CNA - Conference on Regional Medical Programs//1967/Washington, D. C./
             CN - United States. Division of Regional Medical Programs
             TI - Proceedings./G
             IM  - [Bethesda?]/National Institutes of Health, Division of Regional Medical Programs; for sale
                   by the Supt. of Docs., U. S. Govt. Print. Off., Washington/[1967]
             CO - 127 p.:ports
             SE  - Public Health Service publication,/no. 1682/G
             CA    WA 540 A C6p 1967:02NLM
             EL   FULL LEVEL
             IT   MONOGRAPH
             MT - CONFERENCE NAME MAIN ENTRY
             DA - 680209
             Ul   0127651




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      Proceedings:                                        Conference on                                      January 15-17, 1967                                 U.S. DEPARTMENT
                                                          Regional Medical Programs                          Washington, D.C.                                    OF HEALTH,
                                                                                                                                                                 EDUCATION, AND
                                                                                                                                                                 WELFARE
                                                                                                                                                                 Public Health Service
                                                                                                                                                                 National Institutes of Health
                                                                                                                                                                 Division of
                                                                                                                                                                 Regional Medical Programs



























                                                                                                                                                             For Sale by the Superintendent of Documents,
                                                                                                                                                             U. S. Government Printing Office,
                                                                                                                                                             Washington, D. C. 20402
                                                                                                                                                             Price 75 cents (paper covers)










                 Foreword




                    The  "Proceedings:  Conference  on   Re-  son,  Publications  Director  at  the  Uni-
                 gional  Medical  Programs"  is   a   report  versity of  Missouri  Medical  Center,  and
                 of  the  matters  to  which  the  650  par-  her   colleague   Mr.   Normand   Du   Beau
                 ticipants  who  attended  the  meeting   in  for their efforts in the initial  organiza-
                 Washington,  D.  C.   on   January   15-17,  tion and editing of this material.
                 1967  addressed  themselves  at  this   the     We  hope  "The  Proceedings"   will   be
                 first   major   conference   on   the   new  useful  to  the  many   persons   who   are
                 program-authorized  by  the   Congress   of  now  developing   the   more   than   fifty
                 the United States 15 months before.          regional   medical   programs   that   have
                    The  presentations  by   the   speakers,  been  initiated  throughout   the   nation.
                 the  discussions  by  the  panelists,   and  We  believe  it  will  become  a   valuable
                 the   background   papers    prepared    by  document  to  those  individuals   who   in
                 staff  and  consultants  are  published  in  years  to  come  may   be   interested   in
                 full. It was not  possible,  nor  would  it  tracing the  views  of  the  J)ersons  most
                 have served a  useful  purpose,  to  repro-  actively  engaged  in  establishing  a  new
                 duce  the  discussions  of  the  25  groups  and   different   mechanism   for   improv-
                 which  met  for  two  hours  or   more   on  ing  health  care  in  our   country.   The
                 three   separate   occasions   during   the  volume  will  give  a  fair  index  of  the
                 Conference.  Nor  did  it  seem   appropri-  views   widely   held   during   the   year
                 ate  to  publish  in  full  the  more  than  Regional   Medical   Programs   were    in-
                 fifty letters received by the  Director  of  augurated.
                 the  Division  of  Regional  Medical   Pro-
                 grams  from  the  participants  who   wrote
                 to  give  him  their  considered  views  on         Stanley W. Olson, M.D.'
                 the  issues  around  which  the  Conference         Conference   Chairman   and   Editor
                 was structured.  In  making  selections  of
                 materials  for  these  latter  sections  we
                 tried  conscientiously  to   reflect.   the
                 widely  divergent   viewpoints   expressed.
                 If we have  failed  in  our  effort  to  be
                 impartial, the failure is  a  personal  one
                 rather than an  effort  to  suppress  views
                 that  might  be  regarded  as   less   than
                 helpful   to   "the   establishment."   Ac-
                 knowledgement  is  due  Dr.  Joye   Patter-




                 2








          Introduction



            The   Conference   on    Regional    Medical   realized  in  the   future   than   they   have   accurate   while   the   validity   of    many   and   closed    with    the    following    two
          Programs   was   sponsored   by   the    Divi-   been  in  the  past.  A  major  factor   behind   others are yet to be tested.                     sentences:
          sion   of   Regional   Medical   Programs   of   these  movements   is   the   accelerated   ad-     However,   the    Conference,    like    the      ".  .  .   the   committee   is   thoroughly
          the  National   Institutes   of   Health,   to   vance  of   scientific   knowledge   in   medi-   Programs    themselves    brought     together      convinced   of    the    great    importance
          provide  a  national  forum  in   which   this   cine  and  the  need  to  relate  this  advance   those   of   diverse   background   and    in-      of   this   innovative   program   to    the
          new  concept   in   health   could   be   dis-   to the needs of people.                           terest  to  inquire   how   best   to   relate      health   and   welfare   of   every   Ameri-
          cussed.  Its   dual   purpose   was   to   en-      It is  not  possible  to  predict  with  any   current   resources   to   future    potential      can.  The  concept  of'   regional   medical
          courage   ideas    from    a    representative   degree  of  accuracy   the   results   of   any   and  how   to   relate   advances   in   heart      programs   must    be    made    to    work,
          group  of   knowledgeable   individuals   that   one  piece  of  legislation,  like  Public  Law   disease,   cancer,   stroke,    and    related      and  no   effort   should   be   spared   to
          could  be  used  in  preparation  of  the  re-   89-239   which   established    the    Regional   diseases  to  the  needs  of   people   on   a      insure that it does."
          quired   Report   of   the   Surgeon   General   Medical    Programs    for    heart    disease,   regional basis.                                     In  accordance  with  a   request   by   the
          to  the  President  and  the   Congress,   and   cancer,  stroke,  and  related   diseases,   or     There  are  a  number  of  significant   de-   Coordinators   of   the    Regional    Medical'
          to  provide   an   interchange   of   informa-   its  eventual  contribution  to  an   area   as   velopments   that   have    occurred    during   Programs   at   the   Conference,   a   meeting
          tion  on  planning,  activities,   and   goals   complicated  as  health.   Yet,   it   is   the   the   six-month   period   since   the    Con-   of  that  group  from   both   funded   Regions
          for   the   Programs   among   all   organiza-   purpose  of  this  report   of   the   Proceed-   ference.                                         and  those  still   in   developmental   stages
          tions,  institutions  and   individuals   con-   ings   of   our   Conference   to   record   an     One   important   development    has    been   totaling  some  53,  was   held   in   Bethesda
          cerned   with   the   Programs,   individually   attempt   to    evaluate    and    probe    for   the  funding  and  initiation  of  the   first   on   June   16   and   17.   Additional   meet-
          and collectively.                                dominant   trends    and    pervasive    forces   four  operational   Programs.   In   addition,   ings  of   this   group   are   being   planned
             A sincere debt  of  gratitude  is  due  all   that   might   be   more   clearly   identified   the   number   of    Regions    involved    in   for the coming year.
          of  those   who   attended   the   Conference.   during   the    initial    implementation    of   planning   activities   has   been   increased      In  late  June  of  this  year,   based   on
          The   record   of   the   papers   and    dis-   Regional   Medical    Programs.    The    accu-   to  48.  These  two  facts  indicate  the  in-   the  results  of  this  Conference,   the   ad-
          cussions   contained   in   these   Conference   rate  understanding   of   these   trends   and   creasing  rate   of   forward'   movement   of   vice  of   the   National   Advisory   Council,
          Proceedings   and   the   material   contained   forces  of  society  is   an   essential   base   the Programs.                                    and    an    Ad    Hoc    Committee,    Surgeon
          in  the  Report   of   the   Surgeon   General   for  a  Report  to  the  President   and   Con-     During  this   same   period,   the   Presi-   General   William    H.    Stewart    submitted
          to   the   President   and    the    Congress,   gress  concerning   extension   of   the   law.   dent  submitted   his   Health   Message   and   his  Report  to  the   Secretary   of   Health,
          much   of   which   was   drawn    from    the   As   pointed   out   by   Henry   Sigerist,   a   included  the  following   definitive   refer.   Education,   and    Welfare    for    transmis-
          Conference,   form   the    historical    base   medical    historian,    more    than    thirty   ence   to   Regional   Medical   Programs   to   sion  to  the  President  and   then   to   the
          and   the   documentation    for    projection   years   ago:   "The   characteristic   features   support  his  request  for   a   1968   budget   Congress.   As   required   by   Section    908
          of  Regional   Medical   Programs   into   the   of   the   medical   profession   are    deter.   of  $85,314,000  for  the   Division   activi-   of  Public  Law   89-239   it   appraises   the
          1970's.                                                                                            ies:                                             activities  of  the   Regional   Medical   Pro-
             Medicine,   or   more   appropriate           mined  to  a   very   large   extent   by   the   t "in 1968 we will:           Begin    operat-   grams      and      makes       recommendations
                                                       ly  attitude   of   society   towards   the   human
          health,  in  the  next  decade   will   become   body,  and   by   the   valuation   of   health     ing   the   new   regional   medical    pro-   concerning   the   extension   and    modifica-
          an  increasingly  critical   national   issue,   and  disease.  .  .  .  There  is  one   lesson     grams   which   will    narrow    the    gap   tion  of  the   law.   This   Report   on   Re-
          economically,    because    the    cost     of   that  can  be  derived  from  history  .  .   .     between   the    advanced    methods    used   gional   Medical   Programs   to   the   Presi-
          health  continues   to   rise   more   rapidly   that  the  physician's  position   in   society     at  university  hospitals   and   day-to-day   dent   and   the   Congress   (Public    Health
          than   other   costs;   sociologically,    be-                                                       medical   practice   in   the    community."   Service  Publication  No.  1690)  will   be   a
          cause   of   its   relationship.   to    other   is   never   determined   by   the    physician   In   this   same    connection,    both    the   basis for future legislative action.
          domestic   issues   including   poverty,   and   himselfi   but   by   the   society    he    is   House   and   Senate    Appropriations    Com-
          urban  affairs;   and   politically,   because   serving. . . ."                                   mittees   have   heard   testimony   to   sup-   Robert Q. Marston, M.D.
          of  the  rising  expectations  of   Americans,      Already,  in   retrospect,   some   of   the   port  this  appropriation.  In   its   report,   Associate Director, National Institutes
          and   the   promise   that   these    expecta-   ideas,    comments    and    conclusions     of   the    House    Committee    strongly     sup-      of Health, and Director
          tions  may  be   more   rapidly   and   nearly   the   Conference    have    proved    unusually   ported t he   concept   of    the    Programs,   Division of Regional Medical Programs

                                                                                                                                                                                                           3






               Table of Contents




                                                                                                Page
               Section I-Papers Presented           .....           ..........................     5          Evalualion of Medical Care under
                                                                                                              Public Law 89-239
               Remarks                                                                                        Paul  J.  Sanazaro,  M.D ...........................             ..............
               Charles  L.  Hudson,  M.D ...................................                       6          Continuing Education and Regional
               A New Era in Medical Care                                                                      Medical Programs                   ............................................
               Wilbur  J.  Cohen,  Ph.D .....................................                      7          The Report of the Surgeon General to
               With the  Patient  in  Mind                                                                    the President and the Congress              ...................................
               Robert  Q.  Marston,  M.D .........................................               11
               Science and Service                                                                            Section IV-Group Discussions             ..............................
               James   A.   Shannon,   M.D .              ...................................... 18
               Program Evaluation                                                                             INTRODUCTION                     ..............................................
               Vernon  E.  Wilson,  M.D .               ........................................ 21           REPORTS
               The Idea, the Intent and the                                                                   No Prospects for "Instant" Regional
               Implementation                                                                                 Medical Programs
               Sidney Farber, M.D                 ............................................   25           Donald  J.  Caseley,  M.D .......................................
                                                                                                              Regional Medical Program Coordinators
               Section 11    Panel Sessions       ..................................             29           Edmund D. Pellegrino, M.D    ..........................              ..........
                                                                                                              Practicing    Physicians
                                                                                                              Bruce  W.  Everist,  M.D ..........................................
               Program Evaluation                  ...........................................   30
               Chairman:    George James, M.D.                                                                Interpretation and Administration of
               Panel:       Edward Kowalewski, M.D.                                                           the Act
                            C. H. William Ruhe,  M.D.                                                         Paul M. Ellwood, Jr., M.D               .......................................
                            Harvey  L.  Smith,  Ph.D.                                                         STAFF SUMMARY                      ............................................
                            Vernon  E.  Wilson,  M.D.
               The  Report  of  the  Surgeon  General                                                         Section V-Excerpts From Post-
               to  the  President  and  the  Congress            ............................... 36                         Conference Letters         ..............................
               Chairman:    Storm Whaley
               Panel.       Michael E. DeBakey, M.D.                                                          APPENDICES
                            Bruce  W.  Everist,  M.D.                                                         1.  Conference Program     ...............      ................
                            James  T.  Howell,   M.D.                                                         2.  Registered Conference Participants     .......................
                            Ray E. Trussell, M.D.                                                             3.  National Advisory Council               ...................................
                            Paul N. Ylvisaker, Ph.D.                                                              Review     Committee ..........................................
                                                                                                                  Ad Hoc Committee for the Report               .............................
                                                                                                              4.  Division Staff                ..............................................
               Section III-issue Papers                    ...................................   45           5.  Directory of Programs               .......................................
                                                                                                              6.  Guidelines                  ...............................................
               The Development of Cooperative                                                                 7.  Public  Law   89-239 .........................................
               Arrangements      ......  ........................................                46           8.  Regulations                  ..............................................

               4









                                                                                               Section I-Papers Presented



                                                                                               Remarks                                    Representative leaders in the  fields  of
                                                                                               Charles L. Hudson, M.D.                    medicine  and  health  were  invited   to
                                                                                               A New Era In Medical Care                  present papers reflecting their  thinking
                                                                                               Wilbur J. Cohen, Ph.D.                     on the subjects covered  in  the  plenary
                                                                                                                                          sessions.
                                                                                               With the Patient in Mind
                                                                                               Robert Q. Marston, M.D.
                                                                                               Science and Service
                                                                                               James A. Shannon, M.D.
                                                                                               Program Evaluation
                                                                                               Vernon E. Wilson, M.D.
                                                                                               The Idea, the Intent and the
                                                                                               Implementation
                                                                                               Sidney Farber, M.D.


























                                                                                                                                                                                  5





                 Remarks                                           Charles L. Hudson, M.D.
                                                                   President
                                                                   American Medical Association



                 I  am  pleased  to  have   this   opportunity   and  the  precipitant  approaches   there   is   come  intrusion  but   also   something   ex-   Believing    the    premises    upon    whic
                 to add  my  voice  and  that  of  the  Ameri-   often  conflict,  even   though   the   objec-   tremely confusing  to  the  public  as  well.   these  actions  were  based   to   be   fais
                 can  Medical   Association   to   those   who   tives  of   both'approaches   be   the   same.   The  raison   d'C-tre   of   such   complexes   and  concerned  that  this  was   a   revoli
                                                                                                                                                             -'   tionary  change  in  the  system  of   heali
                 will  participate  in  this  meeting  discus-   We  are  present  in   this   conference   not   we  learned,  was  the  provision  of   serv-   care not in  the  public  interest,  the  AM
                 sing  Regional   Medical   Programs.   I   am   to   emphasize   our   differences   but    to   ices  to  people  who  were  the  target   of
                 sorry   that   previous   commitments    will   determine  as  best  we  can   how   the   re-   the  legislative   thrust,   based   on   the   did not support the legislation.
                 not  permit  me  to  stay  on  with  you   in   sources   of   Government   under   the    law   allegation that a  barrier  of  ignorance  of   Then, later,  several  of  us  from  the  AM
                 the  succeeding   days,   but   my   interest   can  best  be  directed  toward   the   health   what was  new      impeded   the   flow    of   were  on   a   mission   to   Washington   I
                 will  remain  with  you  regardless   of   my   care  system  that   is   primarily   serviced   health   care   through    current    conven-   advise  the  Department   of   Health,   Edi
                 absence.                                        by the private sector.                           tional channels.                                cation, and Welfare     regarding  the    ne
                 As  everyone  here  knows,   scientific   ad-   The  origins  of  Public  Law  89-239  to   my
                 vances   have   tended    to    divide    and   knowledge  are  to  be  found   in   the   Re-
                 stratify our profession,  not  only  in  what   port  of   the   President's   Commission   on
                 we do but  in  our  principal  interests.  As   Heart  Disease,  Cancer   and   Stroke,   from
                 we  become  more   specialized   and   diver-   which   document   certain   of   its   recom-
                 sified,  it  should  be  recognized  that  we   mendations   were   selected   for    legisia-
                 become   more   interdependent.   To    coun-   tive   implementation.   As    I    understand
                 teract  this  divisiveness  we   should   set   fit, it is extremely  difficult  to  reproduce
                 ourselves  to   the   task   of   formulating   in  the  language  of  the  law  exactly  what
                 plans   to   assemble   dissimilar   elements   a   narrative   report   contains.   But    it
                 of  health   service   into   an   integrated   seems   reasonable   to   assume   that    the
                 whole.                                          sections  selected   for   the   Bill   retain
                                                                 some  relationship   to   that   report   from
                 The  problem  posed  in  this   endeavor   is
                                                                 whence   they   originated.   And   thus   the
                 a    mode    of    accomplishment     of this
                 task.  How  shall  we  do  it?  We   in   the   Sen@te.Bill  596  was   interpreted   by   the
                 medical  profession   tend   to   favor   the   profession   as    recommending    areas    of
                 retention   of   systems   "that   work" and    service    provision    called     "complexes"
                                                                 that  described  not  only   highly   special-
                 do  best  within   our   resources,   to pro-   zed   medical    and    surgical    treatments
                 ceed   in   an   evolutionary   fashion, per-
                                                                 in  a   medical   school   center   but   also
                 haps   more   cautiously   than   suits   the     i
                 taste  of   everyone.   While   we   are not    dagnostic   and    treatment    stations    in
                 "the last to lay the old aside"   '   neither   the  periphery.  We  inferred  that  this,   a
                 in  clinical  practice  do  we  tend  to   -e   closed  entity  of  indeterminate  size,   ex-
                                                          D      cluding  others  already  practicing  in   the
                 "the  first  by  whom  the  new  are  tried."   area,   was   intended   to   demonstrate   in
                 Government,   on   the    other    hand,    a   a   disparaging   way   perhaps   the   inade-
                 financing  rather  than   a   service   mech-   quacies  of  our   physicians.   A   quantita-
                 anism,   with   its   great   resources    of   tive  capability  to  replace   these   physi-
                 money  and  influence,  has   the   capacity,   cians  or  a  visible   means   of   improving
                 and  I  would  say  inclination,  to   effect   their  capacity   to   provide   health   care
                 rapid   and   major   changes   in   patterns   did  not  appear  feasible  under  this  plan.
                 and   procedures.   Between   the    cautious   This  we  viewed  not  only   as   an   unwel-

                 6






                                                                                                         A New Era in Medical Care                      Wilbur J. Cohen, Ph.D.
                                                                                                                                                        Under Secretary of
                                                                                                                                                        Health, Education, and Welfare



          Pi L.  89-97.  Hearing  the  passage  of  the  89-239  as  an  excellent  model   for   such   We  are  meeting  here  today  to  focus  on   has   high-lighted   the   need   for   com-
          legislation   on   heart   disease,   cancer,  a  purpose  have  led  me  to   give   public   the  future  structure  of  Regional   Medi-   munity  planning  of  all  its  health   and
          and  stroke  in  the  House  of   Representa-  support  to  the  use  of  this   legislation   cal  Programs.   We   are   seeking   advice   medical   care   facilities   and   manpower
          tives   was   imminent,   we   reported    to  for educational purposes.  I  feel  that  the   from  those  of  you  who   will   have   to   resources.   Communities,   many   for   the
          President  Johnson  our  belief  that   pass-  impact of P.  L.  89-239,  if  used  in  this   make  the  programs  work.   We   are   con-   first time, have had to  plan  for  an  ade-
          ing  this,  the  Senate  version,  upon   the  way,  on  the  health  care  of  the   Nation   tinuing  to  try  to  improve  the   formula   quate  number  of  facilities  with  a  full
          heels  of   Medicare   would   be   repugnant  will  be  infinitely  greater  than  if   im-   for bringing all  groups  together  to  fuse   range    of     needed     services-extended
          to  the  physicians  of   the   country   and  plemented  primarily  in   another   fashion.   the  contribution  of  science,   education,   care  facilities,  home   health   services,
                                                                                                                                                                   tient  clinics.  Cooperative  ar-
          would   adversely   affect   their   attitude  The   dissemination    of    the    program's   and  service  for  the  benefit  of  all  of   and    outpa
          toward  any  and  all  Federal  support  pro-  influence  through   the   physician,   espe-   our people.                                    rangements  are  being  developed   to   as-
          grams, especially Medicare.                    cially  those  at  the  periphery,  will   be   many pressures and trends for         change   sure   that    community    resources    are
          As  a  consequence,  a  revised  version   of  broader  than  if  its  substance   is   used   contributed to  the  health  legislation  of   used  to  promote  quality  care  with   the
          the  Senate  Bill  was  prepared   with   the  up  on  services  to  a  limited  number   of   the  89th  Congress,  which  was  the   most   most efficiency and economy.
          assistance  of  the  AMA.   It   passed   the  individuals.                                    health-minded  Congress  in   our   history.   We  are  entering  a  new  era   in   health
                                                      -  To  conclude  on  the   note   on   which   I   More national hea                              tionary  period.  Our   chief   concern   is
          House,   prevailed   in    Conference    Corn                                                                     Ith  measures  for   pro-   care   an   evolutionary,   almost   revolu-
          mittee, and became the law.                    began,   I   believe   the   assignment    of   viding  the   American   people   with   the   the  achievement   of   high-quality,   com-
          It is  the  AMA's  interpretation  of  P.  L.  roles  in  an  integrated  system  will  best   best  possible  health  care  were   enacted   prehensive  care  for  all   Americans.   We
            -239  and  its   regulations   that   serv-  be  determined  by   a   cooperative   effort   in the  89th  Congress  than  at  any  other                                       1
          89                                                                                             time  in  the  past  century.  The  Regional   are  keenly  conscious  of  not  on  y   ex-
          ices will  be  given  incident  only  to  the  on the part  of  all  segments  of  the  pro-   Medical   Program,    Medicare,    Medicaid,   panding    medical    services    to    many
          needs  of  education   and   research;   that  fession  rather  than  if  it  were  made  by   aid  to   medical   schools,   comprehensive   groups   who   have   been   without    them
          the  program,  rather   than   a   geographic  legislative edict. it is  true  that  differ'   health planning, grant  support  for  train-   in the past, but  also  with  the  provision
          entity, is a  sphere  of  influence,  largely  ences  in  roles  will  be   perpetuated   by   ing  professional  and  allied  health  pro-   of a  higher  quality  of  medical  services
          educational  in   intent   and   capable   of  variations  in  breadth  or  depth  of   edu-   fessionals,  and   increased   support   for   for all of the population.
          exchanging    information    and    personnel  cation  and  training,  by   the   complexity   -                  are just  a  few  of  the   The  achievement  of  our  goal   will   not
                                                      I  of the skills required  of  us,  and  by  the   medical research                                                    there    are    serious
          between  the   center   and   the   periphera                                                  developments  that  aim  for  the   delivery   be  easy  because
          institutions  which  are  now   called   hos-  character  of  the   occupations   we   elect   of    comprehensive    high-quality    care.   shortages  in  the  health  professions  and
          pitals.                                        to pursue.                                      Today,  as  never  before  in  history,  you   in health facilities.  The  inherent  nature
          With    this    understanding-rather     than                                  the      most   are  being  asked   to   help   create   the   of  quality  care  rests  with  the   health
          with  an  definitive  interpretation  by  the  The scarcest and  probably        m  is   the   basic  instruments  to   give   people   the   professions, their  ideals,  integrity,  and
                 y                                       essential element of the progra
          National  Institutes   of   Health   I   must  educational  and   research   center,   where   kind of  care  they  need,  when  and  where   vigilance. If they are  going  to  meet  the
          honestly     add-I      have      recommended                                      r           they need it.                                  demands  for  high-quality  care,   improve-
                                                         one  might   anticipate   the   most   efined                                     jor    new   ments  in  the  organization  and  the   de-
          the program  to    the    constituent     and  knowledge  and  techniques   to   be   found.   These programs represent a ma,
          component parts    of  the   AMA   in   coun-                                                  thrust-a   new   momentum   in   the   field   livery of  health   and   related   services
                              and   they    have    re-  Inherent in  this  recognition  is  the  haz-   of  health  care.  A  whole   continuum   of   must   be  made.    The    Government    can
          ties and  States,         embers   of   local  ard  that  judgments  of  high  position   in                                       fficient   see to it  that,  in  ever  increasing  num-
          sponded not only    as m                       a vertical scale  will  disparage  any  other   the  most  economical  and  e
          advisory  groups  but  also  by  leading   in                                                  forms  of  health  care  is   being   devel.   bers,  professional   competence   is   ever
          the  application   for   approval   of   Pro-  contributor  to  the  whole   scheme.   Other                                     le,    has   present  in  providing  patient   care.   We
                                                         contributions,  while   less   refined   per.   oped.   Medicare,  for  examp                  are going  to  have  to  do  a  lot  of  re-
          grams.                                         haps,  may  be  equally  valuable.  For  that   focused  attention  on   ways   to   improve                                s of  utilizing
                                                         reason   I    hope    communication    within   medical care, and the program itself\          thinking about better way
          our   search   for   another   mechanism   in                                                                                                                      have,  how   to   train
                                  graduate      medical  the  program  will   be   open,   free,   mu-   carries  major  incentives  to  provide  new   the personnel we
          this country for post                                                                                                                                ersonnel,  how  to  rationalize   our
          education  and  the  adaptability  of  P.  L.  tually  respectful,   and   multidirectional,   and   improved   services.    The    program   more p
                                                                                                                                                                                                  7









                                                                                                                                             rsities,  hospi-     The  main  purpose  of  the  program  is   to
                    services   and   how   to   create   economy tual  resources.  The   professions   provide   public and private (unive
                    and  efficiency  in  the  organization   and the  specialized  talent  without  which   no   tals, etc.) and  we  have  no  intention  of     afford,   through   such   cooperative    ar-
                    delivery of services.                        modern  society  can   run.   Non-profit   or   submerging   their    identity    in    some     rangements,    the     medical     profession
                    Every   community   will   have   to   reex- voluntary  associations  provide   a   signi-   rigorous master plan.  The  solution  is  to     and  institutions  of   the   Nation   oppor-
                    amine  how  available   personnel   institu- ficant  means   of   harnessing   non-govern-   be  found  in  new  forms   of   cooperation     tunities   to   make   available   to   their
                    tions,  and  equipment  can   serve   to   a mental  resources  toward   a   public   pur.   among institutions."                             patients   the   latest   advances   in   the
                    better  advantage.  Business,   labor,   and pose.,,                                         No  program  better  expresses   this   con-     diagnosis  and  treatment   of   heart   dis-
                    civic  leaders,  under  the  leadership   of The   complexities   of   the   problems   we   cept  and  approach  than  the  grants   for     ease,  cancer,  stroke,  and   related   dis-
                    the  medical  profession,  can   also   help face  in  providing  high-quality  care   re-   Regional   Medical   Programs.   The    very     eases.   And   I   would   emphasize   again-
                    to   introduce   innovations   and    create quire the  best  ideas  and  efforts  of  all   first  words  of  the  Act  setting  up  the     as did  the  Congress  in  reporting  on  the
                    new  and  improved   methods   of   delivery the  Nation's  resources.   Secretary   Gard-   programs  call  for  "cooperative   arrange-     Bill  and  the  President  in   signing   it-
                    of  health  care.  Every   member   of   the ner noted:                                      ments"    among    the    interested     and     that  our  purpose  will  not   be   achieved
                    community  has  become   involved   in   the "We  have  a  multiplicity  of  institutions,   affected   organizations    and    agencies.     until all  medical  practitioners  and  their
                                                                                                                                                                  patients  realize  the  full  benefits   that
                    organization   and   delivery   of   medical                                                                                                  modern   science    and    technology    make
                    care  in  this  country   and   shares   the    I                                                                                             possible.
                    responsibility  for  its        improvement.
                    Effective   community    planning,    active           @i
                                                                                                                                                                  So  now  we  reach  the  real   test.   After
                    cooperation    between    the    educational
                                                                                                                                                                  the  new   legislation   authorizing   grants
                    systems,  health  facilities   and   medical
                                                                                                                                                                  for    Regional    Medical    Programs    was
                    and   other    professional    organizations
                                                                                                                                                                  signed,  it  was   up   to   you-the   health
                                   gradients   for    implement-                                                                                                  leaders  of  the  Nation,   private,   volun-
                    are essential in
                    ing the new health programs.                                                                                                                  tary    and    public-to     do     something
                    While   the   new   programs   enacted    by                                                                                                  about it.
                    Congress  in  the   past   two   years   are
                    national  in  scope,  it  is  up  to   local                                                                                                  In  April   1964   when   President   Johnson
                    groups  to  provide  ideas  and   initiative                                                                                                  met  for  the   first   time   with   members
                    in  carrying  them  out  and   making   them                                                                                                  of his Commission on Heart            isease,
                                                                                                                                                                  Cancer   and   Stroke   he   outlined   their
                    a  success.  These  programs  are   an   ex-
                    pression  of   "creative   federalism."   In                                                                                                  task in the following words:
                    discussing  this  concept  recently   before                                                                                                  "Unless  we  do  better,  two-thirds  of  all
                    a   Congressional    Commi+tee,    Secretary                                                                                                  Americans  now  living  will  suffer  or  die
                                                                                                                                                                                             ase   or   stroke.
                    Gardner pointed out:                                                                                                                          from cancer, heart dise
                    "There is  a  great  potential  for  innova-                                                                                                  I expect  you  to  do  something  about  it."
                    tion  in  the  scope  and  variety  of   the
                    Federal   Government's    partnership    ar-                                                                                                  The  President  was  talking  directly   that
                    rangements.  Through   these   the   Federal                                                                                                  spring  day  to  a   small   group   in   the
                    Government    taps    great    sources    of                                                                                                  White  House  Garden.  But,   indirectly   he
                    strength  in  American  life.  The   private                                                                                                  was  setting  a  challenge  for  all  persons
                    economy  is  the  chief   source   of   eco-                                                                                                  concerned  with  the  Nation's   health.   He
                    nomic  growth   and   vitality.   The   uni-                                                                                                  was  calling  upon  the   practicing   physi-
                    versities-State,    local    and    private-                                                                                                  cians   who   bear   the   heavy    responsi-
                    harbor the bulk of  the  Nation's  intellec-                                                                                                  bility  for   diagnosis   and   treatment-the

                    8









          health  workers   who   assist   and   support   Programs.   We    need    your    advice    on   The   Commission    asked:    "How    are    we  lying    problems    of    medical     manpower
          the   physician-the   educators   who    train   what  more  needs  to  be  done  so  that   we   going to close the gap?"                         and    communications,    which    the     Com-
          the   present    and    future    generations-   can  help  you  step  up  the   time   between   The  answer  to  this        question       was  mission  felt  had  to   be   met   to   effec-
          the  research  -scientists  who  are   extend-   the  discovery   of   medical   miracles   and   strikingly  similar   to   the   answer   found  tively   attack    the    so-called    "killer"
          ing   available   knowledge   and   capability   their  availability  to   the   people   whose   by  many  others  in  related   social   fields  diseases.
          -the   health   officers    who    are    con.   lives may be saved by them.                      in recent years.                                 Although   the    Commission's    Report    had
          cerned    with    preventing    disease    and   Let  us  review  the  path  we  have  traveled   Scientific    progress      has        outpaced  many   facets,   there   were    two    central
          disability-the  volunteers   and   staffs   of   since April 1964.                                changes   in   human   organization.    As    a  themes.   One   was    that    people    every-
          the   private   health   agencies   who    are                                                                                                     where,  not  only  those   near   great   medi-
          devoted  to  furthering   the   education   of   The   President's   Commission,   under    the   society,   we   have   more   knowledge    than
          the  public  and  the  work  of  the   profes-   Chairmanship   of   Dr.    Michael    DeBakey,   we   have   know-how.   As   a   result,    the  cal   centers,   should   have   the    benefit
          sionals.  To  all  of  these,  the   President   was   convened   on   April   17,   1964   and   benefits  of  scientific   progress   are   not  of   the   latest   medical   scientific    ad-
                                                           made  its  report   on   December   9,   1964.   accessible  in  equal  portions  to   all   the  vances.  The  second   was   that   this   goal
          was also addressing his charge:                                                                                                                    could  only  be  accomplished   by   a   fusion
          "I expect  you  to  do  something  about  it."   The   Commission    contacted    60    private   people of the Nation.
          Tonight  we  can  tell  the   President   that   and   professional   agencies    and    organ-   The     Commission     found     that      many  of science, education and service.
          a  good  deal   has   been   done   about   it   izations   and   consulted   over   175   wit.   agencies   and   institutions   were    working  After  the  Report  was  issued,  it   was   up
                                                           nesses.   The    second    National    Confer-   on    overcoming    these    problems.     How-  to   the   Department   of    Health,    Educa-
          since  April  1964.  But  while  the  job  has   ence    on    Cardiovascular    Disease    was
          been started well,  there  is  still  much  to   rescheduled    so    that    the    Commission   ever,   these   efforts   were   often    being  tion,   and    Welfare    to    do    something
          be   done.    Tomorrow    and    Tuesday,    I   could  have  the   advantage   of   its   find.  performed    in     isolation-and     sometimes  about   it.   And   we   did   two    principal
                                                                                                            at cross-purposes.                               things.  First,   the   Department   requested,
          hope  you  will  tell  us  how  the  job   can   ings.                                                                                             and   the   President    and    the    Congress
          be done better.                                  In   looking   back   on   the    Commission's   The  Commission   found   that   its    concern  approved,  additional   funds   to   begin   to
          Regional    Medical    Programs    were    de-   findings,  we  find  eloquent   testimony   to   with   the   heavy   price   of   fragmentation  implement    several     specific     recommen-
          signed  to  fit  into   the   complete   spec-   the  gains  that   scientific   progress   has   was   shared   by    many    others.    Spokes-  datiohs   of    the    Commission.    Secondly,
          trum   of   needed   health    services    and   made  possible.  But  we   also   have   docu-   men   of  medical   groups,   medical   schools  the   Department,    under    the    leadership
          they  represent   the   kind   of   innovative   mentation  that  the  results  of  this  prog-   and  public  health,   among   others,   testi-  of   Dr.   Edward   Dempsey,    Dr.    Stewart,
          and   experimental    approach    needed    to   ress  is  not  being  made  available  to  the   fied both  about  the   penalties   and   prob-  and   Dr.   Shannon,   developed   a   legisla-
          achieve  our  goal.  The  authorizing   legis-   people  who  could  benefit   from   it.   The   lems   of   separated   efforts    and    their  tive  proposal  to  carry  out  that  part   of
          lation  allowed  three  years   for   planning   Commission Report pointed out:                   willingness   to   explore    new    approaches  the Report which       called  for  a   joining
          and  pilot  projects   to   gain   experience.   "The  rising  tide  of   biomedical   research   and remedies.                                    of   the   worlds   of   scientific   research,
          In  order  to  provide  an  early  opportunity   has  already   doubled   and   redoubled   our   On the basis     of   the   extensive    expert  medical    education    and    medical    care.
          for  review  and   evaluation,   the   Surgeon   store   of   knowledge   about   heart    dis-   advice  and  its   own   staff   studies,   the  In formulating the     legislation,   the   De-
          General  is  required   to   report   to   the   ease,   cancer   and    stroke.    Yesterday's   Commission   did   something   about   it.   It  partment    focused    on     the     following
          President   and   the   Congress   next   sum-
          mer   on   what    has    been    accomplished   hopeless    case    has     become     today's   produced   a   113-page    report    containing  recommendation:
          and what changes are indicated.                  miracle  cure.  We  stand   on   the   thresh-   35   major   recommendations   plus   a    ref-  "The    Commission    recommends     that     a
                                                           hold  of  still  great  breakthroughs  in  the   erence    document    including    over     600  broad  flexible  program   of   grant   support
          You  have  been  asked  to   come   to   Wash-   laboratories  and  clinical  centers  of   the   pages   of   documentation   and   many    sub-  be   undertaken   to   stimulate   the   forma-
          ington   to   help   the    Surgeon    General   Nation.    Yet    for    every    breakthrough   sidiary     recommendations.     The      major  tion    of    medical     complexes     whereby
          prepare  this  report  to  the  Congress.   We   there  must   be   follow-through.   Many   of   recommendations        covered      a      wide  university    medical    schools,     hospitals
          need   your   reports   on   what   has   been   our  scientific  triumphs   have   been   hol-   variety   of   proposals.   Some   were    con-  and   other   health    care    and    research
          happening  in   your   localities   in   plan-   low  victories  for   most   of   the   people   cerned  with   strictly   categorical   activi-  agencies  and   institutions   work   in   con-
          ning   and   developing    Regional    Medical   who could benefit from them."                    ties;  others  were   aimed   at   the   under-  cert."


                                                                                                                                                                                                          9







                   Perhaps the best   'way  to   recapture   what   Hospital    Association,    American    Acad-   agency   staffs   and   consumers   met    to-   vestment  in   research.   For   we   realized
                   the   Department   proposed   is   to    quote   emy  of  General   Practice,   as   well   as   gether  all  over  the  country  to  begin  to   that  only  in  this  way   can   we   achieve
                   from   the   President's   message   of   Jan-   many  individuals   from   medical   schools,   plan  Regional   Programs.   Many   of   these   our  objectives  for  the  control  of   heart
                   uary  7,  1965   on   the   legislative   pro-   medical   practice,   hospitals   and   other   sessions,  I  am  told,  have  not  been   en-   disease,   cancer   and   stroke   and   other
                   posal:                                           concerned citizens.                             tirely   comfortable-for   the    participants   diseases.
                   "A   plan   to   improve   our   attack   upon   As  a  result   of   the   views   expressed,   have  not  been  used  to   working   together   Some   have   argued   that   there   is    an
                   these  major  causes   of   death   and   dis-   numerous   changes   were   made    in    the   so  closely  in  the  past.   But   you   have   .nconsistency,  or   even   conflict,   between
                   ability  should   become   a   part   of   the   language of the  bill  which,  I  might  add,   begun   to   work   on   something   that   is   !ni@@  quality  and   widespread   use.   They
                   fabric   of   our   regional   and   community                                                   full  of  many   problems   and   difficulties   .
                                                           ..   .   taxed  all  the  ingenuity   I   had   gained                                                    r)eiieve  that  excellence  is  such  a   rare
                   health  services.   The   services   i)roviaea   rom  30  years  of  legislative   experience.   and  you  are  working  them  out.   That   is   and   tender   flower   that   it   can   only
                   under  this  plan  will  help  the  practicing                                                   progress  and  that   is   hopeful   for   the
                                                          '     -   AS  Many   of   you   know,   the   President                                                    bloom   in   special   and   carefully    pro-
                   physician  keep  in  touch  with  the   latest   joined  personally  in  these   efforts,   in   future of all  medical  care  in  our  Nation.   tected   environments.    They    have    sug-
                   medical   knowledge   by   making    available   which  Dr.  Hudson  participated,   to   find   Reports  indicate  that  our  faith   in   the   gested  that  we  can   lose   everything   by
                   to  him  the   latest   techniques,   special-   just  the  right  words  and   concepts   for   ability  of  local  groups  to   develop   new   trying   to   mass   produce   what   requires
                   ized  knowledge,  and   the   most   efficient   bringing  all   the   groups   involved   to.   approaches   is   proving    to    be    well-   the most skilled craftsmanship.
                   methods.    To    meet    these     ob'i.ectives, gether   in   a   common    attack    against  founded.  We   are   also   looking   to   the
                   such   complexes   should   be   regional   in   these common enemies of man.                    regional  groups  to  find   the   best   ways   This  point  of  view,  I  believe,  is   con-
                   scope;  provide  services  for  a  variety  of                                                   of fitting  together  the  many  related  pro-   trary to  our  national  hist  ry  and  corn-.
                   diseases;   be   affiliated    with    medical   The  Act   that   was   signed   in   October   grams  that   touch   upon   these   problems.   mitment.  I  think  we  have   the   capabili-
                   schools,   teaching   hospitals,   and    med-   1965  was  the  result  of   these   combined   The  key   problems   of   coordination   must   ties as  a  society  to  make  the  very  best
                   ical  centers;  provide  diagnostic   services   efforts.                                        be solved at the  local  level.  If  the  Fed-   available to  all  our  people.  This  is  our
                   in   community   hospitals;   provide    diag-
                   nosis   and   treatment   of   patients,   to-   The  story  of  what  you  have  done  in   a   eral  Government  tried  to   coordinate   all   national  goal.  It  is  this  goal  that  in-
                   gether   with   research   and   teaching   in   little over a year  is  exciting  and  auspi-   its  programs   at   the   Washington   level,   spires  and   integrates   all   the   diverse
                   a  coordinated  system.  .  .  .   Action   on   CiOus.  Under   the   able   leadership   'of   it  would   end   up   imposing   a   pattern.   programs   for   which   the   Department   of
                   this  new  approach,   will   provide   signi.   Dr.   Robert   Marston   you   have    under-   More   important,   only   State   and   local   Health,  Education,   and   Welfare   is   re-
                   ficant  improvements   in   many   fields   of   taken   some   of   the   most    significant   leadership  has   the   knowledge   of   local   sponsible.
                   medicine."                                       cooperative  planning  efforts  in  all   our   needs   and   resources   that   will   enable
                                                                    health  history.   Planning   grants   cover-   them  to  put  all   the   programs   together   Regional    Medical    Programs     have     a
                   The bill was introduced in Congress         in   ink  regions  in  which   some   60   percent   in a way that makes sense.                       unique    and    extraordinary    contribution
                                                                                                                                                                     to  make   in   this   movement.   Their   es-
                   January   1965   and   enacted   in   October'   of  the  population  of  our   country   live   Regional Medical Programs        have     been
                   During    the    intervening    months,    all                                                                                                    sential  purpose  is  to  speed  up  the  dif-
                                                                    have   already   been    awarded.    Applica-   described  as   having   an   obsession   with   fusion   of   knowledge-to   bring    together
                   interested  groups  had  an   opportunity   to   tions for planning  grants  for  the  remain-   quality.   Nothing   is   more    necessary-or   science  and  service  for  the   benefit   of
                   be  heard  and  to  participate   once   again   ing  regions  are   well   along.   Moreover,   fitting.                                         all.
                   in  considering  the   best   ways   to   meet   the proposals for the  first  pilot  projects
                   the   identified   needs.   Many    viewpoints   for  operational  activities   have   already   We   are   all   aware   of   the   tremendous   In the last year  or  so,  the  Public  Health
                   were    heard.    Testimony    was    received   been received and I  trust  grants  for  this   investment   that    has    been    made    in   Service  has  reorganized   itself   so   that
                   from   representatives   of    the    American   Durpose  will  be  made  within   the   corn-   effort and resources     over  the   last   20   under  the  leadership  of  Dr.   Stewart   it
                   Medical    Association,     American     Heart   'ing months.                                    years  to  advance  the  frontiers  of   medi-   will  be  able  to  make  its   maximum   con-
                   Association,    American    Osteopathic    As-                                                   cal   knowledge.   The   advance    of    this   tribution to this effort.
                   sociation,  American   Public   Health   Asso-   During   1966,    innumerable    groups    of   movement   has   been   one   of   our   great
                   ciation,    American    Dental    Association,   practitioners,   educators,   hospital    ad-   accomplishments   as   a   Nation.   We    in-   Regional   Medical   Programs   are    provid-
                   American     Cancer     Society,      American   ministrators,  health   officers,   voluntary   tend  to  maintain   and   extend   this   in-   ing   an    opportunity    and    means    for

                   10







                                                         With the Patient in Mind                        Robert Q. Marston, M.D.
                                                                                                         Associate  Director,  National   Institutes of Health
                                                                                                         Director, Division of Regional Medical Programs



          health  groups  all  over  the   Nation   to   Regional   Medical   Programs   have    been  that  characterize  any   new   health   pro-  Capricorn.  In  a   short   story   entitled
          take  a  somewhat  similar  look  at   their   launched at  a  critical  time  in  American  gram. He  notes  that  in  the  first  stage,  "The Far Limits" he writes:
          needs and potentialities.  It  is  important   Medicine.  The  initial  reception  by   the  available  data  is  limited  and   decisions  "The  Pacific  is  enormous,  plural,   con-
          but    not    enough    for     governmental   Nation  has  been  far   more   enthusiastic  must  be  made   almost   entirely   on   the  tradictory.  One  aches   for   limitations,
          agencies,  either  here  in  Washington   or   than   many   supporters   believed   possi-  basis  of  the  best  judgments  of   respon-  for  boundaries  that  reduce   the   sensa-
          in  State  capitals,  to  examine  how  they   ble. Initial financing  has  been  adequate.  sible  persons.  This  is   where   we   have  tion of awe.  For  each  person  the  limits
          can most effectively  carry  out  their  re-   The  program  is  now  undergoing  a   proc.  been  during   much   of   the   past   year.  are   different.   For   some   people   the
          sponsibilities. Nor is it  enough  for  edu-   ess  of  analysis   to   determine   whether  The   focus   has   been   on    establishing  Pacific is no-larger than  a  tiny  village,
          cational  and   research   institutions   to   the premises  on  which  it  was  based  are  mechanisms     and      approaches      which  a strip of white sand, a reef.  For  a  tiny
          undertake  similar   examinations.   Rather,   still  valid;  whether  the  initial  imple-  promise  better   utilization   of   existing  group, that  inquisitive  body  of  oceanog-
          as  illustrated  by   the   composition   of   mentation   has    been    effective;    and  information  and  the  collection  of   addi-  raphers,  the  Pacific  is  illimitable.  So
          this   conference,   all   those   concerned   whether    experience     suggests      that  tional  data  which  will  form   the   basis  great is their curiosity that their  Pacific
          with  these  disease  problems  and   better   changes  should  be  made  for   the   years  for   more   confident   decisions   in   the  runs  from  the  Bering   Straits   to   the
          health must join in the process.               ahead.  The  fact  that  this  audience   is  future.   In   considering   proposals    for  glittering ice cliffs of Antarctica."
          Happily   this   job   has   already    been   here  to  participate  in  these  considera.  extending    the    legislation,     Congress  The   scope   of   Regional   Medical   Pro-
          started  in  most  parts  of  the   country.   tions   and   decisions    emphasizes    the  faces the  same  difficulties  that  we  have        s will  certainly  lie  somewhere  be-
                                                         fact that this  program  is  indeed  founded  faced. Congress  will  value,  as  we  shall,  gram
          We are doing something about it.                                                                                                         '  tween   Burdick's  tiny  village   and   the
                                                   But   on local concern  for  the  needs  of  those  the  best  judgment   of   those   who   have
          I trust you will  not  be  satisfied-for  we   patients   with   heart   disease,   cancer,  acquired  wide  experience  in   the   health  entire Pacific.
          will  not-until  the  best  of  health  care   stroke, and related diseases.                 fields   and   who   have   assumed   respon-  As the  Nation  begins  an  innovative   and
          is not only  part  of  the  continuing  con-                                                 sibility   for   launching   the   individual  ambitious   venture   in    improving    the
          cern of  health  leaders  and  a  preoccupa-   Much  of  this  paper  and   most   of   the  Regional    Medical    Programs    throughout  quality of health  care  for  patients  with
          tion of some but is part of the  daily  life   meeting  will  be  focused  on  the   Report  the  country.  To   reinforce   the   limited  heart  disease,  cancer,  stroke,  and   re-
          experience of all our citizens.                to  the  President  and  Congress   required  hard  data  that  is  available,  the  Presi-  lated diseases,  it  is  being  watched  in@
          For the next  two  days  you  will  be  able   by  the  enabling   law.   Such   a   Report  dent  and  Congress  will   expect   evidence  tently  by  its  neighbor  nations.   Lancet
          to  concentrate  on   these   problems.   We   comes at a  very  early  stage  in  the  de-  of  firmer   commitments,   clear   purposes,  in a recent  editorial  refers  to  the  Re-
          hope  that  you  will  give  us  your  ideas   velopment   of   the    program.    Nonethe-  and  crisper  definitions.   These   examples  gional  Medical  Programs   as   "An   Amer-
          and   advice   on   how   Regional   Medical   less,  this  Report  will   constitute   the  must   be   developed   by   you   who    are  ican  Catalyst."  A   description   of   the
          Programs   can    best    be    strengthened   basic  document   on   which   the   program  involved  at  the  regional  level   on   the  Connecticut    program    by    Dr.    Henry
          and facilitated. After you  leave,  we  will   for  the  period  from  1969-1974  will   be  basis   of   your   actual   experience   and  Clark   at   a   Boerhaave   Conference   in
          welcome   statements   of   your   reactions   built.                                        future  plans.  Since  the  very  nature   of  Leiden,  Holland,  was  of  great   interest
          and  proposals  as  further  experience   is   In  his  Issue  Paper  on  evaluation,   Dr.  Regional    Medical     Programs     involves  to  health  leaders   from   Holland,   Bel-
          acquired  in  the  planning  and  operations   Sanazaro  has  defined  the  several  stages  opportunities  at  the  regional   level   to  gium,. England, Sweden, and Turkey.
          of Regional Medical Programs.                                                                probe  for   workable   solutions   to   com-  At  one  time  I   was   chairman   of   the
          I  can  assure  you  that   not   only   the                                                 plex  problems,   we   in   Washington   can.  NIH    Postdoctoral    Foreign    Fellowship
                                                         Prepared   in    cooperation    with    Karl  not  conjure  the  required   realistic   ex-
          Surgeon   General   but    also    President                                                                                                Committee  which   brought   young   scient-
          Johnson  and  Secretary  Gardner,  as   well   Yordy,  Assistant  Director,   Division   of  amples    which    indicate     modifications  ists  from   40   countries   for   research
          as  members  of  the  Congress,  are   look.   Regional   Medical   Programs,   and   Stan-  are  needed.  Only  your  efforts   and   ex-  fellowships  in  the  United  States.  These
          ing  forward  as  I  am  to   your   reports   ley  W.  Olson,  M.D.,   Chairman,   Confer-  periences can provide such evidence.           young   physicians   and   scientists   uni-
          and   recommendations.   I   am    confident   ence   on   Regional    Medical    Programs,  A major  problem  is  related  to  the  scope  formly  praised  our   unique   ability   to
          you  will,  once  again,  meet  and   exceed   and   Coordinator,    Tennessee    Mid-South  of   the   program.   Gene   Burdick's   most  bring  together,  for  the  purpose  of  the
          their expectations.                            Regional Medical Program                      pleasant book  is  one  called  the  Blue  of  problem under study,  the  skills  of  those

                                                                                                                                                                                                11





               from  many  disciplines.  Our  foreign  col-                                                 we  are  now  in  the  process  of   testing   tions   for   RegioAal   Medical   Programs.
               leagues  who  have  observed   this   inter-                                                 the  progress  and   capabilities   of   Re-   Deans  and  faculty  members   of   all   of
               disciplinary   achievement    in    research                                                 gional Medical Programs.                       the  Nation's   existing   medical   schools
               will  be  greatly  interested   to   observe                                                 STATUS  REPORT.       Secretary       Cohen,   and  most   of   the   schools   under   de-
               whether  we  can  parallel   this   perform-                                                                                                velopment   have   participated   in    this
               ance  in  the  field  of  medical  care.  To                                                 last  night,  presented   a   splendid   re-   activity along with  most  of  their  teach-
               bring  this  'about,   the   primary   focus                                                 view  of  the  historical   development   of   ing  and  affiliated  hospitals.   Represen-
               must  be  not  on  the  needs   of   medical                                                 the  broad  policy   and   philosophy   that   tatives of State  and  local  medical  soci-
               schools,  the  needs   of   hospitals,   the                                                 led  to  the   establishment   of   Regional   eties   and    health    departments    have
               needs  of  health   departments,   or   even                                                 Medical  Programs.  The  copy   of   a   re-   been  part  of  the  discussions  in  almost
               the   needs   of   physicians   and    other                                                 cent  paper  of  mine   forwarded   to   you   every  instance.  In   addition,   area-wide
               health   workers.   Rather,   the    primary                                                 in  advance  of  this   meeting   summarized   hospital   planning   agencies   and   State
               focus must be  on  the  needs  of  patients.                                                 progress  from   October   1965   to   Octo-   and  local  hospital   associations   repre-
                                                                                                            ber 1966. A  few  illustrated  facts  should   senting   the   Nation's   community    hos-
               This  Conference   is   framed   against   a                                                 suffice to up-date that data:                  pitals  almost  always  have   been   repre-
               series   of   difficult   decisions   facing                                                 0  The   National   Advisory   Council   has   sented.  Members  and   staffs   of   cancer
               American   Medicine.    We    must    decide                                                 met  six  times.  At  four  of  these  meet-   societies  and   heart   associations   have
               how  we  shall   provide   health   manpower                                                 ings  applications   for   planning   grants   participated   along   with   other   public
               for  ever  increasing  needs  and   demands.                                                 were reviewed.                                 and  private  health  agencies  and   repre-
               We  must  decide  how   we   shall   provide                                                 0  As  a  result  of  decisions  reached  at   sentatives of the  public  such  as  elected
               particularly   for   these   receiving   the                                         16      the  April  1966   meeting,   seven   grants   officials,   businessmen,   labor   leaders,
               poorest  care  of  all-the  poor,  the  min-                                                 were awarded.                                  and  leaders   of   religious   and   ethnic
               orities,  the  isolated-both  in  the  coun-                                                 0  At   the   June   1966   meeting,   three   groups,
               try and  in  the  heart  of  cities.  Severe                                                 additional   applications   were   approved.   A  study  of  the  backgrounds  of  the  in-
               economic   pressures   are   being   exerted                                                 0  At  the  August   1966   meeting,   eight   divid,als   who   are   assuming   responsi-
               on the entire field of health,  particularly                                                 more   applications   were   approved    and   bilities  as  full-time   coordinators   and
               on  America's  hospitals.   Urgency   exists
               with  respect  to  how  we  shall   organize                                                                                                staff directors  of  Regional  Medical  Pro-
               to  best  use  the  many  new   technologies                                                 0  Most  recently  at  the   November   1966   grams   indicates   that   about   half   of
               that promise  potential  benefits  if  wise-                                                 meeting,  the  Council   approved   16   ap-   these   individuals   come   directly   from
               ly and effectively used.                                                                     plications, bringing  the  total  of  funded   the  field  of  medical  education.  Another
               These   problems   and   trends   are   pow-                                                 programs to 34.                                substantial  number  were   forrilerly   in-
               erful  in   their   impact.   They   require                                                 0  In   addition,   14   planning   applica-   volved  in   key   positions   in   hospital
               that instruments  of  great  durability  and                                                 tions which will  bring  the  total  popula-   administration.    The    remaining     came
               equally  great  sensitivity  be   structured                                                 tion  covered  by  planning  activities   to   from   leadership   roles    in    voluntary
               so  that  medicine  may  be  favorably   in-                                                 some  90  percent  of  the  nation  are  ex-   health  agencies,  State   government,   and
               fluenced  to  provide  the  greatest   serv-                                                 pected  to  be  presented  to  the  February   the  private  practice  of   medicine.   The
               ice  to  those  in  need.  We  believe  that                                                 Council  Meeting.  The  first  four   appli-   high  caliber   of   person   being   sought
               Regional  Medical   Programs,   with   their                                                 cations for  operational  phases  will  also   and  employed   for   these   positions   is
               emphasis  on  local  initiative  and   local                                                 be presented at that time.                     impressive.
               control, was created  as  such  an  instru-.                                                 There   has   been    widespread    involve-   A study  of  the  make-up  of  regional  ad-
               ment  to  help  solve  these  problems   and                                                 ment  of  individuals  and  groups  in   the   visory   groups   indicates   that   on   an
               cope  with  these  trends.  To   this   end,                                                 development  of  all   of   these   applica-   overall basis . . .

               12








           21 yo are practicing physicians              raised  and  will  continue  to   be   asked   determine  which  of  them  are   favorably   of  this  meeting  and  grows  out  of  the
           18%   are associated with medical            whether   these    arrangements    developed   affecting  the  care  patients   have   re-   fact  that  the  Surgeon  General  of   the
                 schools and affiliated hospitals       for the purpose  of  starting  to  plan  for   ceived, and to what degree.                   Public  Health  Service  is   required   by
           13%   are from Cancer Societies,             a  regional  medical  program  will  be  the   I  have  often  referred  to  the  clinical   the   law   which   established    Regional
                 Heart Associations, and other          most  effective  arrangements  for  specific   pathological   conference   as   a   unique   Medical  Programs  to  make  a  Report   to
                 voluntary health agencies              operational  activities  in  heart  disease,   feature  of  medicine.  It  is  here   that   the   President   and   Congress   on    or
                                                        cancer,  stroke,  and  related   diseases.     even the  most  senior  clinicians  display   before  June  30,  1967.   A   subcommittee
           12%   are administrators of hospitals        Another  issue  suggested   for   discussion   their clinical  judgment  for  all  to  ee,   of !he   National   Advisory   Council   on
           8%    are nurses and other health                                                                                                 s       Rag.0 nal   Medical   Programs   and   t   e
                                                        in  the  paper   on   cooperative   arrange-   It is a method for exposing error an          Surgeon  General  concurred  in  our   view
                 workers                                ments is  the  nature  of  the  local  deci-   thereby  improving  care.  It   and   other
           8%    are from public health depart-         sion-making   mechanism.   The    law    re-   established   traditions   such   as    the   that, in  addition  to  the  steps  already
                                                                                                                                                     taken  toward  the   development   of   in-
                 ments                                  quires  that  all  operational   grant   re-   autopsy, the  use  of  a  case  conference,   .
           14%   represent the public at large          quests  must   be   approved   by   regional   and  the  wide  use  of   consultants   has   formation  for  this  Report,   representa-
                                                        advisory   groups.   The   question   arises   firmly   established   medicine's   commit-   tive  groups  from   the   entire   country
           HIGHLIGHTS    OF    ISSUE    PAPERS.    Let  whether  this  approval  shall   be   merely   ment  to  constant  scrutiny  and  critical   should  be  convened.  As  a  result,   re-
           us  now  focus  attention  on  the   issues                                                                                                ional  coordinators,  representatives   of
                                                        a  pro  forma  endorsement  based  on   con-   evaluation  of  its  judgment   and   tech-   9  ional  advisory   groups,   and   others
           that  are   emerging.   These   have   been  fidence  in  the   applicant   organizations   niques.                                       reg
           described  in  a  series  of  Issue  Papers  and  institutions,  or  whether   it   shall                                                 identified as key people  in  the  develop-
           sent to you  as    background      material  represent  a  careful  evaluation   of   re-   We are  now  entering  a  phase   of   med-   ment  of   approved   and   pending   grant
           for discussion at this Conference.           gional   priorities   based    upon    sound   ical care which requires  that  we  do  for   proposals  have  been   invited   to   this
                                                                                                       populations  of  patients  and  populations   Conference.  Major   health   organizations
           The first of these papers  entitled,   "The  knowledge   of   needs   and   capabilities.
           Development of     Cooperative     Arrange.  This issue is closely related to  the  prob.   OT  physicians  what  we   have   done   so)  who have  expressed  an  interest  in  this
           ments,"  includes  a  fine   statement   by  lems  of  the  review  and  approval   proc-   long and so effectively  for  the  individ-   program   were   also   invited   to   send
           Dr.   Charles   Hudson,    prepared    four  ess  for  operational  grants  to   be   d     ual case and the  individual  practitioner.   representatives.  Appropriate   representa-
           years  ago,  which  expresses   his   views  cussed later.                            is-   The  techniques   of   epidemiology,   med-   tives of other  government   agencies   in-
                                                                                                       ical  ca re  research,     of     community   cluding   the   National   Institutes    of
           on  the  desirability  of  developing   co-  In  the   second   Issue   Paper   entitled,   medicine  must  be  adapted   to   personal   Health,  other  bureaus   of   the   Public
           operative  arrangements.   We   have   been  "Continuing    Education    and     Regional   health,  as  well  as  public  health.   TO   Health   Service,   the   Bureau   of   the
           told   that   Regional   Medical   Programs  Medical  Programs,"   it   is   noted   that   this  end,  we  asked  Dr.  Paul   Sanazaro   Budget,  and  Congress   were   invi'ted   to
           have   made   considerable   progress    in  continuing  education  has  been         ac-   to  prepare  the  Issue  Paper  "Evaluation   attend.  Also  included  are  the  65   in-
           developing    genuine    cooperative    ar-  cepted as an article of faith by         the   of  Medical   Care   Under   P.L.   89-239"   dividuals  who  have  served  as   consult-
           rangements    throughout    the     Nation.  medical  profession.  Although  it  is   re-   and  Dr.  Vernon  Wilson  to  discuss   the   ants to  the  Division  in  helping  define
           Groups  in  virtually  every  region   have  garded as an essential activity for      the   problems  in   a   subsequent   talk.   The   policy  and  philosophy.       Specifically,
           been   probing   to   establish   a   work-  scientific and  clinical  renewal of     the   issue is  how  rapidly  the  still-develop-   these  include  members  of   the   initial
           able  basis  for  starting   the   planning  physician, the Issue Paper points        out   ing  techniques  for  evaluation   can   be   Review   Committee,    members    of    the
           process.   However,  the      initial   ap-  that  this  vital   educational   experience   employed so  that  our  effort  to  improve   ad  hoc  Committee  for   the   Report   to
           proaches  concerning  the  size  and  shape  has  often  been   characterized   by   lack   care will  be  logically  rather  than  em-   Congress,   members   of    the    National
           of  regions  for  planning  purposes   must  of continuity. There  are  two  key  issues.   pirically determined.                         Advisory  Council,  and  liaison  represen-
           be  re-examined  critically  from  time  to  First,  how   can   programs   be   designed                                                 tatives   of   other   National    Advisory
           time,  especially  when  the  region  moves  that effectively  reach  the  physician  and   THE   REPORT   OF    THE    SURGEON    GEN-   Councils with related interests.
           from  planning   into   the   establishment  others in  the  health  field;  and  second-   ERAL   TO   THE    PRESIDENT    AND    CON-
           of  an  operational  program.  Let  me   be  ly,  how  can  self-monitoring  aspects   be   GRESS. The  fourth  and  last  Issue  Paper   All  of  the  members  of  the  Pr6sident's
           quite   specific;   questions   have   been  incorporated   into   these   programs    to   is  concerned  with   the   primary   focus   Commission  on   Heart   Disease,   Cancer,

                                                                                                                                                                                             13






               and  Stroke  have  also  been  invited.  We   port  must  also  speak  to  at  least  four  ment   of    cooperative       relationships   The  planning  phases  of   Regional   Medi-
               are  particularly  interested   in   having   other questions:                              among  major   health   resources   in   the   cal  Programs  are  well  on  the   way   to
               them now  refocus  not  only  on  the  pro-   0  In  specific  terms,  the  type  of  con-  region.  These  activities   are   generally   covering  the  entire  Nation.  We  are  now
               gram as it exists  today  but  on  possible   struction  authority   needed   to   achieve  generic   by   nature    and    consequently   in  the  process  of  reviewing  the   first
               future  modifications.   Their   background   the   goals   of   the   program   and   the  have  not   significantly   involved   prob-   applications for operational grants.
               of  competence  and  the  experience   they   urgency  of   this   need   must   be   made  lems   o.f  categorical  definition.  In  most The  initiation  of  operational  activities
               gained   in    producing    the    document   clear  to  the  President   and   the   Con-  cases  in  order  to  plan  effectively  for   is the most  vital  element  of  our  mutual
               which served to  initiate  the  legislation   gress.  Any  request  for   such   authority  heart  disease,  cancer,   and   stroke   it   task ahead. It is  the  operational  activi-
               establishing  Regional    Medical      Pro-   must  be  substantiated  by   firm,   objec.  has  been  found   necessary   to   consider   ties  to  be  approved,  funded  and  imple-
               grams will prove to be invaluable.            tive  evidence  of  need,  particularly   if  at  times  the  entire   spectrum   of   re-   mented   under   the   current   legislation
               Public   Law   89-239    specifies    three   favorable    matching    requirements    are  sources  available   for   personal   health   that  must  constitute  the  central   focus
               things  that  the   Report   must   accomp-   needed.                                       services.   However,   the   emergence    of   for   recommendations   for   extension   of
               lish:                                         0  Since  the  earliest  days  of  the  pro-  the  operational  phase   of   the   program   the  program.   Based   on   experience   to
                                                             gram,  questions  have   been   raised   re.  will put  a  more  intensive  focus  on  its   date which  includes  staff  analysis,  site
               It must appraise ...                          t)eatedly concerning  the  need  to  clarifv  categorical    purposes.    Only    projects   visits, deliberations by  the  Review  Corn-
               0 The  activities  assisted  by  grants  in   '                                          il which  can   be   shown   to   have   direct
               the light of their effectiveness, and         certain  provisions  of  the  law.  We   sha  significance  for   combating   heart   dis-   mittee  and  the  National  Advisory   Coun-
                                                             have  an  opportunity  in  the   Report   to  ease,  cancer,  stroke  and   related   dis-   cil,  and  discussions  with  other   Public
               It must deal with two issues . . .            identify  these  areas  and  provide  inter-                                                 Health  Service  programs,  we  have   iden-
               0   The   relationships   between   Federal   pretation.                                    eases  can   be   assisted   with   Regional   tified  some  of   'the   impo.rtant    issues
               financing   and   financing   from    other   0  The  law  authorizes  grants   only   for  Medical  Program  grant  funds."   The   im-   which  must  be  considered  in  the  review
               sources of  the  activities  undertaken  on   the  planning  and  establishment  of   'in-  plications  of  this  issue  requires  care-   f  applications  for   operational   grants.
               behalf of the Regional Programs.              dividual  Regional  Medical   Programs.   It  ful  consideration  as   you   discuss   the
               0  The  extension   and   modification   of   has  been  suggested  that  the   goals   of  future of these programs.                      At  the  risk  of  generalizing  from  rela-
                                                                                                                                                          tively  few  examples,  I  should  like   to
               the law.                                      the   program   might   be   achieved   more  It should be emphasized      that  this  Re-   review  with  you  the  characteristics   of
               We  must  give  serious  attention  to  the   readily  by  expanding  this  authority   to  port to the President and   Congress    will   the  operational  proposals   as   we   have
               r                                             allow  grants   for   activities   involving  be  the  basic  document  on  which   recom-   seen  them  in  the  initial   applications.
               elationship  of  Federal  and   non-Federal   multiple  regions  that  will  support   the  mendations  for   future   legislation   ex-   Your  actions  in   developing   operational
               financing.  Congress  will   examine   this   work   of   individual   Regional    Medical  tending  and  modifying   Public   Law   89-   proposals,  and  the  actions  of  our   Re-
               issue carefully. For  instance,  activities   Programs.
               once  started  are  not  easily  curtailed.                                                 239 will  be  based.  In  addition  to  your   view   Committee   and   Advisory    Council
               Yet the  essential  purpose  of  this  pro-   0  A  fourth   major   question   has   been  participation in  the  discussions  at  this   in  approving  these  proposals,  will   ex-
               gram is to  help  bridge  the  gap  between   how rigidly  or  freely  one  may  interpret  meeting, I invite  each  of  you  personally   press far more  effectively  the  nature  of
               the advancing frontier  of  new  scientific   the  emphasis  on  the  disease   categories  to   send   me   any   written   suggestions   Regional   Medical   Programs   than    gen-
               knowledge  and  the  broad  application  to   of  heart,  cancer,  and  stroke.  I  invite  which you  think  will  be  helpful  in  the   eral  policy  statements  and  will   reveal
               patient  care.  All  funds  cannot   remain   your  attention  to  two   paragraphs   from  preparation  of  this  important   document.   most  clearly  the   importance   of   these
               tied  up  in  Continuing  program   support   the   Issue   Paper   concerned   with   the  We anticipate the  preparation  of  a  draft   Programs to society.
               of  yesterday's  advances.  A   significant   Report.   "During   the   planning    phase,  of the Report shortly  after  this  meeting.
                                                             the  major  activities  undertaken   by   Re                                             -   The review of  the  first  operational  pro-
               amount  must  be  available  to   encourage                                              -  Thus,   your   comments    can    be    most
               new  programs  at  the  cutting   edge   of   gional  Medical   Programs   have   involved  effective  if  they  are  forwarded  to   me   posais  has  raised  sharply  the   question
                                                             the  establishment  of  a  planning   staff,                                                 of  what   methods   should   be   used   to
               science.                                                                                    promptly.
                                                             the initiation  of  studies  to  obtain  the                                                 evaluate   such   applications.   Each    is
               Although   not   required   by   the   law,   basic  data  concerning   pertinent   health  OPERATIONAL   GRANTS.   I   come   now    to   characterized  by  a  number   of   specific
               experience  has  indicated  that  the   Re-   needs  and  resources,  and   the   develop-  a very  important  section  of  this  paper.   activities  within  the  overall   proposal.

               14










      However,    a    Regional    Medical    Program   of   the    proposed    cooperative    arrange-   less,   the   written   proposal   should   in-     Not   only   are   the   reviewers   concerned
      must   be   more   than   a    collection    of   ments.   In   evaluating   the    effectiveness   clude   an   exposition    of    the    guiding     that  the  focus  of  the   program   is   out
      projects.   The    review    process,    there-   of    these    arrangements    attention     is   philosophy     and     administrative     proc-     towards  the  periphery,  but  that  the   ap-
      fore,   must    focus    on    three    general   given  to  the  degree   of   involvement   and   esses  which  have   gone   into   the   devel-     plications  themselves   reflect   this   con-
      characteristics   of   the    total    proposal   commitment   of   the    major    health    re-   opment  of  the   proposal   and   should   ex-     cern on the regional level.
      which   separately   and    yet    collectively   sources,  the  role   of   the   Regional   Ad-   plain    how     the    specific     activities
      determine   its   nature   as   a    comprehen-   visory  Group,   and   the   effectiveness   of   proposed  relate  to   these   overall   objec-     Activities    which    have    been     chosen
      sive   and   potentially   effective   Regional   the   proposed   activities   in    strengthen-   tives.  A  justification   of   each   separate     should   seek   to    reinforce    cooperation
      Medical      Program.                             ing  cooperation.   Only   after   the   deter-   project,     however     worthwhile,     cannot     and  mutual  interaction   between   the   ac-
      0  The   first   focus   must   be   on   those   mination  has   been   made   that   the   pro-   provide   a   sufficient   basis   for   making     ademic    community    and    the    community
      elements   of   the   proposal   which    iden-   posal    reflects  a     Regional       Medical   the   essential    determinations.    Consider.     practice  of  medicine.  Such  linkages   will
      tify  it  as  truly  representing  the  concept   Program  concept  and  that  it   will   stimu-   ation   of   other   characteristics   of   the     be   among    the    most    important    con-
      of  a  Regional  Medical   Program.   Our   re-   late    and     strengthen          cooperative   initial   operational   proposals   and   their     tributions   of   the    program.    If    the
      view  groups  have  determined   that   it   is   efforts  will  a   more   detailed   evaluation   review  also  reveal   the   essential   nature     specific  activities  proposed  in  an  appli-
      not  fruitful  to  consider  specific   aspects   of  the  specific  operational  activities   be   of   a   developing   Regional   Medical   Pro.     cation   fail   to   strengthen    cooperative
      of  the  proposal  unless  this  first   essen-   made.                                             gram.   They    provide    concrete    examples     arrangements   or    even    interfere    with
      tial   determination   concerning   the    core   0  If  both  of  the   two   previous   evalua-   of  most  of  the  issues   to   be   discussed     such   cooperation,   the   entire    Regional
      of  the  Program   is   positive.   In   making   tions  are  favorable,  the   operational   ac-   at  this  Conference.   For   instance,   these     Medical   Program   would    be    threatened.
      this   determination   the    reviewers    have   tivities  can  then   be   reviewed,   individ-   proposals      clearly    lead    from      the     The   maintenance   and   nurturing   of   the
      asked  such   questions   as:   "is   there   a   ually  and  collectively.  Each  activity  will   strengths   contained   within   the    region.     cooperation   established   in    the    plan-
      unifying      concept.ual  strategy  which   will be  judged  for  its   own   intrinsic   merit,   This   is   understandable   and    justifiable     ning  phase  of  the   program   will   surely
      be the basis  for  initial  priorities  of  ac-   for  its  contribution   to   the   cooperative   and  may  be  the   most   effective   way   to     pose  a  major  challenge  to   all   Regional
      tion,   evaluation,   and   future    decision.   arrangements,   and   for   the    degree    to   implement  the   first   phase   of   the   re-     Programs,   especially   those    with    more
      making?"   "Is    there    an    administrative   which  it  includes   the   coro   concopt   of   gional   medical   prograi-n.   Leading    from     complex     institutional        relationships
      and    coordinating     mechanism     involving   the    Regional    Medical     Programs.     It   strength   may    develop    some    activities     than  are  represented  in  the  first  appli-
      the   health   resources   of    the    regions   should  also  fit  as  an  integral   part   of   which   can   serve   as   models   for   other     cations.  Thus,  the   review   process   must
      which  can  make   effective   decisions,   re-   the   total   operational    activities,    and   regions  or  a  resource  which  can  be   uti.     be  concerned  initially   with   the   appli-
      late  those  decisions   to   regional   needs,   contribute  to  the   overall   objectives   of   lized    by    adjacent     regions     through     cant's   concept   of   a   Regional   Medical
      and   stimulate   the   essential   cooperative   the Regional Medical Programs.                    effective   interregional   cooperation.   For.     Program  and   his   total   proposal   rather
      effort   among   the   major   health    inter-   This  is  not  a  conventional   review   proc-   tunately,  there  are  examples  in  the   ini.     than with specific activities.
      ests?"  "Will  the  key   leadership   of   the   ess.   The   total   process   for    reviewing   tial  applications  which  give   evidence   of     ,v@Ve  also  see  evidence  in  these   applica-
      overall   Regional   Medical    Program    pro-                                                     interregional   cooperation    in    capitaliz-     .. ns  of  the  design  of  initial   operation-
      vide   the   necessary   guidance   and   coor-   complex    operational    applications     will   ing  on   the   particular   strengths   within     tio           f   the   program    that    can
                                                        often  require  up  to   six   months   or   in   an@adjacent  region.  I  would  like   to   add     al  phases  o
      dination   for   the   development    of    the   some   cases   even    more.    The    applica-   a   cautionary   note,   however,   that    the     serve   through   continued    planning    and
      program?"  "What   is   the   relationship   of   tions  already  in  hand   are   providing   us   full  development   of   a   regional   medical     evaluation  as  the  basis  for  further  evo-
      the    planning    already    undertaken    and   with  a   learning   opportunity   to   develop   program    must    show    equal    concern-f-,     lution   of   Regional    Medical    Programs.
      the   ongoing   planning   process    to    the                                        processes.   strengthening the weaknesses of              u@     We   cannot   emphasize   too   strongly   the
      initial operational proposal?"                    the most appropriate review                                                                   tha     ecessity   of   incorporating   in   the   Re-
                                                        Our  experience  indicates  that   the   inter-   region.                                             n
      0  After  having   made   a   positive   deter-   play  of  an  initial  site   visit   will   be                                                       gional   Medical    Programs    the    methods
      mination  about   this   core   activity,   the   necessary    to    determine    whether     the   Our reviewers question repeatedly           how     of   evaluating   and   modifying   the   pro-
      next  step  widens   the   focus   to   include   essential  criteria  for   a   Regional   Medi-   weaker  institutions,   the   minorities,   the     gram  so  that  it  becomes  to  a   consider-
      both   the   nature   and   the   effectiveness   cal   Program   have   been   met.    Neverthe-   poor,  will  he   helped   by   the   proposal.     able   degree   a    self-monitoring    system

                                                                                                                                                                                                        15









                  which  will  supply   those   participants   at   gional    Medical    Programs    to    consider   explicit    and    concrete    mechanism     for   them  as  we  would  like.  There   has   never
                  all  levels  with  the  information   and   the   both   the    specific    and    broader    ap-   playing  a   meaningful   role   in   the   con-   been   a   greater    opportunity    to    link
                  motivation  and  the  flexibility   to   direct   proaches   for   meeting   identified    health   tinued   development   of   the   overall    Re-   science,  education  and   service,   but   the
                  future   efforts   towards    those    fulcrums   needs   in   the   region.   While   the   many   gional    Medical     Program   a  er          e   di icuitfes are very gr a .
                  of  action  that  accomplish   best   the   ob-   types  of  activities  proposed  in   the   ap-   award  of  grant   support,   we   are   consid-   But "no ashes, no Phoenix"
                  jectives  of  the  program.   For   this   rea-   plications   complicate    the    process    of   ering  the  possibility  of  including  in   the
                  son  it  is   important   to   avoid   freezing   review,  they  show   evidence   of   a   seri-   grant  award  for   operational   activities   a   Mythology  offers   no   tale   more   dramatic
                  the    program    towards    permanent     sup-   ous   effort   to    match    resources    with   proportion  of  the  funds  to   be   used   for   than  that  of  Phoenix.  With   his   flashing
                  port  of  all  initial  activities  undertaken.   needs   and   to   bridge   the   gaps    among   carrying   out   the   purposes   of   the   RMP   gold   and   scarlet   plumage   he    descends
                  Some  of  the  activities   should   be   self-   science, education, and service.                  at  the  discretion  of   the   RMP   with   the   to  the  altar  of  the  sun  and  is  consumed
                  limiting  with  the  transfer  of   effort   to                                                     approval    of     the     Regional     Advisory   to  ashes.  With  the  rising  of  the  sun  he
                  other    priorities   as    the        programs   Regional   Medical   Programs    represent    a   Group.   This   approach   would    lend    sub.   is  reborn  more  glorious   than   before   to
                  evolve.   If   these   programs   become   just   new   relationship    between    the    Federal   stance  to  the   intent   that   the   Regional   signify   for   another   500   years   eternal
                  another   source   of    funds    to    finance   review    mechanism    and     the     regional   Medical    Program    be    more    than     the   hope arising from disappointment.
                  specific  activities,  we   shall   have   lost   framework    for    decision-making.    Neither   sum of its parts.                                  Like    the    soaring    Phoenix,     Regional
                  the   opportunity   to   develop   a   uniquely   grant   support   or   formula    grant    sup-                                                      Medical    Programs    have     arisen     from
                  effective    mechanism    in    bringing    the   port   can   be   applied.   We    intend    to   SUMMARY. The         purpose   of   this   paper   previous   hopes,   expectations    and    dis-
                  advances    of     medical     knowledge     to   work   closely   with   you    in    developing   is the purpose of this Conference:                 appointments.    They    offer    new     hopes
                  bear   on   the   health   problems   of    the   the  potential  of   this   new   relationship.   0  To  help  set  the  stage  for   a   fruitful   and    opportunities    for    new     achieve-
                  people   of   the   regions.    The    develop-   Yet,  there  is   a   potential   contradiction   discussion  of  the   Report   to   the   Presi.   ments in American medicine.
                  ment    of    the    self-monitoring    charac-   between   the   need   to   evaluate    proPOs-   dent and Congress; and
                  teristic   of   the   Regional   Medical   Pro-   als  at  the  national  level  and  the  intent   0  by   free   exchange   of   information,   to
                  grams   is   also   a   presumption   of    the   that    the    Regional     Medical     Program   be   able   to   implement   the   next   stages
                  review  sequence   described,   for   the   fu-   represent   a   new   framework    for    deci-   of  the  program  in  the   best   ways   possi-
                  ture   relationships   between    our    review   sion  at  the  regional  level.   If   specific   ble.
                  process   and   a   regional    medical    pro-   approval    actions    in    Washington    were
                  gram  are  to  be  based  more  on   an   eval.   entirely   on   a   project-by-project   basis,   I  have  focused  first   on   certain   issues,
                  uation  of  the  effective   results   of   the   this  would  tend  to  move   the   major   de-   then   on   the   Report   to   the    President
                  overall   regional   program   and    achieving   cision-making   responsibility    for    deter-   and  Congress,  and  finally   on   the   appli-
                  its  goals  rather  than  on  a  detailed   re-   mining   the   nature    of    each    Regional   cations    for    operational     grants     and
                  view of specific activities proposed.             Medical  Program   to   the   national   level.   their  review,  as  the  basic  tools  for   you
                                                                    Under     these     circumstances      regional   to   begin   defining   the   Regional   Medical
                  As    anticipated,    categorical     questions   decision-making     would      be      confined   Programs   to   serve    patients    in    1969-
                  do  arise.  The  initial  proposals   are   di-   larizely to  the  choice  of  which  activities   1974.
                  rected   toward   the   problems    of    heart   to  -propose   for   national   approval,   and
                  disease,    cancer,    and     stroke.     Some   --                                                Talented     and     distinguished      speakers
                                                                    we  will  have  failed  to  achieve   a   major   and  panelists  will  assist  you.   There   are
                  broader  activities   do   involve   the   more   objective  of   the   Regional   Medical   Pro-
                  effective   functioning     of    the     total     -                                               high   hopes    for    this    Conference    and
                  health-care    system    as    essential    re-   grams.                                            even   higher    expectations    for    Regional
                  quirements    for    improvements    in     the   Our   whole   review   process   is   concerned   Medical    Programs-so    high    indeed    that
                  diagnosis   and   treatment   of   these   dis-   with   strengthening    responsible    regional   we  must  face  realistically  the   possibility
                  eases.   The   initial   proposals   show   the   decision-making.   In    order    to    provide   that   the   many    challenges    may    exceed
                  unique    opportunity    provided    by     Re-   the   Regional   Medical   Program   with    an   our   combined   ability   to   meet   all    of

                  16













       ship












                                                                                                                                             17





              Science and Service                              James A. Shannon, M.D.
                                                               Director, National Institutes of Health



              There was an  article  in  a  recent  issue      husband  at  breakfast   the   following
              of  Science  on   "The   Art   of   Talking      day.
              about  Science."   The   author-a   distin-      I suppose that  the  author  has  heard,
              guished    British       scientist@iscussed      as  have  you  and  1,  many   brilliant
              the oral  transmission  of  scientific  in-      presentations  of  complex  subjects  in                            fill
              formation  in  a  manner  that  is  devast-      which a clever and  intelligent  speaker
              tating to  those,  like  myself,  who  have      builds a complex  structure  in  a  man-
              been   called   on    to    make    general      ner that enables us
              presentations.   His    penetrating    com-      0 to follow the  construction  point  by
              ments  on  the  foibles  of  lecture             nt'
                                                               poi
                                                 rs   are
                                                 would
              even more apt for those who                      to understand   the   transition    from
              engage  in  a  luncheon  talk  such  as   i      one level of complexity to another,  and
              am about to make.                                0 to have the feeling, at its end,  that
              In fact, I was  embarrassed  to  read  this      we have participated in a satisfying in-
              article at the very time that  I  was  pre-      tellectual tour de force,
              paring for today.                                only to find the next day that we really
                                                               do   not   remember   much   about   the
              His first rule is that a 'talk'-as  distin-      presentation  except  the  name  of  the
              guished   from   a   'paper'-should   never
              be read. He  made  the  point  that  it  is      lecturer, the title of his talk, and the
                                                               brilliance of his performance.  At  best
              simpler to read  than  to  listen  and  un-      e  may  remember  some  of   the   major
              derstand-implying,    though    not    pre-      w
              cisely saying, that to  take  the  time  of      points made but not  the  logic  of  the
                                                               setting in  which  they  were  contained
              a captive  audience  to  read  a  disserta-      northe   way   in    which    the    major
              ti6n came  perilously  close  to  insulting      t@ re@ sof  thought  were  woven   into   a
              their   intelligence   even   though  t  he      significant and logical pattern. I  sus,
              thoughts  expressed   are   suitably   pro-      pect that, if we  remember  the  pattern
              found.  He  argued  that   to   deliver   a      at all, it is because it may be inferred
              tightly  argued  thesis   in   well-rounded      from the title.
              phrases  conceived  in   the   leisure   of
              one's study  does  not  give  the  audience      The author  recommends  that  a  lecture
              time  to  think  and  is  like   asking   a      be loosely constructed of few parts.  It
              friend to go for a  walk  while  you  drive      should
              along beside him in a car.                       0  start  from  a  base   of   knowledge
              His second point was  that  only  a  limit-      shared by the audience,
              ed number of points should be ma                 0 build the basic structure of  thought,
              and few of these should be support(              0 provide  for  its  elaboration  within
              in great  detail.  He  suggested  that  the      the time available, and
              effectiveness  of  the   discussion   could      0  most  importantly,  allow   time   to
              best be  judged  by  the  extent  to  which      summarize   the   major   thoughts    or
              the  selected  points  presented  could  be      ideas one wishes the audience  to  re,.'
              recalled when  talking  to  one's  wife  or      tain.

