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                   D E P A R T M E N T  0 F   H E A L T H,   EDUCA'rIO@14,

                                      A N D  W E L F A R E

                          Health Services and Mental Health Administration

                                 Regional Medical Programs Service









                                   National Advisory Council on
                                    Regional Medical Programs













                                     Minutes of the Meeting
                                     November 9 and 10, 1970









                                        Parklawn Building
                                       Conference Room G/li







                              DEPARTMENT OF HEALTH, EDUCATION, AND WELFARE
                                           Public Health Service

                         National Advisory Council on Regional Medical- Programs
                               Minutes of the Twenty-first Meeting   I/ 2/

                                          November 9 and 10, 1970



                 The National Advisory Council on  Regional  Medical  Programs  convened
                 for its twenty-first meeting at 8:30 a.m.,  Monday,  November  9,  1970
                 in Conference Room G/H of the Parklawn 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                Dr. Edmund D. Pellegrino (1.1/9 only)
                     Dr. Bland W. Cannon                   Dr. Alfred M. Popma
                     Dr. Michael E. DeBakey  (11/9 only)   Dr. Russell B. Roth
                     Dr. Bruce W. Everist                  Dr. Mack I. Shanholtz
                     Dr. Alexander M. McPhedran            Mr. Curtis Treen
                     Dr. Clark H. Millikan                 Mrs. Florence R. Wyckoff

                 A listing of RMP staff members  and others attending is appended.
                 The proposed schedule for the four meetings of  1971  was  accepted  as
                 presented:
                         February 2 and 3                  August 3 and 4
                         May 11, 12, and 13                November 9 and 10
                 Dr. Margulies reported that the Appropriation Act  has  not  yet  passed
                 both houses of Congress and that a continuing resolution provides for
                 operations through the end of the current session of Congress.

                 It was noted that Executive administration  of  the  1971  appropriation
                 will also have to be conditioned by budget plans for fiscal year 1972.


                 Proceedings of meetings are restricted unless cl.c@)red by  the  Office
                 of the Administrator, HSMHA.  The restriction relates to all. mat(--rial
                 submitted for discussion at the  meetings,  the  supplemental  material,
                 and all other official documents, including the agenda.

             2/  For the record, it is noted that members  absent  themselves  from  the
                 meeting when the Council is  discussing  applications:  (a)  from  their
                 respective institutions, or (b) in which a conflict of interest might
                 occur.  This procedure does not, of course, apply to en bloc actions--
                 only when the application is under individual discussion.







                                                                                       2



                 Passage of Public Law 91-515, covering Regional  Medical  Programs,
                 Comprehensive Health Planning and National Center for  Health  Services
                 Research and Development was reported.  (See News, Information and
                 Data, Vol. 4, No. 51S, dated November 20, 1970.)
                 Dr. Margulies called attention to the requirement In the now  Act  that
                 the Secretary report annually on progress of the I)rogrims affected  by
                 the Act. He suggested that advice of Council members  on  the  coverage
                 of this report will be welcome.  The first report, due January 1, 1971,
                 presents the initial opportunity for the Secretary to show in successive
                 reports the effects of this and subsequent legislation.
                 The construction provisions of the new Act were mentioned by  a  Counci
                 member As a new point of Council concern.  Dr.  Margulies  reported
                 that the Department has not developed a position on  this  subject,
                 and that it may well be determined by budget considerations.
                 Dr. Margulies stated that HSMM agencies,  primarily  Regional  Medical,
                 Programs Service, Comprehensive Health Planning  and  National  Center
                 for Health Services Research and Development are reviewing their pres-
                 ent and potential related roles in carrying  out  HSMHA  functions.  The
                 Willard Committee is presently studying these programs  and  will  make
                 appropriate recommendations to the Administrator, liSM-LA,.

                 COUNCIL AND THE REGIONS
                 Dr. Margulies opened the meeting to discussion of  Council's  role  in
                 guiding the Regional Medical Programs under the  new  conditions  that
                 have emerged.  These include:
                       Anticipated level appropriations, below the total funding en-
                       visioned when the original legislation was conceived;
                     --Reaffirmed, though broadened, categorical disease concern in
                       the legislation;
                     --Department and BSMHA determination to promote  improved  quality,
                       access and efficiency of @ealth care delivery, and  to  encourage
                       Regional Medical Programs to develop related goals  in  their
                       approaches to categorical disease areas;
                     --New developments in the evolution of RMPS  internal  management--
                       triennial review, a management information system, staff respon-
                       sibilities, etc., are being designed around heightened RMP
                       autonomy.







                                                                                  3



                Discussion of the Councilts roles and desires opened, as Dr. Vernon
                E. Wilson, Administrator of Health Services and Mental Health
                Administration, joined the meeting.
                Initially discussion centered on Council's mode of operation in
                guiding Regional Medical Programs.  Key points queried by Council
                members included:

                    --Review of operational project proposals has been a principal
                      tool by which Council particularized policy and exerted leader-
                      ship, not only to guide, but also to oversee technical. quality
                      of programs.  Is delegation of project approval to Regional
                      Advisory Groups a relinquishment of responsibility?

                    --Council has a real need to experiment with policies and modes
                      of stimulating improvement.  How can this be done, without
                      project by project control?
                    --It is clear that local biases present hazards to well-rounded
                      programming, leading to experimentation without adequate prep-
                      aration, unbalanced programs, neglect of national priorities,
                      other problems.  How can these deviations be contained if local
                      RAG determines program and selects projects?

                    --Who will determine priorities?
                    --Will time lags between National Advisory Council determinations
                      and Regional Advisory Group applications of policy create con-
                      fusion?

                    --What will be the criteria by which Council will approve, dis-
                      approve, or modify Regional Medical Programs?

                    --What can be done when Council finds programs defective or
                      inadequate?
                    --It appears that Council is asked to operate almost like an
                      accrediting agency, but how can this be done without more ex-
                      plicitly stated and fixed rules and standards?

