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             Roy Uttlejohn Associates, Inc.
             WASHINGTON  ATLANTA   CHICAGO  HARRISBURG

















                         The Regional Medical Program Service's

                                   Urban Health Program:








                                       An assessment

                                       performed for


                          The Regional Medical Program Service,

                                  Public Health Service,

                              Health Resources Administration










        Prepared by:                          Principal authors:
        Roy Littlejohn Associates, Inc.       John A. Mitchell, M.D., California  RMP
        1335 Green-Court, N.W.                Henry Wood, New Jersey  RMP
        Washington, D.C.  20005               Marlene Checel, California  RMP
        November      1973                    Madeline Thoma, New Jersey  RMP





                                                                                               gc.










         800 PEACHTREE ST., N. E.
                SUI'RE 604                                                                                               1346 N. BROAD ST.
         ATLANTA. GEORGIA 30308                                                                                          LADELPHIA, PA. 19121
              (404) 874-3815                                                                                         PHI   (215) 978-6086




                    Regional Medical Program Service
                    Public Health Service
                    Health Resources Administration

                    Gentlemen:

                             Roy Littlejohn Associates is pleased to submit this
                    report in accordance with our contract no. HSM 110-72-249.
                             It is our hope that this document will be of real
                    assistance to your organization as it discharges its
                    multi-faceted responsibilities.

                                                                         Respectfully,



                                                                        Roy Littlejohn Associates









                                    Table of Contents


                                                                          @e
             Letter of transmittal

             Acknowledgements . . . . . . . . . . . . . . . . . . . .  .  .

             Introduction and Summary. ;  . . . . . . ... . . . . . .  .  .

             Chapter    I.  Reflections and Conclusions  . . . . . . . .  .  8,

             Chapter    II. Social Legislation and the Sixties . . .   .  .17
             Chapter   III. The History of Regional Medical Programs   .  .24
             Chapter    IV. Record Review . . . . . . . . . . . . . .  .  .37
             Chapter     V. Site Visits . . . . . . . . . . . . . . .  .  .47



             Appendix











                                  ACKNOWLEDGEMENTS



               The authors of this report are happy to have had the opportunity

          to study the efforts of RMP to deal with urban Health problems and

          hope they have done it justice. We would like to  express  gratitude

          to a number of persons who were key to this project effort.

               First of all we wish to thank Harold Margulies, M.D. and

          Cleveland R. Chambliss who authorized and supported the entire

          Urban Health activity. We would also like to express our  very  deep

          appreciation to the Coordinator of the California Regional Medical

          Program, Mr. Paul D. Ward, and to Alvin A. Florin, M.D., the  Co-

          ordinator of the New Jersey Regional Medical Program, who  cheer-

          fully accepted the absence of several of their employees for many

          weeks during the record review, the site visits, and the preparation

          of this report.

               We would also like to thank the Coordinators of the  various

          Regional Medical Programs for their courtesy in meeting with us

          and for their help in arranging our site visits.  Special  thanks

          should also.go to those program staff members who had already been

          terminated due to the RMP phaseout process but who returned to  talk

          with us about the ways in which they helped put together the programs

          within their Regions.  The list of people deserving recognition seems

          endless; certainly it should include the Coordinators and program

          staff members who served onthe Urban Health Task Force with us

          and helped with the planning of the proposed conference, as well  as

          the RMPS members who gave their invaluable advice  and-assistance

          in formulating the program, procuring records, and, in general,

          helping us to feel comfortable in the Parklawn Building.

                                          i





                 Finally our thanks should be expressed to Ken Mcissner, who wrote cer-
             tain sections of the.report and was responsible for overall editing, and
             to Mr. Roy Littlejohn and his associates, the contractors for this pro-
             ject, who graciously and patiently arranged the endless meetings and travel,
             provided us with technical assistance and adv.ice, and were finally res-
             ponsible for the completion of this report.
                Last but not least, Dr. Mitchell would like to express.personal thanks
             to his secretary, Ruth Wightman, who coordinated, typed, and edited for
             weeks on end.







                               INTRODUCTION AND SUMMARY

                         GENESIS OF THE URBAN HEALTH PROJECT

             "In some areas of New York . . . there is one private doctor
        for every 200 persons, but in other areas the ratio is one to 12,000.
        Chicago's inner-city neighborhoods have some  1700  fewer  physicians
        today than they had ten years ago." With those  words  the  President
        of the United States on February 18, 1971, proposed that as part
        of a new "National Health Strategy" concentrated  efforts  should  be
        focused on meeting the special health care needs of scarcity areas--
        rural and urban.
             In developing tactics to implement the new National Health Strategy,
        it was essential then and is essential now that we have  hard  facts,
        not about the scope of the problem--there is no need to further
        document the shortcomings of inner-city health care services--but
        about the methods of implementation:  Which have been effective,
        which have not, and under what circumstances? Unless  we  learn  from
        our earlier-efforts--successful and unsuccessful--we run the risk  of
        repeating the errors the President pointed-out in earlier programs of
        fireenforcing inequities and rewarding inefficiencies and placing the
        burden of greater new demands on the same old system which could  not
        meet the old ones."

            Among the various agencies established in the mid-19608  to  deal
        with pressing social programot the RMPsl the Regional Medical Programs,
        *Ksout initials: Throughout this paper there will  be  references  to
        RMP, RMPS, and RMPS. Short of renaming the agencies  involved,  there
        seems to be no way around this, alphabet soup confusion. To  set  the
        record straight, here is how we will use these  abbreviations:  RMP--
        Regional Medical Program (this may refer to the overall-program or
        to the local agency for a particular region such as the Georgia RMP);
        Rmps--a collective reference to the local Regional Medical Program
        agencies; RMPS--Regional Medical Program Servide, the division within
        the Department of Health, Education and Welfare responsible  for  ad-
        ministration of the overall program and for maintaining contact  with
        the local RMP agencies.






       are unique.  Within an all-encompassing structure which covered the
       entire nation as well as certain U.S. possessions, fifty-six Regional
       Programs were established with function-oriented boundaries defined
       by groups of local health care providers.  (In many, but not all cases,
       these groups were established for the express purpose of planning and
       setting up Regional Medical Programs for their areas.)  The purpose of
       this report is to document and help sharpen the RMP focus on Urban

       health problems.
            Within a broadly-defined set of goals established by  federal
       enabling legislation, and within a more specific framework defined
       in keeping with the goals of successive administrations, the  RMPs
       set out to improve the quality and availability of American health
       care. Predictably, there have been marked differences in  the  way
       people connected with RMP in various localities perceived and went
       about accomplishing their mission.  There have been dramatic successes
       as well as failures. Nor is it surprising in a program  marked  by
       experimentation and decentralization that many of the successes have
       been characterized by serendipity.  Thus, it was decided that RMPS,
       in dealing with urban health problems, should take stock, find out
       what had@worked, and document the special skills and  competencies
       developed within individual regions.














                                         -2-






           Among the events which spurred this project was the initial RMP

      response to the Administration's urban initiative.  In 1971, the Regions
      were asked to devote $1.8 million to Model Cities-related  projects.
      This figure did not represent new, earmarked funds, however.  The funds

      had to come from within the framework of existing Regional  Program
      budgets. In many cases, this resulted in post-hoc  planning;  local

      staffs looked back on what they had already been doing to see  which

      projects, with perhaps a slight shift of emphasis, could be  classed

      as "Model Cities-related."

           In response to the Administration's initiative and to  related

      concerns, Dr. Harold Margulies, Director of the Regional  Medical

      Programs Service within HEW, asked Mr. Cleveland R. Chambliss,  RMPS

      Director of the Division of operations and Development, to let a contract

      to evaluate and recommend changes in the RMPs' urban health care efforts.

      To assist in planning this project, an Advisory Committee on  Urban

      Health was established. The initial appointees were  Henry  Wood,

      Director of Urban Health Planning, New Jersey RMP; John Hall, Ph.D.,

      Director of Urban Health, Ohio State RMP; Teresita Moreno, Assistant

      Coordinator, Area V, California RMP; and John A. Mitchell,  M.D.,

      Deputy Director-of the California RMP.

           As the members of the Urban Health Task-Force discussed the problem

      at the first planning session, held in February, 1972, it became clear

      that the RMPs were doing well in certain areas where concerned program

      staff members had addressed various aspects of the problem.  They

      proposed that a way be found to tap the experience and  expertise

      these staff members had developed and to make this information avail-

      able to all the RMPS.