              18







       author  made   many   other   pertinent   A   further   point   of   general    under-   Finally-and  still  within   our   base   of   A  sifting  of  your   informed   discussion
       its  but  one  I  remember  very  well.   standing   is   our   common    appreciation   common    understanding-you     are     with   will be a  major  input  of  information  to
       recalled  the  practice  of  the  Royal   of the fact  that  in  our  advanced  insti-   us for  a  few  days  to  examine  the  cir-   the   National   Advisory   Council    which
       @itution, from  whose  directorship  he   tutions, especially in  our  better  univer-   cumstances   developing   in   relation   to   will  advise  and  to  the  Division   which
       just retired,  of  giving  the  speaker   sity  hospitals,  there  is  little   useful   the    Regional    Medical    Programs    in   must act.
       ie  30  or  40  minutes   of   solitude   knowledge  lying  undisclosed   in   labora-   order  to  determine  how,  within  a  broad   You  may  well  ask,  at  this  point,   "Of
       ir to his discussion   even   to    the   tory  note-books  or  unread   in   journals   segment   of   medicine,    certain    moves   what  concern  is  all  this  to  the  NIH?"
       @nt of placing  a  guard  at  the  door   and books   in   the   library.    Knowledge   be  made,  in  accordance  with  the  inten-   -an   organization    which,    in    recent
       prevent any  intrusion  into  the  pri-   that can help  to  solve  a  patient's  prob-  tions of the law, to facilitate  the  devel,   years,  has  been  largely  concerned   with
       y  of  the  speaker's  thoughts  as  he   lems is, indeed,  utilized  in  the  day-to-   opment  of  excellence   in   our   handling   the    development    of    new    knowledge
       iposed himself  for  his  presentation.   day   work   of   university-based    physi-   of a  series  of  so-called  dread  diseases   rather than the delivery of services.
       v I want to make three  points.           cians in such a medical center.                -heart  disease,  cancer,  stroke  and   re-   One  can  give  either  of  two  answers  to
       rhe  article  is   commended   to   you   However,   a   comparable   situation    doe   lated  medical  disabilities.  You  will  be   such   a   question-either   would    appear
                                                                                            s   asked   to   comment,   for   the   ultimate
       reading-it  is  serious  but   present-   not    exist    in     many     communities-   benefit  of  the  President  and  the   Con-   to  be  correct  and,  indeed,  each  is  in
       in a light, readable fashion;             though  I   do   not   say   all-where   the   gress, oii the  adequacies  of  the  initial   fact partially correct.
       the adoption of  its  principles  would   physician  has  been  out   of   the   main-   moves   that   are   now   being   made   or   0  The  first  answer  would  be  that   the
       ke for less  slumber  during  presenta-   stream  of  learning  for   a   considerable   that  are  immediately  in   prospect.   You   creation   of    Regional    Medical    Pro-
       is such as this; and,  finally,           period  of  time  and  where  the   diagnos-   will  also  be  asked  to  anticipate   some   grams  permits  a   large   social   experi-
       my  inability  to  match   what he   con- tic  and  therapeutic  resources  are   less   of  the  problems,  assess  the   likelihood   ment  to  determine  what   is   needed   to
       @rs  the  minimal  excellence  of  per-   than optimal.                                  of  success  of  current  strategy,  and  on   facilitate  the  rapid  use   of   available
       -nance  can  be   rationalized, in  part,                                                this  basis,  advise  the  Division  of  Re-   knowledge  in  the   solution   of   serious
       my inability  to  have  the  30 minutes   The  next  relevant  fact  is  that  through   _gional  Medical   Programs   on   how   they  disease   problems   in   the   setting   in
       so of solitude which    he    so strongly legislation-and     particularly     through   may  best  project  their  action  into  the   which   these   problems   generally   occur
       ommends.                                  Titles 18 and  19  of  the  Social  Security   immediate future.                              -that  is,  in  .1  typical  community.   In
       hall,  however,  in  a  rather  halting   Amendments   of    1965-the    Nation    has   More importantly,   you  will  be  asked  to   this  sense  it  is  straightforward  opera-
       hion,  attempt  to  abide  by  some  of   asserted  that   each   individual   has   a   assess,  on  the  basis   of   an   informed   tional research.
       imperatives.   Incidentally,   he   was   right  to  superior  medical  care  and  has   professional   judgment,   the   extent   to   0  The  second  answer  reflects  the   fact
       opposed to the  use  of  notes.           begun  to  provide,  through   many   Feder.   which  the  Division  should   seek   simple   that in the best  of  our  university  medi-
                                                 al,  State  and  private   mechanisms,   for   extension  of  present  legislative  author-   cal  centers  we  have  a  unique   mix   of
       hall  start  from  a  common  base   of   payment  systems   by   which   this   right   ity or seek its  modification  in  order  to   professional  talents.  This   consists   of
       Jerstanding.                                                                         -   heighten  the  prospect   of   success   for   scientists  engaged   in   fundamental   re-
                                                 may  be  secured.  We   are   agreed,   how-   the program.                                   search,   physicians   eagerly    attempting
       dical services at  the  community  lev-   ever,  that  such  systems  must   not   in-
       have  a  lesser  degree  of  perfection   terfere  with  our  general   private   base   Now,  you  will  not  be   asked   at   this   to  apply   such   fundamental   information
       in would be possible if all the  avail-   for the delivery  of  medical  services.  It   time  for  specific   recommendations   but,   to  the  solution   of   disease   problems,
       e  information  were  at  the   disposa                                              .   in view of  the  complexity  of  the  under-   and    physicians    primarily     concerned
                                             !   is   the   national   purpose   to   correct
       the physician treating  the  individual                                                  taking,   to   comment   on   the   problems   with  the  problems  of  medical  care   and
       'ient and if the  physician  were  sup-   aeTIciencies  in  the  delivery  of  medical   of  applying  the   proposed   strategy   to   the   education   of    young    physicians.
       rted by all the diagnostic  and  thera-   services  by  using   the   present   system   your   own   regional   situation    whether   This  combination  of  skills   and   inter-
       Litic  resources  that  are  needed  to   as the  core  structure  for  social  embel-   this   be   rural   or   metropolitan    and   ests  makes   possible   the   delivery   of
       ply this body of  old  and  recent  in-   lishment  rather  than  by   attempting   to   whether  it  be  rich  or  poor  in  medical   medical  services  in  a  professional  set-
       mation  to  the   problems   presented.   build a new system.                            resources.                                     ting that approaches the  ideal.  It  is  in
                                                                                                                                                                                        19










                                                                                                                                                                                                s,   evolve
                  such a setting  that  the  best  of  medical   We look to you to  help  us  do  the  latter   their  impact  on  the   day-to-day   happen- ing with State and local force
                  services are  delivered  or  can  be  deliv-   two.                                           ings in medicine will be profound.            a  system  that  will   make   available   to
                  ered.  The  problem  is  to  determine   how   Let  me  hasten  to   add   that,   in   our   This  transition  will  result  in  an   even the   bulk   of   the   population   'Medical
                  such   know-how    and    such    excellence   view,  the  full  elaboration  of  the   new   higher   rate   of   professional    obsoles' services  that  are  excellent   in   quality
                  can  be  exported  for  use  by   the   com-   mechanisms   we    seek    will    not    be   cence   for   practici   g   physicians   and and  adequate   in   quantity-at   least   in
                  munity at large.,  Or,  to  put  it  another                                                                      n                         a  major  segment  of   the   diseases   that
                  way,  how  can  the   university-type   hos-   achieved in a year or two.                     will   require   a   much   more   purposeful plague us all.
                                                                                                                system  of  professional   renewal   in   the
                  pital-and   there   are   many   of    these   We  also  expect  that  not  all   of   your   future than in the past.                      NIH  does   not   have   the   responsibility
                  that are not, in fact, part of or    closely   strivings will  be  successful.  There  will                                                 of    achieving    these    desirable    ends
                  associated  with  a  university  or  medical   come  a   time   in   some   and,   perhaps,   And  this  brings  me  to  my  final   point.
                                                                 many@f   your   programs   when   it    will   Each    regional    advisory    group    must alone  but  in  conjunction  with  a   series
                  school-how   can   such    an    institution                                                                                                of  other  programs   with   similar   objec-
                  yield  the  isolation  that   protects   and   be   more   appropriate   to    take    your   concern  itself  as  much  with   the   main- tives.  But  I  believe  that  the   Regional
                  fosters  scholarly  activity  and  assume  a   losses  and   begin   anew,   profiting   by   tenance  of  the  professional   capabilities Medical   Programs,    properly    developed,
                  larger  social  function  without,  at   the   your   own   experiences   and   those    of   of  local  physicians  in  a  rapidly  chang,
                  same   time,   placing   in   jeopardy   its   others- If  this  were  not  the  case,  our   ing  and   increasingly   complex   situation is  the  keystone  of   a   structure   which
                  present   purposes.                            problems   and   yours   would    be    very   as   with    arrangements    for    improving will permit  the  delivery  of  the  type  of
                                                                 simple. Unfortunately  they  are  not.         the support  for  and  utilization  of  these medical care services we all desire.
                  As the  one  single institution   most   con-                                                 capabilities.
                  cerned with these present purposes             The  problem  will   be   made   both   more
                  that  is   research and        education-the   difficult and more urgent by the     rapid     Now,  following  my  British   mentor's   ad-
                  NIH  has  been  given  the  task  of   work-   evolution of the medical scene.      I   be.   vice, I shall remind  you  of  the  points  I
                  ing with groups,  such  as  you,  in  devel.   lieve that we are  fast  entering  a  period   would have you remember.
                  oping  programs,  suitable  for  regions  of   of  really  rapid  pay-off  from  our  large   0 The  delivery  of  services  is  less  than
                  quite  diverse  character  and  medical  re.   investment  in  the   biomedical   sciences.   optimal   for   many    segments    of    our
                  sources, that  will                            Advances  have  been  substantial   in   the   population.
                  0 preserve  the  excellence  of          the   past  two  decades  but  they  are  only   a   0  The  financial  barriers  to  good   serv-
                  present  programs,   and,   indeed,   foster   harbinger of what is to come.                  ices  are  being   rapidly   removed   as   a
                  and  develop  institutional  excellence   in                                                  consequence    of    State    and    national
                  science  and  education  where  it  is   now   The   biomedical   science    establishment,   judgments  that  every   individual   has   a
                  lacking,                                       in  its  present  magnitude  and  diversity,   right  to  excellence  in  the  medical  care
                  0 provide for  the  discharge  of  a  large-   is  something  less  than   5   years   old.   he requires.
                  ly  new  social  responsibility  in  a  man-   This is a  fact  that  is  frequently  over.   0  In  a  privately-based  system   for   the
                  ner  that  will  strengthen,   rather   than   looked.  However,   scientists   now   capa.   delivery   of   medical   services,   general
                  weaken,  the  current   institutional   pro-   ble of entering the  field,  at  either  the   excellence    is    now    most    frequently
                  grams, and                                     laboratory or  clinical  level,  are  better   found  in  a  situation  where  there  is   a
                  0   provide,   under   suitable    auspices,   trained  and  generally  more  capa            mix of science, education and service.
                  for  the  linkage  between   these   science   than was true heretofore. It is pre      @ie   0   Although    we    must    contend    with
                                                                                                         cllc"
                                                                 able  that  as   the   biomedical   sciences   circumstances,    NIH,    in    administering
                  based    programs    and    the    community                                                  many   diverse    geographic    and    social
                  apparatus   within   which   medical   serv-   move  from   the   empiricism   so   charac-   the   Regional   Medical    Programs,    will
                  ices are delivered.                            teristic of the past  to  the  clarification   strive  to  preserve  existing   centers   of
                  We believe that  we  can  do  the  first  of   and    generalization    of   our    under-    excellence   in   science,   education    and
                  these three-given adequate funds.              standing    of    biological     phenomenon,   service  while,  at  the  same  time,   work-

                  20




     rogram Evaluation                              Vernon E. Wilson, M.D.
                                                    Dean, School of Medicine, University of Missouri
                                                    Program Coordinator, Missouri Regional Medical Program

     ie  dilemma  of  a   dean   from   the   day                                                                                                 We  have   already   heard   that   the   ap-
      his  appointment  is  to   know   when   to                                                                                                 pearance  of  the   Regional   Medical   Pro-
                                                                                                                                                  grams   through   Federal   legislation   was
     )eak  out  and  when   to   remain   silent.
     )eaking  requires  at  least   an   acknowl-                                                                                                 a  direct  result  of  growing   public   and
     lged topic and  at  best  a  brief,  flavor-                                                                                                 professional    unrest    centered     around
     I  and  meaty  content.  In   pursuing   the                                                                                                 the  slow  rate  at   which   new   knowledge
     )mewhat    evanescent     title     assigned                                                                                                 was  being  put  to  use.  This  concern   is
     r    this    topic-which    evolved     from                                                                                                 not  unique  to  the  health  field  but   it
     @rogram,"   to    "Program    and    Evalua-                                                                                                 is   new   as   a   major   emphasis    among
                                                                                                                                                  the  concerns  of  the  health  care  profes-
     )n,"  to  "Program   Evaluation,"   I   must
     )nfess   that   the   merit    of    silence                                                                                                 sions.  The  agricultural   and   engineering
     omed ever more attractive.                                                                                                                   experiment   stations,   long   an   integral
                                                                                                                                                  part  of  the  land-grant  colleges,   repre-
     nce   detailed   discussion   of   technical
                                                                                                                                                                      t  to  deal   with   this
                                                                                                                                                  sent one  attemp
     /aluation   procedures    would    not    be                                                                                                                            already   have   a
     )propriate  under  our   limits   of   time,                                                                                                 problem. The Engineers
                                                                                                                                                  term for it. They  label  this  activity  the
     t   us   compromise   and    discuss    some                                                                                                 "transfer of technology."
     ell  known  principles   of   program   and,
     @r  the  health   field,   some   relatively                                                                                                 It  would  appear  then  that   the   special
     nused   principles   of    evaluation.    We                                                                                                 mission   of   Regional   Medical    Programs
     ill examine both  in  the  light  of  oppor-
                                                                                                                                                  is  primarily  one   of   research   in   the
     inities   presented    by    the    Regional                                                                                                 "distribution  of  health  care"   with   the
     ledical Programs.                                                                                                                            focus  placed  firmly  upon   the   patient's
     he  challenge  to  Regional   Medical   Pro-                                                                                                 needs,  rather  than  upon   those   of   the
     rams,  as  I  see  it,  is  to   demonstrate                                                                                                 institution or the health professions.
     iat   this   new    endeavor,    established                                                                                                 Until the early  part  of  this  century  the
     rimarily  in  behalf   of   heart,   stroke,
     ancer,  and  related   diseases,   is   more                                                                                                 healing    arts    possessed    a    dismally
     ian  a   static   assemblage   of   existing                                                                                                 small  amount  of  scientific   information',
     @sources, This in  itself  is  a  basis  for                                                                                                 consequently,   the   need   was    primarily
     ery  careful  thought.  Most  of  the  prin-                                                                                                 for  basic  medical   knowledge.   With   the
     !pies  and  programs  which  can   be   con-                                                                                                 momentum    now    established    in    basic
     idered  in   the   field   of   health   and                                                                                                 research  we  can   give   increased   empha-
     ealth  care  have  been   studied   by   one                                                                                                 sis to  indirect  factors,  such  as  popula-
     r   another   of   the   existing    Govern-                                                                                                 tion  size,  number  of   related   organiza-
     iental,  academic,  professional   or   vol-                                                                                                 tions  and  groups,  increased   capabilities
     ntary  groups.  Thus,  at  the   outset   it                                                                                                 in   communication   facilities,    and    an
     eems  apparent   that   the   aim   of   the                                                                                                 ever  accelerating   rate   of   obsolescence
     !egional   Medical    Programs    must    be                                                                                                 of  knowledge.  The   magnitude   of   recent
     ne  of  synthesis,  an  effort  to   combine                                                     a  !S                                       Congressional    appropriations     indicates
     hese   various   factors   into   a    whole                                                                                                 the  need   for   immediate   action.   Addi-
     thich  will  be  greater  than  the  sum  of                                                                                                 tional  and  similar  legislation  is   under
     he parts.                                                                                                                                    serious   consideration.    The    comprehen-
                                                                                                                                                                                            -21








                  sive   health   planning   act   provides   a  professional      and     academic       con-   The  first  step  is  the  establishment   of  and  those  of   the   profession   are   not
                  logical  outlet   for   knowledge   developed  tributions; it  will  require  a  formal  and   need,   either   recognized    or    unrecog-  always   the   same.   To   accomplish    our
                  under  Regional       Medical       Programs.  scientific  search  for  an  appropriate  re-   nized. The  next  step,  after  the  need  is  task   we   must   now    direct    extensive
                  Thus,  research  being  done  in   the   more  lationship    between    all     academicians   determined,  is   to   define   it   and   to  study  toward  the  patient  and  his   needs
                  limited  field  of  Regional   Medical   Pro-  and  professionals  whose   skills   can   be   create  recognition  of  that  specific  need  within  the  context  of  his   normal   pat-
                  grams  can  be  of   value   throughout   the  helpful.  Concurrently,  the   integrity   of   in   both   the   consumer   and    producer.  tern of living.
                  total health care field.                       the   academic    and    research    communi-   Here we  have  a  direct  parallel  with  the  Professional     action   has     classically
                  Because  of  the   large   amount   of   time  ty  must  be  preserved,  both  as   an   in-   opportunities  open   to   Regional   Medical  been one of response,     after  the  patient
                  and   money   to   be   expended,   realistic  ternal  system  and  as  a  part  of  society   Programs.                                      requests and is given      .access   to   the
                  evaluation  of  the  results  is   mandatory.  at  large.  Thus,  the  analogy  of   market-   Having  identified   a   specific   need   or  formal   health   care   system.   We    must
                  Unfortunately,   we   are   hampered   by   a  ing  is  in   all   probability   much   more   needs,   it   is   necessary   to   undertake  now   accept   responsibility   for    health
                  lack   of   effective   measurement    tools.  than  an  analogy.  It  may   prove   to   be   basic  and  applied   research   in   materi-  care  of  the  public  as  a  dynamic,  inti-
                  We  must  start  by   using   available   and  an  actual  pattern  which  will  provide  us   als,  resources  and  their  synthesis.   The  mate part of daily performance.
                  simple    techniques,     while     admitting  with  illustrations  and  some  basic   prin-   medical   profession   has   expended    pro-
                  their inadequacies. It is essential    that    ciples for fruitful pursuit of    the   tasks   portionately  small  amounts   of   its   own  Identification  of  needs   for   concentrat-
                  collaborative   research   in   system    de-  ahead-                                          energies  in  the   endeavor   of   synthesis  ed  research  endeavors  will   require   the
                  sign for the distribution of health    care    _,                                                                                             development   of   end   points   or    goals
                  be initiated in concert with those     aca-    ine Distribution Process. As      a    layman   and  at  the   same   time   has   frequently  against  which  the  effect  of   change   in
                                                                 in this special field, may I      off;r   the   poorly  utilized  the   contributions   which  qualitative   performance   can   be    meas-
                  demic disciplines which  have a        long    oversimplified  explanation       that    the   could be made by other disciplines.
                  tradition   in   simulation,   systems    re-                                                                                                 ured.   Unfortunately,   at   present,   such
                  search,    and    communications    research,  production    and    distribution     process   Having   completed   the   "basic"   research  end  points  are  few  and   largely   unpro-
                  thus  providing   a   base   for   continuing  amounts to a  coordination        of  ma   nY   and   formulated    working    models,    the  ven.
                  analysis and measurement.                      disciplines,  assembled  for      the    con-   next  step  is   the   production   and   de-        of   the   measurement   systems   cur-
                                                                 tribution  which   each   can   make   to   a   livery  of  materials  and   services   which  Most
                  Existing   resources   for   use    in    the  single  goal.  While  such  grouping  of  re-   may  come   from   a   variety   of   places.  rently  used  in   the   health   professions
                  design   of   such   systems   are    impres-  sources,   particularly   in   the   research   In  the  analogy   the   patient   may   move  are  quantitative  rather  than   qualitative
                  sive. indeed.  If  one  looks  at  the  great  process,  suggests  the  antithesis  of   the   to  the  resources,  or  the  resources   may  in  nature.  We  can   measure   quite   ade-
                  array  of   governmental   health   agencies,  traditional   academic    departmental    or-   be  brought  to  the  patient,  but   finally  quately   deaths,   morbidity,   numbers   of
                                                                 ,a                                                                                             personnel,  and   similar   items,   but   we
                  academic    institutions,    voluntary    and  ,  nization,  the  concept  is  not  unfamil-   the  delivery  process  requires   that   the  have  few  means  by  which   we   can   test
                  professional  groups,   as   well   as   sup-  iar   to   academic   institutions.   It   is   end  product  of  health  care   be   synthe'  the  impact   of   health   care   upon   the
                  portive  organizations  like  welfare   agen-  exemplified  frequently  in   institutes   on   sized  in  a  coordinated  and   personalized  daily  performance  of  a  given  individual.
                  cies,    community    action    groups    and  university  campuses,   in   land-grant   ex-   manner  for  the  benefit  of  the  consumer.
                  others,   it   readily    becomes    apparent  Deriment     stations,    and   ,    research                                                  Thus,  our  first  requirement   is   for   a
                  that  the  major  problem  is  not  that   of  'centers.   These   patterns    allow    manv   Market   Identification.   If   we   consider  measurement   system   which    can    assess
                  creating   resources   which   could   apprO'  disciplines  to  proceed  in   a   systematic   health care in the  light  of  the  patient's  the ability  of  the  individual  to  perform
                  priately  handle  the  problem   but   rather  fashion  in  searching   for   new   informa-   need,   recognized   or   unrecognized,   the  as  a  useful  member  of  society  and   his
                  a  coordination  of  those   resources   into  tion   and   combining    that    information   first painful  but  necessary  step  will  be  own   attitude   toward   that   performance.
                  an  effective  unit.  Although  to  some  the  into an orderly whole.                          a  shift  in   emphasis.   Much   basic   re-  Also  required  will  be  a  measurement   of
                  comparison  may   be   a   bit   unpalatable,                                                  search   has   been   sponsored   upon    the  the  social  or  peer  group's  estimate   of
                  I submit that  this  is  a  market  and  dis-  Taking the marketing   analogy    one    step   assumption   that    improvement    of    the  the  value  of  the  individual's   contribu-
                  tribution  process   and   should   be   han-  further, the rational  distribution     proc-   professions  and  institutions   will   auto-  tion  to  the  group   and   their   attitude
                  dled  as  such.  An  approach  of  this  kind  ess  would   be   simulated   and   developed   matically  benefit  patients.   However,   it  toward  that  contribution.  No  single   one
                  does  not  deny  the  essential   nature   of  as follows:                                     may  be  that  the  goals  of   the   patient  of  these  factors  can  be   used   as   the

                  22





               sole    parameter     but     when     assembled   lished   knowledge   about   health    is    not   most  highly  motivated   party   in   the   in-   A   third   problem   concerns   the    obsoles-
                                                                                                                                                  assigned        him   cent  mind,  both   as   it   relates   to   the
               as   a   pattern   they   should   provide    at   utilized   even   by   those   best   acquainted   terchange, yet we have
               least  the  first   steps   in   a   qualitative   with  it.  Advertising  research  has   a   rich   the  most  passive  role.   Patients,   I   sub-   medical   profession   itself   and    to    the
               measurement of health care.                        body    of    basic    knowledge    and    tech-   mit,  may   not   be   so   helpless   as   some   public   at   large.   It    is    clear    that
               Since  diagnosis  is  also  a   part   of   mar.   niques  dealing  with   facilitators,   or   why   of  our   practices   would   seem   to   imply.   planned,   continuing    education    for    the
               ket   definition   and   since   diagnosis   of.   people   choose   one   service    or    product   Our  friends  in  sociology   should   be   able   profession  and   the   public   is   necessary.
               ten      opens      communications       between   as   opposed    to    another.    These    tools   to help us here.                                   A   searching   look   at   potential   integra-
               professional    individuals,    early     detec-   and   techniques   used   so   successfully   in   In  the  fourth   and   final   phase   of   our   tion   of   such   education   with   the   care
               tion  of  disease   would   appear   to   be   a   advertising     could     be     adapted     and   analogy,  we  will  face  a  variety  of   prob-   process    seems    called     for.     Feedback
               logical  first  research  effort  for   improve-   should   be   useful   in   broadening    public   lems   in   the   delivery   of   health   care.   mechanisms.must    be    established    for    a
               ment  in  the  distribution  of   health   care.   education    and     personal     responsibility   These    include    implementation    of     re-   progressive    analysis     of     cause     and
               Such   research   avoids   the   necessity    of   in health care.                                    search    and    development        in      dis-   effect,  or,  at  least,   correlation   between
               premature   decisions   having   to   do    with   Turning  to  the  third  item  in   our   analo-   tribution.  All  patients   should,   have   ac-   continuing education and change.
               delivery  of  health  care   and   would   allow   gy,   namely   research   in    materials    and   cess   to    the    best    source    of    care   ,
                                                                                                                                                                        A  successful  distribution  system   will   it-
               a   "tooling   up"   of    the    communications   resources,   we   should   comment   first    on   regardless   of   geography,    financial    re-   seif   require   an    integrated    information
                                                              -   basic   research   which   has   a   long   uni-   sources,  or  special  interests  of   r)articu-
               system    under    reduced     emotional     ten                                                                                                         service.   Information   should    be    derived
               sion.   Much   diagnostic   support    can    be   versity  tradition   and   is   the   foundation   lar   professional    groups.    New    patterns
               provided.  to   individual         practitioners   upon   which   applied    research    is    con.   are required.                                      from   the   home,   from    the    avenue    of
                                                                                                                                                                        access  to   the   health   care   system,   the
               with  a  minimal   change   in   their   present   ducted.   Basic   research   in    almost    all   The    relationship    between    centers     of   local   hospital,   and   the   large    medical
               practice patterns.                                 academic   disciplines    will    make    imPOr-   excellence    and    the    population     which   center.  It   will   require   the   development
               Status  of  the   patient   needs   study.   In-   tant  contributions   to   health   care.   High   they   would   serve    will    need    to    be   of    common    identification    systems    and
               teraction   between   individuals   is   heavily   on   the   list   should    be    research    in   defined.   Most   organizations    which    sup-   vocabularies.  Many   of   us   hope   that   in
               influenced   by   the   status,    stated    and   synthesis   of    systems,    including    model   port  health   care   use   politically   deter,   the  very  near  future  the   social   security
                                                                  building.   In   our   past,   testing   through   mined     boundaries,      i.e.,  the      city,   number  will  be   issued   at   the   time   of
               felt,  of  each   person.   We   are   proposing
               major  changes  in  the  status   of   the   pa-   models   has   had   little    systematic    and   county,   or   State.   The   probability    'Of   birth,  or   entry   into   the   country,   and
               tient  in   the   health   care   system.   This   comprehensive       attention.     It      could   gaining    coordinated    support    from    all   will   provide    such    identification.    The
               calls   for   a   "shorthand"   method    inter-   produce  large  savings   in   time,   as   well   interested   organizations   for   the   assist,   proposed     information      system      should
               woven  into  the   system   itself   to   assess   as  funds,  but  will  require  the  talents  Of   ance  of  a  single  and   specific   individual   be   designed    to    utilize,    assist    and
                                                            icu   a   variety    of    existing    disciplines-the   will   be   enhanced   by   a   maximum    over-   refine    present    systems,    not     compete
               status, and change in status, part             _
                                                                  engineers,   for   example,   who   until    re-   lap   in   geographical   areas   of    designed   with them.
               larly of the patient.                              cently  were  seldom   formally   invited   into   responsibility.   This   is   particularly   im-
               An   interesting    correlation    exists    be-   the health research conversation.                  portant    in    evaluation          procedures,   The   decision   for   diagnosis   and    treat-
               tween   the   way   we   use   the   time.    of   An  interesting  facet  of   the   dilemma   re-   which    depend    upon    many    groups    for   ment  of  the  patient  will   take   into   ac-
               others   and   our   estimate   of    their    iT- lated   to   manpower   shows   in   the    fact   their information.                                 count   his   desires   which,    among    other
               portance.  Consequently,  accurate             "e' that  although  we  are  faced   with   a   tre-   A    second    problem    to    be    considered   things,   relate   to    the    distance    from
               termination   of   our   expenditure   of    the                                                                                                                               the    patient's    knowl-
               patient's   time   through    the    design    o   mencous    shortage    of    health    personnel   deals   with   control.   Should    such    dis-   health  care and
                                                                  and  a   low   level   of   national   unemploy-   tribution   systems   be   totally   under   the   edge   of   and   confidence   in   the   recom-
               health   services   is    accessible,    measur-   ment,  we  as   a   health   care   group   have   control   of   the   health   professions?    If   mended    resource.     Other     considerations
               eable, and potentially valuable.                   largely  ignored  one  of   our   greatest   po-   not,   how   much   of   the   process    should   are   the   adequacy   of   the   health    care
               Another   little   used   field   of   knowledge   tentials-the    patient    himself.    He     is   be   conducted   in   cooperation   with   other   resources,  the  cost   to   the   patient   and
               is   that   developed   in    advertising    re-   usually   the   most   involved,    often    the   interested    groups?    When    should     con-   the   involved   agencies,   and    the    maxi-
               search.  A   significant   portion   of   estab-   better    educated,    and     certainly     the   trol be turned to them?                            mum    benefit    from    the    care    process
                                                                                                                                                                                                                      23







                which     includes      such      by-products      as   met   by   a   specific   answer   to   the    ques-    cause     progress     toward     them     can     be   integrated     with     detection     and      health
                education,     research,     and     economic     im-   tion,     along     with     additional     synoptic    measured.    Their     evaluation     should     give   care systems.
                pact upon the community at large.                       background      information      or       bibliogra-    us    some    insight    into    whether    or    not   0   Lay   health   education   will   be   a    vital
                Finally,   as   we    have    already    heard,    no   phies   which   should    be    helpful    in    his    we    are    moving    in    the    direction    that   part    of    the    regional    program.    Existing
                matter    how    one    may    describe    a    Medi-   continuing      education.      Such       inquiries    may   be    most    effective    in    meeting    the   adult     education      and      extension      pro-
                cal   Region,   it   must   interact    with    other   will  also  serve  as  a   guide   to   the   physi-    actual needs of patients.                               grams    and    activities    of    voluntary     or-
                regions.     Mechanisms      must      be      devel-   cian's    needs.    In    this    manner    diagnos-    0   The   primary   goal   is    to    deliver    the   ganizations   will   be   utilized   so   that    the
                oped which will minimize the mech                       tic   and   delivery   patterns   of   health   care    highest  percentage  of        quality        patient   potential   recipient   of   care    may    be    in-
                                                                .@ni,   can   quickly   be   modified   in    detail    when    care   as   close   to   the   patient's   home    as   formed as to the role         which    his     physi-
                cal  problems of interregional  relati             n-   research    indicates    the     desirability     of    possible.    This    is    not    only     economical   cian,   the   hospital,   and   the   various    sup-
                ships   and   permit   us   to   focus    upon    tne   doing so.                                               in  the   total   picture   but   in   keeping   with   porting agencies will         play   and    to    the
                patient.                                                                                                        the   desires    of    most    patients.    Certainly   things which  he, the         patient,    can     ex-
                The    Example.    With    no    claims    to     as-   The data    handling    facility    developed     at    the latter assumption merits study.                     pect.  We  need  more         scientifically      de-
                sured     success,     the     Missouri      Regional   the   University   of   Missouri   for   the    pur-    0    Every    patient    should'have    equal     ac.   signed    studies    of    public    attitudes    to-
                @rogram    has    attempted     to     face     these   pose    of    extending    the     competency     of    cess    to    any    needed    national     resource.   ward health care.
                challenges     in     the      planning      process.   the    physician    will    be    integrated    with    For   very   special   services   which    are    not   0   Finally,   in   my   view,   a    crucial    goal
                                                                        cooperative       data       handling       programs
                Projects     will      arise      from      community   established      by      hospitals,      physician's    available   in   the   area,    patients    can    be   will   be   for   each   of   the   several   regions
                groups     and     be     funneled     through      a   offices,   and   state    agencies.    This    inte-    sent    to    centers     of     excellence     else-   to   take   a   unique   approach   to    the    spe-
                refinement     process.     This      should      en-   grated    system    is    expected    to     furnish    where,     thus     eliminating     the     necessity   cial    needs    for    their    particular    areas.
                courage     maximum     motivation      and      par-   feedback     and     monitoring      which      will    for     needless     duplication     of     expensive   Through    meetings     such     as     this     one,
                ticipation at the grassroots level.                     make   it   possible   to   provide   the    desired    equipment, staff and facilities.                        we   can   share   ideas   so    that    a    minimum
                A   general   objective    of    the    program    is   information    while    studying     and     coordi-    0  Maximum          coordination        will       be   of  waste   will   ensue   as   we   seek   to   meet
                the    development     of     models     of     early   nating   the   total   process   in   an   objective    sought    between     the     inputs     of     those   our respective responsibilities.
                detection      integrated       with       continuing   and efficient manner.                                   who    provide    health    care     directly,     as   New     paths     are     seldom     explored      by
                education.                                                                                                      well    as    those    involved     in     supporting   faint   hearts.   We   need   to   be   mindful    in
                                                                        A      University      muleidiscipline      research    that    care,    such    as    welfare,     community   the    development    of     new     systems     that
                Primary    emphasis     will     be     placed     on   unit    is     developing     new     tools     with    resources,        environmental               control   one   may   at   times   work    with    less    than
                those    endeavors    which    can     be     quanti.   which     to      measure      achievement.      Its    groups, and others.                                     perfect   parts   in   order   to   set   the    sys-
                tatively   evaluated,    and    the    initial    as.   staff    members    have     joint     appointm'ents    0     The     development     of     programs      to   tem   itself   in   operation.   It   is    possible,
                sumption    is    made    that    adequate    infor-,   with    other    schools    on    campus,    includ-    assist   in    early    and    effective    detection   even    desirable,    to    have    "proof     runs",
                mation       and      communication              will   ing      Nursing,      Education,       Engineering,    of   disease   will    be    an    important    goal.   a   practice   long   utilized   by   the    printing
                provide      qualitative       improvement.       The   Journalism,     Business     and     Public      Ad-    The   information   gained    can    be    used    to   industry.   From   less    than    perfect    initial
                long    range    plan    provides    for     qualita-   ministration,    Liberal    Arts,    and     Veteri-    effect    changes    in    delivery     of     health   operations,       changes       and       corrections
                tive     measurement     of     delivered      health   nary     Medicine.     Presently     members      of    care,      both      through      personnel       and   can  be  made  to  improve  the                 final
                care.                                                   this    unit    are    studying    two     different    systems.     Early     detection      is      perhaps   product.
                Only   a    few    projects    are    proposed    for   communities    in    which    they    will     meas-    least   threatening    to    the    present    health   As    participants    in    this    national     pro-
                studies   of   delivery   of   care.   It   is    our   ure     efforts     toward     community      health    care     professions     and     is     among     the   gram,  I  believe we  dare  not  do              less
                intent   simply   to   be   supportive   to    exist-   goals,   such   as   rehabilitation   of   the   pa-    easiest     procedures     to     measure     quanti-   than    marshal    the    best     available     tal.
                ing   care   patterns   while    setting    up    the   tient, family reactions and the like.                   tatively.    It    also     possesses,the     highest   ents,  from whatever quarters,  to               join
                necessary         information-gathering         mech-   In    conclusion,    let    us     review,     quite    potential     for   successful            qualitative   in   this   quest   for   improved    health    care.
                anisms.   Under   this   plan,    a    request    for   briefly,   some   goals    worthy    of    consider-    measurements of health care.                            The     opportunities     are     attractive      and
                information    by    the    physician     will     be   ation.    These    goals     were     picked     be-    0     Postgraduate      education      should      be   challenging, to say the least.





           The Idea, the Intent                           Sidney Farber, M.D.
           and the Implementation                         Director of Research, Children's Cancer Research Foundation
                                                          Professor of Pathology, Harvard Medical School


           The privilege  of  speaking  at  the  First    nessed,  that  has  won  the   enthusiastic  uate   much   more   quickly,   safely   and   technology   between   and   among   region-
           Conference   on   Regional   Medical   Pro-    interest and  cooperation  of  medical  so-  effectively,  new   methods   of   diagnosis   al   programs   for   the   rapid   dissemi-
           grams  is  one  for  which  I   am   deeply    cieties,  sharpened  the  focus   of   many  and  treatment;  to  achieve   actual   pre-   nation  of  knowledge  to   assist   doctors
           grateful. It is hard to believe that  in  a    diverse   agencies   concerned   with   hu-  vention    of    the    complications    and   everywhere  in  the  care   of   their   pa-
           little more than  a  year  since  the  his-    man  problems  of  disease,  and   inspired  progress  of  these  dread   diseases;   and   tients.
           toric  signing  by  President  Johnson   of    medical  schools  and  hospitals  alike  to  to  communicate  with  the  aid   of   meth'   The  development   of   the   policy   under
           Public   Law   89-239   on    October    6,    look   beyond   their   own   institutional  ods  already  available  and  perfected   by   which   power   and    responsibility    for
           1965,  with  less  than  a  year   of   ad-    concerns   to   broad   community    needs?                                                 whatever  happens  is  placed  at  the   re-
           ministrative   operation,   it   has   been    Many  reasons  might   be   mentioned   and                                                 glorfat level has  answered  the  fear  that
           possible  to   bring  together       repre-    must play a role,  but  the  one  of  over-                                                 the  Federal  Government   and   specifical-
           sentatives  of   the   health   professions    riding  importance  above  all   others   I                                                 ly  the  National   Institutes   of   Health
           from all over  the  country  for  a  report    am certain is  the  motivation  behind  all                                                 might   dictate   to   any   applicant    or
           on progress  and  a  discussion  of  future    activities of the health  professions:  the                                                 group  what  to  do  and  how  to   do   it.
           plans, plans  for  90%  of  the  people  of    desire  to  give  to  all  our  people  the                                                 The  only  requirement  that  I   can   find
           this  country.  This  evidence   of   truly    very best in  medical  care.  It  is  clear                                                 that  the   Federal   Government   has   im-
           phenomenal   progress   must   be    heart-    that  the  response  of  the   Country   to                                                 posed  is  that   there   must   be   assur-
           warming  indeed  to   the   President   and    the  remarkable   opportunity   opened   by                                                 ances  that  there  is   understanding   and
           the   members   of   the    Congress    who    Public  Law  89-239  stems  from  our   de-                                                 commitment   to   the   purposes   of    the
           have  shown  such  deep  interest  in  this    votion to  those  who  are  ill,  and  this                                                 program  with  true  regional  concert   in-
           program,  and  productive   of   new   hope    transcends   personal   considerations   or                                                 volving  representation   of   the   various
           and  courage  to  families  throughout  the    pre-occupation  with   the   interests   of                                                 health  agencies  and  the  p@lic   in   any
           land  with  loved   ones   suffering   from    one discipline or  one  institution.  This,                                                 given  region.  As  a  close   observer   of
           the  dread  diseases  with  which  we   are    then, is the greatest attraction to all  of                                                 this  program  and  the  way  it  has   been
           here  concerned.  I  see  here  today   am-    us-the  opportunity  to  develop   a   pro-                                                 administered,  I   have   satisfied   myself
           ple  evidence  for   the   statement   made    gram which  has  as  its  goal  the  deliv-                                                 that this point  of  view  on  the  part  of
           repeatedly  during  the  past  few   months    ery of the best  of  medical  services  and                                                 the  Government  is  genuine,  and  in  line
           by  veterans  in  the  health   professions    diagnosis  and  treatment  to  every   man,                                                 with  the  great  traditions  of   the   re-
           that  this  program  has   done   more   to    woman  and  child  in  the  Country,  with-                                                 search  and   training   programs   of   the
           bring  the  many  segments  of  the  health    out  the  intolerable  delay  between  dis-                                                 National  Institutes  of  Health.   It   was
           activities  of  the  Nation  together  than    covery  and  application  caused   or   ex-                                                 for  this  reason  that   a   wise   Surgeon
           any other  event  in  the  history  of  the    plained  by  the   lack   of   the   needed                                                 General  put  the  program  under  the   ad-
           Nation.                                        medical  strength,   mechanisms   and   fa-                                                 ministration  of  the  N.I.H.,   under   the
           What is  the  magic  which  has  been  r..-    cilities which will be  provided  in  these                                                 leadership  of   Dr.   James   A.   Shannon,
           sponsible  for   the   achievement   of   a    Regional   Medical   Programs.   The   idea                                                 who,  with  his  Deputy,  Dr.  Stuart   Ses-
           creative  concert  among  the   many   -se-    behind  these  programs  is  based  on  the                                                 soms, and  a  splendid  staff,  has  presid-
           arate health interests  that  in  the  past    simple  desire  to  save   lives-of   those                                                 ed   over   the   greatest   and   strongest
           have  never   worked   together   in   this    people willo  could  be  saved  today  with                                                 growth  of  medical  research   and   train-
           fashion?  What  is  it  that  has   bridged    the  knowledge  available  today,  if  they                                                 ing  programs  in  history.  You   are   all
           the  gulf  between  town   and   gown   and    could have it;  to  save  even  more  lives                                                 thoroughly  familiar  with  the   insistence
           lured  the  medical  school  faculty   from    if  we  speed  up  and  intensify  clinical                                                 on quality  by  the  N.I.H.  and  the  great
           its  ivory  tower  into  community  activi-    investigation  to    match    the     great                                                 tradition  that  major  reliance  for  final
           ties  in  a  manner   never   before   wit-    strides in pre-clinical research; to  eval-                                                 decision  must  be  placed  on  the   expert
                                                                                                                                                                                               25










            review  by  non-Federal  groups   or   our   cussed   the   many   programs   of    the  ministrative  regulations  and  has   been   fidence  that   these   Regional   Medical
            peers,  our  own  peers,  to  assure  that   N.I.H., and he spoke of  his  deep  inter-  under discussion as   one  of  the  issues   Programs  would   be   a   great   success
            quality  is  maintained   and   scientific   est in the several categorical  institutes  at  this  Conference.  The  need  for  the   throughout  the  country.  Just  20  years
            and  professional  freedom  is  protected.   and in the Institute  of  General  Medical  provision  by   the   Federal   Government   ago, January  lst,  I  organized  a  Chil-
            The caliber and  dedication  of  the  pri-   Sciences in  which  he  had  great  pride.  of enough support  to  insure  a  critical   dren's  Cancer  Research   Foundation,   a
            mary  Review  Group   under   Dr.   George   He  then  turned  to  a  consideration  of  mass  of  medical  strength,  however,  is   private  institution  affiliated  with   a
            James  and  of  the  members  of  the  Na-   the  rapid  progress   in   the   Regional  a prerequisite to fulfillment of the  Pro.   medical   school   and   surrounding   ex-
            tional  Advisory   Council   on   Regional   Medical  Program  activity  and   remarked  gram.  We  should  remind  ourselves   and   isting  hospitals.  This  Institution  was
            Medical  Programs  have   been   responsi-   that this was the goal  for  which  every-  the  Government,  too,  that  all  experi-   concerned  with   both   fundamental   and
            ble  for  sound  and  important  decisions   thing else in the  N.I.H.  was  dedicated,  ence in  the  support  of  biomedical  re-   applied research and  with  the  care  and
                                                         for, as he put it, "this is  the  payoff."  search and in  the  support  of  construc-   study  of  children  with  acute  leukemia
            so far. I  have  had  the  opportunity  to                                                                                                                 "I
            attend  a  number  of  the   meetings   of   It  is  here  that  the  newly   generated  tion of research and  hospital  facilities   and all other forms  of  cancer  found  in
            this  new  Council,  as  a  representative   knowledge  from  medical   research   must  has   shown   that   substantial   Federal   children. From the   very   beginning   we
            .of  the  National  Advisory  Cancer  Coun-  be applied  as  rapidly  as  possible  for  support   attracts   substantial   support   established  a   relationship   with   the
            cil, and can assure  you  that  the  stipu.- the good of  patients  everywhere.  I  can  from other sources.                          doctors  of  the  region  of  our  country
            lation  of  the  Public   Law   concerning   still  hear  his  words  of  deep  concern  These  words  so  far  have  been   spoken   with these words:  "We  are  here  to  as-
            membership  on  the  Council  has  result-   about the availability of sufficient  mon-                                               sist you in the  care  of  your  patient."
                                                         ey  properly  to  support   the   Regional  in  gratitude  and  recognition   of   the   What we did  was  to  accept  any  patient
            ed  in  the   appointment   of   men   and   Medical Programs in  this  time  of  budg.  great  progress  that  has  been  made  in   sent to us by any  doctor,  make  all  the
            women  in  whose  vision,   fairness   and   etary  pressures.  I  am  confident   that  such a short period  of  time.  There  are   diagnostic  studies  and  then  carry  out
            wisdom  you  can  have   complete   confi-   among  the   large   number   of   devoted  some   tough   issues,    however,    that   all  the  expensive   laboratory   studies
            dence. It is a great pleasure  for  me  to   and   informed   members   of   the   Con-  must  be  faced  now  and  in  the   imme-   and  specialized  therapy.  As   soon   as
            add that in continuation  of  the  highest   gress  there  will  be  found   a   leader  diate  future  in  connection  with  these   possible we put  the  patient  back  under
            standards   of   excellence   which    the   worthy  of  taking  his  place,  for   the  program activities. I would like  to  dis-   the  care  of  his  own  doctor,   because
            N.I.H. has always  maintained in  its  ad-   Congress  has  shown  its  dedication   to  cuss  a  few  of  the  sensitive  problems   the best  place  for  any  patient  is  at
            ministration, the  Division  of   Regional   health  and  medical  research   and   its  that  must  be  solved,  particularly   in   home as soon  as  that  is  possible.  The
            Medical Programs   staff,  headed  by  Dr.   understanding   of   the   importance   of  connection  with  the  Report  that   must   doctor is backed  by  a  partnership  with
            Robert Marston,    is  one  of  the   most   the N.I.H.  programs  by  their  appropri.  be  made  to  the  President  and  to  the   a research  institution,  one  kind  of  a
            able, enthusiastic and  helpful  groups  I   ation  record   these   past   20   years.  Congress on June 30, 1967.                   regional center,  which  carries  out  all
            have encountered  in  or  out  of  Govern-   These  years   witnessed   the   construc-                                               the  expensive  diagnostic  and  follow-up
            ment.                                        tion  of  a  remarkable   foundation   for  The first question which     was    raised   studies  and  provides   the   specialized
            The  appropriation  needs  of   the   pro-   the  programs  with  which  we  are   con-  particularly before  the  Congress  passed   treatment not available to the  doctor  in
            gram will require solid justification  and   cerned   in   this   Conference.    Unless  this  Law   was   whether   this   program    s own community.
            the strongest  support  from  all  of  us,   there is  adequate  volume  and  continul-  could  make  effective  progress   without
                                                                                                     interfering with the practice of  medicine   I am  happy  to  report  to  you  that  in
            so that its full potential  may  be  real-   ty  of  support,  the  great  promise   of  in  a  given  area.  It  is  my  hope  and   these  20  years  of   close   cooperation
            ized. I have  a  sad  personal  detail  to   this  Program  cannot  be  fulfilled   and  expectation that there will  be  interfer-   with  doctors  throughout   New   England,
            share with  you.  Just  a  few  days  ago,   the high  hopes  which  have  been  raised  ence, of a very  special  kind,  with  the   I  have  not  heard  a  single   complaint
            actually  two  weeks  ago  last  Thursday,   throughout the Nation  will  end  in  bit-  practice of  medicine  by  these  programs   from any doctor  that  We  had  interfered
            before the tragic  sudden  death  of  Con-   ter disappointment.                         -interference that will  bring  good  both   with his relationship to the  patient,  or
            gressman  John  E.  Fogarty,  I  had   the                                               to the  practioner  and  to  the  patient.   the family, or  taken  anything  from  him
            privilege of a long  discussion  with  him   The principle oi diversification  of  sup-  May I  cite  my  own  personal  experience   that  properly  belonged  to   him.   What
            on one of his  periodic  visits.  We  dis-   port is built into the  Law  and  the  ad-  in this  connection  which  gave  me  con-   we have  done  for  the  doctor,  however,

            26





          is  to  place   behind   him   the   knowledge   knowledge   of   cancer   and   cancer   che-   though   broader    than    the    categorical   I  believe  that  the  categorical  thrust  is
          and  skills  of  experts  who   are   not   in   motherapy;   the   pathologist;   the   hema-   areas   with   which   we   were    concerned.   important  to   this   program,   particularly
          the  private   practice   of   medicine,   and   tologist,  and  any  other   specialist   re-   Thus  attention  was   given   to   the   sup-   at   the   outset.   Specialized    activities
          to  provide  for  him  forms  of  therapy  for   quired   in   a   given    case.    Such    a   port  of   medical   and   continuing   educa-   must  be  related   to   the   more   general-
          his  patient   for   whom   he   had   nothing   patient's  family,  too,  should   be   given   tion,  and  of   medical   libraries,   better   ized  functions  to  be  effective.  I   think
          else  to   offer.   The   doctor   makes   his   the  benefit  of  study  by   epidemiologists   methods     of     constant      communication   this  is  why  Congress  made  so   clear   in
          contribution  to   the   generation   of   new   and  trained  fact  finders   who   seek   to   between   and   among    centers    and    be-   enacting  the  law  that   the   program   was
          knowledge  by  his   reports   to   us   which   learn   more   about   the   background    or   tween   centers   and   doctors,    and    the   to  have  a  broad  involvement  of   all   of
          parallel  our  reports   to   him.   By   this   causation   of   cancer   in   a   particular   need   for   some   mechanisms   for   achiev-   the   health   activities   in   the   region.
          method  we   enable   the   doctor   to   face   case.  Rehabilitation,  long-term  care   fa-   ing    cooperative     relationships     among   Clearly,  the   program   should   not   serve
          both  himself  and  the   family   secure   in   cilities,  as  well   as   home   care   pro-   the   major   health   resources   that   were   to  bring  about  further   fragmentation   in
          the   knowledge   that   he   was    obtaining   grams,  are  all  required  if  patients  are   considered  essential  to   progress   against   the health field.  Its  very  nature  is  that
          for  his  patient  the  results  of   research   to  receive  the  best  care  possible.  Spe-   the  problems  of  heart,  stroke   and   can-   of   an   instrument   of   synthesis    among
          carried   out   anywhere,    and    diagnostic   cialized  activities,  therefore,  require  a   cer.  Mention  should   be   made,   too,   of   diverse  elements,   agencies   and   individ-
          and  therapeutic  assistance  of   a   caliber   framework     of   cooperative       arrange-   the   broad   scope   of    the    recommenda-   uals.  A  representative  of  a  medical   so-
          not otherwise available to him.                  ments  involving  a  wide  variety  of  indi-   tions  in  the  DeBakey  Report   which   were   ciety  is  quoted  as  having  said  "If  this
          It  is  true  that  one  cannot  easily  apply   viduals,  institutions,   and   agencies   if   not  included  in  this  legislation  at  this   cooperation  among   all   of   these   health
          what  has  worked   in   one   part   of   the   they are to be  effective.  In  view  of  the   time,  but   which   can   be   supported   in   resources   in   our   state   is   good   for
          country  to  another   area,   and   this   is   problems  stated  in  the  Issue   Paper   in   part   today   through   other   programs   Of   heart  disease,     cancer  and        stroke,
          good,  but  I  am  confident  that  the   var-   this regard,  I  would  like  to  review  the   the  N.I.H.  These  include  the  creation  of   shouldn't  it  be  good  in  helping  to  meet
          iations  best  suited  for  a   given   region   manner  in  which   the   President,s   Corn.   Centers  of   Excellence   in   the   sciences   other   health    needs?"    I    think    the
          can  be  worked  out  along   the   lines   of   mission  on  Heart   Disease,   Cancer,   and   basic  to  medicine   and   in   the   several   answer   is   obvious.   It   should   be   of
          the   formula   I   have   suggested.    Above   Stroke dealt with this question.                disciplines in the clinical fields. It  is  my   such  benefit.  I  am  sure   we   all   agree
          all, I plead  for  flexibility  in  this  pro.                                                   hope   that   these    recommendations    will   that  if  the  cooperative  pattern   of   the
          gram   from   region   to   region   in   this   Early in its deliberations the        COmmis'   not   be   neglected   and    that    adequate   regional   medical    programs    for    heart
          Country,  flexibility  within  any   one   re-   sion faced up to the issue        that    was   support will  be  found  too  for  the  educa-   disease,   cancer   and   stroke    has    by-
          gion,   as   experience   dictates   what   is   inherent  in  the   categorical   nature   of   tional  and  research  activities  which   are   product   values   of   importance   to    the
          best for the progress of this program.           its  charter.  On  the  basis   of   thorough   essential   for   the   successful   operation   total  health  problem  of  the   region   in-
                                                           discussions   of    the    full    Commission   of these medical programs.                       volved,   we   have   reason   for   satisfac-
          I  have  spent  the  major   portion   Of   my   and  the  advice   of   expert   consultants,                                                    tion, not dismay.
          life in  the  field  of  cancer  research  and   the  policy  decision  was   made   that   it   The  question  has   been   asked   by   many:
          care  and  must  state  that  the   time   has   could  not  react  adequately  to  the  three   "Is   the   present    program    weaker    or   These  programs   are   developing   just   as
          long  since  passed,  if  it   ever   existed,   categories   of   health   that   were    its   better  than  that  advocated   in   the   De-   the   medical   schools   are   taking   meas-
          when  any   one   doctor,   no   matter   what   charge   without   becoming    involved    in   Bakey   Report?"   The   answer   is   clear.,   ure  of   the   needs   of   the   communities
          his  specialty,  can  give  proper   care   to   the  broader  gamut   of   health   problems.   When  all  the   planning   carried   out   by   around   them.   These   programs,    I    be-
          any  one  patient  with   cancer.   From   the   The  Commission   in   its   Report   stated,   the  hundreds   of   experts   in   the   many   lieve,  are   responsible   for   accelerating
          moment   of   suspicion   or   discovery    of   "But  heart  disease,   cancer   and   stroke   regions  of  the  country  is   complete   and   this  trend.  There  are   still   those   who
          the  tumor,  the  patient  should   have   the   cannot  realistically  be  considered   apart   all  the  new  needs  discovered   or   uncov-   oppose    involvement    in    a    meaningful
          benefit   of   discussion   and   consultation   from   the   broad   problems   of   American   ered   by   such   studies   are    supported,   way  of   the   medical   schools   in   these
          of  a  whole  group  of  people,  which   will   science and medicine."                          the  program  will,  indeed  must,   be   bet-   programs  on   the   ground   that   a   medi-
          include  the   surgeon   who   must   operate,                                                   ter   than   the   original    recommendations   cal  school  is  only  an  educational  insti-
          if  operation  is  the  choice;  the  radioth-   It   consequently   gave   consideration   to   or   Dr.   DeBakey    and    the    Commission   tution.  I  believe  that  a  medical   school
          erapist;   the    internist  with      special   some  of   the   underlying   problems,   al-   will be sorely disappointed.                     is   an    educational         institution-and
                                                                                                                                                                                                        27









                something  more.  It  must  be   a   center   strength and  greatness  can  be  achieved  with which  we  are  all  familiar,  cannot   "We   need   to   match   potential    with
                of  medical  research,  not  restricted  in   within  a  university  or  medical  school  be  met  by  the  available  manpower   and   achievement,  to   fuse   the   worlds   of
                amount  and  kind  merely  to   meet   edu-   framework.  Those  who  solve  this   will  facilities utilized and distributed in  the   science  and  practice.  We  need  to   de-
                cational   needs.   The   medical    school   find  rich  rewards.  I  have  worked  out  manner   presently   employed.   And    now   velop  and  support  a  creative   partner-
                must take leadership  in  the  solution  of   such a plan, which will preserve  and  in-  at  this   Conference   we   proclaim   the   ship  among  all  health  resources.   This
                problems  of   disease,   in   identifiable   crease greatness of the discipline  struc-  right  of  every  man,  woman   and   child   way, which  is  the  way  of  a  democratic
                programs,  in  addition  to   the   conduct   ture of the  medical  schools  and  permit  in  the  categories  under  discussion   to   republic-is  the  true  path  to   conquest
                of basic research.                            the  development  of  maximal  interdisci-  the most expert  in  diagnosis  and  treat-   of heart disease, cancer and stroke".
                                                              @linary.  cooperation  with  those   whose  ment available in  the  medical  world  to-
                And finally, to  fulfill  its  mission  and                                                                                             We must  never  lose  sight  of  the  goals
                                                     . .      aeeDest  concern  and  dedication  is   to  day.  These  needs  of  our   people,   for
                make  its  full  contribution  to  societv.        category  of  the   dread   diseases.  the  best  in  medicine-let  us  not   call   of all  who  work  in  the  health  fields-
                the  medical  school  must  make t            0 e                                                                                       eradication  or   prevention   of   disease
                                                              Onther  plans  and  better   ones-can   be  them    demands-must    be    met    either
                greatest  possible  contribution  to  meet-   and will be fashioned.                      by  voluntary   methods   with   Government   and,  through  the   application   of   new
                ing  the  medical  needs  of   the   commu-                                               support  through  programs  of   the   kind   knowledge   from    research,    conversion
                nity  in  which  it  has   been   nurtured.   There is  another  question  deserving  of  we are  discussing  here,  best  suited  to   of the  incurable  to  curable.  And  while
                                                                                                                                                                                                  s
                This  can   be   no   token   contribution,   frank  discussion-one  of   greatest   im-                                                these  goals  are  being  achieved,  let  u
                tossed  from  the  ivory  tower.   If   the   portance to the future of the health    of  each  particular  region  of  the  country,   furnish  assistance  through  the   Region-
                medical %schools do  not  meet  this  chal-   our.people. I refer  to  the  charge  made  or some  system  of  Federal  health  serv-   al  Programs,  to  every  doctor   in   the
                lenge, they  will  lose  the  greatest  op-   by  some  before  this  Bill  was   passed  ices will  be  invoked.  May  I  express  a   care of  his  patient,  and  to  those  who
                portunity  in  the   history   of   medical   that  the  Regional  Center   plan   would  personal reaction  to  the  frequently  ex-   have  no  private  doctor  too,  thus  mak-
                education-now    so     happily     offered   lead to socialized medicine.  I  sha"  not  pressed  fear  of  what   is   called   the
                                                                                                          "threat of Government Medicine"?          V   in  available  for  every  patient  in  the
                                                                                                ,y    em                                            e        t
                                                                                                                                                         g
                through   these   regional    mediCia[   pro- attempt to define this common     -   will  are talking  not  about  some  alien  land,   co un,   care  of  the  kind  all   of   us
                grams.                                        ployed and badly abused term, but           but  about  our  Government,  in  this  de-   would like to have for all  patients.  This
                Cognizance should  be  taken  of  the  fact   assume  that  what  is  meant  is  Federal  mocracy. I do  not  share  such  fear,  nor   may  be  defined  as  the  application   of
                that  medical  schools  traditionally   are   control of the practice of  medicine,  or,                                                all  knowledge  of  medicine,  surgery  and
                                                              in   short   "Government   Medicine".   As  will  I  as  long  as  there  is  a   forum   laboratory  science  for  the  prolongation
                discipline-oriented and have  given  little                                               where  I  have  the  right  to  speak,   as
                support  to  categorical  developments   of   Dr.  DeBakey  has  pointed  out  repeated-  , ng  as  there  are  men  and   women   to   of life, the relief of pain, and  hopefully
                                                              ly and,  with  him,  all  the  members  of  10                                            the  cure  of   patients   suffering   from
                real  strength.  A  critical  mass  of  re-   the  President's  Commission  this   piece  harken to my words.                           what the  Congress  calls  the  dread  dis-
                search and clinical  strength  is  required   of legislation  and  the   programs   that  All of  us  have  heard,  I  am  sure,  the   eases.  The  only  guideline  of   enduring
                to  develop,  accumulate  and  apply  truly   will be created by virtue  of  it  provide  background  sounds  of   predictions   that   value in  the  construction  of  these  Re-
                expert  knowledge  in  a  given  field  as,   .  best  means  of   preventing   "Govern-  the  way  of   voluntary   cooperation   is   gional  Programs   must   be   defined   in
                for  example,  in  modern   cardiology   or   the.
                in  the  field  of  cancer.  The  time  has   meni:  Medicine".  We  all   realize   the  sure  to fail, and that it will  be  neces-   terms of what  is  best  for  the  patient.
                come  for  the  medical  schools   to   em-   vast increase  in  demand  for  good  med-  sary for the public  sector  to  take  over   In the final  analysis  this  is  what  the
                brace  the   development   of   categorical   ical care since the end of  World  War  11  and   bring  order  to  the  health  field.   Regional   Medical   Programs    are    all
                strength  and  no  longer  to  reject  such   alone. This  is  shown  by  several  thou-  This  I do  not  believe.  I  am  confident   about.  The  idea  which  gave   birth   to
                developments  as   a   cardiovascular   in-   sand  community   hospitals   built   with  that  the   Regional    Medical    Programs   this program is clear. The  intent  of  the
                stitute or,,a cancer institute  as  foreign   the aid of the Hill-Burton  Act,  fathered  have  already   demonstrated   the   poten-   programs   should   permit   no   misunder-
                                                              in  the  Senate  by  that  great  champion  tial to fulfill the promise  and  meet  the   standing.   The   implementation,    within
                bodies ill-suited to  the  traditional  ta-   of  medical  research  and  health,  Sena-  challenge that was  so  clearly  stated  in   the guidelines of the  law  and  the  regu-
                bles   of   organization   of   a   medical   tor Lister Hill. The  demands  for  health  the  introduction  to   the   DeBakey   Re-   lations,  remains,  as  it  should  be,  in
                school.  The  challenge  is  here  to  work   services  which  have  increased  so  rap-  port   to   the   President's   Commission,   the  hands  of  those  who  plan  in   each
                out  in   each   region   how   categorical   idly in the last year alone,  for  reasons  from which I now quote:                       of the many regions of the country.

                28







                                                                                           Section II-Pan    el Sessions



                                                                                           Program Evaluation                         Two panel sessions  on  the  second  and
                                                                                                                                      third days of  the  Conference  provided
                                                                                           The Report of the Surgeon General          representatives  of  the   medical   and
                                                                                           to the President and the Congress          health fields an opportunity'to  express
                                                                                                                                      their views on two@of the  major  issues
                                                                                                                                      of the Conference.




















































                                                                                                                                                                            29





                  Program Evaluation

                  CHAIRMAN:                                      On my far left  is  Dr.  Carl  William  Ruhe   The  practicing  physician   is   interested   the perils and pitfalls  of  evaluation  as
                  George  James,   M.D.                          who  is  on  the  staff  of   the   American   particularly  in  how   one   measures   and   I see them.
                  Dean                                           Medical  Association  with  particular   in-   evaluates  the  programs  that   serve   the   What I see  is  the  future  of  evaluation
                  Mt. Sinai School of,Medicine                   terest   in   continuing   education    pro-   ambulatory patient.                            in terms  of  the  opportunities  and  chal
                  PANEL:                                         grams.                                         There  are  some  questions  that  have   to   lenges  of   the   regional   program   anc
                  Edward Kowalewski, M.D.                        Dr.   Kowalewski   and    Dr.    Ruhe    are   be  asked  of  Dr.  Wilson,  and  we   shall   something  of  the  necessary  first  steps
                  Chairman, Board of Directors                   members    of    the    Review     Committee   come to  those  as  we  go  along,  but  the   Lest  any  of  you  thinks  I  am  here  aE
                  American Academy of General Practice           that has  been  working  diligently  to  re.   problem   of   evaluation,   as   shown   by   the  Olympian   sociologist   and   listinf
                  Harvey L. Smith, Ph.D.                         view   the   many   proposals   which   have   the  applications  that  have  come  in,  is   somebody  else's  system,  please   be   as
                  Professor of Sociology and                     been  submitted  for  either   planning   or   certainly  not  solved.  In  many  of  them,   sured  I  am  deeply  involved  in  t   es(
                                                                 operational grants.                            an  attempt  has   been   made   to   answer   problems  myself  so  it  is  my  own  limi
                  Director, Social Research Section                                                             the  problem  by  the  use   of   mechanical   tations that I am speaking of here.
                  University of North Carolina                   We shall begin with Dr. Kowalewski.            help.   This   perhaps   will   offer   some   We  are  at  the  moment,  I   think,   ver
                  C. H. William Ruhe, M.D.                                                                      answers  but  certainly  not  all.  In   the
                  Assistant   Secretary                          DR. KOWALEWSKI: We have two             con-   academic  area  there  is  a  difference  in   1mperfectly  equipped   to   undertake   th4
                                                                 cerns. First,  as  members  of  the  Review.                                                  major tasks involved.  Let  me  start  witi
                  Council  on   Medical Education                Committee  we  have   been   given   respon-   degree of refinement and evaluation.
                  American Medical Association                                                                                                                 the  one  about  which  I  know  least.  Wi
                                                                 sibility  to  evaluate  the  program  appli-   At this time,  I  will  conclude  by  saying   have  heard  suggestions  offered   to   u!
                  Vernon E. Wilson, M.D.                         cations  that  come   before   us.   Second,   that I don't  believe  we  can  provide  one   as to  the  kinds  of  things  we  need  t(
                  Dean                                           as  physicians  we  try  to  interpret   and   rule that will apply  to  all  projects  be-   evaluate,  our   involvements,   for   exam
                  School  of   Medicine                          bring  into  focus  the  practicing   physi-   cause   each   project   has   a   different   pie, in  cost  accounting.  I  myself  knov
                  University of Missouri and                     cian's  responsibility  in.  the   area   of   origin and a different end point.              (and   have   heard   often   from   medica
                  Program Coordinator                            evaluation.  We  attempt  to  integrate  the   DR.  SMITH:  Dr.  James,  Dr.  Wilson,  fel-   administrators   and   deans   of    medica
                  Missouri Regional Medical    Program           latter  concern  with  the  continuing  edu,   low  panelists,  ladies  and  gentlemen:   I   schools)   enough   of   the   problems   o
                                                                 cational   process   in   which   we    have   'shall  try  to  keep  my   remarks   within   cost accounting  in  the  field  of  healti
                  DR.  JAMES:  I  shall  introduce         the   great interest.                                categorical  limits  but  I  suspect  before   care  to  know  there  are  relatively  feN
                  members of the Panel and then            ask   It  is  evident  that  to  measure  properly   I  am  finished  I  will  be  talking  about   things we can  pick  up  and  easily  appi,
                  each  to  speak  in  turn  without   further   there  must  be  a  starting   point.   This   evaluation in related diseases.                in   this   new   and   complex   situation
                  introduction.                                  program  is  in  its  infancy,  but  it   is   The  Division  of  Regional   Medical   Pro-   There is a great  deal  we  shall  need  t(
                  Beginning  on  my  right   is   Dr.   Edward   where  we  must  begin   our   thinking   in   grams, in asking  us  to  evaluate  a  thing   learn and experiment with.
                  Kowalewski.  He  has  been  active  in   the   terms  of   evaluation   of   the   programs   as  complex  as  a  regional  program,   has   Other  suggestions  have   involved   focu!
                  Academy  of  General  Practice   with   par-   our   committee    has    reviewed.    While   asked  us  to  do  the  almost   impossible.   on  the  patient,  i.e.,  patient   improve
                  ticular  interest  in  continuing  education   many   persons   are    vitally    concerned   Yet I think the  existence  of  the  region-   ment or  patient  cure.  Certainly  this  i
                  but  also  in  the   delivery   of   medical   and  already   have   knowledge   pertaining   al   programs   provides   us    with    the   hard   enough   to   demonstrate   in    th
                  care.                                          to  evaluation,  others  submitting   aPP[i-   necessity for trying to  do  this  and  pro'   difficult  relationship  of  physician  an,
                                                                 cations  do  not  have  this  background  of   vides  us  also   with   the   opportunities   patient.  It  is  hard  enough   to   demor
                  Next to him    is  Dr.  Harvey   Smith   who   evaluation so it  will  have  to  be  intro-   and  perhaps  the  beginnings   of   techni,   strate   improvement   in   many    patient
                  is  one  of  the  friendly  sociologists  to   duced.                                         cal resources  to  try  to  do  this  almost   and  even  more  difficult  to   demonstrat
                  whom  Dr.  Wilson   referred.   He   is   on
                  the  faculty  of  the  University  of  North   In  addition,  we'  have  the  problem  that   impossible task.                               a   relationship   between   that   improve
                  Carolina but he  has  also  played  a  lead-   regions differ; i.e., each  particular  area   I  would  like  today,  in   responding   to   ment  and  the  ministrations  of  the  ph5
                  ing role  in  the  North  Carolina  Regional   has  its  own  scope.  We  can't  apply  one   material   presented   to   us   both   here   sician.   This   is   correspondingly   muc
                  Medical Program.                               rule to all.                                   and in other'packets,  to  talk  briefly  on   more difficult to do in a large system.

                  30


























                                                                                                                          I oil- $I

































        George James, M.D. (Chairman)                           Edward Kowalewski, M.D.                               C. H. William Ruhe, M.D.
                                                                Harvey L. Smith, Ph.D.                                Vernon E. Wilson, M.D.

                                                                                                                                                                    31









                    I   am   reminded   of   what   was    enunciated    are   easier   to   monitor.   The   others    be-   ble.   We   are   handicapped   at    all    turns   Similarly,    hospital     administrators     anc
                    by   Robert   Redfield,    the    anthropologist,    come more complex.                                   by   the   inadequacies    of    record    keeping   public    health    medical     care     personne
                    who   said   the   further    away    you    were    We   have   heard   a   good    deal    of    talk   (or   should   I   say   the   irrelevancies    of   are   now   living   in   each   others   pocket,
                    from   the    universe    you    were    studying    about    systems     analysis.     My     comments   record   keeping   to   the   present   task    at   and  elbowing  at   each   other   for   a   morc
                    the    more     generalizations     you     could    on  this  will   of   necessity   be   superficial   .hand?).   The   basic   materials    we    require  effective role in the new program.
                    make.  I  think  we  tend  to  fall  into   this.    because    I    am    not    deeply     knowledge-   in   epidemiology   of    illness    and    preva-   Medical   schools   are   beginning   to    teac@
                    The   larger    universe    looks    easier    to                                                         ience   rates-i.e.,   getting    effective    base
                    generalize  but  all  of   us   agree   we   need    able  about  systems         analysis    but     I   lines   from   existing   records-are   all    but   community    medicine    and     beginning     tc
                    a   tremendous   amount    of    caution.    Sim-    think    some    of    them,    in    my    exper-   impossible to obtain.                                search    for    practitioners    and    teacher@
                                                                         ience,  have  perhaps        been        analogies                                                        who  have  this   kind   of   orientation.   The)
                    ilarly,  quali@  of   medical   care   has   been
                    advocated    as    a    focus    of     emphasis.    rather than analyses.        I  think  it   inter-   Now,  one  of  the   things   that   the   region-   too  are  now  standing   side   by   side   wit@
                    This  literature  is  filled  with   controversy.    esting, for example, to       point    out    some   al  program   is   doing   which   initially   may   public  health  people  for   the   first   time.
                    We   have   some   things   with    w'nic'n    we    analogies between the         line-up   of    cus-   complicate   the   task    of    evaluation    but   The    medical     schools,     in     a     ver)
                    can   steer   our   way   through   but    unless    tomers   in   a   cafeteria   and   the    waiting   would    ultimately    become     its     greatest   significant  way,   are   beginning   to   relatE
                    we   keep   it   awfully    simple    we    shall    rooms   of   our   out-patient    services,    but   contribution  is   that   it   is   changing   the   medical    teaching    to    the    tasks     and
                    really bein peril.                                   I  doubt  that  analogy   at   this   level   will   functions   of   individual    professions.    For   means   of   health    care    systems,    rathei
                                                                         help  any  of   us   to   become   either   better   example,    sociologists    are    emerging    in-   than  to   some   internal   criteria   intrinsic
                    The   results   of    education    are    another    customers     or     more      successful      pa-   to   the   real   world   in    connection    with   to the profession itself.
                    factor  we   have   been   asked   to   evaluate.    tients.                                              the  regional   program.   (I   don't   say   this   There   are    new    emerging    divisions    ol
                    Well,   this   is   Asomething   that   has   de'    It   is   extremely   important   that   a    much   may   be   its   greatest   achievement   but   it   professional    relationships     and     profes-
                    feated  educators   over   a   long   period   Of    better   bridge    be    erected    between    the   may  be  its  most  difficult   in   time.)   They   sional   responsibilities.   Medicine   is    not
                    time-I   include   ourselves   in   this.    What    work   of   many   of   the    systems    analysts   also    are    mixing    and     mingling     with   just   content   (as   indeed   it   never   was,
                                                                                                                              epidemiologists    and     biostatisticians     in   but    the     order     of     magnitude     has
                    are   the   impacts   we    want    to    measure    and    those    who,    like    yourselves,    are   meaningful     working      relationships      and   changed)    to    deal     with     the     acute
                    with      our      educational      programs?-the    deeply    knowledgeable    about    the     health
                    number    of    people    who    come     in?-the                                                         tnis  is  really   a   kind   of   minor   revolu-   phas@of   illness    but    is    now    increas.
                    kinds of professions they represent?                 care   systems.   They,   too,   find   it    mucn   tion.  It   may   not   solve   all   the   health   ingly   assuming   responsibility    for    other
                                                                         easier   to   generalize    about    the    health   ca re problems   but   it   may    well    develop   stages   of   patient    care.    New    emphasis
                    This is one method of evaluation.                    care   systems   the   less   they   know    about   some important resources.                            is  emerging   on   rehabilitation   which   will
                                                                         them!   I   think   they   require   the   correc-
                    Then   we   have   to   evaluate   whether    the    tive    action    of    much    deeper    informa-   Medicine    and    public    liealth    are    now   be   better   coordinated         with      other
                    content  of  our  programs  is   in   line   with    tion.                                                working     far     more     closely     together,   @spects    of    medical    care    and    indeed
                    our   goals.    This    is    another    problem,    We   shall   have   to   evaluate   problems    of   (without     stepping     on     each      other's   medical   rehabilitation   itself   is   undergo-
                    then,    to    determine    whether    we    have    coo                                                  toes),   in   a   very   significant,    rewarding   ing   planning   which   will   require   synthe-
                    communicated   it,   whether    it    has    been       rdination.    This,     in     almost     every   fashion.   What   this   means,   I   think,    is   sizing    and    evaluation     in     connection
                                                                         aspe                                         vior,   ..
                    internalized,   whether   it    changes    behav-        ct    of    complex    human    beha    '        inat   problems   are   being   looked    at    in   with     the     programs     being     discussed
                    ior  on  the  part  of  the   practitioners   and    has  been  extremely  baffling  to          us.      new    ways     by     people     viewing     them   here.
                    whether   this'has    any    impact    on    your    There are some research projects            un-      afresh    or     learning     to     view     them   Again,   we   have   the   problem   of   preven-
                                      they                               derway now to see whether some                   '-
                    clients  when             return     to      nome    .                                           cr'      through   the   eyes    of    their    colleagues.   tion   as   we   plan   to   evaluate   what   we
                    bases,   or   whether   it   has    impact    'an    iceria,   and   mechanisms    at    the    program
                    their own institutions.                              level    among    agencies,    can     be     ana-   From  this  kind   of   mix   will   come   elabo.   have    done.    This    enormous     opportunity
                                                                         lyzed,   isolated        and         communicated.   rations   of   our   frame   of   reference   that   and   primary    challenge    addresses    itself
                    Some   of   these   things   we   can    monitor.    Here   again,   we    may    have    some    leads   will   permit    us    to    develop    evaluative   to all of us.
                    I   suspect   as    an    inverse    relationship    for  evaluation  but   it's   only   a   beginning   criteria    and    evaluative     methods     that   I  think  perhaps   the   time   is   also   past
                    here   the   things    of    lesser    importance    and    the    materials    are    somewhat    fee.   we don't have now.                                   when    mavericks    like    myself    can     be

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      -essed   'into   service   to   do   planning   We  have  all  had  to  take  the   first   leap   levels   at    which    evaluation    can    and   individual   projects   again,   the    way    in
      id  evaluation.  I  think  we  now  need   to   into    program    development    without     an   should   take   place   and   that    when    we   which    one    looks    at    each    individual
      @gin   to   train   planners   and   research   effective  data  base.  This  base   will   have   use  the  term  evaluation   we   may   be   re-   project   from   the   national   level   is   in
      /aluators.  The  mix   of   professions   and   to    be    established    and    its     impact   ferring  to  any  one  of  these  levels  or  to   terms  of  the  total  overall   gain.   Now,   I
      @  interests  that  I  have  indicated   Pro-   brought   to   bear   on    the    program.    I   all of them.                                       suspect   that   the   people   ultimately    are
      des  us   with   an   opportunity   to   pool   think  it  will  also  permit   gross   monitor-   Consider,   for   example,   the    responsibil-   a  little   concerned   with   these   kinds   of
      ir   resources   in   many   directions    to   ing  of  broad  program  impacts   if   we   es-   ity  of  the  Division   of   Regional   Medical   things.   The   expectation   of    the    public
      @gin training for this field.                   tablish base lines in this way.                    Programs   to   show    what    has    happened.   as  to  what  would   come   out   of   the   Re-
      le  need  also  new   record   keeping   sys.   There  is  a   clear   and   present   need   to   It  has  the  responsibility   as   a   Division   gional     Medical     Programs     is     pretty
      !ms-health        monitoring         systems-   begin   to   work   closely   with    individual   to  report  to  the  President   and   to   Con-   clear.
      iat  will  endure  over   time   and   insure   projects    to    develop,    where    feasible,   gress  and  to  the   people,   to   show   what   I  think  the   legislation   has   been   estab-
      iat  we  shall  not  have  need   to   scram.   evaluation   designs   so   that    we    aren't   has   been   done   with   the    money,    what   lished   on   the   basis   that   many    people
      le  again  in  the  future,  as  we  do  now,   constantly    required    to    salvage     even   has   been   done   under    this    new    pro.   are   not   getting   the   ultimate    or    the
      ) find what  our  base  lines  are.  We  will   these  at  a   later   stage   when   we   might   gram which has been started.                       best  care   in   the   areas   of   heart   dis-
      uild  these  base   lines   into   the   sys-   have    been     more     constructively     in-   This  can  be  done  in  a   variety   of   ways   ease,    cancer,    and    stroke,    and    that
      !Ms.                                            volvcd earlier.                                    and  no  doubt   will   be.   Some   of   tlies!   under   the   impetus   of   the   program    and
      ly   comments   have   struck   a    somewhat   In  short,  the   way   of   evaluation   is   a   have   in    them    activity-a    measure    Or   through    the    provision    of    money     to
      egative   note,   emphasizing    our    prob.   very difficult road. I  think  it  is  a  feasi-   success.  Because this  is a  new                  carry  out   the   program,   this   care   would
                                                                                                                                                     Pro'   be  provided   in   a   way   which   is   better
      !ms.  I   don't   think   they   are   insur-   ble   road,   although   some   of    what    we   gram   it   is   possible,   for   example,   to   than it has been provided before.
      iountable.  They  will  have   to   be   sur-   attempt   may   turn   out   to   be    impossi-   show   that   activity   exists    where    none
      iounted  and  within  the  context  of   this   ble-  Now  it   may   be   necessary   to   plan   existed  before  or   at   least   measures   of   As  long  as  people   continue   to   die   from
      rogram.   In   the    meantime    there    is   for  a  future  system  that  will   enable   us   activity.  It   is   possible   to   show   that   heart   disease,   cancer,   and   stroke,    the
      iuch that can be done.                          to   do   it.   It   certainly   is   absolutely   "X"  number  of  projects   are   now   in   ex.   ultimate  goal,   the   ideal,   has   not   been
                                                      necessary. Thank you very much.                    istence.  It  is  possible  to  show  that  ,X,,   achieved.   Obviously   we    will    stop    far
      fe  need   to   monitor   the   systems.   We   DR.    RUHE:    Mr.    Chairman,    the    panel   number   of   the   population   is    "covered"   short   of   that   potential   but   the   ques-
      eed  to   study   our   aims   and   institu-                                                      by  the  projects.  All  of  these  things  will   tion  is:  How   far   can   the   program   take
      ons,  their  caseloads,   their   needs.   We   has been kind to its members,            if  not   no  doubt  be  done.   People   in   the   Divi-   us down that road?
      eed   to   monitor   our   occupations    and   to   the   audience,   to   give   each   member   sion   are   conscious    of    evaluation    of   In  the  final  analysis,   I   think   this   is
      rofessions,    their    programs,       their   of  the  panel  an  opportunity  to        .  sa@  this   kind-that   is,   just   enumeration   Of   really  the  thing  which  the  public   is   in-
                                                      similar  things  from   a   different   set   Or
      eeds,  their  functions  and  the   key   re-                                                      what  is   going   on-and   also   of   an   at-   terested   in.   Evaluation   can   take    place
      itionships   in   implementing   those.    We   biases and backgrounds.                            tempt   to   compare   this   with   what    the   not  only  at  this   level   from   the,   total
      eed  to  do   analyses   of   whatever   ill-   I  don't  know  that   I   have   anything   new   potential  might   be   for   the   program   so   national   concept   but   from   the    regional
      ess  and  prevalence   data   we   can   mus-   to  contribute  but  I  guess  I  will  say'       that  even  though  one   might   be   able   to   level  or  within  an   individual   institution,
      ?r  and  it  is  important  to   find   where   some  of   the   same   things   in   a   little   show  gain,  he   is   not   necessarily   show-   and   here   again   it   is    dependent    upon
      ur peaks  of  illness  are,  in  which  cate-   different  way.  I  would  like  to   plant   at   ing  the  proportion   of   gain   which   could   what  the  objectives  are  and   the   bias   of
      ories  of  people,   which   kind   of   III-   least   a   couple   of    thoughts    in    the   have  or  should   have   taken   place   in   a   the  person  who   is   looking   at   the   pro-
      esses, which areas.                             minds   of   the   audience   and   perhaps   in   given   period    of    time    compared    with   gram.
      ery   important   program   guidelines   will   the  minds   of   the   other   panel   members.   the ultimate possible gain.                        I   have   talked   with    some    people    who
      merge  from  this  effort  that   can   serve   First of all,  there  is  the  thought  that  in   The  ways   in   which   the   gain   is   meas-   represent      individual       institutions-gen-
      s  precursors  of  a  more   extensive   Pro-   a   program   such   as   this,    as    complex   ured,    of    course,    are     multitudinous.   erally   educational   institutions.   I   sensed
      ram development.                                and  as  large  as  it  is,   there   are   many   When   we   get   down   to   the   details   of   their  feeling   that   if   the   program   ena-

                                                                                                                                                                                                         33





                      bles  them  to   strengthen   the   education-   Now  this   way   the   congregation   got   an   thing  more  than  this  be   done,   that   we   becomes   really   to   ascribe   the   change
                      al  program   at   their   institutions   then   immediate   feedback   on   its   own   efforts   do  get  into  the   more   sophisticated   at-   to  what  has   been   carried   on   in   the
                      they  believe  it  has  been  worthwhile.   It   and   the    minister    got    an    immediate   tempts   at   evaluation,   recognizing    that   program.
                      would  be  difficult  to  quarrel  with   this   feedback  on  the  success   of   his   efforts   there    are  pitfalls.   As   one        reads   DR.  JAMES:   Thank   you,   Dr.   Ruhe.
                      in   a   general   philosophical   sense.   If   at exhorting the congregation.                    through  Paul   Sanazaro's   paper   and   lis-   I think it is fair  to  say  that  every   pro.
                      this  money  enables  us  to   make   a   bet-                                          ..  .      tens  to  Vernon  Wilson  talk   and   to   the
                                                                       It  was  kind  of  interesting   the   attitude                                                     gram  is   evaluated.   Many   of   them   are
                      ter  medical  school,  surely  in   the   long   +his   would   produce   in    you    as    you   other   members   of   the   panel,   he   must   evaluated  by  what  I  would  like   to  call
                      run this  will  be  better  for  the  care  of   walked   back   home.   If   you    had    more   stand  a  little  bit  in  awe  at   the   com-   the   "ice   cream   soda"   test.   The   pa-
                      the  people.  If  we  are  able  to  establish   --                                                plexity  of  the  job;  and  of   the   attempt
                      a   new   set   of   courses   in   continuing   people  there  this   week   than   last   week   to   establish   a   base   line   of    health   tients like it,  the  doctors  like  it,   the
                      education   and   bring   these   courses   or   and  a  greater  collection  this   than   last   care,   recognizing   that   the   base    line   administrators  like   it,   everybody   likes
                      educational   opportunities   to   more   phy-   week,  even  if   you   had   nothing   to   do   changes  all  the   time   you   are   working,   it.
                                                                       directly  with  the  collection,  it  sort   of
                      sicians  and  other  health   workers,   sure-                                                     that  it  would  change   any   way;   and   of   What  we  are  after  of   course   is   some-
                                                                       .-- ade  you  feel  good   inside.   You   got   a
                      ly  in  the  long  run  this  will  result  in   rr'                                               trying  to  say  whether  what  you   are   do.   thing   deeper.   The   Academy    of    Medi-
                      better health care.                              good   feeling   that   things    were    going   ing  in  one  project  out   of   25   in   one   cine   in   New   York   which   is   composed
                                                                       forward  and     progressing     and     every-    - .
                      I think this is a    reasonable       expecta-   thing  was  better  than  it   had   been   the   region,  and  what  is  being   done   in   one   of  the  more  prestigious  practitioners   in
                      tion.  It  is  another   method   of   measur.   week before.                                      institution in  that  region,  or  in  one  re.   the   community    and    which    is    about
                      ing.  Some  of   these   kinds   of   measures                                                     gion  compared  with   the   national   effort,   120  years  old  has  had  a   public   health
                                                                       I think that  this  is  a   kind   of   measure   that  any  one  of   these   things   makes   a   committee   for   many   years.   The    major
                      are   relevant   and   simple.   Others    are   '
                      complicated.                                     we  could   make   readily.   We   could   take   difference.                                       ticket   to   admission    to    the    public
                                                                       some   comfort,   for   example,    if    there   This  is  the  kind  of   thing   which   occa-   health   committee   has   been    that    you
                      While sitting listening  to   other   speakers   were    approximately     175,000     physician   sionally   overwhelms   us    and    I    would   know   very   little   about   and   certainly
                      I  was   thinking   about   years   ago   when   registrations   reported    in    all    formal   urge  simply  that  we  make  an   effort.   It   have  had  absolutely   no   formal   training
                      I  was   young   and   spent   all   my   sum-   continuing     education     courses     during   is  most  important  to   have   the   attitude   in   public,   health.   Yet    the    amazing
                      mers   on    a    farm.    We    were    about   the  year  '66  -  '67  as  compared  to   only                                                     record   these   men   have    compiled    for
                      two  miles  away  from  the                      150,000  reported  in  the  year  '65  -   '66.   of  seif-monitoring,   to   make   an   attempt   asking  searching   questions,   of   bringing
                                                             nearest                                                     to look at  these  things  critically,  to  set
                      village  and  we  used.to  trek   across   the   I  don't   know   exactly   what   that   means                                                     out  exceedingly   intelligent   and   provoc-
                      hills every Sunday   .1 morning-we        called and  I  am  not  sure  that  it   means   there   up   measures   which   are   reasonable    and   ative   reports   on   public   health   prob-
                      it    Sabbath    morning-to    attend     Sab-   was better  health  care  but  it  is  a  reas-   in  the  long  run  will  lead   to   what   we   lems   and   programs   is   truly    phenome-
                      bath  School   Church-and   in   this   little   suring  statistic  and  it  is   one   of   the   are trying to do.                                 nal.
                      village   church   there   was   a   signboard   kinds   of   measure   which   can   be    made   The  planning  phase  of  all  of   this   pro,   Similarly   about   20   years   ago    public
                      on  the  wall   to   record   attendance.   it   relatively easily.                                gram  is  extremely  important   to   the   re-   health   people   began   to   evaluate    the
                      had  the  number   up   for   the   attendance                                                     gion.   The   planning   projects,   I   think,   practice   of   medicine   and   during    the
                                                                       We   can    measure    head    count,    dollar   are  very  wise  for  that  reason.   Most   of   last   10   years   the   sociologists    have
                      last  week  and  blank  for   the   attendance   amount,      number      of   regions       and   you  are  in   the   planning   project   stage
                      this  week.  Because  of  the   Scotch   back'   number   of   projects.    We    can    measure   at  this  tiIme.  This  is  a   time   when   you been  evaluating  both.   To   the   best   of
                      ground  of   the   church,   immediately   un,   the   population   cared    for.    We    could   can  most  effectively   set   up   the   means   my  knowledge   no   one   has   yet   started
                      derneath  these   figures   they   had   their   count things like this.                           by   which   critical   evaluation   may   take   to evaluate the sociologist.
                      collection for  last  week  and  a  place  for                                                                                                       It is true  that  in  order  to  carry  out  a
                      collection  this  week.  Before  the   service   I  don't  mean  to  deprecate   these   or   to   place later on.                                   program  of  this   nature   there   must   be
                      was  over  for   the   morning   they   always   minimize  them.  I  think  it  is  valuable  to   The  longer  you  wait  to  do  it,  the   more   evaluation.  The   men   that   appeared   be-
                      put  in  the  figures   for   the   attendance   do  them.  But  I  guess  what  I   am   trying   indistinct   becomes   the   base   line   from   fore  you  today  have   given   you   a   few
                      this  week  and  the  collection  this   week.   to  get  around  to  is  to  urge  that   some-   which  you  start,  the   more   difficult   it   clues.