                 Highlights of Dr. Wilson's thesis were:
                    --Council is not being asked to relinquish authority.  (,ouncil's
                      responsibility is fixed by law.  Council is being asked to ex-
                      panci its delegation of details of the process to lower levels
                      in iccordance with accepted management principles.  Council
                      retairis final responsibility and, as needed, must step in to






                        modify its delegation or correct aberrations,in the use of
                        the delegated authority.
                        --Council has no need to exercise detailed technological super-
                                                              chnical resources, head-
                        vision.  When RmP's have insufficient te
                        quarters and HEW regional office staffs can locate additional
                        technological expertise as needed.
                                          erimentation is needed and should be con-
                        --It is true that exp
                        trolled.  It is expected Council will continue to enunciate
                        needs and considerations that will guide Regional Medical
                        Programs.
                        --National,, as well as local groups, are exposed to biasing
                        influences.  Council has open to it a variety of measures
                        that can help to contain these influences on local planning,
                        such as (a) requiring certain types of participation in decisions;
                        (b) limiting powers of decision; (c) requiring clearance of
                        certain actions through HEW regional offices; (d) fixing other,
                        forms of deci@iorunaking process.  The existing process already
                        involves delegations; the question we are resolving is how and
                        under what circumstances authorities will be delegated.
                        --Congress has established the priority determination process.
                        Council is responsible  or national policy, and the Regional
                        Advisory Group for local-policy.  The form, foresight and terms
                        of Council actions can minimize problems for the local Groups.
                        --Program-centered review concentrates on the decisionmaking
                        performance of the Regional Medical Program.  Where local biases
                        overturn decisionmaking processes that appear to be essentially
                        sound, Council may have to change its delegation; where decision-
                        making capability and program performance have not adequately
                        developed, Council may find it necessary to return a Regional
                        Medical Program to planning status.
                        --Council must approve new directions and major changes in Regional
                        programs.  Regional Medical Programs Service must have most of
                        its funds in time-limited capabilities, and continuously release
                        money for new programs.  Some money must always be free for
                        innovation.
                        --Council's supervisory function is indeed like a medical school
                        accreditation program.  Tho basic principles and rules for the
                        desired performance are fi-,,ed by the law; their application
                        will be particularized by the wisdom of Council and the fact-
                        finding of staff.







                                                                                 5




                 BROADER FUNCTIONS FOR COUNCIL
                 Dr. Wilson reminded Council that the HSMHA is the health  service
                 delivery arm of the Department. Three programs carry ma,jor  shares
                 of this responsibility--Community Health Services, the National.
                 Center for Health Services Research and Development, and the Regional
                 Medical Programs. Each has its Advisory Council, and each  has  its
                 own central mission, although there appear to be possibilities  for
                 the occurrence of overlays and gaps.
                 If HSMHA is to function effectively in improving the nation's health
                 service delivery, it must be internally consistent and  purposeful.
                 This calls for a broad view in the steering of the three  programs,
                 not only in staff direction, but in Council advice and  guidance.
                 Of the three programs, RMP is the one that works most directly with
                 the vendors of health care. This Council has taken an  overview  of
                 the RIQ and has represented the vendors' concerns for  quality  and
                 improvement in health service capability.
                 HSMHA needs communication with the vendors in a broader frame  of
                 reference.  This Council may well be the best agency for that purpose.
                 To develop such a function, the Council would have to interest itself
                 in, and look at, not only the RMP but other HSMU programs.  Council's
                 functions in these other areas would be analytical rather than direc-
                 tive.  Dr. Wilson asked if the Council would accept such a responsi-
                 bility.
                 Discussion by Council of the proposal:
                    --HSMHA does not have the resources or authority to  provide  by
                       direct action for delivery of health services where  supply
                       or accessibility are deficient.
                    --There is a need for greater stabilization and  specificity  in
                       Governmentis choice of programmatic goals, and means of working
                       with private medicine.
                    --Council could be more consistently representative if Regional
                       Medical Programs could participate in selection of  Council
                       membership--perhaps by nomination.
                    --At present Council does not receive the  kind  of  information
                       that would provide a broad view of IISMIIA responsibilities and
                       opt it) L-is







                                                                                   6




                  Dr. Wilson responded:
                    --HSMHA does not have money to adjust health  care delivery by
                       direct intervention.-but can-find facts, show them  to  vendor,
                       facilitate study, experimentation, planning by vendors, and
                       exercise some leverage through work with the Social  Security
                       Administration and the Social and Rehabilitation Service.

                    --HSMHA and its Advisory Councils may become an  instrument  for
                       stabilization and specification of interaction between Goverranent
                       and health care vendors.
                    --Processes of appointment to Council are framed  by  law,  affected
                       by national policy; there is no guarantee that any one  set  of
                       nominees will be successful. 'For example, IISMHA has been  urged
                       to fill two vacancies on this Council with persons under 30
                       years of age. Staff will be asked.to look  into  mechanisms  by
                       which Regional Medical Programs might join in presenting
                       nominations.
                     --Study and proposals of ways to better inform Council will  be
                       developed for Council consideration, if this proposal for broader
                       Council missions is acceptable.

                  Council, by voice vote, adopted the motion:
                       The National Advisory Council on Regional Medical  Programs  will
                       interest itself in policy formulation for all HSMM health
                       service programs without altering its primary concern  for  the
                       Regional Medical Programs.

                  REAFFIRMATION OF GOALS
                  Council recognizes that change s in language and emphases expressed by
                  HSMHA, Council and RMPS are creating a sense of change in goal and ob-
                  jectives among Regional Medical Program people.  Originally, the goal
                  was expressed as "improvement of the quality of medical care  that  is
                  delivered in the United States." Now we are  speaking  of  "innovative
                  improvement of the delivery of health care" as if this and  its  quan-
                  titative connotations were the single goal.

                  Issues Raised:
                     --Viewed side by side, without reference to time or to the contin-
                       uing extension of recognition of realities in health care, these
                       two statements seem to present a dichotomy.







                                                                               7



                      --Another dichotomy looms between the goal of improving either
                        quality or quantity of health care, and the statutory require-
                        ment that the RMPS refrain from changing the patterns of health
                        care and their financing.
                      --The emphasis on quality for cacti medical ict 1)(@rforni(@d for cacti
                        person has played a very strong role in attracting the cooperation
                        of private medicine to Regional Medical Programs. A shift  of
                        emphasis to supplying health care to those who have not had it
                        may cool the interest of private medicine.