                                       -3-






          At a second meeting, on March 16, 1972, the Urban Health Task
    Force members drew up the initial contract for this project.  Under
    that contract, a two-day national meeting on urban health methodologies
    was to be held through which persons with the  appropriate  background,
    particularly staff members  from various RMPs who had been uniquely
    successful in dealing with some aspects of urban health concerns,
    would share their knowledge with a group of 200  participants  composed
    largely of RMP coordinators, Regional Advisory Group  (RAG)  chairmen,
    staff members responsible for urban health planning,for  the  fifty-six
    RMPS, and selected RMPS and DHEW regional office representatives.
         This national meeting was to be followed by four two-day regional
    workshops in the Northeast, South Central, Mid-Continent,  and  Western
    areas of the United States for a group of sixty participants  at  each
    conference, including RMP representatives, selected  governmental  and
    local civic officials, community representatives,  representatives  of
    concerned state and city agencies, and provider-organization represent-
    atives.  In each case the contractor was to prepare a report on the
    meetings, evaluate their impact, provide technical  assistance,  carry
    out follow-up studies, and submit a final evaluation of the entire

    project with conclusions and recommendations for action and future

    activities.

         A minority-owned firm, Roy Littlejohn Associates, was then located

    through the Small Business Administration and chosen as  contractor  in
    accord with Section 8 (a) of the Small Business Act.  After the original
    Urban Health Task Force was expanded to include various RMP staff members,
    preparations for the first conference, to be held in October 19 72, began.
    However in the course of preparations for this conference,  t  became
    evident that certain communications and coordination difficulties


                                     -4-





        would have to be dealt with.  It was also felt that the RMP Coordinators
        should have been consulted in the selection of Urban Health Task Force

        members.

             In order to deal with these problems, the National Conference was
        postponed from October 1972 to May 1973 with the Regional Conferences
        to be held sometime during the-summer of 1973.  In the meantime, the,
        HZW desk officers and representatives chosen by five regional consortia
        of RMP Coordinators were brought into the planning process.
             At that point, as the project was well underway, it was announced-
        that RMP was to be phased out by June 30, 1973.  In the wake of this
        announcement the National Conference on Urban Health was cancelled.
             Due to the imminent phase-out and the fact that many key personnel
        had already begun to shift to other positions, it appeared quixotic at
        best to hold the conferences.  However, in the course of preparations
        for the conference, it had become clear that the varied experience of
        the RMPS, and especially of certain RMP program staff members, repre-
        se.nted a wealth of useful, and sometimes unique, knowledge.
             Therefore it was decided that the project should continue but that
        the emphasis should shift to documentation of the experience of the RMPs
        with urban health problems.  The fruit of that shift in emphasis is
        this report on the experience and involvement of the RMPs with urban
        health problems.


                                      SUMMARY


            The report begins with chapter one, presenting the reflections of
        the Urban health task force members on the information and data gathered
        together with some of the conclusions to be drawn from these data.
        And since RMP was-just-,@!pne of many social-change programs of the early

                                        -5-






        and mid-1960m, Chapter two outlines some of the major historical  forces

        that helped to shape the response of Congress and the Executive  Branch

        to a broad spectrum of problems. Brief descriptions of some  of  the

        key programs and agencies of the 160s are then given to convey  some

        idea of the-milieu in which RMP was established and began to  mature.

              Chapter three is an in-depth historical survey of RMP,  beginning

        with an analysis of the original enabling legislation and of  several

        statutory extensions. RMP's initial mandate was to make  the  fruits

        of biomedical research on certain diseases more readily available  to

        everyone. As the program evolved, however, Congress made  several  sub-

        stantial changes in the statutes which established it.  Eventually,  RMP

        was charged by law with enhancing the quality and availability of primary

        care with particular emphasis on upgrading health services for residents

        of service-scarcity areas.  These goals were to be achieved by fostering

        voluntary regional linkages among health care providers.

              In chapter four data on the activities of all of the  Regions,

        especially as they relate to the development of medical care  services

        in medically underserved areas, are presented and reviewed. Due  to  the

        staggered reporting cycle and to the way the RMPS renewal  application

        forms were structured, valid cross-comparisons were  difficult.  However

        certain trends were discernible. The regions were shifting  their  focus

        toward the development of services in scarcity areas.  Staffing patterns

        were changing to include more minority group professionals and  others

        who were trained in health systems development. Similarly,  there  was

        a trend in the funding of RMP projects away from a few massive,  cate-

        gorical-disease focused projects toward primary health care  projects

        which were of shorter duration and often included matching funds  from

        local governments and community groups. Many of these  were  seed-money


                                          -6-





       grants designed to develop viable projects which could obtain permanent
       funding elsewhere.

             In chapter five, key information gathered by Urban Health Task
       Force members in the course of site visits to a representative sample
       of Regions is presented.'  To some extent, the trends mentioned above
       were also evident in the course of the visits.  As had been suspected,
       the activities of program staff members were discovered to be rather
       different from what might be expected after a simple review of renewal
       applications submitted by various Regions.  A key staff function in most
       of the Regions was to serve as a "skills bank" for local groups in deal-
       ing with the types of problems that fell within the ambit of each Region's
       stated purposes and priorities.  Certain common qualities of successful
       staff members were also identified.  While it was apparent that then*
       skills were, to some degree transferable, more study is needed to develop
       ways to facilitate the development of these qualities in other present
       or potential staff members.
             Finally, a detailed examination.of the methodology employed in
       this study is presented in appendix A.
















                                        -7-














                                            CHAPTER I

                                   REFLECTIONS AND CONCLUSIONS



                   The members of the Urban Health Task Force who prepared this report
              agree that while t'be purpose of the original contract to hold Urban Health
              Conferences was valid, the approach was too narrowly focused.  In this
              Immense country, cultural, social,. economic and geographi-c-'t;onsiderations
              make a tight focus on Urban Health completely inappropriate.  On the other
              hand, the systematic development of medical care resources for those who are
              medically underserved is an Important function which has been carried out
              by many of the RMPs very successf ully.  The.methods used to perform this
              function tend to be very similar although the strategies and tactics pursued
              by each RMP are based on its own determination of the local social and poli-
              tical climate.  Much of this activity goes unreported for various reasons.
              One commonly encountered attitude was that the Regional Medical Program had
              to maintain a ''low profile."  Other program staff felt that efforts to deal
              with the health problems of underserved populations would meet with oppo-
              sition from various groups--Congress, the Administration, organized medicine,
              hospital associations, voluntary health associations, and other unnamed
              groups.  A few felt that this type of activity went beyond the mandate of
              RMP's 'enabling legislation.
                  The  flexibility    some of the programs demonstrated was quite
              impressive.  In several of the regions the ability of the program staff to
              respond to the needs of the commun lty was evident.  The term community is
              used advisedly In this context.  Extensive discussions have gone on around

                                              -8-






              the "search for the community."  For purposes of this report It was felt

              that a number of communities were involved with RMP activities.  There

              were medical provider communities, poverty  communities, and communities

              of Interest in medical affairs developed around specific needs  or  evolved
              through a Comprehensive Health Planning agency. In many  cases,  the  medi-

              cally-underserved community was not a community which could  be  considered

              economically deprived.  Suburbia, exurbia, and sprawling rural farming

              communities also need new medical manpower,-medical  facilities,  regional-

              lzation ofservices, and, particularly, improvement in the- quality of

              available medical care. RMPs have addressed these  fssues.on  many  occasions

              and have been highly successful in meeting these needs.
                  Still the problems of the impoverished,,the sociologically  -and  culturally
              deprived, and the alienated, particularly attracted the attention of  the  Urban

              Health Task Force.  Some of the RMPs undertook to deal with problems in com-

              munities which included isolated Indian tribes living In the mountains and

              inner cities, Mexican-Americans, Puerto Ricans, Cubans, Port.uguese, and  others
              with language difficulties In addition to other  poverty-related  problems.
              Those RMPs which accepted this challenge early and found it difficult to

              Identify leaders and build credibility with community groups now  find  them-
              selves besieged by community groups who have learned that RMP Is a key
              local resource with technical skills accessible to local groups.
                   The skills developed by these RMPs are certainly not  new.  They  come

              from a variety of sources--universities, other federal programs,  schools  of

              public health, and the direct experience of people born In the communities

              they now serve through RMP. These skills typically involve the  use  of  screen-

              Ing and survey techniques, and training of community health V=kers who

              ordinarily do the actual screening or survey field work.  RMPs  have  learned




                to design a program or project to fit the needs of a specific community and
                to find ways to fund the se activities.  In the. sophisticated RMPS, however,
                this Is only the beginning of involvement with the community.  Incorporation
                of community corporations, training of  community  boards,  installation  of

                administrative and management systems,  and  program  evaluation  ordinarily

                continue even though the project may be funded with non-RMP dollars.  The

                RMPs have been extremely successful In helping  communities  recruit  well-.

                qualified professional staff for community programs.  Colleges of Medicine,

                other university resources, county medical societies, voluntary health

                agencies, and the RMP staff Itself have frequently been the source for

                managers and operators of medical care projects in poverty communities.     In

                at least two cases, care In free clinics Is  provided  by  the  professional

                staff of Army Medical Reserve units.