                      34







       f  you  came  here  searching   for   cook-  of  the  panel  like  to   make   additional   them  by  the  physicians   in   the   ivory  All of you, I  believe,  have  been  on  one
       Dook  answers,   obviously   no   one   has  comments?                                      towers.                                       side  or  another  of  the  National  Insti-
       @'hem  for  you.  We  have  a  few  minutes                                                                                               tutes  of  Health  grants   award   process;
       remaining  and  I  thought   perhaps   some  DR.  KOWALEWSKI:  Mr.   Chairman,   I   pro-   The time  required  for  diagnosis  is  very  either  you   have   applied   for   grants,
       of you,  if  you  speak  up  loudly,  would  pose  that  one  practical  means  of  eval'   easily  measured.  The  amount   of   activ-  have  been  on  study  sections   and   site
       like to direct a question  to  one  or  all  uation  will  have  to   be   based   around   ity or participation of  the  patient  isn't  teams,  or  have  been  on  the  staff  that
       of the  members  of  the  panel  along  any  this  statement:  What  is  helping  me   as   hard  to  determine,  and  I   would   argue  has  been  involved.  All  of  you,   there-
       of the lines  that  your  minds  have  been  the  provider  of  medical  care,  the  phy-   about the utilization  of  patient  time  as  fore,  know  that  evaluation  is  something
       proceeding  during   this   period.   Would  sician, and what is helping my patient?        a  measure  of  quality  of  care,   because  which  is  mentioned  in  practically  every
       any  of  you  like  to   comment?@h,   yes,  I  would  hope  that  the  individuals   who   if  any  of  you  has  done  a   study   'in  grant. All  of  you  have  written'  evalua-
       Go ahead.                                    are able  in  this  area  would  attempt  to   out-patient  clinics,  a  close  one,  in  a  tion criteria  diligently.  I  won't  embar-
                                                                                                   iarge  clinic,  and  have  looked   at   the  rass  any  of  you  by   asking   how   many
       QUESTIONER:  I  will  stick  my  neck  out.  build  in  a   system   around   these   two   people  who  leave  without  receiving   the  times you have carried them out.
       We  have   about   9,000   fellows   coming  factors.  What   is   helping   me   provide   attention  which  they  came  to   get   you
                                                    the  service?  What  is   helping   my   pa-                                                 This process of review  is  perhaps  a  lit-
       into the  medical  profession  every  year.  tient?  it  must  be  built  in  because  we   will  find  there  is  a  larger  number  of  tle bit  different  because  there  will  be
       We   probably    have    120,000    doctors                                                 these  people  than  you  think.  Not   only
       practicing  now   that   don't   understand  must  spend the  majority  of  our  time  in   that,  but  if  you  have  someone  in  your  visits, probably by  site  teams,  to  gran-
       anything  about   what   we   are   talking  treating  patients.  If  we  will  have   to   school  of  journalism  or  some  other  de-  tees  as  this  program  continues   through
                                                    spend the majority  of  our  time  in  eva@-                                             nd  the  years.  It  therefore  becomes  evident
       about.                                       uating,   then   we    are   indeed      not   partment do a study of patients a             that if a  section  is  written  on  evalua-
       Is   anybody   besides   Dr.   Smith   from  fulfilling our purpose.  So  this  practical   their reactions to this  process,  you  will  tion in a grant request it is  apt  to  come
                            ing  to  do   anything                                   must     be   find  there  are  a  number  of  people  who  back to haunt one later on.
       down in Carolina try                         area of evaluation somehow                     do  not  seek  care  when  they  should  be-
       to orient  these  people  to  the  problems  built in to answer these two questions.        cause of bad utilization of their time.       It therefore  means  that  evaluation  is  a
       they  are  going  to  run  into   so   that  DR.   WILSON:   Everybody   who   tries   to                                                 subject  which  will  receive  and   perhaps
       when  they  do  get  into  practice  (where  impart   his   own   approaches   finds   it   These  are  simple  things.  These  are  not  sho'uld  receive  an  enormous   amount   of
       they will have a hell of a time  trying  to  amazing  how  little  he  really  was   able   hard to  measure,  and  I  suspect  that  if  attention  and  if  our  group  here   today
       make  a  living)  they  won't  act  in  the  to transmit.  I  would  submit  that  if  we   we  would  measure  a  few  like  this   to-  have    been    somewhat      lacking     in
       same   stupid   way   many   of   us   have  can  get  all  of  these  groups   to   work   gether  as   a   whole   region   we   would  answers at  least  you  can  see  that  this
       done for the past 20 years.                  together to  gather  any  kind  of  informa.   have  made  a  significant   move   forward.  is  in  the  process   of   developing   and
       (Laughter)                                   tion,  no  matter  how  simple,  related  to   I  hope  that  when  those  of  us,  now  at  everyone  looks  to  you   people   in   the
       DR.  JAMES:  I  think  you  @erhaps   posed  progress, this in itself will  have  been  a   the  ivory   tower,   set   up   measurement  field   who   are   working    with    grant
       something  which  is  a  problem.  I  won't  major   move   forward   and    there    are   systems  we  don't  forget  the  individual,  Drojects,  working   with   Regional   Medi-
       refer  to  your  adjectives,  but  at   any                                                 as   Dr.   Kowalewski   has    just    said,  'al'Programs,  to  begin  coming   up   with
                                                    some  very  simple  things  which   can   be                                             do  c
       rate  there  is  a  need   for   continuing  used  for  such  an  information   gathering   who has a lot of other things to              the  answers  which  will  then  be  rapidly
       education  all  the  way   beyond   medical  system.                                        besides   work   with    measurement    Sys-  shared  with   everyone   who   is   working
       school  in  relation  to   all   of   these                                                 tems.  if  we  make   this   simple   enough  in this area.
       different  programs.  The  way  that   many  One of    these  is  the  action  that   pa,   so  we  can  all  get  started  together  on
       of  these  regional  programs   are   being  tients  take  in  response   to   prescribed   it, perhaps  the  system  itself  will  give  Thank you.
       planned is  to  reach  out  into  the  com.  therapy.  Our  social  service  people   em-   us ways to do this easily for everyone.
       munities  and  to  continue  the   instruc-  barrassed  a  number   of   our   physicians
       tion  of  physicians  in  ways  they  would  recently  when  they   did   a   review   of   DR.  JAMES:  Thank  you   very   much.   One
       like  to  be  instructed  and  in  ways  in  what  patients  really  did  with  the  pre.   final  word  and  then  we   shall   proceed
       which  they  need  it.  Would  any   member  scriptions   which   had   been   given   to   to our group discussions.
                                                                                                                                                                                           35





                    The Report of the Surgeon  General
                    to the President and the  Congress

                    CHAIRMAN:                                           As   one   who   participated   in   the   devel-   has  in  the  past,,  there  will  be   need   to   shows  it  was   wise   to   make   the   law   as
                    Storm Whaley                                        opment    of    this    program     and     since   authorize   in   some   fashion    the    support   flexible   as   possible.   And   I   would   hope
                    Vice President for Health Affairs                   then   has   witnessed   its   birth   and    now   of   construction.   This   is   the   one   area   that  we  would   continue   to   hold   to   this
                    University of Arkansas                              lusty  growth,   it   is   most   gratifying   to   that  I   think   deserves   our   most   serious   flexibility.
                                                                        see   the   tremendous    interest    and    con-   consideration  at  this   tirrfe,   because,   if   Obviously    there    are    certain     standards
                    PANEL:                                              cern  at   this   conference   in   relation   to   this  is   an   essential   ingredient   to   the   and    guidelines    necessary     to     maintain
                    Michael  E. DeBakey, M.D.                           this   program's   activities.   And    I    must   undergirding   of   the   program,    then    now   quality  and  excellence.   But   flexibility   is
                    Professor and Chairman                              echo   one   of   the   thoughts   anyway    that   is  th.e time to put it in.                         essential   to    meet    the    varying    condi-
                    Department of Surgery                               was   expressed   so   well   by   Dr.    Farber.   I  personally  believe   it   is   an   essential   tions     and     circumstances     that     exist
                    College of Medicine                                 And   that   is   that   such   interests,   such   .
                    Baylor     University                               exchange    of     information     and     really   ingredient.                                         throughout   the   breadth    of    our    country
                                                                                                                                                                                where    there    are    so     many     different
                    James T. Howell, M.D.                               thoughtful    consideration    by     so     many   I  believe  there  will  be   need   to   provide   ways   of   doing   things;   and   these    vary-
                    Executive Director                                  people,   can't   help   but   make   the    pro-   space   space   to    carry    out    a    number   ing  ways  are   not   necessarily   less   effec-
                    Henry Ford Hospital                                 gram better.                                        of  the  various  activities   of   the   program   tive  or   less   successful.   They   should   be
                    Paul N. Ylvisaker, Ph.D.                            We   are   at   that   stage   in   the   program   that   really   are   essential   to   the   pro-   adapted  or  at  least   be   adaptable   to   lo-
                    Commissioner,     New      Jersey      Department   when,    as    required    by    Congress,     we   gram.   And   I   doubt   that   there   is   any   cal   circumstances   so   as    to    take    the
                    of Community Affairs                                must  give  it   scrutiny   and   appraisal   and   other  way   to   provide   that   space   except   best    advantage    of    the    local    circum.
                    Formerly,     DirectoIr of Public Affairs           suggest,   if   there   is   need   to   suggest,   by  funds  that  will  support   that   type   of   stances   and   to   use   them   in   the    most
                                                                                                                            construction.    I    doubt    seriously     that   effective way.
                    Program, Ford Foundation                            modifications in the legislation.                   there   are   enough    local    resources    for
                    .Ray E. Trussell, M.D.                              I   must   say   that   when   legislation    was   funding   this   type   of    construction.    In   I  would  doubt  that  we  would   want   in   any
                    Director                                            originally    drawn,    there    were     certain   fact,  I  am  sure  that  there  are   not.   And   way   to   change   the   legislative    authority
                    Columbia University School of                       things   that   we   fought   for    but    which   therefore,  I  think  we  need   to   give   this   to   provide   for   any   lessening    of    that
                    Public Health and Administrative                    were,   through   the   wisdom    of    Congress,   most   serious   consideration.   So   I   should   flexibility.  I   would   urge   that   we   main-
                    Medicine                                            omitted  from   the   original   law.   And   now   place   my    greatest    emphasis    and    per-   tain that as strongly as we can.
                    Bruce W. Everist, M.D.                              time   has   passed   allowing   us   to    give,   haps   my   own   focus    upon    this    aspect   Those   are   the   two   main   things   that   I
                    Green Clinic                                        perhaps,     more     prudent     thought      to   of  the   report   and   this   aspect   of   any   would   say   are   most    important    to    our
                    Ruston, Louisiana                                   these  items.  .1   do   not   now   feel   there   amendment to the legislation.                       future   in   effecting   this   program   as    a
                                                                        has   been   any   great   loss,   but   at   one                                                       successful   and   useful   one    in    achieving
                                                                        time  I   thought   there   might   have   been.-   Now,   the   second,    and    perhaps    equally   the goals that we are all seeking for it.
                    Mr.    Whaley    introduced    each    of     the   In light of the development of the pr               important,   aspect   of   the   report    should   Thank you, Mr. Whaley.
                                                                                                                       0-   be   concerned   with   whether   or   not    the
                    panelists   and   then    asked    Dr.    DeBakey   gram,  we  really  lost  little  or   no   ground   legislative    authority      has      sufficient   MR.    WHALEY:    Thank     you,     Dr.     DeBa-
                    to begin the discussion.                            in   this   regard.   In   fact,   perhaps    t@e   breadth     and   flexibility.   And        here,   key.    Another    member    of    the     commit-
                    Dr.   DEBAKEY:   I   had   hoped   to-take    ad-   program   will    be    strengthened    by    tne   again,  i  think  we  owe   a   great   deal   of   tee   who   has   been   working   on   the    re-
                    vantage  of  this  opportunity                say   fact  that  we  will  have   had   greater   time   thanks   to   those    who    worked    on    the   port,   also   a   member    of    the    National
                                                           !O.          to   think   about   how   best   to   do   these
                    some   things   to   this    group    @,,n    @e-   things.                                             language   in   the   original   draft   and   in   Advisory   Council   of   the    Regional    Medi-
                    spect   to   the   purposes    and    implementa-                                                       the   subsequent   modifications   of   it.   For   cal  Programs  as   is   Dr.   DeBakey,   is   Dr.
                    tion   of   the   program.   But    Dr.    Farber   The  one  factor  that  still   gives   me   con-   this   purpose,   I   would   specifically   call   James   T.   Howell,   Executive    Director    of
                    who   has   preceded   me   has   said   it    so   cern,  and  I   think   there   is   reason   for   attention   to   the   tribute   we    owe    Dr.   Henry    Ford    Hospital.    He    has    brought
                    eloquently  I  feel  now  it   would   be   anti-   this  on  the  basis  of   our   experience,   is   Dempsey   in   this   regard   because   of   the   to  the   Council   his   experience   in   hospi-
                    climactic    for    me    to     say     anything   that  if   the   program   is   going   to   move   many   hours   that   he   spent    working    on   tal    administration,     particularly     teach-
                    further in this regard.                             forward  as  rapidly  in   the   future   as   it   this.   I    believe    that    experience    now   ing hospital administration.

                    36




























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                                                                                                                                                                                                                                                                                                                                                                     37









                  DR.   HOWELL:   My   enthusiasm   for    this   The second  challenge,  I  believe,  will  go   the  evaluation  of  physicians.  And  I  be-   nounce  your  name?  How  old  are   you?   I
                  public law in its initial  year  of  activity   to  the   arena   of   the   community   into   lieve  we,,need  to  think  of   some   other   could  answer  the  latter  by   saying:   "I
                  has   stemmed   primarily   from   the   sim-   which  the  law  and  its   activities   will   elements  that   must   come   into   evalua7   could  go  to  the  bar  with  any   of   you
                  ple  flexibility  and  the  brevity  of   the   penetrate.   I   believe   that   arena    we   tion  procedures,  ones   that   perhaps   in   without   embarrassment."    And,    finally,
                  law. It hals provided  lots  of  latitude  in   must consider  to  be  the  hospital.  It  is   our  initial  efforts  may  take   precedence   when  this  was  all  done,   one   of   them
                  which  we  may  work.  At  the   same   time,   here   where   modern   instrumentation    is   over the others.                                observed,   "Well   Commissioner,   I    will
                  in its simplicity  and  in  its  brevity,  it   m -ost  likely  to  be  placed,  where   s@ace                                                  give  you  one  thing:  you  are  the   first
                  does  lead  to  some   interpretative   ques-   provisions  may  be   made   for   education,   These    deal    with    phenomena;     these   Commissioner   in   New   Jersey   who   ever
                  tions  for  which   we   must   provide   the   for research effort. It  is  here  that  most   dea .I  with  processes;   these   deal   with  came into office with a black eye."
                  solutions.                                      physicians  by   tradition   congregate   for   various   types   of    measurements    which
                  One  must  look  to  the   legislative   his-   various  types  of   meetings.   Accordingiy,   we  mav  place  upon  goals   or   objectives   I would  like  to  complicate  the  lives  of
                                                                                                                  of  the  program,  rather   than   evaluation   my  friends  here  in  this   room   and   in
                  tory for  some  of   the   answers   to   the   I  would  say  that  the   second   challenge   of physicians themselves.                       the  National  Institutes   of   Health   and
                  questions    about    interpretation    which   must be issued to the hospital itself.                                                          the  Public  Health  Service.  Perhaps   this
                  naturally arise.                                Like   Dr.   DeBakey,   those   of   us   who   Accordingly,  I  would  hasten  to  ask   you   is the  wrong  time  to  do  it  because  the
                  The    National   Advisory   Council       in   have  been  working  at  the   National   Ad-   to  think   of   evaluation   procedures   in   mood  of  the  country  right  now  is   that
                                                                                                                  terms   of   phenomena   or   procedures   or   "we   have   done   enough   for   a   while"
                  drawing  up  guidelines  has  had   to   look   visory Council level  on  this  law,  believe   processes  rather  than  an   evaluation   of
                  for   proper   solutions   to   these   ques-   in its simplicity  and  its  flexibility  and   human events.                                   and  "let's  retrench."  And  the   mood   of
                  tions.  In  doing  so,  as  Dr.  DeBakey  has   feel  that  relatively  little  needs  to  be                                                   an  administrator   must   always   be,   "in
                  said,  we  have  attempted   to   keep   this   changed  in  the  law  itself.  The  National   Thank you.                                      that case, I  will  retrench  a  little  more
                  flexibility,  this   simplicity.   This   may   Advisory  Council  and  the  staff   of   the   MR. WHALEY:      One of   the   members    of   th3n  the  public  expects  me  to.  I   cer-
                  bother   some   people,   as    is    evident   Division   of   Regional   Medical   Programs   the committee    who  brought  us   his   ex,   tainly   am   not   going   to   rouse    any
                  from  discussions   in   the   corridors   at   have  attempted   to   take   each   of   the   perience and     a   refreshingly   different   sleeping  dogs.  And  once  I  have   got   a
                  this  meeting,'  in  telephone   calls   that   proposals  brought   to   us   from   various   point of view   is  Dr.  Paul  N.   Ylvisaker   good  thing  going,  I  don't  want  to  risk
                  have   come   in,   in   questions   to   the   regions  and  really  have  tried   to   find                                                   it at this time."
                                                                                                                  of  the  Ford   Foundation.   Dr.   Ylvisaker
                  staff, in  visits  that  I  have  been  asked   some  mechanism  by   which   a   grant   can   has  been   advisor   to   the   United   Na-   But there are a  few  of  us,  I  think,  who
                  to   make   to   various   places   in    the   be  awarded  once  the  proposal  is   deter-   tions,  has'   served   in   many   different   foolishly or otherwise  are  willing  to  say
                  country  with  regard  to   some   of   these   mined  to  be  within  the  intent   of   the   roles  for  the   Federal   Government,   and   a  few  things  that  have  to  be  said   in
                  questions of interpretation.                    law.  This,  1,  personally,  would  like  to   soon will begin  his  career  in  State  gov-   the  United  States  today.  And   that   is,
                  Keeping  the  flexibility,   permitting   op-   see kept. If the lack  of  structure  or  the   ernment.   His   particular    concern    has   "yes,  we  have  gone   a   remarkably   long
                  portunity at  local  levels  for  the  deter-   lack of precision  in  spelling  things  out,   been  in  the  area  of  urban  affairs.   He   distance in the  last  few  years.  And  this
                                                                  one,  two,  three,   bothers   some   people,   has   moved   the   committee   (and    some-   legislation,  and  Medicare  in  your  field,
                  mination of  local  need  as  well  as  local   then  I  would  hope  that  we   could   look   times  jarred   the   committee)   with   the   certainly  are  cases  in   point.   But   we
                  desire,   in   mechanisms   by   which    the   beyond  this   toward   a   greater   oppo@u'   things  he  has  had  to  say.  And  I   hope   have a fantastic distance to go."
                  various   professional   elements   of    our   nity for participation at the local levei.      you will  jar  us  this  morning,  Dr.  Ylvi-
                  health   resources   may   work   is    some-   One  other  thing  thas  has   been   brought   saker.                                          We  are  facing  an   incomplete   revolution
                  thing  which,  like  Dr.  DeBakey,   I   feel                                                                                                   in  the  United  States  which   is   working
                                                                  to  me  as  a  problem   has   to   do   with   DR.   YLVISAKER:   I   have   just   returned   itself out  with  great  rapidity.  And  this
                  must   be   preserved   in   the   law.   ine   evaluation  procedures.  I  listened  to   it   from   some   eye   surgery   and   yesterday   revolution is  on  top  of  an  even  greater
                  penetration  will  be   to   the   community.   yesterday  in  a  discussion  group.  And   I   had   to   face   the   New   Jersey   Senate   revolution   going   on    in    the    world
                  And  the  first  challenge,  in  my   estima-   have  had  many   questions   posed   to   me   Committee  for  a  confirmation  of   a   new   around   us.   The   revolution   is   simply
                  tion,  will  go  to  the  physicians  of  the   with  respect  to  evaluation.  Most  of  the   appointment   and   they   asked    me    the   the   assertion   of   the   individual   for
                  community.                                      problem,  it  would   seem,   centers   about   usual   questions.   How    do    you    pro-   equal  treatment   at   a   time   when   re.

                  3 8














































      Storm Whaley (Chairman)                                  Michael E. DeBakey, M.D.                                 James T. Howell, M.D.
      Paul N. Y[visaker, Ph.D.                                 Ray E. Trussell, M.D.                                    Bruce W. Everist, M.D.

                                                                                                                                                                        39







                     sources  are  very   scarce   and   they   can    stantaneous   communication   so   that    ul-  to   come   when   this    legislation    comes   great   growth   industries   of   the   United
                     scarcely  go  around  to  do  the  things   we    timately   a   patient   in   need   of   help  up   before    some    of    the    committees,   States   which   is   medicine,   like   educa-
                     presently want.                                   knows  exactly  where  to  get  it,   how   to  and   when   some   of   the   more    consumer   tion,  like   law,   and   like   these   other
                     But  in  this  mood,  I  would  like  to  com-    g@t it,  and  those  in  the  medical  profes-  public  oriented  figures  are  going  to   be-   services.  How   are   you   organizing   this?
                     plicate  the  discussion  and  the   life   of    s,on  know   where   research   is   and   how  gin   to   ask    you    questions.    Unfortu-   How  even  physically   will   you   distribute
                     the  United   States   and   its   administra-    to avail themselves of it.                      nately, they  will  tend  to  be  of  only  one   the  resources?  Will  it  contribute   to   an
                     tors.  The  point  I  would   like   to   make    Now,  the  point  I  would   like   to   drive  kind  which  are   the   more   familiar   ones   orderly   growth   of   the    community    or,
                     has  to  do  partly  with  the  phrasing  used    home  very  hard  is  that  you   cannot   re-  you   have   heard,    the    most    important   like  the  highway   program,   will   it   be-
                                                                       treat   from   the   complexity   which    has  ones  of  which  relate  to  the  patterns   of   come    engineer-oriented-or  in           this
                     in this legislation.                                                                                   .  I  care  and  to  that   consumer   out   case    doctor-oriented    -    producing     a
                                                                       become  urban   America,   into   either   re.  meclica
                     This   is   a   Regional   Medical    Program.    -ional   patterns    exclusively    or    into  there and how this will affect his life.          wonderfully     engineered     system      with
                     Those  of  us  who  have   worked   with   re-    "'                                                                                                cloverleaves  and  the  rest,.  but  very  lit-
                     gional  problems  for   a   long   time   know    orofessional  patterns.  And   what   I   fear  Let me add a few other considerations.            tle   relevance    to    the    community    of
                     what  a  Holy  Grail  this  thing   called   a    basically  about  the  way  this   legislation                                        es,   go-   which it is a part?
                                                                       has  been   drafted   and   carried   out   so  We are now, in the United Stat
                     region  is.  And  as   a   matter   of   fact,    far  is   that   it   has   been   given   too  ing   into   a   service   economy   based   on   Second,  the  growth  sector   of   our   econ-
                     usually   when   you   use   the   word,   you    narrow  a   base,   which   is   the   medical  large  metropolitan   areas.   We   have   Pat-   omy  is  the  service  sector.   It   is   here
                     are  oversimplifying  this  issue.   And   you    Drofession  and  largely   the   medical   re-  terned    those    metropolitan    areas     on   that   the   great   market   for    employment
                     are  doing  what  they  said   in   the   book    @earch    academic    community,    to    work  manufacturing    and    the    mass     produc-   will  come.  Is  there  in  your  planning  for
                     African   Genesis-"What    a    human    being    out  what  is  one   of   the   great   moving  tion    and     consumption     of     material   these   regional   centers,   which   is    the
                     usually  does   is   to   add   a   territoria    forces in the United States today.              goods.  The   organizing   principle   of   the   planning   for   the   profession    and    the
                     ambition   to   an    otherwise    complicated                                                    metropolis  in  the   days   ahead   will   be-   .
                                                                       And  let  me  draw  this  perspective  a   bit                                                    science   and   the   growth    of    medicine,
                     existence."                                       for  you.  Ted  Howell  said  that  the  prob-  come   the    mass    production    and    con-   thought@for  how   you   can   distribute   the
                     Now   a   region   some   wag   once   defined    lem  is  going  to  be  that  of  the   commu-  sumption    of    strategic    services.    And   employment  all  the   way   from   the   high-
                     as  that  area  which  is  safely  larger   or    nity.  I  could  not  agree  more.  The  prob-  these  services  will   be   largely   in   the   est  levels  of  skill  down  almost  even   to
                     smaller  than  the  last   one   whose   prob,    lem is  going  to  be  to  relate  the  growth  hands   of   certain   guilds    and    certain   the  leaf  raking  areas  which  we   are   go-
                     lems we couldn't solve.                           of  medicine,  both  in  its   excellence   an  public   professions.   For    example,    City   ing  to  be  called  upon  to  provide  in  the
                                                                                                                       Hall  is  going  to  be  picketed  because   it   next  years?  That  is,  have  you   got   non-
                     And  when   we   begin   to   work   for   the    n  its  patterns  of  service,  to  the   pat-  doesn't   give   garbage    services    equally
                                                                       terns  of   distribution   of   the   American                                                    professional     employment     worked     into
                     perfect  definition  of  a  region  either  as    population    and    its    mood    and    its  to  Harlem  and  the   rest   of   the   commu-   this?   Are   you   extending   this   research
                     principle   of   organizing   medical    serv-    aspirations.                                    nity.  And  you  will   be   picketed   because   and   the   work   of   the   profession   down
                     ices   or   principle   of   organizing    any                                                    you   are   not   giving    adequate    medical   to  new   occupations   which   are   available
                     services,  we   soon   realize   the   tremen-    Now,  we  have   got   to   become,   in   all  service   and   equal   access   to   many   of   to  the  poor?  Which  is  one  of  the   ques-
                     dous   complexity   of   American   life.   It    professions,  in  all  the  services,   market  these consumers.                                  tions  that  I  think  you   have   to   answer
                     cries  out,  perhaps  not  so  much  for   de-    and consumer oriented.  If you do         n't,    ow,  the   planners   of   the   future   me-   before you are through.
                     centralization   which    becomes    a    cen-    within two years, your medical         schools
                     tralization,  as   for   instantaneous   corn-    will  be   picketed   by   a   combination   o  TroDolis  are  going  to  have  to   get   hold   And  the  final  thought  to   throw   at   you
                                                                                                                       of  ihe  service   economy   and   its   growth
                     munication    among     people     who     are    the    American    Mayors    Federation    ana  and  try  to  get  some  kind  of  pattern  for   is:  Are  you   going   to   develop   consumer
                     doing  remarkably   similar   work   in   very    CORE.                                           it  which  provides   equal   access   to   the   complaint    mechanisms    in    your     busi-
                     different   places,   and   the   need   some-    And  I  wonder  if  your   medical   faculties  citizen consumer.                                 ness?  If  we  become   market   oriented,   if
                     times  is  not  so  much  to   centralize   or    are ready for that experience.                                                                    this  is  the   day   of   the   consumer   and
                     to   concentrate   even   at   the    regional                                                    You   people   are   now   like   the   highway   you  are  the   growth   industry,   where   is
                     level,  as  to  produce  this  kind   of   in-    The  prelude  to  that  experience  is   going  engineers,  laying   hold   of   one   of   the   the consumer complaint mechanism?

                     40







         Now,   you   have   noticed   that   the    police   word   "health"    appears.    And    there    are   And     yet     the     community     and      the   vacuums   and   only   when    they    are    con-
         review   board   is   a   beginning.    The    Om-   some    people    in    the    upcoming    Consti-   scientific     community     must     come     to-   vinced     that     they      absolutely      must
         bundsman    is    coming,    and    you     better   tutional   Convention   in   April    who    would   gether   if   we   are   to   satisfy   what    is   move.   Yet,    the    public    expectation    is
         watch    out    for     the     Ombundsman.     in   do   away   with   any   reference   to    health,   clearly    the    expressed    intent    of    the   such   that    the    Government    has    clearly
         your   profession.   There   is   not   a   single   holding   that   the   police   power    in    the   public  in  the  use   of   public   funds.   Yet,   moved   far   beyond   the   thinking    of    the
         local    medical    group    you     have     ever   State   is   enough   to   take   all    necessary   there   is   ambivalence   in   the    minds    of   scientific community.
         talked   to   whose   Young   Turks    have    not   measures.                                            the      Government      about      how      these   We    have    an    enormous    opportunity     to
         said   nervously,    "We    are    not    policing   There   are   others,    and    I    share    this   things are to be achieved.                           maintain   a   working   partnership    in    this
         our    profession;    we    are     not     market   view,  who  believe   that   a   positive   state-   We   have    the    Regional    Medical    Program   country   in   contrast   to    the    rapid    or
         oriented."                                           ment   indicating   the   extent   of   the   pub-   legislation    underway.    We    have    legisla-   slow   collapse   into   a   total    governmental
         The     Ombundsman-will     it      come      your   lic   concern   should   be   included   in    the   tion,   passed   in   the   last   week   of   the   system    which    has    occurred    in     other
         way or will you anticipate it?                       State   Constitution    so    there    would    be   last  Congress,   which   will   put   a   similar   countries.   I   look   for    an    uneasy    but
         These   are   some   of   the    questions,    and   no  mistake   about   the   will   of   the   peo-   but   broader    planning    function    in    the   happy     marriage     between     the     Govern-
         [  hope   I   haven't   rocked   you   too   much.   ple  with   this   respect   to   the   kinds   of   hands   of   the   State   agencies    and    also   ment    and    the    private    sector    as    a
         Thank you.                                           problems   that    we    are    discussing    here   parallel    or    competitive    areawide    plan-   consequence    of    Regional     Medical     Pro-
                                                              at the present time.                                 ning  agencies  as   soon   as   it   is   funded.   grams.  And  I  feel  if  they  do   not   fulfill
         MR.   WHALEY:   Dr.   Ray    Trussell    is    Di-   The    Congress    has    enacted    since    1956   Now,   appropriately,   this    legislation    has   the   expectations   that   the   marriage    will
         rector    of    Columbia     University     School   about  65   major   pieces   of   legislation   in   not  been   discussed   here   in   this   confer-   get   very   lopsided   and   may,   indeed,   be-
         of    Public     Health     and     Administrative   the   health   field.   if   this    leaves    any   ence   because,   as   was   explained    to    us   come no marriage at all.
         Medicine.   He   has   brought   to    our    com-   question    in    anybody's    mind    in     this   very  clearly   by   Dr.   Marston   last   night,      It  is   coincidental   that   in   this ve  ry
         mittee   rich   years   of   experience   in   the   room  that  the  public   intent   is   that   the   there   are   discussions   going   on   at    the   building,  in   the   next   room,   is   a con-
         field   of   public    health    and    education.   best   that   the    scientists    and    medicine   policy    level.    And    nobody    knows     how   sumer    group,    the    Teamsters,    who con-
         Dr. Trussell.                                        have  to  offer  shall   reach   the   most   peo-   much    money    there.will    be,    but    those   trary  to  their  headlines  are   a   very con-
         DR.   TRUSSELL:    I    want    to    congratulate   ple,  they   really   should   go   and   read the   of   us   who   have   had   to   do   with    the   cerned    group    of    union    leaders,     the
         Paul   Ylvisaker   on   his   carefully    planned   preambles   to   the   various    pieces    of I eg- delivery   of   health   services    are    urging   largest   union   in   the   country    and with
         out   career.   He   has   gone   from   the   in-                                                        that   in   the    report    to    the    Congress                  ern   in   you   and   your   prod-
                                                              i,lation    for    refreshing    instruction    on   +here   be   mentioned   the   need    for    coor-  a deep    conc
         ternational   level   to   the   Federal    level,   what    the    public    wants    and     what the   @ination    of     these     multiple     planning   uctivity  and   with   your   concern   for    the
         and  now  he  is  going  to   the   State   level.   public hopes it is going to get.                     efforts    being     engendered     by     Federal   total   needs   of    the    public.    We    have
         And  I  only   want   to   invite   him   to   New   The    Congress    has    handed    back    to the   action   in   the    longstanding    Hill-Bu    on   worked   with   this   kind   of   labor    leader
         York City where we could use help.                                                                                                                             for    -many    years    and    his     management
                                                              scientific    community     the     particular job   program,  the  Regional  Medical              Pro,
         The   legislation   which    we    are    discuss.   of    saying     under     what     conditions the   gram,   which   is    now    getting    off    the   counterpart.      They      finance      research,
         ing       toda@yesterday       and        today-is   scientific    community    thinks    it    can de-   ground,  and  the  as   yet   inactive   but   up-   they   finance    demonstrations    on    a    re-
         the   manifestation   of   a   positive   attitude   liver  what  it   already   knows   and   how   it   coming State agency approach. If               the   gional  basis  in  the   New   York   area.   They
         on   the   part    of    the    Congress    toward   can   deliver   what   it   will   know   in   the   scientists can't get together with             the   support   legislation.   They    supported    leg-
         health.  This  is  an  attitude   which   is   not   future   as    a    consequence    of    research.   administrators   at   the   local   level,    then   islation    in    New    York    which    provides
         shared   universally    throughout    the    Unit-   This   is   an   unusual    function    for    the   the  vacuum   that   will   result   will   be   a   this      looking-over-the-shoulder       function
         ed States.                                           scientific  community.   It   is   not   used   to   vacuum    into     which     Government     moves,   that    Paul    talked     about-namely,     medi-
         In   New   York   State   which   has   some    of   planning   for   anything    that    it    doesn't   I   can   tell   you,   from   my   own    experi-   cal   auditing    by    the    State    Department
         the   most    progressive    health    legislation   want  to  do.  It  is  used   to   planning   very   ence,   that   with   the   limited   amount    of   of Health.
         in   the   country,   the    State    Constitution   meticulously    and    very    effectively     for   tax   money    available    in    this    country,   But   the   State   Department   of   Health    in
         has   but    one    sentence    in    which    the   the things that it does want to do.                  Government    tends    to    move    only     into   turn   has   turned   to   the    State    Medical
                                                                                                                                                                                                                        Al







                         Society    for    a    partnership     arrangement   and  brief   that   it   seems   the   law   could   yet   responsive    enough    to    effect    this   And    I     will     recognize     anyone     who
                         so    that    Government    and    the     profes-   only have been passed by accident.                   change.                                              wishes   to   be   recognized   in   the    panel.
                                                                                                                                                                                        Dr. Howell.
                         sions    with    consumer    support    have    an   The   lack   of   obfuscation   and   the   seren.   Public    Law     89-239     cannot     mean     a11
                         opportunity    to    discharge    this    function   dipitous  nature  of  the   law   leave   it   de,   things  to  all  men,  but  it  is   probing   for   DR.   HOWELL:    One    of    the    very    major
                         of   keeping   an   eye   on   how    well    -the   void   of    the    usual    stringent    measures
                         public is served.                                                                                         new    and    better    ways     of     delivering   concerns  that   I   have   had   with   the   law
                                                                              for    coercion    and    regulatory     function.   health    care    without    wholly     disrupting   itself  has   to   do   with   the   interregional
                         There   is    much    going    on    around    us-   This   is   enough   to    unsettle    the    most   the    established    tradition    of    medicine.   program.    What    do    we    anticipate    will
                         so   much   that   we   must   be   careful    not   sophisticated    of    Government    staff.          For    example,    continuing    education     re-   happen   one   of   these    days    when    meth-
                         to   be   like   a   fish.    The    fish    swims
                         around   in   the   water   all   day,   and    he   This  lack   of   regulatory   function   and   of   quires   no   dissembling   on   our   part.    We   odological     approaches      for      evaluation
                         never  stops  to  think   about   the   water   in   coercive  power  is   also   new   to   the   pri.   recognize   our   need    for    current    knowl.   or     measurement     determine     that     some
                         which   he    is    swimming.    And    yet    the   vate    sector.    And    they     have     under-   edge.   And   most   of   us   will   admit   that   plans     have     more     effectiveness     than
                         water   in   which   the    scientific    communi.   standable     misgivings     when     they     see   we   don't    always    have    it.    Cooperative   perhaps others?
                         ty    today    swims    has    changed     tremen-   Government   acting    like    a    true    Chris-   arrangements    among     all     health     agen-   Another    concern    in     the     interregional
                         dously   as   a   consequence   of   public    un.   tian   gentleman.   Incidentally,   the    clarity   cies  have   already   begun   at   this   confer-   area  has  to   do   with   gaps   of   areas   of
                         derstandin'g and uf Congressional              and   of  the  law  is  not   matched   in   this co   n.  ence.    And    they    have    been    relatively   the   country   that   are   not   now    covered.
                         legislative action. And I think it is         ter.   ference.                                             painless.    Demonstration        of       patient   And  what   will   we   do   here   on   the   Na-
                         ribly important that we realize that           the                                                        care   is   not   a   restrictive   or    nebulous   ..
                                                                              Mix   as   used   in    Washington    means   put-   term,   but   rather    a    unique    opportunity   tional   Advisory   Council   to   make    certain
                         water  in  which we scientific fish            are   ting   Dr.   Hudson,    Mr.    Cohen    and    Dr.   for    broadening    the    educational    process   that these areas have been covered?
                         swimming has changed. And we'd                bet-   DeBakey   on    the    same    program.    I    am   to include the patient.                              I  think  there  is  a  major   problem   for   us
                         ter get used to it and adapt to it             and   not   a   lexicographer,   but   I    think    the
                         try   and   meet   the    new    temperature    of   word should be not "mix", but               "cour-   It is a  good  law.  It    was    a    good    la@   to  consider   with   respect   to   the   sharing
                         our times.                                                                                                                                                     of   information   from   one   region   to    an-
                                                                              age."     Semantics     aside,     Public      Law   when it was written.       And  I  think   it   is   other.
                         I  think  I  have  said   enough   for   the   mo-   89-239   has   other   virtues    than    clarity,   the  good  fortune   of   the   people   at   this
                         ment.                                                brevity  and  conciseness.       It    places    a   conference   to   make   it   a   good   law    in   And   another   of    the    problems    is    the
                                                                              new emphasis and a new           direction      on   practice,   not   by   accident,   but   by    de-   one   that   Paul   Yivisaker    has    mentioned,
                         MR. WHALEY: A member of the                Nation-   local responsibility for the     health   of   all   sign.                                                the   regions   within   a   major   urban   area.
                         al Advisory Council who is  in             private   citizens.   Doctors   in   the   past   have   as-                                                        How   may    they    be    put    together?    How
                         practice   of   medicine    in    Ruston,    Loui-   sumed   this   responsibility   for   the    indi-   MR.   WHALEY:   I   am   sure   you   can   under-   mav    they    share    information?    What    is
                         siana, is Dr. Bruce Everist.                         gent    as    a    good    neighbor,    for    the   stand   now   that   it   was   truly    restraint   the     communication     across     these     re-
                         DR.   EVERIST:   I   would   like   to   ask   the   affluent  for  a   fee.   This   can   no   longer   on    my    part    when    I    refrained    from   gions?
                         indulgence   of   this    audience,    and    some   obtain   for   the   poor    for    our    current   mentioning  that   Dr.   Everist   is   the   poet
                                                                              concept   allows    for    equal    medical    at-   laureate   of   our    Council.    His    perform-   Now,   I   propose   this   as   a   major   issue
                         empathy   if   you   can   imagine    a    country                                                        ance  today  is  just  as   I   have   seen   many   about   which   we   on   the    National    Advi-
                         doctor   having   to    follow    one    of    the   tention   for   the   poor   as   for   the   rich.  times.  (I   have   applied   for   the   publica-   sory  Council  are  going   to   require   a   tre
                         most    honored      physicians       in       the   But as a right,  not  as  a  gift.
                                                                                                                                   tion   rights   of   the   gems   which   he   has   mendous     amount      of      feedback      from
                         country,   two   directors,   a   vice   president   I   have   no   doubt   but   that   this   change   dropped:    so    far     I     haven't     gotten   you  people.  You  will  note   that   this   pro-
                         and   a   commissioner.   It   is   obvious   that   can   be   made    by    local    physicians    in   them.)   Some   of   you    might    shudder    to   vision  is  not  in  the  law.  How   this   coop-
                         I can only be dilutely paraphrastic.                 concert   with   Government,    but    with    the   think   he   happened   to   be    the    reviewer   erative   arrangement   is   to   be    made    is
                         Public Law 89-239 is a good law,              new,   lines    of    responsibility    clearly    drawn.   of   your   application.   He   gets    to    tile   largely   going   to   depend   upon   you,    ob-
                         innovative, imaginative, and even           artis-   American    medicine       is         conservative   point.   I   am   sure   we   have   other    com-   viously   upon   us   at   the   National    Advi-
                         tic.  The   language   is   so   clear,   concise,   enough    to    resist    undue    pressure    and   ments    from    members     of     the     panel.   sory Council level as well.
                         42









             MR. WHALEY: Thank you, Dr. Howell.                lice  Review  Board  is  a  warning  in   point   porting  back  to  them   about   the   activi-
             Others?  Do   you   have   questions   fr-OT-Ti   that  no  one  group  is  probably   going   to   ties.   Among   these   are   this   particular                  TRIBUTE TO
                                                               accept  this,  but  probably  you   will   have   request  that   we   return   to   Congress   a
             the  audience   for   just   a   few   minutes?   an overview.                                      statement   of   the    relationship    between          JOHN     EDWARD FOGARTY
             We have about 10 to 12 minutes.                                                                     Federal  financing   for   this   program   and     DR.  OLSON:   During   the    past    week,
             Yes.                                              Whether  this  is  adaptable   in   the   medi-   financing  from  other   sources   of   activi-     we   have    all    been    shocked     and
                                                               cal  field,  I  don't  know.  I   would   think
             QUESTIONER:   I   would   like   to   ask   Dr.   that  the  medical   profession,   seeing   the   ties.                                               grieved to   learn  of  the  death  of  Mr.
                                                                                                                                                                     Fogarty   who   has   had   such   a   deep
             Ylvisaker  with  whom  I  agree   entirely   in   trend  of  the  times,  might   begin   invent-   This,  of  course,  points   up   the   variety     interest  in   the   health   problems   of
             terms   of   being   consumer    oriented    or   ing   a   variant   of   the   Ombundsman   and   of  sources  of  financing  for   the   various     this  nation.   We    have    asked     Dr.
             market     consumer     oriented-Dr.      Trus,   to   begin   experimenting   with   it   before   medical  activities   that   we   are   engaged     Sidney  Farber  if  he   would   come   and
             sell  referred  to  it   as   the   environment   the public  might  foist  it  on  to  the  var-   in  today.  And   they   wanted   a   statement     pay tribute to Mr. Fogarty.
             in   which   the    fish    swim-whether    his   ious professional groups.                         indicating    what    sources     are     being     DR. FARBER:      Dr.   Olson    and    mem-
             reference     to     the     Ombundsman     and                                                     used.  And  I  think  it  is   important   also     bers  of the    Conference:    Just     one
             consumer     complaint     bureau     was     a   So,  as  I  say,  yes  and  no.  I  am  talking   to  point  out  that  there   are   non-Federal     week  ago   today,   we   lost   John   Ed-
             figure   of   speech   which   he   used   with   about   a   wave,   a   concept,   a    demand,
             something   more   explicit   in   mind.    And   but  I  am  feeling  my  way  in  the  institu-   sources   of   financing   that    are    being     ward   Fogarty,   longtime   chairman    of
                                                               tion.                                             used   in   this   program,   the   extent   of     the     Committee     of     Appropriations
             if  he   had   something   more   explicit   in                                                     which  is   sometimes   difficult   to   deter-     concerned   particularly    with    matters
             mind,  would  he  be  good   enough   to   tell   MR.  WHALEY: Other questions?                     mine,  but  it  would   be   certainly   highly     of health and education.
             us what he had?                                   QUESTIONER:    What    type    of     construc-   desirable  in  your  own   thinking   in   your     There   are   some   in   this   room   who
                                                                                                                                                                     knew  him  as  a  devoted   friend.   There
             DR. YLVISAKER:      Yes andno.                    tion  did  -Dr.  DeBakey  have  in   mind   be-   own  regions  to  try   and   make   some   es,     are  many   more   who   had   the   privi-
             I  have  been  interested  to  see   how   this   ing built into this law?                          timate  of  this.  Because,  for   one   thing,     lege  of  appear4ng   before   him   as   a
             Ombundsman         concept      has       begun                                                     it is  important  to  maintain  it.  And  in  a     citizen  witness  and   learned   then   of
             sweeping  the                                     DR.  DEBAKEY:  Well,  actually,  I   think   it   sense, it  is  part  of  the  partnership  that     his  great  integrity,   his   deep   devo-
                               country.   Inside   of    ten   might   be   best   described   as    construc-   exists.                                             tion,  his  compassion  and,   above   all,
             years,   it   has   gone   from,   you    know,   tion  that  is  essential  or  needed  to  car,   So   I   think   Congress   would   take   some     his  great  knowledge  of  the   needs   of
             where  did  that  come  from,   to   almost   a   rying   out   the    program,    wherever    it   interest  in  having   information   on   these     the   country   for,   medical    research,
             common  figure   of   speech   in   the   Unit-                                                                                                         training and care.
             ed  States.  It   is   being   adopted   in   a   may     be-affiliated     institutions,     the   aspects of the financing.                           I  believe  it  can  be  said  without   ex
             number   of   jurisdictions,   in   Long    Is-   center  itself,  and  so  on.  It  is   related   MR. WHALEY: Our time          has  run  out.  I     aggeration  that  no  man   in   the   his-
             land,  as  I  recall,  in  one   of   the   New   primarily  to  program   activities   such   as   had   written   down   a   few   comments    on     tory   of   the   House   of    Representa-
                                                               those   related   to   continuing    education,
             York   suburban   counties.   And    I    think                                                       e remarks of each of        our    panelists,     tives  has  made  a  contribution  to   the
             you     wIill   see   probably    many    munici- those  related  to   demonstration   of   care,   th
                                                                                                                 but in  the  words  of  Dr.  Everist,  I  don't     health  of  -the  country   as   great   as
             palities adopt it  very  shortly.  It  will  be   those  related   to   administration   of   the   wish   to   be   dilutely   paraphrastic    be-     that   made    by    Mr.    Fogarty.    The
                                                               program, and so on.                                                                                   enormity  of  his  contributions  will   be
             an experiential thing. It will grow.                                                                cause  it  would  ruin  the  very  fine  state-     felt  all  over  this  country   and   over
             There  are   several   things   about   it   to   , would  say  that  this  type   of   construc-   ments which we have had.                            the  world   for   generations   to   come.
             keep in mind.                                     tion  is  pretty   hard   to   come   by   from   So,   members   of   the   panel,   the    deep     It was felt  proper  that  all  of  us  who
                                                               other    sources-that    is,     from     other   appreciation  from   all   of   us   for   what     had   benefited   so    much    from    his
             One is  that  there  is  a  public  receptivity   financing.  And  speaking   of   that,   if   I                                                       labors  might  stand  for   a   moment   in
                                                                                                                 you have done.
                                                                                                  om nts,                                                            his memory.
             to   the   idea   of   a   consumer   complaint   might just take a few more m           e      I   (Applause)
             mechanism.   Second,   that   they   are    not   would  call  your   attention   to   the   fact                                                       (The group stood in silence.)
             satisfied to  start  in  one  field.  The  fact   that  there  is  written  into  the  law   cer-
             that   you   overthrew   the   New   York   Po-   tain  interests  that  Congress  had   in   re-

                                                                                                                                                                                                              43







                                                                                                                  The   second   we    hope    yoti    will    make discussion group for this final         ion.
              DR.   OLSON:   This   concludes   the    final   We  are  deeply  grateful   for   your   pres-                                                                                       sess
              plenary  session  of   the   conference.   The   ence   and   for   your   contributions.    We     after    you    have    returned     home     and I met Dr. Pellegrino  in  the  corridor  as  1
              attendance   has   been   a   splendid    one.   would  ask   that   you   make   two   further     have   had   an   opportunity   to   reflect   on was  coming  into  the  hall   this   morning.
              We   have   had   approximately   650   regis-   contributions.                                     the   matters   you   have   had    under    dis- He  said,  "Stan,  is  there   anything   spe-
              trations.  We  have   had   outstanding   reP-   The  first  you  will  make  in  the   discus-     cussion   these   past   two   days.   I    would cial  you  want   out   of   this   discussion
              resentatives  of  the  health  field  both  on   sion sessions   to  which  you  will   adjourn     hope   you   would   write   to    Dr.    Marston group?"  And  I  commented      that      he
              the platform and in the audience.                in just a moment.                                  and   give   him   your    considered    judgment ought  to   use   his   judgment;   that   the
                                                                                                                  about   any   aspect   of   the    program    you discussion   group   should   feel   free   to
                                                                                                                  consider   to    be     important             and pursue   anything    it    wanted    and    in
                                                                                                                  significant.                                    depth. I told him we had had      plenty    of
                                                                                                                                                                  breadth  in  the  last  couple    of     days,
                                                                                                                  Dr. Farber made   reference    to    the    capa- what we needed now was some depth.
                                                                                                                  ble,  dedicated  and   loyal   staff   that   Dr.
                                                                                                                  Marston   has   developed   in    the    Division So  I  would  hope   that   participants   and
                                                                                                                  of   Regional   Medical    Programs.    I    have chairmen    alike    would    address    them-
                                                                                                                  come  to  know   this   staff   and   their   ca- selves  to  the  issues  that  have  been   so
                                                                                                                  pabilities  in  the   past   seven   weeks   that ably    presented    here this    morning    and
                                                                                                                  I  have   been   associated   with   the   prepa- that   you   will    come to   your   own   con-
                                                                                                                  ration  of  this  conference.   I   should   like clusions  about  what  is   right   with   the
                                                                                                                  to take just a  momen                   recognize law,   what   is   wrong' what   needs   to   be
                                                                                                                  several   people   that   have    performed    in retained,   what    needs to be changed.
                                                                                                                  an outstanding fashion.                         Dr.  Marston,  is   there anything   you    want
                                                                                                                                                                  to add?
                                                                                                                  These   are   Mrs.   Judy   Silsbee,   Mr.    Ly-
                                                                                                                  man   Van    Nostrand,    Mr.    Edward    Fried- DR.     MARSTON:      No.
                                                                                                                  lander,   Miss   Dale   Carter,    Mr.    Charles DR.  OLSON:  I  would   just   like   to   say
                                                                                                                  Hilsenroth,   Mr.   Stillman   Wright   and   Dr. this   has   been   a   wonderful   experience
                                                                                                                  John Hamilton.                                  for  me  to  work  with  Dr.  Marston.  And  I
                                                                                                                  In   addition,   as   you   know,    the    staff hope  that  many  of   you   have   an   equal
                                                                                                                  has  served  as   recorders   for   the   discus- opportunity  to  get  to   know   him   as   I
                                                                                                                  sion    sessions.    The    stenographers    have have.
                                                                                                                  worked,   some   until    one    o'clock,    some Thank you.
                                                                                                                  all  night,  to  get  out  the   various   things
                                                                                                                  that   were    needed    for    the    conference
                                                                                                                  program and registration.
                                                                                                                  I  should  like  to  ask  the   staff   that   is
                                                                                                                  here  to  stand   so   that   we   might   recog-
                                                                                                                  nize   their   very   significant   contribution.
                                                                                                                  (Applause)
                                                                                                                  I  would  call  your  attention   to   the   fact
                                                                                                                  that  you  will  be  going   into   a   different


                  44







                                                                                            Section III-Issue Papers



                                                                                                                                       Four  Issue  Papers  were   prepared   to
                                                                                            Cooperative Arrangements                   provide a focus  for  discussion.  "These
                                                                                            Program Evaluation                         are not the only issues calling  for  at-
                                                                                                                                       tention, but, certainly, these are  areas
                                                                                            Continuing Education                       of  common  concern.  .  .  "  said   Dr.
                                                                                            Surgeon General's Report                   Marston in his Conference speech.









































                                                                                                                                                                              45





                The Development of
                Cooperative Arrangements

                Prepared by the staff of the  Division  of    for its superiority  over  systems  estab-   ternist - pediatrician - psychiatrist,  and  the  hopes  and   aspirations   of   physi-
                Regional   Medical   Programs   as   back-    lished by government and welfare.            other mixtures. If the profession  fulfills  cians.
                ground to  the  first  discussion  session    ,Evaluations   could   be   made   of   the  its promises, there will  be  new  and  in-  "As  I  finish  this  chapter   after   six
                                                              needs of the public for medical  care,  of   creased efforts to  keep  people  well,  an  months   of   struggle   and    interrupted
                In  an  editorial  in  the  November   23,    the kinds of  services  required,  and  of   emphasis  on  health   rather   than   dis-  effort, I am at my desk,  having  just  re-
                1962  issue  of   Science,   Dael   Wolfie    the  numbers  and  kinds   of   physicians   ease,   an   augmentation   and   an    en-  turned from  seeing  a  patient  with  dis-
                pointed out that  honesty  and  objectivi.    and   institutions   needed   to   provide   hancement  of  the  field   of   preventive  seminated  tupus   erythematosus   who   is
                ty,  reliance  on  the   evidence   rather    these services.  Based  on  these  evalua-   medicine.                                    alive  and  at  the  moment  well   because
                than upon bias, wish, authority,  or  per.    tions, educators could  construct  curric-   "The  greatest  challenge  of  the  present  of the  miracle  of  medical  progress.  In
                sonal advantage, is one  of  the  greatest    ula to deliver graduates  consistent  with   is inherent in the job description of  this  recalling  her  happiness  and   the   took
                gifts,hat science has  given  to  society.    modern   requirements.   Community    hos-   physician, who  must  feel   the   signifi-  of  fondness   and   gratitude   she   gave
                A goal of  the  groups  applying  for  Re.    pitals could  continue  to  employ  direc-   cance  and  importance  of   his   practice  me, I  cannot  help  reaching  out  in  ap-
                gional Medical Programs  is  to  work  to-    tors  of  medical  education  required  to   and must  believe  in  his  unique  ability  preciation   to   those    persons,    some
                ward meaningful relations  which  will  be    provide  excellent  training  programs  of   as a  true  specialist  to  perform  duties  known   to    me    and    many    unknown,
                based   on   objective   data   and   real    perhaps  a  different  character  but   of   that others in  the  more  narrow  special-  whose  efforts  have  permitted  me   this,
                needs.  There   has   been   concern   for    quality equal to those in  the  university   ties  might  find  impossible.   Under   no  the  supreme  reward  of   the   physician.
                some  years   because   health   resources    centers.  Differences  between  university   other circumstance  will  there  be  effec-
                and   organizations   with    nonidentical    hospitals    and    community    hospitals   tive  competition  to   careers   in   sub-  "A  moment's  reflection   will   show   us
                but related  and  overlapping  goals  have    would  disappear  in   the   collaborative   specialism.  The  divisive  forces  in  the  what we all must know:  we  are  not  self-
                often  not  been  able  to  work  together    efforts to  train  interns  and  residents   profession    of    medicine     themselves  sufficient,  even  as  an  individual   one
                effectively or to seek joint solutions  to    through an  interchange  of  teachers  and   point  up  the   interdependence   of   its  does not practice alone."
                new problems.                                 trainees, the sites to  be  determined  by   parts and the  real  need  for  cooperative
                                                         .    the  competence  of   the   hospitals   to   effort.  With  such  a  sincere  effort   I  Congress  and  others   involved   in   the
                Many  have   defined   the   problem   and    satisfy the  future  service  requirements   would predict  that  our  intraprofessionai  development  of   Regional   Medical   Pro-
                have offered a logical  solution.  A  fine    of the trainees.                             differences would disappear.                 grams  were  convinced  with   Dr.   Hudson
                example is given in the  following  state-                                                                                              that  individuals  and  even   institutions
                ment by  Dr.  Charles  L.  Hudson  at  the    "The inevitable centralization  of  knowl-   "Numerous  unilateral   attempts   at   ad-  cannot  cope  with  the   complexities   of
                1962  Teaching  Institute  of  the   Asso-    edge and  techniques  with  stratification   justment   of   medical    practice    have  modern  medicine   in   isolation.   Public
                ciation  of  American  Medical   Colleges:    according  to  levels  of  knowledge   and   failed,  because   any   undertaking   that  Law   89-239,   which   authorizes   grants
                "A  restoration  of  harmony   among   the    competence     would     continue,     but   seeks to alter the  position  of  one  ele,  for  the  planning  and  establishment   of
                elements involved  could  be  effected  by    equally  important  would  be  the   areas   ment,  without  regard  to  the  effect  on  Regional  Medical    -Programs,      begins
                a  sincere  collaboration   among   physi-    manned  by  the   physician   with   broad   the  integrated  system,  causes   unhappi-  with  the  following  two   statements   of
                cians  as  physicians,  in  teaching   and    training.  His  primary  contributions  to   ness  and  strife  in  the  whole   profes-  purpose:
                research, in training of interns  and-resi    the system  would  be  in  medicine,  with   sional  complex  and  will   increase   its  0  To  encourage  and  assist  in  the  es-
                dents, and in patient care  in  the  'nos-    occasional  exceptional  additions   where   susceptibility  to   outside   interference  tablishment  of  regional  cooperative  ar.
                                                              circumstances required them.                 and even domination.
                pital and in the office. This,  an  educa-                                                                                              rangements    among    medical     schools,
                tion  and  practice  complex,   could   be    "The  key  to  success  of  an  integrated   "As  to  the  medical  practice  of  tomor-  research  institutions  and  hospitals  for
                formed  if  physicians  were  willing,  if    medical  practice  would  be  the   proper   row-if   intelligence,   good   will,   and  research  and  training   (including   con-
                necessary,  to  surrender  some   preroga-    identification  of   the   physician   now   technological  advances  exert  their   po-  tinuing   education)   and   for    related
                tives  in  the  interest  of  creating  an    sometimes  referred  to  as  the   general   tent   force-the   changes   should   hope-  demonstrations  of  patient  care  in   the
                effective  private  medical  care   system    practitioner, personal  physician,  family   fully go in the direction  of  better  care  fields of heart  disease,  cancer,  stroke,
                that would be  recognized  by  the  public    physician,  first-contact  physician,  in-   for the sick  and  greater  fulfillment  of  and related diseases.

                46











           0  To  afford  to   the   medical   profession   vanced     capabilities,      private   practi-
           and  medical  institutions  of   the   Nation,   tioners,    community       hospitals,      and
           through       such  cooperative        arrange   other    interested    private    and    public
           ments,  the  opportunity  of   making   avail-   agencies       throughout       a       Region.
           able  to  their  patients   the   latest   ad-   Through     such     channels,      information
           vances  in   the   diagnosis   and   treatment   and   assistance   can   be   moved   out    to
           of these diseases.                               upgrade  and   maintain   daily   practice   at
                                                            the   highest   possible   level.   The    same
           Other sections of    the  law  and  the   leg-   local  groups   can   feed   back   information
           islative  history  that  led  to  its   enact-   on  needs  as   a   basis   for   further   re-
           ment   indicate   that    all    organizations   search  and  training.        In   this    way,
           and   groups    concerned    with    realizing
                                                            science  and   service   may   be   linked   in
           these  purposes  are   to   be   included   as   systems      of    mutual     support       and
           an  integral  part  of  the  cooperative   ar-   benefit.
           rangements.   These   include,   in   addition
           to  those  identified   above,   medical   so.   In  the   development    of    the     )rogram,
           cieties,   health    departments,    voluntary   emphasis   has   been   continuous   y   placed
           agencies,   other   health   professions   and   upon   its   cooperative   and   c(   ntrifugal
           individuals  concerned   with   health.   Sec.   features.  It  is  believed  that   t,e   exten-
           tion  903  specifically  provides   that   the   sion  of  excellence  in  health  care  to  all
                                                            parts  of  a  Region  can  be  facilitated   by
           Regional    Advisory    Groups     must     be
           "broadly   representative"   and   must    ap.   bringing  together  all  the   major   institu-
           prove    applications     for      operational   tions   and   interests   for   planning    and
           grants.                                          action.  The  product   of   the   efforts   of                                                  A
                                                            organizations   working   together    can    be
           The   Program   Guidelines    emphasize    the   much  greater  than  the  sum   of   the   sep-
           essential   importance   of   regional   coop-   arate  efforts.   As   the   President's   Com-
           erative  arrangements        among       these   mission   on   Heart   Disease,   Cancer,   and
           groups    throughout    the    planning    and   Stroke  pointed  out:  "A   creative   partner-
           operational    phases    of    the    Regional   ship  among  all  our  health   resources   ...
           Medical   Programs.   While   it   is   recog-   is  the  true   path   to   the   conquest   of
           nized   that   the   full    development    Of   heart disease, cancer, and stroke."
           such   arrangements   involves    all    medi-   During  the  first  year  of  the  program,   a
           cal   institutions'organizations   and   indi-   great  deal   of   emphasis   was   placed   on
           viduals  within  a  Region,   and   may   take   the     term     "cooperative     arrangements"
           considerable  time,  the  initiation  of  this   ,
           effort is  a  critical  aspect  of  the  plan-   DOth  by  the  applicants  and   by   the   re-
           ning   process   for   a   Regional    Medical   viewing    groups.    One    applicant,     who
           Program.                                         was  also  a   consultant   to   the   program,
                                                            stated   that   in   the    strictest    sense,
           "Cooperative     arrangements"     are     in-   justification  of  the   program   would   rest
           tended  to   facilitate   effective   exchange   on  the  ability   to   demonstrate   the   de-
           of   information   and   ideas   and   working   velopment      of   cooperative        arrange-
           relationships    among    centers    of    ad-   ments  where  they   had   not   existed   pre-

                                                                                                                                                                                                          47








                    viously.   All   have   agreed   that   the  complex    problems    which    cannot    be   made  on  a  basis  of   the   wisdom   and   C. Commitment  of  effort  by  individuals,
                    documentation  of  this   aspect   of   the  met  by  individual  institutions   or   or-   experience  of  the  participants  and  the   organizations and institutions
                    program  is  an   appropriate   accomplish-  ganizations. In  the  early  stages,  it  is   advisory   groups.    A    primary     goal   II. Regional Medical  Program  vs.  collec-
                    ment  to  report  to  the   President   and  inevitable  that  most  decisions  will   be   should be,  as Wolfie  suggests,  to  begin   tion of projects
                    Congress.                                                                                   by  establishing  mechanisms   which   will   .A.  Relevant  characteristics  of  Regional
                    The   requirement   for   the   development                                                 allow the substitution of  objectivity  for   Medical  Program  on   which   this   judg-
                    of   regional   cooperative    arrangements                                                 bias, and data for wish or authority.         ment can be made
                    was  the  major   factor   in   determining                                                 Some  insight  into  the  problems  to   be   1.  Overall  leadership  and  guiding  phi-
                    the  sizes  and  shapes   of   Regions   as                                                 anticipated in the  future  can  be  gained   losophy
                    various parts of  the  country  probed  for                                                 from a  study  of  the  issues  which  have   a. Is there a  unifying  conceptual  strat-
                    what  seemed  to  be  the   best   workable                                                 arisen in the review of  the  early  opera-   egy which will be  the  basis  for  initial
                    conditions.  A   part   of   the   planning                                                 tional applications.                          priorities  of  action,   evaluation,   and
                    process will be to reexamine the      ' fac-                                                A primary goal  of  Public  Law  89-239  is   future  decision  making?  Are  there  suf-
                    tors that lead to  the  conclusion  that  a                                                 the   establishment   of    decision-making   ficient feedback  loops  in  the  strategy?
                    given Region  offers  the  best  opportuni-                                                 mechanisms  on  the   local   level   which   b.  Is  there  an  administrative   mechan-
                    ties  for  effective  utilization  of   re-                                                 assumes  that  different  priorities  exist   ism which can:
                    sources.  In  some   instances,   political                                                 in  different  parts  of  the  country.  On   0 make decisions
                    considerations   may   have   deserved    a                                                 the  other  hand,  neither   the   National   0 relate to regional needs
                    relatively higher priority  in  the  estab-                                                 Advisory  Council  nor  the  Public  Health   0  stimulate   cooperative   effort   among
                    lishment of  an  application  for  a  plan-                                                 Service  can  delegate  their   basic   re-   major health interests
                    ning grant  than  will  be  the  case  with                                                 sponsibility  and    accountability    that   C. Are the  key  leadership  persons  iden-
                    regard to operational  grants.  In  others,                                                 Federal funds will be expended wisely-        tified?  Do  they  work  with   the   major
                    deficiencies  of  resources   may   require                                                 A   number   of   Regional   Medical   Pro-   health  interests?  Do  they  have  experi-
                    the   development   of   cooperative    ar-                                                 grams  have  submitted   applications   for   ence and  skills  appropriate  for  provid-
                    rangements  across  great   distances,   at                                                 operational  grants  which  are   currently   ing  leadership  to  a  complex   endeavor?
                    least   for   Interim   purposes.    Almost                                                 being  reviewed.  These   applicants,   the   d.  Is  there   involvement   and   commit-
                    surely,  close  relationships  between  ad-                                                 Review   Committee,   the   Council,    and   ment of the  major  health  interests  such
                    jacent Regions will prove beneficial  .  An                                                 staff have identified issues in  the  proc-   as:
                    editorial in the  August  12,  1966,  issue                                                 ess of  working  with  these  applications.
                    of The  Journal  of  the  American  Medical                                                 The following  list  is  not  meant  to  be   'D Medical schools
                    Association   comments   that   cooperative                                                 complete, for future  grant  requests  will   0 Practicing physicians
                    arrangements  within   Regions   seem   as-                                                 bring  out  additional  issues,   and   one   0 Hospitals
                    sured  and  that  the  next   question   is                                                 could  speculate  that  still  others  will   0 Public health agencies
                    whether  such  cooperation  can  exist  be-                                                 a ri se:                                      e.  Will  the  ongoing   planning   process
                    tween Regions.                                                                                                                        .   interact with the first  operational  steps
                    The   development   of   cooperative    ar-                                                 1.  Characteristics  of  early  operational   in  the  development  of  a  program   that
                    rangements   requires   organization    and                                                 proposals                                     meets  the  broader  needs  of  the  entire
                                                                                                                A.  Many   projects   contained   in   each   region?
                    communication,   sharing   of    resources,
                    ability to reach joint decisions,  and  the                                                 complex proposal                              2. Nature  and  interrelationship  of  spe-
                    development     of   the   capability    to                                                 B.  Sizable  budget   requests,   including   cific  proposed  activities  in  regard  to
                    evolve  new  and  creative  approaches   to                                                 large hardware requests                       the goals of PL 89-239

                    48






                                                                                                             Evaluation of Medical Care
                                                                                                             Under Public Law 89-239

          B.   Evidence   that   priorities   have   been   erational   activities   as    necessary    for  Paul J. Sanazaro, M.D.                             in  the  quality  of  care.  For  example,  in-
          set at the regional level                         further     development,     extension,     and  Director, Division of Education                    creasing  the   number   of   trained   person-
          Ill. Quality standards                            solidification    of    regional    cooperative  Association of American Medical                    nel   or   providing   specialized   facilities
                                                            arrangements                                     Colleges                                           and  services  in   areas   where   these   are
          A. Regional vs. National standards                VI. Length of  commitment                        Chairman, Health Services Research                 marginal   or   nonexistent   constitutes,   on
          B.   Emphasis   on   grantees'   own    evalua-                                                    Study Section, Public Health Service               the  face  of  it,   a   distinct   improvement
          tion   mechanisms    as    quality    uplifting   A.  Degree  of  emphasis  to   be   placed   on  Consultant, Division of Regional                   in  the  quality  of  care.  In   this   sense,
          factor at regional level                          self-limiting nature of projects                 Medical Programs                                   evaluation   of   a   Regional   Medical   Pro-
          IV.  Criteria   for   judging   appropriateness   B.   Need    for    long    range    commitment                                                     gram   can   be    directly    comparable    to
          of support                                        for  "core"  activities  which  are   essential  Prepared   as   background   to    the    second   evaluating the quality of care.
          A.   Scope   and   limitations   of    Regional   investment  for  conduct  of   specific   proj-  discussion session                                     term    "medical    care"    has    several
                                                            ects                                                                                                The
          Medical   Programs    legislative    authority,                                                    Evaluation  in  the  field   of   medical   care   unique     meanings       depending          on
          including categorical focus                       VII.   Relationship   of    operational    pro-  consists   first   in   collecting   information   whether  it  is  defined  as  a   process,   as
          B.  Availability  of  other  sources  of   sup-   posals   to   ongoing    planning    activities  on  the  operations   and   end-results   of   a   a system,  or  as  an  area  of  study.  It  is
          port                                              A.  Need   for   documentation   of   relation-  program,    then    making     judgments     re-   also   analyzed   in   different    ways    de-
          C.  Priority   on   innovative   and   leverage   ship                                             garding   the   effectiveness   and   efficiency   pending    on    whether     individual     pa-
          effects                                           B.  Extent  of  prior  planning  and  its   re-  of    the    programs    or    services    under   tients,  a  community,  or   the   entire   Na-
                                                            lationship   to   proposed    operations    and  study   with   respect   to   both    individual   tion  are   the   recipients.   The   following
          V.  Criteria  for  judging  level  of   support   continued planning                               patients   and   communities.   On   a    short-   components  of   medical   care   are   partic-
          A.    Geographic    distribution    -    Should   C.  Extent  to   which   needs   of   periphery  term   basis,   evaluation   identifies    need-   ularly  relevant   to   the   evaluation'of   a
          consideration   of   availability   of    funds   of the region need     to     be     documented  ed   revisions   and    improvements    in    an   Regional Program:
          for  later  proposals  be  a  part   of   deci-   as   basis    for    undertaking    operational  operating   program.   Its    long-term    func-   0  Supply  or  availability  of   health   care
          sion  on  amount  awarded   to   first   appli-   activities                                       tion  is  to  provide  a   rational   base   for   personnel,  facilities,   and   services,   in-
          cants?                                            Vill.  Need  to  spell  out  relations                   policy    decisions    governing     the   cluding preventive measures.
          B.  Partial  or   phased   support   as   mech-                                               @ip  =       directions   of   such    programs    or   0   Utilization   of   personnel,   facilities,
                                                            with   adjacent   regions   and   to    justify  services.   When   conducted   with    a    high   and   services,     including        preventive
          anism for:                                        the proposed region                              order   of   technical    competence,    evalua.   measures,    by    individual    patients    or
          1.  Allowing  fuller   development   of   plans   IX.   Adequacy   of   administrative   arrange-  tion    may    also    contribute    substantive   population groups.
          before   proceeding   to   fuller   implementa-   ments,    including    fiscal    accountability  knowledge  to  the   field   of   health   serv-   0   Process   of   patient    care:    accuracy
          tion                                              of grantee                                       ices   research   and   is    then    designated   of   diagnosis,    adequacy    of    treatment,
          2.  Permitting   better   decisions   on   dis-   Examples   such   as    these    coming    from  as evaluation research.                            and  appropriate   utilization   of   consulta-
          tribution of funds                                early   operational   grant    requests,    and  A   distinction   exists   between    evaluating   tive  resources   and   specialized   technical
          3.  Early review of progress                  4:  others  yet   to   come,   will   continue   to  a   Regional   Medical   Program   and    evalu-   services.
          C.  Need  to   support   "critical   mass"   0.   test  the   workability   of   developing   co-  ating   medical   care.   Public   Law    89-239   0  End  results:   the   effectiveness   of   a
          activity  which  will  have  a  sufficient  im-   operative    arrangements    over    a     wide  and   the   Guidelines   emphasize    the    de-   treatment    or    program    as     determined
          pact to permit evaluation of results              range  of   activities.   The   first   Confer-  livery  of  medical  care,  i.e.   the   person-   by  the   consequences   for   the   individual
          D. Support of costly activities as          na-   ence  discussion   session   is   directed   at  nel,   facilities,   services,   and   resources   patient   or    population,    including    ex-
          tional   or   interregional   resources    when   reviewing   experiences   in    the    develop-  necessary    to    improve     diagnosis     and   pressed  views  of   patients   and   potential
          justified  by   the   involvement   of   unique   ment  of   these   regional   cooperative   ar-  treatment.    However,    only    in     certain   patients  toward  the  availability   and   ac-
          capabilities  in  a  specific  Regional   Medi-   rangements   and    considering    plans    for  limited   situations   will    increasing    the   ceptability,of medical care.
          cal Program                                       extending    and    modifying     these     ar-  capabilities   for   delivering   medical   care   0   Unmet   needs:   individual   patients   or
          E.  Extent  of  need   for   support   of   op-   rangements in the future.                        automatically     assure     an      improvement   population  groups   with   identifiable   dis-
                                                                                                                                                                                                             49








