications submitted to RNPS related to renal disease projects. It was the unanimous opinion of the committee that there is a need to define the mechanism of evaluation of these projects. It is clear that there is a significant gap between the existence of'prbven life-saving techniques in kidney disease control and their application on a broad scale. In reviewing the submitted proposals on renal disease, it became@ obvious that there was inadequate screening at the local level. This is a result of the lack of an established advisory group in renal disease In most areas and the difficulty in finding local expertise. not involved with the submitted projects. This Committee recognizes the need for the development of kidney disease projects at the local level, based upon the unique needs of a given region. However based upon our present review experience, we would recommend that these projects undergo more intensive peer revi@w and applicants be encouraged to submit the proposal to a panel of reviewers in the field. These reviewers could be from within or outside of the region. Local_Regional Medical'Pi6grams inten to submit proposals could receive aid in'the preparation and teth ical review of their project from the Kidney Disease Control Program. it would, therefore, be possible for a region to submit a realistic proposal which best suits its particular area And has undergone extensive review. In view of the fact that the total amount of funds and manpower which will be available for kidney disease projects wil.1 not fulfill the total national needs for these projects,, we believe that. the ex@sten@ce@@@@ 14 of a categorical review body at the Federal level may have distinct advantages. A Kidney Disease Review Conmiittee would be capable of examining all projects in this area and determining a priority Assignment based upon a proper national distribution of facilities with emphasis on sharing of facilities and the promotion of inter- regional cooperation. In collaboration with the Kidney Disease Control Program, the Committee would therefore be capable of providing an overall perspective which would be geared to avoiding wasteful duplication of effort and expense in this area and stimulating activity where needs exist. Ultimately, we are confident that advances in the state of the 'art and in the development of new funding mechanisms will evolvp- to the point where there will be no advantage to the con8ideration,of kidney dis ease projects separately. A non-categorical approach to evaluation of these projects will be more appropriate at that time. For the present, however, we feel that the establishment of a categorical peer review group, which is capable of comparing the numerous kidney disease projects submitted by the various Regional Medical Programs, would be an effective way of ensuring the development of kidney disease activities that embody local needs as well as a broader national or interregional overview. XIV. RECOMMENDATIONS FOR ACTION - REVIEW OF APPLICATIONS 1/ ALABAMA REGIOLNAL MEDICAL PROGRAM - RM 00028 2/11 Total direct cost levels for continuation. New, renewal, and developer mental activities for the next three years are As follows: 03 $1,765,557 04 - $1,654,245 05 - $12373,606 :Request for developmental funding is approved as requested. Council did not believe another site visit was needed to appraise the capacity of the Region to utilize this type of funding. This Council action,differs from Review Committee in that approval for developmental component and additional funds for this purpose are recommended. This Couicil'action also reflects consideration of the policy is sues raised by the Continuing Education and Trainin Branch regarding Project #37 -.Taking the Lid Off the LPN and Project #4R - Health Manpower in Junior Colleges. Council believes the Region's priorities should be the determining factor concerning these education activities since present policy does not preclude their funding. Lo a 12-1110FILli 1)@ I: oci. The designation 01 02, etc. relates to the first, second, etc., budget 15 ARKANSAS RI-'GI.ONAI, MEDICAL PROGRA@L - @l 00052 2/71 (Supplement is recommended at a minimum of $111,925, $113 734, Additional funding 9 $122,884 with the maximum to be determined by staff after receiving technical site visit team is recommendations regarding funding for Project #37 - ComT)rehensi.ve Program for Kidney Disease Control. CALIFORNIA REGIONAL MEDICAL PROGRAM - RM 00019 2/71 & l' ement) Approval of developmental component funding for California RNP. Approval of increasing level of funding for current 03 year by $407,768 of which $200,000 is for developmental funding. Approval of future funding for California @T for both core.i projects and developmental funding at following levels. 04 - $8,363,994 05 -.$8,363,994 66 $83,363,994 Subject to following conditions: 1) overall RMPS funding restrictions and 2) satisfactory program priorities to be included in May 1971 application. Delegation to California RAG decisions regarding Allocation for all projects included in both November 1970 and February 1971 applications except for Project #65 - Comprehensive Renal De@tection, Diagnosis and TreAtment Program (Area VIII) and #74, Blood Banki!ij This action differs from Review Committee recommendations in the number of years of funding recommended. Council concurred with site visit team that this Region needed guidance from Council regarding overall level of funding to be anticipated before sub- mitting application for three-year funding of operational projects in May 1971. COLOT,ZADO/UTYOMING REGIONAL MEDICAL PROGRAM RM 00040 2/71 (Suppl.ementl No additional funding is recommended. Developmental. funding is disapproved. Region may rebudget available funds into Project #22 and Project #24 if the RAG determines that they: a) respond to a recognized need ror local regionalization and improvement; And b) demonstrate integration into the Regionts health care system in a way that will permit dis- engagement of RMP funding within a short time. Because of Council policy regarding use of MV funds for basic education, Project #23 is ineligible. and staff interpretation of policy regarding Project #23., 16 ('ONNI-"CTICUT IZF,,GlONAI, Ml,"D ICA 1, PitOGRA,@,l l@.M 00008 2/71 (Stipplemeno Additional funding at a reduced amount of $70,496 is retonmended for the current 03 year. This Council action is the same as recommended by the Review Committee. FLORIDA REGIONAL MEDICAL PROGRAM - RM 00024 2/71 Additional funding at d level of $200,000 03 year; $160,000 04 year; $145,000 - 05 y@.,i@'is recommended. Attion on Project #38, The Florida Statewide System of Patidnts With tnd Stasze Kidnev Disease, was deferred to provide time for advice, revision and resubmission as recommended by the Ad Hoc Panel on Renal Disease. This Council action concurs with the combined recommendations of the Review Committee, and Ad Hot Panel on Renal Disease and staff with regard to renewal of Project #15. R GREATER DELAWARE VALLEY,.r7-,@TONAL MEDICAL PROGRAM @M 00026@2/71 ities presented in this No additional funding i,@-,;"@-ecommended for activ application. Region has option to rebudg et available funds into new Project #27 Director of Medital Education - as well as for previously approved Projects #6, #8, #109 #14, and #15. RMPS funding is precluded for the training of lay personnel proposed in Project #28, First Care Cardiopulmonary Resuscitation nin Program (December 1969 Council). Projects #25, RegiQnal I)i,-,.llvsis Training Project - Crozer-Chester M6dical Center and #26 ---'.@-:"-.@7ionstration and Evaluation of a Dialysis Training Program - thom".