                   The Regional Advisory Groups provide substantial input, information,
                and occasional technical support for many of these activities.  Comprising a

                wide variety of skilled professionals,  university  scientists  and  admini-

                strators, community practitioners, allied health professionals,.and repre-

                sentatives of the public, the Regional Advisory Groups provide not only

                technical skills but mature political and social judgment.  Although many

                of the Regional Advisory Group membership lists appear to lean toward

                categorical disease.prograrm, this is not necessarily true.  In many cases

                the Regional Advisory Groups had quickly identified the need for assisting

                the underserved populations of the regions  before  the  President's  health
                message and the statutory changes which enco uraged Regional  Medical Programs

                to move in that direction.

                    The aspect of RMP which attracted many  of  the  program  staff,  people

                who are involved In community health activities, as well as Begional Advisory




                                                 -10-






             Group members who are also concerned with this type of activity, was the
             opportunity to provide small amounts of money in a short  period  of  time  to
             begin activities rapidly after needs have  been  identified.  Thus  RMPs  were
             often able to help local government agencies move in new directions when
             local tax support could not provide for  health  care  services  developmental
             research.  Also, through  RMP- local community groups could be'helped in
             organizing and seeking funds from private or-public sources.
                 The academic background of persons employed by the various RMPs in
             community health activities was examined and as stated previously these
             backgrounds were varied.  There seems to be little  relationship  between  the
             academic preparation they had received and the skills they  were  applying  in
             problem solving.  All of them, however, seemed to have  a  thorough  knowledge
             of the local and national health scenes, health agencies, health legislation
             and, above all, to have good, sound business and  management  skills.  All  of
             them were community organizers although we were unable to identify anyone
             who had received academic training as a community organizer.
                Obviously these skills are, to  some degree, transferable since in many
             cases a single staff member who had been extremely  successful  in  developing
             new community health programs for underserved populations became the
             leader of a number of people who extended the successful activities to other
             parts of the region.  This generally involved somewhat informal on-the-job
             training.
                 An attempt was made to try to Isolate specific methods and tech.niques
             used by programs and staff members in developing and implementing RMP efforts
             to improve health care for the under'served which might be taught formally in
             an established educational institution. For the most part,  thi-s  effort  was







              Programs are generally linked to public or private hospitals p   roviding

              excellent patient linkages between primary care and secondary and ter-

              tiary services.

                   In some regions careful  attention  Is paid to financing methods so

              that RMP projects rapidly become self-sufficient  and  the  Regional  Medical

              Program is able to reinvest  resources in other problems.  A  review  of  the
              funding history of the RMPs  indicates a definite tendency to move from fund-
              Ing a few large projects for  prolonged periods toward  funding  many  projects

              at a much lower cost for  shorter  periods.

                  One poorly  documented  but  apparently valuable function of many of the
              RMPs was to bring together  fragmented  and disjointed  categorical   programs

              Into a rational system of primary care.   In several regions  this  was  done

              through a committee of project directors  for Maternal and.Infant Care,
              Children and Youth, Family  Planning.and  health  education  projects.  These
              led to cooperative 'rather than competing efforts,  reorganization  of  charts,
              centralization of records,and avoidance of duplication of effort.  These

              projects were also instrumental in developing useful   patient Information and
              referral systems, training health aides to provide comprehensive patient

              services, and, in some cases, providing "one-stop" services.    There  is  some
              Indication that the success of such efforts  has  encouraged  the  institutions

              Involved to rationalize other patient care services.

                  Currently the organization and delivery of medical care services is
              being strongly Influenced on several fronts.  Three  specific  aspects  of  the
              changes which have occurred are clearly related to the influence some of the

              RMPs have had on the delivery system:


                                                -13-





                  The mass migration of large population grou:)s from  farms  into-
                  Incorporated communities has recuired  a  reorganization  of  the
                  medical care delivery system.  According to the 1970 census, almost
                  60% of the population of the United States  lived  in  or  near  248

                  lourbanized areas" occupying 1% of the total land area.  The Bureau
                  of the Census defines an "urbanized area" as a place with a popu-
                  lation of 50,000 or more in a  contiguous,  closely  built-up  area.
                  At  the same time the remaining farm population has tended to cluster

                  around smaller towns and villages  instead  of  remaining  scattered
                  across the land.  Rural blacks and In-migrating ethnic populations
                  have occupied much of the inner cities giving birth to new centers
                  of population and a bewildering array  of  overlapping  political

                  jurisdictions.

             2.   The iripact of new scientific and engineering knc&-iledge on rmd-icine

                  has had much less influence on the health  care  available  to  dis-

                  advantaged population grouos than has  generally  been  realized.
                  The.gap between the best care available and that which is usually
                  provided is wider now than It ever was.  Little  has  been  done  to

                  upgrade the quality of services available  in  the  inner-cities  or
                  In the disadvantaged small towns and villages of our country.
                  The distribution of primary care providers has continued to worsen
                  and only experimental programs have been carried out to improve the
                  distribution of these vitally needed services.  Inner-city hospitals
                  have become old and available'services are deteriorating.  Many
                  rural hospitals built thro.ugh the Hill-Burton  Program  are  under-
                  utilized and poorly situated.








                     Changes in the-financing of medical care have aggravated these
                     problems.  With the majority of the population, including the poor,
                     having third-party coverage to pay for some or most of their

                     medical care, there has been a substantial increase in demands on

                     the system for more-and better care.  And as more fed-eral dollars

                     are committed to the purchase of health care, there is an in-
                     creasing need to assess and upgrade the quality of'the care

                     provided.  Increased demands which will soon be placed on the

                     delivery system by some form of national health insurance  are

                     almost sure to overwhelm that system and cause a decrease in

                     quality and a increase in the cost of care.

                  Some of the RMPs have made well-organized attempts to provide solutions

             to these problems.  The decentralized operation of these RMPs has mobilized
             knowledgeable people within communities to solve local health care problem s,
             while the same structure has served to promote regionalization of services
             on a logical basis when appropriate.  Diverse strategies and tactics have
             been developed to secure support from local, regional, state, and national

             power centers.  This has often required a long-range commitment on the
             part of the leaders of the programs.

                  In some Regions there Is no evide nce of organized efforts to address
             these Issues in health care.  In others there were only token efforts.
             There Is some evidence that commitments made at the federal level have

             produced movement at the regional level.  Job descriptions with titles such as'
             Urban Health Coordinator and Coordinator for Community Health SerVices appear
             much more frequently In recent applications, and programmatic-approaches to
             to the development of primary health care services for the underserved have






          been developed In several Regions.

              The collective experience of the RMPs substantiates a  conclusion  which
          many had reached individually--that the strongest and most  universally  ex-
          pressed need among the disadvantaged, both urban and rural is for compre-
          hensive primary medical care.;  Historically public health clinics, pub-
          lic hospitals, and "welfare medicine" have gained a reputation-for being
          second-rate, fragmented, and degrading for the people forced to use them.
              Many of the RMPs have learned to assist communities In  developing  high
          quality ambulatory health services with the dignity and convenience  of  the
          patient a high priority.  Users are not sorted out by disease category or
          ability to pay.  In most cases these gains have been achieved by building on
          and expanding already available services and facilities rather than by estab-
          lishing new health facilities.  These programs are deliberately aimed toward
          self sufficiency through carefully designed accounting and billing  systems.
             Through a broad-spectrum approach to the problems  encountered, the  RMPs
          have been proving that excellent comprehensive medical care can be made
          available to.large numbers of disadvantaged individuals and  families.  This
          can be done in ways which reflect the dignity and humanity of the people
          served and without unduly disrupting traditional fee-for-service solo or

          group medical practice patterns.











                                               CHAPTER II

                                 SOCIAL LEGISLATION AND THE SIXTIES



                    The Regional Medical Program was created and has  matured  as one part
               of a major change in federal policy and should be seen  in  proper perspec7
               tive as part of a complex matrix of  social-change  programs.  The 1960s
               was an era of rapid, almost breathtaking, social  change.  It  was an age of
               secular and Institutional messiahs, of Marshall McLuhan and of Esalen--

               salvation through media or massage. By the end  of  the  decade  one
               widely read author, Alvin Toffler, echoi ng the early Greeks, proclaimed
               that the only thing modern man could be sure of was that he could not be
               sure of anything--only change, at an ever-accelerating rate--was certain.
               Toffler even gave a name to the syndrome of fears, anxiety, and malad-

               justment that resulted:  Future Shock.