                  Conclusions:
                      --The fact is that delivery of more health care where little or
                        none has been delivered before is an improvement in quality--
                        the authorizing legislation is directed at needs of all the
                        people, not confined to those that were receiving care at the
                        time it was passed.
                      --The fact is that extension and change in the delivery of health
                        care are taking place through agencies other than the Regional
                        Medical Programs.  The quality of each medical act is as important
                        in these extensions and changes as it was in the services delivered
                        before the Act was passed.
                      --Regional Medical Programs offer the vendors of health care a voice
                        in the shaping of change, to protect and improve the quality of
                        care wherever it is delivered.
                   Council passed by voice vote, with three abstentions and dissent, the
                   motion:
                        Council requests the Regional Medical Programs Service to
                        communicate to Coordinators and Advisory Groups of Regional
                        Medical Programs assurance of Council's continued interest
                        in improving the quality of care delivered by all health
                        personnel.
                   Dr. Irving Wright, National Chairman, I.ntersociety Commission on Heart
                   Disease Resources, presented a progress report on Heart Guidelines,
                   80 percent of which has been completed.  Eight sections of the 30-part
                   report have been published in issues of the jourrial Ci.rculati-on.  it
                   is anticipated the completed report will be published during the
                   latter Dart of 1971, and will include the provision of facilities,
                   instr@i.meTitatioii, manpower and other resources.







                                                                              8


                   Dr. Jeremiah Stamler summarized the highlights of the major report on
                   atherosclerosis, which will be published in Circulation in December.
                   He spoke of the prevention and risk factors ii heart  isease, including
                   hypertension, hyperlipedemia, diabetes, obesity, sedentary living and
                   family history,emphasizing the wide professional agreement which now
                   supports prevention of atherosclerosis by.changes in eating habits.
                   Dr. Margulies stated that RMPS now has the responsibility for inple-
                   mentation of the excellent guidelines.
                   Dr. Edward T. Blomquist presented a report on facilities for the
                   treatment of renal disease:
                       There are about 10,000 new end-stage candidates in the United
                       States each year whose lives could be extended by transplantation
                       or dialysis.  Of these, 7,500 would be acceptable for trans-
                       plantation, while dialysis would be the chosen mode of therapy
                       for the remaining 2,500.  In light of the number.of such persons
                       actually receiving treatment, we are falling far short of our
                       goal to provide adequate therapy for all renal disease patients.
                       Only 12 percent of the transplant need and 31 percent of the
                       dialysis need was-met last year.  Overall, the nation provided
                       service to less than one out of every five (17 percent) of
                       those end-stage candidates who might have benefited from either
                       transplantation or dialysis.
                   APPLICATION OF COUNCIL POLICY-TO SPECIFIC ACTIVITIES
                   Council discussed at length a number of specific types of activities
                   that have been urgently proposed or opposed by many of the Regional
                   Medical Programs.  Discussion of several of these activities began
                   with generic forms and principles and was followed by review of
                   applications and site visit reports for specific project proposals.
                   Council was keenly aware that the conclusions reached are to serve as
                   guides to Regional Advisory Groups in their development of programs
                   and approval of projects.  Council stated, or reiterated, a number of
                   principles to be communicate d to Regional Coordinators and Advisory
                   Groups.

                   General Prin   les
                   Ne           People and Vendors of health care:  Regional Medical
                   Pr                     thority or funds to n  t all felt needs for
                   he                     people or for sustained services to th(@ vendors
                   of health care by direct intervention.  Regional Med-@cal Programs are
                   to concentrate on those needs for which voluntary participation by the
                   vendors in regioiaalization can affect improvement.  Priority .:ankiiig
                   of projects in a Regional Medical Program is to be influenced MOSL
                   importantly by the amount of benefit obtainable for the service
                   population per dollar of Regional Medical, Program investment.










                                                       Regional Medical Programs do not
                   have  authority  or  funds  for  support  of  services.   Each   operational
                   project is to be designed to be integrated into the health care
                   system of its Region, and to be disengaged from Regional Medical
                   Program funding  at  the  end  of  its  initial  project  period  of  three
                   years  or  less.  Projects  in  operation  that  are  failing  to   disengage
                   from Regional Medical Program support by the end of their third
                   year  may  be  allowed  a  reasonable  period  in  which  to  become  self-
                   supporting  or  be  terminated.  Council  recommends  no  more  than  18   to
                   24 months as a "reasonable period" but refrained from setting a
                   maximum which might tend to become a customary period.

                   Pickup of projects formerly support d from other grant funds:  Council
                   reaffirmed its earlier recognition that Regional Medical Program
                   funds are not intended to replace grants lost through discontinuance
                   or  reduction  of  other  grant  programs.  Service  or   training   projects
                   initiated under other programs may be considered for Regi.onai- Medical
                   Program support only to the extent that they:   (a) respond to
                   recognized need for local regionalization and improvement; and
                   (b) demonstrate  that  they  are  integrating  into  the  Re@,,ion's  health
                   care system in a way that will permit disengagement of Regional
                   Medical Program funding within a short time.
                   Coro@     care  units:  Council  affirmed  that   although   coronary   care
                   units are now established community resources Regional Medical
                   Program funding units may be desirable when such units make
                   important contributions to regionalized improvement in medical. care,
                   including  overall  efficiency  and  cost  and  when  projects  are   planned
                   to disengage from Regional Medical Program support promptly.  To
                   qualify  for  Regional  Medical  Program  assistance,  coronary   care   unit
                   projects must also meet the following conditions:   (a) An
                   organizational  structure  and  staff  capable  of  implementing   a   high
                   quality  system  must  be  present;  (b)  the  mechanisms  for  entry  into
                   the system require development; and (c) @ funding does not
                   finance established technology, equipment, or patient service
                   operations.

                   Training for coronary care units:  Council requested RHPS to
                   instruct all Regional Medical Programs having coronary (--are unit
                   training projects to disengage
                                                     - Regional Medical  1'rograin  funding  at
                   the end  of their current proj(@et period,,; or w@i.Lliiti zA
                   period thereafter, @is noted abovc@.