                                                                                                                                                        the only  objective  of  the  program,  then
              eases  not  yet  diagnosed,  or   diagnosed                                                                                               the  evaluation  of   this   program   rests
              but not under treatment.                                                                                                                  entirely on  the  fact  that  ten  rehabili-
              In  a  limited,  technical  sense  the  re.                                                                                               tation  aides  were  or  were  not  trained.
              quirements  for   evaluating   a   Regional                                                                                               By analogy, this  level  of  evaluation  ap-
              Medical  Program   in   accord   with   the                                                                                               plies  to  the  establishment  of   special-
              stated  purposes  of  Public   Law   89-239                                                                                               ized  patient  care   units,   demonstration
              can  be  met  by  limiting  the  evaluation                                                                                               programs,   diagnostic   or        treatment
              of medical care  to  its  first  component,                                                                                               services, and  so  on.  The  fact  of  their
              supply or  availability.  However,       in                                                                                               establishment   provides    the    necessary
              order  to  evaluate  the  effectiveness  of                                                                                               and   sufficient   information   needed   in
              the  increased  supply  of  personnel,  fa-                                                                                               judging  whether  or  not   the   objectives
              cilities,  and  services  and   their   im.                                                                                               were met.
              proved distribution,  it  is  necessary  to                                                                                               2.  Objective  description   and   analysis.
              include  the  other  components  of   medi-                                                                                               For  this  level,  descriptions  of   educa-
              cal  care:  utilization,  the  adequacy  of                                                                                               tion  and  training  programs,   facilities,
                                                     Its,
              diagnosis and treatment, end resu                                                                                                         services,  and  capabilities  of   personnel
                           needs.     The      assumption
              and  unmet                                                                                                                                are  compiled  in  accord  with   prevailing
              seems   warranted   that   the   law    was                                                                                               professional   concepts    and    standards.
              passed  with  the  implicit   belief   that                                                                                               For  example,   a   program   for   training
              there  would   be   demonstrable   improve-                                                                                               nurses  to   staff   coronary   care   units
              ment in the care, and  in  the  results  of                                                                                               should  be  described  in   terms   of   the
              care, of patients with the  specified  dis-                                                                                               functions  nurses  will   be   expected   to
              eases.  It  appears  to  be  a   legitimate                                                                                               perform  as  a  result  of  their  training.
              responsibility  of  those  conducting   Re-                                                                                                                  ill  have  been   defined
              gional  Medical   Programs   to   ascertain                                                                                               These functions w
                                                                                                                                                        by  appropriately   informed   and   experi-
              so far as  is  feasible  the  relationships                                                                                               enced  experts.  Evaluation  of  the  train-
              between    improved    h'ealth      manpower,                                                                                             ing program  will  be  directed  at  answer-
              facilities,  and  services  and  the  other                                                                                               ing   two   questions:    (1)   Has      the
              defined elements of medical care.                                                                                                         program   been  designed  in   accord   with
              As stated, evaluation  is  a  dual  process                                                                                               generally  accepted   principles   of   such
              of  data  collection  followed   by   judg-                                                                                               training? and  (2)  Was  the  program   car-
              ment.   Depending   upon   the   particular                                                                                               ried out  as   planned?   Descriptive   data
              program   or   services,   evaluation   may                                                                                               bearing  on   these   questions   must    be
              be carried out at varying  levels  of  pre-                                                                                               coilected   before   a   judgment   can   be
              cision  and  sophistication.  These  levels                                                                                               made.  Similarly,  with   respect   to   the
              will be described separately.                                                                                                             operation  of  coronary  care   units,   the
              1.  Evaluation  to  determine  whether  the                                                                                               basis  of  judgment  regarding  their   ade-
                                                                                                                                                        quacy  is  simply   an   accurate   descrip-
              stated  objectives  of  a  particular  pro-                                                                                               tion  of  the  services  which  these  units
              gram were  met.  If  the  stated  objective                                                                                               provide,  together  with  a  description  of
              of a program  is  to  train  ten  rehabili-
              tation  aides,  and  this  is  accepted  as                                                                                               their  overall  operation  and   administra-

              50








      tion.  These   descriptions   are   then   com-   the  adequacy  of  utilization  will  rest   on  or   program   element   are    achieved    eco-  the  next  step   can   be   taken.   The   se-
      pared   with   prevailing   professional    and   two    comparisons:    (1)    between     rates  nomically   in   terms    of    dollars,    man-  quence may be outlined as follows:
      administrative   judgments   of    what    con-   per  1,000  general   population   in   control  power,    time,    space,     and     resources.  1. Collection of information and data.
      stitutes   proper    staffing,    organization,   and    experimental    communities    or    be-  Competence      in      operations      research  0  Specification  in  detail  of   the   objec-
      resources,   and   administration   for   coro-   fore  and   after   the   introduction   of   a  and    economics    is    required.    Two    or  tives  of  ,  the   programs,   services,   and
      nary care units.                                  program   in   the    same    community,    and  more     training     programs     for     aides  end resu ts which are to be evaluated.
      3.  Evaluating  utilization  by   patients   or   (2)  between     utilization    rates       and  might    be    compared       to        discover  0   Establishing   the   criteria   on    which
                                                        known   prevalence   of   the    target    dis-  whether     comparable     skills     can     be
      populations.   The    question    of    whether   eases.                                           achieved    more     economically.     Appropri,  judgments will be based.
      or  how  the  improved  staffing,   facilities,                                         in    the  ate    economic    bases    are    needed     to  0   Designing   the   instruments    or    rec-
      and   services    bring    about    improvement   4. Evaluation  of improvement                    compare    these    programs    with    training  ords for data collection.
      in   medical   care    cannot    be    answered   patient,   care   process.   Direct    compari-  programs   which   produce    fully    qualified  0    Applying    the    appropriate     methods
      without   information   concerning   the   uti-   sons  on  a  controlled  basis   are   required                                                    for   collecting   the   relevant   descriptive
      lization   of   such   personnel,   facilities,   to   determine    changes    attributable    to  professional    personnel.    Similarly,     the  information with minimal bias.
      and   services    by    patients.    Two    ap-   the    program    in    accuracy    and       '  costs    of    establishing    and     operating     Statistical    analysis    and/or    summary
                                                                                                   corn
      proaches  are  possible.  Prior  to   the   in-   pleteness  of diagnoses,  adeq        uacy    of different   types   of   coronary   care   units  of descriptive information.
      stitution  of  the   program,   baseline   data   treatment     programs,     and     appropriate  need   to   be   compared   in    relation    to
                                                                                                         1.                                                0    Interpretation    and    comparison     of
      can   be   obtained    on    the    utilization   referral   of    patients    for    specialized  demonstrable      improvements      in       the
      rates  of  various   personnel   and   services   services.  This   level   of   evaluation   en-  outcomes  of  care   given   in   these   units.  results against agreed-upon criteria.
      by  all  persons  with   the   specified   dis-   compasses   the   techniques   of   the    med-  It  is  also  appropriate   to   compare   costs  11.    Judgments    regarding    adequacy    or
      eases  in  the   population   served   by   the   ical audit  in  office,  clinic,  and  hospital  and   staffing   economies    or    the    func-  inadequacy    of    program,    program    com-
      Regional  Program.   if   baseline   data   are   settings.                                        tional   efficiency    of    such    specialized  ponents, or results.
                                                                                                         units   with   an   at-large   monitoring   sys,  Quality,  effectiveness,  and   efficiency   of
      not   available,   a   comparison   group    of
      patients   to   whom    the    new    resources   5.  Evaluation  of  end  results.  This   level  tem   dispersed   throughout    the    hospital.  medical   care   cannot   be    measured    di-
      are  riot  available   must   be   studied   in   constitutes   the   definitive    measure    Of  The   critical   element   in    such    evalua'  rectly  in   standardized   units.   They   can
      order   to   determine   that   other   changes   effectiveness   of   personal   health    serv'  tions  is  an  agreed-upon   set   of   criteria  be   inferred   from   one   or   more   objec-
      totally  unrelated  to   the   Regional   Medi-   ices.   By   use   of   matched    populations,  of   adequacy   for   services   and   end   re-  tively   specifiable   indexes   derived   from
      cal   Program   have    not    brought    about   data  can   be   compiled   on   decreases   in  sults.  Only  then  can   the   relative   costs  established      professional        standards.
      equivalent   changes   in   utilization.   Both   interval    between    onset    Of     Symptoms  be rationally analyzed.                           These   indexes   can   serve   as   the   base
      approaches   require   the   use   of   edidem-   and   receipt   of   care;   end   results   of                                                 . .information  or  data  for  judging   the   de-
                                                        care;  prevention   of   complications;   alle.  7. Evaluation  of the      effectiveness      of
      iologic   methods   applied   to    probability   viation  or  reduction   of   disability;   im-  preventive measures.      This  is   the   most.  gree  to  which  a  program  or   its   results
      samples   of   general   populations.   It   is   provement   in    social    functioning;    in.  difficult  level  of  evaluation  since  it  at,  meet   or   do   not    meet    the    criteria
      inappropriate   both   in    terms    of    the   creased   longevity;   and   so   on.   Whereas  tempts    to    determine    the    extent    to  specified.    Judgments    of    quality    are
      overall  objectives  of   Public   Law   89-239   techniques  for   the   preceding   four   lev-  which   diseases   are   being   reduced,   con-  based   on   consensus   of   physicians    and
      and   correct   methodology   to   base   eval-   els  of  evaluation   are   well   worked   out  trolled,  or   eradicated   from   the   popula-  other   professional   personnel.    Effective-
      uation  on   changes   'in   the   numbers   or                                                    tion  by   the   application   of   pre.ve.ntive  ness   and   efficiency   of   a   program   or
      characteristics   of    only    patients    who   and  can  be  applied   in   pre-tested   form,                                            ogic    procedure    can    be     defined     somewhat
      receive     care.    Similar         approaches   the  determination  of  end  results  is  still  measures.    The    use    of     epidemiol       more   objectively,   because   data   can   be
                                                        under   research    and    development.          methods  is  also  essential   for   this   form
      are    necessary    to    determine     whether                                                    of evaluation.                                    collected    on    effectiveness,    and    the
      changes   in   frequency   of    duration    of   6.   Analysis   of   cost-effectiveness.   This                                                    dollar    and    manpower    investment     can
      hospitalization   for   equivalent    disorders   form   of    evaluation    focuses    on    the  Evaluation    is    a    sequential     process,  be    objectively    related    to     outcomes
      or    their    complications    are     brought   efficiency   of   a   program   and   questions  each   step   of   which   must   be   appropri-  (cost-effectiveness     analysis).     However,
      about   by    the    program.    Judgment    of   whether  the  results  of   a   given   program  ately   planned   and   carried    out    before  even   under   the   best   of   circumstances,
                                                                                                                                                                                                      51








                evaluation  is  a   difficult   and   demanding   cilities   through   education   and   training   made  to   the   evaluation   of   the   impact   methods  of   data   collection;   failure   to
                procedure,   especially   in   the   field   of   of   health   care   personnel    and    demon-   of   any   program   on   the   medical    care   specify  clearly  the   goals   and   end   re-
                personal health services.                         strations of patient care;                        system   and   on   the   quality   of    care.   sults  to  be  evaluated;  failure  to   estab-
                Section   908    of    Public    Law    89..239   0   extending   the    productive    interrela.   Study   of   one   component   of   the   medi-   lish   criteria   before   attempting   evalua-
                states  that  the  Report  to   the   President   tionships   of   extensive   research,   teach-   cal    care    system    will    not    provide   tion;   confusion      of   availability     of
                and   Congress   will   include   "an   apprai-   ing,  and  patient  care  activities  to   com-   sufficient   information   to   make   possible   services  with  utilization  or   with   actual
                sal  of  the  activities  assisted  under  this   munity      hospitals     and        practicing   wise    decisions     concerning         needed   patient   benefit;   inadequate    access    to
                title  in  the  light  of  their  effectiveness   physicians;                                       modifications   in   other    components    and   or  lack  of   availability   of   standardized
                in  carrying   out   the   purposes   of   this   0    creating    an    effective    environment   links.   The   evaluation   of   medical   care   rates   for   prevalence   and   incidence   of
                title."  On  page  65  in   the   first   para-   for    continuing    adaptation,     innovation   within    Regional     Medical         Programs   diseases.
                graph,   the   Guidelines    stipulate    that'   and    modification     without     interfering   must   be   comprehensive    in    scope    and   One   approach   of   proven   merit   is   the
                                                                                                                    long-range    in    perspective.    The    most
                "special  effort"  is  to  be  made  to  incor-   with    the    patterns    or    methods     of   productive  attack   on   this   problem   will   establishment  of   a   health   services   re-
                porate   evaluation   in   the   planning   and   financing   patient   care    or    professionsi  result  from  cooperative   efforts   by   uni-   search  unit,  a   form   of   an   operational
                operational     phases.     "Research      into   practice,  or  with   the   administration   or   versities  and   private   organizations   uti-   and  epidemiologic   research   unit,   as   an
                better    means    of     accomplishing     the   hospitals.                                        lizing   the   resources   of   a   number   of   integral  part  of  a  health   services   pro-
                purposes  and   objectives   of   the   Region-   It   is   legitimate   to   question    whether   units within the Public Health Service.           gram.   By   this   means,    an    administra-
                al  Medical   Program"   qualifies   for   sup-   augmenting   existing    patterns    for    the                                                     tive  mechanism   is   set   up   for   feeding
                port  in  an  operational   grant.   In   order                                                     Evaluation     as     Operational     Research.   the   results   of   evaluative   studies    to
                to  analyze  the  role  of  evaluation  in  the   organization   and   delivery    of    services                                                     those   who   must    make    decisions    gov-
                Regional  Medical  Programs,  it   will   first   wl 11   automatically    bring    about    maxi-  The    particular    form     of     evaluation
                                                                  mum    possible     improvements     in     the   which   is   undertaken   and   the   technical   erning    the    day-to-day    operations    of
                be   necessary   to    identify    the            health  of   the   population   in   proportion   competence   of   those    who    design    and   the   program   as   well   as    future    im-
                and   provisions   of    Public    Law        S=  to   available   knowledge   and    techniques.   conduct  the  study   are   essential   consid-   provements.    Given    long-term     responsi-
                which   have   implications   for   the    pur-   The  potential   impact   and   the   projected   erations.  In  addition,  failure  to   proper-   bilities,  such  units  are  more   likely   to
                pose,   scope,   level   and   limitations   of   total   investment    in    Regional    Medical   IY utilize or  apply  the  results  of  evalua-   develop    and    maintain    records     which
                evaluation.                                       Programs    are    such    that    considerable   tion  will  defeat  the   basic   purposes   of   cumulatively     become      more      valuable
                Within  Public  L@w   89-239   and   the   pub,   effort  should  be  devoted   to   the   devel-   evaluation,    namely,    to    improve    pro-   and   informative   because   of   the    docu-
                lished   Guidelines,   the   following    major   opment   of   standardized   data   on    inci.   grams    and    their     effectiveness     and   mentation   of   changes   over   time.    This
                categories  of  objectives   are   defined:       dence  and  prevalence  of  the   target   dis-   efficiency.                                       resource  is  not  likely   to   be   developed
                0  making  available  to  patients   the   [at-   eases   in   the   general    population    (as                                                     when   ad   hoc    evaluative    studies    are
                                                                                                                    Many   circumstances   may    vitiate    evalu-   carried  out   on   a   short-term   basis   by
                est   advances   in   prevention,    diagnosis,   described  in   paragraph   1,   page   16   of   ation   and   prevent   its   effective    con-   consultants    who    have    no     continuing
                treatment, and rehabilitation;                    the    Guidelines).    Furthermore,    signifi-   tribution   to   the   continual    improvement   responsibilities to the program.
                0   developing   more    effective    distribu-   cant    effort    should    be    devoted    to   of  programs.  The  list  of   potential   con-   Even   under   the   most   advantageous   cir-
                tion and utilization  of  all  types  of  medi.   analyses    of    factors    which    determine   taminating  factors  is   long.   It   includes
                cal resources;                                    the  degree  of   success   achieved   in   im-   such   factors   as   the    introduction    of   cumstances,    continuing     evaluation     of
                0 establishing      cooperative      arrange-     proving  the  delivery  of  medical   care   to   undue   bias   and   subjectivity   by    those   health   services    based    on    operational
                ments   among    medical    institutions    and   all persons who could benefit from it.            administratively    responsible     for     the   and    epidemiologic    research     encounters
                professions    to    overcome     fragmentation   It  is  only  by  using  techniques  of  evalu-   program;     resistance     of     professional   certain   problems   with   predictable   regu-
                and   insularity   and   meet   the   diversity   ation  which  link  together   personnel,   fa-   personnel   to   evaluation;   arbitrary    re-   larity. These will be listed briefly:
                of  needs,   resources,   and   existing   pat-   cilities,  services,   utilization,   end   re-   striction  of   the   limits   of   evaluation;   0   One   of   the   most   important    poten-
                terns  of  education   and   services;            sults,  and  cost-effectiveness        analyses   changes  in  the  program  while  it   is   be-   tial  contributions  of   evaluation   is   the
                0   improving   health   manpower    and    fa-   that   an   approach   can    begin    to    be   ing    evaluated;    use    of    inappropriate   analysis  of  alternate   approaches   to   the

                52








          attainment   of    program    objectives.    Very   when     cumulative     evaluation,     studies,   this   decision   was   made   when   the    par-  Medical    School     Departments     of     Pre-
          often   the   decision   at    issue    is    not   reports,  and     research      have        both   ticular    program    was    instituted.    None-  ventive   Medicine   and   a   few   other   uni-
          whether   a   particular   program   in    opera-   defined   the   system   and    its    component   theless,   it   is   legitimate    to    subsume,  versity   departments,       medical         care
          tion  is  effective   but   whether   an   alter-   parts   and   related   their   operations    to   under    evaluation,     questions     concerning  research  units  have  developed            well-
          nate   program   might   be    more    effective.   objectively   specifiable   effects.   In   this   the   appropriateness   of   the    program    in  qualified  faculties  in  medical            care
          To   base   evaluation   upon   an   all-or-noth-   period,   the    data    base    becomes    more   terms  of  the   cultural   attributes   of   the  and   patient   care   research,   health    eco-
          ing   answer   for   an   entire    program    is   important     in     supporting      operational   area   or   population   and    the    likelihood  nomics,     medical     sociology,     operations
          much    less    productive     than     providing   decisions   than    empirical    judgments    of   that   elements   of   the   program   might   be  research   and    systems    analysis,    epidem-
          alternate      program      components      which   administrators.                                    applicable   to   other   areas    and    popula-  iology,     demography,     health,      services
          can    be    independently     evaluated     with   Many    Regional    Medical     Programs     are   tions.   The   methods   used   must   take   in-  statistics,    and    medical    care    adminis-
          respect     to     their     consequences     and   in  the  first  stage.  It  will  be  some  time   to   careful   account   the   possibility   that  tration.
          costs.                                              before   the   second    stage    is    reached.   the    unique    circumstances    operating    in  The    national    impact    of    Public     Law
          0   It   may   be    that    the    major    con-   The   third   stage   can    only    be    dimly   a   particular   program   may   make   it    Im-  89-239   will   best   be    evaluated    through
                                                              glimpsed  in  the  distant  future,   and   will   possible  to    achieve     comparable     effec-  the   cooperative   efforts   of    the    Public
          tribution   of   evaluative   research   is    to                                                        eness   and   efficiency   in   other    areas.
          determine   whether    the    traditional    ways   not  be  reached  at   all   unless   activities   'EIV                                               Health      Service,      other      governmental
          of    carrying    on    professional    practices   in    acquiring    appropriate    data     bases   Sources   and    Resources    for     Evaluation.  agencies,   the    individual    Regional    Pro-
          and   delivering   medical   services   are,   in   are promptly established.                          A   sound   program   of   evaluation   in    the  grams,   and   a   number   of    other    public
          fact,  the  most  effective.  If  arbitrary   as-   0    Evaluation     of     demonstrations     in   field of  medical   care   requires    the    di-  and   private   resources.   The   National   In-
                                                              which   the   purely    medical    aspects    of                       tive   involvement    of    a  stitutes    of    Health,    the    Bureau     of
          sumptions     and     unwarranted     limitations                                                      @rect and coopera
          are   placed   upon   the   scope   of    evalua-   the   services   rendered   are    assumed    to   number     of     disciplines     and      compe.  Health   Services   and   the            National
          tion,   even   though   some   limitations    are   be  effective  may   be   based   on   a   false   tences.    Background    or     experience     in  Center for Health Statistics       as   well   as
          always   necessa   ,   the    hope    that    con                                                      medical  care   is'   not   essential   for   all  other   offices   within   the   Public    Health
                            ry                            -   assumption.    To    the    extent     feasible,
          tinuing    experimentation     and     innovation   evaluation   should    concern    itself    with   contributors  in   order   for   them   to   make  Service   have   unique   sources    for    medi-
          will    lead    to    dramatic    improvements.in   all  the  factors  that   actually   or   poten-   substantive    contributions;     the     princi.  cal   care   research   and    evaluation.    The
                                                                                                                 ples   of   evaluation   can    in    many    in.  task    of    evaluating    the     effectiveness
          medical  care  is  less  likely   to   be   real-   tially  influence  effectiveness,  as   it   has
          ized.                                               been  defined  for   the   purposes   of   eval-   stances     be     transferred     from     other  and   efficiency   of   Regional   Medical   Pro-
                                                              uation.  These  factors   include   the   relia-   fields.  Many  individuals  will   have   to   be  grams   calls   for   the   cooperative    effort
                                                              bility  and  validity  of  the   medical   meas-   recruited  into  the  medical   care   field   to  of   staffs   of   universities,    members    of
          0  There  are   several   stages   in   the   evo
          lution  of   new   health   care   programs,   on   ures   of   diagnosis    and    treatment.    In   make   possible   the   level   and   scale    of  the  health  professions,   and   of   units   of
          a  local,  regional,  or  national  level.   Ini-   settings  where   such   access   is   feasible,   evaluation that is called for.                     governmental    agencies.    Only    then     can
          tially,   decisions   are   made    and    imple-   such   factors   should   be    identified    as                                                      the   requisite   talent   and   competence    be
          mented   on   the    basis    of    best    judg-   the  objects  of  evaluation.  If  this  is  not   Potential    sources    of    professional    as.  mobilized   to   provide   the   data   essential
          ments    of    those    responsible    for    the                                                       istance    or    consultation    include    many  to   local   and   national    policy    determi-
                                                        es-   done,   programs    may    be    evaluated    as   Sluepartments    in    the    university:     SO-  nations   which    must    shape    wisely    the
          program. After a program has been                   highly  effective  in  terms  of  their   opera-
          tablished,   a   number   of    new,    unrelated   tion  and   costs,   although   they   may   not   ciology,    Social     Psychology,     Economics,  future  of  medical  care  for  all   our   citi-
          facts   begin   to   influence   decisions,   but   be   advancing   the   actual   care   of    pa-   Political    Science,     Business         Admin-  zens.
          in   the   absence   of    an    organized    and   tients.                                            istration,    Administrative     Science,     Ed-
          definitive  body   of   data,   the   administra-                                                      ucational      Psychology.      Schools         of
          tors  of  the   program   require   wide   lati-,   0   Finally,   the   question    may    properly   Public    Health    generally    possess    high-
          tude   in   making   decisions    because    fac-   arise   whether   a   particular   program    is   level    competence    in    epidemiology     and
          tual  guidelines   are   still   imprecise.   The   an   appropriate   one   for   the    area    or   medical    care    organization.    In    several
          third   phase   of    such    programs    emerges   population    to    be    served.     Presumably   such   Schools,   as   well   as    in    several
                                                                                                                                                                                                                   53





                  Continuing Education and
                  Regional Medical Programs
                                                                                                                                                           or- should   give   consideration    to    these
                                                                only  an  additional  increment  in   the   ex- between all individuals, groups and          reas  of  interrelated   function.   It   is
                  Prepared   by   Staff   of    the    Continuing    array   of    activities    already    un. ganizations   involved   in   continuing    edu-a
                  Education   Branch   of   the    Division    of tensive                                               he     region.     Difficult     judg. meaningless,   for   example,   to    design
                  Regional    Medical    Programs     also     as derway along     with     widespread      discus- cation  int
                  background    to    the    second    discussion sion of needs    and    solutions.    Yet    there ments   will   have   to   be   made    as    to educational  programs  for   physicians   in
                  session                                       is  cause  for   thoughtful   concern   and   awhich    educational    programs    will     re- the  functioning  and  appropriate  use   of
                                                                hard    took    at     past     accomplishments ceive  priority,  for  all   educational   needs intensive  care  units   without   consider-
                  Continuing   education   and    training    ad, and  future  prospects,   for   there   are   acannot  be   met   at   once.   Strong   consid- ing  the  education  of   the   other   per-
                  dress  themselves   quite   directly   to   the number    of    knowledgeable    persons    who eration  to  the  health  needs   of   the   re- sonnel  essential  for  the  unit's   opera-
                  primary   purpose   of   the   Regional   Medi- have    entertained    serious     reservations gion  should   be   given   in   setting   these tion as well  as  the  availability  of  the
                  cal    Programs-to     make     more     widely about  the   effectiveness   of   current   ac- educational priorities.                    necessary  facilities  and   equipment.   It
                  available  to  the  patients  of   the   Nation tivities  in  continuing   education   in   im-                                            is  also  wasteful  of  scarce   human   and
                  the   latest   advances   in   the    diagnosis proving   patient   care.   The   approach   to Design   of   Education   Programs.   The    de, physical  resources  to   carry   out   such
                  and  treatment  of   heart   disease,   cancer, developing  truly   effective   training   pro- sign   of   educational   programs    to    meet programs  where  they  will  not   be   uti-
                  stroke   and    related    diseases.    Because grams   must   be   viewed   in    the    broad these needs req u i res          considerable lized optimally.
                  the   more   successful    continuing    educa- context of health care.                     creative    thought.    Based    on     previous Continuing  education  by   definition   im-
                  tion   and   training   programs   are    often Educational   program    design    takes    its experiences,   however,   some   of   the    im. -plies some  continuity  to  the  education-
                  dependent   upon   cooperative    efforts    of origins  in   identification   of   the   educe-portant   factors   to    be    considered    in al  process,  yet  the   continuing   educa-
                  a   number   of   individuals   and   organizes tional  needs  of   the   health   professional effective    educational    design    can     be tion  of  most  individual  health   person-
                  tions,  the  creation  of   regional   coopera-                                             -identified.     Many     educational      experi-
                  tive    arrangements    by     the     Regional These   educational   needs   in   turn    have ences   which   have   staying   qualities   are nel today  is  characterized  by  the  lack,
                  Medical Programs may provide sign             their  origins  in  the  health  needs  of  in, characterized by active participation        rather than  the  presence,  of  continuity.
                                                              if" dividual  patients  and  in  the  patterns   of                                            of The  framework  of  the   Regional   Medical
                  cant  new  opportunities   for   the   develop, medical   care    and    the    total    health the  learner   in   the   learning   experience, Programs   provides   an   opportunity   for
                  ment   of   effective   continuing    education needs   and   resources   of   the   particular These    experiences    have     also     linked program  design  which  can   achieve   bet-
                  activities.  The   regional   nature   of   the region.    The    sequence    of    educational that  participation  to   the   ultimate   focus ter continuity. The challenge is  to  struc-
                  Programs  can   also   provide   other   assets design     commences     then     with      the of    the    educational     process-care     of ture  programs  which  relate  not  only  to
                  to   continuing    education    and    trainin@ identification   of   the   health   needs   of the  patient.  The   clinical   clerkship,   in- current   educational   needs   but    which
                  an   opportunity   for   close   relation    of the    population     accompanied     by     an ternship    and    residency     programs     in take   into   consideration   the   previous
                  teacher   and   learner   in   development    o.fanalysis   of   the   existing   resources   to medicine    have    recognized    the    irnpor- educational  experiences  of  the   partici-
                  programs,     convenience     and      accessi. meet   those   needs.   Out   of   these   con- tance   of   participation.   Judged   on   this pant.
                  bility  of   programs,   and   opportunity   to siderations,    discrepancies    between    re, basis,    the    standard    two-day     program Consideration  must  be'  given   to   other
                  build   together   links   between    education                                             of  sequential   lectures   may   not   be   the
                                                                sources    and    needs    become     apparent.                                              factors  which  have   inhibited   effective
                  and  health  care.  Indeed  one  of   the   rea1                                            most    effective    mechanism    for     contin u.
                                                                The   challenge   then    becomes    the    de- "'                                           educational  activities  in  the  past  such
                  potentials   of   continuing   education    and sign   of   methods   to   meet   these    dis- ing education.                             as   the   problems   of   time,   distance,
                  training   within   Regional    Medical    Pro- crepancies.                                 Although   health   care    has    become    in- commitment  of  available  effort   to   the
                  grams   is   the   opportunity   to   integrate Some   of   these    discrepancies    can    be creasingly   complex    with    resulting    re- actual delivery of  health  care,  financial
                  these  activities  into   the   larger   sphere met   by   programs   in   continuing    educa- quirements for  close          collaboration loss,  and   established   habit   patterns.
                  of health care which they subserve.
                                                                tion  and   training.   Often,   however,   the among   specialized    personnel,    our    edu- Modern  technology  offers   potential   for
                  Relation    of     Educational     Needs     to human  resources   available   within   a   re- cational   programs   continue   to    be    de- overcoming   some   of    these    problems.
                  Health   Needs.   Although    Regional    Medi- gion    for    continuing     education     are signed    in    a    manner    which    suggests The   use    of    television,    computers,
                  cal   Programs   have   stimulated    addition- scarce.    Conservation     and     appropriate each   health   professional   is    functioning teaching   machines,   or   other   applica-
                  al  attention   to   the   problems   of   con- utilization   of   these    scarce    resources independently.       Educational        programs tions  of  modern   techniques   and   hard-
                  tinuing  education,  this   new   interest   is requires    close     working     relationships designed  to  meet  patients'          needs ware  is  being  explored  in  some   places

                  54






                                                                                                                                                      for       had   direct    involvement    with    education
                                                                                             s      yed   are li mited. One potential resource        the       in   health   affairs   the   potentiality    of
           ind    many    Regional    Medical     Programs care. These factors need to be a sa            advice,  counsel,  and  training  is
                    ring   the    effective    utilization at  each  step  in  the  process  for  one  to                        ividuals    who     have       their   involvement    is    very    real    and
           are conside                                                             relative    signifi,   modest cadre of ind
           of   these   educational   tools.   The    com- understand  fully  the              ultimate   established   units   of   research   in   medi.      should be encouraged.
           ments   in   this   document    about    design cance of their effect on the                   cal  education   in   recent   years.   A   re-       Cooperative   Efforts   in   Educational    Pro-
           and  evaluation  are,   however,   very   rele- goal of improved health care.     se     who   source   exists    in    the    colleges    and       grams.   In   addition   to   ongoing    evalua-
                    ucational      programs      utilizing The manpower resources of tho     --           schools    of    education    throughout    the       tion    and    modification    of    educational
           vant for ed                                                                     ri
           these   techniques.   By   providing   an   OP- have   competencies   and   expe    ence    in country            graduate    activities    in       programs,    consideration    must    also    be
                                     use     of      these educational   evaluation   as    it    applies           where
           portunity to integrate the                                                                     educational   research   are   being    carried       given   to   the   development   of    effective
                                                         specifically    to    continuing     education                                                         cooperation   among   the    people,    institu-
           techniques    into    a    total    educational                                                  t.  Although  few   of   these   units   have                               d      agencies      al-
           program  related   to   the   real   education- and  training  in   the   health   professions ou                                                    tions,  organizations  an
           al  needs   of   the   region,   the   Regional                                                                                                      ready   involved    in    the    education    of
           Medical   Programs   can    help    to    avoid
           the   danger   that   these   techniques    may                                                                                                      health    personnel.    The    development    of
           be   developed   in   isolation   from    those                                                                                                      improved    programs    requires     utilization
           needs.                                                                                                                                               of  their  strengths  and   should,   in   turn,
                                                                                                                                                                provide a    mechanism        for          those
           Educational  Evaluation.  Even   if   the   de-                                                                                                      strengths   o   expand   and    grow.    Cooper,
           sign    of    educational    programs     gives                                                                                                      ative   activity   in    continuing    education
           areful   onsideration    to     the     factors                                                                                                      and   training   should   become    a    symbio-
           c        c
           discussed,  one   may   anticipate   that   the                                                                                                      tic   relationship.   If    possessiveness    by
           resulting  programs   will   not   be   totally                                                                                                      any  single  group  occurs,  or  if   monolithic
           successful   in   meeting    the    educational                                                                                                      programs    are    attempted,    the    benefits
           needs.   The   successes   and   the   failures                                                                                                      of  symbiosis  will  be  lost  to   the   detri-
           nlLJSt   be   evaluated   and    analyzed    to                                                                                                      ment of better health care.
           serve  as  the  basis   for   appropriate   de-                                                                                                      The  necessity  of   cooperative   efforts   for
                           the       improvement       and
           cisions  about                                                                                                                                       effective   continuing   education   is   inher-
           continued   renewal    of    the    educational                                                                                                             the   nature   of   our   medical    sys-
                    Since   resources    for    continuing                                                                                                      ent in        termined   both   by    the    re.
           activity.                                                                                                                                            tem. it is de
           education  and  training   are   scarce,   con-                                                                                                                        modern      medicine       and
                                                                                                                                                                quirements  of
           tinued   evaluation   of   educational   effec-                                                                                                      the   patterns   of   our   society.   The   Re-
           tiveness   is   necessary   to    assure    the                                                                                                      gional    Medical    Prop-ram     provides     a
           efficient   use   of   these   resources.    As                                                                                                      mechanism     for     cooperative      relation-
           discussed   above,   the   ultimate   criterion                                                                                                                      n    the    medical     environs
                                                                                                                                                                ships  betwee
           of offoctive@      of   am   dto,!stionpi   ag,                                                                                                             RP@mimpilp moti*Otmod      ilm     ooool.
                       o,,,,          .   ,  ISO     owfoo                                                                                                      FMO"T
               vtsih  I  Ali,  po(41hdiot      ON                                                                                                               opment     and     dissemination     of      new
           m   n    of change In       th   care.    There                                                                                                      Knowledge    and    the     environment     pri-
           are   many   components,   however,   of    the
           effectiveness,   including   the   success   in                                                                                                      marily   concerned   with   the   delivery    of
           reaching   the   desired    audience,    effec-                                                                                                      health   services.   Only   if   both   environ-
                                                                                                                                                                ments    are    involved     and     cooperating
           tiveness  of   information   transfer,   effec.                                                                                                      will  the  full  impart   of   continuing   edu-
           tiveness   in   bringing    about    behavioral                                                                                                      i-,ati(,n  and   training   programs   be   made
           change,   and   the   effectiveness   of    the
           behavioral   change   in   improving    patient
                                                                                                                                                                                                               55





              The Report of the Surgeon  General
              to the President and the Congress
              Prepared by  staff  of  the  Planning  and  portunities for major  innovations.  It  is  the  experience  and  insight  of  a  wide   The fundamental  purpose  of  the  Act  as
              Evaluation  Branch  of  the  Division   of  impossible to say  with  any  precision  at  variety  of  people  concerned  with   Re-   formally stated in  Section  900  (b)  is:
              Regional   Medical   Programs   as   back-  this time  what  the  nature,  extent,  and  gional  Medical  Programs  through  a  na-   ". . to  afford  to  the  medical  profes-
              ground to  the  third  discussion  session  diversity  of   these   medical   complexes  tional  conference.  One  of   the   major   sions  and  medical  institutions  of  the
                                                          will be in the  future.  We  do  know  that  objectives of the Conference  is  to  pro-   nation . . .  the  opportunity  of  making
              PREFACE                                     these   developments   will   be    closely  vide  a  forum  for  this  purpose  and  a   available to  their  patients  the  latest
              The Report to  the   President   and   the  watched  by  the  Congress   and   by   the  common   frame   of   reference   out   of   advances  in  the  diagnosis  and   treat-
              Congress is set forth as  a  specific  re-  American   people.   The   Committee   does  which an additional  input  of  ideas  can   ment of these diseases."
              quirement  in  Section  908  of  the   Act  expect  that,  as  experience  is   gained,  be secured before drafting the report.       B.  Prescribed   Mechanism   for   Attain-
              authorizing  support  for  Regional  Medi.  the  various   aspects   of   the   program  IDENTIFIED ISSUES                            ment of Objective
              cal Programs, as follows:                   may  alter  to  deal  with   new   problems  Divisional  Staff  and  the  Ad  Hoc  Com-   The  prescribed  methodology  is   region-
              "On or before June 30,   1967,  the   Sur-  and  opportunities  and   to   extend   the  mittee  have  identified   certain   items   al    cooperative    arrangements    among
                                                          coverage  of   the   complexes   into   new
              geon  General,  after  consultation   with  communities   and   situations.   The   im-  ano issues. These  points  are  set  forth   medical  schools,  research  institutions,
              the Council, shall submit  to  the  Secre-  pressive  endorsements   of   the   concept  on  the  following  pages  for  discussion   and  hospitals,  with  broad  based  advi-
              tary for  transmission  to  the  President  give  a  basis  for  launching   the   pro-  during  the  meeting  on  January  17.  In   sory   committees   to   insure    commit-
              and then to  the  Congress,  a  report  of  gram as soon as  possible,  but  the  final  addition,  conference   participants   are   ment   to   broad   regional   needs   and
              the activities under this  title  together                                               encouraged to  identify  and  discuss  is-   guard  against  the  domination   of   any
              with (1) a statement of  the  relationship  form in all  its  particulars  is  not  and  sues  and  topics  not  included  in  this   individual institution or group.
              between  Federal  financing  and   financ-  cannot be clear at  this  time.  Therefore,  paper.                                       Ill. Progress Report
              ing from other sources of  the  activities  the need for  careful  and  continuous  re-                                               In  accordance  with  the   specifications
              undertaken pursuant  to  this  title,  (2)  evaluation  assumes   a   special   import-  1. Background of the Report
              an appraisal of  the  activities  assisted  ance  for  this  program.  The   Comnlittee  There will be brief  discussion  of  broad   in Section 908, this Section  will  report
              under this title in  the  light  of  their  urges  that   the   program   be   adminis.  trends in  science,  medicine  and  educa-   on  0  activities  supported   under   the
                                                          tered at all times with a view  toward  the                                               program,  0   the   relationship   between
              effectiveness in carrying  out  the  rpur-  identification  of   productive   modifica-  tion,  and  social  and  economic  aspects   ,Federal  financing  and   financing   from
              poses of this  title,  and  (3)  recommen-  tions  for  submission   to   the   Congres  leading to the  enactment  of  Public  Law   other sources  of  the  activities  under-
              dations  with  respect  to  extension   or                                            s  89-239. The legislative  history  will  be
              modification of this title  in  the  light  when  the  extension   is   considered   in  summarized   including   the   Administra-   taken, and 0 an  appraisal  of  activities
              thereof."                                   the future."                                 tion's proposal (S. 590  and  H.R.  3140),   assisted in the light of their  effective-
                                                                                                       the  Senate  and   House   Hearings,   and   ness,
              The  purpose  and   importance   of   this  INITIAL APPROACH                             their respective Reports.                    A. Activities under the Program
              provision was clearly stated in  the  fOl-  The Report is  a  staff  responsibility  of                                               1. Chronology of implementation
              [owing excerpt  from  the  related  Report  the  Division  of  Regional  Medical   Pro-  11.  The  Nature  and  Purpose  of  Public   0  Bill  signed  into  Law'   -   October,
              of  the  Senate  Committee  on  Labor  and  grams.   A   special   Ad   Hoc   Committee     Law 89-239                                1965.
              Public Welfare:                             of leaders in the fields  of  health,  edu-  A. Basic Objective and Purpose               0  First  Council  meeting   -   December,
              "The bill calls for  reevaluation  of  the  cation  and  community  affairs   was   es-  Primary objective is to ensure  that  per-   1965.
              program  and  the  submission  of  a   re.  tablished to furnish expert advice.          sons  throughout  the  country  have   the   0  Division  of  Regional   Medical   Pro-
              port to the Congress  by  June  30,  1967.  The   Committee   held    three    meetings  benefits of medical scientific    advances   grams  established  at  NIH  -   February,
              The  Committee  views   this   requirement  between   September   and    November    of  in  heart,  cancer,  stroke  and   related   1966.
              for   accomplishments   and    recommenda-  1966  to  help  shape   the   approach   to  diseases. Attainment of this objective  is   0      Firstapplicationsfor.planninggrants
              tions of further  development  as  an  im-  the  Report  and  identify   issues   which  impeded  by  the  gap  that   exists   be-   received - April, 1966.
              portant and integral part of  this  legis-  require  consideration.  In  addition,   it  tween  scientific  advance   and   day-to-   0  First  awards  for  planning  grants  -
              lation.  This  program  provides  the  op-  was   considered   important   to    obtain  day  practice  in  parts  of  the  Nation.   June,1966.

              56







          0   First   applications   for    operational                                                                                                   3.  Estimates  of  type  of  non-federal  re-
          grants received  -  October,  1966.                                                                                                             sources  likely  to  be  made  available   in
          0  First  national  conference   on    Region-                                                                                                  the future
          al Medical Programs - January, 1967.                                                                                                            4.  Policies  and  procedures  for   assuring
                                                                                                                                                          diversification of support
          2.   Basic   data   concerning   applications                                                                                                   C. Appraisal of Effectiveness
          received  and  approved;  amount           of                                                                                                   1.   Methods   of   evaluation   being    de-
          awards;   population   served;    participat-                                                                                                   veloped  and  applied   by   Regional   Medi-
          ing  organizations;  staffing;   nature   and                                                                                                   cal Programs
          variety    of    cooperative    arrangements;                                                                                                   2.  Data  on   scope   of   cooperative   ar-
          feasibility   and   other   studies    under-                                                                                                   rangements
          taken, etc.                                                                                                                                     3.    Approaches    being    developed     to
          3. Analysis  of  Major  Planning   Activities                                                                                                   measure    changes    in    resources     and
                                                                                                                                                          facilities  that  will   extend   "opportuni-
          1)  Organization  and   staffing   of   plan-
                                                                                                                                                          ties"  for  applying  the   latest   advances
          ning unit.                                                                                                                                      4.  Approaches   being   developed   to   de-
          <>  Collection  and  analysis  of   data   on
                                                                                                                                                          termine   impact   of   programs    on    the
          resources,  problems   and   needs.
                                                                                                                                                          diagnosis  and  treatment   of   heart   dis-
             Strengthening      of       communications
          and   relationships    among    health    re-                                                                                                   ease, cancer and stroke
                                                                                                                                                          5.  Examples  of  "critical   incidents"   in
          sources.                                                                                                                                        the   development   of    Regional    Medical
             Development   of    feasibility    studies                                                                                                   Programs
          and  proposals   for   priority   operational
                                                                                                                                                          IV.  Problems  and  Policy   Issues   Requir-
             Arrangements    for    continued     plan-                                                                                                   ing Consideration
                                                                                                                                                          This  section   is   most   important   since
          ning.                                                                                                                                           recommendations     for     extension     and
          4. Analysis  of  Major  Activities  of  Oper-                                                                                                   modification  of  the  law  will  arise  from
          ational Programs                                                                                                                                the  problems   and   policy   issues   which
                                                                                                                                                          have  been  identified.   Inclusion   of   an
          5.    Interregional    Developments                                                                                                             item  for  discussion  in  the  report   does
             Multi-State   (New   England,         Mid-
                                                                                                                                                          not  necessarily  mean  that  a   change   in
          West, Rocky Mountain area)
                                                                                                                                                              law is indicated.
                                                                                                                                                          the
             Intrastate (New York, California)
                                                                                                                                                          A. Continuation of Program
          B.   Relationship   of   Federal   and   Non-                                                                                                   There   is   considerable   and    compelling
          Federal Financing
                                                                                                                                                          evidence  of   the   effectiveness   of   the
          1.  Resources  made   available   from   non-                                                                                                   Act  in  bringing   about   cooperative   re-
          federal  sources   for   pre-planning   prior                                                                                                   gional  efforts  among   the   major   health
          to grant awards                                                                                                                                 resources  for  the  purposes  specified   in
          2.  Resources  made   available   from   non.                                                                                                   the  Act.   Attainment   of   the   fundamen.
          federal  sources  for  planning  and   opera-                                                                                                   tal  purpose  of  assisting  all   physicians
          tions after grant awards                                                                                                                        and  medical  institutions   to   bring   the

                                                                                                                                                                                                    57









             benefits  of  medical   research   advances    space  for  educational   programs;   acute    process and  should  not  take  over  total     terials, standardization  of  data  collec.
             to  their  patients  appears  realistic  on    shortages  of  patient  care  and  support-    support for the application  of  all  medi-     tion,  refinement  of  evaluation   proced-
             the  basis  of  early  experienciD.   While    ing  facilities  have  required   immediate    cal scientific advances.                        ures.  The  available  methods  of  financ-
             current  legislative  practice   makes   it    attention.  The  same   conditions   gener,    Congress  has  evinced  interest   in   the     ing of  these  needed  services  are  often
             unlikely  that  a  new  authorization  will    ally  make  it  impossible  to   meet   the    amount of non-Federal      resources     made   awkward and inadequate.
             not include  a  time  limit,  the  Regional    needs  for  space  for  continuing   educa-    available  to  these  programs  as  an  in-     It  has  been  suggested   that   modifica-
             Medical  Program  effort  should   be   es-    tion  programs   through   renovation   and    dex  of  local   commitment   and   support     tion  of  the  Act  to  permit  grants  di-
             tablished   as   a   continuing    program.    remodeling.                                    and as a  reflection  of  budgetary  reali-     rectly  for  these   "support"   activities
             Such  a  long-term   commitment   is   par-    During the  conduct  of  feasibility  stud-    ties.   It   has   been   emphasized   that     may be desirable  in  order  to  facilitate
             ticularly  important  in  order  to  enlist    ies  and  pilot  projects,  Regional  Medi-    diversification of fund  support  will  en-     the  development  of  individual   Regional
             the participation of all  institutions  and    cal  Programs  have  been  forced  to  rent    hance local initiative and control.             Medical  Programs.   Proposals   for   such
             to  provide  a  sound  basis  for  recruit-    space,outside the  hospital  for  the  con-    In  reviewing   grant   requests,   primary     support  would  have  to  be  directly  re-
             ment of high caliber manpower.                 duct  of  educational  programs   and   the    attention  is  given  to  the  extent   and     lated  to  the  achievement  of  the  basic
             S. Construction of New Facilities              use of  the  educational  staff.  This  aP-    nature   of   local   support.   Continuing     purposes   of   Public   Law   89-239   and
             The   original   Administration   proposals    proach  is   not   only   costly   but   it    consideration  will  be  focused   on   the     would  be  made  only  after   review   and
             for authority  to  support  Regional  Medi-    significantly   reduces   the   impact   of    policies  and  procedures  that   are   em-     approval   by   the    National    Advisory
             cal   Programs   included   provision   for    these efforts. It  is  more  difficult  for    ployed locally  for  ensuring  diversifica-     Council  on  Regional   Medical   Programs.
             grant  assistance  to  aid  both  new  con-    many  medical  practitioners   and   allied    tion  of  resources  for  Regional  Medical     E. Interpretation of Act
             struction  and  renovation.   This   provi-    personnel to participate.  It  is  impossi.    Programs. It has been  felt  that  a  poli-     A  keynote  of  Public   Law   89-239,   in
             sion  was  amended  in  the   Congress   to    ble  for  certain  desirable  programs   to    cy  placing  responsibility  at  the  local     oth  its  legislative  and   administrative
             limit  the  definition  of   "construction"    be organized,  particularly  those  involv-    level for  assuring  balanced,  diversified     D
             so  that  only  renovation   and   remodel-    ing demonstrations of patient care.            support is  a  more  effective  and  aDDro-     aspects,  has  been  flexibility   of   ap-
                                                                                                                                                           proach.  The   primary   purpose   of   this
             ing costs were  eligible  for  support.  The   The   issue    of    matching    requirements  priate  approach  than   a   rigid   matching   approach  is  to   place   maximum   respon-
             Report  of  the  House  Committee   on   In-   for   construction   also    needs    further  requirement,  particularly  in  view  of  the   S]Diiity  on  local  leadership  to  develop
             terstate   Commerce   stated    that    "the   consideration.    Reports    indicate    that  cooperative   and   innovative   nature    of   appropriate    mechanisms,     plans     and
             lack of this  authority  for  new  construc-   many   community   hospitals   have    insur-  this new program.                               programs.    Administrative       guidelines
             tion  should  create  no  serious   problems   mountable  difficulties  in   raising   funds  D. Inter-Regional Support Activities            and  policies  have  encouraged  local  ini-
             during  the  3  years  authorized  in   this   for  the  construction  of   facilities   for
             legislation and when a request is ma       a   continuing   education.     There    is     a  Public   Law   89-239    authorizes    grants   tiative while,  at  the  same  time,  ensur-
             for extension of  this  legislation  in  tne   danger  that  a  -rigid   matching   require-  only  for   the   planning   and   operations   ing the established statuto  'ry     purposes
             future,  the  committee  will  review   this   ment in this  respect  will  distort  or  im-  of   individual   Regional    Medical    Pro-   are  pursued.  Instead  of  rigid   national
             question again. . . ."                         pede   progress   toward   the    achievement  grams.    No    consideration    was    given   directives,   heavy   reliance   has    been
             Experience to  date                                                                           during  the  development  of   the   legisi@-   placed  upon  the  review   and   evaluation
                                    has  identified         of the program's purposes.
             number of areas in    which authority     to                                                  tion to other types of grant support.           of  local  program  proposals   by   non-Fe-
             assist new construction is essential      to   C.   Relationship   of   Federal   and   Non.                                                  deral  consultant  groups,   both   at   the
                                                                                                           Reports  have  indicated  that  certain   re-
             the   development   of   Regional    Medical   Federal Funding                                sources  and  activities  to  facilitate  and   regional  level  through  the  Regional  Ad-
             Programs.  Priority  needs  have  been   re-   Regional    Medical     Programs     provide,  support   the   development   of    Reizional   v'sory  Group  and  at  the  Federal   level
             ported  for  space   in   community   hospi-   through    cooperative    arrangements,     a  Medical   Programs   may,   in    some    in-   by   an   expert   Review   Committee    and
             tals   to   conduct   continuing   education   broad   systematic   framework   for    plan-  stances,   best   be    developed    on    an   the  National  Advisory   Council   on   Re-
             programs   and   to    carry    on    demon-   ning  and  action.  It  is  recognized   that  inter-regional  basis,  e.g.,   training   of   gional Medical Programs.
             strations  of  patient  care.  Most   commu-   the   Federal   grant   funds   should    not  continuing  education   and   other   leader-   Specific  examples  of  flexibility  of  ap-
             nity  hospitals  do  not  include   adequate   finance all  the  needs  identified  in  this  ship  staff,  preparation  of  teaching   ma-   proach are:

             58











      1)   The    fundamental    recognition    that   ministration     proposal     requested     au-   operative   relationships    among    the    ma-
      attention  must   be   given   to   developing   thority   to   make   grants    to    encourage   jor   health   resources    in    the    region.
      and  maintaining   a   sound   foundation   of   programs      of    regional        cooperation   These   activities   are    generally    generic
      clinical   capability    upon    which    more   among   the   major   health   resources    for   by   nature   and    consequently    have    not
      sophisticated   programs   can    be    built.   heart  disease,  cancer,  stroke,   and   other   significantly   involved   problems   of   cate-
      For  example,  it  is  recognized   that   in-   major   diseases.   The    law    as    enacted   gorical   definition.   In   most   cases,    in
      creased  accessibility  to  the  most   recent   provided   for   grants   to   encourage   pro-   order  to  plan  effectively  for   heart   dis-
      advances   in   cancer   treatment   is    in-   grams    of    regional    cooperation    among   ease,  cancer,   and   stroke,   it   has   @een
      effective  if  there  are  serious   gaps   in   the   major   health   resources   for    heart   found   necessary   to   consider    at    times
      basic   diagnostic   and    treatment    capa-   disease,    cancer,    stroke    and    related   the  entire   spectrum   of   resources   avail-
      bilities. Similarly,  it  is  recognized  that   diseases.                                         able for personal health services.
      "improved     diagnostic     and     treatment   The   categorical   emphasis   of   the    pro-   However,   the   emergence   of    the    opera-
      capability."    must    necessarily    include   gram   has   been   widely   discussed.    Some   tional  phase  of  the  program   will   put   a
      preventive  and   rehabilitation   activities.   have felt that  it  is  not  prudent  or  prac-   more  intensive   focus   on   its   categorical
      2)  The   establishment   of   new   organize.   tical   to   develop   Regional   Programs   on   purposes.   Only   projects    that    can    be
      tional   mechanisms   to   reflect   the   co-   a   categorical   basis.   Others   have    ar-   shown   to   have   direct   significance    for
      operative  relationships   required   in   the   gued  that   the   efforts   of   the   program   combating   heart   disease,   cancer,    stroke
      program.  One  expression   of   this   devel-   should     be   exclusively   focused        on   and   related   diseases   can    be    assisted
      opment  is  the  organization  of   new   non-   immediate    measures    to    reduce    losses   with    Regional    Medical    Program     grant
      profit  agencies   to   serve   as   the   co.   from  the   three   "killer   diseases";   they   funds.
      ordinating    agency    for    the    Regional   have  pointed  out  that   the   highly   corn'   The   experiences   of   the   Regional    Medi-
      Program.   These    new    arrangements    can   plex skills  and  facilities  required  to  ap-   cal   Programs   will   be   especially   impor-
      involve  a   spectrum   of   new   administra-   ply  the  recent   scientific   gains   against   tant    in    determining     what     modifica-
      tive  and   fiscal   problems   that   require   these    categorical    diseases    make     it   tions,    if   any,    are    necessary       or
      innovation   and   inventiveness   for   their   particularly   desirable   to   organize   such   desirable  on  this  issue   in   the   legisia-
      solution.                                        efforts   on   a   regional    basis.    Others   ti,e   authorization.   The   impact   of    the
      On  the  basis  of  experiences  to  date,  it   have  suggested   that   the   scope   of   the   categorical   limitations   on   the   potential
      appears  that  flexibility  of  approach   has   three  diseases   and   related   diseases   is   of   the   Regional    Medical    Programs    to
      facilitated   progress   toward    accomplish-   so  broad  that   their   control   necessarily   contribute   most   effectively   to    improved
      ment   of   the   aims   of    the    program.   requires    attention     to        fundamental   health  of  the  people   and   the   best   use
      However,   reports   have   indicated    that,   questions   of   manpower    and    facilities.   of    available    manpower    and    facilities
      in   some   instances,   unreasonably    rigid   The  initial   period   of   program   develop-   needs   to   be   determined.   Similarly,   the
      or  lax  interpretations  of   the   Act   and   ment    has    provided    opportunities     to   best  ways   of   facilitating   the   diffusion
                                                       test  these  viewpoints   through   a   variety   of   knowledge    concerning    the    diagnosis
      the   Guidelines    have    complicated    un-    f experiences.                                   and  treatment   of   heart   disease,   cancer,
      derstanding   and   action.    The    question   0
      at  issue  is  whether  portions  of  the  Act   During   the   planning   phase    the    major   stroke   and   related   diseases    needs    to
      or  Guidelines  need  to   be   clarified   or   activities   undertaken   by   Regional   Medi-   be   identified.    These    discussions    must
      amplified to insure needed flexibility.          cal   Programs   have   involved   the   estab-   take   into   account   the   fact   that    the
                                                       lishment  of  a  planning  staff,  the  initia-   legislative   proposal    for    extension    of
      F. Categorical Emphasis                          tion  of  studies  to  obtain  the  basic  data   Public  Law   89-239   will   probably   request
      The  legislative   history   of   Public   Law   concerning   pertinent   health    needs    and   authorization   for    the    program    through
      89-239  indicates  that   the   original   Ad-   resources   and   the   development   of    co-   1973.

                                                                                                                                                                                                      59



























































            60




                                                                                             Section IV-Group Discussions


                                                                                             REPORTS  prepared  by  four  group   dis-  The  registrants  participated  in  three
                                                                                             cussion  leaders,  each  of  whom  repre-  discussion  sessions  held   during   the
                                                                                             sents a different health interest, and     Conference.  The  sessions  served  as  a
                                                                                             SUMMARY  report  by  Division  staff   on  forum in which participants  could  free-
                                                                                             thoughts  and  attitudes   expressed   in  ly express their thoughts on  the  topics
                                                                                             the  group  discussions   regarding   key  which had been  underscored  in  the  Is-
                                                                                             issues of the Conference                   sue Papers and in  the  presentations  of
                                                                                                                                        the principal speakers.





































                                                                                                                                                                          61




                                                                                                               REPORT: No Prospects For
                  Introduction                                                                                 "Instant" Regional Medical
                                                                                                               Programs
                                                              Deans   of   medical   schools,   practicing     Donald J. Caseley, M.D.                       referrals,  which   were   all   accomplished
                  MONDAY      MORNING      AND      AFTERNOON, physicians,   regional   information   offi-    Medical Director, Research and                with   no   more   than   relatively   modest
                  JANUARY 16                                                                                                                                 philanthropic support.
                  The  twenty-five  discussion   groups   were cers,  hospital  administrators,  and  other    Educational Hospitals and
                  structured  so  that  the   health   profes- categorical  groups   met   for   the   same    Associate Dean, College of Medicine           Discussion   group   productivity   can    be
                                                                                                               University of Illinois
                  sions,   public   and   private    agencies, purpose.                                                                                      measured  in  terms  of  both   the   matters
                  practicing  physicians,  and  citizen   mem' The  reports  by   four   group   discussion    Chicago, Illinois                             discussed  and  those  that,   although   im-
                                                                                                                                                             portant,   never    managed    to    surface.
                  bers  of  Regional  Advisory   Groups   were leaders  attempt  to  encapsule   the   con-
                  represented.  The    groups         averaged                                                        everal  ingredients  for   a   viable  This  exercise  covered  rather   well   most
                                                              tent and preserve  the  tenor  of  the  ses-     Of the s
                  twenty persons.                             sions  they  chaired.  A  staff  summary  of     and productive group    discussion,     none  of   the   principal   subject   areas   upon
                  A  typical  group  included  representatives the   problems     and     policy    issues     is  more  indispensable  than  to  have   at  which    the    conference    concerns    re.
                  from  fifteen  States,  six   Regional   Med"brought  up  during  the   discussion   ses-    least one  participant  who  has  had  real-  volved.
                  Cal  Programs,  and  the   Advisory   Groups sions is also included.                         life,  three-dimensional   experience   with
                  of  three  of  these  Programs  as  well  as                                                 the   subject   under   examination.   Group  On the issue most vital at this time
                  the Program     Coordinators     of      two                                                 four   was   more   than   thrice   blessed.  whether   or   not   the   regional   medical
                  others.  The  same  group   included   three                                                 This  optimistic  and   enthusiastic   group  program    concept    should    survive
                  medical  school  deans,  a  private  practi-                                                 included  a  former   USPHS   surgeon   gen-  there  was  no  dissent  from  the   position
                  tioner, a  hospital  administrator,  a  mem-                                                 eral,   highly   sophisticated   in   health  that  it  was   far   too   early   to   make
                  ber of  the  National  Advisory  Council  on                                                 care  planning;  a   former   assistant   to  definitive   judgments   which   would   sup-
                  Regional  Medical   Programs,   the   public                                                 the   secretary   of   the   Department   of  port  a  phaseout  of  the  effort.  It   was
                  information  officer  from  a   State   uni-                                                 Health,   Education,   and   Welfare,    who  well  recognized  that   an   "action-orient-
                  versity  medical  center,  a  member  of   a                                                 had  been  deeply  involved  in  the  devel.  ed"   Congress   and   a   highly   expectant
                  State  board  of  health,  a  staff   member                                                 opment   of    the    legislative    program  public  were  geared  to  the  "instant  pro-
                  from  an  agency  of   the   Department   of                                                 under   discussion;   and   a    participant  gram"  concept  and  that  the   energy   in-
                  Health,  Education,  and  Welfare,   and   a                                                 who  had  been  intimately   involved,   for  put  requirements   to   achieve   true   mo-
                  representative  from  a   voluntary   health                                                 years,  in  a  successful,  ongoing   proto-  mentum  were  far  too   great   to   warrant
                  agency.                                                                                      type   regional   medical    program.    His  comprehensive   appraisal   for   at    least
                  The  participants  brought  to  their  group                                                 skillful  and  objective  account   of   the  three  years.  Some  felt  that  1975   would
                  discussions   attitudes   reflecting   their                                                 operation   of   the   Bingham   Associates,  be  an  optimum  target  date   for   overall
                  respective  regions,  professions,  and  in-                                                 a  regional  plan  to  relate  small,  rural  appraisal  for  purposes  of  continuing   or
                  stitutions  or  agencies.  In  the  sessions                                                 Northern  New   England   hospitals   to   a  phasing out the program.
                  they  spoke  with  candor  about   the   is-                                                 metropolitan   medical   center,    produced
                  sues  of  the  Conference  and  in  the  en-                                                 an  affirmative  climate  for  the   discus-  How to Change Without Changing?
                  suing  exchange  brought  out   other   mat-                                                 sions. A  real  tone  of  optimism  and  ex-  One  reason  for  the  requirement   for   an
                  ters of concern.                                                                             citement  was   injected   into   the   pro-  extended  period  of  trial  for   the   pro-
                  TUESDAY MORNING, JANUARY 17                                                                  ceedings  by  the   fact   that   for   more  gram  needed   discussion   in   depth,   but
                  For  the  final  session  the  structure  of                                                 than  two  decades  a   voluntary   arrange-  was  well   repressed.   This   had   to   do
                  the groups  was  altered  so  that  partici-                                                 ment  had  been  in  effect  for   physician  with the  very  basic  nature  of  a  concept
                  pants   of   many    groups    shared    the                                                 post-graduate     education,        improve-  that  aims  at  improved  patient  care   and
                  same  interests.  In  this  way,  for  exam-                                                 ments  in  professional  staffing,  periodic  implies    experimenting    with    different
                  ple,  Program  Coordinators  had   the   op-                                                 exchanges  of   key   personnel,   upgrading  methods   for   the   delivery   of    health
                  portunity  to  discuss   problems   of   mu-                                                 of   technical   personnel   and   services,  services,  but  there   seemed   to   be   an
                  tual   concern   and   to    share    ideas.                                                 and   effective   mechanisms   for   patient  almost  instinctive  desire  to  avoid   con-

                  62






                                                             fronting    this    essential     component     of the operational phase  was    so     indistinct the  law   with   specific   funding   mecha-
                                                             the   program   in   the   face   of   the    lan. that  the  addition  of  a   facility   construc- nisms for effective implementation.
                                                             guage    of    the     law,     "to     accomplish tion    component    would    further     becloud The   categorical   emphasis   of   the   Re-
                                                             these   ends   without   interfering   with    the theissues.                                    gional   Medical   Program   seemed   to   be
                                                             patterns  .  .  .  of  patient  care  or   profes-
                                                             sional   practice."   A    careful    review    of Federal and Non-Federal Funding               an  area  where  attitudes  of  the   discus-
                                                                                                                                                              sants  reflected   with   remarkable   preci-
                                                             the   intent   of   the   Congress   to    upgrade When   the   relationship    of    federal    and sion'  the  nature  of   their   professional
                                                             the    operational    effectiveness     of     the non-federal    funding    was    discussed    the backgrounds.    The    participants     whose
                                                             health   care   establishment    and,    at    the usual   doubts   were   expressed    about    the occupational    orientation    was     toward
                                                             same   time,   declare   a   state    of    perma- slim   chances   for   new   outlays   by   state program  planning  for   health   care   felt
                                                             nent   immunity    against    any    change    for and    municipal    governmental    units     for that   casting   regional   arrangements   in
                                                             the     present     methods     of      delivering any   reason,   even    though    this    program a   disease   oriented   manner   would    be
                                                             health   services   could   have   been   a   neat might  well  prove  itself  to   be   most   use, virtually  self-defeating.  Their  own  plan-
                                                             and   lasting   contribution   to   the    confer, ful   and   productive.   The   group   did   not ning  in  the  program  had   virtually   19-
                                                             ence.   If    experimentation    with    different appear  to  be  sensitive  to   the   fact   that nored  the  categories  in  favor  of  health
                                                             means   to    organize    and    deliver    health patient  care,  as  a   process,   is   presently care   of   patients   as   a   comprehensive
                                                             services     is     desirable,     the     program being  funded   from   a   variety   of   sources process.   The   participants   whose   back-
                                                             should    indeed    be     continued     and     aand with high dollar outlays'     By        rea- ground   was   primarily   in   the   private
                                                             guaranteed   life   expectancy    of    the    law ligning   some   of   the   funds   into    some, practice  sector   were   overtly   apprehen-
                                                             should   be   such   that    an    appraisal    of what   different    patterns,    the    necessary sive  when  total  health   care   was   sug-
                                                             the   results   would   be    valid    from    the local   and   regional   resources    to    blend gested  as   the   framework   for   regional
                                                             standpoint of time as well as content.           with federal    funding    might     well     be- medical   program    planning.    It    would
                                                             Construction                                     come available   without   the   need   to    de- probably  be  fair  to  say  that   some   of
                                                             Experience   over    the    past    decade    with velop new local funding sources.              them  would  have  felt  a  bit   more   com-
                                                             a   host   of   other    programs    would    lead                                               fortable  if  a  single  category,  such   as
                                                             one   to   assume   that    attitudes    of    the Inter-Regionai Relationships                  cancer,  had  been  made  the   central   fo-
                                                             participants    would    be    almost    uniformly one area where there was     total         una. cus  of  the   planning   process.   Specula-
                                                             in   favor    of    generous    federal    funding nimity  was  the  need  for   the   law   to   be tion on the  part  of  the  majority  of  the
                                                             for   construction   of   new   facilities.   This either    amended    or    reinterpreted     with group   centered    around    the    distinct
                                                             assumption   proved   to   be   in   error.   Sev- respect  to   the   relationships   and   activi- Possibility that when the'real  core,   is-
                                                             eral   good   and   valid   reasons    were    ad- ties  which   are   sure   to   develop   between sue  was   faced,   i.e.,   the   operational
                                                             vanced   for   postponing   this   issue   for   aregions.  Patient   care   services   for   popu- phase  of  the  program,  it  would  be  vir-
                                                             couple   of   years.   The   one   most   strongly lation   groups   normally   follow    tradition- tually  impossible  to  maintain   any   real
                                                             espoused    was    that    as    some    of    the al  trading   area   lines.   Because   so   many semblance of a categorical approach.
                                                             strong   suspicions   of   one    or    more    of of  these   are   at   complete   variance   with
                                                             the   involved    groups    are    beginning    to political    subdivision     boundaries,     sub. Continuing Education
                                                             abate    somewhat,     it     would     be     the stantial   efforts   will   be    necessary    to The  nature  of  the   discussion   on   con-
                                                             height  of  folly   to   reintroduce   this   fea- maintain    productive    and    smooth     work- tinuing   education   has   been    purposely
                                                             ture,   which   had    raised    serious    doubts ing     inter-regional     arrangements.     This left until the  last,  because  this  subject
                                                             about  the  earlier  versions  of  the  bill.   It aspect   of    the    Regional    Medical    Pro- was   interlaced   throughout    the    three
                                                             was    clear    from    the    discussions    that gram   was   regarded   as    sufficiently    im- sessions  and  seemed  to  be  the   one   on
                                                             the   nature   of   the   program   direction   in portant    to    warrant    an    amendment    to which  most  of  the   participants   claimed

                                                                                                                                                                                                     63




                                                                                                                 REPORT: Regional Medical
                                                                                                                 Program Coordinators
                                                                                                           I     Edmund D. Pellegrino, M.D.                   there was  a  real  need  for  construction
                    at least a  bit  of  expertise  and  concern- Flexibility-the Real Challenge                 Director, Medical Center and Professor       of facilities  at  community  hospitals  to
                    ing  which  there  were   some   strong   and Withal,  the  discussions   pinpointed   the   and Chairman, Department of Medicine         implement    programs     of     continuing
                                                           under- flexibility which is intrinsic in  the  pro-                                                             ether   this    should    come
                    fixed  feelings.  it  is  entirely                                                           state university of New York at              education. Wh
                    standable   why   groups,   such   as    this grams  and   served   to   assure   partici-
                                                  area        and                                                Stony Brook                                  from Hill-Burton funds,  the  hospital  it-
                    one, should seize on such an                pants  from  widely  separated  regions   of     Member, National Advisory Council on         self,  or  a  revised  RMP  law   was   not
                    tease  away  at  it,  if  not   continuously, the country that the potential for '                                                        agreed   upon   and   no   firm   recommen-
                                                                                                         'M'     Regional Medical Programs and
                    at  least   repeatedly.   Continuing   educa- aginative   and   innovative   thinking   at                                                tion   was   made.   The   impression   was
                    tion  is  a  subject  that  is  uppermost  in the local and regional  level  is  the  real   member, Ad Hoc Committee for the             da
                                                                                                                 Report to the President and the              clear that if the  concerns  of  the  prac-
                    the   minds   of   both   academicians    and challenge  of  the  legislation.  The   con-   Congress                                     ticing profession could  be  allayed,  con-
                    practitioners,  for  each  is   forever   re.                                                                                                               ould    indeed    satisfy
                                                                versations  reflected  further  a  sense  of                                                  struction funds w
                    minding  the  other  that  there  should   be relief  that   no   single   area   of   the   The   discussion   in   group   5   was   con' an  important  functional  need  not  pres-
                    more to it  and  it  should  be  better.  The country  had  either  a  corner   on   plan'   ditioned   somewhat   by   its    composition- ently met by rental,  renovation  or  Hill-
                    chairman   attempted   to   probe   precisely ning  competence  or   any   magic   potions   it consisted   of   the   coordinators   Of   all Burton funds.
                    what  was   meant   by   "continuing   educa- that  could  produce  a   live,   effective,   regional   programs    approved    to    date.
                    tion,"  what  its  content  should  be,   how "instant" regional medical program.            The   opinions   expressed   were   based   in Relationship of Regional Medical
                    content    should    be    determined     and More    th,an  anything  else,   the   confer- some     operating     experience,     however Programs and Comprehensive Health
                    tested  for  validity,  by   whom   and   how ence  brought  together   individuals   with   slight,  and  covered  most   areas   of   the Planning Legislation
                    often  reviewed.  it   was   further   asked, widely   diversified   backgrounds,   objec-   country.                                     A matter of obvious  concern  for  all  the
                    "What is the proper  setting  for  this  edu. tives,  attitudes  and  motivations  for   a                                                coordinators  was  the  present   and   fu-
                    cational  process?  How  will   the   results
                                                  tools       and day and a  half  of  ventilation,  idea  ex-   Construction Funds                           ture  relationship  of  P.L.   89-239   and
                    be appraised? What kinds of                                speculative     conversation.     The  c  ordinators  did  not  exhibit  a  con- P.L.  89-749.  Very   few   were   familiar
                    techniques   are   needed?   How   can   they Change and                                        0                                         fwith   the   details    of    Comprehensive
                    best  be  utilized?"  There  was  as  wide  aAs  the   chairman   said   in   summarizing    sensus  on the     important     matter      o
                    disparity  in  responses   to   these   ques- the  conference,  "Regional   medical   pro-   construction  funds  as  part   of   any   re- Health  Planning  legislation.  One  urgent
                    tions,  in  this  setting,   as   there   has grams   have   brought   together    strange   vision   of    P.L.    89-239.    Most    were need  seemed  to  be  for  each   coordina-
                    been  on  the   national   scene   where   it bedfellows; however, they are  still  a  bit   greed  that  the  housing   of   central   fa- tor  to  have  as   much   information   as
                    may  not  be   much   of   an   overstatement reluctant to turn out the lights."             cilities  and  administrative  staff   was   asoon as it  is  available.  The  group  ap-
                    to  call  present  efforts  something  of  an                                                functional   necessity   in   regional    pro- parently  felt  that  much   depends   upon
                    educational wasteland.                                                                       grams.   But,    rather    firm    differences the  agency  selected  to  administer  P.L.
                    in   spite   of   the   generally   expressed                                                were  expressed   on   the   matter   of   how 89-749  in  any  state.  In  those  regions
                    doubts  as  to  both  the   goals   and   the                                                to  finance  such  facilities  and  where   to involving cooperative        arrangements
                    techniques   of    contemporary    continuing                                                place   them.   There   were   clear   indica- which cross state  lines,  there  was  gen-
                    education  'Programs,  many   of   the   par-                                                tions   that   the   relationships    fostered uine  concern  that  confusion        and
                    ticipants  were  willing,  even   eager,   to                                                thus   far   between   medical   schools   and conflict  would  occur   if   Comprehensive
                    settle  most  of  the  efforts,   funds   and                                                practitioners  by  RMP   were   still   rather Health  Planning  were  assigned  to  state
                                                                                                                 precarious.    Construction    of    an    RMP health departments.
                    hopes  for,   the   regional   medical   pro-
                    gram  concept  on  this   one   area,   which                                                facility   on   a   medical   school    campus The  need  to  coordinate  the  efforts  of
                    both   the   medical   education   establish-                                                would  reinforce  the  fears  of   the   prac- these two  pieces  of  legislation  at  the
                    ment  and  practitioners  readily  agree   is                                                ticing  profession  that  the   program   will national level was  seen  by  all.  Further
                    important   and   essentially    n6nthreaten-                                                ecome medical center dominated.              questions  concerned   better   definitions
                    ing to  existing  patterns  of  the  delivery                                                Both   practitioners   and   medical    school of  relationships   of   Regional   Medical
                    of health services.                                                                          representatives,  however,     felt       that Programs  to  all  Public  Health   Service
                    64









     programs and to Hill-Burton programs.          ongoing    evaluation    of    methods    and   of   matters   of   immediate    concern-like   Inter-Regional Coordination
     Most  coordinators  seemed   to   feel   that  Procedure.   In   addition,   such   meetings   developments    in    CHP,    awarding     of   Some   form   of   inter-regional    coordi-
     their   present   efforts   under    Regional  would  impart  some   sense   of   unity   to   grants,   etc.-was   suggested    and    wel-   nation   was   considered    desirable    by
     Medical     Programs     would     eventually  the  entire  program  and  facilitate  inter-   comed by all.                                    any  of   the   coordinators.   Some   have
                                                    regional cooperation.                           A   meeting   between   representatives    of   m
     evolve    into     comprehensive     planning                                                                                                  already  engaged  in  such   meetings   with
     even  though  the  present  effort  is  cate-  The    program     coordinators     expressed   the     Comprehensive     Health     Planning   programs  in   contiguous   areas.   Support
     gorical.   As    "related    diseases"    are  the  need  for   an   organ   of   communica-   group   and    the    program    coordinators   for  other  inter-regional  activities   be-
     gradually   included    in    RMP    planning  tion  with  the  RMP  Washington   staff.   A   was  strongly   urged   and   is   recommend-   sides   meetings   was    acknowledged    by
     and    operation,    they    thought     some  newsletter   informing    all    coordinators   ed unanimously to the staff of RMP.
     means    of    interdigitating    with    CHP                                                                                                  some.  Such  support  might   be   used   to
     would   become   essential   at   local    as                                                                                                  encourage     inter-regional      evaluation
     well as national levels.                                                                                                                       efforts to  enable  the  sharing  of  scarce
     Some   of    the    coordinators    indicated                                                                                                  personnel  and   to   foster   comparability
                                                                                                                                         I  I       of   computer   programs   and   information
     that   in   their   states   RMP   and    CHP
     might  be   handled   by   the   same   body.                                                                                                  networks.
     Others    suggested    interlocking    boards
     as   providing   a   reasonable   means    of                                                                                                  Categoric@ Emphasis
     communication and coordination.                                                                                                                The   present   categorical   emphasis    of
     One view held that RMP should       be   lim-                                                                                                  RMP  apparently   has   not   produced   any
     ited  to  demonstration  and       that    it                                                                                                  serious  problems  to   this   point.   Most
     should turn its programs over       to    CHP                                                                                                  coordinators  felt   that   at   this   time
     when  they   are   fully   operational.   An-                                                                                                  there is sufficient  flexibility  to  permit
     other   opinion   stressed   the   importance
     of  RMP  even  in  the  presence  of  a  well                                                                                                  rather broad planning.
     developed   CHP.    Under    these    circum-                                                                                                  No   strong   impressions   were    recorded
     stances,  many  said,  the  categorical   ap-                                                                                                  on the  functions  and  responsibilities  of
     proach  would  be  an  advantage   since   it                                                                                                  Regional   Advisory    Groups.    Apparently
     covers   a   more   manageable   and   easily                                                     A                                            the  coordinators  are  feeling  their   way
     identified set of disorders.                                                                                                                   and  trying  to  meet  the  requirements  of
     The  coordinators   were   unanimous   on   a                                                                                                  the  legislation  in  a  variety   of   ways
     number of points:                                                                                                                              suited to local requirements.
                                                                                                                                                    There  was  general  satisfaction  with  the
     Increased Communication for                                                                                                                    law  as  now  drafted  and  a  general  con-
     Unified Cooperation Action                                                                                                                     sensus  that  the  program   was   too   new
     All   expressed   a   need   for   continuing                                                                                                  to  sustain  drastic  changes.  The   gener-
     contact  with  each  other  under  the   aus-                                                                                                  al  nature  of  the  present   law   permits
     pices  of  the  RMP  staff.   Regular   meet-                                                                                                  the  high  degree   of   flexibility   which
     ings    were    recommended    to     provide                                                                                                  each   coordinator   apparently   feels   is
     each  coordinator   with   the   benefit   of                                                                                                  essential  in  evolving  a   program   which
     experiences   in   other   parts    of    the                                                                                                  meets  the  specific  needs  of  a  particu-
     country  and  afford   a   ready   means   of                                                                                                  lar region.