                    One of the byproducts of the age was a sometimes-bewildering array of
               new agencies designed to nurture and moderate social change.  Although  a  des-
               cription of the details of these programs is beyond the scope of  this  report,
               it should be noted that the unifying principle of these ambitious  social  pro-
               grams, which seemed to echo the New Deal of t-he 1930s, was a resurgent popu-
               lism. Born in an era of optimism amid the trappings  of  a,latter-day  Camelot,
               this movement reached a peak in the mid 160s. Civil  disobedience  and  passive
               resistance were the hallmark of a civil rights movement which  seemed  destined
               to prevail.  As Ghandi had before him, Dr. Martin Luther King called upon
               his fellow countrymen to remake an entire society not under the threat of
               overwhelming power but because it was the just thing to do.  As the decade


                                               -17-






      drew to a close, Dr. King, who had, for many, become the voice of Americals
      conscience, was silenced by an assassin's bullet--the third of the four
      great leaders of the decade to die in this manner (John Kennedy and Medgar
      Evers preceeded him, and Robert Kennedy followed him.)  Dr. King had lived
      long enough, however, to see sorrow turn to anger, frustration, and rage.
            In August 1965, Watts went up in flames sparking an era of violent,
      confrontation.  Television, the electronic wonder of an earlier age,
      made violence a commonplace sight in every American home:  The Southeast
      Asian War, the riots in Newark, the Democratic Convention of 1968, the
      riots in Detroit, Soviet Tanks trampling on the gentle revolution in
      Czechoslovakia, the campaigns against "crime in the streets," the American
      people witnessed and seemed bewildered by all of these events.  Symbolic
      of the changes which marked the 160s was the euphoric, dramatic hope
      embodied by Woodstock and the bloodstained denouement at Altamont--both
      captured on film and preserved in technicolor.
           In the midst of all this, a "war on poverty" was declared.  "For
      the first time in our history," said Lyndon B. Johnson, "it is possible
      to conquer poverty.  We have the power to strike away the barriers to
      full participation in our society.  Having the power, we have the duty."
      And thus a generation of social acfion programs and agencies, each with
      a more-or-less direct or indirect effect on health, was born.
           The Economic Opportunity Act of.1964 resulted in a, number of "anti
      poverty" programs including Community Action Programs, the Job Corps, Volun-
      teers in Service to America, Work Training Programs, and a program to help
      students from poor families work their way through college.  To indicate
      strong presidential support, the agency for the poverty war was lodged in
      the executive office and a new, independent bureaucracy was created.







                                                                        By the and of

               January 1966, more than 900 grants had been made for the establishment

               or planning of Community Action Programs including programs  for  the  fifty

               largest cities in the country. In line with this  local  participation  and

               community action approach,-the Office of Health Affairs had  begun  to  de-

               velop the Neighborhood Health Centers concept which has had  a  profound  and

               lasting effect on the development of health care services for the poor.

               New ethnic professionals appeared.  Veteran  minority  group  professionals

               achieved greater visibility. Poor whites found that  they  had  a  powerful

               voice and, when appropriate, allied themselves with  other  leaders  of  the

               poverty community, crossing what had once seemed to  be  Impenetrable  racial

               barriers as they did so.

                    A prominent element in the downward  social and economic spiral  in  the

               large cities,which seemed to bar progress  on many fronts while  fostering  a

               raft of new problemsswas the lack of decent housing. In  order  to  mount  a

               program on an unprecedented scale to help city  agencies  demolish,  build,

               or refurbish local living units, the Department of Housing  and  Urban  De-
               velopment (HUD) was created to administer Federal spending and  to  en-sure

               compliance with Federal guidelines.
                  The Demonstration Cities and Metropolitan   Development Act (Model Cities)
               was intended to enable cities to use  resources already  available  through

               programs designed to help people help themselves.  Most  large  cities  had

               deteriorating central districts crowded with poor  people--people  who  were

               poor in many ways: economically, educationally, nutritionally--the list

               seems endless.

                    The Model Cities Program carried civic renewal a giant-step    forward

               by requiring that local community representatives be Involved in    setting


                                                  -19-






             goals and. priorities and in helping to administer local projects.  These
             requirements were given substance by requirements that other federally
             funded programs operating in the community--including RMP operational pro-
             jects--file certificates of Model City relatedness with a sign-off by Model

             Cities officials.

                  For men and women previously 16cked into welfare subsistence or  low
             paying, dead-end menial jobs, Manpower and Job Training Programs were ini-
             tiated. New skills could be learned through employment  with  cooperating
             firms which provided classroom education in basic skills such as  reading
             and arithmetic along with on-the-job training for vocational skill develop-
             ment.  Supplemental payroll funds were provided by the federal government
             to offset the anticipated reduced productivity of these "apprentices."
             Other programs included New Careers, which supplied training and opportunities
             for entry to such fields as nursing and library assistance, and Operation
             Mainstream to help previously "unemployable" people support themselves with

             simple jobs.

                 The idealistic energies of young adults were, to someextent, harnessed
             through the Volunteers In Service To America (VISTA) program, sometimes

             described as a "domestic peace corps."  VISTA volunteers fostered com-
             munity development and attempted to encourage disadvantaged people to draw

             upon resources which were available but not well publicized.  Their  work

             was more successful In southern and rural regions than in the metropolitan

             ghettos.

                 Some of the Great Society programs were directly connected with health.
             The two most prominent were, of course, Medicare and Medicaid, Titles XVIII
             and XIX of the Social Security Act.  In addition to changing Ihe perspective
             on health care (to that of a basic human right rather than a privilege), these
             programs Introduced a new actor-on the urban health care scene, the Social

                                              -20-





         Security Administration.  In seeking to inform older citizens of their rights
         under the new law, and especially to encourage participation in Part 8 of
         Medicare, the optional coverage for outpatient treatment prov'ided at a nomi-
         nal cost, the Medicare Alert program was instituted.  Through this program,
         senior citizens were hired and sent out to visit with and Inform others
         about the program and to encourage eligible citizens to enroll.  This double
         benefit approach, which in providing benefits for a target group also pro-
         vides meaningful employment for unemployed or underemployed members of that
         group, was a pattern followed successfully in many other programs including
         some of the RMPs which provided training for "community health aidei" in the
         course of programs such as the Mobile Multiphasic Screening Project Instituted
         by one of the Eastern industrial state RMPS.

              Medicaid has been successful In some ways, disappointing In others.  The
         facts that this program is administered and funded on a state-by-state basis
         and that the target population is somewhat unstable, with Individuals gain-
         Ing and losing eligibility as the economy fluctuates, have led to the dis-
         couraging paradox of a program which is often grossly underfunded while cer-
         tain Individuals manage to abuse the system and rake off substantial sums

         of money.'

             One other Significant aspect of the Medicare a'nd Medicaid programs has
         been the role of third-party payers, especially Btue Cross and Blue Shield.
         Partly because the medical community was apprehensive of a large-scale
         federal bureaucracy concerned with health care, partly because the federal
         government had neither the time, nor the resources, nor sufficient skilled
         manpower to.staff such a bureaucracy, partly because the large third-party
         payers have a good deal of political 'I cl-Out," the actual day-to-day administra-
         tion of the Medicare and Medicaid programs was left to various third-party
         payer organizations operating-under contract with'the

                                                 -21-






              Social Security administration.

                   This pattern, preserving a major role for  organizations  such  as  Blue

              Cross and Blue Shield in attempts at dealing with  nationwide  health  pro-
              grams, remains an important element of many current  National  Health  pro-

              posals including the "National Health Insurance Standards Act" and the
              "Family Health Insurance Plan" proposed by President Nixon on February 18,

              1971.

                   One other health-related program,  the Partnership  for  Health  Program
              (Public Law 89-749), deserves mention.  With its enactment in November, 1966,
              the stage was set for Comprehensive Health Planning to be implemented for both
              public and private sectors at the state, area,'and  local  levels.  This  plan-
              ning effort was to Include a  majority  of health consumers, defined by   the
              Surgeon General as those who  "live  where the problems are."
                 Section  314(a) of the Act made grants  available to each of the    states
              for Comprehensive Health Planning.  In order to qualify for these     grants,
              each State had to designate a  single  age ncy to administer the planning pro-
              cess and submit a "plan for comprehensive health planning" for approval

              by HEW.
                   Section 314(b) provides grants for public  or  nonprofit,private  agencies
              or organizations to develop comprehensive regional or  local  health  planning;
              to develop and revise areawide health-plans; and to coordinate existing and

              planned health services, manpower, and facilities.