                   Moi)ilc- f--or@)n.;.ir  (,,ar(,              wiLli              to d@tL(-
                   demonstrated tli@it initial cost,,-; arc! high, and              Lo        iia:-,
                   not de@/eloped capability to I)rc@dict@ the degree of             t@l@,,IL (-,,in 1)(-'
                   expected for i,,iven combination  of  organization,  staff,  c@rlijtf)merit,







                                                                                   10


                    population and to assure geographic coverage and regional coopera-
                                                       seems likely that the sum re-
                    tion.  in subjective comparison, it   gram would produce greater
                    quired to demonstrate a mobile unit pro             gram instead.
                    benefits if invested in a well-planned preventive pro
                    Council asked RMPS to advise Regional Medical Programs to fund no
                    new mobile coronary care projects.
                    Registries: To date, only systematically operated  cancer  registries
                    have yielded benefits that justified their operation. The    benefits
                    of registries of stroke patients, for example, are highly suspect
                    because diagnosis is inaccurate. Similarly for  other  diseases,  the
                    funds required to operate registries could yield greater benefits  if
                    invested in preventive programs or in identification of  hazards  and
                    risk factors.  Well-run cancer registries have provided data necessary
                    for evaluation of treatment, continuing education and follow-up bene-
                    ficial to patients.  Multihospital registries also may offer side
                    benefits to regionalization through the negotiation  and  cooperation
                    involved in their planning, operation and distribution of information.
                    .Registries generally, like multiphasic screening, hospital admission
                    tests and examinations, and history taking, are special forms of
                    patient data acquisition. Council can muster  little  enthusiasm  for
                    perfunctory, underutilized registries.  On the other hand, it is felt
                    that Regional Medical Programs should be  enhancing  applications  of
                    modern data handling to medical care in projects that meet other
                    Regional Medical Program requirements.
                    Council decided that cancer and other registries, where the state
                    of the art permits, may qualify for Regional Medical  Program  assis-
                    tance when: (a) they make  important  contributions  to  regionalized
                    improvement of patient care; (b) planned to disengage Regional Medical
                    Program funds promptly; and (c) Regional Medical Program  funding  is
                    confined to organization, planning of output and development  of  new
                    methods, and does not support major equipment purchases or operation.
                                      in :  Council sees multiphasic scree-
                      ltiphasic_Scr                                       iii.ng as a
                                 of patient data acquisition that has not yet demonstrated
                    its value.  Hypothetically, it could contribute importantly to health
                    maintenance and other widely publicized new concepts in medical care,
                    and to improved utilization of physicians and other shortage categor-
                    ies of health personnel.  Council recognizes that many Regional Medical
                    Programs are being pressed to support multiptiasic screening.  It  is
                    recognized also that the failure of multipliasic  screening  projects
                    to demonstrate a positive cost-benefit ratio may be due  as  much  to
                    state of the art problems as to problems of planning  and  execution.
                    Council deferred action on two multiphasic screening project applica-
                    tions until the Yay 1971 meeting when there will be a report  on  the
                    state of the art--with specific application to  RMP.  It  was  recom-
                    mended, therefore, that a subcommittee of  Council  be  appointed  to









                 investigate and obtain expert testimony, with staff assistance, on
                 the state of the art of multiphasic screening and similar forms of
                 patient data acquisition.

                 Computer-assisted dosimetry networks:  Council reiterated its earlier
                 findings with respect to dosimetry service systems.  It was held that
                 a dosimetry service should:  (a) support itself, including equipment
                 costs; (b) provide for consultation about the patient between the
                 physician responsible for dosimetry and the physician requesting the
                 service; (c) require that equipment at the participating treatment
                 stations be tested and calibrated regularly and systematically;
                 (d) utilize Regional Medical Program funds only if it meets a recog-
                 nized need for regionalization; and (e) confine expenditure of such
                 funds to support of planning and organization.

                 Council passed the proposal that Nebraska and South Dakota become
                 separate Regional Medical Programs, with the recommendation that core
                 and current project support be maintained at present levels until
                 Council review of the separate applications of the two newly estab-
                 lished regions.







                                                                                   12


                RECOHMNDATION   R ACTION:
                                          ecommendations in the format developed  by
                The Council recorded their r
                the Review Committee in response to FAST recommendations.

                ALABAMA REGIONAL ME
                RM 00028 11/70.1 - Operational SuPRlement - Approval with conditions
                The Council concurred with the Review Committee that additional funds
                be provided to the Albama RNP in the amount of:
                01 - $246,950            02 - $185,924         03 - $127,421
                to conduct the following three projects:
                #23 - Guidance Counselers' Continuing Education in the Health Field (Revision)
                #25 - Production of Audiovisual Materials for Reality Orientation

                #26 -                                          uskegee.
                Council further recommended that the Program may rebudget funds for Projed",,-.--'@-l'
                #24 - Birmingham Community Medical Television Network - if considered a

                priority program by the RAG.
                ALBANY REGIONAL MEDICAL PROGRAM
                RM 00          I - OPERATIONAL SUPPLEMENT - Non-Approval
                The Council concurred with the Review Committee that no additional funds
                should be provided for this application and that the proposed renewal of
                the two projects in the application - #4R - Consultin& Phvsicians Panel

                                         al Learnin  Centers
                and #5R -  ommunit  Hos ital Learnin         - without  satisfactory
                program evaluative data raises serious concerns about both the Region's
                review processes and its capacity to change  direction away from the
                heavy concentration on continuing education programming.






                                                                                 13


               ARKANSAS REGIONAL MEDICAL PROGRAM

               RM 00055  11/70.1 - OPERATIONAL SUPPLEMENT - Approval

               The Council concurred with the Review Committee that additional funds

               should be provided in the amount requested to increase core activities

               in the Arkansas RMP.

               01 - $189,382          02 - $203,069            03 - $222,993

               CALIFORNIA REGIONAL MEDICAL PROGRAM

               RM 00019  11/70.1 - OPERATIONAL SUPPLEMENT - Deferral for site visit

               In eight of the many questions raised by the Review Committee con-
               cerning California's Regional priorities and review procedures,  the
               Council deferred action on this application pending the report  from

               the December site visit scheduled to study the Region's request  for

               developmental component funding and renewal of core support.