- Jefferson University are disapproved. Council agrees with Review Committee and Ad Hoc Panel on Renal Disease that two dialysis training pr6jects in same area raise serious questions about cooperative planning and review procedures in the Region. This Council action differs from Review Committee recommendations e in respect to funding rc@- nded. 17 HAWAII REGIONAL MEDICAL PROGRAM RM 00001 2/71 ment) Additional funds are recommended for three years: 03 - $366,300 04 - $285,182 05 $285,11 Request for one year developmental funding is approved. Because of Council policy, Project #23, Mobile Coronary Care, is not recommended for support. This Council action concurs with Review Committee recommendations. INDIANA REGIONAL MEDICAL PROGRAM - RM 00043 2/71 (Su ent) Additional funding of $150,000 for one year is recommended for this Region. Request for developmental funding is disapproved. This Council action coincides with Review Committee recommendations. ILLINOIS REGIONAL MEDICAL PROGRAM - RM 00061 2/71 Increase in support for one year only to a total level of $2 million is recommended for the Illinois ]@P. Developmental funding request is disapproved at this time. This Council action coincides with Review Committee recommendations. INT REGIONAL MEDICAL PROGRAM - RM 00015 2/71 Additional funding of $225,000 recommended for this Region for one year. Request for develop-mental funding is approved as requested. Region may rebudget funds into any projects included in this appli at@ion@ or for continued cooperative planning for Project #29, Physician'S Assistants Training; (11/70 application). However, Council would like@ to advise egion that decision to continue funding of Project 1116R@ Endocrine raamm - would raise doubts about Regional priorities. This Council action coincides with Review Committee recommendations. 18 LOITISIANA REGIONAL MEDICAL PROGRAIM - Rm 00033 2/71 Additional funding of $400,000 for one year is recommended. Request for developmental funding is disapproved. Region may rebudget available funds into supplemental, core, planning and feasibility studies or projects included in this Application. Project #9, The Metrop6l Or an Bank, is approved with advice to Region about the budget and the educational program plans, as noted by the Ad Hoc Panel on Renal Disease. This Council action coincides with recommendations of the Review _committee and incorporates the advice of the Ad Hoc Panel on Renal Disease. @IARYLAND REGIONAL MEDICAL PROGRAM RM 00044 2/71 No additional funding is recommended for activities proposed in this application. 'rlie request for developmental funding is disapproved. Project #33, A Comprehensive Regional Approach to Education and TherApy for Chronic Renal Failure, is disapproved as recommended by the Ad Hoc Panel on Renal Disease. Advice to Region should convey Council's specific desire that in- formation about program concerns should not be interpreted as criticism of the new coordinator, rather as hope that he can mobilize MRMP resources for coordinated action. This Council action coincides with recommendations of both Review Committee and Ad Hoc Panel on Renal Disease. @IETROPOLITAN WASHINGTON REGIONAL MI.-DICAL PROGRAM - RM 00031 2/71 18 are reco n Total direct cost funding for tbree-year leve mm6 ded for continuation, new or renewal activities as follows: 04 - $1,658,351; 05 - $1,359,906; 06 - $1,116,353. Request for developmental funding is disapproved. Additional funding for continuation of Project #12, Mobile Ct)r Care Unit, is not recommended, but Region may tebudget funds for completing two full years of activity, as originally proposed, providea-- 19 @IETROPOLITAN RMP CONT. All kidney disease projects are disapproved. Project #16 - Mobile Dialvsis Center, Project #47 A Regional Nephrology ProEram, and Project P31 - Ca2itol Hemodial@sis Trainiaa are disapproved as recoimuended'by the site visit team and the Ad Hoc Panel on Renal Disease. Region should be advised of Councills interest in further review only of a comprehensive proposal for renal disease, rather than project"by-project proposals. Region may rebudget funds into projects included in this application if RAG determines that they are of high priority and within RMPS policy. Project #17, National Career Council, Project #23, Inhalati6n Therapy Training, and Project #43, Cervical Cancer Detection raise policy issues. One year funding only is recommended for Project #2R. This Council action differs from Review Committee recommendations only@ in level of funding recommended for each of three years, coincides with recommendations of Ad Hoc Panel on Renal Di8ease:and incorporates advice, from the December@7-8, 1970 site visit team. MICHIGAN