                   In keeping with the concept of "partnership for  health,"  large  num-
              bers of provider and consumer groups were Involved in  the  development  of

              state and areawide plans for health.  These  plans  evaluate  current  health

              programs in view of current and future health needs  and  make  recommendations

              for improvements;  additionally,  they establish state and areawide priorities.


                                                 -22-









                                    CHAPTER III


                     THE HISTORY OF REGIONAL MEDICAL PROGRAMS



            The role of the RMPs in general, and particularly with respect to
      urban health, has been shaped by a complex history of legislation,
      Administration directives, and departmental regulations.  In 1965 the

      federal government set out to ensure that research on heart  disease,

      cancer, and stroke would pay off in measurably improved health  care

      services.  A presidential commission headed by a well-known Texan,

      Houston's Dr. Michael E. De Bakey, came to the conclusion that to  a
      substantial degree, medical research in these areas had not paid  off
      in better health care for everyone.  The fruits of this research were
      simply not being translated into new, more effective procedures  standard
      throughout the health care delivery system. To meet this  problem  an
      amendment to the Public Health Service Act [42 USC, Ch. 6A] was passed

      by Congress and approved by the President. This legislation,  "The  Heart
      Disease, Cancer, and Stroke Amendments of 196511 [P.L. 89-239], authorized

      what has come to be known as RMP, the Regional Medical  Program.  The

      Program--programs actually, for some fifty-six regional bodies  were

      established--has a number of characteristics that testify to the

      realities (perhaps the genius) of the-American political process.

            First of all this new network of agencies, although based on federal

      legislation, was to develop from the bottom up through the initiative

      of local groups. This feature reflected the fear of many,  especially  of

      health care professionals, that the'program might turn into  a.huge,

      centralized, and stultifying federal bureaucracy. To quiet  these  fears,

      the law was deliberately vague as to structure and contours, referring



                                       -24-






      simply to "regional cooperative arrangements among medical schools,
      research institutions, and hospitals for research and training (including
      continuing education) and for related demonstrations of patient care

      in the field of heart disease, cancer, stroke, and related  diseases."

      Health care professionals were invited to define viable  regions--with
      boundaries that made sense in terms of efficient functioning--not neces-
      sarily based on state or political subdivision borders.  The  resulting
      structure emphasized voluntary cooperation and decentralized  decision

      making. In view of this, it is not surprising that the RM?s  have  been

      strikingly successful in bringing together representatives of  various

      groups and helping them organize and institute joint endeavors to

      improve the quality, availability and accessibility of health care
      services.  Bringing these groups together has been not only a prime
      mission for all RMPs but a precondition for the organization, approval,

      and funding of each RMP.

           At its inception, RMP had a well-defined function:  to help the pro-
      viders of health care in "making available to their patients the latest ad-

      vances in . . '. diagnosis and treatment," and a specific focus:  heart

      disease, cancer, stroke, and related diseases.  There were, in ad-  -

      dition, certain key restrictions:  RMP was not--to underwrite the provision

      of services to individuals except as an incident to research, training,

      or demonstration activities and even then, only upon the referral of  a

      practicing physician.

            In addition, RMPs were to accomplish their mission without "interfering

      with the patterns, or the methods of financing, of patient care or profes-

      sional practice, or with the administration of hospitals."

           On October 15, 1968 (three and a half months after the expiration

      date of the original legislation) a two-year extension was enacted

                                        25-





   -[P.L. 90-5741.  While the original law had authorized appropriations of
    up to $200,000,000 for the fiscal year ending June 30, 1968, less than
    one-third that amount, $65,000,000, was authorized for the period ending
    June 30, 1969, and $120,000,000 through June 1970.  Aside from these
    drastic cuts in proposed funding, the first RMP extension law made only
    minor substantive changes:  1% of appropriations could be set aside for
    evaluations.  Where appropriate, services could be provided for patients'
    referred by a practicing dentist (but, as before, only in connection with
    research, training, and demonstration activities).  Federal hospitals
    were to participate.  Also, coverage was extended to the District of
    Columbia (which had a program effective as early as January 1, 1967--
    apparently without explicit legislative authority), and to Puerto Rico
    and other U.S. possessions.  Finally, multi-program grants, for services
    to two or more regions, were to be permitted.
          The life of the Program was once more extended, this time for three
    years, on October 30, 1970.  As before, the second extension [P.L. 91-5151,
    was enacted four months after the expiration date under previous legislation.
    Authorized appropriations for the first year were only $5,000,000 more
    than for the period ending June 30, 1970.  But by the third year of the
    extention, the fiscal year ending June 1973, the maximum permissible
    appropriation was to double, to a quarter of a-billion dollars.
         Along with this expanded funding,-the new law called for significant'
    expansion in RMP's responsibilities, both  categorical and functional.
    The new categorical authority extended RMP's focus to include kidney
    disease.  In addition, certain noncategorical responsibilities were added.
    Chief among these were "to strengthen and improve primary care and the
    relationship between specialized and primary care;" and "to improve health
    services for persons residing in areas with limited health services."


                                    -26-




            Regionalism which had begun as a compromise approach, emerged as a
      major program strength and almost an end in itself.  The De Bakey report
      and the initial legislative proposals had called for a network of regional
      centers for research as well as diagnosis and treatment stations.  Some
      existing facilities were to be included in this network, but many would
      be newly built.  In August 1965, five AMA representatives met with the
      President and the Secretary of HEW.  The bill's provisions,, the President
      was told, were "jeopardizing AMA's attempts to work with the Secretary of
      HEW . . . relating to the medicare law."  And so, the regional centers and
      stations were discarded.  The final enacted version, as mentioned above,
      contained only vague references to encouraging and assisting in  "the
      establishment of regional cooperative arrangements . . . 11  But the RMPs had
      been so successful in building programs based on such voluntary,  co-
      operative arrangements, and these collaborations had been so fruitful,
      that the 1970 legislation, in providing for RMP to take responsibility
      for strengthening and improving primary care, specified that this was
      to be done by promoting and fostering "regional linkages among health care
      institutions and providers."
            In addition to an expanded categorical focus and new, noncategorical
      goals, RMP was asked to promote prevention and  rehabilitation.  (The
      original mandate had referred only to diagnosis and treatment.)  RMP's
      responsibility for generally improving available health manpower  and
      facilities was tied to more specific-aims--upgrading quality and enhancing
      capacity.  And, as mentioned previously, RMP was given another new, non-
      categorical assignment--"to improve health services for persons residing
      in areas with limited health services."
            In mid-1973, as the second legislative extension was about to expire,
      RMP stood accused of losing sight of its purpose, exceeding its authority,


                                       -27-






        I
     and failing to develop a consistent unified  approach.  Faced  with  extinc-
     tion, RMP was extended for one more year. Ironically,  this  was  the  first
     time the progriam's operating authorization was extended  before  the  expi-
     ration of enabling legislation for the previous period.
           obviously the 1970 renewal, P.L. 91-515, in addition to extending
     RMPis authorization, provided a much wider scope and broader range of
     purposes.  What may be less obvious (but no less true) is that these
     changes, like the inclusion of authorization for the  District  of  Columbia
     in the first RMP renewal law, were largely  an  after-the-fact  ratification
     of things which had already been done.  In examining the development of
     these broadly-based activities, two intertwined threads may be traced.
     First, pressure from below: from the start many  RMP  staff  members  looked
     at their mandate as authorizing a wide range of activities designed to
     extend the highest quality health care to everyone, especially to those
     who, by circumstance, had not had access to health care on a par with
     other members of society--the isolated, rural poor and the alienated,
     inner-city poor.  Second, there were, from the start, pressures from above,
     from Administration spokesmen and from ranking HEW officials, seeking to
     have regional groups interpret their mission in the  light  of  then-current
     Administration policy.
           Two strategies began to emerge.  One, was for RMP to provide services
     rather than funds. At the end of 1968,- RMP was still largely in  the  plan-
     ning phase. In connection with the process of  pulling  providers  together,
     defining appropriate regional boundaries, establishing  patterns  of  organ-
     ization, and framing and following through on coherent  requests  for  plan-
     ning funds, RMP staff members had begun to build up a reservoir of vital
     skills--concrete knowhow about getting things done within the complex
     matrix of social and political customs, structures, and organizations