               CENTRAL NEW YORK REGIONAL MEDICAL PROGRAM
               RM 00050  11/70.1 - OPERATIONAL RENEWAL AND SUPPLENENT - Approval with

               conditions.
               The Council concurred with the Review Committee that additional funds
               be provided to continue #2R-Mobile Stroke Rehabilitation Service -

               for one year.
               01 - $95,016           02 - -0-                  03 - -0-
               The Council failed to see the relevance of Project #16 -       c@ment
               Personnel Training Program - to patient care.  The Council would
               like to see a revised proposal related to Regi.onal Biomedical
               Electronics Safety Program, which indicated commitment to and
               interest of other hospitals than the hospital proposing the training.





                                                                                       14




                 COLORADO-WYOMING REGIONAL MICAL PROGRAM
                 RM 00040  11/70.1 - OPERATIONAL SUPPLEMENT - Approval with conditions
                 The Council concurred with the Review Committee that additional funds
                 be provided for Project #21 - Radiation Therapy    Planning a Community
                 Hospital by Time-Sharing Computer - in the reduced amount of:
                 01 - $19,474             02 - $20,495               03 - $22,740

                 CONNECTICUT REGIONAL NEDICAL PROGRAM
                 RM 00008  11/7011 - OPERATIONAL SUPPLEMENT - Approval with conditions
                 The Council concurred with the Review Committee that additional funding
                 be provided the Connecticut RMP for initiating Project #26 - PlanniaE
                 Neighborhood Services in Hartford and #28 - Southern Connecticut Kidney
                  sease Pro ram - with the condition that the Hartford area be include

                 in the Kidney Program  prior  to  funding.
                 01 - $183,348            02 -  $2,-137,965          03 - $145,447
                 Further, Council concurs with  the  Review Committee concerns related to
                 Project #27    University  of  Connecticut School of Nursing Regional
                 Facult ; #29    Regional Reference Laboratory Service; #30           onal
                 Nuclear Medicin       ram.  In light of its general policy concerning
                 RMPS replacement of 314(e) funding in the cervical cancer area, no
                 funds were recommended for Project #32 - Cancer of the Cer

                 GEORGIA REGIONAL MEDICAL PROGRAM
                 RM 00046  11/70.1 - OPERATIONAL SUPPLEMENT - Nonapproval on basis of policy
                 In light of its general policy regarding the inadvisability of replacement
                 of RMPS funding for 314(e) funding for cervical cancer service projects,
                 no funds are recommended for this application which includes #34
                 Demonstration for Detection of Female Genital Cancer and #35 -           lo

                 Screening Project.






                                                                                  15



               (;REA'rER DELAWARE VALLI,"Y RE(;IONAL MEDICAL PROGRAM

               RM 00026  1.1/70.1 - OPERATIONAL SUPPLEMFNT - Approval with conditions
               The Council concurred with the Review Committee that additional funding
               be provided not only for the physics portion of Project #20 - Regional
               Radiation Therapy Network and #22 - Thera-Flicks Curative Workshops,

               but also for #21 - Development of Tumor Control Centers in Delaware

               Medical Society.
               01 - $131,853            02 - $130,713            03 - $131,659.
               Council concurred with the Review Committee that  the RMP could rebudget
               funds for Project #23 - Coronary Care Trainin -   if it is high priority.





                                                                               16



              INDIANA REGIONAL MEDIGAIL PROGRAM
            .RM'00043  11/70.1 - OPERATIONAL SUPPLEMENT - Non-Approval
              The Council recommended that no additional funding be provided at this
              time for this application but,that funding for Project #21 -      onal
              Radiation Therapy Development and Physics Support ProRram - be  recon-
              sidered with the report from the December site visit team at the  next
              Council meeting.  The Council concurred with the Review Committee that
              no funding be considered for Project #22   Train            for
              Regional Centers - Respiratory Assistants   for the reasons noted in

              t@ Committees' critique.

              INTERMOUNTAIN REGIONAL MEDICAL PROGRAM
              RM 00015  11/70.1 - OPERATIONAL SUPPLEMENT - Non-approval - policy and

              revision
                                                                          tional funds
              The Council concurred with the Review Committee that no addi
              be provided for the activities proposed in this application.  Project
              #28     ior Cance           n Earlv Detection with Cytological Techniques
              cannot be supported under current policy regarding basic education, but
              the continuing education activities could be supported in the Intermountain
              Program.  Project #29 -               Train Physician  Assistants  for
              Genera  PractitiorErs in.Rural Communities  was not sufficiently developed

              to warrant funding at this time.

              IOWA REGIONAL MEDICAL PROGRAM
              RM 00027  11/70.1 - OPERATIONAL SUPPLEMENT   Approval with conditions
              The Council concurred with the Review Committee that additional funds
              of a reduced amount should be provided the Iowa RMP for the following

              activities:
              #3S   Stroke Man  gement Project   for one year





                                                                                  1 7


               #12 S - A Continuing Cancer Educational Program for Physicians - one year

               #16 - Single Concept Films for Providing Continuing Education to Physicians

               and Allied Health Professionals - three years

               01 - $91,902              02 - $58,894               03 - $60,479

               In light of its decision to table consideration of proposals involving

               technology pending the deliberations of the newly organized Council

               subcommittee for study of multiphasic screening and  related  patient  data
               acquisitions systems, the Council took no acti-on on Project #15 -

               A Multiphasic Health Screening Pro

               KANSAS REGIONAL MEDICAL PROGRAM

               RM 00002  11/70.,l - OPERATIONAL SUPPLEMENT - Approval with conditions

               Council concurred with the Review Committee that  additional  funds  should

               be provided to the Kansas RNP to support Projects #41 - Cancer Information
               Service and #42 - Cancer Care Continuina Education Program, and #44 -
               A Nu.rse Clinician Program.  The Region may rebudget funds for Project #43

               A Model Rehabilitation Project.  Funds recommended are:

               01 - $274,837             02 - $281,498              03 - $299,641

               No action will be taken on Project #40 - Comprehensive Nephrology

               Traini     o ram - until the Council has an opportunity  to  review  Kansas

               Rte A,Lniversary Review application and site visit findings.