REGIONAL NEDICAL PROGM4 RM 00053 2/71 (Supplement) Additional three ear funding at a reduced level is recommended f r t -Y 0 wo new projects as follows: 01 - $368,073 02 - $366,098 03 - $388,274 This Council action coincides with Review Committee recommendations. NEI? JERSEY REGIONAL MEDICAL PROGRAM - RM 00042 2/71 Total direct cost levels for continuation, new@and renewal activities recommended for the n6xt three years as follows: 01 - $2 989,501 02 - $1,454,750 03 $11)276 466 The second and third year levels do n.ot reflect core support which was not requested at this time. Request for developmental funding is approved as requested. Request for one additional year of support for Project #3R, R6gi6nal Training Center for Cardiac Nursing, is approved. This Council action coincides with Review Committee and incorporate advice and recommendations from December 1970 site visit team. @41 II I . :@@ @@:@ @@:I 20 PM 00034 2/71 (Su plement) NEW MEXICO REGIONAL @kiEDICAL PROGRAM Additional funding as requested for Project #16, Heart, Sound, and Murmur Scre for New Mexico School Children, As follows: 03 $45,188 04 - $55,558 05 $57,069 This Council action coincides with Review Committee recommendations. NEW YORK METROPOLITA.@, MEDICAL PROGRAM - RM 00058 2/71, (supplement Additional funding of $200,000 for develo mental component,is reco ended p MM for one year. No additional funding is recommended or new Projects #25, #261, #27, and #28; 'however, Region has option to rebudget available funds into these Activities, provided RAG determines they are of high priority for present goals and objectives of Region. This Council action coincides with Review Committee recommendations. NORTH DAKOTA REGIOtIAL@@---@.'--@:",-AL PROGRAM - RM 00060 2/71 Additional funding o -4:@@,30,000 is recommended for one year. Request for developmental funding is disapproved. Region may rebudget available funds for increased core or approved projects in line with its own priority. This Council action coincides with Review Committee recommendations and incorporates advice from the December 1970 site visit team NORTHI,ANDS REGIONAL MEDICAL PROGRAM - RM 00021 2/71 Approval of level'of.,l-@,.,'@.-Lig for three years for all activities, includg continuation, new ac-i:@,,@lties.and developmental funding as follows: 03 - $1,954,400 04 - $1,511,600 05 - $1,3789700 Approval of developmental funding as requested for three years. Regipn may robudget available funds into any of activities proposed in this application, if @"@,',,--'-determines they ate of high priority for Regional objectives with. RMPS policies. Attention to RMP policy is particularly pertinent in regard to Project #20, Diabetes' Education Center, and l@?!- Contrpni.til. P,(-.art Disease. Rep,,istry. Region ilroject lt!22, ii23, aid iii2 at-lu Llie invited title C' LO[i C-'Ii(IL@d for Project #14, as note@,@:"-j the Review Committee. 21 NORTHLA"DS RMP CONT. Ibis Council action coincides with Review Committee recommendations And incorporates advice from the site visit team. OREGON REGTONAL_M)?DICAL PROGRAM - RM 06012 2/71 A total direct cost level of $1,064 291 for the 15-month 04 year is recommended for this region. Region may rebudget available 04 year funds into core, continuation projects, renewal projects and new projects in line with its priorities and objectives. Approval for'the renewal projects is for one year only with the exception of Project #4R, ehensive Stroke Care with onal Education, which is approved for the 05 and 06 years as requested. 