                                      -28-





       that surround the U.S. health care system.  These skills, as they
       developed, made it possible for RMP to provide a broad spectrum of sup-
       port on a number of levels.  By assigning staff members to work with
       representatives of other agencies and of community groups, the RMPs  made
       substantial contributions to programs such as neighborhood health centers.
             The second strategy emerged as the regions began to look once  more
       at the legislation establishing the program. With a  more-or-less  expan-
       sive reading of the specific functional and categorical purposes specified
       in the enabling legislation, it was possible to find all sorts of overlaps
       between the mission of RMP and the nationwide priorities established
       through the political process.  For example, from its inception, RMP
       was involved in health manpower training. This was seen as one  of  the
       keys to translating new knowledge into improved care. In  carrying  out
       this part of its mission, RMP soon became involved in providing job
       training for people who had previously had few, if any marketable skills.
       Also, RMP was involved in helping to define and establish a number of

       new allied health professions. These development activities  often  could
       be, and sometimes were, designed to build on the skills of people already
       employed in the system at lower, less rewarding levels.  In some cases,

       new career ladders were evolved.  New opportunities for advancement
       could be opened for people who had been stuck in previously "dead  end"
       positions.  And since these programs-were directly relevant to RMP's
       stated purpose, they were eligible for sponsorship and funding through RMP.
             In a similar manner, another facet of RMP's purpose  emerged.  From
       the outset, RMP was concerned with the fact that new medical  knowledge
       was not being reflected in widely available improved health care.  At first
       this was seen as basically a matter of communications.  Available knowledge

       was not being widely disseminated.  As it turned out, communication was

                                        -29-






        I
     only part of the problem. The reason many people were not  benefitting

   -from the fruits of biomedical research was that they had limited access

     to health care of any kind. Title XIX of the Social Security Act  (Medi-

     caid) was designed to help many of these people, but funding tended to be

     inadequate and coverage was often spotty--in many states the "working poor"

     were excluded, for example.  Further, it was discovered that funding alone

     was not enough. Often, there were no available  facilities.  Sometimes

     when the government became a 'third-party payer" the facilities that had

     been available all along remained the only sources of medical care.

     People who had always had to put up with impersonal, inefficient hospital

     outpatient clinics still had to look to these clinics.  But now a new

     layer of red tape had been added--an up-to-date, valid Medicaid card was

     required.  In order for members of certain groups to benefit from ad-

     vances in the treatment of heart disease, cancer, and stroke, new ways

     of providing health care in general had to be established. Thus,  well

     before the legislative mandate embodied in P.L. 91-515 (the second RMP

     extension law), many Regions were involved, in a number of ways, in

     strengthening and improving primary care.

          On February 18, 1971, President Nixon delivered a message to Congress
     describing a "new National Health Strategy that [Would] marshall a variety

     of forces in a coordinated assault on a variety of problems." The  new

     strategy was to be built on four basic principles: (1) assuring  equal

     access; (2) balancing supply and demand; (3) organizing  for  efficiency

     by emphasizing health maintenance and preserving cost consciousness; and

     (4) building on strengths--structuring incentives to help rationalize

     the existing system and reorient it toward common goals without sacrificing

     the diversity which characterized the system and made it strong.



                                     -.30-






            Based on these four principles, the President pronosed a six-point
       program which would          begin with measures designed to increase
       and improve the supply of medical care and conclude with a program
       which Cwould] help people pay for the care they require."

            On March 24, 1971, the RMP Coordinators, at a meeting in Atlanta,
       Georgia, unanimously adopted a position paper outlining ei gh'L. key

       aspects of the programs proposed by the President in which they felt

       RMPs should play an important role:



       111.  Health Maintenance Organizations


            RMPs provide the best and most economical way in which a federally

            supported health program can furnish immediate assistance to

            organizations and institutions, both urban and rural, interested

            in developing HMOs and other innovative systems of  health  care

            delivery.  The RMPs' advantageous relationship with private

            physicians and community hospitals will be a key factor  in  the

            successful development of su ch systems."



        2.  Demonstration and promotion of new techniques for improving the

            efficiency and effectiveness of health care


            RMPs have already become deeply involved in such demonstrations.

            They have one of the best records in promoting these  new  tech-
            nique's to the practicing professionals and community  hospitals

            as well as implementing them in the teaching programs of the

            medical schools.




                                         -31-






                  For example, new techniques for screening and early diagnosis
                  and patient and family education for promoting community
                  prevention of disease have been demonstrated by many RMPs.11
                  The establishment of a series of new Area Health  Education  Centers

                  as recommended by the Carnegie,Commission on Higher Education
                  Regionalization has been the hallmark of RMP from its inception.
                  The cooperative arrangements developed between the  medical  schools
                  and key community hospitals and other groups by RMPi'c:onstitute  an
                  impressive start in the implementation of Area Health Education

                  Centers."

             114. The Emergency Health Personnel Act
                  This act has important implications for innovative ways of solving the
                  health care crisis in rural as well as urban ghetto areas  and  other
                  problems such as health care for migrant workers.  However,  the  act
                  does not explicitly provide for supervision of the personnel assigned
                  to these areas. The RMP Coordinators propose an  important  role  for
                  RMPs in the implementation of this act, particularly in the cooperative
                  arrangements with nearby health facilities and with the area medical
                  schools to assure proper supervision and adequate  consultation  for

                  the assignees.11

                  Meeting the health manpower crisis

                  There exists already a severe shortage of nearly every  type of health
                  manpower.  The demand inevitably will mount rapidly in  the event  of
                  national health insurance.  The RMPs' accomplishments in the recruit-

                  imnt, training, and development of new skills in the health care
                  fields have been conspicuous.  These, as well as innovative approaches

                                               32







                 to training physician assistants, and   improving medical communication

                 and transportation, are in urgent need of support and expansion."
            116. Accessibility of health care

                 RMP has as a major goal the improvement  of  accessibility  to  health

                 care. Examples of  RMP-supported  activities  are  regionalization  of

                 emergency medical services  expansion of urban and rural primary
                                             31

                 care, and extension of rehabilitation   ind other specialized

                 services."

                 The accomplishments of RMPs in categorical diseases contribute

                 directly to improvements in the total health care   system.  The

                 important role of RMP in the improvement of  quality  of  care  should

                 not be overlooked.  For example, work of the Inter-Society

                 Commission on Heart Diseases, funded by an RMP contract, established

                 quality standards.  Local RMPs are'assisting the providers in

                 meeting these standards."

            118.  Finally, the RIlPs have encouraged and supported Comprehensive Health
                 Planning Agencies at both state and areawide levels.. They have stimu-

                 lated the organization of many B agencies, and have effected several

                 CHP-RMP mergers.   Recognizing the complementary roles  of  these  two

                 programs in the improvement of h ealth care-, Regional Medical Programs

                 will continue this close collaboration with CHP."

                 About three months later, on June 30, 1971, Dr. Vernon   E. Wilson

            HSMHA Administrator, issued a seven-page document, the Statement of

            Eurpose for Regional Medical Programs., to specify what RMPs are, what
            their evolving mission had become, and the basis on  which  they  would  be
            judged by HEW evaluators.  Specifically, it was stated the "RMF-is a


                                              -33






           framework or organization within which all providers can come together
           to meet health needs that cannot be met  by  individual  practitioners,
           professionals, hospitals, and other institutions acting alone.  It
           Is also a structure deliberately designed to take  Into  account  local

           resources, patterns of  practice  and referrals, and needs.  As such

           It is a potentially'import'ant  force for bringing about and -assisti. ng
           with changes in the provision 'of personal -health services an d  care."

           Three of the programs' unique characteristics were described:
           Ill.  RMP is primarily linked to and works through providers, especially

               practici ng health professionals; this means the private sector

               la rge I y.

           112.  RMP is essentially a voluntary approach drawing heavily upon

               existing health resources."

           "3.  Though RMP continues to have a categorical emphasis, to be

               effective that emphasis frequently must be subsumed within or made

               subservient to broader and more comprehensive approaches."*
               This document went on to itemize RMP's specific mission and
           objectives, principally to:
           111.  Promote and demonstrate among p@oviders at the local  level  both
               new techniques and innovative   delivery patterns for improving the

               accessibility, efficiency, and effectiveness of health care.  At

               this time the latter would include,-for example, encouraging
               provider acceptance of and extending resources supportive of,

               Health Maintenance Organizations."
           112.  Stimulate and support those activities that will-both help existing

           *This third statement is quite significant.   This is one of the -first HEW-
           prepared documents specifically referrina to the need for a broad construc-
           tion of the enabling legislation's categorical purpose provisions.

                                            '-'34






           health manpower to provide more and better care and will result

           in the more effective utilization of new kinds  (or  combinations)

           ,of health manpower. Further, to do this in a way that  will  insure

           that professional, scientific, and technical activities of all

           kinds (e.g. information -training) do indeed lead to  professional
           growth and development and are appropriately placed within the

           context of medical practice and the community.  At this time
           emphasis will be on activities which most effectively and im-
           mediately lead to provision of care in urban and rural areas

           presently underserved."