                                                                                                                                                                                             65






                      REPORT- Practicing Physicians


                      Bruce W. Everist, M.D.                         practitioner   for    continuing    education  ious   about   the   ways   and   means    of  might  be  10  years  ahead  of   its   time.
                      Green Clinic                                   seemed  to  be  the  key  issue  as  seen  by  evaluation.  No  one   mentioned   the   pos-  Others  felt  that  we  should   wait   until
                      Ruston, Louisiana                              this  group.  They  felt  that  this  was   a  sibfe  invasion  of  the  privacy  of   prac-  the   medical    manpower    situation    had
                      Member, National Advisory Council         on   more   serious   problem    for    physicians  tice  and  it  seemed   the   paramount   is-  improved   before   continuing    the    pro-
                      Regional Medical Programs and                  than   for   paramedical   personnel    where  sue was improvement in patient care.           gram.
                      Member, Ad Hoc Committee for the               motivation   can   more   easily   be    sup-                                                                         -federa   f   nancing
                      Report to the President and the                plied. The  group  felt  funds  for  training  A  less  surprising,  but  unexpected,   turn  The question of non             I  i
                      Congress                                       paramedical   personnel   were    a    neces-  of  the  discussion  was  toward   the   dol-  was  brought  up  briefly.  It  was  felt  by
                                                                     sity.                                          lar  value  of   the   program.   The   group  several that  local  initiative  and  sharing
                                                                                                                    dealt   with   the   problem    unemotionally  of  cost  was  a  superior   arrangement   to
                      Discussion  group  13  was   made   up,   in   Cooperative Arrangements                       and  reiterated  the   need   to   show   the  100% grants.
                      general, of doctors  in  the  private  prac-   Cooperative    arrangements     were     men-  economic   advantages   of    this    program  There   was   a   near   consensus   on   the
                      tice  of   medicine   with   strong   repre-                                                  over others. Several  felt  that  the  desig-  inadvisability  of  changing   the   law   in
                                                                     tioned  by  several,  noting  that  this  law  nation of  regions  allowed  for  better  ad-
                      sentation  by  the  presidents  of   organi-   has   given   impetus   to   many    coopera-                                                 any  important  area  at   this   time.   The
                      zations  representing   men   in   practice.                                                  ministration  of   the   program   and   th!t  group felt that it  was  too  early  to  give
                      Most  of  the  discussants   had   come   to   tive  arrangements   not   previously   made.  the   federal   government   should    voucn-  a  valid  judgment  and   that   they   would
                      Washington  to   criticize,   the   program,   Several   had   noted   the   frequency    of  safe quality control.                          like  to   see   the   law   continued   long
                                                                     meetings  among  health   officials,   hospi-
                      not to praise it. Initially, there  was  the   tal  administrators,  practicing   physicians                                                 enough   to   make   a   proper   evaluation.
                      usual ritual of  damning  all  federal  pro-   and    lay    health    organizations.    The  Categorical Emphasis                           In general, they felt  that  the  law  as  it
                      grams but  in  this  group  it  was  carried   demonstrations  of   patient   care   section  The  categorical   emphasis   of   the   pro-  is  parallels  other  federal  programs  that
                      on  with   more   ceremony   than   meaning.   of  the  law  was  applauded.  The   men   in  gram  seemed  agreeable  to   most   of   the  are  directed  in  large  part   toward   di-
                      Most of  the  group  had  a  clear  idea  of   practice  felt  this  was  still   the   best  discussants.   The   views   expressed   were  rectly   affecting   patient   care,   rather
                      what  the  program  is  about.  A   minority   known   method   of   continuing   education.  those  relating  to  a   need   for   limited  than  indirectly  affecting    it     through
                      had a distorted view.                                                                         and  workable   programs   in   the   disease  research.
                      Pervading  the  meeting  was   the   overall   Evaluation                                     categories cited in the law.                   In  summary,  the  group  was  in  favor   of
                      feeling  that  though  those  present   were   A  surprising  aspect   of   the   discussion                                                 extending the law virtually        unchanged.
                      certainly  critical  of  the  program   they   was  the  sophistication  and  concern   rel-  Construction                                   They were not in favor of a    request    for
                      were  also   cognizant   of   a   need   for   ative to  evaluation    of    the    program.  The  majority  of  the  group  was   not   in  construction   funds.    They    were    con-
                      change  and   were   willing   to   consider   Most felt that    an    unexamined    program  favor  of   requesting   construction   funds  cerned   about   program   evaluation,    the
                      any   reasonable    proposal.    The    con-   would   be   worthless   and   that   meticu.  at  this  time.  The  reasons   were   sever-  co.st  dollar,  and  new  ways   to   motivate
                      tributions  to  the  discussion  were   con.   lous care should  go  into   new   ways   and  al,  i.e.,   too   expensive,   adequacy   of  private   practitioners   toward   continuing
                      cerned  with  the  major  problems  of   the   means  of  evaluation,  and  that   the   re-  present  construction  authority,  the   fear  education.
                      program  and  scant   attention   was   paid   suits   of    each    region's    experiences  of  a  change  in   the   emphasis   of   the
                      to  petty  issues  and   personal   idiosyn-   should  be  shared  by  all.   The   majorit@  program,   and   the   quality   of   patient
                      crasies.                                       felt  that  the  program   must   be   provea
                                                                     valid  before   long   term   extension   can  care  should   have   priority   over   build
                      Continuing Education                           be  advised.  On  the  other  hand,  it   was  ings.
                      Continuing education   was   discussed    at   agreed   that  several   years         should
                      length  by  the  group  and  though   nearly   elapse   after   operational   programs   are  Other Items
                      all  felt  that  it  was  needed,   no   one   under  way  before   a   pertinent   analysis  Some    general     philosophic     questions
                      seemed  to  have  a  clear  idea  of   meth-   can  be   made.   No   one   in   the   group  arose.  The  question  of  timing  was   dis-
                      odology.   Motivation   of    the    private   seemed   particularly   concerned   or   anx-  cussed.   Some   felt   that   this   program

                      66






        REPORT: Interpretation and
        Administration of the Act


        Paul M. Ellwood, Jr., M.D.                                                                         pered   by   knowledge   that   few    programs   the  categories  be   hardened   rather   than
        Executive Director                                                                                 had   full-time   staff,   acknowledged   lead-   softened?  It   might   be   speculated   that
        American Rehabilitation Foundation                                                                 ers,  or   time   to   develop   agreement   on   there   was   unspoken   and   perhaps   naive
        and Clinical Associate Professor of                                                                real  or  tentative  plans.   Even   with   the   belief  that   greater   categorization   just
        Physical Medicine and Rehabilitation                                                               passage   of   time   and   with   the    emer-   couldn't happen.
        Clinical Associate Professor of                                                                    gence   of   structure   and   leadership    it
        Neurology and Pediatrics                                                                           must   be   assumed   that   highly    success-   Money, Sharing, and Continuity
        University of Minnesota                                                                            ful   new   regional   arrangements   for   the   Payment    mechanisms     outside     Regional
        Minneapolis, Minnesota                                                                             diseases   under   attack    will    be    rare   Medical   Programs   do    not    exist    for
                                                                                                           events.   It   would   therefore   seem    wise   starting   or   sustaining   a   program    of
                                                                                                           to   construct   a   superb   educational   and   this  scope.  Money   as   an   incentive   to
        The flexibility that  is   evident   in    the
                                                                                                           intelligence  system  to   spot   these   valu'   begin  and  to   continue   will   be   neces-
        enabling  legislation  and  the  initial   ad-                                                     able   rare   events   as   they   emerge   and   sa ry.
        ministration   of   the    Regional    Medical
                                                                                                       1   to   rapidly   permit   others   to   hitchhike
        Program    for    Heart    Disease,     Cancer                                                 i,  on  the   originators'   successes.   If   per-   There   was   general    support    for    the
        and  Stroke   apparently   is   conducive   to                                                     massiveness  is  next  to  godliness,   so   is   ideal  of  a  partnership  between  the   pri-
        individual  initiative  and   hopefully,   in-                                                     plagiarism next to originality-                   vate   and   public   sectors   in   financing
        novative  solutions   in   the   several   re-                                                                                                       the   Regional    Medical    Programs.    Some
        gional   programs.   The   participants    ex-                                                     Categorical Emphasis: "We can live                expressed   skepticism   that   private   sup-
        pressed   satisfaction,    even    enthusiasm,                                                     with it if you don't enforce it."                 port   would     be    more     than     token
        for  the  permissive  features  of  the   pro-                                                     The  Regional  Programs'  avowed           pur_   amounts   until   ideas   proved    themselves
        gram.  If  there   was   any   manifest   anx-                                                     pose   of   breaking   down   old   inhibitions   @nd  .look  their  place  along   with   other
        iety   about   the   present    approach    it                                                     to  the   rapid   diffusion   and   application   Tunctional  elements  of   the   health   care
        came   from   some   allied   health   profes-                                                                                                       system.
        sions   and    voluntary    health    agencies                                                     of   discovery   to   everyday   medical   care
        who  would  advocate   the   use   of   guide-                                                     coupled   with    the    programs'    retention   The  medical  school   deans   in   particular
        lines  or  regulations  to  assure   inclusion                                                     of    hardened    categorical    disease    em.   were  outspokenly   reluctant   to   start   a
        of their particular group.                                                                         phasis   may  seem         inconsistent.     It   program    without    some    assurance     of
                                                                                                           would   indeed   be   inconsistent   were    it   continuing  but  not   necessarily   spiraling
        At  this  admittedly  early   stage   in   the                                                     not   for   enlightened    administration    of   financial support.
        life  of   the   program,   group   6   demon-                                                     the   Regional   Programs   thus    far.    Our
        strated  few   if   any   tangible   evidences                                                     group  did  not  dispute  the  political,   so-   Random but Important Thoughts
        of  the  possible  benefits  of  the   permis-                                                     cial,   or   perhaps   even   the    biological   Information  systems  are  critical   to   the
        sive   approach   in   the   form   of   truly                                                     wisdom   of    focusing    this    effort    on   program.   The   contents    of    the    Blue
        creative  regional  planning.  None   of   the                                                     cancer,  heart   disease   and   stroke.   They   Cross   information   system   are   available
        programs    represented    defined    specific                                                     didn't   wholeheartedly   support   it   either   to the program.
        integrating    methodology     or     concepts                                                     -they   accepted   it.   They    accepted    it   There  is  not  such  a  great  disparity  be-
        that  held  promise  of  delivering   on   the                                                     on  the  premise  that  this  is  a   realistic   tween   the   physician   and   new    methods
        original   vision   of    regional    arrange-                                                     way to achieve a difficult objective.             as  there  is  between  the  needs   of   peo-
        ments,                                                                                             It  is  important   to   recognize   the   con-   ple and the demand for medical care.
        Creativity                                                                                         text   in   which    this    endorsement    was
                                                                                                           given.  It   was   given   passively,   without
        This   estimate   must   be   strongly    tem-                                                     consideration   of   the    question:    Should

                                                                                                                                                                                                        67





                     Staff Summary

                     Group Ditcussions:                                funding    for    Regional     Medical     Programs the   regions.   The   group   felt    that    such which  has  not  yet   been   laid   to   rest,
                     Problems   and   Policy    Issues                 seemed      high.       Some       misunderstanding allocation    is    necessary    in    order    for and    accentuate    the    town-gown    split.
                     0   Continuation of the Program                   of   the   program    was    also    evident,    as each  region   to   receive   a   fair share       of Others    felt    that    construction    needs
                     0   Construction of New Facilities                fears     were     expressed     concerning     the available Federal funds.                        could   be   adequately   met   under   present
                     0   Relationship of Federal and Non-              development    of    regional     medical     "cen-                                                 -programs  ' through   changes   in    existing
                                                                                                              ,d         Nearly    every    group    discussing the        top
                         Federal Funding                               ters"  to  which  patients  wou                   be ic   related   continuation   of   the progra  mauthorities,   or   through   more    extensive
                     0   Inter-Regional Support Activities             directed.                                         to  (1)  the  need  to   resolve   the relation-  use   of   the    construction    possibilities
                     0   Interpretation  of  the   Act                 At    one    session    there     was     extensive ship       betwen       Comprehensive        Health under the present RMP authority.
                     0   Categorical Emphasis                          discussion of the need for               continuing Planning  (P.L.  89-749)  and      Regional     Among   those    who    favored    construction
                                                                       planning    activities    as    part     of     the Medical   Programs;    and    (2)    whether    the authority,  either  now  or  in   the   future,
                     Continuation   of   the   Program                 operational     phase     of     regional      pro- scope     of     Regional     Medical      Programs the   need   was   recognized   for    specific
                     Discussion  of  this  issue  focused  on   the    grams.     There     was     uncertainty      about should     be     categorical     or     comprehen- facilities   which   fell   into   four   broad
                     progress   made   in   the   development    of    long-term    support    for    planning     activi- sive.                                           categories:
                     cooperative   arrangements,   and    on    the    ties   in   contrast    to    "action"    programs.                                                 0   For   continuing   education   and   train-
                     potential  for  future  progress.   The   con.    It   was   stated    that    rushing    into    the Construction of New Facilities                  ing   purposes.   The   needs   of    community
                     sensus  seemed  to  be   that   although   the    operational    phase    of    a    program    with- Comments on the need for           construc-    hospitals  in   this   regard   were   particu-
                     ultimate   effectiveness   of   the    program    out   careful   planning   could    prove    detri- tion    authority    covered    a    wide     spec- larly   stressed   and   included    the    up-
                     cannot    be    accurately    determined    at    mental in the long run.                           trum.    No    clear-cut    major@     "for"     or grading    and    expansion    of    laboratory
                     this  early  stage,  progress  to   date   ap-    0   the   as.sumption     that     Congress      will "against"      construction      emerged.      This facilities  to  be  used  in   training   para-
                                                                       n
                     pears promising and that the      .    program    extend    the    life    of    Regional     Medical issue    clearly    posed     a     dilemma     for medical   personnel.    However,    needs    of
                     has   great   potential.    The    discussions    Programs,     several     factors     were     dis- many.   Some   of   those   who   saw    a    clear medical  schools   for   postgraduate   facili-
                     concerning   current   needs   and   desirable    cussed   as   being   important   to    its    suc- need    for     and     philosophically     favored ties   were    also    mentioned    since    no
                     programs   indicated   there   should   be   a    cess:                                             construction,     argued     against     it      on money   is   available    for    these    under
                     continuation  of   the   program.                 0    Advisory    Committees    must    be     deep- pragmatic   grounds.   They   felt    that    plan. existing programs.
                     It  was  generally  felt  that   the   present    ly interested and actively involved.              ning   was   not   far    enough    along    across 0  For  specialized   facilities   for   demon-
                     3-year   authorization   will   not    provide    0   Regional   programs    must    not    be    re- the   country   to   build   a   good   case    for stration   purposes    necessary    for    both
                     enough   time   to   put   adequate   regional    garded   as   merely    a    means    of    setting such   authority.   Some   felt   that   a    clear continuing     education     and     up-grading
                     programs  into  operation.   It   was   point-    up medical complexes.                             idea  of  the  types  of  facilities   which   will of care.
                     ed out  several  times  that  wit h   only   two  0    Active     participation     of     practicing be    needed    when    programs     are     estab- 0  For  central  or  core  facilities  such  as
                     years   of   the   present   program   remain-    physicians is essential.                          liihed   has    not    been    developed.    Others computer   and             tefe-communication
                     ing, it  is  difficult  to  recruit  personnel    0   Proprietary    hospitals    should    be    in- had     reservations     in     connection     with centers.
                     of  the   quality   needed   to   insure   the    cluded in the program.                            how   this   would   affect    the    funding    of 0 For housing administrative staff.
                     success   of   regional   programs.    Several    0    Adequate    support    must    be     acquired other     construction     programs     such     as Most  of   the   alternatives   to   RMP   con-
                     statements   were   made   to    the    effect    from State and private sources.                   Hill-Burton    and     how     Regional     Medical struction  were   viewed   as   providing   on-
                     that it will  be  5  to  7  years  before  Re-    n   one   group   it   was    emphatically    stat- Programs would coordinate with them.            ly partial answers. For example:
                     gional  Medical  Programs  will   affect   pa-
                     tient care widely.                                ed    that    local    advisory    groups    cannot References   were   made   by   those    not    fa- 0   Renovation   is   frequently   not   possi'
                                                                       effectively   establish    priorities    or    make voring    separate     RMP     construction     au- ble.   Many   hospitals,   especially   smaller
                     Some   practicing   physicians    felt    that    decisions    without     some     indication     of thority  at  this   time   to   the   fears   "con- ones,  do  not   have   any   "excess"   space'
                     the    gap    between    medical     knowledge    the   dollar   amount   available   to   the    re. struction"   would   arouse   on   the   part    of The  same  is  true,   though   to   a   lesser
                     and    practice    had    been    exaggerated,    gion.    It    was    recommended    that     mini- practitioners     and     community      hospitals. extent,   for    certain    medical    schools-
                     and   that   the   contemplated    level    of    mum   operational    funds    be    allocated    to It   could   revive    the    "centers"    concept, new ones and the "have not's."
                     68








                                                                 0   Rental   might   in   large   measure   meet   become      self-supporting.      This      would    ments   might    be    destroyed    if    these
                                                                 the  needs  for  office  space,  but   not   for   not   only   bring   in    local    funds,    but    were  required.  The  concept   of   a   flexi-
                                                                 specialized facilities.                            would      phase      demonstration      projects    ble, balanced      support            mechanism
                                                                 0  Hill-Burton  is  not  really  a  viable   al.   into  the  overall   system   of   local   health    seemed   more   desirable.   If    construction
                                                                 ternative-the     funds     are     insufficient   services.    Concern    was    expressed,    how-    authority   was   approved   for    the    pro-
                                                                 and   matching   would   be   a   very   serious   ever,   that   support   might    be    withdrawn    gram,   then   more    specific    requirements
                                                                 obstacle.                                          prematurely     and      projects      abandoned.    relating   to   construction   might   be   de-
                                                                                                                    In   this   same   connection    the    apprehen-    veloped.
                                                                 In  sum,  the  reactions   of   the   discussion   sion   was   expressed   that   Regional    Medi-
                                                                 groups    were    mixed.     Many     Conference   cal    Programs    might    prime    the     pump    Inter-Regional Support Activities
                                                                 participants   recognized   that   new   facili-   and   then   leave    regional    res.ources     to
                                                                 ties'would   be    necessary    to    accomplish   support  the  cost.  It  was  noted  that   local    The   need   for   interregional    cooperation
                                                                 the  objectives   of   Regional   Medical   Pro-   money   would    be    obtained    more    easily    was  recognized  by  virtually   all   of   the
                                                                 grams.    But    the    question    of    "when"   if  the  operational   projects   were   of   ob-    discussion  groups.   Some   felt   this   need
                                                                 and    "by    what    mechanism"    such    con-   vious benefit to the public.                         should   be   met   by    informal    relation-
                                                                 struction    should    be    supported    turned                                                        ships   among   the   regions,   while   others
                                                                 out to be the real issue.                          The   problem   of    providing    a    mechanism    felt   new   mechanisms    to    support    in-
                                                                                                                    for   coordinating   multiple    financing    was    terregional   activities   should   be   devel-
                                                                 Relationship of Federal and Non-                   discussed    by    some     participants.     One    oped.
                                                                 Federal Funding                                    group    recommended    that    the    regi    na
                                                                                                                                                              @  .  1    Interest in  this  area  is  indicated  by  the
                                                                 The   question   of    Federal    and    non-Fe-   core  receive   full   Federal   support,   wniie    number     of     interregional     conferences
                                                                 deral   funding   was    discussed    by    most   the   operational      projects     would      be    ]ready  held,  including   a   regular   series
                                                                                                                    funded   on   a    variable    matching    basis,
                                                                 of  the  groups,  with   few   strong   feelings   depending   on   the   local   resources   avail-    In   the   Northern   New    England-New    York
                                                                 as   to    how    the    problem    should    be   able.   Others   suggested   that    there    was    area,  meetings   of   Ohio   Valley   regions,
                                                                 solved.   Most   of   the   groups   agreed   to   merit   to   partial   local   funding   of   the    and  others  for   the   Western   States.   In
                                                                 the   principle   that   the   private    sector   core unit.                                           the    Northern     New     England     region,
                                                                 must    supplement    and     complement     the                                                        a   formal   interregional   relationship   has
             MIMI                                                funds   provided   by   the   Federal    sector;   Some    discussants    related     funding     to    been   developed   for   data   gathering   and
                                                                 that   sharing   of   costs   increases    local   the   view   of   Regional    Medical    Programs    communication.
                                                                 initiative  and   forces   a   greater   commit-   as   an   interlocking,   collaborative   effort.    It   was   generally   agreed   that   regional
                                                                 ment   to   the   program.   In   this   connec-   This  view  holds  that  in  order   to   coordi-    boundaries  are  not   yet   firmly   delineat-
                                                                 tion,  the  large   investment   of   time   and   nate    funding,    RMP    must    defin!     th!    ed,  and  that  they   should   remain   flexi-
                                                                 money    by    interested    individuals     and   principles   governing   the   distribution    Or    ble  in  order  to  respond  to  future  devel-
                                                                 organizations     in     developing     applica-   funds,   possibly   by   defining   more   clear,    opments.   In    addition,    since    regional
                                                                 tions  was  cited  as   evidence   of   such   a   ly   the   role   of   the   various   interested    boundaries   do   not   lend   themselves    to
                                                                 commitment.                                        groups   involved.    Some    voluntary    health    cope  with   all   the   health   problems   of
                                                                 Several     discussants      recognized      RMP   agencies   were    participating,    for    exam-    -n  area  (e.g.,   regional   distribution   for
                                                                                                                    ple,   but   were    concerned    about    losing    a
                                                                 funds   as   "seed   money"   but   each    dis-    ,-                                                  patient   care   is   not    necessarily    the
                                                                 cussant   came   to   a    slightly    different   Eneir  identity   in   the   program.                same    as     for     education     programs),
                                                                 conclusion  about   it.   One   individual   in-   Specific     matching      requirements      were    flexible   regional   boundaries   and   strong
                                                                 sisted   that   it   be    clearly    understood   generally    opposed,    with     the     feeling    interregional    cooperation     are     useful
                                                                 that    pilot    programs    must     ultimately   that     developing     cooperative      arrange-    and necessary.

                                                                                                                                                                                                                      69





                 The  discussion   of   grant   support   for   interpretation of the Act                      Group    members    may    represent    more  ed  covered  the  entire  spectrum  of   pos-
                 certain  interregional  activities   brought   There  were  a      number     of     issues   than  one   of   the   required   categories  sibilities. The  consensus,          however,
                 forth   a   number   of   advantages   which   brought  up  which  reflected  either:   (a)   was also raised as a question.                seemed to    be in  favor  of  retaining  the
                 might be derived:                              confusion   about   and    misinterpretation   It  was  felt   that   the   program   needs  categorical limitations,  at  least  for  the
                 ,O interregional       communication     and   of  the  Act;  and   (b)   suggestions   for   health    manpower    training    provisions  present.
                 the sharing  of  regional  capabilities  and   clarification or  improvement  of  the  leg-   with   emphasis   on   paramedical   person-
                 strengths would be encouraged.                 islation or guidelines.                        nel training.  There  is  uncertainty  about
                 0  Scarce,  skilled   manpower   and   other   The  phrase,  "the   opportunity   of   mak-   what  can  be  funded   by   RMP   in   this
                 specialized   resources   would   be    more   ing available to  their  patients  the  lat.   regard.
                 effectively utilized.
                 0  Comprehensive  evaluation   on   an   in-   est  a
                                                                .    dvances,"    caused     some     confu-   tthhee prroloegraofmthweaspracticing physician in
                 terregional basis could be developed.          sion.  Among  various  interpretations,   it                      stressed,   noting   that
                 0   Communication    and    computer    net-   was  taken  to  mean  that  Regional   Medi-   it  is  through  him  that  individual   pa-
                 works  could  be  made   compatible.           cal  Programs  would   support   basic   re-   tient care  is  improved.  For  this  reason
                 0 National    leadership   and     coordi-     search,  diagnosis  and  treatment  to   the   many  believed  the   practicing   physician
                 nation might be developed.                     exclusion  of   prevention   and   rehabili-   should  be  closely  involved  in  the   de-
                 0   Such   efforts   would   contribute   to   tation, and  research  in  the  delivery  of   velopment  of  the  program.  It  was   rec-
                 maintaining  the  flexibility  of   regional   health  services   or   actual   improvement   ognized   special    provisions    may    be
                 programs.                                      in such delivery.                              necessary   to   reach   those    physicians
                 The most   frequently   mentioned    activi-   Questions  were   raised   about   the   re-   with no hospital affiliation.
                                                                quirement that   the  program   not   inter-
                 ties    recommended    for     interregional   fere with  patterns  of  financing,  patient   There   was    some    confusion    as    to
                 support were:                                  care,  or  professional  practice.  It   was   whether   local   programs   were   intended
                 0    Education,    including    programming,                                                  to   become   self-sustaining   after    the
                 via TV, radio and telephone.                   pointed  out  that   changes   in   patterns   planning  phase,  or  whether   they   could
                 0   Development    of    compatible    hard-   of  patient  care  are  obviously  going  to   expect   continued     Federal      support.
                 ware,   including   computers    and    com-   occur  as   the   program   is   implemented   Would  funding   be   limited   to   experi-
                 munications networks.                          and  that   the   whole   purpose   was   to   mental   programs,   or   would   wide-scale
                 0  Data  collection,  including  the  estab-   bring  about  a  change.  It  was   stressed   demonstration projects be supported?
                 lishment  of   compatible   techniques   re-   however,  that   the   program   would   noi
                 lated  to  disease  patterns   and   medical   change   the   physician-patient   relation-   It was felt  that  RMP  should  build  eval-
                 care administration.                           ships per se.                                  uation   into   the   program.   There   was
                 0   Development   of   interregional    sys-   In   connection   with   Regional   Advisory   some  suggestion  that   RMP   offers   many
                 tems of evaluation    to  effectively  iden-   Groups, it was  suggested  that  a  clearer'   avenues for setting  the  criteria  for  im-
                 tify national as well  as  regional  trends.   delineation  of  responsibility  be  defined   proved  patient  care,  possibly   by   pro-
                 0  Research   programs,   including   opera-   for  these  groups.  The   word   "advisory"   viding  guidelines   listing   indices   and
                 tions   research,   studies   of    manpower   seems   a   misnomer,   since   the   Guide-   their  applications  for   evaluating   pro-
                 and facility  utilization,  and  studies  of   lines  state   that   the   group   is   em-   grams.
                 health  needs  of  minority  groups.           powered    to    approve    or    disapprove   Categorical Emphasis
                 0  Development  of   interregional   facili-   projects.   Some    commented    that    the
                 ties and resources.                            program   has   not   placed   enough    em-   Discussion  on   whether   the   categorical
                 0   information   exchange   systems   among   phasis  on   public   or   consumer   repre-   emphasis   of    Regional    Medical    Pro-
                 regions.                                       sentation.   Whether    Regional    Advisory   grams  should  be  retained   or   eliminat-

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           Reasons   for    retaining    the    categorical   seemed      to     prefer     leaving       this
           limitations    ranged    from    questions    of   undefined and up to local judgment.
           proper  timing   to   outright   opposition   to   Those who favored broadening the            leg-
           broadening      of    the    legislation.      A   islation felt that the emphasis of           Re-
           number  of  participants  felt   it   might   be   gional    Medical     Programs     should     be
           premature   to    modify    the    law;    heart   upon    effectively     coordinating     diverse
           disease,   cancer   and   stroke    are    major   efforts   to   improve   the   Nation's   health
           problems   and   they   will   provide   further   and  upon   raising   the   quality   of   medi-
           experience   as   to   how   the   program   can   cal  care  delivered  to   the   patient   wher-
           be  expanded;   let   RMP   take   hold   as   a   ever   he   resides.   It   was   stated    that
           concept   and   an    approach;    don't    con-   these   goals   necessarily   transcend    cate-
           fuse   progress   by    introducing    questions   gorical  limitations.  This  group   felt   that
           about   disease   categories   now.   In   rela-   the   program   should   expand    to    include
           tion  to  this,  it  was  felt  that  there  was   the  entire   spectrum   of   health   care   in
           plenty  for  RMP  to  do  within   its   present   the   framework    of    regional    cooperative
           categorical    limits.    Some    offered    the   arrangements;   at   the    least,    the    law
           opinion   that    RMP    would    be    overbur-   should   be   changed   to   read   "and   other
           dened  if  it  had  other  major   diseases   to   major diseases."
           deal with.                                         Fear   was   expressed   that   if   the    pro-
           Some   felt   there   was   no   need   to   end   gram   were   limited    to    heart    disease,
           the    categorical    limitations    now,    al.   cancer   and    stroke,    this    would    only
           though   they    assumed    that    the    scope   lead   to   further   fragmentation    in    the
           of   the    program    would    inevitably    be   health   field.   The   fundamental   need   for
           broadened;   if   the   concept   of    coopera.   everyone   to    have    comprehensive    health
           tive  arrangements  proved   to   be   a   valid   services   was   expressed,   with   the    view
           one    for    heart    disease,    cancer    and   that  categorical   limitations   are   a   step
           stroke,  it  would  be  a  valid   concept   for   backward.   Planning   of    Regional    Medical
                                                              Programs     should     be     approached     in
           other diseases.                                    terms of patient needs.
           It was stated     that   the   cooperation    Of   Although   one   group    did    not    consider
           the practicing    physician  is   essential   to   the   categorical   limitation    a    hindrance
           the   success   of   the   program,   and   that   to  good  regional  planning,   they   did   see
           categorical  limits  on   the   scope   of   the   it  as  a  problem   in   developing   practical
           program   were   and   may   still    be    very   and     completely      "economical"      opera-
           important   to   a   large   segment   of    the   tional   programs.   Certain   of   these   pro-
           practicing   physicians.    There    was    also   grams,    such    as    continuing    education,
                                                          .   are   sure   to   extend   beyond   the    Cate-
           some    discussion    of    whether     "related   gorical    limitations    imposed     by     the
           diseases"   should   be    defined.    It    was   present   legislation.   It   did    not    seem
           recognized    that    some    medical     groups   prudent,  therefore,  to  limit   use   of   RMP
           wanted  definition  of   these   "related   dis.   operational   grants   on   a   narrowly   cate-
           eases,"    but    most     of     the     groups   gorical basis.

                                                                                                                                                                                                                71






                                                                                                                                        Section V-Excerpts From
                                                                                                                                        Post-Conference Letters



                                                                                                                                        All participants were urged  to  express
                                                                                                                                        their opinions not only during the  Con-
                                                                                                                                        ference itself but afterward by  letteri
                                                                                                                                        Many did, and in doing  so  helped  the.
                                                                                                                                        St'aff obtain a  clearer  picture  of  how
                                                                                                                                        Regional  Medical  Programs  are  viewed
                                                                                                                                        at the "grass roots" leveL









































                                                                                                                                                                            73





                   PARTICIPANTS EXPRESSED
                   THEIR VIEWS ABOUT ...


                                                                 when  the  grant  is  not  made  specifical-   groups  to   a   certain   extent   parallel  and    implementing    operational    grants
                   ... REGIONAL ADVISORY GROUPS                  ly to that organization.                       their responsibility for decisions.           for  particular  regions   using   some   of
                                                                                                                                                              what I  have  learned  in  our  sessions.  I
                   Much  concern   regarding   the   structure,  Darrell C. Crain, M.D.                         George E. Wakerlin, M.D., Ph.D.               am  writing  this  letter,  however,  as  an
                   the   representation,   the   veto    power,  Delegate, D.C. Medical   Society               Program Director                              individual physician in the program.
                   and  the  tenure  of  the   Regional   Advi-  Washington, D.C.                               Missouri Regional Medical Program                                          one   of    the
                   sory  Committees  was  expressed.  .   .   .                                                                                               It  seems  to  me  that
                   Several  regions   jumped   the   gun,   ap-                                                                                               significant strengths of  the  current  leg-
                   pointed    advisory     committees     which  The  present   advisory   groups   associat-   The  possibility  of  giving  authority  and  islation is the clear  fixing  of  responsi-
                                                                 ed   with    Regional    Medical    Programs   responsibility  to   Regional       Advisory  bil'ties for
                   took charge  of  the  whole  situation  with                                                                                                 I          health   care   planning    and
                   almost   complete   disregard   of    impor-  should  be  strengthened  by   more   exten-   Councils  to  establish     priorities    in  programming  in  the   hands   of   Regional
                                                                 sive  lay  representation.  In  my   opinion   grants,  before  grant  applications  go  to  Advisory grou
                   tant   segments   of    interested    groups                                                                                                              ps   who   are    individuals
                   within their areas.                           the  legislation  should  encourage   active   Washington,   was   discussed.   I   believe  identified  with  and   committed   to   the
                   There  was   much   concern   expressed   of  participation   by   business    and    con-   that   Regional   Advisory   Councils    al-  region they  serve.  It  is  this  facet  of
                                                                 sumer  groups  not  excluding   the   insur-
                   the  tenure  of  these   Regional   Advisory  ance  industry  which  serves   as   trustee   ready   possess   this    authority.    Some  the  program  which  makes   it   distinctly
                   Committees   for   many    reasons.    There  for some hundred million consumers.            i-zuidelines  from   Washington   indicating  different  from  systems  tried   in   other
                   is no law or.regulation  limiting  the  ten-                                                 that they were  expected  to  do  this  sort  countries  where  responsibilities  for  the
                   ure  of  these  committees  and   they   can  James F. Oates, Jr.                            of  thing  would  make   their   discussions  decisions  about  the  delivery  of   health
                   and  probably  will  be   self-perpetuating.  Chairman of the Board                          and   decisions   much   more    meaningful.  care  have   been   progressively   central-
                   There  was  a  strong  feeling  that   these  The Equitable Life Assurance                   I believe that  ours  would  be  willing  to  ized.  In  watching  dynamics  in  different
                   committees  be  subject  to   rotation   and  Society of the United States                   accept this responsibility.                   regions  to  date,  I   am   encouraged   by
                   limited  tenure  such  as  in  the  case  qf                                                 Russell C. Mills, Ph.D.                       the fact  that  various  health  groups  are
                   our Advisory Councils at NIH.                                                                                                              beginning to  really  talk  to  one  another
                                                                 The   medical   schools   of   the   country   Program Coordinator                           for the first time, to  explore  the  actual
                   Cornelius H. Traeger, M.D.                    may  have  too  important  a  role  in  this   Kansas   Regional   Medical   Program    and  needs in their  area  in  a  thoughtful  and
                   Practicing Physician                          program.                                       Associate Dean, University of Kansas          responsible  fashion,  and  to  design   re-
                   New York City and                             P. M. Huggin, M,D.                             Medical Center                                search   programs    to    determine    what
                   Member,   National   Advisory   Council   on  Medical Director                                                                             kind  of  health  care   is   required   and
                   Regional Medical Programs                     East Tennessee                                                                               how  it  can  be  delivered.  These   groups
                                                                                                                I  want  to  take  this  occasion  to   con-
                                                                 Tuberculosis Hospital                          gratulate   you   on   the   Conference   on  are  beginning  to  take  real   pride   and
                   It  is  necessary  to  include  more  laymen                                                 Regional   Medical   Programs    held    'in  pleasure  in  mutual   cooperative   efforts
                   in all  stages  of  the  program.  r)articu-                                                                                               designed  to  create  better  medical  care.
                   larly  as  members  of  the  Advisory   Com-  Missouri   RMP   has   found   that   commu-   Washington  on   January   15-17.   It   was
                   mittees.                                      nity  cooperative   arrangements   are   fa-   an   impressive   assemblage   of    talent,
                                                                 cilitated by  requiring  each  project  pro-   the  Conference  addressed  itself   to   an  I realize,  however,  that  unless  the  Re-
                   Many   feel   that   private   practitioners  posal  to  provide  for  a  comm ni            important problem, and  I  felt  all  of  us  view  Committee  is  terribly  clear   about
                   have  been  excluded  by  either  the   med-                                        u   ty   learned   much   from    the    proceedings.  its function, it runs  the  risk  of  making
                                                                 coordinating    committee    composed     Of
                   ical schools or  the  State  health  depart-  representative   health    profession    and   As  a  member   of   your   Review   Commit-  centralized    value  judgments        about
                   ments.  The  private   practitioner   should  lay  leaders  and  vested   with   decision-   tee, I have had  a  chance  to  think  quite  what  is  "important"  in   this   or   that
                   be  represented  on  the  planning   council  making responsibility.                         intensively  about  the  program.   I   thus  program  within  a   region.   As   planning
                   in every region.  Particularly  should  this                                                 thought  I  might  try  to  spell  out  some  and   operational   grants   are   reviewed,
                   representation   be    from    the    State,  There appears to be     evidence  that   the   of  my  thoughts  about  the  role  of   the  the    Review    Committee    will    become
                   county,   or   city   medical    association  contributions     of   regional     advisory   Regional   Advisory   Groups   in   planning  progressively   more   sophisticated.   This

                   74










           may   cause   it   to    develop    unwittingly   in  which  we  serve  the  health   needs   of   I  note  the  lack  of  any   official   repre-   those  who   are   not   participating   either
           some  rigidity  about   what   is   needed   in   the American people.                             sentation    from    any    voluntary    health   locally   or   nationally;   this   would    do
           regional   programs.   I   thus    hope    that   David E. Rogers, M.D.                            agency   in   the   Regional    Medical    Pro-   much  to  alleviate  the   effect   of   rumors
           this group will  try  to  keep  the  initiative   Professor and Chairman of the                    gram    National    Advisory    Council,    the   and   false   notions   regarding   the    pro-
           in  the  hands  of  the  region  and   careful-   Department of Medicine,                          RMP   Review    Committee,    or    the    Con-   gram.
                                                                                                              sultants   representing    National    Advisory
           ly  avoid   making   specific   judgments   re-   School of Medicine,                                                                                Edwin P. Jordan, M.D.
           garding     operational      priorities      or   Vanderbilt University and                        Councils with related interests.                  Executive Director
           specific items within the     context  of  'in-   Member, Regional Medical                         While it is true that advisory          commit-   American Association of
           dividual  proposals.  To     do    so     would   Programs Review Committee                        tees   to   planning   groups    have    repre-   Medical Clinics
           create  the   hazard   of   making   each   re-                                                    sentation   from   the   American   Heart   As-
           gional   program    resemble    every    other-                                                    sociation    and    the     American     Cancer
           precisely  the   thing   which   the   legisla-                                                    Society,   these   are   inevitably    isolated   A   newsletter   should   be    developed    by
           tion is designed to avoid.                        ... THE REVIEW COMMITTEE
                                                             AND THE NATIONAL                                 and   fragmented    and    not    capable    of   your  Division  which   could   keep   all   of
                                                             ADVISORY COUNCIL                                 bringing  to  bear  the   full   organizational   us  informed  as  to  the   progress   of   the
           I thus believe that all      involved      must                                                    strength  and  capabilities   of   the   volun-   program.    This    newsletter    could    also
           keep  in  mind  that   the   only   centralized                                                    tary health agencies.                             point  out   some   of   the   obstacles   that
           responsibility  to  judge  is  whether  a   re-
           gion  does   or   does   not   understand   the   Voluntary    health    agencies    are     not   How  important   it   would   be   to   utilize   may   have    been    encountered    and    how
           concept  of   a   regional   program,   whether   specifically  represented  on   any   of   the   fully  this  wealth   of   dedicated   individ-   these problems were solved.
           its   advisory   group   has    real    commit-   committees   which   comprise    the    review   uals   in   a   systematic   organized   manner   information    meetings    held    periodically
           ments   to   it,   and    whe*er    they    are   process    -for    Regional    Medical    Pro-   to  bring  into  reality   more   quickly   and   perhaps  on   a   regional   level   might   be
           moving  to  obtain  the   kind   of   personnel   grams.   Insofar   as   the   American   Heart   completely  the   goals   of   Regional   Medi-   very helpful as the program develops.
           who  will  plan   broadly   and   imaginatively   Association  is  concerned,  I  realize   that   cal Programs.                                     Guy F. Robbins, M.D.
           for  the  regions  that   they   serve.   Deci-   on  most   committees   there   are   individ-
           sions   regarding   priorities   for   specific   uals   who   for   one   reason   or   another   W. A. Krehl, M.D., Ph.D.                          Director of Planning
           projects,     what     particular      programs   are   strongly   oriented    towards    Heart.   Director, Clinical Research Center                Memorial Sloan-Kettering
           would  be  most   profitable   for   an   area,   Even  so,  I   hope   that   in   the   future   University Hospitals                              Cancer Center
           what  data  will  be  required  to   mount   an   when   vacancies   occur   on   these   review   University of Iowa
           effective    program,    etc.,    should    and   committees   that   representation   of    the
           must  be  decided  by  the   region.   Clearly,   appropriate    voluntary    health    agencies                                                     I  would   like   to   emphasize   the   impor-
           the   Regional-Planning   and   Regional    Ad-   will be considered.                              .  .  .   IMPROVED                COMMUNICATION   tance    of    Dr.    Vernon    E.     Wilson's
           visory  groups   must   feel   true   responsi-                                                    ABOUT                                             suggestion     concerning     the      dissemi-
           bilities  for   both   the   design   and   the   Lewis E. January, M.D.                           THE REGIONAL MEDICAL PROGRAMS                     nation   of   information   with   regard    to
           ways   of   implementing    their    particular   President                                        FROM NATIONAL SOURCES                             the  manner   in   which   individual   regions
           program.                                          American Heart Association                                                                         are   proceeding   with   their    work.    The
                                                                                                                                                                "Newsletter"   that   Dr.    Wilson    suggest-
           I  felt  your  conference  went  far  to  clar-                                                    My   general   impression   from    the    con-   ed would be extremely helpful.
           ify  this  important,  indeed,   central   the-   I  was  distressed  by   the   lack   of   any   ference   is   that   one   of   the    biggest   J. S. Denslow, D.O.
           sis,    upon    which     regional     programs   emphasis  or   consideration   of   the   role   problems  is  the   dissemination   of   infor-   Kirksville College of
           should  rest.  It  is  an  exciting  new   con-   of   voluntary   health   agencies   as   full   mation   both   by   regional          planning   Osteopathy and Surgery
           cept   and   will   make   important   and,   I   partners  in   the   development   of   "coop-   groups   and   at   the   national   level   on   Kirksville, Missouri
           believe,  profitable  changes   in   the   ways   erative arrangements."                           what   is   being   done,    particularly    to

                                                                                                                                                                                                             75









                    ... EVALUATION OF                                Others  are  dismayed  by  the  complexity       NEW CONSTRUCTION FOR                       several  members   in   attendance   were   a
                    OPERATIONAL ACTIVITIES                           of the process of evaluation-                REGIONAL MEDICAL                               bit  unhappy.  Apparently  they   felt   much
                                                                                                                  PROGRAM PROJECTS                               as  did  Dr.  Hudson  about   the   construc-
                                                                     My  opinion  after  a  lengthy  discussion                                                  tion  of  large  centers  to  which  patients
                    Some  regard  evaluation  as  one   of   the     was that  we  might  have  to  forego  the   Planning is not far enough along-              would  be  referred.  They  felt   that   the
                    chief strengths of the program-                  Regional  Medical  Programs  for  lack  of                                                  only function of  the  doctor  in  the  field
                                                                     adequate   methods   of   evaluating   our   I do not think any major changes          are  would  be  to  beat  the   bushes   to   find
                    The evaluation effort holds the       great-     progress. I  do  feel  that  an  obviously   needed  in  P.L.  89-239  this  year.  It  is  people who needed referral.
                    est responsibility  and  challenge  for  the     good  program  should  not  die  for  lack   simple,  permissive  and  allows  wide   lat,  William H. Raymond, M.D.
                                                                     of ultra-sophisticated    methods       of   itude  of  support  for  planning  and  oper,  Member, Albany Regional
                    future.  RMP  staff  should  draw   together     measuring   progress   even   though   one   ating activity.
                    those  interested  in  evaluation  from  the                                                                                                 Advisory Group
                    several  regions,  so  that  they  might  be     Of  the  most   encouraging   aspects   of   I  do  not  think  an   attempt   should   be
                    in  contact.  This  could   also   encourage     the  Regional  Medical  Programs  is  this   made  .  .  .  to  provide  money   for   new
                                                                     _, session with quality production.          construction.   From   what   I   heard    in  The   proposal    for    developing    actual
                    a  uniformity  in   data   collection   that     'Olj
                    would   make    one    program    comparable     Guy D. Campbell, M.D.                        Washington,     planning     is   not     far  brick.  and  mortar  facilities  for   health
                    to the other in the  future.                     Program Coordinator                          enough   along   across   the   country    to  care is  beyond  the  scope  that  this  pro-
                                                                     Mississippi Regional Medical Program         build a good    case for such money            gram should now be considering.
                    James  E.  C.  Walker,  M.D.                                                                  and  a  poor  case   would   tend   to   cast  Hector W. Benoit, Jr., M.D.
                    Professor of Medicine and Society                                                             doubt  on  the  value  of  the   total   pro-  Member, Missouri Regional
                    School of Medicine                               It is impractical for each region  to  de-   gram.                                          Advisory Groups
                    University  of   Connecticut                     velop  its  own  methods  for   evaluating   Henry  T. Clark, Jr., M.D.
                                                                     care and for  documenting  the  effect  on   Planning Director
                                                                     delivery  of  care  of  Regional   Program                                                  I  was  quite  concerned  about  the   possi-
                    Research  in  the  area   of patient    needs                                                 Connecticut Regional Medical Program           bility  that  attempts  might  be   made   to
                                                                     activities. Methods  of  evaluation  could
                    and   how   best   to   meet these     needs,    -                                                                                           modify  P.L.  89-239  in  this   session   of
                    modes of  practice,  use  of  allied  health     more  reasonably  be   developed   as   re:  To   me,   this   program   has    tremendous  the   Congress.   In   my    opinion,    this
                                                                     search  programs  in  a  few  regions  ana
                    professionals,  specific  and  n  w   eauca-     ..                                           potential   to   upgrade   the   caliber   of  would  be  a  strategic  error   since   many
                    tional processes,  is  greatly  ni  ded  and     tnen be made generally available.            medicine   in   our   country.   However,   I  of us  have  just  now  been  able  to  reas-
                    should be specifically stated.                   The  voice  of  practicing  physicians  at   don't   want   to   consider    changes    in  sure   the   uneasy   private    practitioner
                                                                     the  Conference  seemed   rather   faintly   category,  financing  or   construction   un-  segment   and   other   groups    that    the
                    By  title,  the  Act  is   disease-oriented.     heard. . . . Future legislation should  be   til  experience   with   the   present   pro-  Regional   Medical   Program   was   not    a
                    You  have  noted  that  it  should  be   pa-     acceptable  to  physicians  and   to   the   gram clearly shows the need.                   Federal  enterprise,  the  nature  of   which
                    tient oriented. Here I  think  greater  pre-     AMA,  for  without  their  active  support   W. J. Hagood, Jr., M.D.                        was  going  to   be   dictated   from   Wash-
                    cision in  the  definition  of  goals  would     and  enthusiasm,  a  great  barrier   will   Little Retreat Clinic                          ington.
                    be  valuable,  both  as  a  guide  for   the     exist   between   the   Regional   Program   Clover, Virginia                               Basically,  I  would  oppose  at  this   time
                    future  and  as  a  healthy   exercise   for     and its goal of improving patient care.                                                     an  inclusion  in  the  law  of   funds   for
                    the  administrators  and   educators   work-
                    ing them out.                                    Charles P. Summerall, III, M.D.              Brick   and   mortar    authorization    will  construction  of  general  facilities  relat-
                                                                     Secretary                                    open  the  door  for  construction   of   re-  ing   to   the   Regional   Medical   Program
                    E. S. Bowerfind,  Jr.,  M.D.                     South Carolina Regional Advisory             gional "centers"-                              because  most  of  us  do  not  yet  have   a
                    Assistant Professor of Medicine                  Group and Acting Regional                                                                   clear  idea  of  the  types   of   facilities
                    University Hospitals of Cleveland                Program Coordinator                          Following  the  plenary  session   at   which  which  will  be  most   suitable   when   our
                                                                                                                  Dr.   DeBakey    spoke    of    construction,  programs   have   been    fully    developed.


                    76










                                                           I

        . . .On  the  other   hand,   there   are   some  The   legislation   should    be    changed    to  voice-the    basic    purpose     of     Regional   0   While   the   funds   noted   above   should
        impoverished    areas    of     the     country   allow  for   construction.                         Medical    Programs     is     education.     The   be  of   first   priority,   there   should   be
        where    serious     problems     exist     and   Merrill  0.  Hines,   M.D.                         basic   form   of   this   education   is    con-   monies   available   to   assure   proper    and
        where   able   people   are    struggling    to   Medical Director                                   tinuing    education,    with    the     explicit   complete    utilization    of    these    educa-
        cope with them.                                   Ochsner Clinic                                     purpose   of    making    productive    in    pa-   tional   facilities.   One   of   the   greatest
        Marc J. Musser, M.D.                              New Orleans, Louisiana                             tient  care  the  billions   of   dollars   which   problems for those     Iof  us   with   practical
        Program Coordinator                                                                                  have   gone   into   basic   research   in    the   experience     in      continuing      education
        North Carolina Regional                                                                              last three decades.                                 concerns    curriculum    design    and    moti-
        Medical Program                                   Possibly   the   time    has    come    to    add  At  this   time   the   educational   muscle   of   vation.   These   are   inextricably    interwo-
                                                          construction    components    to    the    legis,  the   ncin-university   hospital   is   so   weak   ven   with-a   need   to   know   patterns    of
        Spaceis needed      for    continuing    educa-   lation.   The   great   diversity   of   programs  that it is difficult  for  it  to  do  its  pres-   medical    care    and    physician    function.
                                                                                                                                                                 The  greatest   single   area   of   information
        tion   and   for   administrative   activities-   may   cause    problems    in    defining    con-  ently  assigned  task.  If  it   is   to   become
                                                          struction  needs.   I   hope   that   when   con,  the   cornerstone   of   the    Regional    Medi.   lack  and  misinformation  is   in   the   field
        We  wish   to   particularly   encourage   your   struction   features   are   built    into    the  cal    Programs     and     their     educational   of  the   function   of   physicians   in   care
        support  of  legislation   which   will   allow   program,   they   will   be   coordinated    with  muscle,   then    the    non-university    teach.   and  their  needs   and   motivations   in   re-
        new   construction.    There    is    a    need   Hill-Burton,    health    research    facilities,  ing   hospital   needs   a    great    deal    of   lation    to    continuing     education.     To
        within   the    Medica]'Centef    and    COMMU'   and   health   educational   facilities    legis-  help.                                               make   the   primary   building   funds    noted
        nity  Hospitals  for  office  space   and   for   lation  in   such   a   way   that   insofar   as                                                      above   really   effective,   we   sorely   need
        facilities    devoted    to    education    and   university    medical    centers     are     con-  I  am writing to ask in        the      strongest   support    within    non-university     hospital
        training.                                         cerned,    structural    needs    can     support  Possible voice that your      report   to    Con-   settings     for     the     measurement     and
        The   Medical   College   hopes   cost    shar-   educational      concepts.                         gress   in   June   make   clear   request    for   evaluation     of     continuing      education,
        ing  will  not  be  required,   for   if   con-                                                      funding in two very important areas:                and   for   the    measurement    and    evalua-
        struction   funds   are   awarded    contingent   John Parks, M.D.                                   <>   Funds   to   provide   educational   facili-   tion    of    physician    performance,    drive
        upon   matching    funds    being    available,   Dean, School of Medicine                           ties    and    equipment    in     non-university   and   motivation.   We   should   be   able   to
        it  might   be   impossible   in   many   cases   George Washington University                       hospitals.    These    should    include,    most   really  find  out  what  it  is  that  we   have
        for the construction to take place.                                                                  importantly,     auditorium      and      confer-   to   teach,   and   what   changes   in   behav-
        Frank M. Woolsey, Jr., M.D.                       I  am  writing  both  as   an   individual,   and  ence   room    space    and    their    accouter-   ior  we  are  trying   to   bring   about   with
        Program Coordinator                               as  the  President  of   the   national   organi.  ments,   library   facilities   and    materials,   our  continuing  education.  It  is   of   great
        Albany Regional Medical Program                   zation   (Association    of    Hospital    Direc.  audio-visual    materials,    audio-visual    de-   importance    that    within    each     region,
                                                          tors   of   Medical      Education)         which  partments,       and      areas          designed   depending    upon    factors     peculiar     to
        If  additional   construction   authority   and   represents   over    70%    of    the    nation's  specifically     for      educational      demon-   that  region,  there  be  one   or   more   non-
        funding   seems   necessary   in   the   health   non-university       teaching          hospitals.  strations   in   patient    care.    These    are   university   hospitals   with   funds    availa-
        care  field,  it  should  be  thought   of   in   While   the   universities   and   their    medi-  brick   and   mortar    and    equipment    funds   ble  to  construct  and   staff   divisions   of
        terms   of   multipurpose   facilities    (gen-   cal   centers   may   be   the   nervous   system                                                      measurement    and    evaluation     in     con-
        eral   health   care,    professional    educa-   of    the    Regional     Medical     Prograkms,   which    most     hospitals     simply     cannot   tin ing    education.     These     would     be
                                                                                                                                                                    u
        tion needs).                                      there   cannot   be   much   doubt    that    the  ' upply   from   monies   available   in    their   staffed    with    physicians,    educationists,
        James F. Oates, Jr.                               non-university     teaching     hospitals     and  local   communities   or   through   their    pa-   educational    psychologists    and     sociolo-
        Chairman of the Board                             the   community    hospitals    will    be    the  tient   care   efforts.   They   are   the   very   gists.   Each     region     is     sufficiently
        The Equitable Life Assurance                      muscle    of    these    programs.    It    seems  basic   equipment   most    of    these    hOsPi-   different   to   have   different   needs    and
        Society of the United States                      that  the   people,   in   the   form   of   Con-  tals   must   have    to    adequately    perform   to    require    different    approaches     and
                                                          gress,  have  spoken  in   a   loud   and   clear  their task in the future.                           measurements.     Thus     one     center     or

                                                                                                                                                                                                               77




                                                                                               RMP     should     be      Though  I  do  not   know   the   merits   of      cleaning is necessary seems obvious.
                      one university  center     would     not          The program goals of                              the  requests  before   you   for   operating      The major benefit  from  this  law  at  the
                      suffice.                                          emphasized,  and  the   categorical   nature                                                         present time, and  for  some  little  while
                                                                        de-emphasized.  I  would  like  to  add  the      funds,  I   have   major   misgivings   about
                      Robert L. Evans, M.D.                                                                     feel      making  awards   in   this   field   at   the      into the future, will lie in its effect  in
                      President                                         weight of my views to those who           nd      present   time.   Such   awards   would   put      bringing  together  diverse  groups   with-
                      Association of Hospital                           that ,cooperative arrangements"       a    d      huge   pressures   on    program    coordina-      in  and  without  the  medical   community,
                      Directors of Medical Education                    distribution of services are primary,     an             nd  the   country   to   develop   re-      with   community   health   as   a   common
                                                                        "Heart   Disease,   Cancer,   and    Stroke"      tors arou
                                                                                                                          quests  for  operating  funds   before   ade-      goal.
                                     RICAL EMPHASIS                     are just means to that end.                       quate   planning   has   been   done.    This
                      ... THE CATEGO                                    The   overlap   between   89-239         and      type  of "hurry-up,      half-baked"      ap-      Walter Hume, M.D.
                      GIVEN BY CONGRESS TO            Ms                89-749  will  be   confusing   and   hazard-      proach  would,  in  my  judgment,   put   the      Louisville, Kentucky
                      REGIONAL MEDICAL PROGRA                           ous  to  the  future.  I  would  hope   that                               I    Programs    de-      Member, Ohio Valley Regional
                                                                        these  two  programs  are   made   identical      whole Regional  Medica                             Advisory Group
                      we have found that we can work         quite                                                        lopment    in    jeopardy-just     when     a
                                                           uthori-      at least  where  state  and  regional  areas      ve
                      effectively within the present a                                                                    lot  of  first  class  people  are   becoming
                      zations  for  heart,  cancer,  stroke,   and      overlap.                                          aware of its  bright  promise.                     ... HEALTH MANPOWER
                      related  diseases.  it  would   perhaps   be      James E. C. Walker, M.D.
                      somewhat  easier  to  do   what   we   think      Professor of Medicine and Society                 Henry T. Clark, Jr., M.D.
                      the  program  is  designed  to  do  if   au-      School of Medicine                                Planning Director                                  The   most    critical    immediate    problem
                                                      to     areas                                                        Connecticut    Regional    Medical    Program      in   organizing   successful   regional   pro-
                      thorization  were  expanded                       University of Connecticut                                                                                                           try   will   be
                      covered  by  all  of  the   other   National                                                                                                           grams throughout the coun
                      institutes of Health,  but  this  is  not  a      ... THE RATE ( F DEVELOPMENT                      PARTICIPANTS     SPOKE      TO                     the    shortage    of    manpower.    However,
                      critical problem with us at this time.            OF      REGIONAL      MEDICAL       PROGRAMS      THE    IMPORTANCE    OF    ...                     once  this  is  solved  the  success  of   the
                      Russell C. Mills, Ph.D.                                                                             ... CONTINUING EDUCATION                           regional   programs   will    be    determined
                                                                        We  may,  by  moving too  rapidly,         re-                                                       ultimately  by  two  factors:  (1)   the   in-
                      Program Coordinator                               strict  planning   and,   as   a   result,   devel-                                                  terest  and  enthusiasm  that   can   be   en.
                                                        am     and                                                        I feel that the focus in this               program,
                      Kansas Regional Medical Progr                     op   operational   programs   which    will    give                                                  genaered   and   maintained   in    the    two
                      Associate Dean, University of Kansas              very  little  direct  help   to   weaker   institu- in  its  operational  phase,    will           and                                     m   will
                      Medical Center                                    tions.  This,   in   turn,   will   tend   to   in- should     be      aimed      toward      continuing groups around which the progra
                                                                                                                          medical     education,     both     for      medical tend  to   polarize,   namely   the   clinical
                      In   the   Missouri    region    categorical    em- crease    dependence    on     existing     centers                                                faculties  of  medical  schools,   and   prac-
                      phas'is   has    not    significantly    interfered and   fail   to   stimulate   growth   and    devel'and  paramedical  personnel.   There          is titioners   in   community    hospitals    and
                      with     program     planning     and      develop- opment    of    presently    weak    but     poten. the    problem     of     motivating     physicians, (2)  the  extent  to  which   motivation   can
                      ment.    Not    unexpectedly,    several     physi- tially strong centers.                          as   probably   the    people    who    need    such be stimulated.
                      cian  leaders   in   fields   of   medicine   other I    believe    that     the     planning     phase education   most   would    tend    to    use    ait
                                                                        should  be well  de                               least.    Some    sort    of    obligatory    educo- Samuel Proger, M.D.
                      than   heart,   cancer,    stroke    and    related                     veloped       before       we                                                  r
                                                        gret         that sugszest    changes     in     the     legislation. tional    program,    or    re-examination    f    0President
                      diseases,  have  expressed  re                                                                      recertification   at   set    intervals    seem    tBingham AssociatesFund
                      their   fields   are   not   involved.    Ultimate- Once    the    need    is    documented,    through be    the    only    sure    method    o@    keeping
                      ly,   expansion   of    the    RMP    concept    to careful      planning,      necessary       changes the medical populace current.
                      include  all   fields   of   medicine   would   ap- can be recommended.                                                                                . .. PATIENT CARE
                                                                                                                          There   seems   to   be   overlap   in   areas    of
                      pear desirable.                                   Frank L. McPhail, M.D.                            responsibility,    and    indeed    of    financing,                                      ity for
                                                                        Montana State Director                                                         I     programs      di. I was impressed by the necess
                      'George E. Wakerlin, M.D., Ph.D.                                                                    of    the    various    medica
                                                                        Mountain States Regional                                                     That      some       form emphasizing our efforts at improving
                      Program Director                                                                                    rected toward health.                                                              y other con-
                      Missouri Regional Medical Program                 Medical Program                                   of    governmental    and     legislative     house- patient care rather than an

                      78











       sideration.  This  should   be   emphasized  the  objectives  as   "improved   capability
       in the Report.                               for   diagnosis   and   treatment."   I   am
       Kinloch Nelson, M.D.                         sure  that  those   of   us   who   have   a
       Dean                                         broad  point   of   view   understand   this
       Medical College of Virginia and              means  diagnosis  obviously   has   to   in-
       Program Coordinator                          clude  preventive  medicine.  .  .   .   and
       Virginia Regional Medical Program            detection programs....
                                                    In  fact,  if,  when  the  new   legislation
       . . .DENTISTRY                               comes  into  being,   I   personally   would
                                                    like  to  see   two   words   added.   These
       In relation  to  Section  903  (b)  (4)  of  would   be   "prevention"   and   "rehabili-
       the  law,  perhaps  future  regulations  or  tation." I believe  it  would  clarify  what
       administrative    guidelines    might    be  obviously  was  the  intent  of   the   Com-
       written to spell out the  intent  that  the  mission  and  the  Congress   as   well   as
       specific  mention  of  "practicing   physi-  the directive from the President.
       cians"  should  not  be  construed  to  ex-  I  would  like  to  make  a  plea  for  con-
       clude  "practicing   dentists"   and   that  tinuing  aid  to  the  supporting   services
       representatives  of   "medical   societies"  -facilities    and    medical     education,
       should  not   be   construed   to   exclude  both    undergraduate     and     continuing
       "dental societies".                          education.
       The  last  sentence  of  Section   901   (c
       providesIthat "no   patient shall  be  fur-  Howard A. Rusk, M.D.
       nished hospital or  medical  care  at   any  Director
       facility unless he has  been  referred  to-  Institute of Rehabilitation Medicine
       such a  facility  by  a  practicing  physi-  New York University Medical Center
       cian."  The  term  "practicing   physician"
       should   be   expanded   to   include   "or
       dentist"  or  a  term   such   as   "health
       practitioner"  or  "practitioner   of   the
       healing  arts"   should   be   substituted.
       This  would  allow  referrals  by  dentists
       for such problems as oral cancer.

       Maynard K. Hine, D.D.S.
       Immediate Past President
       American Dental Association


       ... AND PREVENTION
       AND REHABILITATION


       I  have  been  somewhat   disturbed   about
       the  language  in  the  Act  which  defines

                                                                                                                                                                                      79







                                                                                                                                 APPENDICES



                                                                                                                                 0 Conference Program
                                                                                                                                 0 Registered Conference Participants
                                                                                                                                 0 National Advisory Council
                                                                                                                                   Review Committee
                                                                                                                                   Ad Hoc Committee for the Report
                                                                                                                                 0 Division Staff
                                                                                                                                 0 Directory of Programs
                                                                                                                                 0 Guidelines
                                                                                                                                 0 Public Law 89-239
                                                                                                                                 0 Regulations





































                                                                                                                                                                   81






                                                                                                                                                                                Appendix 2-Registered Conference
                    Appendix l@onference Program                                                                                                                                              Participants


                    Conference on                                      Discussion Sessions: 10 a.m.-12 noon                Introduction of Speaker:                             ACHTER, Mrs. Renee
                                                                       "Development of Cooperative Arrangements"           Edward W. Dempsey, Ph.D.                             Chief Occupational Therapist, American
                    Regional Medical Programs                                                                                                                                   Occupational Therapy Association; Director,
                                                                       Luncheon Meeting-International Ballroom-            Professor of Anatomy                                 Occupational Therapy, D.C. General Hospital
                    SUNDAY,     JANUARY     15                           East, 12:30 p.m..                                 Columbia University
                                                                                                                           College of Physicians and Surgeons                   ACOYA, Clarence
                    Registration-Concourse, 3-6 p.m.                   Chairman:                                                                                                Executive Director, New Mexico Commission
                    Opening   of    Conference                         Stanley W. Olson, M.D.                              Speaker;                                             on Indian Affairs; University of New Mexico
                                                                                                                                                                                School of Medicine
                    Reception-Terrace,   6:30    p.m.                  Speaker:                                            Sidney Farber, M.D.                                  'ADAMS, Wright, M.D.
                                                                                                                           Director of Research                                 Associate Dean, University of Chicago
                                                                       James A. Shannon, M.D.                              Children's Cancer Research Foundation
                    Dir.ner     Meeting-international Ballroom-        Director                                            Professor of Pathology                               School of Medicine
                     West, 7:30 p.m.                                   National Institutes of Health                       Harvard Medical School                               ALPERT, Louis K., M.D.
                    Chairman:                                          "Science and Service"                               "The Idea, the Intent and the                        American Diabetes Association; Professor of
                                                                       General Session-international Ballroom-                                                                  Medicine, George Washington University
                    Robert Q. Marston,    M.D.                           West, 2 p.m.                                      Implementation"                                      *AMES, Verner J., D.O.
                    Remarks:                                                                                               Panel Session: "The Report of the Surgeon            Professor of Practice, Kansas City College
                    Charles L. Hudson,    M.D.                         Panel Session:  Program Evaluation                  General to the President and the Congress"           of Osteopathy and Surgery
                    President                                          Chairman:                                                                                                ANDERSON, Gaylord W., M.D.
                    American   Medical    Association                  George James, M.D.                                  Chairman:                                            Director, School of Public Health, University
                    Leo J. Gehrig, M.D.                                Dean                                                Storm Whaley                                         of Minnesota
                    Deputy   Surgeon   General                         Mt. Sinai School of Medicine                        Vice President for Health Affairs                    ANDERSON, Otis L., M.D.
                    U.S. Public Health Service                                                                             University of Arkansas                               Manager, Washington, D.C. Office, American
                    Introduction  of  Speaker:                         Speaker:                                                                                                 Medical Association
                    Philip R. Lee, M.D.                                Vernon E. Wilson, M.D.                              Panel:                                               ANDERSON, Robert S., M.D.
                    Assistant  Secretary   for                         Dean                                                Michael E. DeBakey, M.D.                             Professor of Medicine, Meharry Medical
                    Health and Scientific Affairs                      University of Missouri                              Professor and Chairman                               College
                    U.S. Department of                                 School of Medicine                                  Department of Surgery                                ANDRESEN, Donald C., M.D.
                    Health,  Education,  and  Welfare                  Panel:                                              College of Medicine                                  Chief, Cardiology, Darthmouth Medical
                    Address:                                           Edward Kowalewski, M.D.                             Baylor University                                    School
                    Wilbur J. Cohen                                    Chairman, Board of   Directors                      Bruce W. Everist, M.D.                               ANDREW Edward  .,  r.,
                    Under Secretary  of                                American Academy of General     Practice            Green Clinic                                         Dean, College of Medicine, University of
                    U,S. Department of
                    Health,  Education,  and  Welfare                  C. H. William Ruhe, M.D.                            Ruston, Louisiana                                    Vermont
                                                                       Assistant Secretary                                 James T. Howell, M.D.                                ANDREWS, Neil C., M.D.
                    MONDAY,     JANUARY     16                         Council on Medical   Education                      Executive Director                                   Assistant Dean, College of Medicine,
                    General Session-International Ballroom-            American Medical Association                        Henry Ford Hospital                                  Ohio State University
                      West, 9-10 a.m.                                  Harvey L. Smith, Ph.D.                                                                                   'ANNIS, Jere W., M.D.
                                                                       Professor of Sociology and                          Ray E. Trusself, M.D.
                    Chairman:                                                                                              Director                                             President, American Association of
                                                                       Director, Social Research Section                                                                        Medical Clinics
                    Stanley  W.  Olson,   M.D.                         University of North Carolina                        Columbia University School of
                    Conference Chairman                                                                                    Public Health and Administrative Medicine            'APPEL, James Z., M.D.
                                                                       Discussion Sessions: 3:30-5:30 P. m.                Paul N. Ylvisaker, Ph.D.                             Immediate Past President American
                    Speaker:                                           "Continuing Education, Research and Patient         Ford Foundation                                      Medical Association
                    Robert  Q.  Marston,  M.D.                         Care"                                                                                                    ARBONA, Guillermo, M.D.
                    Associate Director                                                                                     Discussion Sessions: 11 a.m.-I p.m.                  Professor of Preventive Medicine and Public
                    National Institutes of Health                      TUESDAY, JANUARY 17                                                                                      Health, School of Medicine, University of
                    Director                                           General Session-International Ballroom-             "Surgeon Generat's Report on the       Regional      Puerto Rico
                    Division of Regional Medical    Programs             West, 9 a.m.                                      Medical  Programs to be presented to the
                    "Philosophy and Goals of the Regional Medi-                                                            President and the Congress"                          Physician indicated in Conference
                    cal  Programs  for  Heart  Disease,  Cancer,       Chairman:                                                                                                Registry that activities also
                    Stroke  and   Related   Diseases"                  Stanley W.  Olson, M.D.                             Adjournment-1. p.m.                                  include regular practice


                    82











                ARONOFF, Billie Louis, M.D.                           BELL, Louise N.                                      BOREL, Richard A.                                    Center; Member, North.Carolina Regional
                Associate  Professor  of  Surgery,  University        Research  Assistant,   Department   of               President,   WBNS-TV   Inc.;   Member,    Ohio       Medical   Program    Special    Committee
                of Texas S.W.; Member, Texas Regional                 Preventive Medicine, University of                   Regional Advisory Group
                Advisory Council                                      Pittsburgh School of Medicine                                                                             BRUCE, John M., M.D.
                                                                                                                           BORHANI, Nemat O., M.D.                              Alternate   Member,   Louisiana    Regional
               'BABSON, William W., M.D.                              BENNETT, Granville A., M.D.                          Program   Coordinator,   California   Regional       Advisory Group; Director, Division of Local
                President, Massachusetts State Medical                Dean, College of Medicine, University of             Medical  Program;  Chief,  Bureau   of   Chronic     Health Services, Louisiana State Board of
                Society                                               Illinois                                             Diseases,  California  State   Department   of       of Health
                                                                                                                           Public Health
               *BACASTOW, Merle S., M.D.                            'BENOIT, Hector W., Jr., M.D.                                                                               BUNNELL, Kevin P., Ed.D.
                Director,  Medical  Education,   Maine   Medical      Member,   Regional   Advisory   Council;             BOSTICK, Warren L., M.D.                             Program   Coordinator,   Mountain    States
                Center, Portland; President, Applicant                Missouri  State  Medical   Association               Dean,  University  of  California  College  of       Regional Medical.Program; Regional Medical
                Agency,   Maine   Regional   Medical   Program        BENSON, W. W.                                        Medicine, Los Angeles                                Programs Review Committee
                BARNES, David A.                                      Member, Mountain States Regional Advisory            BOUGHN, Pete
                                                                      Council; State Registrar of Vital Statistics,        Director  of  Public  Information,  University of    BUTTERWORTH, Theron H., Ph.D.
                Medical Administration, Mayo Clinic                   Idaho  Department  of  Public   Health               Nebraska College of Medicine                         Member,  Board  of  Trustees,  Society   of
                                                                                                                                                                                Public Health Educators; Health
                BARNES, James T.                                                                                           BOWEN, Ted                                           Communications   Branch,   Public    Health
                Executive Director,  Medical Society of               BERNSTEIN, Dr. Leon
                                                                      Branch Chief,  Basic  Policy  Division  of           Member,   Texas   Regional   Advisory   Group;       Service
                North Carolina                                        Political Standards,  Bureau  of  Health             Hospital  Administrator,   Methodist   Hospital,     *BUTTRICK, Walter W., Jr., M.D.
                BARR, Robert N., M.D.                                 Insurance, Social Security Administration            Houston                                              President-Elect,  Vermont   State   Medical
                Secretary  and  Executive   Officer,   Minnesota                                                           BOWERFIND, Edgar S., Jr., M.D.                       Society; President, Vermont Heart
                State Board of Health                               'BERRY, Leonidas H., M.D.                              Secretary,  Citizens  Commission   on   Graduate     Association
                                                                      Member, National Advisory    Council    on           Medical  Education;  Assistant  Professor   of
                BARROW, J. Gordon, M.D.                               Regional  Medical   Programs;   Professor,           Medicine,   Western   Reserve   University           *CALL, Lloyd S., M.D.
                Director,  Medical  Education,  and   Clinical        Cook County Graduate School of Medicine;                                                                  Member, Executive Committee,
                Professor of Medicine, Emory University               Senior Attending Physician, Michael Reese            BOYD, Richard F., M.D.
                School of Medicine; Member, Steering                  Hospital, Chicago                                    Regional Health  Director,  Public  Health           Intermountain Regional Medical Program
                Committee, Georgia Regional Medical                                                                        Service (Region Vill
                Program                                               BERSON, Robert C.. M.D.                                                                                   CALLISON, M. K., M.D.
                                                                      Executive Director, Association of American          BOYLE, Richard E., M.D.                              Dean, University of Tennessee College of
                BARTLETT, John C., LL.B.                              Medical Colleges                                     Assistant  Professor  of  Medicine,   University     Medicine; Member, Executive Committee,
                Assistant Program Coordinator, Iowa                                                                        of  Colorado  Medical   Center;   Representative     Memphis    Regional    Medical    Program
                Regional   Medical   Program;   Administrative        BICKNELL, William J., M.D.                           of   Program    Coordinator,    Colorado-Wyoming     CAMPBELL, Charles W.
                Assistant for Plans and Operations,                   Medical Director,  Job  Corps,  Office  of           Regional Medical Program                             Albuquerque Community Council; Member,
                University of Iowa College of Medicine                Economic Opportunity                                 BRANCH, David R.                                     New  Mexico   Regional   Advisory   Board
                BATSON, Randolph, M.D.                                BIHLMEYER, Earl F.                                   Associate Director  of  Public  Relations,
                Dean, School of Medicine, Vanderbilt                  Administrative Assistant  to  the  Dean,             University  of  Rochester  School  of   Medicine     CAMPBELL, Guy D.. M.D.
                University                                            University of  South  Dakota  School  of             and Dentistry                                        Program Coordinator, Mississippi Regional
                                                                                                                                                                                Medical Program; Chief, Pulmonary Disease
                                                                      Medicine                                             BRAYTON, Donald, M.D.                                Section, Veterans Administration Hospital,
                BATTISTELLA, Roger M., Ph.D.                                                                               Director  of  Regional  Medical   Program,           Jackson
                Assistant  Professor,  Hospital  and   Medical        BISTOWISH, Joseph M., M.D.                           Assistant  Dean,  University   of   California
                Care Administration, Sloan Institute of               Director of  Public  Health,  Metropolitan           School of Medicine, Los Angeles                      *CANNON, Bland, M.D.
                Hospital  Administration,   Cornell   University      Nashville Health Department                          BRINKLEY, Sterling B., M.D.                          Vice-Chairman,    Tennessee     Mid-South
                BAUER, Franz K., M.D.                                 BLAIR, Lucy                                          Vocational   Rehabilitation    Administration,       Regional Medical Program, Medical Center
                Associate Dean, University of Southern                Executive Director, American      Physical           Department  of  Health,   Education,   and           Planning  Council;   Member,   Council   on
                California  School  of  Medicine,  Los  Angeles;      Therapy Association                                  Welfare                                              Medical   Education,    American    Medical
                Los Angeles County General Hospital                   BOETTNER, Charles H., M.D.                           BROWN, Ray E.                                        Association
                BAUMAN, G. Duncan                                     Executive  Director,  Health  Advisory               Member,  Ad  Hoc  Committee   for   the   Report     CANNON, Wilson P., Jr.
                Business Manager, St. Louis Globe-                    Committee, Appalachian Regional                      to the President  and  the  Congress;  Director,     Senior  Vice-President,  Bank  of   Hawaii;
                Democrat,, Chairman, Bi-State Regional                Commission;   Medical   Director,   Public           Graduate Program in Hospital                         Chairman,   Hawaii   Regional    Advisory
                Advisory Group                                        Health Service                                       Administration,   Duke   University    Medical       Committee

                                                                                                                                                                                                                            83








                                                                                                                              CLEERE, Roy L., M.D.                                  COOK, Ellen, M.D.
                   CARAVATI, Charles M.. M.D.                            CASTLETON, Kenneth B., M.D.                                                                                ssistant   Professor of Medicine, College of
                   Assistant  Dean  and  Director,  Continuing           Chairman, Intermountain Regional Medical             Member, Colorado-Wyoming Regional                     A
                   Education, Medical College  of  Virginia              Program; Dean, University of Utah College            Advisory Council; Director of Public Health,          Medicine, State University of New York at
                                                                         of Medicine                                          Colorado Health Department                            Syracuse
                   CARPENTER.. Chester J.                                                                                                                                           COOK, Ernest W., Ph.D.
                   Director, Planning and Program                        CHADWICK, Donald R., M.D.                        *CLINE, John W., M.D.
                   Development,   Arizona   State    Health              Director, National Center for Chronic                American College of Surgeons                          Chief, Division of-Medical Care Standards,
                   Department                                            Disease Control, Public Health Service               COBB, Alton B., M.D.                                  Rhode Island Department of Health
                   CARPENTER, Robert R., M.D.                                                                                 Member, Mississippi Regional Advisory                 COON, Robert W., M.D.
                   Assistant   CoordinstOr-Sayfor,    Texas              *CHALECKE, William E., M.D.                          Committee; Director, Chronic Illness                  Program Director, Northern New England
                   Regional Medical Program, Saylor                      President, Health organization of Western            Services, Mississippi State Health                    Regional Medical Program; Chairman,
                   University College  of  Medicine  Methodist           New York                                             Department                                            Department of Pathology, University Of
                   Hospital                                              -CHAMBERS, J. W., M.D.                               COCKBURN, Thomas A., M.D.                             Vermont College of Medicine
                   CARR, James G., Jr.                                   Program Coordinator, Georgia Regional                Medical Director, Poverty Program,                    COONEY, James P., M.D.
                   Administrator,  Memorial   Hospital   of              Medical Program; Member, Medical                     City of Detroit                                       Senior Vice-President for Research and
                   Natrona   County,'   Member,   Colorado-              Association of Georgia                                            ert J., M.D.                             Medical Affairs, American Cancer Society
                                                                                                                              COFFEY, Rob
                   Wyoming   Regional   Advisory    Council              CHIAZZE, Leonard, Jr., Sc.D.                         Past President, Medical Society of D.C.;              COOPER, Nathaniel H., M.D.
                   'CARR, T. L., M.D.                                    Assistant Professor, Community Medicine              Professor of Surgery, Georgetown University           Director, Community Program, American
                   President  New   Mexico   Medical   Society           and International Health, Georgetown                 School of Medicine                                    Heart Association, Inc.
                   CARROLL, A. J.                                        University School of Medicine                        COGGESHALL, Howard C., M.D.
                   Assistant Director of Operational Studies,            CHONTOS, Stephen A.                                  Program Coordinator, North Texas Regional             COPELAND, Murray M., M.D.
                   Association of American Medical Colleges              Health Professions Representative; Medical           Medical Program; Associate Professor of               National Advisory Cancer Council;
                   CARSON, Bruce F.                                      Alumni Publications Editor, University of            Medicine, Southwestern Medical School at              Associate Director and Professor of Surgery,
                   chief, Legislative  Reference  and  Liaison           Pittsburgh                                           Dallas                                                M.D. Anderson Medical Hospital and Tumor
                   Branch, National  Institutes  of  Health              CHOTAS, Georgia A.                                   COHART, Edward M., M.D.                               Institute
                   CARTER, John M.                                       Health Sciences Editor, Office of Health             Secretary-Treasurer, Association of Schools           CORDAY, Eliot, M.D.
                   Member,   President's   Commission    on              Center Relations, J. Hillis Miller Health            of Public Health; Chairman, Yale                      Immediate Past President, American
                   Heart  Disease,  Cancer,   and   Stroke;              Center, University of Florida                        Department of Epidemiology and Public                 College of Cardiology; Associate Professor
                   Editor, Ladies Home Journal                                                                                Health                                                of Medicine, University of California School
                                                                         OCHRISTOFERSON, Lee A., M.D.                                                                               of Medicine, Los Angeles
                   CARTER, Robert E., M.D.                               Chairman, State Development Committee,               COHEN, Raphael
                   Associate Dean, University of Iowa College            North Dakota Regional Medical Program;               Director, Medical and Allied Health                   COX,   Dr.   Sherman
                   of Medicine                                           Associate Professor, University of North             Education, General Learning Corporation               Special Assistant to Deputy.Chief, Division
                   ,CARVER, Terrell O., M.D.                             Dakota School of Medicine                            COHEN, Wilbur J., Ph.D.                               of Dental Health, Public Health Service
                   Member, Mountain States Regional Advisory             CHIOCCO, Antonio, Sc.D.                              Under Secretary, Department of Health,                'CRAIN, Darrell C., M.D.
                   Council;  Administrator  of  Health,  Idaho           Acting Dean, Graduate School of Public               Education, and Welfare                                Medical Society of D.C.; Clinical Associate
                   State Department of Health                            Health, University of Pittsburgh                     COLE, Warren H., M.D.                                 Professor of Medicine, Georgetown
                   CASELEY, Donald J., M.D.                                                                                   American College of Surgeons; Emeritus                University School of Medicine
                   Medical  Director   and   Associate   Dean,           CLARK, Dean A., M.D.
                                                                         Director, Program in Medical and Hospital            Professor and Head of Department of
                   University of Illinois  Hospitals;  Vice                                                                   Surgery, University of Illinois College of            CRANER,   John    L.
                   Chairman,  Illinois  Regional   Advisory              Administration; Member, Western                                                                            Association of American Medical Colleges
                   Comrniftee                                            Pennsylvania Regional Advisory Committee             Medicine                                                                 osephine K., R.N.
                   CASSIDY, John J.                                      CLARK, Henry T., Jr., M.D.                           COLLINS, V. P., M.D.                                  CRAYTOR,   Mrs.    J
                   Director  of  Public  Relations,  Albany              Program Coordinator, Connecticut Regional            Consultant in Radiology to the National               Rochester Planning Committee Member;
                                                                         Medical Program                                      Institute of General Medical Sciences and             Associate Professor of Nursing, School of
                   Medical  College  and   Medical   Center                                                                   Baylor University College of Medicine                 Medicine and Dentistry, University of
                   Hospital                                              CLARK, R. Lee, Jr., M.D.                                                                                   Rochester
                   CASTLE, C. Hilmon, M.D.                               Member, President's Commission on Heart              COLYAR, A. B., M.D.
                                                                         Disease, Cancer and Stroke; Director, The            Commissioner, Oklahoma State Department               CRISPELL, Kenneth R., M.D.
                   Program   Coordinator,     Intermountain                                                                                                            SI           Dean, University of Virginia School of
                   Regional  Medical Program; Associate Dean,            University of Texas M.D. Anderson Hospital           of Health; Member, Oklahoma Region
                   College  of  Medicine,  University  of  Utah          and Tumor Institute                                  Advisory Council                                      Medicine