05 - $54-,444 06 - $56,617 Council takes exception to its general policy regarding phase-out of RMP rojects because of Project 4R's outstanding demonstration qualities. p This Council action differs from Review Committee recommendations in the level of funding recommended for the 04 yeat4 Project #21 was withdrawn by the Region and Council concurred with staffis recommendation that $91,580 additional funding was needed to support on-going projected SOUTli DAKOTA REGIONAL MI,@DICAT PROGRAM - ItM 00067 2/71 AO roval of South Dakota R egional Medical Program as a separate Region. p Three-ye6r funding for core and one year continued funding for t6tonary 'care activities in three South Dakota hospitals is recommended as foiows@.. Oi - $379,500 02 - $313vOOO 03 - $376,000 This Council action coincides with Review Committee recommendations. SUSGUERANNA VALLEY REGIONAL MEDICAL PROGRAM RM 00059 2/71 (SPECIAL ACTION) Approval of two years' additional funding for Project #6R, nar Care Nurses' Training Program, G6isinger Medical Center and one yeAr@ funding for Project #25,, Altoona Coronary Care Traihin&, in following amounts: 01 $88,425 02 $31,551 22 SUSQUElikNNA VALI,LY CONT. Deferral of remainder of application for new funding, pendin-. a site visit to study the program progress, plans for priorities for the future. This Council action differs from Review Committee recommendations. Council considered as a special action the Region's third proposal for CCU Training at the Altoona Hospital and recommended funding for one year. TLXAS [ZLGIOi4AL MLDI-@--l.@ ROGRAM "I 00007 2/71_ (SUPPLEMI,"NT & SPI:CIAL ACTION) Additional funds are recommended as follows: 03 - $26,900 04 - $26,500 Region may rebudgel available funds into.any of the other activities included in the supplemental application in line with Region's' priorities. Council wishes to advise the Texas RAG that any RMP funding for both Project i/53, Choriocarcinoma and Related Trophoblastic Diseases and #50i !7@nritrol of llvpertension and Chronic Renal Disease should be transit..j,--;,,..:-,@..-on-Ly to permit project directors time to locate t other sources of @L@,@..'ing. Council recognizes that long-range supVo is necessary to @@'omplish the aims of Project #50, but does not believe P&IP should be the source. The previous restriction on expenditure of funds for Project #14v, Stroke I)e-,nonstration PE e P.- should be _@g@a@ o@@og@@iv atient Care lifted. This Council action incorporates recommendations from both Review Committee and the Ad [loc Panel on Renal Disease. VIRGINIA REGIONAL @11,DICAL PROGRAM - 101 00049 2/71 @.5u@lerLe@ is reco e 9 No additional fur..,; mmended for th Vir inia Regional Medical Program. The request for developmental funding is disapproved. Council will reconsider request for additional funding for Project 1710, Mtiltipbasic Scree@;;-.Ji-ig Program, in May when mniittee special Council subdo reports its recomw..,'@,@fions. Action on Project @,.-cureinent of Cadaver kidneys for Trans is.deferred, pending Regioh's response to advice-.from Ad lloc Pane on Renal Disense. 23 VIRGINIA RNP CONT. Region should be advised of Council policy regarding support of new mobile units in relation to Project #11. This Council action incorporates recommendations from Review Committee and Ad Hoc Panel on Renal Disease. WASHINGTON-ALASKA REGIONAL MEDICAL PROGRAM - RM 00038 2/71.1 & 2/71.2 Additional funds are recommended as follows: 04 - $289,778 05 $268,129 06 $3030700 Developmental funding is approved as requested. Additional funding is recommended for Project #9R Alaska Medical Library, and #38R - Medical Computer Service, as requested. Additional funding is recommended for the Regional Kidney Program. as noted by the Ad Hoc Panel on Renal Disease. Region should be advised, however, that despite the Panel's concerns about specifics of the Regional Education Program Region may incorporate continuing pducAti6h@@@ on renal disease into overall continuing education program when ap_r 7 ptiate. This Council action coincides with recommendations of Review Committee and the Ad Hoc Panel on Renal Disease. WESTERN NEW YORK REGIONAL MEDICAL PROGRAM - RM 00013 2/71 Additional funding is recommended for West6m New York as fbllows'.@. 04 - $359,424 05,- $374,827 06 $113,265 The request for developmental funding is disapproved. Region has option to rebudget funds into projects included in this application, but should be Advised on Countil's concerns about lack of priorities for the overall program. Funding for Project #21,, Choriocarcinoma and Related Trophoblastic Disease, should be considered as transitional and short-term only to provide time to develop other sources of funding. Cduncil cites Project #IR, Telephone Lecture Network, for special consideration in funding. This Council action coincides with Review Committee recommendations. 