      "3.  Encourage providers to accept, and enable them to initiate, region-
           alization of health facilities, manpower, and other  resources  so

           that  more appropriate and better care will be accessible and avail-

           able at the local and regional levels.  In fields where there are

           marked scarcities of resources such as  kidney  disease,  particular

           stress will be placed on regionalization so that the cost of such

           care may be moderated."


      "4.  Identify or assist to develop and facilitate the  implementation  of

           new and specific mechanisms that provide quality control and improved

           standards of care. Such quality guidelines  and  performance  review

           mechanisms will be required especially in relation to new  and  more

           effective comprehensive systems of health services."


           During 1972 and early 1973, the RMPs began to invest their energies

      and develop expertise in the organization and implementation  of  emer-

      gency medical services.  These efforts were quite consonant with the

      emphasis on urban health care since it was in the scarcity areas--both






   -Urban and rural--that emergency services were so essential, so often
    overburdened, and so much in need of upgrading. In fact, as  the  RMPs
    began to deal with EMS programs, it became evident that many of the
    problems faced and skills needed were the same whether in an  isolated
    rural area or in an underserved, inner-city ghetto.  As a result, it
    was seen that the Urban Health Project would have a far more,widespread
    impact than had originally been projected.
         This is the background against which the announcement came that  RMP
    was to be phased out of existence within a ma tter of  months.  Despite
    the fact that the program was, in fact, extended for another year, through
    June 1974, the future remains uncertain.  As a result, many projects
    have already been phased out, key personnel have been terminated or
    have left on their own initiative in many areas, and long-range  planning
    has been severely disrupted. However, as the Urban Health  Task  Force
    discovered, in the course of its site visits, a wide range of projects
    had been initiated and/or supported by RMP staff members and RMP funds,
    and as late as mid-1973 many of these projects were still going strong.
    To supplement the information gathered in the course of the site  visits,
    which would only cover a representative sampling of the Regions,  various

    sources of information were examined, and information on the nature

    and extent of each Region's involvement-with urban health was  extracted.
















                                     -36-










                                            CHAPTER IV


                                           RECORD REVIEW



                    Upon review of the data compiled from each Region's most recent renewal
               application and related  doc-uments, I.t was evident that each 'region had, in
               fact, developed along independent lines. The resulting diversity  was  lmz
               pressive.  Because each region had developed Its own staffi6g pattern, and
               because of variations in the types of grantee and composition of RAGS, there
               were significant differences in the characteristics of the applications and
               progress reports submitted to the Regional Medical Program Service.  At-
               tempts to make valid cross comparisons were complicated by differences  in
               the status of the regions, the periods for which progress reports were ren-
               dered, and the different stages of development of the regions.  Two regions--
               Ohio and Delaware--could not be evaluated at all because of recent changes

               in status.

                   The,stated objectives of the regions were examined in order to determine
               each regi.on's intentions with regard to the development of medical care ser-
               vices in medically underserved areas, both urban and rural.  Because of
               lack of consistency in statements of objectives and priority ranking,  the
               Task Force used the technique of placing all of the objectives into  three
               groups. A high priority was assigned to any objective statement  that  was
               listed in the top one third of the objectives; a medium priority to  those
               where the statement fell into the middle one-third of the objectives; or a
               low priority where the objective statement was among the last one-third of
               the objectives.

                   Fifty-four applications were reviewed, and Improvement  of services to



                                               -37-




               medically underserv*d areas was a stated objective In fifty-one. Thirty-
               three regions listed it as a high priority; nine, as a medium priority; four,
               as a low priority; and five regions listed this objective but did not dif-
               forentiate between objectives as to priority. Three regions failed to men-
               tion medically underserved areas In their objective statements (see Figure                       1).

                                                     FiGtmz I
                                                  SITE V'ISIT TEAM
                                          Urban Health Task Yorce - Rmps
                                           Objectives of 54 RMPS Regarding
                                Medical Care Services in Medically Undersorved @as
                                                    SPRIM 1973









                                                                         Priority not
                    NO   6%








                  Yes
                   94%                                                     High
                                                                           Priority
                                                                             65%





              radical Care Services                                    Priority
              To Medically @erserve%l                                   Rating
              A.reas a-- an Fe-tP
              Progra.,,i Objective


               The Task Force then examined the operational projects                          which had been

        funded during the period studied. Using the project ob                           jectives statements,

        the projects were assigned to one of two groups--thost whose objectives
        appeared substantially to emphasize improvement of medical care for an
        underserved population group and those which did not describe this as a
        stated objective. These data were then analyzed to associate the objec-

        tives set by each region with actual dollar allocations. Some very strong

        trends were evident. Useful data were obtained for fifty-three of the

        regions. Twenty-two of the regions committed up to 25% of their opera-
        tional-project dollars to madical'care for the underserved. Another

                                                        -38-





           twenty-two regions allocated between 26% and 50% of their operational
           dollars to such projects, and eight regions committed between 51% and
           75% of its operational funds in the manner (see Figure II



                                                                  FIGURE 11
                                                               SITE V74:rT T-@,4
                                                                 TM T,.SK FORCE - P-,:pS
                                                     r=Tl= ALLOC:@10,; OF @3    P-:PS'FOR
                                               OPERA=O.@ PR              -M To Z=:rCAr
                                                       FOR TECE M=!=-@y --_nrpZZRV=I)
                                                                        .19;,3
                           100


                           45


                           40



                       t7i 35

                       p
                       :il
                       2   30
                       t')              22                 22
                           25
                       to


                           20
                       tw
                       0




                           lo

                                                                           8 R.-Ts




                           0
                                                       26                                  ove E. 7

                                    Percentage of fords allocated to 0
                                                                                    projects related to
                                    radical care for the redicallv L,nder5arved.





                  As the applications were reviewed, it became apparent that three very
          specific techniques were employed by most of the regions in dealing with
          medical problems of the underserved. Many of the operational projects
          contained.more than one of these elements; however in order to categorize
          the projects for statistical purposes, the Task Force agreed on three
          general methods or categories which could be considered the primary purpose

                                                             -39-





    -of each project. These were: development of primary medical care
       services, training of new types of health manpower, and consumer health
       education. During the study period, 272 funded operational projects were
       identified. Of these# 172 wave aimed at the development of primary medical
       care services including emergency medical services; 64 dealt with training
       of new types of health manpower specifically to provide health care for
       the underservod; and.36 dealt.with-consumer health education (86* pi,gu!:e


                                                   I ri n nr Xxx
                                                BITZ V:ESIT TEOLK
                                       URBAN BMTH TASX rORCZ - RMI?S
                                     )LTIO'44 OF 272 RMP OF@TXONAL P       S
                                       FOR nM MM:RCALLY UIMERSERVEF)
                                          BY TY3PE OF kWOR ACTMTY
                                                 WJUNC; 1973





                    Consumer Health Education










                                        n                   63%
                                        v                 Access to
                                                       Hedical Ca










                                    PAjort TYPE-- O!- OPEq;%TIO-t.NL ACTJVIT@




              As the applications were examined                 it became obvious          that the region
       had used different methods of allocating money for specific:%operational
       activities. It seemed useful, therefore, to look at the percentage of
       dollars allocated by each region to program staff and to operational activ-
       ities and to examine the extremes in order to determine who-ther or not
       there actually was a diffsrance in the operational activities conducted by

                                                       -40-




          the various regions.  The percentage of total grant awards allocated tu
          operational activities as a proportion of  total  dollars  awarded  to  the
          region varied from a.low of 109 to a high of 82%.  The mean was 54%.
                 Developmental Component funds had been instituted to provide mature
          regions with discretionary funds, so that they might respond more rapidly
          to new initiatives in keeping with local priorities.  Twenty-three regions
          were identified as having been authorized to use this method.  Of these,
          seven regions provided enough information in their applications for
          analysis.  Most of the other regions had not been authorized to use a                                 -
          Developmental Component for long enough to have reported activities.
                 Ninety-five Developmental Component activities were identified, fifty-
          five of which were clearly related to medical  care  for  the  underserved.
          IL"hese projects were categorized as follows:  thirty-six  involved  access
          to viedical care, twelve related to consumer health  education,  and  seven
          to tew manpower development (see Figure IV).-,----


                                                    FIGURE  IV
                                                 SITE VISIT TEI--'4
                                         TMBAN  H@TH  TASK  FO AC=  -  R.@
                                95 DEVELOP@@i.AL CO.'-Lt'0!4EIir OFE.@LlOtZAL ACTIVITIES
                              ]?ERCEL,4TAGE RELATED TO tt-;DICA.L CA.7-.E OF TiiE  @EitsERVEO
                                            BY TYPE OF F.AJOR AC--IVITY
                                                   SPRING 1973




                                                                       13% Ne-vt @power
                                                                       @elopment
                                                                       22% Consumer
                                                                       @ea).t;h Education


                           42Y.            589                            ACCO38 to
                         Other       @ical care                        ft4ical care
                                     the underiserved






                      Developmntal Comp*nenL                         Ty" of Major. Xctivity
                       Operating Activities


                                                        -41-






   -It appears that Developmental Component funds were being used to comply
     with new program directions.