                   84










             CROCKETT, Charles L., Jr., M.D.                     DEBAKEY, Michael E., M.D.                           DUCKWORTH, T. A.                                    ELIEL, Leonard P., M.D.
             Associate  Professor  and  Assistant  Dean,         Member,   President's   Commission   on   Heart     Chairman, Wisconsin Regional Advisory               Member,   Oklahoma   Regional    Medical
             Continuing Education,  University  of  Virginia     Disease,  Cancer,  and  Stroke;   Member,           Committee;  Senior   Vice-President   and           Program   Executive   Committee;   Vice
             School of Medicine                                  Ad  Hoc  Advisory  Committee  for  the   Report     Secretary, Employers Insurance of Wausau            President  and  Director  of  Research,
                                                                 to the President and the Congress;                                                                      Oklahoma Medical Research Foundation;
             CROSBY, Edwin L..   M.D.                            Member,  National  Advisory  Council   on           DUNN, Donald W.                                     Professor of  Medicine,  University  of
             Consultant,  Executive  Vice-President  and         Regional  Medical   Programs;   Professor   and     Executive  Director,  Minnesota  Hospital           Oklahoma School of Medicine
             Director,  American  Hospital   Association         Chairman,  Department  of   Surgery,   Saylor       Association; Member, Northiands Regional            ELLER, C. Howe, M.D.
             CULBERTSON, James W., M.D.                          University College of Medicine                      Advisory Committee                                  Member  of  the   Executive   Committee,
             Proposed   Chairman,   Professional   Education     DECESARE,   William   R.,   M.D-                    DUNN, Marvin R., M.D.                               Bi-State  Regional   Medical   Program;
             Committee,   Memphis    Regional    Medical         Chief, Science Review Section,   Division  of       Associate Dean, Woman's Medical College             Commissioner of Health, St. Louis County
             Program;  Professor  of  Medicine;   Chief,         Research  Facilities  and  Resources,  National     of   Pennsylvania                                   Health Department
             Section  of  Hemodynamics,  University   of         institutes of Health                                DUTTON,   C.   B.                                   ELLWOOD, Paul M., M.D.
             Tennessee College of Medicine                       DEFRANTZ, Robert                                    Attorney, Member, Indiana Regional                  Executive Director, American
             CUMMINGS, H. W., Jr., M.D.                          Director,   Community   organization,   Flanner     Advisory    Group                                   Rehabilitation   Foundation;   Faculty,
             Member,  Texas   Regional   Advisory   Council;     House, Indianapolis                                 Du VAL, Merlin K., M.D.                             University of Minnesota
             Chief,  Internal  Medicine  Service,  Methodist     DEHNE, Edward J., M.D.                              Acting  Coordinator,   Arizona   Regional           ELMORE, Marjorie J., Ed.D.
             Hospital;  Professor  of  Medicine,  Saylor         Nevada  State  Health   Officer                     Medical  Program;  Dean,  University   of           Member, Mountain States Regional Advisory
             University College of Medicine                      DEMPSEY,   Edward   W.,   Ph.D.                     Arizona College of Medicine                         Council; Dean, School of Nursing,
             CUNNINGHAM, Joseph A., M.D.                         Member,   President's   Commission   on   Heart     DYER, N. Allen, M.D.                                University of Nevada
             Professor, Medical College,  University  of         Disease,  Cancer,  and  Stroke;  Liaison,           Member. West Virginia Regional Advisory             ENGLE, H. Martin, M.D.
             Alabama; Council Member, National                   National  Institute  of  General  Medical           Committee;  Director,  Bureau  of   Heart           Chief  Medical  Director,  Department   of
             Committee for Medical Technology                    Sciences Council; Professor of Anatomy,             Disease Control, West Virginia State                Medicine and Surgery, Veterans
             Education                                           College  of  Physicians  and  Surgeons,             Department of Health                                Administration
                                                                 Columbia University
             CURRY, Mrs. Edward                                                                                      *DYGERT. H. Paul, M.D.                              ENNES, Howard
             Member, Kansas Regional Advisory                    DENSLOW, J. S., D.O.                                            ashington-Alaska     Regional           Assistant  Vice   President   Co@mmunity
             Council; Member, Board of Directors,                Vice President  Kirksville  College  of             Member, W
                                                                 Osteopathy  and  Surgery;  Member,   Scientific     Advisory Committee; Trustee, Washington             Services and Health Education, Equitable
             American  Heart  Association   and   Kansas         Review   Subcommittee,   Missouri    Regional       State Medical Association                           Life Assurance Society
             Heart Association                                   Medical Program                                     EASTWOOD, Richard T.                                ENSIGN, James M.
             -CURRY, John J., M.D.                               DETMER, L. M.                                       Fiscal Agent and Secretary, Texas Regional          Vice  President  Blue  Cross   Association
             Member, Maryland Regional Advisory                  Assistant  Director,  Division  of  Long-Term       Advisory Committee; Executive Vice
             Committee;   Maryland   Heart   Association         Care,   American   Hospital   Association           president, Texas  Medical  Center,  Inc.,           EVANS, Robert L., M.D.
             *DAILY                                                                                                  Houston                                             President, Association of Hospital Directors
                    , Edwin F., M.D.                             DIANA, Joseph A., Jr.                                                                                   of Medical Education
             Health  Insurance  Plan  of  Greater  New  York     Secretary to the Faculty,  University  of           EDDS, M. V., Jr.
             DAVIS, Burnet M., M.D.                              Michigan Medical School                             Director of Medicine, Brown University,'            *EVERIST, Bruce W., M.D.
                                                                                                                     Chairman, Rhode Island Advisory                     member,  National  Advisory   Council   on
             Special  Assistant  for  Continuing  Education,     *DIEZ-LEE, Marina, M.D.                             Committee                                           Regional   Medical    Programs;    Member,
             Extramural Programs, National Library of            Chief,  Medical   Branch,   Smithsonian                                                                 Ad Hoc Committee for the Report to the
             Medicine                                            Institution,  Science  Information   Exchange       EDWARDS,     Charles C., M.D.                       President and the Congress; Green Clinic.
             DAVIS, Edwina                                       *DIMOND, E. Grey, M.D.                              Director,  Division   of   Socio-Economic           Ruston, Louisiana
             Science Editor,  Emory University                   Director,  Scripps  Clinic  and  Research           Activities, American Medical Association
                                                                                                                                                                         FARBER, Sidney, M.D.
             DAWBER, Thomas R., M.D.                             Foundation                                          EICHMAN, Peter L., M.D.                             Member,   President's   Commission    on
             Program  Coordinator,  Tri-State   Regional         'DREW, Frank E., M.D.                               Member, Wisconsin Regional Advisory                 Heart Disease, Cancer, and Stroke; Director
             Medical Program; Associate Professor of             President,  State  Medical  Society  of             Committee; Dean, University of Wisconsin            of Research, Children's Cancer Research
             Medicine,  Boston  University  Medical   Center     Wisconsin                                           Medical    School                                   Foundation
             DEARING, W. Palmer, M.D.                            DRISCOLL, Dr. Edward J.                             ELAM, Lloyd C., M.D.                                F", Dr. Marion S.       oman's     Medical
             Executive Director, Group Health                    Associate Director for Extramural Programs,         Dean, School of Medicine, Meharry Medical           President Emeritus, W
             Association of America                              National  Institute  of  Dental  Research           College                                             College of Pennsylvania; Member,

                                                                                                                                                                                                                     85







                    President's Commission on Heart Disease,              FORD, Malcolm J., M.D.                               GEHRIG, Leo J., M.D.                                  GRAZE, Gerald     Committee,     New     York
                    Cancer, and Stroke                                    Acting Program Coordinator, Florida                  Deputy  Surgeon  General,  Public   Health            Member, Working
                                                                          Regional Medical Program; Florida State              Service                                               Metropolitan   Regional   Medical    Program;
                    FELGNER, Leonard                                                                                                                                                 Assistant to Dean,  Albert  Einstein  College
                                                                          Board of Health                                      GEIGER, Frank L., M.D.                                of Medicine
                    Division of Hospital-Medical Facilities,              FORDYCE, Alice                                       Chief, Cancer, Heart Disease and T13
                    Silver Spring                                         Albert and Mary  Lasker Foundation                   Services, South Carolina State                        -GREENE, Laurence W., Jr., M.D.
                    FELIX, Robert H., M.D.                                                                                     Board of Health                                       Governor's   Advisory    Committee,    WICHE;
                    Member, Bi-State Regional Medical                     FORNEY,  Vernon  J.,  D.D.S.                                                                               President-Elect   Wyoming    State    Medical
                    Program Committee on Organization; Dean,              Regional  Health  Director,Public Health             GENDEL, Evelyn, M.D.                                  Association
                    St. Louis  University  School  of  Medicine           Service (Region V)                                   Assistant Director,  Maternity  and  Child            *GRIZZLE,  Claude  O.,  M.D.
                    FETTER, Franklin C., M.D.                             *FRANKLIN,  Max  S.,  M.D.                           Health,  Kansas  State  Board  of  Health;            Director, Wyoming Study Program,
                    Dean and Vice President Medical College               President, St. Louis Medical Society;                Associate Professor, Preventive Medicine,                                                  Program
                    of South Carolina                                     Member, Si-State Regional Advisory     Group         Kansas University Medical Center                      Mountain States Regional Medical
                                                                          FRANTZ, Ivan D.,  Jr.,  M.D.                         GENTRY, John T., M.D.                                 GRONVALL,  John   A.,   M.D.
                    FISK, Shirley C., M.D.                                                                                                                                                           hool of Medicine, University
                    Deputy  Assistant  Secretary  (Health   and           Member of Executive Committee and                    Assistant Dean, School of Public Health,              Acting Dean, Sc
                    medical), Department of Defense                       Regional Advisory Group, Northlands                  University  of  North  Carolina;   Member,            of Mississippi Medical Center
                                                                          Region; Research Professor of Medicine               Board of Directors, North Carolina                    GROSSE, Robert N.
                    FITZ, Reginald H., M.D.                               and Biochemistry, University of Minnesota            Regional Medical Program                              office of  Assistant  Secretary  for  Program
                    Program Coordinator, New Mexico Regional              Medical School; President, Minnesota                 GILBERT, Robert P., M.D.                              Coordination, Department of Health,
                    Medical Program; Dean, School of Medicine,            Heart Association                                                                                          and Welfare
                    University of New Mexico                                                                                   Associate Dean, Jefferson    Medical College;
                                                                          FRECHETRE, Alfred L., M.D.                           Member, Greater Delaware Valley Regional              GROVER, M. Roberts, Jr., M.D.
                    FLAGLE, Dr. Charles D.                                Commissioner, Massachusetts Department               Advisory Committee                                    Director,   Continuing   Medical   Education,
                    Professor of Public Health Administration,            of Public Health; Trustee of Tri-State                                                                     University of Oregon Medical School;
                    The John$ Hopkins School of Hygiene and               organization, Tri-State Regional Medical             GILES, Julian W., M.D.                                Program    Coordinator,    Oregon    Regional
                    Public Health                                         Program                                              Member, Alabama Regional Advisory                     Medical Program
                                                                                                                               Committee; Hospital Director, Tuskegee
                    *FLANAGAN, Thomas, M.D.                               FREYMANN,  J.   G.,   M.D.                           Veterans Administration Hospital                      GRULEE,  Clifford  G.,  M.D.
                    Member, Central New York Regional                     Association of Hospital Directors of                                                                       Dean, University  of  Cincinnati  College  of
                    Medical Program                                       Medical Education; Medical Director, Boston          -GLADUE, J. Raymond, M.D.                             Medicine
                    FLEMING, George M., Ed.D.                             Hospital for Women                                   Special Consultant to Bureau of     Health,
                    Member, Texas Regional Advisory Group;                FRIEDRICH, Rudolph, D.D.S.                           Social Security Administration; Baltimore             GUTHRIE, Eugene H., M.D.
                    Medical Administrator, Methodist Hospital,            Director, Division of Oral Surgery,                  City Health Department; Private Practice,             Assistant  Surgeon  General.  Public   Health
                    Houston                                               Columbia University                                  Internal Medicine                                     Service
                    FLORIN, Alvin A., M.D.                                FULLARTON, Jane E.                                   GOLDSTEIN, Gloria                                     -HAGOOD, W.  J.,  Jr.,  M.D.
                         ram  Coordinator, New Jersey Regional            Office of the Director, Legislative Reference        Assistant to the Dean, Medical College of             Member, Virginia Regional Advisory
                    Prog                                                                                                                                                             Committee;  Medical   Society   of   Virginia
                    Medical Program; New Jersey State                     and Liaison Branch, National Institutes of           Alabama
                    Department of Health                                  Health                                               GRABER, Mrs. Joe Bales                                HAINES, Thom   W  Ph.D.
                                                                                                                                                                                                     as     ;evelopment     Office
                                                                          GALLAGHER, Joseph A., M.D.                                                                                 Director, Research
                    FOLEY, Paul                                                                      of Health                 Special Assistant to the   Director, Bureau           Public Health  Service (Region IV)
                    Administrative   Assistant,    Metropolitan           Deputy  Director,   Bureau                           of Disease Prevention and Environmental
                    Washington, D.C. Regional Medical Program             Manpower, Public Health Service                      Control, Public Health Service                        -HALL, Wesley W., M.D.
                    *FOLLMER, Hugh C., M.D.                               GALLIHER,  Herbert  P.,  Jr.                         GRAHAM, W. Donald, M.D.                               Chairman,   Board   of   Trustees,   American
                    Associate Director, Mountain States                   Consultant; Department of Industrial                 Deputy Director, Hawaii Regional Medical              Medical Association
                    Regional Medical Program (Nevada)                     Engineering, University of Michigan                  Program; University of Hawaii School of               HAMILTON, T. Stewart, M.D.
                    FOOTE, Franklin M.                                    GARCIA-PALMIERI, Mario R., M.D.                      Medicine                                              Member,   Connecticut    Regional    Advisory
                                                                                                                                                                                     Committee;   Executive   Director,   Hartford
                    Member, Connecticut Regional Advisory                 Secretary of Health, Puerto Rico                     GRAPSKI,   Lad F.                                     Hospital;   American   Hospital   Association
                    Board; Commissioner of Health, State of               Department of Health                                 Chairman-elect,    Executive    Committee,            Committee on P.L. 89-239
                    Connecticut                                           GARDNER,   Clair,   D.D.S.                           Council on Teaching Hospitals, Association
                    FORBES, Charles M.                                    Chief, Program Planning, National Institute          of American Medical Colleges; Director,               HAMILTON, Wallace
                    Director, Division of  Support  Activities,           of Dental Research, National Institutes of           Loyola University Hospital; Associate Dean,           Director   of   Institutional    Development,
                    Memorial Sloan-Kettering Institute                    Health                                               Loyola University Stritch School of Medicine          Columbia City (Rouse Company)

                    86











           HAMLIN, Frank H.                                     HAYMAN,   Charles,   M.D.                          'HILL,  Lucius  D.,  M.D.                             HOWE, Robert D.
           Chairman,   Rochester   Regional    Advisory         Member,   Metropolitan    Washington,    D.C.       Member, Executive Committee,                         Member, Mountain States Regional
           Group;  New  York  State   Hospital   Review         Advisory   Committee;   Associate   Director,       Washington-Alaska    Regional    Advisory            Advisory Council; Hospital Administrator,
           and  Planning  Council;   The   Papec   Company      D.C. Department of Public Health                    Council;   Washington   State   Medical              Billings Deaconess Hospital
           HANDY, George H., M.D.                               HAYNES,   Colonel    Inez                           Association                                          HOWELL, James T., M.D.
           Member,   Planning   Committee,    Wisconsin         General Director, National League for              'HILL, Luther, M.D.                                   Member, National Advisory Council on
           Regional  Medical  Program;   Assistant   State      Nursing                                             Member,  Board  of   Censors,   Medical              Regional Medical Programs; Member,
                                                                                                                    Association of State of Alabama                      Ad Hoc Advisory Committee for the
           Health Officer,  Wisconsin  State  Board  of         'HECKLER, G. Barrett, M.D.                                                                               Report to the President and the Congress;
           Health                                               Chairman,   Medical   Education    Committee,       HILL, S.  Richardson,  Jr.,  M.D.                    Executive Director, Henry Ford Hospital
           HARDIN Robert C., M.D.                               Wilmington Medical Center                           Member,   Alabama    Regional    Advisory
           Program Coordinator, Iowa Regional                   HEDMEG,   Andrew,    M.D.                           Committee; Dean, Medical College                     HOWELL, Harold N.
           Medical  Program;  Dean,  College   of               Louisiana   Regional   Advisory    Committee;       of Alabama                                           Managing Director, Blue Cross Association,
           Medicine, University of Iowa                                                                                                                                  Utica, New York; Member, National Board
                                                                President and State Health Officer,                 HINE, Maynard K., D.D.S.                             of Governors, Blue Cross Association
           HARDY, Robert C.                                     Louisiana State Board of Health                     Immediate Past President, American Dental           -HUDSON, Charles L., M.D.
           Executive Director, Oklahoma Health                  HEINTZELMAN, J. H. L., M.D.                         Association;  Indiana  University  School   of       President, American Medical Association
           Sciences Foundation                                  Director, Division of Medical Care,                 Dentistry
           HARKNESS, James P., Ph.D.                            Tennessee   Department   of   Public   Health                                                            HUGGINS, Perry M., M.D.
           Medical  Sociologist,  New  Jersey  College  of                                                          HINES,  Merrill  O.,  M.D.                           Medical Director, East Tennessee
           Medicine and Dentistry                               HELLER,  Ben   I.,   M.D.                           Medical    Director-Trustee,    Ochsner              Tuberculosis Hospital, Knoxville
                                                                Acting    Program    Coordinator,    Oklahoma       Medical Center
           HARKNESS, Stuart F., D.O.                            Regional  Medical  Program;   Professor   and                                                            HUGHES, Gerald E., M.D.
           Administrative Dean, Michigan College of             Head, Department of Laboratory Medicine,           *HIRSCHBOECK,   John   S.,    M.D.                    Secretary for MAetings, American Academy
           Osteopathic Medicine                                 University   of   Oklahoma   Medical   Center       Program   Coordinator,   Wisconsin    Regional       of Pediatrics
           HARRELL, George T., M.D.                             HENDERSON, Robert R., M.D.                          Medical Program                                      HULL, Edgar, M.D.
           Dean, College of Medicine,                           Medical Director, Hunterdon Medical Center          HISCOCK, William                                     Dean, Shreveport School of Medicine of
           Pennsylvania State University                                                                            Office of Program   Planning and Education,          Louisiana State University; Member,
                                                                HERRON,  John  T.,   M.D.                           Public  Health   Service                             Louisiana Regional Advisory Group
           HARRIS, Robert                                       State Health Officer, Arkansas State                                                                     HUME, Walter I., Jr., M.D.
           Supervisory Budget Examiner,     Office of  the      Department   of    Health                          *HISCOE,  D.  Bonta,   M.D.                           Member, Ohio Valley Regional Advisory
           Secretary, Department of Health, Education,          *HESS,  Orvan  W.,   M.D.                           Michigan   State   Medical Society                   Council
           and Welfare                                          Member,       Connecticut Regional     Advisory     HOLECHEK,    James    A.                             HUMPHREY, George D., M.D.
           HARRISON, Bernard P.                                 Committee;     President, Connecticut     State     Public Relations  Director,    Maryland              Member, Mountain States Regional Advisory
           Director,  Legislative   Department,   American      Medical Society                                     Hospital  Service,  Inc.                             Council; President Emeritus, University Of
           Medical Association                                  HICKS, Al                                           HOLLOMAN, Frank                                      Wyoming; Wyoming Chairman, Cancer
           HARTFORD, Thomas J., M.D.                            Public Information Officer, California              Executive Director, Memphis Mid-South                Crusade
           Vice  President  for  Area  Medical   Programs,      Regional Medical Program; Public                    Medical   Center   Council                           HUMPHREYS, George H., M.D.
           American Cancer Society                              Information  Officer,  School  of   Medicine,
                                                                University of California, Los Angeles              *HOLLOMAN, John L. S., Jr., M.D.                      Professor of Surgery, Columbia University
           HARVEY. A. M., M.D.                                                                                      President, National Medical Association              College of Physicians and Surgeons;
           Director, Department of Medicine, The                *HILDEBRAND, Paul R., M.D.                                                                               Chairman, Physicians and Surgeons
           Johns  Hopkins  School   of   Medicine               Director, Colorado.Wyoming Regional                 HOLTHAUS, Joseph M., M.D.                            Faculty Committee on Regional Programs
           HAY, George A.                                       Program; Immediate Past President,                  Associate Dean of Medicine,     Creighton            HUNT, Andrew D., M.D.
           Administrative   Vice   President    Woman's         Colorado State Medical Society                      University  Medical   School;   Member, iffee,       Secretary, Michigan Regional Advisory
           Medical  College  of   Pennsylvania;   American      HILL,  Dudley  A.,   M.D.                           Advisory   Group   and   Executive   Comm                                     of Human Medicine,
                                                                                                                    Nebraska-South   Dakota    Regional    Medical       Council; Dean, College
           Hospital  Association   Committee   on               Commissioner  of   Health,   Niagara   County                                                            Michigan State University
           P.L. 89-239                                          Health Department                                   Program
                                                                HILL,Joseph   K.,    M.D.                           HOWARD, Ernest B., M.D.                              HUNTER, Thomas H., M.D.
           HAYES, John J.                                                                                                                                                      cellor for Medical Affairs, University
           Hospital  Administration   Specialist,               President   and   Dean,   Downstate   Medical       Assistant  Executive  Vice   President,              Chan
           Veterans Administration Central Office               Center, State University of New York                American   Medical    Association                    of Virginia School of Medicine

                                                                                                                                                                                                                     87







                                                                        JOHNSON, Trois, M.D.                                  KELLOW, William F., M.D.                             KISSICK, William L., M.D.
                   HUTCHISON, Meryle V., R.N.                                                                                 Dean, Hahnemann Medical College                      Director, Office of Program Planning and
                   Assistant Director, Washington, D.C.                 Regional Health Director, Public Health                                                                    Evaluation, Office of the Surgeon General,
                   office, American Nurses Association                  Service (Region 11)                                   KELLY, Ann S.                                        Public Health Service
                   IREL.AND, Charles S., M.D.                           'JONES, A. Curtis, Jr., M.D.                          American Association of Medical Record
                                                           bia          Member,   Mountain   States Regional      Advisory    Librarians                                           KISTNER, Robert A., D.O.
                   Member, Metropolitan District of Cofum               Committee;   President,   Idaho   State   Medical                                                          Dean, Chicago College of Osteopathy
                   Regional Advisory Committee; College of                                                                    KEMBLE, Elizabeth L., R.N., Ed.D.                                        E., Ph.D.
                   Medicine, Howard University; Assistant               Association                                           Dean, School of Nursing, University of               KLARMAN,      Herbert                   tion,
                   Medical Director, Freedmen's Hospital                                                                      North Carolina                                       Professor  of  Public Health Administra
                                                                        JONES, Edith A.                                                                                            The   Johns   Hopkins School of Public Health
                   IRELAND, Ralph L., D.D.S.                            American Dietetic Association; Chief,                 KENDALL, Patricia L., Ph.D.                                              M.D.
                   President, American Association of Dental            Nutrition Department, Clinical Center,                Bureau  of  Applied  Social  Research,  Queens       KLIEGER, Philip  A.,,
                   Schools; Dean, College of Dentistry,                 National Institutes of Health                         College, New York                                    Medical Consultant, Vocational
                   University of Nebraska                                                                                                                                          Rehabilitation Administration, Department
                                                                        'JONES, Frank W., M.D.                                KENDRICK, General Douglas B., U.S.A.                 of Health, Education, and Welfare
                   JACOBSEN, Carlyle F.,  Ph.D.                         Member, Board of Directors,    North     Carolina     Commanding General, Walter Reed Army
                   Chairman, Central New York Regional                  Regional  Medical   Program;   President,   North     Medical Center                                       KNUDSON, A. B. C., M.D.
                   Advisory Group; President, Upstate Medical           Carolina State Medical Society                                                                             Director, Physical Medicine and
                   Center, State University of New York                                                                       KENNEDY, Thomas P., Jr.                              Rehabilitation Service, Veterans
                                                                        JONES, Warren L., M.D.                                Chairman, Tennessee Mid-South Regional               Administration; immediate Past President,
                   JACOBSON, Leon O., M.D.                              Vice Chairman, Planning Committee,                    Advisory Board                                       American Academy of Physical Medicine
                   Program Coordinator'   Illinois Regional             Nebraska-South Dakota Regional Medical
                                        an, University of                                                                     KENNEY, Howard W., M.D.                              and    Rehabilitation
                   Medical Program; DeBiological Sciences               Program; Assistant Dean, University of                Member, Regional Medical    Programs
                   Chicago, Division Of                                 South Dakota School of Medicine                       Review Committee; Medical Director,       John       KOLB, Mary Elizabeth
                   JAMES, George, M.D.                                  JORDAN, Edwin P., M.D.                                A. Andrew Memorial Hospital, Tuskegee,               President, American Physical Therapy
                   Member, Regional Medical  rograms                    Executive Director, American Association       of     Alabama                                              Association
                   Review Committee; Member, Ad Hoe        the          Medical Clinics                                                                                            KOOMEN,   Dr.   Jacob
                   Advisory Committee for the Report to                                                                       KENNEY, John A., Jr., M.D.                           Member, North Carolina Regional Advisory
                   President and the Congress; Dean, Mt. Sinai          JORDAN, Harold B.                                     Member,  Metropolitan Washington, D.C.               Committee; Director, North Carolina State
                   School of Medicine                                   Administrative  Assistant  to  Dean  and   Public     Regional Advisory Committee; Associate               Board of Health
                                                                        Information Officer, College of Medicine,             Professor and Head, Division of
                   -JEHL, Joseph R.,   . -                                                                                                    oward University College             -KOWALEWSKI, Edward J., M.D.
                   Chairman, New Jersey Ad Hoc Committee,               Howard University                                     Dermatology, H
                                                                                                                              of Medicine                                          Member, Regional Medical Programs
                   Inc.; President, Medical Society of                  JOSEPHINE, Sister Ann                                                                                      Review Committee; Chairman of the Board
                   New Jersey                                           Member, Executive Committee,                          KERRIGAN, Gerald A., M.D.                                                ican Academy of General
                                                                                                                              Dean, Marquette University                           of  Directors,   Amer
                   JOHNSON, Clifford F.                                 lntermounta 'in Regional Advisory Council;            School of Medicine.                                  Practice
                   Chief, office of Research information,               President,  Utah  State   Hospital   Association,
                   Office of the Director, National Institutes          Administrator, Holy Cross Hospital                    KETTERING, Harvey E., It                             KREHL, William A., M.D.
                                                                                                                              Executive Director, Baltimore Goodwill               Chairman, Ad Hoc Committee of the
                   of Health                                            JOY, Dr. E. H.                                        Industries, Inc.                                     American Heart Association; Professor of
                   JOHNSON, Emery A., M.D.                              Montgomery County, Maryland, Health                   KING, Dr. Imogene M.                                 Medicine, Clinical Research Center.
                   Assistant Director, Bureau of Indian Health,         Department                                            Division of  Nursing,  Public  Health  Service       University Hospitals, Iowa City
                   Public Health Service                                KAREL, Frank, III
                                                                        Associate Director of Public Relations,               KING, M. Kenton                                      KUSHNER, Daniel S., M.D.
                   -JOHNSON, George D.,    M.D.                         The  Johns  Hopkins   University   and   Hospital     Dean, Washington University School of                Director of Medical Services, Mt. Sinai
                   President, South Carolina State Medical                                                                    Medicine, St. Louis                                  Hospital of Greater Miami
                   Association                                          KASSEL,  Henry   W.,   M.D.                           KINNARD, Charles M.                                  LAND, Francis L., M.D.
                   JOHNSON, Kenneth L.                                  Regional Health Director, Public Health               Vocational   Rehabilitation    Administration,       Chief, Division of Medical Services, Bureau
                   Public Relations Director for University of          Service (Region Vill)                                 Department of Health, Education, and                 of Family Services, Welfare Administration,
                   Tennessee Medical Units                              -KAY,  Raymond   M.,   M.D.                           Welfare                                              Department of Health, Education, and
                                                                        Member, California Regional Advisory                  KINZER, David M.                                     Welfare; Representative of Council On
                   -JOHNSON, Maxwell A., M.D.    State Medical          Committee;   Southern    California    Permanente     Executive Director, Illinois Hospital                Medical Education to the Ad Hoc Committee
                   President-Elect, Oklahoma                                                                                  Association                                          on Education for Family Practice
                   Association                                          Medical Group


                   88











        'LANG,   Leonard   P.,    M.D.                          LEVITT, Le  Roy  P.,  M.D.                            MALONEY, William F., M.D.                             McCLENAHAN, J. Everett, M.D.
         Medical Society of Delaware                            Dean,   The   Chicago   Medical.School;   Member,     Dean of Medicine, Tufts University                    Member, Steering Committee, Western
                                                                Coordinating  Council   of   Medical   Schools                                                              Pennsylvania Regional Medical Program;
         LANG, Robert A., M.D.                                  and Teaching Hospitals of Illinois                    MANNARINO, Emanuele U., M.D.                          President, Pennsylvania Medical Society,,
         Executive Secretary, Academy of Medicine                                                                     Chief, Neurosurgery Section, Department of            Medical Director, McKeesport Hospital
         of Cleveland                                           LEWIS, Irving J.                                      Medicine and Surgery, Veterans
                                                                Chief, Health and Welfare Division,                   Administration                                        McCLURE,   James   A.,    M.D.
         LAWRENCE, Clifton F., Ph.D.                            Bureau of the Budget                                                                                        President, Kansas Medical Society
         Associate   Secretary,    American    Speech           LIEBERMAN, James, M.D.                                MARSH, Homer F., Ph.D.                                McCOMBS,   Robert   P.,   M.D.
         and    Hearing    Association                                                                                Vice  President,  University  of   Tennessee;         Member, Tri-State and Maine Regional
                                                                Director,  Audiovisual   Facility,   Communicable     Representative,   University   of   Tennessee.        Advisory   Committees;   Professor   of   Graduate
         LAWTON,    Robert     P.                               Disease  Center,  Public  Health   Service            Medical Units                                         Medicine, Tufts University School of
         Associate Dean, School of Medicine Yale
         University; Member, Planning Committee,                LINDEE, Robert G.                                   "MARSHALL, John F., M.D.                                Medicine
         Connecticut   Regional    Medical    Program           Assistant Dean, Stanford University                   United Progress, Inc.                                 McCORD,   William   M.,   M.D.
         LEE,  Lyndon  E.,  Jr.,  M.D.                          School of Medicine                                    MARTIN, Dr. Samuel P.                                 Chairman,   South   Carolina   Regional   Advisory
         Chief, Extra VA Research and Director of               LINDSAY,  Dale  R.,   M.D.                            Provost, University of Florida                        Group; President, Medical College of
         Surgical Service, Veterans Administration              Special Assistant  to  the Chancellor,                College of Medicine                                   South Carolina
         LEE,  Philip  R.,   M.D.                               Health  Sciences,  University  of  California,        MASLAND, Richard L., M.D.                             McFADDEN,   R.   Bruce,   M.D.
                                                                Davis                                                                                                       Medical Committee, Chronic Disease
         Assistant      Secretary for Health and                                                                      Director, National Institute  of Neurological         Section, Oregon State Board of Health
         Scientific Affairs, Department of Health,              LOW, Richard J.                                       Diseases and Blindness, National Institutes
         Education,    and     Welfare                          Executive  Officer,  Dartmouth   Medical   School     of Health                                             McGRANAHAN,     Robert      S.
                                                                                                                                                                            Health Sciences Editor, State University
         LEIN,  John   N.,   M.D.                               LUKEMEYER,    George    T.                            MASUR, Jack, M.D.                                     of New York at Buffalo
         Assistant    Dean    and Director, University of       Program Coordinator, Indiana Regional                 Director, Clinical Center and Associate
         Medicine;        Member, Washington-Alaska             Medical  Program;   Associate   Dean   for            Director, Clinical Care Administration,               McHUGH, Thomas J.
         Regional Advisory Committee                            Continuing   Education,   Indiana   University        National Institutes of Health                         Member,   Western New York Regional
                                                                School of Medicine                                                                                          Advisory   Council;    Administrator,    Emergency
        ILEINBACH, Samuel P., M.D.                                                                                    MATTINGLY, Thomas W., M.D.                            Hospital, Buffs o
         Iowa    State    Medical Society                       LUMMIS, Wilbur S., Jr., M.D.                          Program Coordinator, Metropolitan
                                                                Deputy Director, Hawaii State Department              Washington, D.C. Regional Medical Program;            'MCKEAN,   Robert   S.,   M.D.
         LE MAISTRE, Charles M., M.D.                           of Health                                             District of Columbia Medical Society                  Director,   Mountain    States Regional      Medical
         Program    Coordinator,    Texas    Regional                                                                                                                       Program    (idaho)
         Medical Program; Vice Chancellor,                    *LYNCH, Richard V., Jr., M.D.                           MATTISON, Berwyn F., M.D.
                                                                Chairman,   Executive   Committee,    West            Executive Director, American Public Health            McNULTY,   Matthew   F.,   Jr.
         Health Affairs, University of Southern Texas,                                                                                                                      Member,   Alabama   Regional    Advisory    Board;
         Austin                                                 Virginia  Regional   Medical   Program;   West        Association                                           Director, Council of Teaching Hiispitals
         LE  ROY,  George   V.,   M.D.                          Virginia State Medical Association                    MAYER, Andrew, M.D.                                   "MCPHAIL,   Frank   L.,   M.D.
         Medical Director, Metropolitan Hospital,               LYONS, Richard H., M.D.                               Assistant Director, Professional Activities,          Director,   Mountain   States   Regional   Medical
         Detroit                                                Program Coordinator, Central New York                 American College of Surgeons                          Program (Montana)
                                                                Regional  Medical   Program;   Professor   and
         LESSER,   Arthur   J.,   M.D.                          Chairman,  Department   of   Medicine,   State        MAYES, William F., M.D.                               MEADOW, Henry C.
         Deputy   Chief,    Children's Bureau, Welfare          University  of  New  York,   Upstate   Medical        Member, Board of Directors, North Carolina            Associate Dean, Harvard Medical School
         Administration,   Department   of    Health,           Center                                                Regional  Medical   Program;   Dean,   School         MEADS, Manson, M.D.
         Education,    and     Welfare                                                                                of Public Health, University of North                 Dean,  The  Bowman   Gray   School   of   Medicine
                                                                MACER, Dan J.                                         Carolina                                              of  Wake   Forest   University
         LEVINE, Peter B.                                       Director,  Veterans   Administration   Hospitals,
         Coordinator,    Program    in Health and               Pittsburgh; Member, Executive Committee,              McBEATH, William H., M.D.                             MEEK, Peter G.
         Hospital      Administration, University    of         Council of Teaching Hospitals                         Program Coordinator, Ohio      Valley Regional        Executive  Director,   National   Health   Council
         Colorado    Medical    Center                                                                                Medical Program
                                                              "MAC LAGGAN, James C., M.D.                                                                                   MEILING,  Richard   L.,   M.D.
         LEVINE,    Rachmiel,     M.D.                          Member, Coordinating Committee,                     ';McCALLIE, David P., M.D.                              Dean, College of Medicine, Ohio State
         Professor    and    Chairman, Department of            California   Regional   Medical   Program;            Private Practitioner, Chattanooga,                    University;   Program    Coordin'ator, Ohio
         Medicine, New York Medical College                     President,  California   Medical   Association        Tennessee                                             Regional    Medical    Program


                                                                                                                                                                                                                          89






                    MEINERSHAGEN, Charles W., M.D.                       MORSE, Robert W.                                     NEMIR, Paul, Jr., M.D.                                ORGANICK, Avrum B., M.D.
                                                                         Member, Cleveland Regional Advisory                  Director, Division of Graduate Medicine and           Assistant Coordinator, Wisconsin Regional
                    Director, Section of Chronic Diseases,               Committee;  President,  Case  Institute   of         Associate  Professor  of  Surgery,  University        Medical Program; Assistant Dean, Marquette
                    Missouri Division of Health; Member,                                                                                                                            University School of Medicine
                    Scientific Subcommittee, Missouri                    Technology                                           of  Pennsylvania  School  of  Medicine
                    Regional   Medical   Program                         MOSES, Campbell. M.D.                                NICHOLSON, Hayden C., M.D.                            O'ROURKE, Edward, M.D.
                                                                         Member,   Western   Pennsylvania    Regional         Dean and Vice President for Medical                   Assistant Director, Bureau  of  Health
                    MENGER, James M.                                     Advisory   Committee;   Medical    Director,         Affairs, University of Miami School of                Services, Public Health Service
                    Staff Assistant, House Committee on                  American Heart Association                           Medicine                                              PALMQUIST, Emil E., M.D.
                    Interstate and Foreign Commerce,                                                                                                                                Regional Health Director, Public Health
                    U.S.  House  of   Representatives                    MOU, Thomas W., M.D.                                 NIGAGLIONI, Adin, M.D.
                                                                         Associate Director, Central New York State           Chancellor, Medical Sciences Campus,                  Service (Region III)
                    MERCER,  Dr.   Sherwood   R.                         Regional Medical Program; Associate                  University of Puerto  Rico  School  of                PARKER, Ralph C., Jr., M.D.
                    Vice  President  and   Dean, Philadelphia            Professor  of  Preventive  Medicine,   State         Medicine                                              Program Coordinator, Rochester Regional
                    College of Osteopathy                                University  of  New  York,  Upstate  Medical         NILSON, George T., M.D.                               Medical  Program;  Clinical  Associate
                    -MEREDITH,   Lawrence    C., M.D.                    Center                                               Field  Director,  Bingham   Associates    Fund;       Professor of Medicine,  University  of
                    President, Ohio State Medical   Association          MUELLER, Ralph R.                                    Secretary,  Applicant  Agency,   Maine Regional       Rochester Medical Center
                    MERRILL,  Joseph  R.,   M.D.                         Budget  Examiner,  Bureau  of   the   Budget         Medical Program
                                                                                                                                                                                    PARKS, John, M.D.
                    Chief, General  Clinical  Research  Centers          MURTAUGH, Joseph S.                                  NINE-CURT, Jos6, M.D.                                 Dean, George Washington University
                    Branch, Division of Research Facilities and          Chief, Office of  Program  Planning,  Office
                    Resources, National  Institutes  of  Health          of the Director, National Institutes of Health       Director, School of Public Health, University         School of Medicine
                                                                                                                              of Puerto Rico School of Medicine                     PASCASIO, Anne, Ph.D.
                    MILLER,  Brewster  S.,  M.D.                         MUSSER, Marc J., M.D.                         I      NORTH, John Paul, M.D.                                Member, Regional Medical Programs
                    Medical  Director,  United  Cerebral  Palsy          Executive Director, North Carolina Regiona           Director,  American  College   of   Surgeons          Review Committee; Associate Research
                    Research and Education Foundation, Inc.              Medical  Program;  Professor  of   Medicine.                                                               Professor, School of Nursing, University
                                                                         Duke University School of Medicine                   NOVITCH, Mark, M.D.                                   of Pittsburgh
                    MILLER,  George   E.,   M.D.                         NADEL, E. M., M.D.                                   Office of  the  Assistant  Secretary  (HSA),
                    Member, Regional Medical Programs                    Chief, Pathology and Laboratory Medicine,            Department of Health, Education, and                  PATE, James W., M.D.
                    Review Committee; Director, Office of                                                                     Welfare                                               Program Coordinator, Memphis Regional
                    Research in Medical Education, College of            Veterans   Administration   Central   Office                                                               Medical Program; Professor of Surgery.
                    Medicine, University of  Illinois                    NAHM, Dr. Helen                                      NYBERG, Charles E.                                    University of Tennessee
                    .MILLER, J. E., M.D.                                 Dean,  School  of  Nursing,  University   of         Assistant Executive   Director,     American
                                                                         California, San Francisco                            Academy of General Practice                           PATTERSON, Dr. Athol J.
                    Chairmar?, Board of  Chancellors,                                                                                                                               Acting Head, Division of Public Health
                    American  College  of   Radiology                    NEFF, Kenneth, M.D.                                  -NYE, Dan A., M.D.                                    Administration, Tulane University ShcOOt
                    .MILLIKAN,  Clark  H.,  M.D.                         Administrative   Director,    Nebraska-South         President   Nebraska   State   Medical                of Medicine
                    Member, Natior?al Advisory Council On                Dakota Regional Medical Program; Executive           Association
                    Regional Medical Programs;                           Secretary, Nebraska State Medical                    'O'BRIEN, William A., II[, M.D.                       PATTERSON, Joye, Ph.D.
                    Consultant in Neurology, Mayo Clinic                 Association                                                                                                Publications Director,  University  of
                                                                                                                              Member, Mountain States Regional Advisory             Missouri Medical Center
                    MILLS,  Russell  C.,   Ph.D.                         NEIBEL, Oliver J., Jr.                               Committee    (Nevada);    Chairman,     Nevada
                    Program   Coordinator,   Kansas    Regional          Executive Director and General Counsel,              State   Medical   Association   Professional          PATTISHALL, Dr. Evan
                                                                         College of American Pathologists                     Education and Research Committee                      Professor and Chairman, Department of
                    Medical Program; Associate Dean,                                                                                                                                Behavioral Science, Pennsylvania State
                    University of Kansas Medical Center                  NELLIGAN, William D.                                 O'DOHERTY, Desmond S., M.D.                           University College of Medicine
                                                                         Executive  Director,  American  College   of         Chairman, D.C. Medical Society Committee
                    MONAHAN, Jack F.                                     Cardiology                                           on   Regional   Medical   Programs;   American        -PAUL, Oglesby, M.D.
                    Executive Director,  Florida Hospital                                                                     Academy  of   Neurology;   Medical   Director,        Chairman, Illinois Regional Advisory
                    Association                                          NELSON, Kinloch, M.D.                                Georgetown Hospital                                   Committee;  Professor   of   Medicine,
                                                                         Program   Coordinator,   Virginia   Regional                                                               Northwestern University School of Medicine
                    ,MORGAN,  Robert  J.,   M.D.                         Medical Program; Dean, Medical College of            OGDEN, C. Robert
                    President-Elect,    Nebraska State Medical           Virginia                                             Member, Washington-Alaska Regional                    PEAVY, James E., M.D.
                    Association; Chairman, Steering Committee,                                                                Advisory  Board;  President,   North   Coast          Commissioner of Health, Texas State
                    Nebraska-South Dakota Regional Medical               NELSON, Russell A., M.D.                             Life Insurance Company                                Department of Health
                    Progra m                                             President,  The   Johns   Hopkins   Hospital

                    00










          PEEPLES, William J.. M.D.                         'RAYMOND, William H., M.D.                            ROGERS, Arthur M.                                   ISAWARD, Ernest, M.D.
          Temporary   Program    Coordinator,    Maryland     Member, Albany Regional Advisory Council;           Chairman,   Connecticut   Regional   Advisory       Medical Director, The Permanents Clinic,
          Regional Medical Program; Commissioner,             Medical Society of New York State                   Committee; Director of Traffic, Scoville            Portland; Kaiser Foundation Health Plan
          Maryland State Department of Health                 REIDY, William G.                                   Manufacturing Co.                                   SCHAEFFER, Joseph N., M.D.
          PELLEGRINO, Edmund D., M.D.                         Association of American Medical Colleges            ROGERS,  David  E.,   M.D.                          Professor and Chairman, Department of
          Member, National Advisory Council on                RICHARDSON, Arthur P., M.D.                         Member, Regional   Medical    Programs    Review    Physical Medicine and Rehabilitation,
          Regional Medical Programs and Ad Hoc                Chairman,    Georgia    Regional    Adviso          Committee; Professor of Medicine,                   Rehabilitation institute, Wayne State
                                                                                                       'y                                                             University
          Advisory Committee for the Report to the            Group; Dean, Emory University School of             Vanderbilt University School of Medicine
          President and the Congress; Director,               Medicine                                            ROSE, John C., M.D.                                 SCHEELE,  Leonard  A.,   M.D.
          Medical Center, State University of New             RICHWAGEN, Lester E.                                Dean, Georgetown University School of               President, Warner Lambert Research
          York, Stony Brook                                   Professor  of   Hospital   Administration,          Medicine                                            Institute; Former Surgeon General, Public
          PENROD, Kenneth E., M.D.                            Mary Fletcher Hospital, Burlington, Vermont         ROSENOW, Edward C., Jr., M.D.                       Health Service
          Member, Indiana Regional Advisory                 -RIFNER,  Eugene   S.,   M.D.                         Executive Director, American College of             SCHLOTFELDT,    Rozelia    M.
          Committee; Provost, Indiana University              President, Indiana State Medical Association        Physicians                                          Dean and Professor of Nursing, School
          Medical Center                                      RIVALL, J. W.                                       ROSINSKI,  Dr.  Edwin   F.                          of Nursing, Western Reserve University
          PENDLETON, John L.                                  Member, Executive Committee, Northlands             Office of  the  Secretary, Department of            SCHMIDT, Alexander M., M.D.
          Chief, Grants Programming and                       Regional   Medical    Program;    Hospital          Health,   Education,   and Welfare                  Assistant Dean, University of Utah
          Coordination, Public Health Service,                Administrator, Eitel Hospital, Minneapolis          ROSS, Mabel, M.D.                                   SCHNAPER, Harold W., M.D.
          National Center for Chronic Disease     Control     ROBBINS, Guy F., M.D.                               Regional Health Director, Public Health             Associate Director, Research Service,
          PHILLIPS, Basil A.                                  Director  of  Planning,  Memorial   Sloan-          Service (Region 1)                                  Veterans Administration Control Office
          Administrative Director, Tennessee                  Kettering   Cancer   Center                         ROSS, Ralph H.                                      -SCHNEIDER, Margaret J., M.D.
          Mid-South Regional Medical Program                  ROBBINS,  Lewis  C.,   M.D.                         Member,   Northern   New   England   Regional       American Medical Woman's Association
          POLICOFF, Leonard D., M.D.                          Consultant,  Health   Hazards   Appraisal,          Advisory Board
          Member, Planning Committee, Albany                  National  Center  for   Chronic   Diseases                                                              SCHWARTZ, Herbert A.
                                                                                                                  ROWDEN, Dorothy                                     Public Relations, American Cancer
          Regional Medical Program; Chairman,               'ROBERTS,  David   L.,   M.D.                         Assistant to the President, The John and            Society, Inc.
          Albany  Subcommittee   on   Stroke;   Professor     Regional Director, Mountain States Regional         Mary R. Markle Foundation
          and Chairman, Department of Physical                Medical Program (Nevada)                            RUHE, C. H. William, M.D.                           SCHWARTZ, Mortimer L., M.D.
          Medicine and Rehabilitation, Albany                 ROBERTS,  Dean   W.,   M.D.                         Associate Secretary, Council on Medical             Member, New Jersey Regional Advisory
          Medical Center                                                                                                                                              Committee; Professor of Medicine,
                                                              Director of Greater Delaware Valley Regional        Education,  American   Medical   Association,
          POPMA, Alfred M., M.D.                              Medical Program at Hahnemann Medical                Member,   Regional   Medical   Programs   Review    New Jersey College of Medicine
          Regional  Director,  Mountain  States  Regional     College;    Department    of     Community          Committee  and   Ad   Hoc   Advisory   Committee    *SCRIVNER, W. C., M.D.
          Medical  Program  (Idaho);   Member,   National     Medicine,   Hahnemann   Medical    College          for the Report to the President and                 Illinois State Medical Society
          Advisory Council on Regional Medical                                                                    the Congress
          Programs                                            ROBERTSON, George J., M.D.                                                                              SESSOMS,  Stuart   M.,   M.D.
                                                              Chairman,   Committee   of    Application,          RUSK,  Howard   A.,   M.D.                          Deputy Director, National Institutes of
          PORTES, Caesar, M.D.                                Tri-State   Regional   Medical    Program;          Director, Institute of Rehabilitation  Medicine,    Health
          President, Illinois State Medical Society;          Bingham   Associates    Fund;    Assistant          New York University Medical Center
          Medical  Director,  Cancer  Prevention   Center     Professor of  Medicine,  Tufts  University                                                              SHAFFNER, Louis, M.D.
          of Chicago                                          School of Medicine and Dentistry                    ISABATIER, Joseph A., Jr., M.D.                     Associate Professor of Surgery, Bowman
          PRIMAS, H. R., Jr., D.D.S.                          ROBERTSON, J. D., D.M.D.                            Member, Louisiana Regional Advisory                 Gray School of Medicine
          President National Dental Association               Cancer  Control  Branch,   Public   Health          Committee; President, Louisiana State               SHANHOLTZ,  Mack   I.,   M.D.
                                                              Service                                             Medical Society                                     Member, National Advisory Council on
          RAMMELKAMP, Charles, M.D.
          Member, Cleveland Regional Advisory                 ROBINS, Hugh B., M.D.                               SANAZARO, Paul J., M.D.                             Regional Medical Programs; Member,
          Committee;  Professor  of   Medicine,   Western     Allegheny   County    Health    Department          Director, Division of Education,                    Virginia Regional Medical Program; State
          Reserve University                                                                                      Association  of  American  Medical   Colleges       Commissioner of Health, Virginia
                                                              ROEMER,  Milton  I.,   M.D.                                                                             Department of Health
          RAUSCH, Verna                                       Professor  of  Public  Health,  School  of          SARGEANT, John                                      SHANNON,   James   A.,   M.D.
          President American Society of Medical               Public Health, University  of  California,          Executive Secretary, Medical and
          Technologists                                       Los Angeles                                         chirurgical Faculty of Maryland                     Director, National Institutes of Health
                                                                                                                                                                                                                  91






                                                                                                                                   SPIELHOLTZ, Jess B., M.D.                               STRONACH,   William    C. rican   College   of
                                                                           Hospital Administrator, University of                   Member, Washington-Alaska Regional                      Executive  Director,  Ame
                   SHEEHAN, John F., M.D.    I Center and                  Arkansas Medical Center                                 Advisory Council; Deputy Director,                      Radiology
                   vice President    for     Medica                                       Ph.D.                                    Washington  State  Department  of  Health               STURM, Herman M.        tics, U.S. Department
                   De'an, Loyola University Stritch School of              SMITH, Harvey L-,                                                                                               Bureau  of  Labor  Statis
                                                                           Program Coordinator, North Carolina                                ries C., M.D.
                   Medicine                                                Regional Medical Program; Professor  Of                 SPRAGUE, Cha  medicine, Tulane                          of Labor
                   SHEPS, Cecil G., M.D,                                   Sociology, University of North Carolina                 Dean, School Of er,   Louisiana    Regional             SUAREZ,  Ram6n  M.,  M.D.
                   General Director, Beth Israel Medical                                                                           University; Memb                                        Medical Society of  Puerto  Rico;  Director,
                                                                           -SMITH, Robert, M-D.                                    Advisory committee                                                                         Clinices;
                   Center, New York City                                   Mississippi Medical and Surgical Society                                                                        Fundacion de lnvestigaciones
                                                                                                                                   -SPRING, William C., Jr.. M.D.                          Professor  of  Clinical   and   Experimental
                                                                                                                                                                                                                   University of
                   SHERMAN, Charles D., Jr., M.D.                          SMITH, Robert Leslie, M.D. blic Health                  Program Coordin ator,   Greater    Delaware             Medicine  (ad   honorem),
                   Chairman, Subcommittee on Cancer,                       Regional Health Director, Pu                            Valley Regional Medical Program                         Puerto Rico
                   Rochester Regional Medical Program;                     Service (Region IX)                                                                                             SUMMERALL, Charles P., III, M.D.
                   Clinical Associate Professor of  Surgery,                                                                       STACEY, John M.
                          of   Rochester   Medical   Center;               SMITH, Robert M.                                                                           edical               Program Coordinator, South Carolina
                   Univ                                                    Chief, Hospital insurance Branch, Division              Director, University of Virginia M                      Reional    Medical    Program;    Associate,
                   New j  State Medical Society                            of Health insurance, Social Security                    Center                                                  Department  of  Medicine,  Medical   College
                   SHOREY,  Winston  K.,  M.D.                             Administration                                          STEBBINS, Ernest L., M.D.                               of South Carolina
                   Chairman,  'Arkansas  Regional   Advisory               SMYTHE Chaves M., M.D                                   Dean, School of Hygiene and Public                      SURGENOR, Douglas M., Ph.D.
                   Group; Dean, University of Arkansas                     Director,'Assc)ciatiOn of American Medical              Health,  The  Johns  Hopkins   University               Program   Coordinator   Western   New   York
                                                                                                                                                                                                                              Schoolof
                   School of Medicine                                      Colleges                                                STEPHAN, pauiine H.                                     Regional Medical Program; Dean,
                   SIBLEY, Hiram             ital Planning                 SNODGRASS  'Glen                                        staff Assistant, office of  the   Director,             medicine,  state  University  of  Nev   York
                   Executive Director,      Hosp                           Assistant to the Dean, School Of Medicine,              National Cancer Institute, National                     at Buffalo
                   Council for Metropolitan Chicago                        University Of California, Davis                         Institutes of Health                                    SUTER,   Emanuel,    M.D-
                                                                                                                                                                                                                                      ge of
                   SIFONTES,  Jose  E.,   M.D.                             SNYDER, Joseph E., M.D.                                                                                         Dean,  The  University  of   Florida   Colle
                     , School of Medicine, University Of                   Assistant Vice President  Presbyterian                  STEPHENSON, Sam E., Jr,, M.D.      Tennessee            Medicine
                   Dean                                                    Hospital, New York City; Hospital                       Chairman, Visitation Committee.
                   Puerto Rico                                                                                                     Mid-South Regional Medical Program; , of                TABLEMAN, Betty
                   SIGMOND,   Robert   M.                                  Association of New York State                           Associate  Professor  of  Surgery,  Schoo               Assistant  to  State  Has ith Director, Michigan
                   Executive  Director.  Hospital   Planning               SOLOCHEK, Bernard                                       Medicine, Vanderbilt University                         Department of Public Hearth
                   Council of Allegheny County                             Barkin, Herman and Associates                           STEWART, Thomas B.                                      -TAYLOR,  George  E.,   M.D. ittee, Rochester
                   SIMARD,  Ernest  E.,   M.D.                             SORG, Nathan F.                                         Member,    Washington-Alaska     Regional               Member,    Planning     COMM
                     !dent, College of American Pathologists;              Member, Iowa Regional Advisory Committee                Advisory Committee; Judge of the Superior               Regional    Medical    Program;    Rochester
                   Pres                      pathology, Salinas                                                                                                      t Alaska              Regional  Hospital   Council
                   Chief,  Department  of    ital                          SOULES@ Mary E., M.D.       Montana State               Court, State of Alaska; Presiden                        TERRY, Luther L.,
                   Valley    Memorial     Hosp                             Director, Disease Control,                              Heart Association                                                               M-D.
                                                                                                                                                                                           vice President for Medical Affairs,
                   SIMS, Helen M.                                          Board of Health                                         *STICKNEY, J. Minott, M.D.                                                      y[vania;      Former
                   Director  of  Informational Services,                   SPARKMAN, Donal R., M.D.                                Program Coordinator, Northiands Regional                University   Of    Penns- blic Health  Service
                   University  of  Kansas   Medical   Center               Program Coordinator, Washington-Alaska                  Medical Program; Consultant in Medicine,                Surgeon    General,    Pu
                                                                           Regional Medical Program; Associate                     Mayo Clinic                                             THOMA,   George   E-,   M.D.               uls
                   SLATER,  Robert  J.,   M.D-
                   Former Member, National Advisory Council                Professor of Medicine, University Of                    STONE, William S-, M.D.                                 Assistant  to  the  Vice  President  St.  Lo
                   on Regional Medical Programs;                           Washington School of Medicine                           Dean, University of Maryland School Of                  University Medical Center    I
                   Consultant; Director, Association for the               SPEERS, James F., M.D.                                                                                          THOMAS,   Mrs.   David    N.    tive     and
                   Aid  of  Crippled  Children                             Deputy  Commissioner, Iowa State                        Medicine                                                Member, West Virginia Execu                Board,
                                                                           Department of Health; Member, Iowa                      STOREY,   Patrick 13., M.D.                                                     ember,      National
                   SLFF-TH,  Clark  K.,   M.D.                                                                                                   community         Medicine,               Advisory    Boards;     M
                   Member, Ad Hoc Advisory Committee for the               Regional Advisory Group                                 Professor   of   of   community   Health,               American Cancer Society
                   Report to the President and the Congre!Sl.              SPENCER, William A., M.D.                               Department                                                         John   F.,   M.D.
                                             rdinator, West Virgt                                      Advisory Group;             Hahnemann Medical College                               *THOMAS,                                   council;
                   Acting     Program      COO                  pl@        Member, Texas Regional                                                                                          Member,   Texas      Regional       Advisory
                                             gram, Dean, School Or         professor and Chairman,     Department of
                   Regional    Medical     Pro                                                         iversity College  of        STRICKLER, James C., M.D.          New York             Member,   Committee   on    Cancer,    Texas
                   medicine, West Virginia University                      Rehabilitation, Saylor Un    institute for              Assistant to the President, The                         Medical       Association
                   SLEIGHT,     Robert.E.                                  Medicine; Director, Texas                               Hospital-Cornell Medical Center
                   member,     Arkansas     Regional     Advisory     Group; Rehabilitation

                   92










            THOMPSON, G. D. Carlyle, M.D.                      @RER, Ray A., M.D.                                  WALKER, James E. C., M.D.                          WHITNEY, John M., M.D.
            Member,   Intermountain   Regional    Advisory     President, Memphis-Shelby County Medical            Chairman, Research and Evaluation                  Regional Health Director, Public Health
            Committee; State Director  of  Public  Health,     Society                                             Committee; Member, Advisory Committee,             Service (Region VI)
            Utah States Health Department                      ULSTROM, Dr. Robert A.                              Connecticut Regional Medical Program;              -WHITTAKER, L. A., Jr., M.D.
            THOMPSON, Spencer B., M.D.                                                                             Professor of Medicine, University of               President,  Arkansas  Medical   Society
                                                               Associate  Dean,  University  of   Minnesota        Connecticut School of Medicine
            Interim Planning Director, Texas Regional          College  of  Medical  Sciences                                                                         WHITTEN, E. B.
            Medical Program (Galveston); Assistant             -VADHEIM, A. L., M.D.                               WALTER, William A., M.D.                           Director, National Rehabilitation Association
            Dean, University of Texas Medical Branch           President, Montana State Medical                    Chief, Special Programs Branch, National           WICKS, Edwin O., M.D., Dr. P.H.
            'TILLMAN, Walter W., Jr., M.D.                     Association;  Member,   Mountain   States           Cancer Institute, National Institutes of           Member, Steering Committee, New Mexico
            Vice Chairman, Missouri Regional                   Regional Advisory Committee                         Health                                             Regional Medical Program; Director, New
            Advisory Council
            *TOMITA, Theodore, M.D.                            VAN NESS, Edward H.                                 WARD, Paul D.                                      Mexico  Department  of  Public   Health
            President,  Hawaii  Medical  Association           Executive Secretary, New  York  State  Joint        Program Coordinator, California Regional           WILBAR, Charles L., Jr., M.D.
            TOOMEY, Robert E.                                  Council  on  Regional  Medical   Programs           Medical Program                                    Secretary of Health, Pennsylvania State
            Member,  South  Carolina   Regional   Advisory     VAN ORMAN, William T., Ed.D.                        WARREN, James V., M.D.                             Department of Health
            Committee; Hospital Administrator,                 Regional  Health  Director,  Department   of        Professor of Medicine, Ohio State University       WILLARD, Harold N., M.D.
            Greenville Hospital System                         Health, Education, and Welfare (Region Vill)        College of Medicine                                Thayer Hospital Rehabilitation Center,
            TOUSIGNAUT, Dr. Dwight R.                          *VAUGHAN,  William  O.,   M.D.                                                                         Waterville, Maine
            Director of  Professional  Practice,  American     Tennessee  Medical  Association;   Associate        WATTS, Charles D., M.D.                            *WILLIAMS, Jasper F., M.D.
            Society of Hospital Pharmacists                                                                        Medical Director, North Carolina Mutual            Chairman,  Council  on  Hospitals   and
                                                               Professor, Pediatrics, Vanderbilt University        Life Insurance Company
            'TOMPKINS, Harvey J., M.D.                         School of Medicine                                                                                     Medical  Education,  National   Medical
            President,  American  Psychiatric  Association     VAYDA, Eugene, M.D.                                 *WATTS, Richard W., M.D.                           Association
            *TOWNSEND, Thomas E., M.D.                         Medical Director, Community Health                  Member, Steering Committee, Cleveland              WILLIAMSON, Kenneth
            Member,   Arkansas   Regional   Advisory           Foundation                                          Regional Medical Program; Chairman,                Director,  Washington  Service  Bureau,
            Committee;  Arkansas   Medical   Society           VIGORITO,  Thomas   F.,   D.O.                      Professional Education Committee, Heart            American Hospital Association
                                                                                                                   Association, Northeast Ohio
            *TFTAEGER, Cornelius H., M.D.                      Dean,  College  of  Osteopathic  Medicine                                                              WILSON, David B., M.D.
            Member,  National  Advisory  Council  on           and Surgery, Des Moines                             WEGMAN, Dr. Myron E.                               Hospital Director, University of Mississippi
            Regional Medical Programs                          VOLKER, Joseph. F., D.M.D., Ph.D.                   Dean, School of Public Health, University          Medical Center,, President-Elect, American
            TRUSSELL, Ray E., M.D.                             Vice President for Birmingham Affairs and           of Michigan                                        Hospital Association
            Member, Ad Hoc Advisory Committee for              Director of the Medical  Center,  University
            the Report to the President and the                of   Alabama   in   Birmingham                      WELLS, Joseph A., M.D.                             WILSON, Leslie
                                                                                                                   Associate Dean, Northwestern University            President American Society of Radiologic
            Congress; Director, Columbia University            WAGNER, Henry N., M.D.                                                                                 Technologists; Department of Radiology,
            School of  Public  Health  and  Administrative     Director,  Nuclear   Medicine, The    Johns         *WESTLAKE, Robert E., M.D.                         University of Missouri Medical Center
            Medicine                                           Hopkins Hospitals                                   Member, Ad Hoc Committee for the Report
                                                                                                                   to the President and the Congress                  WILSON, Marjorie P., M.D.
            TUREN, Milton                                      WAKERLIN, George E., M.D., Ph.D.                                                                       Associate Director for Extramural Programs,
            Budget Analyst,  Bureau  of  the  Budget           Program Director, Missouri Regional                 WHALEY, Storm                                      National Library of Medicine
            TURIEL, Samuel N.                                  Medical Program                                     Vice President for Health Sciences,                WILSON, Vernon E., M.D.
            Executive Director,  Association  of  Hospital     *WALKER, A. Earl, M.D.                              University of Arkansas                             Program Coordinator, Missouri Regional
            Directors of Medical Education                     Professor of  Neurological  Surgery,  The           *WHISNANT, J. P., M.D.                             Medical Program; Dean, School of Medicine,
            TURNER, Thomas B., M.D.                            Johns Hopkins University School of                  Mayo Foundation Director for Northiands            University of Missouri
                                                               Medicine                                            Regional Medical Program; Associate
            Member, Steering Committee, Maryland                                                                                                                      WILSON, William L., M.D.
            Regional  Medical  Program;  Dean,   The           WALKER,   Cornelia  B.,   M.D.                      Professor of Neurology, Mayo Graduate              Professor of Medicine, University of Texas,
            Johns Hopkins School of MedicirFe                  Director,  Heart  Disease  Control  Program,        School of Medicine                                 South  Texas  Medical  School;   Progam
            TWISS, Maurine C.                                  New  Hampshire  State  Medical  Society,,           WHITE, Joseph M., M.D.                             Director, Texas Regional Medical Program
            Director of Public Information, University         New  Hampshire   State   Health   Department        Ex-Officio Member, Oklahoma Regional               (San Antonio)
            of Mississippi Medical Center, Member,             WALKER, Howard, Ph.D.                               Medical Program; Associate Director and            *W"TEN, Carroll L., M.D.
            Pre-Planning Committee, Mississippi                Director,  Statewide  Academic  Extension           Associate Dean, University of Oklahoma             President, American Academy of General
            Regional Medical Program                           Service. University of Kansas                       Medical Center                                     Practice


                                                                                                                                                                                                                93



                                                                        Appendix 3-National Advisory Council
                                                                                          Review Committee
                                                                                          Ad Hoc Committee
                                                                                          for the Report


                     WITTRUP, Richard D.                                    NATIONAL ADVISORY COUNCIL                              George   E.   Moore,    M.D.                              Edwin  L.  Crosby,   M.D.
                                                                                                                                   Director                                                  Director
                     Member,   Ohio   Valley   Regional   Advisory          ON REGIONAL MEDICAL PROGRAMS                           Roswell Park Memorial institute                           American Hospital Association
                     Committee;   Administrator,   University   of          Leonidas H. Berry, M.D.                                Buffalo, New York                                         Chicago, Illinois
                     Kentucky Hospital                                      Professor, Cook County Graduate                        -William  J.  Peeples,  M.D.                              George James, M.D. (Chairman)
                     WITTSON, Cecil L., M.D.                                School of Medicine                                     commissioner    of    Health                              Dean
                     Member, Executive Committee, Nebraska.                 Senior Attending Physician                             Maryland State Department of Health                       Mount Sinai School of Medicine
                     South  Dakota   Regional   Medical   Program;          Michael Reese Hospital                                 Baltimore,      Maryland                                  New  York,   New   York
                     Dean,  College  of  Medicine,  University  of          Chicago, Illinois
                     Nebraska                                                                                                      Edmund   D.   Pellegrino,   M.D.                          Howard   W.   Kenney,   M.D.
                                                                            *Mary 1. Bunting, Ph.D.                                Director of the Medical Center                            Medical Director
                     WOOLFORD, Robert M., M.D.                              President                                              State University of New York                              John A. Andrew Memorial Hospital
                     Member,   Ohio   Valley   Regional   Advisory          Radcliffe College                                      Stony   Brook,   New    York                              Tuskegee Institute
                     Committee                                              Cambridge, Massachusetts                                                                                         Tuskegee,       Alabama
                     WOOLSEY, Frank M., Jr., M.D.                           *Gordon R. Cumming                                     Alfred   M.   Popma,    M.D.
                     Program    Coordinator,    Albany    Regional          Administrator                                          Regional Director                                         Edward J. Kowalewski, M.D.
                     Medical Program; Professor of Post-                    Sacramento County      Hospital                        Mountain States Regional Medical Program                  Chairman, Committee of Environmental
                     Graduate Medicine, Albany Medical Center                                                                      Boise, Idaho
                     WOZAR, Louis                                           Sacramento, California                                 Mack  1.   Shanholtz,   M.D.                              Medicine
                     Member,   Ohio   Valley   Regional   Advisory          Michael E. DeBakey, M.D.                               State    Health     Commissioner                          Academy of General Practice
                     committee                                              Professor and Chairman                                 State   Department   of   Health                          Akron,     Pennsylvania
                                                                            Department of Surgery                                  Richmond,       Virginia                                  George  E.  Miller,  M.D.
                     WRIGHT, Jane C., M.D.                                  ga@for University
                     Member, President's Commission on Heart                Houston, Texas                                         'Robert  J.   Slater,   M.D.                              Director, Cbnter for Medical Education
                     Disease,   Cancer,   and   Stroke;    Adjunct                                                                 Dean,   College   of    Medicine                          College   of   Medicine
                     Associate Professor of Research Surgery,               Bruce W. Everist, Jr., M.D.                            University    of     Vermont                              University of  Illinois
                     New  York  University  School  of.   Medicine          Chief of Pediatrics                                    Burlington,      Vermont                                  Chicago, Illinois
                     WRIGHT, Thomas H., Jr.                                 Green Clinic                                           William H. Stewart, M.D. (Chairman)                       Anne Pascasio
                     Member, North Carolina Regional Advisory               Ruston, Louisiana                                      Surgeon General                                                           ,  M.  D.
                     Committee; Wright Chemical Corporation                 Charles J. Hitch                                       Public    Health     Service                              Associate Research Professor
                     YAKEL, Ruth M.                                         Vice President for   Administration                    Bethesda,       Maryland                                  Nursing School, University of Pittsburgh
                     Executive   Director,    American    Dietetic          University of California                                                                                         Pittsburgh,     Pennsylvania
                                                                            Berkeley, California                                   Cornelius    H.     Traeger, M. D.
                     Association                                                                                                   New   York,   New   York                                  Samuel   H.   Proger,   M.D.
                     YEAGER, J. Franklin, M.D.                              John R. Hogness, M.D.                                                                                            Professor    and    Chairman
                     Silver Spring, Maryland                                Dean, School of Medicine                                                                                         Depattment    of    Medicine
                                                                            University of Washington                               REGIONAL         MEDICAL   PROGRAM
                     YERBY, Alonzo S., M.D.                                 Seattle, Washington                                    REVIEW         COMMITTEE                                  Tufts University School of Medicine
                     Member,    Tri-State    Regional     Advisory                                                                                                                           President, Bingham Associates Fund
                     Committee; Professor and Head,                         James T. Howell, M.D.                                    Mark Berke                                              Boston,        Massachusetts
                     Department of Health Services                          Executive Director                                       Director
                     Administration, Harvard School      of Public          Henry Ford Hospital                                      Mount Zion    Hospital and Medical Center               David  E.  Rogers,   M.D.
                     Health                                                 Detroit, Michigan                                        San   Francisco,    California                          Professor    and    Chairman
                     .YLVISAKER, John R., M.D.                              -J. Willis Hurst, M.D.                                   Kevin P. Bunnell, Ph.D.                                 Department    of    Medicine
                                                                            Professor and Chairman                                   Associate     Director                                  School   of    Medicine
                     Pontiac, Michigan                                      Department of Medicine                                   Western Interstate Commission for                       Vanderbilt     University
                     YLVISAKER, Paul N., Ph.D.                              Emory University School      of Medicine                 Higher       Education                                  Nashville,      Tennessee
                     Commissioner, New Jersey Department of                 Atlanta, Georgia                                         Boulder,      Colorado
                     Community    Affairs;    Member,    Ad    Hoc ident    Clark H. Milliken, M.D.                                                                                          C.  H.  William  Ruhe,  M.D.
                     Committee  for  the  Report   to   the   Pres          Consultant in Neurology                                -*Sidney    B.     Cohen                                  Assistant     Secretary
                     and the Congress                                                                                                Management          Consultant
                                                                            Mayo Clinic                                              Silver Spring, Maryland                                 Council on Medical Education
                     YODER, Franklin D., M.D.                               Rochester, Minnesota                                                                                             American Medical Association
                     Vice  Chairman   and   Director   of   Public                                                                 .*Deceased,    April    1967                              Chicago, Illinois
                     Health, Illinois Department of Public Health           *Former member


                     94








                                                                                                                Appendix @Division Staff



        Robert J. Slater, M.D.                              Boisfeuillet Jones                                  PRINCIPAL STAFF OF                                   The   Grants    Management    Branch    interprets
        Executive Director                                  Director                                            THE DIVISION OF                                      grants    management    policies    and    reviews
        The Association for the Aid of                      Emily and Ernest Woodruff Foundation                REGIONAL MEDICAL PROGRAMS                            budget requests and expenditure reports.
        Crippled Children                                   Atlanta, Georgia                                                                                         Chief ...................     James   A.   Beattie
        New York, New York                                  Charles E. Odegaard, Ph.D.                          The  Office  of  the  Director  provides   program
        John D. Thompson                                    President                                           leadership and direction.
        Director, Program in                                University of Washington                            Director ..........   Robert  Q.   Marston,   M.D.   The  Grants  Review  Branch   handles   the   pro-
        Hospital Administration                             Seattle,     Washington                                                                                  fessional  and  scientific  review   of   applica-
        Professor of Public Health                                                                              Assistant Director                                   tions and progress reports.
        School of Public Health                             Edmund D. Pellegrino, M.D.                          for Program Policy   ..........   Karl  D.   Yordy   Acting Chief  ............   Martha  L.   Phillips
        Yale University                                     Director
        New Haven, Connecticut                              Medical Center                                      Associate Director                                   Head, Operations Section    .... Lorraine   Kyttle
        Kerr L. White, M.D,                                 State University of New York                        for Continuing
        Director, Division of Medical Care                  Stony Brook, New York                               Education   .........  William  D.   Mayer,   M.D.   The   Planning   and   Evaluation    Branch    ap-
        and Hospitals                                       Carl Henry William Ruhe, M.D.                       Executive Officer  ........  Charles    Hilsenroth   praises and  reports  on  overall  program  goals,
        School of Hygiene and Public Health                 Assistant     Secretary                                                                                  progress  and  trends  and  provided  staff   work
        The Johns Hopkins University                        Council on Medical Education                        Assistant to Director                                for  the  Surgeon  General's  Report  to  Congress
        Baltimore, Maryland                                 American Medical Association                        for Systems and                                      required  under  Section   908   of   Public   Law
                                                            Chicago, Illinois                                   Statistics  . . @.......... Maurice   E.    Odoroff  89-239.
      AD HOC COMMITTEE         FOR                          Clark K.  Sleeth,  M.D.                             Assistant to Director                                Chief  ...............   Stephen    J.    Ackerman
      THE REPORT TO THE PRESIDENT                           Dean                                                for Communications and                               Assistant Chief  ............   Daniel  1.   Zwick
      AND THE CONGRESS                                      School   of    Medicine                             Public  Information  ...  Edward  M.   Friedlander
                                                            West Virginia University                                                                                 Head, Planning Section      Roland   L.   Peterson
       Ray E. Brown, L.H.D.                                 Morgantown, West Virginia                           Public Information Officer   ..... Harold    Wolfe
       Director
       Graduate Program in    Hospital                      Ray E.  Trussell,  M.D.
       Administration                                       Director                                            The    Continuing    Education    and     Training
       Duke University Medical Center                       School of Public Health and                         Branch  provides  assistance   for   the   quality
       Durham, North Carolina                               Administrative Medicine                             development  of  such   activities   in   Regional
       Michael E. DeBakey, M.D.                             Columbia     University                             Medical Programs.
       Professor and Chairman                               New  York,   New   York
       Department of Surgery                                Burton Weisbrod, Ph.D.                              Chief  .............  William   D.   Mayer,   M.D.
       College of Medicine                                  Associate     Professor                             Assistant to Chief   .........  Cecilia    Conrath
       Saylor University                                    Department of Economics
       Houston, Texas                                       University of Wisconsin                             Head, Evaluation
       Bruce W. Everist, Jr., M.D.                          Madison,      Wisconsin                             Research Group    .... Frank  L.   Husted,   Ph.D.
       Chief of Pediatrics                                  Robert E. Westlake, M,D.
       Green Clinic                                         Syracuse,   New    York
       Ruston, Louisiana                                    Storm Whaley (Chairman)                             The    Development    and    Assistance    Branch,
       James T. Howell,   M. D.                             Vice President of Health Sciences                   serves  as  the  focus  for   two-way   communica-
       Executive Director                                   University of Arkansas Medical Center               tion  between  the  Division  and  the  individual
       Henry Ford Hospital                                  Little  Rock,  Arkansas                             Regional Medical Programs.
       Detroit, Michigan                                    Paul N. Ylvisaker, Ph.D.                            Chief ............   Margaret  H.  Sloari-,   M.D.
       George James, M.D.                                   Commissioner                                        Head, Liaison Section        Ian  Mitchell,   M.D.
       bean                                                 New Jersey Department of
       Mount Sinai School of Medicine                       Community Affairs                                   Head, Clinical
       New York, New York                                   Trenton,   New   Jersey                             Programs Section    .........  Philip  A.  Klieger


                                                                                                                                                                                                                  95





                   Appendix 5-Directory of Regional                          INDEX
                                   Medical Programs
                                                                                                                                                                                       OREGON  ..........................        106
                                          Regional    Medical     Pro,       Region                                                Page MASSACHUSETTS, see Tri-State                                 , see Greater Delaware
                   The  Directory  list                                                                                                                                      ........... 102 PENNSYLVANIA
                   grams   for   which   Planning    or    operational       ALABAMA (see also Tennessee                           MEMPHIS ..............                              Valley; Susquehanna Valley;
                   grants  have  been  ,warded   or   which   are   in       M id-South)                      ....................... 97                           C.                  102 Western Pennsylvania
                   earlier stages Of development.              urposes       ALASKA,  see   Washington-Alaska                      METROPOLITAN WASHINGTON, D                          103 PUERTO RICO ......................    107
                   Regions were defined for planning P                                                                             97 MICHIGAN                     .........................
                   In  the  planning  applications.   State   designs'       ALBANY   ...........................                                                                      103 RHODE ISLAND, see Tri-State
                   tions  do  not  necessarily   indicate   that   the                                                             97 MINNESOTA, see Northlands                .........
                   regions   are   coterminous   with   State   bound,       ARIZONA  ..........................                                                                       103 ROCHESTER .......................      107
                   aries. The original   definitions  of  the  regions       ARKANSAS  (see   also   Memphis) .......              97 MISSISSIPPI (see also Memphis)               ......
                   may  be  modified  on  the  basis  of   experience.                                                             98                                                  SOUTH CAROLINA     ..................      107
                                                                             BI-STATE ..........................                   MISSOURI (see also BI-State;
                   August 1, 1967                                                                                                  98 Memphis) ............ .."                 ........ 103 SOUTH DAKOTA, see Nebraska.
                                                                             CALIFORNIA  ......                     ................ 98 MONTANA, see intermountain;                    South Dakota
                                                                             CENTRAL NEW YORK                        ............... Mountain States                                   SUSQUEHANNA VALLEY        ..............   107
                                                                             CLEVELAND                       ....................... 98 MOUNTAIN STATES                  ................. 103 TENNESSEE MID-SOUTH (see also
                                                                                                                                   99                                                  Memphis)    .......  :................      108
                                                                             COLORADO-WYOMING                        ............... NEBRASKA-SOUTH DAKOTA                    .......... 104
                                                                                                                                   99                                                  TEXAS  ............................         108
                                                                             CONNECTICUT                       ..................... NEVADA, see Intermountain
                                                                             DELAWARE   VALLEY,   see   Greater                                                                        TRI-STATE  .........................        108
                                                                             Delaware Valley                                       NEW HAMPSHIRE, see Tri-State                        UTAH,7ee  .   intermountain
                                                                             FLORIDA  ..........................                   99 NEW JERSEY (see also Greater
                                                                                                                                   Delaware Valley)                   .................. 104 VERMONT, see Northern New England
                                                                             GEORGIA  ..........................                   99
                                                                                                                                   NEW       MEXICO        ....        ................. 104                              .......  108
                                                                             GREATER     DELAWARE      VALLEY ........             100                                                 VIRGINIA   ...................
                                                                             HAWAII   ..............                    ............ loo NEW  YORK,  see  Albany;  Central  New        WASHINGTON-ALASKA         .........    ....  109
                                                                                                                                   York;  New  York  Metropolitan   Area;
                                                                             IDAHO, see intermountain;                             Rochester; Western New York                                         D.C., see Metropolitan
                                                                                                                                                                                       WASHINGTON,
                                                                             Mountain States                                       NEW YORK METROPOLITAN AREA           ....           104 Washington, D.C.
                                                                             ILLINOIS (see also  Bi-State)  ..........             100 NORTH CAROLINA  ...                .............. 105 WEST VIRGINIA (see also Ohio Valley)   109
                                                                             INDIANA (see also   Ohio   Valley)               ....... 100
                                                                                                                                   .101 NORTH DAKOTA                 .................... 105 WESTERN INTERSTATE COMMISSION
                                                                             INTERMOUNTAIN                        ..................                                                     FOR HIGHER EDUCATION (WICHE),
                                                                                                                                   .101 NORTHERN NEW ENGLAND                  .......... 105 see Mountain States
                                                                             IOWA     .............................                101 NORTHLANDS                  ..................... 105 WESTERN NEW YORK    ...............     109
                                                                             KANSAS   ..........................
                                                                                                                                                                                                                                     109
                                                                             KENTUCKY,      see      Me-phis;      Ohio      Valley; OHIO STATE (see also Cleveland;                   WESTERN PENNSYLVANIA . - -
                                                                              Tennessee Mid-South                                   Ohio   Valley)                 ...................... 106                                    .. 110
                                                                                                                                   . 101                                               WISCONSIN      ......................
                                                                             LOUISIANA                       ....................... OHIO     VALLEY                ...................... 106
                                                                                                                                   .. 102                                              WYOMING, see Colorado.WyOming;
                                                                             MAINE    ..........................                                              .......   .....          106 intermountain; Mountain States
                                                                             MARYLAND                       ........................ 102 OKLAHOMA ...........