24 WEST VIRGINIA REGIONAL MEDICAL PROGRAM RAi4 00045 2/71 Additional funds Are recommended as follows: 02 - $260,000 03 - $260,000 04 $260,000 Region may rebudget available funds into any activities included in this application if RAG determines they are of high priority and in line with RMPS policy. Attention is called specifically to Council policy on registries related to Project #12, Cancer Education and Service. Region should be advised of Council's special interest in Project #8, Medical Self-Audit. This Council action coincides with Review Committee recommendations. WI.SCONSIN REGIONAL MEDICAL PROGRA!4 - RM 00037 2/71 (Su lement Action on this request for developmental funding is deferred pending Council consideration of Region's triennial application in August 1971. Council suggests that Region incorporate plans for developmental funding .in Triennial application. This Council action coincides with Review Committee recommendations. XV. ADJOURNMENT The meeting was adjourned at 12:30 p.m. on February 3, 1971. I hereby certify that, to the be st of my knowledge, the foregoing minutes d and attachments are accurate an complete. Director Regional Medical Programs Service April 26, 1971 NATIONAL ADVISORY COUNCIL MEETING ATTENDANCE AT THE FEBRUARY 2-3, 1971 RMPS REPRESENTATIVES IN REGIONAL OFFICES RMPS STAFF Mr. Ken Baum Mr. William A. McKenna ReizionI Dr. Edward T. Blomquist Mr. T. H. Griffith Region IV Mr. Cleveland Chambliss Mr. Maurice C. Ryan Region V Mt. Spencer Colburn Mr. C. Ray Maddox Region VII miss Cecilia Conrath Mr. Daniel P. Webster Region @VII Mr. Tom Croft Mr. Ronald S. Currie Region IX Mr. Herbert Dunning Mr. Hugh S. Campbell Region X Mr. Gerald T. Gardell Mr. Terrance T. Genz OTHERS ATTENDING Mr. Samuel 0. Gilmer Jr. 9 @irs. Eva Handal Dr. Vernon Eo Wilson, Administrator. Mr. Charles Hilsenroth Dr. Margaret H. Edwards, NCI, N H Miss Dona Houseal Mrs. Frances H. Howard, NLM, NIH Mr. Frank Ichniowski Dr. William J. Zukel, NHLI, NIH Dr. Philip A. Klieger Dr. Alan Kaplan Dr. Marshall J. Keyes Mr. John M4 Korn, Jr. Dr. Harold Margulies Mr. Frank Nash Dr. Herbert B. Pahl Mr. Ronald L. Peterson Mr. Eugene S. Piatek Mr. Michael J. Posta Miss Leah Resnick Mr. Abraham Ringel Mr. Dale Robertson Mr. Morton Robins Mrs. Jacki Rosenthal Mr. Richard L. Russell choeni Mrs. Pat S Mr. R. Shaw Mrs. Sarah J. Silsbee Mr. Thomas H. Simonds Dr. Margaret H. Sloan Mri James A. Smith Mr. Dan Spain Mr. Lee E. Van Winkle Mr. David Lovenvirth, RMPS Consultant NAT-MIAI, ADVISORY COUNCIL ON FINAL MEDICAL PROGRAMS BRENNAN, Michael J., M.D. (72) ltcPHEDRAN, Alexander M., M.D. (73) President, Michigan Cancer Foundation Emory Uftiversity Clinic 4811 John R Street 1365 Clifton Road, N'. E. Detroit, Michigan 48201 Atlanta, Georgia 30322 CANNON, Bland W., M.D. (73) MLI,IKAN Clark H. M.D. (72) 910 Madison Avenue Consultant in Neurology Memphis, Tennessee 38103 Mayo Clinic Rochester, Minnesota 55902 CROSBY, Edwin L., M.D. (71) Executive President OCHSNER, Alton, M.D. (73) American Hospital Association Ochsner Clinic Chicago, Illinois 60611 1514 Jefferson Highway New Orleans, Louisana 70121 DEBAK.EY, Michael B., M.D. (72) President and Chief Executive Officer ROTH, Russell B., M.D. (73) Baylor College of Medicine 240 West 41st Street Houston, Texas 77025 Erie, Pennsylvania 16508 EVERIST, Bruce W., M.D. (71) WYCKOFF, Mrs. Florence R. (72) Chief of Pediatrics 243 CdrrAlitos Road Green Clinic Watsonville, California 95076 Ruston, Louisiana 71270 HINES, Mr. Harold H., Jr. (74) EX OFFICIO MEMBER Senior Vite President Marsh & McLennan, Inc. MUSSER, Marc J., M.D. 231 South LaSalle Street Chief Medical Officer Chicago, Illinois 60604 Veterans Administration Washington,' D. C. 20420 HUNT, William R., M.D. (71) Commissioner County of Allegheny 101 courthouse Pittsburgh, Pennsylvania 15@'@-l', CHAIRf4AN Vernon E. Wilson,, M.D. Administrator 'Health Services and Mental Health Administration 5600 Fishers Lane -R@lville, Maryland 20852