               MAINE REGIONAL MEDICAL PROGRAM

               RM 00054  (AR-1-CDS)  11/70 - DEVELOPMENTAL COMPONENT AND SUPPLEMENTAL

               APPLICATION - Approval with conditions

               The Council. concurred with the Review Committee and the site visit team

               that the Maine RMP should be provided developmental component funding

               for two years to coincide with tore support.
               Developmental Component        01 - $95,108     02 - $95,108      03 -  -0-
               The Council also recommended that additional funding be provided for






                                                                                 18



               Project #18  Nursinjz and Allied Health Continuing Education
               and #19 - Interactive Television, as requested.
               01 - $316,081             02   $223,547            03 - $157,148

               MARYLAND REGIONAL MEDICAL PROGRAM
               RM 00044  11/70.1 - SUPPLEMENTAL APPLICATION - Approval as requested.
               The Council concurred with the Review Committee that additional funding
               be provided the Maryland RNP to initiate Project #31 -Rheumatic Fever
               Prevention - Department of Pediatrics, Sinai Hospital of Baltimore.
               01 - $37,135             02 - $35,903                03 - $37,184
               METROPOLITAN WASHINGTON D.C. REGIONAL MEDICAL PROGRAM
               RM 00031  11/70.1 - OPERATIONAL SUPPLEMENT - Non Approval
               The Council concurred with the Review Committee that no additional funds
               be provided to the Metro Washington RMII at this time.  Council will
               reconsider Project #2R - Cerebrovascular Disease Follow-up and Surveillance
                  tem - in light of the. December 1970 site visit findings.  Council
               does not consider Project #38 - Continuing Education for Inactive Nurses
               worthy of support for the reasons cited by the Review Committee.

               MICHIGAN REGIONAL MEDICAL PROGRAM
               @l 00053  11/70.1 - OPERATIONAL SUPPLEMENT - Approval as requested.
               The Council concurred with the Review Committee.that additional funds
               be provided the Michigan RNP to conduct Project #29 - Demonstration and
               Teach           ialized Care of Stroke in a Generalized     ital-
               oi  - $104,353                 02 - $146,050              03 - $153,900

               MISSISSIPPI REGIONAL MEDICAL PROGRAM
               R,Nt  00057  11/70.1 - OPERATIONAL S        - Non-approval for policy
                                                 UPPLEMENT
               In light of its general policy regarding the inadvisability  of replacing





                                                                                1 9

               l@MP@) funding for 3L4(c) funding for cervical cancer service project,,;,*
               no funds are recommended for this application which includes only

               Project #15 - Cervical Cancer Control Program.

               MISSOURI REGIONAL MEDICAL PROGRAM
               RM 00009  11/70.1 - OPERATIONAL SUPPLEMENT - Approval with conditions
               The Council concurred with the Review Committee that additional funds be
               provided to the Missouri RMP for Project #64 - Biomedical Instrumentation.
               Council would be interested i-n reviewing revised proposals for the Kansas
               City core staff and the Green Hills Cooperative Health Care Project (Yf65)
               in the Region's Anniversary Application, along the lines suggested by  the
               Committee.  The Council agreed with the Committee that Project #66 -
               Regional Blood Inventory System - did not seem to be an activity that an

               RM'P organization should undertake.

               MOUNTAIN STATES REGIONAL MEDICAL PROGRAM
               RM 00032  11/70.1 - OPERATIONAL SUPPLEMT - Approval with conditions
               The Council agreed with the Review Committee that additional funds  should
               be provided to the Mountain States RNP to continue Project #2R - A Proposal
               for the Continuation of a Program to Provide Intensive Coronary Care for
               Hospitals in the Mountain State Region, for two years, rather than one,
               in light of policy discussions, and to conduct Project #15 - A Program
               for Continuing Education for Nursing - Montana Division - for three years.
               01 - $239,129             02 - $242,391              03 - $98,407
               The Council does not recommend that RNP funding be utilized for Project
               #14 - A Proposal to Develop a Demonstration Rehabilitation  Services  Team
               in the Southern Nevada Area of the Mountain Sta -s Re ion - because the
               relevancy of the proposed services to care for stroke patients is
               questionable and the services are ordinarily part of routine hospital

               services.





                                                                                    v


                  NEW YORK METRO REGIONAL MEDICAL PROGRAM
                  RM 00058  1        OPERATIONA@ SUPPLEMENT -  Approval  with  conditions
                                                      EMEN-R
                  The Committee concurred with the Review Committee that additional two-
                                 provided the New York Metro REP for Project #20
                  year funding be
                  A Demonstrat                                                      ctor-

                                     nc,e,a
                  Consultants at Eh:xktteended Care Facilities; Project #22

                                           r at rqew xuL,
                  Continuing E ucation Center at New York University; and Project #23
                  Educ tiion aLnidu Training.         litation of the Cancer Patient.
                  01 - $250,000                                 02 - $250,000
                ..In light of its general policy regardin g the inadvisability  of  replacing
                  RNPS funds for 314E funds for cervical cancer service projects,  no  funds
                  were recommended for Project #21
                      ams.  Council agreed with Committee that Project #24
                                                            he Development  of  the  Home
                  as a Health C e Facilit - has.-not  really  been  revised.  The  Region
                  should be informed that Council does not advise the utilization of RMP
                  funds to support the project as proposed.  However, if this is a high
                  priority for the      Council suggests rebudgeting for a modified program.
                  NORTHWESTERN OHIO REGI  AL MEDICAL PROGRAM
                  RM  0063  11/70.1 - OPERATIONAL SUPPLEMENT - Non-Approval
                  Council concurred with the Review Committee that no  additional  funds  be
                  provided to the Northwestern Ohio RMP at this time.  This Region's
                  reorganizational problems, noted previously by Council, have not been
                  solved.  Project #19 -  Longitudinal Study of Attitude qhan      in
                             - did not appear a high priority for an RMP
                   Council will reconsider funding of Project # 18 - Lhe               nt
                   of Multiphasic Health Screening in Northwestern Ohio -  after cofisiderat-;'@'@",-
                   of the deliberations of the newly formed Council  subcommittee  study  of mul,,l'
                   phasic screening and related patient data acquist3on systems.