                       96













           Name Of Region                                 Alabama                                               Albany                                                Arizona                                                Arkansas


           Preliminary Planning Area                      Alabama                                               Northeastern N  ew York and portions of               Arizona                                                Arkansas
                                                                                                                Southern Vermont and Western Massachusetts


           Estimated Populatioa                           3,500,ODO                                             1,9DO,000                                             1,635,DOD                                              1,960,000

           Coordinating Headquarters                      University of Alabama Medical Center                  Albany Medical College of Union University            University of Arizona College of Medicine              University of Arkansas Medical Center

           Program Coordinator                            Benjamin B. Wells, M.D.                               Frank M. Woolsey, Jr., M.D.                           Merlin K. DuVal, M.D.                                  Winston K. Shorey, M.D.
                                                          University of Alabama                                 Associate Dean and Professor                          Dean, College of Medicine                              De@n          of Medicine
                                                            Medical Center                                      Chairman, Department of Postgraduate Medicine         University of Arizona                                  U iv' School
                                                                                                                                                                                                                              n  ersity of Arkansas
                                                          1919 Seventh Avenue South                             Albany Medical College of Union University            Tucson, Arizona 85721                                  4301 West Markham Street
                                                          Birmingham, Alabama 35233                             47 New Scotland Avenue                                                                                       Little Rock, Arkansas 72201
                                                          (tele: 2@325-4794)                                    Albany, New York 12208                                (tele: 602-884-1505)                                   (tele: 501-MO4-5000)
                                                                                                                (tele: 518-462-7521)


           Program Director








           Grantee                                        University of Alabama Medical Center                  Albany Medical College of Union University            University of Arizona College of Medicine              University of Arkansas Medical Center

           Effective Starting Date                        January 1, 1967                                       July 1, 1966                                          April 1, 1967                                          April 1, 1967
           of Planning Grant


           Program Period for                             Two years, six months                                 Three years                                           Two years, three months                                Two years, three months
           initial Planning


           Effective Starting Date                                                                              April 1, 1967
           of Operational Grant






















                                                                                                                                                                                                                                                                97








                                                                                                                                                                                   Central New York                                     Cleveland
                 Name of Region                                   Bi-State                                                 California                                              s  acuse, New York and 15                            Northeastern Ohio
                                                                                                                                                                                   yr
                 preliminary Planning Area                        Eastern Missouri and Southern Illinois                   California                                              surrounding counties
                 Estimated Population                             4,700,000                                                18,600,000                                              1,800,000
                                                                                                   Medicine                California Committee an                                 Upstate Medical Center, State University
                 Coordinating Headquarters                        Washington University School of                          Regional Medical Programs                               of New York at Syracuse
                                                                                                                                                                                   Richard H. Lyons, M.D.
                                                                  William H. Danforth, M.D.                                Paul D. Ward                                                              Medical
                 program Coordinator                                                                                       Executive Director                                      Director Regional
                                                                  vice Chancellor for Medical Affairs                      California Committee on                                 Progr@'m of Central New York
                                                                  Washington University                                    Regional Medical Programs                               750 Eist Adams Street
                                                                  660 Soq-th Euclid Avenue                                                                                         Room 1500
                                                                  St. Louis, Missouri 63110                                Room   304                                              State University Hospital
                                                                                                                           665 Sutte@sStreet                                       Syracuse  New York 13210
                                                                  (tele: 314-361-64DO, ext. 3013)                          San   Franci co, California 94102                              1
                                                                                                                           (tele: 415-771-5432)                                    (tele: 315-473-5600)


                 program Director




                                                                                                                                                                                   Research Foundation of State University                Application under development
                                                                  Washington University School of Medicine                 California Medical Education                            of New York
                 Grantee                                                                                                   and Research Foundation
                 Effective Starting Date                          April 1, 1967                                            November 1, 1966                                        January 1, 1967
                 of Planning Grant
                 Pr,,   in Period for                             Two years, three months                                  Two years, eight months                                 Two years

                 Effective Starting Date
                 of operational-Grant

















                         98






                           Name of Region                                   colorad@Wyoming                                          Connecticut                                             Florida                                                  Georgia
                                                                                                                                     Connecticut                                             Florida                                                  Georgia
                           PreliminarY Planning Area                        Colorado   and    Wyoming
                           Estimated Population                             2,300,000                                                2,800,000                                               5,910,000                                                4,400,000
                                                                                                                                     Yale University School of Medicine and                  Florida Advisory Council an Heart Disease,               Medical  Association  of   Georgia
                           Coordinating Headquarters                        University of Colorado Medical Center                    University of Connecticut School of Medicine            Cancerand Stroke, Inc.
                                                                                                                                                                                             Samuel P. Martin, M.D.                                   J. W. Chambers. M.D.
                                                                            C,    Wesley Eisele,   M.D.                              Henry T. Clark, Jr., M.D.                                                                                        Coordinator for Georgia Regional
                           program Coordinator                                                                                       Program Coordinator                                     Provos@',J. Hillis Miller                                 Medical Program
                                                                            Associate  Dean for Post-Graduate                        Connecticut Regional Medical Program                      Medic I  Center                                        Medical  Association  of   Georgia
                                                                             Medical Education                                                                                               Universi y of Florida
                                                                                                                                     272 George Street                                               tle, Florida 32601
                                                                            University of    Colorado Medical Center                                                                         Gairiesvil                                               938 Peachtree Street, N.E.
                                                                            4200    East Ninth   Avenue                              New Haven, Connecticut 06510                                                                                     Atlanta, Georgia 30309
                                                                            Denver,  Colorado   80220                                (tele: 203-776-6872)                                                                                             (tele: 404-876-7535)
                                                                            (tele: 303-394-7376 or 8406)

                                                                                                                                                                                                                                                      J. Gordon Barrow, M.D.
                           Program Director                                 Paul R. Hildebrand, M.D.                                                                                                                                                  Director for Georgia Regional
                                                                            University of Colorado Medical Center                                                                                                                                       Medical Program
                                                                            4200  East  Ninth  Avenue                                                                                                                                                 Medical  Association  of   Georgia
                                                                                                                                                                                                                                                      938 Peachtree Street, N.E.
                                                                            Denver,  Colorado   80220                                                                                                                                                 Atlanta, Georgia 30309
                                                                                                                                                                                                                                                      (tele: 404-875-0701)


                                                                                                                                                                                                                                                      Medical  Association  of   Georgia
                           Grantee                                          University of Colorado Medical Center                    Yale University School of Medicine
                           Effective starting Date                          January 1, 1967                                          July 1, 1966                                            Application under development                            January 1, 1967
                           of Planning Grant                                                                                                                                                                                                          Two years, six months
                           Pr gram Period for                               Two  years,  six   months                                Two years
                             "I
                           Initial planning


                           Effective Starting Date
                           of operational Grant
















                                                                                                                                                                                                                                                                                             99





                      Name of Region                                       Greater Delaware Valley                                        Hawaii                                                      Illinois                                                      Indiana
                      Preliminary Planning Area                            Eastern Pennsylvania and portions of                           Hawaii                                                      Illinois                                                      Indiana
                                                                           New Jersey and Delaware
                      Estimated population                                 8,830,000                                                      800,000                                                     10,700,000                                                    4,900,000
                                                                                                                                          University of Hawaii College of                             Coordinating Committee of Medical Schools                     Indiana University School of Medicine
                      Coordinating Headquarters                            University City Science Center                                 Health     Sciences                                         and Teaching Hospitals of Illinois
                                                                                                                                                                                                      Wright Adams, M,D:                                            G                          .0.
                                                                           William C. Spring, Jr., M.D.                                   Windsor C. Cutting, M.D.                                    Professor of Medicine and Associate Dean                      A                          University
                      Program Coordinator                                  Program Coordinator                                            Dean, School of Medicine                                    Division of Biologic8i Sciences
                                                                           Greater Delaware Valley                                        University of Hawaii                                        Univ rsity of Chicago                                                                     aItCenter
                                                                           Regional Medical Program                                                         Mall                                      Chicgo, -Illinois 60637
                                                                                                                                          2538            The
                                                                           301 0     Line Avenue                                          Honolulu, Hawaii 96922
                                                                           Bal.@ty'nwyd, Pennsylvania 19004                                                                                           (tele: 312-MU4-6100)                                          (late: 317-639-8877)
                                                                           (tele: 215-MO7-1790, 91, 92)

                      Program Director                                                                                                    William          D.aGraham, M.D.
                                                                                                                                                            u''rctor
                                                                                                                                                            yMedical Program
                                                                                                                                          H@-a              Re'a
                                                                                                                                          Leah              H-apt.I
                                                                                                                                          3675              K,IaAv@ nue
                                                                                                                                          H                 "IuIu,Ha ai, 96816
                                                                                                                                          (tele: 808-78660 or 722)
                                                                           University City Science Center                                 University of Hawaii College of                             University of Chicago                                         Indiana University Foundation
                      Grantee                                                                                                             Health     Sciences
                      Effettive Starting Date                              April 1, 1967                                                  July    1,     1966                                         July 1, 1967                                                  January 1, 1967
                      of plaiming Grant
                      program Period for                                   One year                                                       Two           years                                         Two years                                                     Two years, six months
                      initial Planning


                      EffectiVO Starting Date
                      of operational grant
















                              100













        ie of Region                                  Intermountain                                             I owa                                                     Kansas                                                    Louisiana

        liminary Planning Area                        Utah and portions of Wyoming, Montana,                    Iowa                                                      Kansas                                                    Louisiana
                                                      Idaho, and Nevada

        imated Population                             2,200,000                                                 2,760,000                                                 2,200,000                                                 3,5DO,000
        irdinating Headquarters                       University of Utah College of Medicine                    University of Iowa College of Medicine                    University  of  Kansas   Medical   Center                 Louisiana  State Department of Hospitals

        gram Coordinator                              C. Hilmon Castle, M.D.                                    Willard A. Krehl, M.D., Ph.D.                             Charles E. Lewis, M.D.                                    Joseph A. Sabatier, Jr., M.D.
                                                                                                                                                                          Ch irma     Department    of   Preventive                 Pro
                                                                                                                Department of Internal Medicine                              a                                                      Lou;ram Coordinator
                                                      Associate Dean and Chairman                                                                                                                                                        san
                                                      Department of Postgraduate Education                      University of Iowa                                           Medici9n'e and Community Health                                 a Regional Medical Program
                                                      Un I"' rsity of Utah College of Medicine                  Iowa City, Iowa 52240                                     University  of  Kansas   Medical   Center                 Claiborne Towers Roof
                                                      50 North Medical Drive                                                                                              39th and Rainbow Boulevard                                119 South Claiborne Avenue
                                                      Salt Lake City, Utah 84112                                (tele: 319-353-4843)                                      Kansas City, Kansas 66103                                 New Orleans, Louisiana 70112
                                                      (telat 801-322-7901)                                                                                                (tole: 919-AD6-5252, ext. 422)                            (tole: 504-522-5678)


        igram Director





        intee                                         University of Utah                                        University of Iowa College of Medicine                    University  of  Kansas   Medical   Center                 Louisiana State Department of Hospitals

        ettive Starting Date                          July 1, 1966                                              December 1, 1966                                          July 1, 1966                                              January 1, 1967
        Planning Grant
        I     Period for                              Two years                                                 Two years                                                 Two years                                                 Two years
        t'..rl, MP,,,,,,g
        active Starting Date                          April 1, 1967                                                                                                       June 1,1967
        Operational Grant



















                                                                                                                                                                                                                                                                          1 f)l








                   Name of Region                                   Maine                                                  Maryland                                                  Memphis Medical Region                               Metropolitan Washington, D.C.
                   Preliminary Planning Area                        Maine                                                  Maryland                                                  Western Tennessee, Northern Mississippi,             District of Columbia and contiguous counties
                                                                                                                                                                                     and portions of Arkansas, Kentucky,                  in Maryland (2) and Virginia (2)
                                                                                                                                                                                     and Missouri
                   Estimated Population                             985,000                                                3,520,000                                                 2,400,000                                            2,050,000
                   Coordinating Headquarters                        Medical Care Development, Inc.                         Steering Committee of the Regional Medical                Mid-South Medical Council for                        District of Columbia Medical Society
                                                                                                                           Program for Maryland                                      Comprehensive Health Planning, Inc.
                   Program Coordinator                              Manu Chafteriee, M.D.                                  Thomas B. Turner, M.D.                                    James W. Culbe rt' 'n ;sD@                           Thomas  W. Mattingly, M.D.
                                                                                                                                                                                                       .i OM
                                                                    Pro ram Coordinator                                    Dean, School of Medicine                                  Professor and Cardp  g                               Program     Cordiralor
                                                                       9                                                                                                                                                                  Metoplt@@        W.Sh, ngton, D.C.
                                                                    Maine Regional Medical Program                         The Johns Hopkins University                              'apar'm ant ofdlnternal Medicine                       Regional Md        IProgram
                                                                                                                                                                                            f Me icine                                                  ,     C.
                                                                    295 Water Street                                       725 Wolfe Street                                          College0                                             Di@trr               a Medical Society
                                                                                                                                                                                                                                                't of      Clumbi
                                                                    Augusta, Maine 04322                                   Baltimore, Maryland 21205                                 Un,,e r, ity of Tennessee
                                                                                                                                                                                     858 Mad iso n Avenue                                 2007 Eye Street, N.W.
                                                                    (tale: 203-622-7566)                                   (tole: 301-955-3181)                                      Memphis, Tennessee 38103                             Washington, D.C. 20006
                                                                                                                                                                                     (tele: 901-JA6-8892, ext. 437)                       (tale:   202-223-2230)


                   Program Director





                   Grantee                                          Medical Care Development, Inc.                         The Johns Hopkins University                              University of Tennessee College of Medicine          District of Columbia Medical Society
                   Effective Starting Date                          May 1, 1967                                            January 1, 1967                                           April 1, 1967                                        January 1, 1967
                   of Planning Grant
                   Program Period for                               Two years                                              Two years                                                 Two years, three months                              Two years, six months
                   Initial Planning


                   Effective Starting Date
                   of Operational Grant

















                          102














            Name of Region                                  Michigan                                                 Mississippi                                             Missouri                                                mountain States

            Preliminary Planning Area                       Michigan                                                 Mississippi                                             Missouri                                                Idaho, Montana, Nevada, and Wyoming



            Estimated Population                            8,220,000                                                2,320,000                                               4,500,000                                               2,200,000

            Coordinating Headquarters                       Michigan  Association for Regional Medical               University of Mississippi Medical Center                University of Missouri School of Medicine               Western Interstate Commission for
                                                            Programs,    Inc.                                                                                                                                                        Higher Education

            Program Coordinator                             D. Eugene Sibery                                         Guy D. Campbell, M.D.                                   Vernon t.  Wilson, M.D.                                 Kevin P. Bunnell, Ed.D.
                                                            Executive    Dire ctor                                   Regional Coordinator                                    Executive  Director for Health Affairs                  Associate Director
                                                            Greater Detroit Area Hospital Council                    Mississippi Regional,Medical Program                    University of Missouri                                  Western Interstate Commission for
                                                            966 Penobscot Building                                   University of Mississ ppi Medical Center                Columbii,  Missouri 65201                                  Hi gheir  Ed ucation
                                                            Detroit, Michigan 48226                                  2500 North State Street                                                                                         unive rs  ty Ea st Campus
                                                                                                                     Jackson, Mississippi 39216                              (tele;   314-449-2711)                                  30th    Street
                                                            (tele: 313-963-4990)                                     (tele: 601-362-4411)                                                                                            Boulder, Colorado 80302
                                                                                                                                                                                                                                     (tele: 303-443-2111, ext. 6342)

            Program Director                                                                                                                                                 George E. Wakerlin, M.D.                                Alfred M. Popma, M.D.
                                                                                                                                                                             Director, Missouri Regional Medical                                Director
                                                                                                                                                                               Program                                               =rl        States Regional Medical Program
                                                                                                                                                                             Lewis Hall                                              525 West Jefferson Street
                                                                                                                                                                             406   Turner    Avenue                                  Boise, Idaho 83702
                                                                                                                                                                             Columbia,     Missouri 65201                            (tele: 208-342-4666)
                                                                                                                                                                             (tele:   314-449-2711)


            Grantee                                         Michigan Association for Regional Medical                University of Mississippi Medical Center                University of Missouri School of Medicine               Western Interstate Commission for
                                                            Programs,    Inc.                                                                                                                                                        Higher Education

            Effective Starting Date                         June 1, 1967                                             July 1, 1967                                            July 1, 1966                                            November 1, 1966
            of Planning Grant

            Program Period for                              One    year                                              Two years                                               Three years                                             Two    years
            Initial Planning

            Effective Starting Date                                                                                                                                          April 1, 1967
            of Operational Grant







                            Name of Region                                             Nebraska-South Dakota                                     New Jersey
                             Preliminary Planning Area                                                                                                                                                          New Mexico                                                   New York Metropolitan Area
                                                                                       Nebraska and South Dakota                                 New Jersey                                                     New Mexico
                                                                                                                                                                                                                                                                             New York C       and Westchester, Nassau, and
                            Estimated Population                                       2,200,000                                                                                                                                                                             Suffolk Couint6es
                                                                                                                                                 6,800,ooo                                                      1,000,000
                                                                                                                                                                                                                                                                             11,400,000
                            Coordinating Headquarters                                  Nebraska State Medical Association                        New.jerseY Joint Committee for Implementation                  University of New Mexico School of Medicine                  Associated Medical Schools of Greater New Yaq
                                                                                                                                                 of P L. 89-239
                           Program Coordinator                                         r" "        Mor'a r''M. D.                                Alvin A. Florin, M.D.
                                                                                       "O'ram     'O(, rdinator                                  New Jersey                                                     Re
                                                                                       Nobr@ska-S.-t h Dakota Regional                           Regi      Medical Program                                      De                                                           Vincent de Paul Larkin, M.D.
                                                                                       Madice I Program                                          88   Ronal,                                                    Un                                                           New York Academy of Medicine
                                                                                       a Sha        .,Iding                                           Oss  treat
                                                                                       L@  rp       B                                            East Orange, New Jersey 07018                                  90(                                                          2 East 103d Stree-t
                                                                                       n.1,,     Nebr. ka 68508                                                                                                 Alt                                                          New York, New York 10029
                                                                                                                                                                                                                                             87106
                                                                                       (tele: 402-432-5427)                                      (tele: 201-675-1100)
                                                                                                                                                                                                                (tele: 505-277-2321)                                         (tele: 212-TR6-8200)
                          Program Director








                         Grantee
                                                                               Nebraska State Medical Association                            Founda!ion for the Advancement of Medical                     University of New Mexico
                                                                                                                                                  Educetion and Research in New Jersey                                                                                   Associated Medical School$ of Greater New York
                        Effective starting Date
                        Of Planning Grant                                     January     1,     1967                                       July   1,   1967
                                                                                                                                                                                                           October 1, 1966                                               June 1, 1967
                        Prpgram P riod for
                        Initial pla:ning                                      Two years                                                     Two years
                                                                                                                                                                                                          Two Years, nine months                                        Two years
                        Effective Starting Date
                       of operational Grant


















                          104











                Name of Region                                  North Carolina                                         North Dakota                                            Northern New England                                   Northiands

                Preliminary Planning Area                       North Carolina                                         North Dakota                                            Vermont and three counties in                          Minnesota
                                                                                                                                                                               Northeastern New York


                Estimated Population                            4,900,000                                              650,000                                                 550,000                                                3,600,ODD

                Coordinating Headquarters                       Association for the North Carolina                     University of North Dakota                              University of Vermont College of Medicine              Minnesota State Medical Association Foundation
                                                                Regional Medical Program

                Program Coordinator                             Marc J. Musser, M.D.                                   Theodore H. Harwood, M.D.                               John E. Wennberg, M.D.                                 J. Minott Stickney, M.D.
                                                                Executive Director                                     Dean, School of Medicine                                Program Coordinator                                    Northlands Regional Medical Program
                                                                North Carolina Regional Medical Program                University of North Dakota                              Northern New England Regional                          200 First Street S.W.
                                                                Teer House                                             Grand Foiks, North Dakota 58202                           Medical Program                                      Rochester, Minnesota 55901
                                                                4019 North Roxboro Road                                                                                        University of Vermont College of Medicine
                                                                Durham, North Carolina 27704                           (tele: 701-777-2514)                                    25 Colchester Avenue                                   (tele: 612-224-5738)
                                                                                                                                                                               Burlington, Vermont 05401
                                                                (tele: 919-477-9685)
                                                                                                                                                                               (tele: 802-86@ll, ext. 244)


                Program Director







                Grantee                                         Duke University                                        North Dakota Medical Research Foundation                University of Vermont College of Medicine              Minnesota State Medical Association Foundation


                Effective Starting Date                         July 1, 1966                                           July 1, 1967                                            July 1, 1966                                           January 1, 1967
                of Planning Grant

                Program Period for                              Two years                                              Two years                                               Three years                                            Two years, six months
                Initial Planning


                Effective Starting Date
                of Operational Grant












                                                                                                                                                                                                                                                                          105.










                 Name of Region                                   Ohio State                                             Ohio Valley                                            Oklahoma                                               Oregon

                 Preliminary Planning Area                        Central and southern two-thirds of Ohio                Greater part of Kentucky and contiguous parts          Oklahoma                                               Oregon
                                                                  (61 counties, excluding Metropolitan                   of Ohio, Indiana, and West Virginia
                                                                  Cincinnati area)

                 Estimated Population                             4,480,000                                              5,900,000                                              2,500,000                                              1,900,000
                 Coordinating Headquarters                        Ohio State University College of Medicine              Ohio Valley Regional Medical Program                   University of Oklahoma Medical Center                  University of Oregon Medical School

                 Program Coordinator                              Richard L. Meiling, M.D.                               William H. McBeath, M.D.                               Kelly West, M.D.                                       M. Roberts Grover, M.D.
                                                                  Dean, College of Medicine                              Director, Ohio Valley Regional Medical Program         Professor and Head, Department of                      Director Continuing Medical Education
                                                                  Ohio State University                                  1718 Alexandria Drive                                    Continuing Education                                 Universiiy of Oregon medical School
                                                                  410 West Tenth Avenue                                  P.O. Box 4025                                          University of Oklahoma Medical Center"                 3181 Southwest Sam Jackson Park Road
                                                                  Columbus, Ohio 43210                                   Lexington, Kentucky 40504                              800 Northeast Thirteenth Street                        Portland, Oregon 97201
                                                                  (tele: 614-293-5344)                                   (tele: 606-278-6071)                                   Oklahoma City, Oklahoma 73104                          (tole: 503-228-9181, ext. 519)
                                                                                                                                                                                (tele: 405-CE5-9421, ext. 395)



                 Program Director







                 Grantee                                          Ohio State University College of Medicine              The University of Kentucky Research Foundation         University of Oklahoma Medical Center                  University of Oregon Medical School


                 Effective Starting Date                          April 1, 1967                                          January 1, 1967                                        September 1, 1966                                      April 1, 1967
                 of Planning Grant

                        an Period for                             One year                                               Two years                                              Two years                                              Two years, three months
                         Planning


                 Effective Starting Date
                 of Operational Grant

















                      106












            Name of Region                                 Puerto Rico                                             Rochester                                               South Carolina                                          Susquehanna Valley

            Preliminary Planning Area                      Puerto Rico                                             Rochester, New York and surrounding counties            South Carolina                                          24 counties in Central Pennsylvania



            Estimated Population                           2,630,000                                               1,200,ODO                                               2,500,000                                               2,130,000

            Coordinating Headquarters                                                                              University of Rochester School of Medicine              Medical College  of  South  Carolina                    Pennsylvania   Medical   Society
                                                                                                                   and Dentistry

            Program Coordinator                                                                                    Ralph C. Parker, Jr., M.D.                              Charles P. Summerall. III, M.D.                         Richard B. McKenzie
                                                                                                                   Clinical Associate Professor of Medicine                Associate in Medicine (Cardiology)                      Executive Assistant
                                                                                                                   School of Medicine and Dentistry                        Medical College  of  South  Carolina                    Council on Scientific  Advancement
                                                                                                                   University of Rochester                                 Department of medicine                                  Pennsylvania   Medical   Society
                                                                                                                   260 C rittenden Boulevard                               Medical College Hospital                                Taylor Bypass  and  Erford  Road
                                                                                                                   Rochester, New York 14620                               55 Doughty Street                                       Lemoyne,   Pennsylvania    17043
                                                                                                                   (tele: 716-4734QO, ext. 3112)                           Charleston,  South  Carolina   29403                    (tele: 717-238-1635)
                                                                                                                                                                           (tele: 803-723-9411)


            Program Director








            Grantee                                                                                                University of Rochester School of Medicine              Medical College  of  South  Carolina                    Pennsylvania   Medical   Society
                                                                                                                   and Dentistry


            Effective Starting Date                        Application under development                           October 1, 1966                                         January 1, 1967                                         June 1, 1967
            of Planning Grant

            Program Period for                                                                                     Two years, nine months                                  One year                                                Two years
            Initial Planning


            Effective Starting Date
            of Operational Grant

















                                                                                                                                                                                                                                                                       107










                     Name d Region                                      Tennessee Mid-South                                      Texas                                                     Tri-State                                                Virginia

                     Preliminary Planning Area                          Eastern and Central Tennessee and                        Texas                                                     Massachusetts, New Hampshire, and                        Virginia
                                                                        contiguous parts of Southern Kentucky and                                                                          Rhode Island
                                                                        Northern Alabama

                     Estimated Population                               2,600,000                                                10,500,000                                                6,925,000                                                4,500,000
                     Coordinating Headquarters                          Vanderbilt University School of Medicine and             University  of   Texas                                                                                             Medical College of Virginia and University
                                                                        Maharry Medical College                                                                                                                                                     of Virginia School of Medicine


                     Program Coordinator                                Stanley W. Olson, M.D.                                   Charles A. LeMaistre, M.D.                                Norman Stearns, M.D.                                     Kin .loch Nelson, M.D.
                                                                        Professor of Medicine                                    Vice-Chancellor for Health    Affairs                     Medical Care and                                         Dean, Medical College of Virginia
                                                                        Vanderbilt University                                    University  of   Texas                                    Educational Foundation                                   1200 East Broad Street
                                                                        mlinical Professor of Medicine                           Main Building                                             22 The Fenway                                            Richmond, Virginia 23219
                                                                          eharry Medical College                                 Austin,  Texas   78712                                    Boston, Massachusetts    02115
                                                                        110 Baker Building                                                                                                                                                          (tele: 703-M[4-9851)
                                                                        110 21st Street South                                    (tele:   512-GRI-1434)                                    (tele: 617-734-33DO)
                                                                        Nashville, Tennessee 37203

                                                                        (telei 615-255-0692)


                     Program Director







                     Grantee                                            Vanderbilt University                                    University  of   Texas                                                                                             University of Virginia School of Medicine

                     Efective Starting Date                             July 1, 1966                                             July 1,  1966                                             Application under review                                 January 1, 1967
                     of Planning Grant

                           m P:riod for                                 Two years                                                Three   years                                                                                                      Two years
                              la
                            P    ning

                     Effective Starting Date
                     of Operation[ Grant

















                         108
















               Name of Region                                   Washington-Alaska                                        West Virginia                                           Western New York                                         Western Pennsylvania


               Preliminary Planning Area                        Washington and Alaska                                    West Virginia                                           Buffalo, New York and 7 surrounding counties             Pittsburgh, Pennsylvania and 28 surrounding
                                                                                                                                                                                                                                          counties



               Estimated Population                             3,200,000                                                i,aoo,ooo                                               1,920,000                                                4,200,000

               Coordinating Headquarters                        University of Washington School of Medicine              West  Virginia  University  Medical  Center             School of Medi  no, Stat  University of Now              University Health Center of Pittsburgh
                                                                                                                                                                                 York      uffa 0, in cooperation with the
                                                                                                                                                                                                 c          0
                                                                                                                                                                                       at  B
                                                                                                                                                                                 Health Organiza  tion of Western New York

               Program Coordinator                              Donal R. Sparkman, M,D.                                  Charles L. Wilbar, Jr., M.D.                            John R. F. lngall, M.D.                                  Francis S. Cheever, M.D.
                                                                Associate Professor of Medicine                          West  Virginia  Regional  Medical   Program             Director, Regional Medical                               Dean, School of Medicine
                                                                School of Medicine                                       West  Virginia  University  Medical  Center               Procm for Western New York                             Universit-y of Pittsburgh
                                                                University of Washington                                 Morgantown, West Virginia 26506                         2211      n Street                                       Flannery Building
                                                                AA 312 University Hospital                                                                                       Buffalo, New York 14214                                  3530 Forbes Avenue
                                                                Seattle, Washington 99105                                (tele: 304-293-4511)                                    (tele: 716-833-2726, ext. 32, 50)                        Pittsburgh, Pennsylvania 15213
                                                                (late: 206-543-3498)                                                                                                                                                      (tele: 412-683-1620, ext. 320, 321)



               Program Director








               Grantee                                          University of Washington School of Medicine              West  Virginia  University  Medical  Center             Research Foundation of the State University              University Health Center of Pittsburgh
                                                                                                                                                                                 of New York


               Effective Starting Date                          September 1, 1966                                        January 1, 1967                                         December 1, 1966                                         January 1, 1967
               of Planning Grant

               Program Period for                               Two years, ten months                                    Two years, six months                                   Two   years                                              Two years, six months
               Initial Planning


               Effective Starting Date
               of Operational Grant












                 Name of Region                                  Wisconsin

                 Preliminary Planning Area                       Wisconsin

                 Estimated Population                            4,100,000

                 Coordinating Headquarters                       Wisconsin     Regional Medical Program, Inc.

                 Program Coordinator                             John S. Hir      ec      D,
                                                                            s':'      'M
                                                                 Wisconsin  R@g@,.' ". I Mad i@. I Program, Inc.
                                                                            i@c
                                                                 110 East W     .r, si,, Aeru,
                                                                 Milwaukee, Wisconsin 53202

                                                                 (tele:   414-272-3636)


                 Program Director








                 Grantee                                         Wisconsin Regional Medical Program, Inc.

                 Effortive Starting Date                         September   1,    1966
                 of Planning Grant


                 Program Period for                              Two years
                 Initial Planning

                 Effective Starting Date
                 .of Operational Grant























                      1 1 0






               Appendix 6-Guidelines for Regional
                             Medical Programs



               Division of Regional Medical Programs                If the  applicant  believes  there  is  a  conflict    The   Commission    presented    35    recommenda-    the  diversity  of  needs,  resources   and   exist-
               National Institutes of Health                        between  the  provisions  of  the   Guide-and   the    tions  aimed  at  reducing  the  toll   of   these    ing patterns of education and service.
               Bethesda, Maryland 20014                             effective   implementation    of    the    proposed    diseases   through   the   development   of   more    0  Cooperation  among   all.   essential   elements
               U.S.    DEPARTMENT    OF    HEALTH,    EDUCATION,    program  in  his  region,  he  is   encouraged   to    effective  means  of  making  the  latest  medical    of  the  health  resources  in  a  region   is   an
               AND WELFARE                                          consult with the  staff  of  the  Division  of  Re-    advances  available  to  a  greater   portion   of    essential   means   of   coping   with   the   com-
               Public Health Service                                gional  Medical  Programs.  This  is  a  new   pro-    the  population  and  through  the  provision   of    plexities,  specialization,  high  cost,   manpower
               July 1966                                            gram  in  an  exploratory  phase.  It  is  expected    additional   opportunities   for   research.   The    needs,   and   educational   and   training   needs
                                                                    that  policies  and  procedures  will  evolve  with    major   recommendations    of    the    Commission    which  are   the   by-products   of   the   dynamic
                                                                    time  as  both  the  applicant  and  the   Division    are  the   basis   for   the   proposed   regional    advances  of  medical   science.   The   objectives
                                                                    learn  from   actual   planning   and   operational    medical  programs   authorized   by   Public   Law    of  the  Act  will  not  be  achieved  by  a   pro-
               TABLE OF CONTENTS                                    experience.  As  with  all  statements  of   policy    89-239 (hereafter referred  to  in  this  text  as    gram  which  serves  the  interests  of  a   single
               AND USE OF THIS GUIDE                                and  procedure,  the  Guide  attempts   to   strike    "The  Act."  See   Exhibit).                          category, institution,  or  organization.  A  basic
                                                                    a   balance   among   desirable    and    necessary                                                          aim  of  the   program   is   to   overcome   frag-
               1. History and Purposes of Regional                  procedures.   The   Division   encourages    diver-    The  Act  is   intended   to assist   our   medical   mentation and insularity.
                 Medical Programs                                   sity  and  innovation   in   the   development   of    institutions   and   professions   infcapitalizing    0  In  order  to  insure   an   effective   linkage
                                                                    the  Regional  Medical  Program.        But    this    on the  rapid  advances  of  scienti  ic  medicine    between    research    advances    and     improved
               11. Composition of a Regional Medical                flexibility of  approach  must  take  place  within    in the prevention, diagnosis, treatment'       and    patient  care,  it  is  desirable  to  establish  a
                 Program                                            the  boundaries  of  the   legislative   authority,    rehabilitation of patients  afflicted  with  heart    continuing   relationship   among   the    research
                                                                    applicable  general  policies,   and   the   neces-    disease,  cancer,  stroke  or  related   diseases.    and   teaching   environment   of    the    medical
               Ill. Policies and Definitions                        sary accountability for public funds.                  To  paraphrase  the  statement  of   purposes   in    center,  the  patient  care  activities   involving
               [V. General Grant Information                                                                               the  Act,  these  grants  are  to  encourage   and    the  community  hospital,   and   practicing   phy-
               V. Preparation and Review of Ap-                     1.    HISTORY    AND    PURPOSES    OF     REGIONAL    assist  in  the  establishment  of  regional   co-    sicians.  The  impact  of  research   advances   on
                                                                      MEDICAL PROGRAMS                                     operative       arrangements  among        medical    the  development  of  high  quality  patient   care
                 placation                                                                                                 schools,  research   institutes,   hospitals   and    has  typically  been  most  direct  in   the   uni-
                                                                    The  impetus  for   the   Regional   Medical   Pro-    other  medical  institutions  and   agencies   for    versity   medical-centers    or    other    medical
                                                                    grams  was  contained  in  the   President's   1964    the  purpose  of  affording   the   medical   pro-    centers   which    combine    extensive    research
                                                                    Special   Health   Message   to    Congress    when    fession  and  the  medical  institutions  the  op.    teaching   and   patient   care   activities.   The
               This Guide is for use  in  applying  for  support    he  proposed   to   establish   a   Commission   on    portunity   of   making   available    to    their    primary   benefits   of   this   interrelationship,
               under Title  IX  of  the  Public  Health  Service    Heart  Disease,  Cancer,  and  Stroke  "to   recom-    patients the  latest  advances  in  the  diagnosis    however,  have   often   been   confined   to   the
               Act  (Public  Law   89-239),   which   authorizes    mend  steps  to  reduce  the  incidence  of   these    and  treatment  of  these  diseases.  Grant  funds    medical center  itself  and  affiliated  hospitals.
               grants  to  assist  in  planning,   establishing,    diseases   through   new   knowledge    and    more    will  support  through   these   cooperative   ar-
                                                                                                                                                                                 A basic  premise  of  the  Act  is  the  desirabil-
               and  operating  Regional  Medical   Programs   to    complete  utilization   of   the   medical   knowl-    rangements  research,  training  (including   con-    ity  of  extending   this   productive   interrela-
               combat  Heart  Disease,   Cancer,   Stroke,   and    edge  we  already   have."   In   March   1964,   a    tinuing  medical  education)  and   related   dem-    tionship  to  additional  hospitals  and  to  prac-
               related diseases. It  is  therefore  intended  to    Commission     of  distinguished        physicians,    onstrations of the  highest  standard  of  patient    ticing   physicians   through   the   establishment
               be  used  for  both  planning   and   operational    scientists,   and   informed   citizens   was   ap-    care.  Through  these   means   the   program   is    of regional cooperative arrangements.
               grant applications.                                  pointed  to  accomplish   this   task.   The   Com-    also intended  to  improve  generally  the  health    <>  The  financing  of  patient  care  is  not  the
                                                                    mission  collected   information   from   agencies,    manpower  and  facilities  of  the   Nation.   The    objective  Gf  the   regional   medical   programs.
               The contents  of  this  Guide  include  the  his-    groups,  and  institutions  concerned  with   these    Act states that these      purposes   should    be    The  payment  of  patient  care  costs  is  limited
               tory  and  purposes,  composition,  policies  and    diseases through letters,  staff  visits,  surveys,    accomplished   without   interfering   with    the    to  those  costs  incident  to   research,   train-
               definitions  and  general   information   regard-    etc.,  held  hearings  at  which  expert  witnesses    patterns  of  professional  practice  or  hospital    -
               ing  the  preparation  and  review  of   applica-                                                                                                                 ing   and   demonstration   activities    supported
                                                                    from  the  widest  possible  range  of   interests,    administration.                                       by these grants.
               tions  for  a  Regional  Medical   Program.   The    both   public   and   private,   presented    their    The intent of the Act is built upon.  the  follow-    0  It  is  assumed  that  the  development  of  the
               provisions  of  this  Guide   are   intended   to    views,   and   submitted   a   report   which   in,    ing basic premises and assumptions:                   full  capabilities  of  a  regional  medical   pro-
               carry  out  the  purposes   and   objectives   of    cluded the following points:                           0  The  program  will  utilize  and   build   upon    gram  will  take  a  number  of  years.  The   pur-
               the  authorizing  legislation,  consistent   with    ,Our  Nation's  resources  for  health   are   rel-    existing  institutions  and  manpower   resources.    pose  of  the  first  three  years  of  legislative
               overall policies of  the  Department  of  Health,
               Education,   and   Welfare   and   sound   fiscal    atively  untapped.  The   rising   tide   of   bio-    0 The  active  participation  of  practicing  phY-    authorization  is  to  encourage  and   assist   in
               procedures.  These  provisions  must  be   inter-    medical   research   has   already   doubled    our    sicians is essential  to  the  success  of  a  re-    the   planning   and    implementation    of    the
               preted in light of the basic  objectives  of  the    store   of   knowledge   about    heart    disease,    gional   medical    program.                          first  steps  toward   the   establishment   of   a
               program,  and  the  clear  intent  of  the   Con-    cancer and stroke. . . ."                              0   The   purposes   can    best    be    achieved    regional   medical   program.   It    is    assumed
               gress  to  stimulate  initiative  and  innovation    "Yet  for  every  breakthrough,   there   must   be    through  initiative,  planning,  and   implementa-    that  the   development   of   a   plan   and   the
               at  the  regional  level  in  planning  and   im-    follow-through.  Many  of   our   scientific   tri-    tion  at  the  regional  level  under   conditions    implementation  of  the  initial  elements   there-
               plementing  regional  programs  that  are  fitted    umphs  have  been   hollow   victories   for   most    which   encourage   innovative   approached    and    of will  constitute  a  learning  experience  which
               to the needs and resources of the region.            of  thle  people  who  could  benefit  from  them."    programs  specifically  designed  to   deal   with    can be  utilized  in  taking  additional  steps  in

                                                                                                                                                                                                                              1 1  1













               the cooperative effort  against  heart  disease,   throughout  the  Nation.  The   consequence   of   The  Regional  Medical   Programs   present   the   option of  the  applicant,  related  disease  or
               cancer and stroke.                                 rapid  expansion  in   the   body   of   medical   medical  interests  within  a  region   with   an   diseases; but only if such group
               The  background  against  which  these   assump-   knowledge  is  increased   specialization,   re-   instrument  of  synthesis  that  can   capitalize   0 is  situated  within  a    geographic    area,
               tions and  premises  are  set  includes  a  num-   sulting  in  the  prolongation  of  the   educa-   on and  reinforce  the  various  trends  and  re-   composed of any part or     parts  of  any   one
               ber  of  trends  and   influences   which   have   tional  process.   A   continuing   process   of   sources  seeking  to  make  more  widely   avail-   or  more  states  which  the   Surgeon   General
               been  affecting  the  nature  of  medical  serv-   education  throughout  the  career  of  a   phy-   able  the  latest  advances  in   diagnosis   and   determines,  in  accordance  with  regulations,@
               ice, education, and  research  for  some  years.   sician is therefore of great importance.           treatment of these diseases.  It  is  the  inter-   to be appropriate  for  carrying  out  the  pur-
               The  opportunities  created  by  the  impact  of   The continued  evolution  of  medical  ea.         action of  these  trends  at  this  time,  rather   poses of the Act;
               science  on   modern   medicine   have   already                                           ucation    than an  abstract  conceptualization,  which  not   0 consists  of  one  or  more  medical  centers,
               been  mentioned.  Along  with  the  creation  of   and the  growth  of  the  medical  centers  car-   only  justifies  but  requires   a   synthesizing   one  or  more  clinical  research  centers,  and
               opportunities,  however,  the   increasing   im-   ries with it  increased  problems  in  maintain-   force  such  as   the   Regional   Medical   Pro-   one or more hospitals; and
                                                                  ing an  effective  linkage  between  the  medica,  grams.  The  Regional   Medical   Programs   rep-   0  has  in   effect   cooperative   arrangements
               pact of  science  has  changed  the  nature  and   center  and  the  practicing  physician.  Recent
               shape  of  modern  medicine,  raising   a   num-   reports  have  emphasized  the  need  for  those   resent  a  general   concept,   rather   than   a   among  its  component  units  which   the   Sur-
               ber of situations which are  very  difficult  to   concerned  with  medical  education  to   assume   specific  blueprint.  The  opportunity  is   pre-   geon  General  finds  will   be   adequate   for
               manage,  including   increased   specialization,   responsibilities in meeting national  needs  for   sented  to  go  beyond  concept   into   specific   carrying out effectively the  purposes  of  this
               increasing  complexities  and  costs  of   diag-   improved health  care.  It  has  become  clearly   planning   and   implementation    of    programs   program.
               nosis and treatment,  and  the  difficulties  in   apparent  that  the  medical  center  represents   which  represent  pragmatic  steps   toward   the
               transmitting  a  rapidly   expanding   body   of   an   indispensable   resource   for    improving   achievement  of  the  '  overall  goals  of   the   S.  The National Advisory Council on
               knowled&.     The     tremendous     growth    a,f health in its area  of  influence.  In  the  en-   legislation. It is an opportunity  to  mix  crea-      Regional Medical Programs
               knowledge   through   large    scale    research   vironment  of  medical  education,  new   atten.   tive ideas and  specific  actions  in  developing   'he  National  Advisory  Council   on   Regional
               efforts is a characteristic of  our  times,  not   tion  is  being  given  to  the  need  to   cope   improved  means for advancing       the    health   @edical  Programs  consists   of   the   Surgeon
               just In medicine but  in  most  aspects  of  our   effectively  with  the  problems  brought  about   standards of the American people.                   General,  who  is  the  chairman,  and  12  mem-
               society.  Wherever  this  phenomenon  is   seen,   by  the  developments   in   modern   scientific                                                       bers, not  otherwise  in  the  regular  fulltime
               it  calls  for  the  development  of  new  means   medicine.                                                                                              employ of the United  States,  who  are  leaders
               of  coping  with  steady  and   dynamic   h
                                                         t:n,                                                                                                            in  the  fields  of  the  fundamental  sciences,
               if the benefits of the knowledge are      c    b:  @.ny  medical   leaders   are   stressing   that   11.  COMPOSITION OF A REGIONAL                      the medical  sciences,  or  public  affairs.  In
               realized.                                          inose involved  in  health  care  must  maintain       MEDICAL PROGRAM                                 particular,  one  of  the  twelve  council  mem-
                                                                  a continuous  relationship  to  the  educational   A.  Definition of a Regional Medical                bers  must  be  outstanding  in  the  field   of
               The forces of  change  can  be  viewed  as  part   process  and  that  medical.  schools  and  hos-
               of  a  continuum  existing  over   many   years,   pitals should  have  an  increasing  involvement       Program                                         heart disease, one in  cancer,  and  another  in
               rather than a revolutionary  or  radical  alter-   in  the  process  of  continued  learning.   The   B.  The National Advisory Council on                stroke,  and  two  must   be   practicing   phy-
               ation of  current  patterns.  This  trend  calls   very forces that have  tended  to  separate  the       Regional Medical Programs                       sicians. The role of the Council  is  to  advise
               for  the   development   of   Regional   Medical   centers of  medical  knowledge  from  the  prac-   C.  Categorical Emphasis                            and assist the Surgeon  General  in  the  formu-
               Programs  which  create  an  effective  environ-   ticing physician are creating  an  ever  greater                                                       lation  of  policy  and  regulations   regarding
               ment  for  continuing  adaptation,   innovation,   need  to  bring   physicians   into   continuing   D.  The Region                                      the  regional  medical  programs,  and  to   make
               and modification. The  development  of  a  great   contact  with  the   environment   of   teaching   E.  Cooperative Arrangements Among                  recommendations   to    him    concerning    ap-
               medical  research  effort  is  the  product   of   and research.                                          Resources Within The Region                     proval of  applications  and  amounts  of  grant
               a deliberate national policy  to  stimulate  and   Another  trend  is  usually  described  as   the   F.  Interregional Cooperation                       awards.  No  grant  may  be  awarded  unless  it
               support   the   development   of   new   medical                                                                                                          has  been  recommended  for  approval   by   the
               knowledge  at  a   rapid   rate.   The   passage   regionalization  of  medical   services.   There   G.  The Regional Advisory Group                     Council.
               of the  legislation  authorizing  Regional  Med-   have   been   numerous   regionalization    pro-   H.  Relation of Regional Medical
               ical   Programs   represents   a   corresponding   posals during the  past  35  years  and  efforts       Programs to Programs of Other                   C.  Categorical Emphasis
               commitment  to   assist   the   development   of   have  been  made  to   implement   various   ap-
               necessary measures  to  bring  the  benefits  of   proaches  to  regionalization.  The  concept  of       Health Agencies                                 The  focus  of  the  Regional  Medical  Programs
               this  new  knowledge  to  the  patient  in   the   Regional  Medical  Programs  includes  the   re-                                                       under the authorizing legislation  is  on  prob.
               field of  heart  disease,  cancer,  stroke,  and   gional  approach  to  the  provision  of  highly                                                       lems  of  heart  disease,  cancer,  stroke,  and
               related diseases.                                                                                                                                         related diseases. This  rather  broad  categori-
                                                                  specialized services involved in  the  diagnosis   A.  Definition  of  a  Regional  Medical  Program   cal approach must  be  a  consideration  in  the
               The  process  of  medical  education  in  aII  its nd   treatment   of   heart   disease,   cancer,   The  Act  defines  a  regional  medical   program   development   of   specific   program   elements
               aspects  has  also  been  undergoing  a   change   stroke, and related  diseases.  The  legislation   as   a   cooperative    arrangement    among    a   under  a   Regional   Medical   Program.   Heart
               under  the  impact  of  the  growth  of   knowl-   provides  a  very  flexible  framework  for  the   group of public  or  private  nonprofit  institu-   disease,  cancer,  and  stroke  are  appropriate
               edge.   The   development   of   great   medical   implementation  of  a  regional  approach  which   tions or agencies engaged  in  research,  train-,   targets because of their prevalence  as  killing
               centers  built   around   education,   research,   is appropriate to the voluntary  nature  of  our   ing,  diagnosis,  and   treatment   relating   to   and  disabling  diseases.  These  diseases  pre-
               and high-quality patient care  has  taken  place   medical institutions.                              heart disease, cancer,  or  stroke,  and  at  the   sent  a  complex  challenge  to   the   research


               112









                     investigator,    and    the    advances    which    are   tive   attitude   and   stimulate   participation   and     professions,   voluntary    health    agencies,    and   ation  of   effectiveness   of   the   regional   coop-
                     being    made    require    diagnostic    and    treat-   initiative  among  the       program          elements;     representatives   of    other    organizations,    in-   erative    arrangements    established    under     the
                     ment    techniques     of     great     sophistication.   0   Provide   for   the    necessary    decision-making     stitutions,  and   agencies   and   members   of   the   Regional Mefical Program.
                     Because  of  the  broad   scope   of   heart   disease,   framework   for   the   activities   conducted    under     public  familiar  with  the  need  for  the   services
                     cancer,  and  stroke  it   would   be   difficult   and   the   Regional   Medical   Program   grant;    0    In-     provided   under   the   program.   It    should    be   H.  Relation of Regional Medical Programs
                     perhaps   detrimental   to   some   types   of    medi-   clude   administrative   and    fiscal    arrangements,     broadly    representative    of     the     geographic       to Programs of Other Health Agencies
                     cal  services   and   educational   activities   if   a   which   provide   for    adequate    program    coordi-     areas  and  of  the  social   groups   who   will   be   An  essential    function    of    Regional     Medical
                     rigidly    categorical    approach     were     adopted   nation   and   fiscal   accountability;    0    Provide     served by the Regional Medical Program.                  Programs  is  to   plan   and   to   provide   an   en-
                     for   all   relevant   program    elements.    However,   for   effective   administration   of   central    pro-     The   Regional   Advisory   Group    should    provide   vironment   for    coordinating    the    health    re-
                     the   emphasis   of   the    program    does    require   gram  elements   which   serve   the   entire   region;     overall   advice   and   guidance   to   the   grantee   sources  of  the  Nation  in  order   to   assure   the
                     that    the    program    elements    be    shown    to   0    Include    mechanisms    for    the     evaluation     in    the    planning    and    operational    program   availability  of  the   best   of   medical   care   to
                     have   significance   for    combating    heart    dis-   of  the   effectiveness   of   the   Regional   Medical     from  the  initial  steps   onward.   It   should   be   all persons.  It  is  not  the  intent  of  a  Regional
                     ease, cancer@ stroke and related diseases.                Program,   including   the    acquisition    of    uni-
                                                                               form  data  for  the  use  in   evaluating   effective-     actively  involved  in   the   review   and   guidance   Medical    Program    grant    to    supplant     other
                                                                                                                                pr         and   in   the   coordinated   evaluation    of    the   sources   of   support   for   the   various    program
                     D.  The Region                                            ness and the means to evaluate specific              o-     ongoing    planning    and    operating     functions.   elements   that   are   related   to   achieving    its
                                                                               gram  elements  of  the  Regional  Medi           .  cal    it   should   be   constituted   to   encourage    CO-   purpose.   The   Regional    Medical    Program    pro-
                     A region is a geographic area composed               OT   Program;   0    Provide    for    continual    planning     0
                     part  or  parts  of   one   or   more   states   which.   ' -                                                         peration    among    the    institutions,    organiza-   vides   an    opportunity    to    introduce    program
                     the   Surgeon   General   determines    to    be    ap-   and   implementation   of    the    further    develop-     tions,   health    personnel,    state    and    local   activities   which   draw    upon    and    effectively
                     propriate   for   the   purposes   of   the    program.   ment of the Regional Medical Program.                       health   agencies,   and   with   the   state    Hill-   link  activities   already   supported,   or   support-
                     It   should   be   an   economically    and    socially                                                               Burton  agencies.  It   should   be   concerned   with   able   in   the   future,   through   other    sources.
                     cohesive area taking into considerat       ion     such   F.  Interregional Cooperation                               continuing  review  of   the   degree   of   relevance   Current   examples   of    other    Federal    programs
                     factors    as    present    and    future    population   The  definition   of   a   particular   region   neces.     of  the  planning  and   operational   activities   to   that  provide  essential   inputs   into   the   health
                     trends   and   patterns   of   growth;   location   and   sarily   requires   consideration   of    relationships     the  objectives   of   the   Regional   Medical   Pro-   resources  of   the   region   are-.   0   The   Bureau
                     extent    of    transportation    and     communication   to   adjoining   regions.   Interregional   cooperation     gram   and   particularly   with   the   effectiveness   of  States  Services;   0   The   Bureau   of   Medical
                     facilities    and    systems;    and    presence    and   is   to   be   encouraged,   especially   in    program     of these activities in   attaining    the    objective   Services;    0    The     National    Institutes     of
                     distribution  of   educational   and   health   facili-   elements   where   a   uniform    approach    is    de-     of  improved  patient    care.    Therefore,     Advi-   Health,  particularly the  National  Heart          In-
                     ties   and   programs.    The    region    should    be   sirable.    Some    examples    where     interregional     sory Group members       should    be    chosen    who   stitute,  National  Cancer  Institute  and          Na-
                     functionally   coherent;   it   should    follow    ap-   cooperation     might  be  beneficial          include:     will   provide   a   broad   background   of    knowl-   tional Institute of Neurological Diseases           and
                     propriate    existing    relationships    among     in-   0   Development   of    standardized    criteria    for     edge, attitudes and experience.                          Blindness;     0    Other constituents        of    the
                     stitutions   and   existing   patterns    of    patient   data   gathering    and    analysis;    0    Continuing     The    grantee  institution   named   on   the    face   Department of  Health,  Education, and             Wel-
                     referral   and   continuing   education;   it    should   education    programs    drawing    on    the    educa-                                                              fare,   particularly   the   Social   Security   Admin-
                     encompass   a   sufficient    population    base    for   tional   resources   of   more   than    one    region;     page  of   the  application   is   legally   and   ad-   istration,   the    Office    of   Education,       the
                     effective   planning   and   use   of   expensive   and   0  Referral  of   patients   for   highly   specialized     ministratively  responsible   for   the   conduct   of   Vocational    Rehabilitation     Administration     and
                     complex     diagnostic     and     treatment      tech-   diagnosis  and  treatment  not  available             .     the   Regional  Medical    Program.    The    Advisory   the    Welfare    Administration;    and    0     Other
                     niques.                                                   every region;  0  Program  planning and             cc).    Group     does  not   have    direct    administrative   government   agencies,    particularly    the    Office
                                                                               ordination between regions.                                 responsibility  for  the  program,   but   the   clear   of    Economic    Opportunity    and    the    Veterans
                     E.  Cooperative Arrangements Among                                                                                    intent of  the  Congress   was   that   the   Advisory   Administration.    The    Regional     Medical     Pro-
                         Resources Within the Region                           Regional   boundaries   should   not   cut   off    ex-     Group  would   insure   that   the   Regional   Medl'.   gram   grants   should    concentrate    on    catalyz-
                     It  is  recognized  that  the   full   development   of   isting   relationships   and   patterns   and    should     cal    Program  is   planned   and    developed    wit   ing   and    synthesizing    efforts    in    achieving
                     a   Regional   Medical    Program,    which    involves   not  operate   to   the   detriment   of   the   objec-     the   continuing   advice   and   assistance   of    .   more   effective    communication    among    all    of
                      otentially   all   medical   institutions,   organize-   tives of the legislation.                                   group  which  is   broadly   representative   of   the   the health related elements in the region.
                     p                                                                                                                     health   interests   of   the   region.   The'Advisory   New   sources   of   possible   support   for   activi-
                     tions,  and  personnel   within   the   region,   could   G.  The Regional Advisory Group                             Group,  therefore,   is   an   inherent   element   of
                     take a number of years in many area           S.    The                                                               a   Regional   Medical   Program   that    helps    to   ties   related   to   the   Regional    Medical    Pro-
                     program     emphasizes     the      development      of   The   Act   specifies   that   an   applicant   for   a     accomplish   the   basic    objective    of    broadly   grams    should    also    be     considered     during
                     cooperative   arrangements    which    are    effective   planning    grant    must    designate    a    Regional     based regional cooperation.                              both   the    planning    and    operational    phases.
                     in   making   the   latest   scientific   advances   in   Advisory   Group.   The   Act   also   specifies   that                                                              For    example,    the     reimbursement     principles
                     these   diseases   more    widely    available.    Con-   the   Advisory   Group   must   approve   an   applica-     In  order  to   serve   these   purposes   the   Advi-   for  hospitals  and   other   providers   of   Medicare
                     siderable  flexibility  is  provided  for  the   devel-   tion   for   an   operational   grant   under   Section     sory   Group   should   operate   under    established   services    should    make    available    to     these
                     opment     of     cooperative     arrangements     that   904.   The   Advisory   Group   must   include    prac-     procedures   which   insure   continuity    and    ap-   institutions    additional    amounts    of     capital
                     are  appropriate   to   the   needs,   resources,   and   ticing   physicians,    medical    center    officials,     propriate   independence   of   function    and    ad-   funds,   which   may    contribute    to    accomplish-
                     patterns   of   the   region.   The   cooperative   ar-   hospital    administrators,    representatives     from     vice.   The   Advisory   Group    is    expected    to   ing   the   objectives   of   the   Regional    Medical
                     rangements   should:    0    Encourage    a    coopera-   appropriate    medical    societies,    other    health     prepare  an  annual  statement   giving   its   evalu-   Programs     through     a     cooperative     approach













                  to  the   use   of   medical   resources   in   the   111. POLICIES AND DEFINITIONS                         the   program   and   members   of    the    public   sire to incorporate systems ana    lysis    method-
                  region.                                               A. Policies                                           familiar with  the  needs  for  the  services  pro-   ologies into their applications.
                  In  order  to  assure   coordination   within   the                                                         vided under the program.                              The   use   of   systems   analysis   methodologies
                  Federal  Government,  the  Division   of   Regional   1.   General   Responsibilities   -    The    named   The  recipient  of  an   operational   grant   must   in  regional  medical   programs   is   encouraged,
                  Medical   Programs   is   developing   an    active   grantee is  obligated,  both  for  itself  and  co-   comply   with   the   assurances   under    Section   but  only  to  such  an  extent  as  it   is   con-
                                                                        operating   institutions,   to    administer    the   0
                  exchange  of  information   with   these   agencies   grant   in   accordance   with   regulations    and    04 (b), namely:                                      sidered  applicable  as   an   essential   integral
                  to  assure  that  all  pertinent   activities   are   policies  of  the  Division  of  Regional   Medical   a.   Federal   funds   awarded   to   any   grantee   component   of   the   individual   program    pro-
                  effectively interrelated.                             Programs. Where a policy is not stated            r   (1)  will  be  used  in  accordance  with  applica-   posed  by  the  applicant.  The  applicant   should
                                                                                                                                                                                                 the   development    of    innovative,
                                                                        where the institutional  policy  is  more  restric.   ble provisions  of  the  Act  and  the  regulations   emphasize
                                                                        tive   than   the    Regional    Medical    Program   thereunder  and  (2)  will   not   supplant   funds   adequately   formulated   studies   of   realistic-
                                                                        policy, institutional policy prevails.                that  are  otherwise   available   for   establish-   ally  restricted  problems   involving   the   ap-,
                  Ill.  POLICIES AND DEFINITIONS                                                                              ment  or  operation   of   the   Regional   Medical   placation   of   "systems"   methodologies   rather
                                                                        2.   General   Assurances-Specific   attention   is   Program  with  respect  to  which  this  grant   is   than   submit   an   application    dominated    by
                  A. Policies                                           directed  to  the  requirement  to  honor  the  as-   made.                                                 general proposals  for  the  utilization  of  large
                  1. General   Responsibilities                         surances provided in the Act.                         b.  The  grantee  will  provide  for  such   fiscal   scale   "systems"   approaches   for   the   design
                  2. General   Assurances                               The  recipient  of  a  planning  grant  must   com-   control   as   fund   accounting   procedures    as   of a regional medical program.
                  3. Surveys   and Questionnaires                       ply  with  the  assurances  in  Section  903   (b),   are  required  by  the  Surgeon  General   to   as-   The   Division   of   Regional   Medical   Programs
                  4. Systems Analysis                                   namely:                                               sure   proper   disbursement   of   an   accounting   will  explore  through  contracts   and   selective
                                                                        a.  reasonable  assurances   that   Federal   funds   for such federal funds.                               studies  the  applicability  of  systems   analysis
                  5. Publications                                       awarded to  any  grantee  will  be  used  only  for   c.  The  grantee  will   make   such   reports   in   to   the   planning   and   implementation   of   a
                  6. Patents and    Inventions                          the   purposes   for   which   awarded    and    In   such   form   and   containing   such   information   regional   medical   program.   One   approach   to
                  7. Other Public   Health Service Grant                accordance  with  the  applicable   provisions   of   as  the  Surgeon   General   may   from   time   to   the  use  of  systems  analysis  in  current  grant
                     Policies                                           the Act and the regulations thereunder,               time  reasonably  require  and   will   keep   such   applications,  within   the   framework   of   this
                                                                        b.   reasonable   assurances   that   the   grantee   records  and  afford   such   access   thereto   as   policy,  is  the  incorporation  of  limited   num-
                     a.  Clinical Research and Investiga-               will provide  for  such  fiscal  control  and  fund   the  Surgeon  General   may   find   necessary   to   bbrs  of  personnel  with  such   analytic   skills
                         tion Involving Human Beings                    accounting   procedures   as   are   required    by   assure  the   correctness   and   verification   of   into  the   planning   process.   These   personnel
                     b.  Protection of Individual Privacy               the  Surgeon  General   to   assure   proper   dis-   such reports, and                                     may   come   from   university    departments    or
                         in Research and Investigation                  bursement  in  the  accounting  for  such   Federal   d.  Any  laborer  or  mechanic  employed   by   any   schools  of  industrial  engineering,  schools   of
                     0   Administration of Personality                  funds,                                                contractor  or  subcontractor   in   the   perform-   public   health,    commercial    systems    firms,
                                                                        c.  reasona  le   assurances   that   the   grantee   ance  o  work  on   any   construction   aided   by   those   with   experience   in   program   planning
                         Tests, Inventories or                          will  make  such   reports   in   such   form   and   payments  pursuant  to   any   grant   under   this   and   budgeting,   and   a   variety    of    other
                         Questionnaires                                 containing  such   information   as   the   Surgeon   section will  be  paid  wages  at  rates  not  less   sources.  It  is  expected   that   from   such   a
                     0   Investigation of Persons Below                 General  may   from   time   to   time   reasonably   than  those  prevailing  on  similar   construction   beginning   areas   worthy   of    more    detailed
                         the College Age Level                          require,   and   will   keep   such   records   and   in  the  locality  as  determined  by  the   Secre-   activity   may    well    become    apparent    and
                                                                        afford  such  access   thereto   as   the   Surgeon   tary  of  Labor  in  accordance  with  the   Davis-   qualify  for  subsequent  additional   grant   sup-
                     c.  Animal Care                                    General  may   find   necessary   to   assure   the   Bacon   Act,   as    amended    (40    USC    276a-   port.   Applicants   are   encouraged   to   direct
                  B. Definitions                                        correctness  and  verification  of  such   reports,   276a-5);  and  the   Secretary   of   Labor   shall   any  questions  they  may  have  -relative  to  the
                  1. Approved Program                                   and                                                   have  with   respect   to   the   labor   standards   use  of  systems  analysis  to  the   Division   of
                  2. Budget Period                                      d.  a  satisfactory  showing   that   the   grantee   specified  In   this   paragraph,   the   authority   Regional Medical Programs.
                  3. Clinical Research Center                           has  designated  an  advisory   group   to   advise   and   functions   set   forth   in   Reorganization   5.   Publications-Grantees    may    publish    ma-
                  4. Construction                                       it (and  the  institutions  and  agencies  partici-   Plan  Numbered   14   of   1950   (15FR   3176;   5   terials  relating   to   their   regional   medical
                                                                        pating   in   the   resulting   regional    medical   USC  133z-15)  and  section  2  of   the   Act   of   program  without   prior   review   provided   that
                  5. Grant                                              program)   in   formulating   and   carrying    out   June 13, 1934, as amended (40 USC 276c).              such  publications  carry   a   footnote   acknowl-
                  6. Grantee                                            the  plan  for  the  establishment  and   operation   3.    Surveys    or    Questionnaires-Surveys    or   edging   assistance   from   the   Public    Health
                  7. Hospital                                           of  such  regional   medical   program.   The   ad-   questionnaires   arising   from    and    supported   Service,   and   indicating   that   findings   and
                                                                        visory  group   includes   practicing   physicians,   by  a  grant  should  Include  a  positive   state-   conclusions  do  not  necessarily   represent   the
                  S. Medical   Center                                   medical  center  officials,  hospital   administra-   ment  clearly  setting  forth  that  the   contents   views of the Service,
                  9. Non-Profft                                         tors,  representatives   from   appropriate   medi-   are in no way  the  responsibility  of  the  Public
                  10. Practicing Physician                              cal  societies,  voluntary  health  agencies,   and   Health Service.                                       6.   Patents    and    Inventions-The    Department
                                                                        representatives    from    other     organizations,                                                         of  Health,  Education,  and  Welfare   regulations
                  11. Program Period                                    institutions   and    agencies    concerned    with   4.   Systems   Analysis-This    policy    statement   (945 F.R., Part  6  and  8)  provide  as  a  condi-
                  12. Related Diseases                                  activities of the  kind  to  be  carried  on  under   is  to  be  used  by  those  applicants   who   de-   tion  that  all  inventions  arising  out  of   the

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            activities assisted by  Public  Health  Service   7. Other Public  Health  Service  Grant  Policies    caution  to  assure  proper   care   and   humane   3.  Clinical  Research  Center-A   Clinical   Re-
            grants must  be  promptly  and  fully  reported   -The  following  Public  Health   Service   grant    treatment  of  research  animals.  The   booklet,   search Center is an institution (or  part  of  an
            in the  Public  Health  Service.  Any  process,   policies  are  also  applicable   to   any   such    Guide  for  Laboratory  Animals,  Facilities  and   institution),  the  primary  function  of  which, .
            art  or  method,  machine  manufacture  or  im-   activities supported  through  a  regional  medi-    Care   (PHS   Publication   #1024)   should    be   is  research,  training   of   specialists,   and
            provement thereof,  may  constitute  an  inven-   cal program grant:                                   obtained   from   the   Division   of    Research   demonstrations   and   which,    in    connection
            tion 'if it is new and  useful  and  would  not   a.  Clinical  Research  and   investigation   In.    Grants, Information Office,  National  Institutes   therewith,  provides  specialized,   high-quality
            have been obvious  to  a  person  having  skill   volving   Human   Beings-This    policy    state-    of  Health,   Bethesda,   Maryland,   20014.        diagnostic  and  treatment   services   for   in-
            in the art to which it relates.                   ment  is  currently  being  revised   by   Public    The   Public   Health    Service    endorses the    patients  and  outpatients'   The  clinical   re-
                                                                                                                                                                       s:arch center  may  be  a  part  of  the  medical
            In order  for  the  Public  Health  Service  to   Health Service.                                      following guiding  principles  in  the  care and    c nter or  it  may  be  a  separate  institution.
            carry  out  its  responsibility   under   these   b.  Protection  of  Individual  Privacy  in   Re-    use of animals:
            patent regulations, it is  essential  that  the   search and Investigation-                            0  Animals  should  be  acquired,  retained, and    4.    Constructio@onstruction    means    altera-
            Service  be  advised  before  awarding  Govern-                                                        used in  compliance  with  applicable  state and    tion,  major  repair  (to  the  extent  permitted
            ment  funds  of  any  commitments  or   obliga-   (1) Administration of personality  tests,  inven-    local law.                                          by  regulations),   remodeling   and   renovation
            tions  made  by  the  institutions  or  by  the   tories  or  questionnaires.  No  grant  or  award                                                        of  existing  buildings   with   prior   approval
            professional personnel to  be  associated  with   of   the   Public   Health   Service   Extramural    0  Animals  should   receive   every   considers,   (including  initial   equipment   thereof),   and
            the  activities  carried  on  under  the  grant   Programs in support  of  research  or  investiga-    tion  for  their  bodily   comfort,   be   kindly   replacement  of  obsolete,   @uilt-in   (as   de-
            which would be  in  conflict  with  the  inven-   tion  involving  the  administration  of  person-    treated  and  properly  fed,  be  kept  in  sani-   termined   in   accordance   with    regulations)
            tions  agreement.  When  submitting  an  appli-   ality  tests,   inventories   or   questionnaires    tary facilities, and be  provided  with  suitable   equipment of existing buildings.
            cation  for  Regional  Medical  Programs,   the   shall be  awarded  by  the  Public  Health  Serv-    medical care.
            grantee must provide  in  letter  form  either:   ice  unless  the  application  includes   a   de-                                                        5.  Grant-A  grant  is  the   total   amount   of
                                                              scription of  the  manner  in  which  the  rights    0 With any  operation  likely  to  cause  greater   direct  and  indirect  costs  which  is   awarded
            a. a  statement  indicating  no  previous  com-   and welfare of the  subjects  are  assured,  that    discomfort  than  that   attending   anesthetize-   to  a  grantee  for  support   of   an   approved
            mitments or  obligations  have  been  made,  or   is,  how  their  informed  consent  is   obtained    !ion,  the  animal  should  first   be   rendered   program for a specific period of time.
            b.  a  detailed  explanation  of  such   commit   or  why  this  consent  is   deemed   unnecessary    incapable  of  perceiving  pain  and  should   be
                                                          -   or undesirable in the particular instance.           maintained in that  condition  until  the  opera-   6.   Grantee-The   grantee   is   the   applicant
            ments or obligations where they do exist.                                                              tion  is  ended.  Exceptions   should   be   made   institution  who  is  named'on  the   face   page
            One such letter  will  suffice  for  the  named   (2) Investigations of persons below the       col-   only  when  anesthesia  would  defeat   the   ob.   of  the   application   and   who   assumes   re-
            grantee and all  cooperating  institutions  re-   lege age level.  No  grant  or  award  of  Public    jective of the experiment.  In  such  cases,  the   sponsibility for the grant.
            ceiving support under  the  grant.  It  is  the   Health  Service  Extramural  Programs   in   sup-    anesthesia  should  be   discontinued   only   so   7.   Hospital-The   term   "hospital"    includes
            responsibility  of  the  institution  named  as   port  of  research  or  investigation   involving    long  as  it  is  absolutely  essential  for  the   general,  tuberculosis,  and   other   types   of
            the grantee on  the  application  to  ascertain   administration  of   investigational   procedures    necessary observations.                             hospitals,  and  related  facilities,   such   as
            the facts relating to  patents  and  to  report   to persons below  the  college  age  level  shall       If the  nature  of  the  study  requires  sur-   laboratories,  outpatient  departments   (nurses'
            these on behalf of all  entities  participating   be  awarded  by   the   Public   Health   Service    0                                        cautions   home  facilities),  central  service   facilities
                                                              unless the  application  includes  a  description    vival  of  the  animal,  aseptic  pre
            in the Regional Medical Program.                  of  the  manner  in  which  the  rights  and  re-    should  be   observed   during   the   operation,   operated  in  connection  with   hospitals.   and
            In subsequent years  an  annual      invention    sponsibilities are respected, that  is,  how  the    and  care  should  be  taken  to  minimize   dis-   other health  facilities  in  which  local  capa-
            statement  Form  PHS-3945  must      be   filed   informed consent  of  the  parents  or  guardians    comfort  during   convalescence   comparable   to   bility  for  diagnosis  and  treatment  is   sup-
            whether or not an invention has      occurred.    is  obtained,  or  why  this  consent  is  deemed    Precautions  taken  in  a  hospital   for   human   ported  and  augmented  by  the  program   estab-
            Where there are no inventions to     report,  a   unnecessary or  undesirable  in  this  particular    beings. If the  animal  is  severely  incapacited   lished  under  this  Act.  It  does  not  include
            single form PHS-3945 is all  that  is  required   instance.                                            and  survival  is  not  a  requirement   of   the   institutions  furnishing  primarily   domiciliary
            for the institution named  on  the  application                                                        experiment,  the  animal  should  be   sacrificed   care.  Proprietary  hospitals   may   participate
            as the grantee  and  for  all  cooperating  in-   The professional judgment  of  the  grantee  will    in  a   humane   manner   immediately   following   in  the  Regional   Medical   Program   but   may
            stitutions.  Where  there  are  inventions   to   determine what constitutes      respect  for  the    final observation.                                  not be funded under the Act.
            report,  a  separate  annual  invention  state-   rights  and  responsibilities   of   parents   or                                                        8.   Medical   Center-Medical   Center    is    a
            ment must be filed for each  one.  Here  again,   guardians,   what   constitutes   informed   con-    B. Definitions                                      medical  school  or  other  medical   institution
            it is the responsibility of the grantee to  re-   sent,  and  what  constitutes  a  validation  for                        m-An     approved     program   involved   in   postgraduate   medical   training
                                                              deeming  this  consent  to  be   unnecessary   or    1. Approved Progra
            port on behalf of itself and all other entities                                                                                ity   approved   by   the   and  one  or  more  hospitals  affiliated  there-
            articipating  in  the  Regional  Medical   Pro-   undesirable in a particular instance.                is  an  identified  activ
            p                                    I                                                                 Division  of  Regional   Medical   Programs   for   with  for  teaching,  research,  and   demonstra-
            gram.  The  Regional  Medical   Program   grant   c. Animal Care                                       support  for  a  specific  period  of  time.        tion purposes.
            for the following year will not be issued until
            the  invention  statement  form  PHS  3945  has   Each  person   assigned   or   appointed   to   @    2.  Budget  Period-The  budget  is   the   period   9.  Non-Profit-Non-profit  as  applied   to   any
            been  received  by  the  Division  of  Regional   project  receiving  any  Public  Health   Service    of  time  within   a   program   covered   by   a   institution  or  agency  means   an   institution
            Medical Programs.                                 support  is  required  to  exercise  every   pre-    specific budget, usually 12 months.                 or  agency  which  is  owned  and   operated   by
                                                                                                                                                                                                                   115










                  one or more  non-profit  corporations  or  asso-   D. Relationship to Other Sources of                   under   Section   903   and   operational    grants   C. Eligible Activities
                  ciations no part of the net  earnings  of  which       Support                                           under  Section  904.  The  operation   of   a   Re-   -. .
                                                                                                                                                                                 !.n!s section  gives  examples  of  types  of  ac-
                  inures, or may lawfully Inure,  to  the  benefit                                                         gionaf  Medical   Program   obviously   should   be
                  of any private shareholder or individual.          E. Single  Grant  Approach                            based   upon   sound   planning.    For    example,   itivities which  would  be  eligible  for  support
                                                                                                                                                                        .    .   under   a   Regional   Medical   Program    grant.
                                                                                                                           one  purpose  of  planning  for  a  region  is   to
                  10.  Practicing  Physlcian-A   practicing   phy-                                                                                                     .  .      The  intent  of  the  program  is   to   encourage
                  sician Is any  physician  licensed  to  practice   IV.  GENERAL GRANT INFORMATION                        help   establish    the    geographic    boundaries   innovations  and  creativity   in   the   develop-
                  medicine In  accordance  with  applicable  state   A. Types of Grants                                    that are  necessary  for  effective  and  efficient   ment  through  cooperative  efforts   of   program
                  laws.                                                                                                    operation  of  the  region.  Planning   also   pro-   elements  to   be   included   in   the   Regional
                                                                     1.   Planning-Section   903   of   the   Act    au-   vides  an  opportunity  for  the   advisory   group   Medical  Program.   The   listing   therefore   is
                  11.  Program  Period-The   program   period   Is   thorizes  the  Surgeon  General,  upon   the   rec-   to  participate  in  the  initial  stages  of   the   intended  to  be  helpful  in  the   understanding
                  the  time  for  which  new  or  continuing  sup-   ommendation  of   the   National   Advisory   Coun-   program.   In   some   areas   of   the    country,   of  the  scope  of  a  regional  medical  program,
                  port   has   been   recommended.   The   initial   cil  on  Regional   Medical   Programs,   to   make   much   relevant    planning    may    have    taken   rather than to be definitive.
                  grants,  may  be  for  any  period  up  to  June   grants  to  assist  in  the  planning  and   devel-   place  before  passage  of  this  legislation.   In
                  30, 1969.                                          opment of Regional  Medical  Programs.                such  instances  the   grantee   may   request   an   Many  different  types  of   activities   can   be
                  12.  Related   Diseases-Related   diseases   are   !.   Operational-Section   904    authorizes    the   operational  grant  without  having  first  applied   supported  under  a   Regional   Medical   Program
                  those  diseases  which  can  reasonably  b         burgeon    General,    also    upon     recommenda-   for  a  planning   grant   under   Regional   Medi-   grant.  Special  attention  must   be   given   to
                                                                 a                                                                                                               the  functional   interrelationships   among   the
                  considered to bear a direct relationship      to   tion  of  the  National  Advisory  Council  on   Re   cal Programs.                                         various   program   elements,   and    how    they
                  heart disease, cancer or stroke.                   gional   Medical   Programs,   to    make    grants
                                                                     to  assist  in   the   establishment   and   opera-   A   grantee   who   has   received    a    planning   relate  to  the  goals  of  the  Regional  Medical
                                                                     tion  of  the  Regional   Medical   Programs.   The   grant  need  not  wait  for   the   completion   of   Program.
                                                                     initial  authorization  of  this  program   through   that  planning  grant  before   applying   for   an   Certain   program   elements    deserve    special
                  IV. GENERAL GRANT INFORMATION                      fiscal  year  1968   Indicates   that   operational   operational   grant   under   Section   904.    The   discussion.  Applications  for  a  Regional  Medi-
                                                                     grants  under  Section  904  will   be   considered   grantee   may   wish   to   request   funds   under   cal  Program  grant,   both   planning   and   op-
                  A. Types of Grants                                 pilot  projects  for  the  establishment  and   op-   Section  904  to  finance  operational   activities   erational,  must  include  specific  reference  to
                  1. Planning                                        eration-of   Regional   Medical    Programs.    The   which   represent   the   first   elements   of   a   program  plans  for  education  and  training   of
                  2. Operational                                     designation  of  operational  programs   as   pilot   complete    Regional    Medical    Program.    Such   health   personnel.     Continuing       education
                  3. Supplemental                                    projects   emphasizes   the   exploratory    nature   grants  for  the  partial   Implementation   of   a   should   receive   particular   emphasis   as   an
                                                                     of the first period of authorization.                 Regional   Medical   Program   will   be   awarded,   integral  part  of  the  total  Regional   Medical
                  B. Relationship of  Planning  Grant  to                                                                  however,  on  the  condition  that   the   planning   Program.   However,   meritorious   programs    of
                                                                     3.    Supplemental-The    exploratory    and    de-   for  implementation   of   additional   phases   of   continuing  education   presented   in   the   ab-
                  Operational Grant                                  velopmental   aspects   of   a   Regional   Medical   the   Regional   Medical    Program    will    pro-   sence of, or unrelated to, plans  for  the  fuller
                  C. Eligible Activities                             Program,  both   in   the   planning   and   opera-   ceed.  Grants  for  partial   implementation   will   development  of   a   Regional   Medical   Program
                  1. Under a  Planning Grant  (including             tional  phases,  lead  to  the   expectation   that   be  awarded  for  limited  time  periods  and   the   cannot   be   supported   through   grants   under
                  Feasibility Studies)                               the   grantee   will   wish   to   add   additional   continuation  of  such  a  grant  will  be   condi-   this  program.  Therefore,  the  relationship   of
                  2. Under an Operational Grant                      program   elements   or    to    expand    existing   tioned   upon   the   submission,    review,    and   continuing  education  to  other  aspects  of  the
                                                                     program   elements   subsequent   to   the    award   approval  of  additional  elements  of  the   corn-   proposed   planning   or   operational    activity
                  0Continuing Education and Training                 of the  Initial  grant.  The  practice  of  submit-   plate   Regional    Medical    Program    by    the   must be indicated.
                  0Research                                          ting  requests  for  supplemental  funds   is   en-   end of  the  initial  period  of  award.  T@e  pur-
                  0Demonstration of Patient Care                     couraged   insofar   as   the   submission   of   a   pose of  these  conditions  Is  to  allow   initial   Both  the  planning  and  operational   phase   of
                  0Support of Administrative Core                    supplemental   request   is   preferable   to   the   steps  in  the   implementation   of   a   Regional   a   Regional   Medical   Program   should   stress
                  0Alteration and Renovation                         inclusion  in  the  Initial  application  of   pro-   Medical  Program,   while   at   the   same   time,   the  development  of  more   effective   relation-
                                                                     gram   elements   which   represent    only    very   Insuring  progress   toward   the   full   develop-   ships  between  ongoing  research  activities   in
                  0Communication Systems                             preliminary  Ideas  or  for  which  It  Is   diffi-   ment of the Regional Medical Program.                 the fields of heart disease,  cancer,  stroke,  or
                  0Communications  and  Public                       cult  to  justify   particular   budget   requests.                                                         related   diseases   and   the   other    proposed
                  Information                                        Supplemental  grant  requests   will   be   submit-   Planning  should  continue  after  the   initiation   activities of an  educational  or  service  nature
                                                                     ted  on  the  same  form  as  the  Initial   appli-   of   an   operational   program    under    Section
                  0Computers                                         cation  and  will  go  through  a  similar   review                                                         u   er   the   Regional   Medical   Program.   The
                                                                                                                           904.  This  continued  planning  may  be   financed   _nci
                  0Diagnostic and Treatment Equipment                and award process.                                    either  by  continuing  the  planning   grant   un-   Regional   Medical   Program   should   seek    to
                  0Support of Staff ln'Cooperating                                                                         der  Section  903,  or  by  the  inclusion  of  the   maintain   an   effective   interaction    between
                                                                     B. Relationship of Planning                           support   of   planning   activities   under    the   ongoing  research  activities  and  other  aspects
                  Institutions                                         Grant to Operational Grant                          operational   grant.   Conversely,   however,   op-   of  the  Regional  Medical  Program,  so   as   to
                  0Consultant Services                               The  Act  does  not  provide  a   specific   sequen   erational   activities   may   not   be   supported   assure that the activities  specifically  directed
                  <> Transportation  of  Patients                    tial  relationship  between   planning       grants   from planning grant funds.                            toward  the  goal  of   improved   diagnosis   and

                  116








       :reatment  may  receive  the   benefit   of   future   educational    and    training    programs     within     proposed  project  will   extend   those   efforts.   However,  if   special   justification   exists   for
       research advances.                                     the   region;   evaluation   of   additional   educa-     It  is  anticipated  that  such  major  investments   the  support  of  research  which  is  essential   to
                                                              tional  and  training  needs  in  the  region;   pro-     for  equipment   and   supplies   will   more   ap-   the   effective   accomplishment   of   the    objec-
       1.   Under   Planning   Grant   (including    Feasi-   jections  of   methods   of   meeting   those   needs     propriately be in  pilot  projects  or  operational   tives  of   the   Regional   Medical   Program,   and
       bility  Studies)-The  scope  of   planning   activi-   including   specification   of   appropriate   curri-     grants  rather  than  in  feasibility  studies   or   if  it   can   be   demonstrated   that   the   other
       ties  which  are  related   to   accomplishing   the   culum    content,    etc.;    preliminary    thoughts     planning grants.                                      sources   of   support   are   not   appropriate,   a
       objectives  of   the   Regional   Medical   Programs   relative  to  the   mechanism   of   evaluating   the     Considerations   under   the    Regional    Medical   limited  amount  of  research   activity   could   be
       can  be   quite   broad.   However,   planning   and   effectiveness   of   future   programs   in   meeting                                                           supported   under   the   Regional    Medical    Pro-
       conceptualization     concerned     with     general                                       of                    Programs  will  be  given  to   continuing   educa.
                                                              the  needs;  the  relationship              ontinuing     tion   and   training   programs    for    medical,   gram grant.
       health  matters  but   not   related   to   develop-   education and training programs        toc the  over.                                                           <> Demonstrations of Patient Care
       ment  of   a   Regional   Medical   Program   should   all  objectives  of   the   Regional   Medical   Pro-     allied  health  personnel   and   associated   pro-   Demonstrations  of   patient   care   may   be   sup-
       not be included.                                                                                     c           fessions.  However,   it   should   be   emphasized
                                                              gram   including   their   anticipated   effe   tive-     that the  primary  intent  of  the  legislation  in   ported  when  related   to   the   research,   train-
       In  general,   planning   should   include   studies   ness   in   bringing    about    cooperativesarra@ge-     this  area  is  the  support  of  those  activities   ing,   and   continuing   education   activities   of
       of  resources,  distribution  of  services,  patient   ments  between  the  various  health   in   titutions     that  are  beyond  those   normally   accepted   as   the  program.  The  Act  provides  that   the   costs
       flow,  and  program  elements   that   are   needed,   and personnel within the region.                          basic  preparation   for   work   in   the   health   of  patient  care  may   be   supported   only   when
       design  of  specific  program  elements   that   in-   2.   Under   an   Operational    Grant-Pilot    proj-     field.  Thus,  support   of   basic   programs   in   such  care  is  incident   to   research,   training,
       cludes   a   mechanism   for   program   evaluation,   ects  for  the   establishment   and   operation   of     medical   education,   residency   training,    and   or   demonstration    activities    encompassed    by
       planning   for   cooperation   among   institutions'   a   Regional   Medical   Program    can    cover    a     basic  education  and  training  in  allied  health   the  purposes  of  the  program  and  only   if   the
       and  plan@ing  toward  the   more   effective   dis.   great variety of activities.                              areas  is  not  normally  anticipated.   If,   how-   patient   has   been   referred   by   a   practicing
       tribution and utilization  of  all  types  of  medi-                                                             ever,   the   applicant   can   demonstrate    that   physician.  Grant  funds  could  be   used   to   pay
       cal resources.                                         0 Continuing Education and Training                       funds  are  not  available   from   other   sources   the  other   costs   incident   to   the   demonstra-
       The   development   and   operation   of    regional   It is assumed that before applying           for   an     and  the  particular  basic   educational   program   tion  activity,  including   staff   and   equipment.
       medical   programs,   individually    and    collec-   operational  grant  in  this  area,  certain  activi-     is  essential  to  the  success  of  the   Regional   0 Support of Administrative Core
       tively,   can   be   aided   by   well    conceived,   ties   will   have   been   undertaken   during    th!    Medical  Program   then   consideration   will   be   The  grant  may  be  used  to  pay  the   costs   for
       properly   implemented,    and    continuous    com-   planning    process    (see    above).    Operationai     given to such a request.                              the  central  administration   of   the   total   Re-
       munication    and    public    information     tech.   grant   funds   can   support   costs   of   programs                                                           gional   Medical   Program.   This   could    include
                                                              including   teaching   staff,    equipment,    educa-     Applicants  are   encouraged   to   explore   Inno-   the   salaries   of   a   program   coordinator   and
       niques  and  activities  which   are   designed   to   tional   materials,   transportation,    rental    or     vative  training  approaches   and   the   develop-   other   administrative   staff   as   well   as   the
       provide   a   maximum   of    understanding,    par-   renovation   of   space   and   related    demonstra-     ment  of  new  types   of   health   personnel   to   other  costs  incident  to  the   central   coordina-
       ticipation    and    support    among    cooperating   tions   of   patient   care.   However,   the   grant     meet  the  manpower  needs   of   the   region   as   tion of the Regional Medical Program.
       organizations   and   individuals,   as   well    as   may   not   supplant   previous   support   for   on-     identified in the planning process.                   0 Alteration and Renovation
       among   lay   publics   for   whom   the    programs   going   activities   in   this    area.    Documenta-                                                           Ninety  percent  of  the  costs  of  alteration   and
       will be established.                                   tion  of  the  additive  nature   of   the   proposed     0 Research                                            renovation   may   be    charged    to    operational
                                                              program    should    be    made.     Stipends     for     Research   into   better   means   of   accomplish-   grants.   No   such   charges   are   permitted    to
       To  plan  and  implement   such   activities,   pro-   trainees  and  participants  in  the   program   will     ing   the   purposes   and   objectives   of    the   planning grants.
       vision  for  including  professional  staffing   and   be  considered  only   when   it   is   fully   docu-     Regional    Medical    Program    is    supportable   0 Communication Systems
       budgetary   support   for   a   communication    and   mented   that   such   funds   are   not    available     u                          grant.    Since    other   A  grant  may  support   the   purchase   or   rental
                              componen                                                                                  nder  an  operational
       public  information               t   may   be   in-   from  other  sources   and   their   expenditure   is     Public    Health    Service    grant     mechanisms   of   communication   systems   to   be    used    for
       cluded in grant applications.                          absolutely   necessary   for    the    implementation     provide  excellent  means  for   the   support   of   educational,   diagnostic    or    other    purposes.
       The  emphasis  on  continuing   education   in   the   of the program.                                           biomedical   research,   the   grantee   under    a   However,   if   such   requests    represent    major
       Act   deserves    particular    mention.    Creative   In   instances   where   major    expenditures    for     Regional  Medical  Program  is  required  to   look   funding  investments,   they   should   include   (as
       approaches   in   the   development   and    manage-   equipment      and    supplies     are      requested     to  these  and  other   sources   of   support   as   mentioned    under    Continuing    Education     and
       ment  of   cooperative   arrangements   to   achieve   special   emphasis   should   be   given   to   meas-     well.   The   support   of   research    activities   Training   above)   documentation   of:   the   meas.
       high  quality  education   programs   as   well   as                                                                                                                   urements   of   effectiveness   of    the    program;
                                                              urement      of   effectiveness   of   the    program     through  other  Public  Health   Service   researcn
       new   ways   of   applying    educational    researc                                                                                                                   the  numbers  of   people   affected   by   the   sys
                                                              including   measurements   in    change    in    per-     support   mechanisms   does    not    lessen    the   tem;   the   degree   to   which   the    information
       findings  are  vital.  Indeed  the  history  of  the   formance     of   participants,   numbers   of   par-     importance    of    planning    and    implementing   produced  might   be   generalized   to   other   Re-
       legislation  itself  stimulates   this   aspect   of   ticipants,   and    degree    information    produced     a   Regional   Medical   Program   in   a    manner   gional   Medical   Programs;   and    knowledge    of
       regional medical programs.                             might be     applicable  to  other   regional   medi-     which  insures  a  close  and  continuous   linkage   related    efforts    already     accomplished     by
       Examples  of   activities   for   consideration   in   cal  programs.  There   should   also   be   acknowl-     between all  of  the  activities  of  the  regional   others   with   indications   of   the   manner    by
       planning  in  the  area  of   continuing   education   edgement   of   related   efforts   already    accom-     program   and   the   environment    of    research   which  the  proposed  project   will   extend   those
       and  training  are:   identification   of   existing   plished  by  others  with  indications  of  how   the     and 'teaching.                                        efforts.
                                                                                                                                                                                                                              117






                      0    Communications    and     Public     Information   the  purposes  of  the  program.  The   location   of       V. PREPARATION AND REVIEW OF                         L.  Change   in   the   Program    Period
                      A    communication     and     public     information   such   equipment   should   be   planned   with   its       APPLICATION
                      component  as  an   integral   part   of   the   pro-   efficient and effective use in mind.                                                                             M.  Early  Termination   of   the   Grant
                      posed      regional  medical     program        might   0  Support  of  Staff  in  Cooperating   Institutions       A. Eligible         Applicants                       1.  By the Grantee
                      include:                                                The  grant  can  be  used  to  pay  the   salary   of       B. Method of Obtaining Application                   2.  By the Public Health Service
                                                                              staff  involved  in  the  conduct  of  the   Regional       C. Method of Preparing Application                   N.  Reports
                      Utilization  of   a   qualified   communication   and   Medical   Program,   not   only   in   the    grantee
                      public   information   specialist,   and    necessary   institution  but  also  in  the  other  instit  tions       D. Review    of    Application                       1.  Progress
                      supporting  staff,  in  both  planning   and   opera.                                                u              E. Notification of Applicant                         2.  Regional   Advisory Group
                      tional  activities.                                     cooperating   in   the   program.   The   level    Of
                                                                              salary support must be consistent         with   t he       F. Financial        Management                       3.  Expenditures
                      Development      of studies   to   evaluate    profes.  salary  policies  of   the   institution   concerned.       1. General        Requirements                       4.  Time or Effort
                      sional  and  public   attitudes   toward   the   pro.   The   staff   might   be   engaged   in   supervising       2. The     Amount      Awarded                       5.  Invention
                      grams.                                                  and  coordinating   the   activities   of   the   Re-       3. Direct Costs                                      0.  Miscellaneous
                                                                              gional  Medical  Program  in   the   institution   or
                      Development   and   maintenance   of   a   flow    of   be   involved   in   specific    program    elements,       0Personnel                                           1.  Safety Precautions
                      professional   and   general   information   to   all   such as those discussed above.                              0Consultant Costs                                    2.  Federal Income Tax
                      special   and    general    interest    groups    and   0 Consultant Services
                      publics,  among   other   existing   regional   medi-   The  grant  could   pay   for   consultant   services       0Hospitalization       Costs                         3.  Military Service
                      cal   programs,   and   between    them    and    the   related   to   any    program    element    of    the       0Travel
                      Division of Regional Medical Programs.                  Regional   Medical   Program   and    justified    as       0Rent                                                V.  PREPARATION     AND     REVIEW     OF
                      Preparation  and  distribution  of  printed,   visual   the   most   effective   means    of    accomplishing       0Communication                                       APPLICATION
                      and   other   information   material   for    profes-   a particular purpose to be served.
                      sional and lay publics.                                 0  Transportation of Patients                               0Printing and Reproductions                          A. Eligible Applicants
                                                                              When  justified   as   the   most   efficient   means       0Equipment                                           The  following  are  eligible  applicants  for   bot
                      Participation   of   this   component   in   planning   of  carrying  out  the  purpose   of   the   program,       0Alteration and Renovation                           planning   and   operational   grants:   public,   c
                      and    conducting    programs,     seminars,     con-   grant  funds  may  be   used   to   pay   the   costs       "Construction"                                       private    non-profit       universities,     medicE
                      ferences    and    other    means    of    exchanging   of   transportation   of   patients   referred    for       0Costs     not     Permitted                         schools,   research    Institutions,    and     othe
                      professional general Information.                       diagnosis  and  treatment   In   other   Institutions                                                            public,   or   non-profit   private   agencies    an
                      Plans  that  do  not  specifically   further   under-   as  part  of   a   research,   training   or   demon-       4. Indirect Costs                                    institutions  located  in  any  state,  the  Distric
                      standing,   participation   and   support   as   pre-   stration  program.  The  use  of   grant   funds   to       5. Rebudgeting    of     Funds                       of   Columbia,   Puerto   Rico,   or    the    Virg!
                      viously   defined,   or   which   would   appear   to   pay  transportation   costs   should   be   carefully       6. Refunds                                           Islands.  The  applicant  must   be   authorized   t
                                                                                . .  d  against  the  use  of   funds   for   other                                                            represent   the   participating   institutions   wh,
                      provide  only   for   publicity   for   the   program                                                               0Interest or Other Income
                                                                                                                           I
                      and   aggrandisement   of   its   officials,   shou--   =s     within     the     Regional     Medica     Pro                                                            propose  to  be  involved  in   the   planning   ani
                      not  be   included.                                     gram.                                                       0Royalties    and    Profits                         operation   of   the   Regional   Medical    Program
                      Questions related to these aspects      of              D.  Relationship  to   Other   Sources   of   Support       7. Unexpended          Balance                       The  applicant  must  be  able   to   exercise   pro
                                                                      r             expected   that    no    institutional    funds       8. Obligations or Expenditures                       gram   coordination   and   fiscal    responsibility
                                                               th: D
                                                                    @     !   t  s
                      posed program may be directed to                 [VI:   !                                                                                                                in  assuring  the  effective   use   of   the   gran
                      sion of Regional Medical Programs          for    an-   ?ormerly  devoted  to  these   activities   will   be       9. Accounting,         Records and Audit             funds.  The   applicant   is   legally   responsible
                      swers or special consultation.                          displaced  by  the  use  of  the   Regional   Medical       0Accounting                                          for  expenditure  of  funds  both  by   itself   ant
                                                                              Program  grant.   Not   only   should   the   grantee       0Records                                             cooperating institutions.
                      0 Computers                                             avoid   substituting   these    grant    funds    for
                      Grant  funds   may   be   used   to   purchase   com-   other  sources  of  support,  but  he   should   also       0Audit
                      puter  time,  or  if  the  needs   of   the   program   continue   to   seek   additional    resources    for       10. Equipment (Titfe and Accountability)             B.  Method   of   Obtaining   Application
                      are  sufficient,  the  rental  of  a   computer.   As   carrying  out  the   objectives   of   the   Regional       G. Additional  Funds                                 Application  form  NIH-925,  which  is   used   bott
                      with all  other  activities,  the  costs  of  acquir-   Medical Program.                                            1. For    Continued    Support                       for  planning  and   operational   grants,   whether
                      ing   computer   capability    must    be    measured                                                                                                                    they  are   new,   continuation,   or   supplemental
                      against  the  benefits  to   be   derived   for   the   E. Single Grant Approach                                    2. Supplemental          Funds                       may  be  obtained  by  writing   the   Division   o@
                      program.
                                                                              Planning  as  well   as   operational   grants   will       3. Support     Beyond      the Program Period        Regional   Medical    Programs,    National    lnsti
                      0 Diagnostic and Treatment Equipment                    each   be   single   instruments   of   support   for       H. Program          Evaluation                       tutes   of   Health,   Bethesda,   Maryland,   20014
                      Funds   may   be   used   to   purchase    diagnostic   activities   under   the   Regional   Medical    Pro-       1. Changes in Approved Program                       C.  Method   of   Preparing   Application
                      and  treatment   equipment   which   is   Identified,   grams.  The  single  grant   approach   Is   Intended
                      through   the   planning   process,   as   being    a   to  Insure  an  appropriate   degree   of   cohesive-       J. Change   of   the   Grantee                       Applications   should   be   prepared   in   accord.
                      specific  need  of  the  region   in   carrying   out   ness in the cooperative approach.                           K. Change of Program Coordinator                     ance   with   information   contained    In    these

                      118










            guidelines  and  with  the   specific   instructions   Programs   in   advance   of   the   performance   of   owned    automobiles    are     chargeable     under     Operational   grant   funds   may    not    support
            included with the application.                         the   act   which   requires   the   obligating    or   this category.                                           more  than  90%  of  the   cost   of   such   "con-
                                                                   expenditure of funds.                                   Less  than   first   class   travel   accommodations     struction" or equipment.
            D. Review of Application                               2.   The   Amount   Awarded-There   is    no    fixed   shall  be  used  except   in   extenuating   circum-     New  facilities  may  not  be   constructed   under
            Applications  will  be  reviewed   by   the   staff,   limitation  on  the  amount   of   funds   that   may   stances.  Automobile   mileage   and   any   foreign     this   program.   Where   construction    of    new
            by  consultants  to   the   Division   of   Regional   be  awarded.  The   budget   must   have   a   direct   travel  must  be  in  accordance  with   institution     facilities  is  considered   necessary   for   fur-
            Medical    Programs,    and    as    required     by   relationship  to   the   activities   proposed.   The   policy.  Any  foreign  travel  must  receive   prior     thering   the   program,    the    applicant    may
            statute,  by  the  National  Advisory   Council   on   size   of   the   various   program   elements    in-   approval   from    the    Division    of    Regional     seek  construction  funds  under   other   applica-
            Regional   Medical   Programs.   Under   terms    of   cluded  .  in  the   budget   should   be   carefully   Medical Programs.                                        ble   Federal   programs,   such   as   the   Hill-
            the  law,  a  grant  may  not  be   awarded   unless   considered  in  terms  of  the  relative   effective-   0 Rent                                                   Burton,  Health  Research   Facilities,   and   the
                                                                                                                                                                                    Health    Professions    Educational     Assistance
            it   has   been   recommended   for   approval    by   ness   in   accomplishing   the   purposes   of   the   The  expenses   for   rental   of   facilities   not     programs.
            the National Advisory Council.                         Regional    Medical     Program.     The       budget   owned  by  the  grantee  or   participating   insti-
            The   rigorous   review   process   requires    that   should  also  have  a  direct  relationship  to   the   tution  may  be  charged  in   proportion   to   the     0 Direct Costs not Permitted
            sufficient   information   be   provided   in    the   reasonable expectations for the rate        of    im-   space   actually   utilized   for    the    program.     The  following  direct   costs   or   charges   are
            application  to  enable  the  reviewers   to   reach   plementation of the proposed programs.                  Rental  costs  may  not  be  in  excess   of   corn.     not allowable:
            considered    and    informed     judgments     con.   3.   Direct   Costs-The   following   are    examples   parable rentals  in  the  particular  locality,  and     -  Honoraria  as  distinguished   from   consultant
            cerning  the  nature,  feasibility   and   soundness   of  direct  costs  that   may   be   charged   to   a   must  be  in  accordance  with  institution  policy.     fees
            of  the  proposal  and   to   weigh   the   use   of   Regional Medical Program grant:                         0 Communication                                          -  Entertainment   (cost   of   amusement,   social
            grant   funds   for    the    particular    proposal   0 Personnel                                             That   portion   of   communication   charges   nec-     activities,  entertainment  and  incidental   costs
            against  benefits  to  be  gained   from   the   use   Salaries,  wages,  and  fringe   benefits   of   per-   essary  to  the  planning   or   implementation   of     thereto,   such   as   meals,   lodging,   rentals,
            of grant funds elsewhere.                              sonnel  in  proportion  to   the   time   or   effort   the  program  or   project   may   be   charged   to     transportation and gratuities)
                                                                   expended   on   the   program    and    in    accord-   this  category.  In  no   case   may   institutional     .. yment to Federal employees
                                                                                                                                                                                     I'a
            A  complete,  informative   application   will   fa.                                                                                                                    -Petty cash funds
            cilitate  and  expedite  the  review  of  an   apple   ance  with      institutional   policy,    may     be   local   and   regular   monthly   telephone    costs         bgranting  (a  subgrant   is   any   allocation
                                                                   charged  to  this   category.   Adequate   time   and   and  normal   postage   charges   not   related   to     -Su
            cation.  When   necessary   in   the   judgment   o?   effort  records   must   be   maintained   in   order   the   Regional   Medical   Programs    be    charged     of grant  funds  by  the  grantee  to  other  indi-
            the  staff  or  consultants,   additional   informa-   to substantiate these costs.                            to the grant.                                            viduals  or   organizations   for   purposes   over
            tion  or  justification  may  be   required   either   0 Consultant Costs                                      0 Printing and Reproduction                              which  the  grantee  institution   named   on   the
            by   supplemental   documents    or    by    confer-                                                                                                                    application  does  not  maintain   scientific   and
            ences and visits.                                      Grant  funds  may   be   used   to   pay   consultant   Printing of   pamphlets,   brochures    and    other     financial  responsibility.  A   grantee   may   con-
                                                                   fees   for   services   related   to   any    program   materials  necessary  for  this   program   may   be     tract for services, but may not subgrant.)
            E, Notification of Applicant                           element   of    the    Regional    Medical    Program   charged to this category.
                                                                   providing  that   these   services   are   the   most   0 Equipment                                              4.  Indirect  Costs-Institutional   indirect   cost
            Copies  of   a   Notice   of   Grant   Awarded   are   effective   means   of   accomplishing   a   particu-   Rental   and   purchase   of   equipment   for   the     rates  will  be  based  on  the  percentage   rela-
            sent  to  the   grantee.   This   notice   indicates   lar  purpose,  and  that  the   consultant   is   not                                                            tionship that  total  institutional  indirect  cost
                                                                                                                           planning   or   implementation    of    a    program     is to the total  direct  salaries  and  wages  paid
            the    program    period,    the    amount     being   on  the  staff  of   the   grantee   or   cooperating   may  be  charged  to   this   category.   When   ac-     by the  institution  (not  just  the  research  in-
            awarded   (including   the   budget   period    cov-   institution.  If  consultation   is   obtained   from   quiring  equipment,  consideration  of   the   rela-     direct cost pool).
            ered),   and   any    special    conditions    under   a  staff  member  of   the   grantee   or   cooperat-   tive   advantages   of   lease    versus    purchase
            which the grant is awarded.                            ing   institution,   a   proportionate   amount    of   should be considered.                                    Data   taken   directly   from   the   grantee   or
                                                                   his  regular  salary  may  be  paid  by  the   grant.                                                            c    rating   institutions   most   recent   annual
                                                                                                                           <C>  Alteration  and   Renovation   ("Construction")     .oope
            F. Financial Management                                In   either   case,   consultant   costs   must    be   linder  the   Act   "construction"   means   altera.     Tinancial   report   and   immediately    available
            1. General     Requirements-Funds           granteol   supported  by   a   clear   statement   of   services   tion,  restoration  to  a  sound   state,   remodel-     supporting  information  will  be  utilized  as   a
                                                                   performed   and   if    appropriate,    the    number   ing  and  renovation  of  existing         buildings     basis  for  determining  the  indirect  cost   rate
            may   be   used   only   for   services,   materials   .of man days of service.                                                                                         applicable   to   a   Regional   Medical    Program
            and other  items  required  to  carry  out  the  ap-                                                           (including  initial  equipment  thereof),  and   re-     grant at the institution.
            proved  program.  Circular  A-21   of   the   Bureau   0 Hospitalization Costs                                 placement  of   obsolete   built-in   equipment   of
            of  the  Budget  should  be  used  to   the   extent   The    method    of    determining    hospitalization   existing   buildings.    Built-in    equipment    is     Total  expenditures  as   taken   from   the   most
            practicable  in  determining  allowable  costs   re-   costs   is   still   under   consideration   by   the   equipment  affixed  to   the   facility   and   cus-     recent  annual  financial  report   will   be   ad-
            lated   to   the   grants   for   Regional   Medical   Division   of   Regional   Medical    Programs.    It   tomarily   included   in   a   building    contract.     justed  by  eliminating  from  further   considera-
            Programs.   Where   the   Division    of    Regional   will be distributed at a later date.                    The  applicant  is  required  to  furnish  in   suf-     tion  the  following   items   or   categories   of
            Medical    Programs    requires    prior    approval   0 Travel                                                ficient detail plans  and  specifications,  as  well     expenditure:
            for  items  not  listed  in  the  approved   budget,   Per   them   reimbursements   to   travelers,    per-   as  a  narrative  description,   to   indicate   the     0  The   costs   of   equipment,   buildings,   and
            a   written   request   must   be   made   by    the   sonal   transportation   charges,   and    reimburse-   need,   nature   and   purpose   of   the   proposed     repairs  which  materially   increase   the   value
            grantee  to  the  Division   of   Regional   Medical   ments  for  authorized       use    of     personally   "construction."                                          or useful life of buildings or equipment.
                                                                                                                                                                                                                                  119












                   However,    depreciation    and    use     charges     may    all   institutional   indirect   cost   rate   has   been    and   protection    of    the    institution's    physical    material   shall    be    refunded    to    the    Public
                   be   Included   in    determining    total    expenditure.    audited   and    approved    by    the    PHS,    another    facilities;                                                   Health Service.
                   6   Advertising   other   than    for    recruitment    of    Government    agency,    or    an     independent     ac-    0    Reimbursements    and     other     receipts     from    7.     Unexpended      Balance-Continued      use      of
                   personnel,    procurement    of    scarce     items     or    counting  firm.   In   addition,   the   total   institu-    the    Federal    Government    which    are    used    by    any    unobligated.    or    unexpended     funds     re-
                   the'disposil    of    scrap    or    surplus     material.    tional   indirect   cost,   and   direct   salaries   and    the   institution   to   support   directly,   in    whole    maining  in   the   grant   account   at   the   end   of
                   0    Bad debts                                                wages   should   be   stated   as    separate    amounts.    or   in   part,   any    of    the    administrative    or    the  budget   period   should   be   justified   by   the
                   0    Contingency reserves                                     The    institution     should     indicate        whether    service   (indirect)    activities    received    pursuant    grantee    when    the     Expenditures     Report     is
                   0    Commencement and.         convocation       costs        fringe   benefits   are   included    in    the    salary    to  an   lnstitution's   base   grant   or   any   similar    submitted   to   the   Division   of    Regional    Medi.
                   0    Entertainment costs                                      and   wage   base   or   not.   A    detailed    Indirect    contractual     arrangement     with      the      Federal    cal    Programs.    If    adequate    justification    is
                   0    Fines and penalties                                      cost    proposal    should     accompany     each     new    Government   shall   be   treated   as   a    credit    to    received,    the    Division    of    Regional    Medical
                   0    Interest,     fund     raising     and     investment    or    continuing    grant    application.     When     an    the  total  indirect  cost  pool.   Such   set-off   shall    Programs   will   advise   the    grantee    that    such
                   management costs                                              applicant    is    submitting    a     planning     grant    be   made   prior   to   the    determination    of    the    funds    may    be    used    during    the    subsequent
                   0   Losses    on    other    agreements    or    contracts    application   to   the   Division   of   Regional   Medi-    indirect   cost   rate   submitted   to    the    Division    budget   period.   If   inadequate   justification,    or
                   0  Profits   and   losses   on   disposition   of   plant,    cal   Programs,   the    above    '    procedures    also    of    Regional    Medical    Programs.    These    credits    no     justification     is     presented,     unexpended
                   equipment, or other capital costs                             apply.                                                       include     indirect     cost     reimbursements      con-    funds   will   be   used   toward    payment    of    the
                   0    Public    Information    services     costs              Indirect   costs   are   those    which,    because    Of    tained     in   payments       for        hospitalization,    total    amount    requested    for    the     subsequent
                   0 Scholarships and student aid costs                          their    incurrence     usually     for     common     or    interdepartmental      charges       and       centralized    budget    period.    The    unexpended     balance     as
                   0   Special   services   costs   incured    for    general    joint  objectives,  are  not  readily  ldentifi        ad    facilities operated by the Institution.                       shown   in   the   final   Expenditures    Report    must
                   public relations                                              with   individual   projects.   All   costs    represent-    S.     Rebudgeting     of     Funds-The     grantee     or    be   returned   to    the    National    Institutes    of
                   0 Student activity costs                                      ing    charges    associated    with    the    activities    cooperating   Institutions    may    depart    from    the    Health,     PHS,      DHEW,      Bethesda,      Maryland,
                   0 Student dormitory costs                                     of    the    grantee    or    cooperating    Institutions    approved   budget   and   use   the   funds   for    other    20014.
                   0 Student services costs                                      which   are   supportive   of   the   conduct   of    the    items   required   for    the    project,    except    for    8.     Obligations      or      Expenditures-Obligations,
                   0  Costs   used   In   arriving   at   a   hospitalization    Regional     Medical      Program,      except      those    the following restrictions:                                   commitments,       encumbrances,       or        expendi-
                   rate or interdepartmental        charge                       which   are   specifically   approved   by   the    Div!-    0   Grant   funds   may    not    be    used    for    any    tures    will    normally    be    made    within     the
                   0  Unrelated hospital costs                                   sion   of   Regional   Medical   Programs    as    direct    purpose    contrary     to     the     regulations     and    period    indicated    on    the    notice    of    grant
                   0 Other inappropriate costs                                   costs,   are   classified   as   indirect   costs.    The    policies   of   the   Division   of    Regional    Medical    award.   Grant    funds    may    not    be    used    to
                   Where     any     types     of     expense      ordinarily    general types of indirect costs are:                         Programs   or   the    grantee    or    the    cooperating    reimburse     any     such      obligations,      commit-
                   treated    as'    general    administration    and    gen-    * General       administration       and         expenses    institutions.                                                 ments    or    expenditures    made    prior    to    the
                   eral     'expenses     or     departmental     administra-    which   are    Incurred    for    the    executive    and    0    Grant    funds    may    be    transferred    between    beginning  date  of  the  initial   grant   for   a   new
                   tration   expenses   are    charged    to    a    Division    administrative   offices   of    an    institution    re-    budget    categories    to    the    extent    that     no    or   renewal   project.    In    exceptional    instances
                   of     Regional     Medical     Programs     grant      as    ceiving    grants,    and    other    expenses    of    a    category   is   increased    or    decreased    by    more    the  grantee  may,  at  its  own  risk,  prior   to   the
                   direct   costs,   the    similar    type    of    expenses                                                                 than   20%   of    the    approved    budget.    Increases                           a c
                                                                                 general   character   which   do   not   relate    solely                                                                  beginning date of           antinuation    award,     in-
                   applicable   to   other   activities   of    the   institu.   to  any  specific  unit  in  the   institution,   or   to    or   decreases   in   a   budget   category   in    excess    cur   expenditures   which    exceed    existing    Divi.
                   tion    must,    through    separate    cost    groupings,    any specific project in the institution;                     of   20%   must   be   approved   by   the   Division   of    sion   of   Regional    Medical    Programs    authoriza-
                   be   excluded   from   the   indirect   costs    allowable    0     Program     administration     expenses      'which    Regional Medical Programs.                                    tion   but   which   are    considered    essential    to
                                                                                                                                                                                                            the   conduct   of   the   project.   The   Division   of
                   to   a   Division    of    Regional    Medical    Programs    apply   to    program    activities    administered    in    6.    Refunds-During    the    program     period,     re.    Regional Medical
                   grant.                                                        whole   or   in   part   by   a   separate   organization                                                                                        Programs    may     allow     reim.
                                                                                                                                              funds   and   rebates   should   be   credited   to    the    bursement    of    such     expenditures     from     the
                   The  indirect  cost  rate  will   then   be   co              or   an    identifiable    administrative    unit.    Ex-    account.   Credits    received    after    the    termina-    continuation grant.
                                                                  .Mpute@        amples   of   work    relating    to    grant    programs    tion   of   the   program   period   shall   be   returned
                   by   dividing   the    total    direct    salaries    anci    which    is    sometimes     performed     under     such    to   the   Public   Health    Service.    Checks    should    9. Accounting Records and Audit-
                   wages   paid   by   the   institution   into   the   total    organizational    arrangement     are:     grant     ad-,    be   made    payable    to    National    Institutes    of    0 Accounting
                   adjusted  indirect   cost   incurred   by   the   institu-
                   tion.                                                         ministration,     purchasing,     personnel,     account-    Health,      PHS,      DHEW,      Bethesda,      Maryland,    Accounting   for   the   grant   funds   will    be    in
                                                                                 ing, etc.;                                                   20014.                                                        accordance    with    the    grantee     and/or     coop-
                   When,   under   an   operational    grant,    the    coop-    0    Operation    and    maintenance     expenses     In-    0  Interest and other income                                  erating    institution    accounting    practices    con-
                   erating   Institutions   are   preparing    their    budg-    curred    for    operating     and     maintaining     an    Interest    or    other    income    earned    on    grant    sistently   applied   regardless   of   the   source   of
                   ets  for  submission  to  the  grantee,              the      lnstitution's    physical    plant,     Including     ex-    funds   must   be   returned   to   the   Public    Health    funds.   Itemization   of   all    supporting    expendi-
                   institutions'    Indirect    cost    rates,    @ased    on    penses    normally    Incurred     for     administration    Service.                                                      tures   must   be   recorded   in    sufficient    detail
                   salaries and wages, should be stated In              the      or   supervision   of   the   physical    plant;    jani-    0  Royalties and Profits                                      to   show   the    exact    nature    of    expenditures.
                   budget.  To  substantiate  this  rate,  the          co-      torial   service;    utilities,    including    telephone    When   the    costs    of    publishing    material    are    Each   recipient    of    grant    funds    shall    keep
                   operating   institutions  should   supply            the      installation     and     maintenance      costs;      and    provided    from    Public    Health    Service    grants,    such    records    as    the    Surgeon    General    may
                   grantee     with     adequate     substantiating     data,    other    expenses     customarily     associated     with    any   royalties   or   profits   up    to    the    amount    prescribe,   including   records   which    fully    dis-
                   such   as   documents   certifying    that    the    over-    the  operation,     maintenance,        p    reservation,    charged    to    the    grant    for    publishing     the    close   the    amount    and    disposition    by    such

                   120









              recipient  of  the  proceeds  of  such   grant,   the   in  determining  that   there   is   a   proper   ac-    supplemental  grant  forms  a  part   of   the   ini-   J. Change of Grantee
              total  cost  of  the  program   or   undertaking   in   counting  in  use  of  grant  funds.  Failure  of   a    tial  award  and  only   one   report   of   expendi-   If  the  grantee   expects   to   relinquish   active
              connection   with   which   such   grant   is    made   grantee  to  appeal  a   proposed   audit   disallow-    tures is required.                                      direction   of   the   program,   the   Division   of
              or  used,  and  the  amount  of   that   portion   of   ance  within  thirty  days   after   receipt   of   a    Supplemental   applications    are    processed    in   Regional   Medical   Programs   must   be    notified
              the  cost  of  the  program   or   undertaking   sup-   written  notification  will  make   the   action   of    the   same   manner   as   new    applications    and   ---  ediately.   The   grantee   may   request   that
              plied  by   other   sources,   and   to   make   such   the   Division   of   Regional    Medical    Programs    must   compete   for    available    funds,    except       grant   be   terminated,   in   which   case    a
              records  available  as  will  facilitate  an   effec-   conclusive.                                              those  applications    to    meet    increased    ad-   ine
              tive  audit   by   authorized   personnel.   Such   a                                                            ministrative  costs,   such   as   fringe    benefits   terminal    progress    report,    an    expenditures
              system must meet the following criteria:                10. Equipment (Title and Accountability)                 or  salary   increases,   may   be   administratively   report,   and    invention    statement    (PHS-3945)
              -  A   special   grant   account   must   be   estab-                                                                                                                    must  be   submitted.   The   grantee   may   request
              lished   for   each    Regional    Medical    Program   Title   to    equipment    purchased    with    grant    approved.                                   iod-if      that   the   program   be   continued    under    the
              grant  and  be  maintained   at   the   grantee   in-   funds  resides  in  the   grantee   institution   and    3. Support beyond      the    Program     Per rogram    direction of another institution.
              stitution  designated   on   the   application.   Re-   accountability  may  be  waived   at   the   termina-    additional    support    beyond     the     p
              sponsibility   for    expenditure    of    funds    b   tion  of  the  grant  by  the  Division  of  Regional    period is required,    a   new    application    must   If  the   grantee   terminates   its   responsibility
              participating   institutions   must    be    assume-@   Medical   Programs   as   long   as   the   equipment    be    submitted.    This    application    will    go   for   the   program,   the   new   institution    may
                                                                  u   is  used   to   further   the   objectives   of   the    through  the  normal  review   process   and   will-.   submit  a  new  grant   application   for   the   re-
              by the named grantee institution.                       Public  Health   Service.   The   Division   of   Re-    compete   with   other   applications   for   availa-
              - The accounting records at the grantee           in-   gional   Medical    Programs,    however,    reserves    ble  funds.  If  approved,  an  initial   grant   for   mainder  of  the   program   period.   The   applica-
              stitution   shall   provide     the   in  rmat          the   right   under    unusual    circumstances    to    a  new  program   period   will   be   awarde           tion  should   include   the   reasons   for   trans-
              needed to identify the receipt and expe                 transfer  title  of  equipment  to  the  Division  of                                                            ferring  the  program   and   the   probable   effect
              lure  of  all  program  funds  separately               Regional   Medical    Programs    or    to    another    H. Program Evaluation                                   of  the   move   on   the   program.   Administrative
              each grant. Expenditures shall be recoi                                                                                                                                  approval  may   be   given   by   the   Division   of
              by the component program and budget (             ost   grantee.                                                 The  grantee  should  make  a   special   effort   to   Regional   Medical   Programs   to    continue    the
              categories shown in the approved budget.                Excess   materials   and   supplies    retained    by    incorporate  into  all  aspects   of   the   planning   program  at  the   new   institution.   Applications,
              -  Each  entry  in  the  accounting  records  at  the   the   grantee   upon   termination   of   the    pro.    and   operational   activities   appropriate   mecha-   however,  that  reflect   major   changes   will   be
              grantee   or   cooperatinglnstitution   shall   refer   gram  hiay  be   accounted   for   under   the   same    nisms  for  evaluating  the  effectiveness   of   all   referred  to  the  National   Advisory   Council   on
              to   the    documentation    which    supports    the   terms as equipment.                                      as pacts   of   the    Regional    Medical    Program.  Regional    Medical    Programs    for    recommenda-
              entry  and   the   documentation   shall   be   filed                                                            The concern with the evaluation        should     be-   tion.
              in such  a  way  that  it  can  be  readily  located.   G. Additional Funds                                      gin   in   the   planning   process   so   that   the
              -   The   accounting   records   shall-provide    ac-                                                            planning   process   may   include    planning    for   K. Change of Program Coordinator
              curate   and   current   financial   reporting    in.   To  obtain  additional  funds  for   support   of   a    evaluation   mechanisms.    The    exploratory    na-
              formation.                                              program,   the   procedures   vary    according    to    ture    of    the    Regional    Medical     Programs   The   program   coordinator   named   in   the    ap-
              -   The   accounting   system   shall   possess    an   the need as follows:                                     makes  the  need   for   the   realistic   evaluation   plication  shall   be   responsible   for   coordina-
              adequate  means  of   internal   control   to   safe-                                                            mechanisms    especially    important.     Particular   tion  of  the   program   during   the   period   for
                                                                      1.    For    continued     support-An     application    attention  to  the  evaluation  process   will   pro-   which the grant was awarded.
              guard   the   assets,   check   the   accuracy    and   form  requesting  support   for   the   next   budget    vide the  means  for  the  grantee  to   assess   his   A   change   of   program   coordinator   or    other
              reliability   of   the   accounting   data,   promote   period   of   the   program   period    (continuation    progress  and   accomplishments   and    will    also   key   official   directing   the   program   requires
              operational    efficiency,    and    encourage    ad-   grant)  will  be  mailed  to  the  grantee   institu-    provide   the   basis   for   the   preparation    of   approval  by   the   Division   of   Regional   Medi-
              herence   to    prescribed    management    policies.   tion   about   4   months   before   the    beginning    progress  reports  which   can   be   used   by   the   cal   Programs.   The   grantee   is   required    to
              0 Records                                               date  of  the  next  budget   period.   It   is   the    Division   of   Regional    Medical    Programs    in   notify  the  Division  of   Regional   Medical   Pro-
              ments  to   support   entries   on   the   accounting
              The   financial   records,   including   all    docu-   responsibility  of  the  grantee  to   request   this    evaluating   the   accomplishments   of   the   total   grams if such a change is necessary.
                                                                      application  form  if  it  is   not   received.   The    national program.
              records,     mus't  be  kept  readily   available   for application   should   be   submitted   in    accord-
              examination    by    authorized     personnel.     No   ance   with   the   instructions   accompanying   the    1. Changes In Approved Program                          L. Change in Program Period
              such   records   shall   be   destroyed   or   other-   form.                                                                                                            The  program   period   may   be   extended   up   to
              wise   disposed   of   within   three   years   after                                                            The   Division   of   Regional    Medical    Programs
              the  termination  of  the   program.   Unless   writ-   2.    For    supplemental     funds-if     additional    does  not  intend  to  interfere   with   administra-   12  months   (but   not   beyond   June   30,   1969)
              ten   approval   is   obtained   from   the    Public   funds   to   conduct   the   program   are   required    tive  or  program  flexibility   which   @erves   the   without  additional  funds,  if  requested   by   the
                                                                      within   any   portion   of   the   program    period    objectives  of   the   Regional   Medical   Frograms.   grantee   before   the    end    of    the    program
              Health   Service   to   dispose   of   the   records,
              they  must  be   retained   until   the   audit   has   over  those   budgeted   and   approved,   and   such    If,  however,  a  change   is   determined   by   the   period.
                                                                                                        n  the  institution    grantee to be desirable, and if that c@an
              been  completed   and   all   questions   about   the   funds are not available withi                                                                               @e
              expenditures are resolved.                              receiving  support  for  the   program,   a   supple-    would  constitute  a  substantial   change   in   ine   M. Early Termination of Grant
              0 Audit                                                 mental    application    may    be    submitted.    A    nature   of   the   program   originally    approved,   1.   By   the   Grantee-A   grant   may   be   termi-
              The Division of Regional       Medical       Programs   face   sheet,   budget   page,   and    justification    the  grantee  should  consult   with   the   Division   nated   or   cancelled   at   any   time    by    the
              follows generally accepted     auditing     practices   are   required   for   a   supplemental   award.    A    of Regional Medical Programs staff.                     grantee   upon   written    notification    to    the
                                                                                                                                                                                                                                      1 2  1





                                                                                                                           Appendix     7-Publ'c     Law     89-239

               Division  of  Regional   Medical   Programs   stat-   submitted  by   the   named   grantee   on   behalf   Public Law 89-239                                       professional  practice,  or   with   the   adminis-
               ing the reasons for termination.                      of all cooperating  institutions  to  the  Division   89th Congress, S. 596                                   tration  of  hospitals,  and  in  cooperation  with
               2. By the  Public  Health           -A        grant   of   Regional    Medical    Programs    for    each   October 6, 1965                                         practicing   physicians,     medical         center
                                           Service                                                                                                                                 officials,  hospital  administrators,  and   repre-
               may  be  revoked  or   terminated   by   the   Sur-   budget  period  of  the  program  period.  If   the
               geon  General,  in  whole  or  in  part,   in   any   grantee  fails  to  submit  an   expenditures   re-   AN ACT                                                  sentat.ives from appropriate voluntary       health
               time  within  the  program   period   whenever   it   port  within  120  days  after  the  end  of   each   To  amend  the  Public   Health   Service   Act   to    agencies.
               is  determined  that   the   grantee   has   failed   budget  period,  future  awards  for  that  project   assist in  combating    heart    disease,    cancer,         "Authorization of Appropriations
               in  a  material  respect   to   comply   with   the   may be withheld.                                      stroke, and related diseases.
               terms   and   conditions   of   the   grant.    The                                                                                                                 "Sec.  901.  (a)  There  are   authorized   to   be
               grantee  will  be  promptly  advised  of  the  rea-   A  supplemental  grant  forms   a   part   of   the   Heart Disease,                                          appropriated  $50,000,000  for  the   fiscal   year
               sons for  termination  of  the  grant  in  writing.   existing  grant  and  only  one   expenditure   re-   Cancer, and                                             ending  June  30,   1966,   $90,000,000   for   the
                                                                     port   need   be   submitted   on   the    combined   Stroko Am,n,i-                                          fiscal   year   ending   June   30,    1967,    and
               N, Reports                                            grants.                                               ments of 1965.                                          $200,000,000  for  the  fiscal  year  ending   June
               All repdrts required  to   be   submitted   to   the  4.  Time  or  Effort   Report-Charges   for   sala-                                                           30,  1968,  for  grants   to   assist   public   or
               Public  Health  Service  should  be  sent  to   the   ries  and   wages   of   individuals   other   than   Be it enacted   by   the   Senate   and   House   Of    nonprofit   private    universities,        medical
               Division  of  Regional   Medical   Programs,   Pub-   members  of  the   professional   staff   will   be   Representatives   of   the    United    States    of    schools,   research   institutions,    and    other
                                                                                                                           America   in   Congress   assembled,    That    this    public  or  nonprofit  private   institutions   and
               lic    Health    Service,    Bethesda,    Maryland,   supported  by  time   and   attendance   and   pay.   Act  may   be   cited   as   the   "Heart   Disease,    agencies  in  planning,  in  conducting  feasibili-
               20014.                                                roll  distribution  records.  For  members  of  the   Cancer, and Stroke Amendments of 1965".                 ty  studies,  and  in  operating   pilot   projects
               1.   Progress   Reports-The    grantee    is    re-   professional  staff,  quarterly  estimates  of  the                                                           for  the   establishment,   of   regional   medical
               quired  to  submit  an  annual   progress   report.   percentage  distribution  of  their  total   effort   Sec. 2. The Public Health Service Act            (42    rograms   of   research,   training,   and   demon-
               This  report  should  contain   sufficient   detail   must  be  used  as  support  in  the   absence   of   U.S.C., ch. 6A) is amended by adding at          the    P
                                                                                                                           end thereof the following new title:                    stration  activities  for  carrying  out  the  pur-
               to  inform  the  reader  of   the   accomplishments   actual  time  records.  Time  and  effort   reports                                                           poses  of  this  title.  Sums  appropriated   under
               with   particular   respect   to   the   objectives   are  not  to  be  sent  to  the  Division  of   Re-   "TITLE      IX-EDUCATION,      RESEARCH,      TRAIN-    this section  for  any  fiscal  year  shall  remain
               originally  set  forth.  These   progress   reports   gional   Medical   Programs   but   must   be   re-     ING,      AND      DEMONSTRATIONS      IN      THE    available  for  making  such   grants   until   the
               must  be  submitted  with   the   application   for   tained  by   the   grantee   and   must   be   made     FIELDS     OF     HEART      DISEASE,      CANCER,    end  of  the  fiscal  year  following  the   fiscal
               a  continued   support.   In   addition,   grantees   available  for  inspection  by  the  Public  Health     STROKE,     AND     RELATED     DISEASES              year for which the appropriation is made.
               may  be  required  to  supply   other   information   Service staff.                                                                                                "(b)  A  grant  under  this  title  shall  be   for
               needed  for  guidance  and   development   of   the                                                                            "Purposes                            part  or  all  of  the  cost  of  the  planning  or
               national  program  and  are   encouraged   to   re-   5.  Invention   Report-Immediate   and   full   re-   "Sec.  900.  The  purposes  of   this   title   are-    other  activities  with  respect   to   which   the
               port   significant   developments    promptly    at   porting of all  inventions  to  the  Public  Health   ,(a)  Through   grants,   to   encourage   and   as-    application  is  made,   except   that   any   such
               any  time.  A   terminal   progress   report   must   Service is required.
               be  submitted   to   the   Division   of   Regional                                                         sist  in  the  establishment  of  regional   cooper-    grant  with  respect   to   construction   of,   or
               Medical   Programs   within   three    months    of   0. Miscellaneous                                      ative   arrangements    among    medical    schools,    provision  of  built-in  (as  determined   in   ac-
               the termination of the program period.                                                                      research  institutions,  and   hospitals   for   re-    cordance   with   regulations)    equipment    for,
                                                                     1.    Safety    Precautions-The    Public    Health                                          c                any  facility  may  not  exceed   90   per   centum
                                                                                                                           search  and  training  (including        ontinuing
               2.    Regional    Advisory    Group-The    Regional   Service assumes no responsibility wit          re-                                                            Or  the  cost  of  such  construction   or   equip-
               Advisory  Group   is   expected   to   prepare   an   spect to accident, claims or illness ari       !ng    education)  ani  for   related   demonstrations   of    ment.
               annual  statement  on  the  effectiveness  of   the   out  of  any  work  undertaken  with  the   assist-   patient  care  in  the  fields  of  heart   disease,    "(c)  Funds  appropriated  pursuant  to  this   ti-
               regional    cooperative     arrangements     estab-   ance  of  a  Public  Health  Service   Grant.   The   cancer,  stroke,  and  related   diseases;              tle shall not be  available  to  pay  the  cost  of
               lished  under   the   Regional   Medical   Program.   grantee institution  is  expected  to  take  neces-   "(b)  To  afford  to  the  medical  profession   and    hospital,  medical,  or  other  care  of   patients
               The  report  should  be  submitted  to  the   Divi-                                                                                                e     Nation,    except to  the  extent  it  isi  as  determined  in
               sion   of   Regional   Medical   Programs   b   the   sary steps to insure  or  protect  itself  and  its   the   medical   institutions    of    th   ts,   the    accordance   with    regulations,    incident    to
                                                          y                                                                through such cooperative arrangemen
               grantee  along  with  the   annual   progress   re,   personnel.                                            opportunity  of  making  available  to   their   pa-    those   research,   training,   or    demonstration
               port. Periodic  reviews  of  grants  by  the  staff   2. Federal  Income    Tax-Determination    of     a
               of the  Division  and  the  Advisory  Council  will                                                         tients  the  latest  advances   in   the   diagnosis    activities   which   are   encompassed    by    the
               include  consideration  of  the  effectiveness   of   tax  status  of  an   individual   receiving   com-   and  treatment  of  these  diseases;   and              purposes  of  this  title.  No  patient  shall   be
                                                                     pensation    in   any   form   from   the    Public                                                           furnished  hospital,  medical,  or  other  care  at
               the  Advisory  Group  in  serving   its   essential   Health  Service  grant  is  the  responsibility  of   "(c)  By   these   means,   to   improve   generally    any facility incident  to  research,  training,  or
               purpose.                                              the internal Revenue Service.                         the  health  manpower   and   facilities   available    demonstration   activities   carried    out    with
               3.   Expenditures    Report    (Form    NIH-925-3)-   3.  Military  Service-The   Public   Health   Serv.   to  the  Nation,  and  to  accomplish   these   ends    funds  appropriated   pursuant   to   this   title,
               A  single  expenditures   report   and   a   single   ice will  not  intercede  on  behalf  of  an  indi-   without  interfering  with  the  patterns,  or   the    unless  he  has  been  referred  to  such  facility
               narrative  progress  report  is  required   to   be   vidual in relation to military status.                methods   of   financing,   of   patient   care   or    by a practicing physician.

               122










                                   "Definitions                        11(f) The  term  'Construction'  includes  altera-      lishment  and  operation   of   such   regional     find  necessary   to   assure   the   correctness
                                                                       tion,  major  repair  (to  the  extent   permitted      medical   program,   which    advisory    group     and verification of such reports; and
                  "Sec.  902.  For  the  purposes  of  this   title-   by   regulations),   remodeling   and   renovation      includes   practicing    physicians,    medical     "(4)  any  laborer  or   mechanic   employed   by
                  "(a)   The   term   'regional   medical   program'   of existing buildings  (including  initial  equip-      center  officials,   hospital   administrators,     any   contractor   or   subcontractor   in    the
                  means   a   cooperative   arrangement   among    a   ment  thereof),  and  replacement   of   obsolete,      representatives   from   appropriate    medical     performance   of   work   on   any   construction
                  group of  public  or  nonprofit  private  institu-   built-in  (as  determined   in   accordance   with      societies,  voluntary  health   agencies,   and     aided  by  payments   pursuant   to   any   grant
                  tions or  agencies  engaged  in  research,  train-   regulations) equipment of existing buildings.           representatives  of  other  organizations,  in-     under  this  section  will  be  paid   wages   at
                  ing,  diagnosis,   and   treatment   relating   to                                                           stitutions,   and   agencies   concerned   with     rates  not  less   than   those   prevailing   on
                  heart disease, cancer,  or  stroke,  and,  at  the                "Grants for Planning                       activities  of  the  kind  to  be  carried   on     similar  construction  in  the  locality  as  de-
                  option  of  the  applicant,  related  disease   or   "Sec. 903.   (a)   The   Surgeon   General,   upon      under  the   program   and   members   of   the     termined  by  the  Secretary  of  Labor  in   ac-
                  diseases; but only  if  such group-                  the   recommendation   of   the   National   Advi-      public familiar with the  need  for  the  serv.     cordance   with   the   Davis-Bacon    Act,    as
                                                                                                                               ices provided under the program.                    amended    (40    U.S.C.    276a-276a-5);     and
                    "(1)   is'situated    within a   geographic    area, sory  Council   on   Regional   Medical   Programs                                                        the  Secretary  of   Labor   shall   have,   with
                    composed   of   any   part or  parts  of  any  one established by  section  905  (hereafter  in  this
                    or  more   States,   which the   Surgeon    Gener- title referred to as the  'Council'),  is  author.    "Grants  for  Establishment  and   Operation   of     respect  to  the  labor  standards  specified  in
                    al  determines,  in  accordance   with   regula-                                                                 Regional Medical Programs                     this   paragraph,   the   authority   and   func-
                                                                       ized  to  make  grants  to  public  or   nonprofit                                                          tions   set   forth   in   Reorganization    Plan
                    tions,  to  be  appropriate  for  carrying   out   private   universities,   medical   schools,   re-    "Sec.  904.  (a)  The   Surgeon   General,   upon
                    the purposes of this title;                                                                                                                                    Numbered  14   of   1950   (15   F.R.   3176;   5
                                                                       search   institutions,   and   other   public   or    the  recommendation  of  the  Council,   is   au-     U.S.C.  133z-15)  and  section  2  of   the   Act
                    "(2)   consists   of   one   or   more   medical   nonprofit  private   agencies   nnd   Institutions    thorized  to   make   grants   to    public    or     of  Juno  13,  1934,  as   amended   (40   U.S.C.
                    centers,   one   or   more   clinical   research   to  assist  them  In  planning   the   development    nonprofit   private    universities,      medical     276c).
                    centers, and one or more hospitals; and            of regional medical programs.                         schools,  research   Institutions,   and    other
                    "(3)  has   in   effect   cooperative   arrange-   11(b)  Grants  under  this  section  may  be  made    public or nonprofit  private  agencies  and   in-
                    ments   among   its   component   units    which   only           placation  therefor   approved   by    stitutions  to  assist   in   establishment   and     "National Advisory Council on Regional
                    the  Surgeon  General   finds   will   be   ade-        _upon ap
                    quate   for effectively carrying  out  the  pur-   the Surgeon   General.   Any   such    application    operation of  regional  medical   programs,   in-                  Medical Programs
                                                                       may  be  approved  only  if  it  contains  or   is    cluding  construction  and  equipment  of  facil-
                    poses   of this title.                             supported by-                                         ities in connection therewith.                      "Sec.  905.   (a)   The   Surgeon   General,   with
                  "(b)   The   term   'medical   center'   means   a      "(1)   reasonable   assurances   that   Federal    "(b)  Grants  under  this  section  may  be  made   the  approval  of  the  Secretary,   may   appoint,
                  medical   school  or  other  medical   institution      funds  paid  pursuant   to   any   such   grant    only  upon  application  therefor   approved   by   without  regard  to  the  civil  service  laws,   a
                  involved  in  postgraduate  medical  tra         g           be  used  only  for   the   purposes   for    the  Surgeon  General.   Any   such   application   National  Advisory  Council   on   Regional   Medi-
                                                             t  inin       '!c                   accordance   with    the
                  and     one or  more   hospitals   affiliated   hee-    wih  h paid and  in                                may  be  approved  only  if  it  is   recommended
                                                                                                                                                                                 cal  Programs.  The  Council   shall   consist   of
                  with   for   teaching,   research,   and    demon-      applicable provisions of  this  title  and  the    by  the  advisory  group  described  in   section   the   Surgeon   General,   who   shall    be    the
                  stration purposes.                                      regulations thereunder;                            903(b)(4)  and  contains  or  is   supported   by   chairman,   and   twelve   members,   not    other-
                  "(c) The  term      @clinical research     center'                                                                                                             wise  in  the  regular  full-time  employ  of   the
                  means an  institution  (or  part  of  an  institu-      "(2)  reasonable  assurances  that  the  appli-    reasonable assurances that-                         United  States,  who  are  leaders  in  the  fields
                  tion)  the  primary  function  of  which  is   re-      cant  will  provide  for  such  fiscal  control      "(1)  Federal  funds  paid  pursuant   to   any   of   the   fundamental   sciences,   the    medical
                                                                          and   fund   accounting   procedures   as   are      such grant  (A)  will  be  used  only  for  the
                  search,  training  of  specialists,   and   demon-      required  by  the  Surgeon   General   to   as-      purposes  for  which  paid   and   in   accord-   sciences,  or  public  affairs.  At  least  two  of
                  strations    and      which,    In      connection      sure  proper  disbursement  of   and   account-      ance  with   the   applicable   provisions   of   the   appointed   members   shall   be   practicing
                  therewith,  provides   specialized,   high-quality      ing for such Federal funds;                          this  title  and  the  regulations  thereunder,   physicians,  one  shall  be  outstanding   in   the
                  diagnostic  and  treatment  services   for   inpa-      "(3)  reasonable  assurances  that  the  appli-      and  (B)  will  not  supplant  funds  that  are   study,  diagnosis,  or  treatment  of  heart   dis-
                  tients and outpatients.                                 cant will  make  such  reports,  in  such  form      otherwise  available  for   establishrpent   or   ease,  one  shall  be  outstanding  in  the  study,
                  "(d)  The  term  'hospital'   means   a   hospital      and  containing   such   information   as   the      operation  of  the  regional  medical   program   diagnosis,  or  treatment  of   cancer,   and   one
                  as defined  in  section  625(c)  or  other  health      Surgeon  General  may   from   time   to   time      with respect to which the grant is made:          shall  be  outstanding  in  the  study,   diagnosis
                  facility in which  local  capability  for  diagno-      reasonably  require,   and   will   keep   such      "(2) the applicant will    provide   for   such   or treatment of stroke.
                  sis  and   treatment   is   supported   and   aug-      records and  afford  such  access  thereto  'as      fiscal  control  and  fund  accounting   proce-   "(b)  Each  appointed   member   of   the   Council
                  mented   by   the   program   established    under      the  Surgeon   General   may   find   necessary      dures  as   are   required   by   the   Surgeon   shall  hold  office  for  a  term  of  four  years,
                  this title.                                             to  assure  the  correctness  and  verification      General  to  assure  proper   disbursement   of   except  that  any  member  appointed  to   fill   a
                  "(a)  The  term  'nonprofit'  as  applied  to  any      of such reports; and                                 and accounting for such Federal funds;            vacancy  prior  to  the  expiration  of  the   term
                  institution or  agency  means  an  institution  or      "(4) a satisfactory  showing  that  the  appli-      "(3) the  applicant  will  make  such  reports,   for   which   his   predecessor    was    appointed
                  agency  which  is  owned  and  operated   by   one      cant  has  designated  an  advisory  group,  to      in  such  form  and  Records  containing   such   shall   be   appointed   for   the   remainder   of
                  or  more  nonprofit   corporations   or   associa-      advise  the  applicant  (and  the  institutions      information  as   the   Surgeon   General   may   such  term,  and   except   that   the   terms   of
                  tions  no  part  of  the  net  earnings  of  which      and agencies  participating  in  the  resulting      from  time  to  time  reasonably  require,  and   office  of  the   members   first   taking   office
                  inures, or may  lawfully  inure,  to  the  benefit      regional  medical   program)   in   formulating      will keep such  records  and  afford  such  ac-   shall  expire,  as  designated   by   the   Surgeon
                  of any private shareholder or individual.               and  carrying  out  the  plan  for  the  estab-      cess  thereto  as  the  Surgeon   General   may   General  at  the  time  of  appointment,  four   at

                                                                                                                                                                                                                               123






              the end of the first year,  four  at  the  end  of   vanced  specialty  training  in  such  facilities,   "Section 1. Titles I to  IX,  inclusive,  of  this
              the second year,  and  four  at  the  end  of  the   as  he  deems  useful,   and   shall   make   such   Act may be  cited  as  the  'Public  Health  Serv-
              third year  after  the  date  of  appointment.  An   list or  lists  and  related  Information  readily   ice Act'."
              appointed  member  shall  not   be   eligible   to   available  to  licensed  practitioners  and  other   (b) The Act  of  July  1,  1944  (58  stat.  682).
              serve continuously for more than two terms.          persons  requiring  such   Information.   To   the   as  amended,  is   further   amended   by   renum-
              "(c)   Appointed   members   of    the    Council,   end  of  making  such  list  or  lists  and  other   bering  title  IX  (as  In  effect  prior  to  the
              while   attending    meetings    or    conferences   information  most  useful,  the   Surgeon   Gener.   enactment  of  this  Act)  as  title  X,  and   by
              thereof  or  otherwise  serving  on  business   of   al shall  from  time  to  time  consult  with  in-   renumbering   sections   901   through   914   (as
              the Council, shall be  entitled  to  receive  com-   terested national professional organizations.        in effect prior to the  enactment  of  this  Act),
              pensation  at  rates  fixed  by   the   Secretary,                                                        and   references   thereto,   as   sections   1001
              but  not  exceeding  $100   per   day,   including                       "Report                          through 1014, respectively.
              traveltime,  and  while  so  serving   away   from                                                        Approved October 6, 1965, 10:15 a.m.
              their  homes  or  regular   places   of   business   "Sec. 908. On or    before  June  30,  1967,   the
              they  may  be  allowed  travel  expenses,  includ-   Surgeon General,    after  consultation  with  the
              Ing per  them  In  lieu  of  subsistence,  as  au-   Council,  shall  submit  to  the   Secretary   for   LEGISLATIVE HISTORY:
              thorized  by  section  5  of  the   Administrative   transmission  to  the  President   and   then   to
              Expenses  Act  of  1946  (5  U.S.C.   73b-2)   for   the  Congress,  a   report   of   the   activities   HOUSE     REPORT     No.     963      accompanying
              persons   In   the    Government    service    em-   under  this  title  together  with  (1)  a  state-   H.  R.  3140  (Comm.  on  Interstate   &   Foreign
              ployed intermittently.                               ment   of   the   relationship   between   Federal   Commerce).
              "(d) The  Council  shall  advise  and  assist  the   financing  and  financing   from   other   sources   SENATE   REPORT   No.   368   (Comm.   on    Labor
              Surgeon General In the preparation of r         U'   of the  activities  undertaken  pursuant  to  this   & Public Welfare).
              lations for, and as  to  policy  matters  ari:igng   title, (2) an appraisal of the activities  assist-   CONGRESSIONAL    RECORD,    Vol.    111    (1965):
              with  respect  to,  the  administration  of   this   ed under this title In the light of  their  effec-        June  25: Considered in Senate.
              title. The Council  shall  consider  all  applica-   tiveness in carrying  out  the  purposes  of  this        June   28:   Considered   and   passed   Sen-
              tions  for  grants  under  this  title  and  shall   title,  and  (3)  recommendations   with   respect   ate.
              make   recommendations   to   the   Surgeon   Gen.   to extension or  modification  of  this  title  in        Sept. 23: H. R.  3140  considered  in  House.
              eral with  respect  to  approval  of  applications   the light thereof.                                        Sept.  24:  Considered  and   passed   House,
              for  and  the  amounts  of   grants   under   this                                                        amended, in lieu of H. R. 3140.
              title.                                                             "Records and Audit                          Sept.   29:   Senate   concurred   In   House
                               "Regulations                        "Sec.  909.  (a)  Each  recipient   of   a   grant   amendments.
                                                                   under  this  title  shall  keep  such  records  as
              "See.  906.  The  Surgeon  General,   after   con.   the  Surgeon  General   may   prescribe,   lnclud-
              sultatlon  with  the  Council,   shall   prescribe   Ing  records  which  fully  disclose  the   amount
              general  regulations  covering   the   terms   and   and  disposition  by   such   recipient   of   the
              conditions   for   approving   applications    for   proceeds of such grant,  the  total  cost  of  the
              grants  under  this  title  and  the   coordinatio2  project  or   undertaking   In   connection   with
              of  programs  assisted  under  this  title   witri   which  such  grant  is  made  or  used,  and   the
              programs  for  training,  research,   and   demon-   amount  of  that  portion  of  the  cost  of   the
              strations  relating  to  the  same  diseases   as-   project   or   undertaking   supplied   by   other
              sisted  or  authorized  under  other   titles   of   sources,  and  such  records  as  will  facilitate
              this Act or other Acts of Congress.                  an  effective  audit.
                "Information on Special Treatment and              "(b)   The   Secretary   of   Health,   Education,
                             Training Centers                      and  Welfare  and  the  Comptroller   General   of
                                                                   the United  States,  or  any  of  their  duly  au-
              "Sec.  907.  The  Surgeon  General  shall   estab-   thorized  representatives,   shall   have   access
              lish, and maintain on  a  current  basis,  a  list   for  the  purpose  of  audit  and  examination  to
              or  lists  of  facilities  in  the  United  States   any  books,   documents,   papers,   and   records
              equipped  and  staffed   to   provide   the   most   of the recipient of any  grant  under  this  title
              advanced   methods   and   techniques    In    the   which are pertinent to any such grant."
              diagnosis  and   treatment   of   heart   disease,
              cancer, or  stroke,  together  with  such  related   "Sec. 3.  (a)  Section  1  of  the  Public  Health
              information, including  the  availability  of  ad-   Service Act is amended to read as follows:


               124





           Appendix S-Regulations of Regional
                            Medical Programs

           March 18, 1967                                             (k)   "Geographic    area"    means    any    area    that    funds    will    not     supplant     funds     otherwise    funds   solely   for   the   purposes   for   which    the
                                                                      the    Surgeon     General     determines     forms     an    available   for    establishment    or    operation    of    grant   was   made,   as   set   forth    in    the    ap-
                                                                      economic   and    socially    related    region,    taking    the regional medical program.                                proved    application    and    award    statement.     In
           SUBPART E-GRANTS FOR REGIONAL                                                                                                                                                         the   event   any   part   of   the    amount    paid    a
           MEDICAL     PROGRAMS      I                                into    consideration    such    factors    as     present    (d)    Advisory    group;    establishment;     evidence.    grantee   is   found   by   the   Surgeon    General    to
                                              this    Subpart     E   and    future    population    trends     and     patterns    An  application   for   a   grant   under   section   903    have   been   expended   for   purposes    or    by    any
           Authority: The provisions of                               of   growth;   location   and    extent    of    transpor-    of  the  Act   shall   contain   or   be   supported   by    methods   contrary   to   the   Act,    the    regulations
           issued  under  sec.  215,  58      Stat.    690,    sec.   tation   and    communication    facilities    and    sys-    documentary     evidence     of     the     establishment    of  this   subpart,   or   contrary   to   any   condition
           906, 79 Stat. 930; 42 U.S.C.      216,   299f.    Inter.   tems;    presence    and    distribution     of     educe,    of   an   advisory   group   to   provide    advice    in
           pret  or  apply  secs.  900,   901,   902,   903,   904,   tional,    medical    and    health     facilities     and    formulating   and    carrying    out    the    establish-    to   the   award,   then   such   grantee,   upon    being
           905,  909,  79  Stat.   926,   927,   928,   929,   930,   programs,   and   other   activities    which    in    the    ment   and   operation   of   a   program.                   notified   of   such   finding,   and   in   addition   to
           42  U.S.C.  299,   299a,   299b,   299c,   299d,   299e,   opinion   of    the    Surgeon    General    are    appro-                                                                 any   other    requirement,    shall    pay    an    equal
                                                                                                                                    'k-e')    Advisory    group;     membership;     descrip-    amount    to    the    United    States@    Changes     in
           299i.                                                      priate  for   carrying   out   the   purposes   of   Title    tion.   The   application    or    supporting    material    grant   purposes    may    be    made    only    in    ac-
           0 54.401   Applicability.                                  ix                                                            shall   describe    the    selection    and    membership    cordance with procedur       es   established    by    the
           The   provisions    of    this    subpart    apply    to   0 54.403   Eligibility.                                       of    the    designated    advisory    group,     showing    Surgeon General.
           grants    for     planning,  establishment,          and   In order  to  be  eligible  for  a   grant,   the   appli-    the   extent   of   inclusion   in    such    group    of    lbl Ob      tion   of   funds.    No    funds    may    be
                                                                                                                                    practicing     physicians,     members      of      other             'iga
           operation   of.    regional    medical    programs    as   cant shall:                                                   health    professions,    medical    center    officials,    charged   against   the   grant    for    services    per,
           authorized  by   Title   IX   of   the   Public   Health                                                                                                                                          r    material    or    equipment    delivered,
           Service    Act,    as    amended    by    Public     Law   (a)   Meet   the   requirements   of   section   903    or    hospital     administrators,     representatives     from    formed      o
           89-239.                                                    904 of the Act;                                               appropriate      medical        societies,   volu   ntary    pursuant   to   a   contract    or    agreement    entered
                                                                      (b) Be located in a State;                                    agencies,    representatives    of    other     organiza-    into   by   the   applicant   prior   to   the   effective
           0 54.402       Definitions.                                (c)   Be   situated   within   a   geogIraphic   area    ap-  tions,    institutions     and     agencies     concerned    date of the grant.
           (a) All terms not defined herein         -shall      have  propriate   under   the   provisions    of    this    sub-    wit@  activities  of  the   kind   to   be   carried   on    (c) Inventions      or   discoveries.      Any       grant
           the meaning given them in the Act                          part   for   carrying   out   the    purposes    of    the    uncer    the    program,    and    members     of     the    award   hereunder   in    whole    or    in    part    for
           (b)   "Act"   means   the    Public    Health    Service                                                                 public   familiar   with   the   need   for   the   serv-    research  is   subject   to   the   regulations   of   the
           Act, as amended.                                           Act.                                                          ices   provided   under    the    program.                   Department    of    Health,    Education,     and     Wel-
           (c)  "Title  IX"  means   Title   IX   of   the   Public   0 54.404   Application.                                       (f) Construction;       purposes,        plans,        nd    fare  as  set  forth  in  Parts   6   and   8   of   Title
           Health Service Act, as amended.                                                                                          specifications; narrative      description..With      re-    45,   as   amended.    Such    regulations    shall    ap-
           (d)    "Related    diseases"    means     those     dis-   (a)  Forms.   An   application   for   a    grant    shall    soect  to  an  application   for   funds   to   be   used    ply   to   any   program   activity   for   which    grant
           eases    which    can    reasonably    be     considered   be   submitted    on    such    forms    and    in    @uch    In   whole   or   part   for   construction   as   defined   funds   are   in   fact   used    whether    within    the
           to  bear   a   direct   relationship   to   heart   dis-   manner    as    the    Surgeon    General     may     pre-    in   Title   IX,   the   applicant   shall   furnish   In    scope   of   the   program   as   approved    or    other-
           ease,  cancer,  or  stroke.                                scribe.                                                       sufficient   detail   plans   and    specifications    as    wise.    Appropriate    measures    shall     be     taken
                                                                      (b)   Execution.   The   application   shall    be    exe-    well   as   a   narrative   description,   to    indicate    by   the   grantee   and   by    the    Surgeon    General
           (a)  "Title  IX   diseases" means     heart     disease,   cuted   by   an   Individual   authorized   to   act   for    the   need,   nature,   and   purpose   of    the    pro-    to  assure   that   no    contracts,    assignments,    or
           cancer, stroke, and related diseases.                      the   applicant   and   to    assume    on    behalf    of    posed construction.                                          other     arrangements     inconsistent      with      the
           (f)    "Program"    means    the    regional     medical                                                                                                                              grant   obligation   are   continued   or   entered    in-
                                                                      the   applicant   all   of   the   obligations   specified    (g) Advisory group;      recommendation.      An      ap-    to   and   that   all   personnel    involved    in    the
           program  as   defined   in   section   902(a)   of   the   in   the   terms   and    conditions    of    the    grant
           Act,                                                                                                                     placation   for   a   grant   under   section   ?@4    of    supported   activity   are    aware    of    and    comply
                                                                      including    those    contained    in    these     regula-    .
                                                                                                                                    the  Act   shall   contain   or   be   supported   by   a    with   such   obligation.   Laboratory    notes,    relat-
           (g)   "Practicing   physician"    means    any    physi-   tions.                                                        copy   of   the    written    recommendation    of    the    ed    technical    data,    and    information    pertain-
           cian   licensed   to   practice    medicine    in    ac-   (c)   Description   of    program.    In    addition    to    advisory group.                                              ing     to     inventions     or     discoveries      made
           cordance    with    applicable    State     laws     and   any    other    pertinent     information     that     the                                                                 through    activities    supported    by    grant    funds
           currently   engaged   in   the   diagnosis   or   treat-   Surgeon    General    may    require,    the     applicant    0   54.405    Terms,    conditions,    and    assurances.    shall   be    maintained    for    such    periods,    and
           ment of patients.                                          shall   submit   a   description   of   the   program   In
           (h) "Major    repair"    Includes     restoration     of   sufficient    detail    to    clearly     Identify     the    In   addition   to   any   other    terms,    conditions,    filed   with    or    otherwise    made    available    to
           an existing building to a sound state.                     nature,   need,   purpose,   plan,    and    methods    of    and   assurances   required    by    law    or    Imposed    the   Surgeon   General   or   those   he    may    desig-
                                                                                                                                    by   the   Surgeon   General,   each   grant   shall   be    nate   at   such   times   and   In   such    manner    as
           (1) "Built-in   equipment"    is    equipment    affixed   the    program,    the    nature    and    functions    of                                                                             determine    necessary    to     carry     out
           to  the   facility   and   customarily    included    in   the    participating    institutions,    the    geographic    subject   to    the    following    terms,    conditions,    he      may
           the construction contract.                                 area   to   be   served,    the    cooperative    arrange-    and  assurances   to   be   furnished   by   the    gran-    such Department regulations.
           0)   "Advisory   group"   means   the    group    desig-   ments,   in   effect,   or    intended    to    be    made    tee.   The   Surgeon   General   may    at    any    time    (d)     Rep-orts.   The   grantee   shall    maintain    and
           nated   pursuant   to   section   903(b)(4)    of    the   effective,   within   the   group,    the    justification    approve   exceptions   where   he   finds    that    such    file   with   the   Surgeon   General    such    progress,
           Act.                                                       supported  by  a   budget   or   other   d@ta,   for   the    exceptions   are   not   inconsistent   with   the    Act    fiscal,   and    other    reports,    including    reports
                                                                      amount   of    the    funds    requested,    and    finan-    and   the   purposes   of   the   program.                   of   meetings   of    the    advisory    group    convened
             Subpart E added 1/18/67, 32 FR 571.                      cial   or   other   data    demonstrating    that    grant    (a)  Use  of  funds.   The   grantee   will   use   grant    before   and   after    award    of    a    grant    under
                                                                                                                                                                                                                                                     125





                 section  904  of  the  Act,  as   the   Surgeon   Gen-    ning  and  use  of facilities,   personnel,         and   no  person  in  the  United  States   shall,   on   the    tients  is   payable   from   grant   funds   only   to
                 eral may prescribe.                                       equipment, and training of manpower.                      ground  of  race,  color,  or   national   origin,   be    the  extent  that  such  care  is   incident   to   the
                 (a) Records   retention.     All         construction,    (d)  The  population  to   be   served   by   the   re-   excluded   from    participation    in,    be    denied    research,   training,    or    demonstration    activi-
                 financial,  and  other   records   relating   to   the    gional   medical   program   and    relationships    to   the  benefits  of,  or   be   subjected   to   discrim-    ties   supported   by   a   grant    hereunder.    Such
                 use  of  grant   funds   shall   be   retained   until    adjacent  or  other  regional  medical             pro-   ination   under   any   program   or    activity    re-    care  shall  be  incident  to  such   activities   only
                 the  grantee  has  received   written   @notice   that    grams.                                                    ceiving   Federal   financial    assistance.    Regula-    if   reasonably   associated    with    and    required
                   records    have    been     audited     unless     a                                                              tions    implementing    the    statute    have    been    for  the  effective   conduct   of   such   activities,
                 the                                                       (a)  The  extent  to   which   all   the   health   re-   issued  as  Part  80  of  Title  45,  Code  of   Feder-    and  no  such   care   shall   be   charged   to   such
                 different period is permitted or required           in    sources  of   the   region   have   been   taken   into   al   Regulations.    The    regional    medical    pro-    funds  unless  the   referral   of   the   patient   is
                 writing by the Surgeon General.                           consideration   in   the   planning    and/or    estab-   grams    provide    Federal    financial     assistance    documented  with   respect   to   the   name   of   the
                 (f)  Responsible  official.  The  official   designat-    lishment of the program.                                  subject  to  the  Civil  Rights  Act  and   the   regu-    practicing   physician   making   the   referral,   the
                 ed  in  the  application  as   responsible   for   the    (f)  The  extent  to  which   the   participating   in-   lations.  Each  grant  is   subject   to   the   condi-    name  of   the   patient,   the   date   of   referral,
                 coordination   of   the   program    shall    continue    stitutions  will   utilize   existing   resources   and   tion  that  the   grantee   shall   comply   with   the    and    any    other    relevant    information    which
                 to  be  -responsible  for   -the   duration   of   the    will   continue   to   seek    additional    nonfederal   requirements   of    Executive    Order    11246,    30    may be prescribed by the       Surgeon         General.
                 period   for    which    grant    funds    are    made    resources  for   carrying   out   the   objectives   of   F.R.  12319,  and   the   applicable   rules,   regula-    grant   funds   shall   not   be   charged   with   the
                 available.  The  grantee   shall   notify   the   Sur-    the regional medical program.                             tions,    and    procedures     prescribed     pursuant    cost of-
                 geon  General  immediately  if   such   official   be-                                                              thereto.                                                   (1)   Care   for   intercurrent   conditions    (except
                 comes   unavailable   to   discharge   this    respon-    (g)   The    geographic    distribution    of    grants
                 sibility.   The   Surgeon   General   may    terminate    throughout the Nation.                                                                                               of   an   emergency   nature   where   the    intercur-
                 the   grant   whenever   such   official   shall   be-                                                              0    54.409    Expenditures    by    grantee.              rent   condition   results   from    the    care    for
                 come   thus    unavailable    unless    the    grantee    0 54.407  Termination.                                    (a)  Allocation   of   costs.   The   grantee shall   al-  which   the   patient   was   admitted    for    treat-
                 replaces  such  offici   I   with   another   official                                                              locate   expenditures    as    between    direct    and    ment)   that    unduly    interrupt,    postpone,    or
                                                                           (a)    Termination    by    the    Surgeon     General.                                                              terminate the conduct of such activities.
                 found    by    the    Surgeon    General     to     be                                                              indirect   costs   in   accordance   with   "ner"'Y
                                                                           Any   grant   award   may   be   revoked   or    termi-                                               in,,  prac.    (2)  Inpatient  care  if   other   care   which   would
                 qualified.                                                nated  by  the  Surgeon  General   in   whole   or   in   accepted     and     established      account
                             Award.                                        part  at  any  time   whenever   he   finds   that   in   tices  or  as  otherwise   prescribed   by   the   Sur-    equally   effectively   further   the    purposes    of
                  54.406                                                   his  judiment the grantee  has        failed    in    a   geon General.                                              the   grant,   could   be   provided   at   a   smaller
                 Upon    recommendation    of    the    Nationa     Ad.    material    respect    to    comply    with    require-   (b)   Direct   costs   in   general.   Funds    granted    cost.
                                                               I
                 visory    Council    on    Regional    Medical    Pro-    ments  of  Title  IX  and  the  regulations   of   this   for   direct   costs   may   be   expended    by    the    (3)  Bed   and   board   for   inpatients   in   excess
                 grams,  and  within  the     limits  ot avail     able    subpart.    The    grantee    shall     be     promptly   grantee    for     personal     services,   rent"    of    of   the    cost    of    semiprivate    accommodations
                 funds, the Surgeon  General  shall        awa  rd    a    notified  of  such  finding  in   writing   and   given   space,   materials,    and    supplies,    and    other    niess   required   for   the   effective   conduct   of
                 grant   to    those    applicants    whose    approved    the reasons therefor.                                     items   of   necessary   cost   as    are req ui red  to   such   activities.   For   the    purpose    of    this
                                                                                                                                                                             'r  t              paragraph,         "semipwivate         accommodations"
                 programs   will   in   his   judgment   best   promote    (b)   Termination   by   the   grantee.    A    grantee   carry   out   the   purposes    of    the   an .    The    means   two-bed,   three-bed,    and    four-bed    ac-
                 the  purposes  of  Title  IX.  In   awarding   grants,    may   at   any   time   terminate   or    cancel    its   Surgeon    General    may    issue     ruIes'   instruc-       modations.
                 the  Surgeon   General   shall   take   into   consid-    conduct   of   an   approved   project   by   notifying   tions,   interpretations,   or   limitations    supple.    corn
                 eration,   among   other   relevant    factors,    the    the  Surgeon   General   in   writing   setting   forth   menting   the   regulations   of   this   subpart   and    0 54.410   Payments.
                 following:                                                the reasons for such termination.                         prescribing   the   extent    to    which    particular
                 (a)  Generally,  the  extent   to   which   the   pro-                                                              types   of   expenditures    may    be    charged    to    The   Surgeon   General    shall,    from    time    to
                 posed   program   will   carry   out,   through    re.    (c)   Accounting.    Upon    any    termination,    the   grant funds.                                               time,  make  payments  to   a   grantee   of   all   or
                 giona      peration,  the  purposes   of   Title   IX,    grantee   shall   account    for    all    expenditures   (c) Direct   costs;   persona                              a  portion  of  any  grant   award,   either   in   ad-
                      I coo                                                and  obligations   charged   to   grant   funds:   Pro-                                    I    services.     The    vance   or   by   way   of   reimbursement   for    ex-
                 within  a   geographic   area.                            vided,  That  to  the   extent   the   termination   is   costs   of   personal   services   are   payable   from    penses   to   be   incurred   or   incurred   to    the
                 lb)  The  capacity  of  the  institutions   or   agen-    due  in   the   judgment   of   the   Surgeon   General   grant  funds  substantially      in    proportion    to    extent   he    determines    such    payments    neces-
                 cies   within   the    program,    Individually    and    to  no  fault  of  the   grantee,   credit   shall   be   the time or effort the ind      ividual   devotes    to    sary  to  carry  out  the  purposes   of   the   grant.
                 collectively,  for    research,    training,       and    allowed    r  the  amount   required   to   settle   at   carrying   out   the   purpose   of   the   grant.   In
                 demonstration activities     with  respect  to   Title    costs   defmoonstrated   by    evidence    satisfactory   such   proportion,   such   costs   may   include   611    0   54.411   Different   use    or    transfer;    good
                 IX.                                                       to    the    Surgeon    General    to    be     minimum   direct  costs   incident   to   such   services,   such    cause for other use.
                                                                           settlement   costs,    any    noncancellable    obliga-   as   salary    during    vacations    and    retirement    (a)  Compliance  by  grantees.   If,   at   any   time,
                 (c) The  extent  to  which   the   applicant   or   the   tions  incurred  prior  to   receipt   of   notice   of   and  workmen's  compensation            charges,.In        the    Surgeon    General    determines    that     the
                 participants  in   the   program   plan   to   coordi'    termination.                                              accordance   with   the   policies    and    accounting                                                          are
                 nate  or   have   coordinated   the   regional   medi-                                                              practices   consistently   applied   by   the   grantee    eligibility  requirements  for  a  program
                 cal   program   with   other   activities    supported                                                              to all its activities.                                     no  longer  met,  or  that  any  facility   or   equip-
                 pursuant   to   the   authority   contained   in   the    0 54.408      Nondiscrimination.                                                                                     ment    the    construction    or    procurement     of
                 Public  Health  Service  Act   and   other   Acts   of    Section  601  of  Title  VI   of   the   Civil   Rights   (d)  Direct  costs;  care   of   patients.   The   cost    which  was  charged   to   grant   funds   is,   during
                 Congress   including   those   relating    to    plan-    Act  of  1964,   42   U.S.C.   2000d,   provides   that   of   hospital,   medical   or   other   care   of   pa-    its  useful  life,  no  longer  being  used   for   the

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                 purposes  for  which   it   was   constructed   or   a  footnote  acknowledging  assistance  from   the
                 pr  cured either by  the  grantee  or  any  trans-   Public  Health  Service,   and   indicating   that
                 feroee,  the  Government  shall  have  the   right   findings  and   conclusions   do   not   represent
                 to recover its proportionate  share  of  the  val-   the views of the Service.
                 ue  of  the  facility  or  equipment  from  either
                 the grantee or  the  transferee  or  any  institu-   0 54.413  Copyrights.
                 tion that  is  using  the  facility  or  equipment   Whpr!  the  grant-supported  activity  results  in
                 The Government's proportionate share           hali
                 be  the   amount   bearing   the   same    ratio to  copyrightable material,  the  author  is  free  to
                 the  then  value  of  the  facility  or  equipme      opyr'ght,  but  the  Public  Health  Service  re-
                                                                nt,   ce      a  royalty-free,  nonexclusive,  irrevoca-
                                                                      ., e@
                 as  determined  by  the  Surgeon   Gener   1,   as   ble license for use of such material.
                 the  amount  the  Federal  participation  bare  to
                 the cost of construction or procurement.                54.414    Interest.
                 (b) Different  use  or   transfer;   notification.
                 The  grantee  shall  promptly  notify   the   Sur-   Interest  or   other   income   earned   on   pay-
                 geon  General  in  writing  if  at  any  time  dur-  ments  under  this  subpart  shall  be   paid   to
                 ing its  useful  life  the  facility  or  equipm ant th!  @nited  States  as  such  interest   is   re-
                 for construction  or procurement of          which   ceivea by the grantee.
                 grant funds  were  charged  is  no  longer  to  be
                 used for  the  purposes  for  which  it  was  con-
                 structed or  procured  or  is  sold  or  otherwise
                 transferred.
                 (c)   Forgiveness.   The   Surgeon   General   may
                 for  good  cause  release  the  grantee  or  other
                 owner   from   the   requirement   of    continued
                 eligibility  or  from  the  obligation   of   con-
                 tinued  use  of  the  facility  or  equipment  for
                 the  grant  purposes4   In   determining   whether
                 good   cause   exists,   the    Surgeon    General
                 shall  take  into   consideration,   among   other
                 factors, the extent to which-
                 (1) The facility  or  equipment  will  be  devoted
                 to   research,   training,   demonstrations,    or
                 other activities related to Title  IX  diseases.
                 (2)  The  circumstances  calling  for  a  c   ange
                 in the use of the  facility  were  not  known,  or
                 with   reasonable   diligence   could   not   have
                 been known  to  the  applicant,  at  the  time  of
                 the  application,  and  are   circumstances   rea-
                 sonably  beyond  the  control  of  the   applicant
                 or other owner.
                 (3)   There   are   reasonable   assurances   that
                 other facilities not previously utilized  for  Ti-
                 tle IX  purposes  will  be  so  utilized  and  are
                 substantially  the  equivalent   in   nature   and
                 extent for such purposes.
                 0 54.412     Publications.                                                                                                                           U.S. GOVERNMIENT PRINTING OFFICE: 1067@ 166-753
                 Grantees  may  publish   materials   relating   to
                 their  regional  medical  program  without   prior
                 review  provided  that  such  publications   carry

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