                                                                                21




               NORTIFLANDS REGIONAL MEDICAL PROGRAM_
               RM 00021  11/70.1 - OPERATIONAL SUPPLEME-NT - Approval as requested
               The Council agreed with the Review Committee that additional  funding
               be provided the Northlands RNP for the conduct of Project #19 - A
               Proposal for a Mobile Health Unit. However, Council advises staff  to
               negotiate with the RMP about the Committee's suggestions to  increase
               the amount of time provided by the project director and the nurse .
               If their time cannot be increased, the effects on the project  should

               be carefully assessed.
               01 - $54,059           02 - $30,835               03 - $30,335

               OHIO STATE REGIONAL MEDICAL PROGRAM

               RM 00022  11/70.1 - Operational Supplement - Non-Approval
               The Council concurred with the Review Committee that no additional funds
               be provided for the activities proposed in this application: #25 -
               Continuing Education in Respiratory Disease Prevention and Therapy and
               #26 - Cooperative Development and Improvement of Health-Related Volunteer
               Services.  Council believes Project #25 needs complete revision.  The
               Region may want rebudget funds for Project #26 if it is important for

               program development.





                                                                                22



                OHIO VALLEY REGIONAL MEDICAL PROGRAM
                RM 00048  11/70.1 - OPERATIONAL SUPPLEMENT Approval with conditions.
                The Council concurs with the Review @mittee that additional  funds
                be provided to the Ohio Valley RNP for the conduct of Project #20
                Renal Dialysis Techn  ist and Project #21               iatric
                Heart Clinics in the following reduced amounts.
                01 - $139,523          02 - $153,325   03 - $159,704    04 - $87,946
                The Council does not recommend RMP funding for Project #19 - Pre-

                                               -vaj-uar-i-o,,
                Stroke Diagn  ic and Treatment Evaluation Center.
                OKIAHOMA REGIONAL MEDICAL PROGRAM
                RM 00          I - OPERATI             T - Approval with conditions'
                Council concurred with the Review Committee that additional funding
                be provided to continue Project #4R - Continuin Education Pro  ram
                for the Enid Area - for one additional year.
                01 - -0-                 02 - $42,104                03 - -0-
                The Council agreed with the Review Committee that no funds should be
                provided for Project #11 -
                     sis on Indian Children, as proposed in this application.  The
                Council further agreed with the Review Committee that RNP funds should not
                be utilized for Project #12 - Oklahoma                                y
                               east Cancer Phase II:  Therm    h

                P'UERTO RICO REGIONAL MEDICAL PROGRAM
                RM 00065 11/70 1 - OPERATIONAL SUPPLEMENT - Approval with conditions
                The Council concurred with the Review Committee that additional funds
                should be provided for Project #12 - Inter-Agency Center for Cancer-

                .1-i a uez - in reduced amounts.
                01   $100,000                02 - $100,060            03   $100,000





                                                                               23


              While the Council did not recommend additional funding for the core
              supplement for Biostatistics, Research and Evaluation Section, the

              RMP may want to rebudget funds for this purpose.
              In line with its policy concerning the inadvisability of replacing
              RNP funding for 314E funding for cervical cancer service projects, no
              funds should be provided for Project #13 - Early Detection of

              Carcinoma of Uterine Cervix.

              SOUTH CAROLINA REGIONAL MEDICAL PROGRAM

              RM 00035  11/70.1 - OPERATIONAL SUPPLEMENT - Non-approval

              The Council concurred with the Review Committee that additional
              funding should not be provided to the South Carolina RMP to initiate
              Project #38 - Professional Education for Early DiaRnosis for Head

              and Neck Cancer.

              TENNESSEE MID-SOUTH REGIONAL MEDICAL PROGRAM

              RM 18-04 (AR-1-CSD)  11/70 - DEVELOPMENTAI, COMPONENT, RENEWAL,
              CONTINUATION AND SUPPLEMENTAL APPLICATION - Approval with conditions.

              The Council concurred with the Review Committee that the Tennessee-
              Mid South should not be awarded developmental funding status, as such,
              at this time, but that three-years funding be provided the RNP for core,

              core planning and operational projects as follows:
              01 - $2,410,000             02 - $2,190,000           03 - $2,190,000
              The RMP should be advised not to utilize RNP funds for Project #32 -

              Medical                          - because of policy.

              TRI-STATE-REGIONAI, MEDICAL PROGRAM

              RM 62-03 (AR-1-CSD) ll./70 - DEVELOPMENTAL COMPONENT, RENEWAL@
              CONTINUATION AND SUPPLEMENTAL APPLICATION - Approval with conditions
              The Council concurred with the Review Committee that developmental
              component funding should be provided to the Tri-State RNP, as well as





                                                                                     24


                  funds to continue support of core and on-going projects and to

                  initiate two new projects as follows:
                                    DEV.                    OTHER               TOTAL
                  01             $147,000               $2,114,685           $2,261,685
                  02              147,000                1,868,591            2,015,591
                  03              147,000                1,896,035            2,043,035
                  Funding should be contingent upon the  RNP',s submission  of satisfactory
                  information about the process by  which  budget  allocations will be
                  reviewed and decision made for small  contract  studies  and activities.
                  WASH NGTON/ALASKA REGIONAL MEDICAL PROGRAM
                  RM 00038   11/70.1 - OPERATIONAL SUPPLEMENT - Approval
                  Council concurred with Review Committee  that  additional  funding  should
                  be provided to Washington RIT for renewal of #9R - Alaska Medical
                  Library and 38R - Medical COMDUter Services.

                  11/70.2 - OPERATIONAL SUPP
                  The Council concurred with  the Review Committee that no additonal
                  funds should be provided at this time for the renal diseases activities
                  proposed in this application.  The Council would be interested in
                  reviewing a less diffuse renal diseases program that focused on
                  clearly delineated high priority areas of need for the Region.


                  14EST VIRGINIA.REGIONAL MEDICAL PROGRAM
                  101 00045 11/70 - OPERATIONAL SUPPLEMENT - Approval as requested
                  The Council concurred with the Re  view Committee that  additional  fun  s
                  should be provided as requested for Project #8 -           inR   Education
                  of West Virgi                                             dit - Peer
                  Review of Patient Care; Project #9     Comunitv   Hospital   Assistance






                                                                                25




               Program - Library Assistance;   Project #10 - Multi-Unit Communication

               Facility at West Virginia University Medical Center for the Purpose

               of Furthering Continued Education of Medical Personnel.


               WESTERN NEW YORK REGIONAL MEDICAL PROGRAM


               RM 00013 11/70.1 - OPERATIONAL SUPPLEMENT - Deferral for site visit


               Council deferred action on this application pending consideration of the

               findings of the December site visit team.





                                                                                26



               SPECIAL ACTIONS:
               BI-STATE REGIONAL MEDICAL PROGRAM - RM 00056
               1.  The Council concurred with the reconsidered recommendation of
               the Review Committee that additional funds be provided for Project
               #13 - A Proposal to Establish a Program of Rehabilitation for Patients
               Who Have a Mvocardial Infarction in the amount requested.
               01 - $73,800              02 - $64,140              03 - $67,167
               2.  In accordance with its general policy decision regarding the.
               replacement of RMPS grant funds for 314(e) grant funds to continue
               cervical cancer service projects,* Project #14 - Clinical and Cytological
               Detection of Cancer in an Indigent Female Pop lation   was disapproved;

               no RNPS funds to be used.



               ADJOUPI,MNT
               The Meeting was adjourned at 3:00 p.m. on November 10, 1970.


                                                       I hereby certify that, to the
                                                       best of my knowledge, the fore-
                                                       going minutes are accurate and
                                                       complete.





                                                       Harold Margulies, M.D.
                                                       Acting Director
                                                       Regional Medical Programs Service






                                                                             27


           ADDENDUM TO RECOMMFNDATIONS FOR ACTION BY NOVEMBER, 1970  COUNCIL:

           Subsequent to the November meeting, the Acting Director asked  the

           National Advisory Council to reconsider its actions concerning

           the utilization of RMP funds to continue cervical cancer  projects

           formerly supported with 314(e) funds. Through an  individual  poll
           of members, Council approved a change in policy which would permit

           an individual Regional Medical Program to support from its own
           resources those projects which had been approved by the Regional
           Advisory Group and included in applications reviewed by the November
           1970 National Advisory Council.  Service on training projects initiated
           under other programs may be considered from RMP support only to the
           extent that they: a) respond to recognized need for local regionalization
           and improvement; and b) demonstrate that they are integrating into
           the Regions health care system in a way that will permit disengagement
           of Regional Medical Program funding within a@short time.
           Applications and projects affected by this change are as  follows:
           Connecticut Project #32 - Cancer of the Cervix Stu@.
           Georgia, Projects # 34, 35 - #34 - Demonstration for Detection of Female

             Genital Cancer, #35 - Cytology Screening Project.

           Mississippi, Project #15 - Cervical Cancer Cont  .1 Pro ram.
           New York Metropolitan, Project #21 - Eight Cervical Cancer Detectio      rams.
           Puerto Rico, Project #13 - Early Detection of Carcinoma of Uterine Cervix.
           Bi-State, Project #14 - Clinical and Cytological Detection of Cancer in

             an Indigent Female Population.





                                                                                      28

                           ATTENDANCE AT THE NATIONAL ADVISORY COUNCIL MEETING

                                         November 9 and 10, 1970


                        RMPS STAFF                    RNPS REPRESENTATIVES IN
                                                      REGIONAL  OFFICES
                   Miss Rhoda Abrams
                   Dr. Edward T.  Blomquist       Mr. William A. McKenna     Region I
                   Mrs. Marilyn Buell             Mr. Clyde L. Couchman      Region III
                   Mr. Cleveland  Chambliss       Mr. Maurice C. Ryan        Region V
                   Dr. Veronica Conley            Mr. C. Raymond Maddox      Region VII
                   Miss Cecilia  Conrath          Mr. Daniel P. Webster      Region VIII
                   Mr.  Joseph de la Puente       Mr. Ronald S.  Currie      Region IX
                   Mr.  Herbert Dunning           Mr. Hugh S.  Campbell      Region X
                   Mr.  .Gerald T.  Gardell
                   Mr.  Terrence T. Genz
                   Mr.  Sam 0. Gilmer, Jr.
                   Mrs. Sheila Gould
                   Miss Sue Guyon                     OTHERS  ATTENDING
                   Mr.  Charles T.  Heaney
                   Mr.  George Hinkle             Dr. J. Gordon Barrow,  Georgia  RNP
                   Mr.  Frank ichniowski          Dr. Bernard Daitz, CHS, HSMHA
                   Dr.  Alan Kaplan               Dr. Margaret H. Edwards,  NCI,  NIH
                   Dr.  Philip A.  Klieger        Mr. Wendell Maddrey, NCHSR&D, HSMHA
                   Mr.  John M. Korn,  Jr.        Dr.,Charles A. Rosenberg, VA
                   Dr.  Marian Leach              Mr. Robert  Walkington,  NLM
                   Mr.  Harrell Little            Dr. William Zukel, NHLI, NIH
                   Dr.  Frank Mark
                   Mr.  Rodney Mercker
                   Mr.  Ted Moore
                   Mr.  Gene Nelson
                   Mr.  Roland L.  Peterson
                   Mr.  Mike Posta
                   Miss Leah Resnick
                   Mr-. Abraham Ringel
                   Mri Morton Robins
                   Mrs.  Jackie  Rosenthal
                   Mrs. Rebecca Sadin
                   Mrs. Sarah Silsbee
                   Mr.  Thomas H.  Simonds
                   Dr.  Margaret H.  Sloan
                   Mr.  Dan Spain
                   Mr.  Matthew Spear
                   Mr.  Frank Van Hee,  Jr.
                   Mr   .Lee E. Van  Winkle
                   Mr.  Richard  W.  White
                   Mr.  Frank  Zizlavsky