         Next the most easily measured method of utilizing program staff dollars
     to move in new directions was examined.  This was the data on page 11 of
     each application under the title, "Core-Supported Feasibility and  Planning
     Studies,"  Applications from each region were reviewed to determine how
     different RMPs used this method of allocating funds or program  staff,time-
     to achieve their objectives.  Usable data were obtained from fifty-four

     applications.

         Obviously, there were vast differences between the regions in their
     interpretations of the term, feasibility and planning studies.  This

     made it difficult to find similarities which could be classified and
     recorded.  For purposes of this report, the total number of feasibility and
     planning studies and the funds committed to such efforts were recorded.

     (In the course of doing so it was noted that the amounts recorded on RMPS
     Form 8 of each renewal application under Core Activity Summary for Feasibility
     and Planning Studies seldom agreed with.the amounts recorded on the descrip-
     tions of activities. The funds recorded here are compiled from  the  totals

     reported on RMPS Form 11.)  In addition, the number of activities and

     total funds apparently committed by each Region to improving medical

     services for the underserved were recorded.  T-hose activities  were  further

     broken down into the three categories:  New Health Manpo@ert Consumer
     Health Education, and Development of Primary Health Care Services.
         The n @ er of feasibility and planning studies varied from zero in six
     regions to a high of 104 in one region,  Expenditures, among the regions
     that reported such activities, ranged from $200 to $387,820 in one year.
     No valid statistical analysis was possible since program years (r @ rting
     periods) varied from ten to twenty-seven monthal furtheri, there was no


                                     -42-






           consistent definition of terms or method of utilization, and the regions
           vary in size and population; so much of the data reported are not

           readily comparable.

                   The total number of.feasibility and planning studies was 734 with an
           overall funding of $3,797,682. Of these, 214 projects (total funding:
           $1,300,000) were relevant to services for the underserved.                                   There were 131

           projects concerned with developing new medical services, 45 with new health
           manpower, and 38 with consumer health education. Thirteen regions reported
           no activities related to the medical problems of underserved populations.
           In a number of cases feasibility and planning studies were reported but

           no costs were recorded since the activity had led to a projedt'-funded as
           a developmental component project, an operational project or an on-going

           program staff activity (see Table 1).


                                                               TABLE I
                                                          SZTE VISZT TEAM
                                                        HEALTH TASK FORCE - R14PS
                                                                  @INIM   STTMIES   RELATED
                                          .217 FEASIBILITY AM PL
                                           To gMICAL CARE FOR TEIE MDICALLY UNDERSERVED
                                                     BY TYPE Or MAJOR ACTIVITY
                                                             SPRIW. 1973











                                               of
                                     z4aicr Activity              Number                Percent


                                          TOTAL                      214                100.0%



                                   Access to Medical Care            131                  61.2

                                   sw manpower Development             45                 21.0

                                   Consumer Health Education           38                 17.8



                   Interestingly, a number of regions provided RMPS                           Form 11 data on
           activities proposed for the next program year. The proportion and nature
           of the proposed activities suggest a continued shift in priorities with


                                                              -43-









       I
    increased emphasis on medical services for the underserved  and  minority
    ethnic groups, and on consumer involvement.  In addition it was noted
    that a number of the on-going program staff activities reported could
    be considered relevant to the development of new medical  services,  but
    this type of reporting was very inconsistent and could not be  used  for
    statistical purposes.
         It also proved impossible to analyze staff assignments and job
    descriptions and compare them with previous years since  the  application
    (RMPS Form 6) for the most of the region did not contain  a  description
    of prior-year staffing.  However a significant number of the applications
    contained job descriptions which were variously titled but which appeared
    to be oriented toward the development of new medical services,  community
    involvement, and/or the development of new health manpower.  These  often
    appeared to be newly-created positions.
         This strongly suggests that most of the Regions would have been
    moving toward a different type of program in response to federal  initia-
    tives in their next program year. This was confirmed during  site  visits
    to the various regions.
        A number of regions appeared to spend substantial funds  through  the
    contract mechanism.  Among those reported were: contracts to develop  new
    emergency medical services; to develop curricula for new health  profes-
    sionals; and to develop financing and management capabilities for  vari-
    ous new services including HMOs, health screening, and health surveys.
    Because these'also were not reported consistently and required  detailed
    analysis of annual staff reports and annual Regional Advisory Group  re-
    ports, it was impossible to develop statistically sound data.  But  again
    the data conveyed impression that contract money was being used to  move


                                    -44-






        rapidly along the course charted 1-y new f ederal initiatives ard in  keep@
        ing with responsibilities newly assigned to RMP.

             An effort was also made to determine what, if any, relationship

        there was between the assignment of a high priority to  medical  care  for

        the underserved and the allocation of all funds by  the  various  regions.
        The analysis reflected that a large proportion of the  regions  which  had
        given medical care for the underserved a high priority in their state-

        ment of objectives, had invested between 25% and 75% of their total

        resources in operational and/or program staff activities which would

        further these objectives.  The applications foz each of the Regions

        which deviated substantially from this correlation were examined in an

        attempt to determine the cause for this deviation.  For the most part

        the anomaly appeared to result from the fact that long-range, large-scale

        projects had been funded prior to the change in directions, and that pro-

        posed new projects would have brought these regions more closely into

        alignment with their stated objectives. The  anomalous  regions  tended  to

        be those which were mature and had begun operational activities early with

        substantial commitments to categorical disease programs.

            The data strongly suggest that most of the regions in the country
        had made rather substantial changes in their objectives  in  keeping  with

        the new federal initiatives and RMP-              A variety of methods
                                            .priorities.

        had been used to reach underserved communities  which  included  alienated

        ethnic minorities, members of the youth culture,  isolated  rural  communi-

        ties, and impacted inner-city areas.  The most common method for develop-

        ing such activities appears to be screening and health  surveys,  many  of

        which were conducted as Developmental  Component  activities,  feasibility

        studies, or pilot projects, but some of which were also  funded  with  con-

        tract monies or undertaken directly by program  staff.  There  appears  to


                                         -45-






    have been a substantial change in the investment the various RMPs had
    made in moving in these new directions, and impressions gleaned from  the
    continuing applications suggest that the majority of RMPs had intended  a
    substantially increased investment in this effort. Further  there  appear
    to have been two significant changes in program staff  personnel:  greater
    representation of minority ethnic groups and a wider variety,of  technical
    expertise.

         Perhaps the most important conclusion to be drawn was that the raw
    data were not a good evaluative tool since there was no consistency in
    the way the various RMPs spent money or reported their  expenditures.  The
    raw data for each region had to be interpreted on the basis of  narrative
    reports and a crude analysis of the type of financing each region utilized.
    One region, for example, reported a Developmental Component with  specific
    project numbers and project reports, all funded as feasibility studies and
    pilot projects. Since this money was then allocated to program  staff,  a
    greatly exaggerated picture of the functional activities of this region
    was given.
        The extent to which the information in the renewal  applications  gave
    a distorted impression became evident as the Urban Health Task Force
    members made their site visits to the Regions selected.















                                    -46-











                                             CHAPTER  V


                                            SITE VISITS



                   In the course of this study,twelve Regions were visi-ted by  the  Urban
              Health Task Force.  These @ere Bi-State, Tri-State, Greater belaware Valley,
              Metropolitan Washington, Ohio Valley,- Wash'ington/Alaska, Metropolitan  New

                                                                        -"Aid/South.   Al-
              York, Alabama, Rochester, Illinois, Georgia, and Tennessee-
              though many staff members and most projects had been terminated as a re-
              suit of the phaseout, in each case sufficient staff and volunteer personnel
              were brought together to provide a great deal of Info rmation.  Even before
              the visits were begun, some impressionistic information on a wide range
              of program staff activities throughout the United States had been available.
              Although these activities had received.some attention.t.here has been no
              organized effort to describe the skills, methods, or output of program staff
                                           . .   6 ..        --. .. ...         . . --. . ........ .
              members. Thus, the Regions visited were  chosen to provide a diverse sample
              with different kinds of problems--cultural, geographic, ethnic, and economic--
              and a variety of problem-solving approaches.
                  .Although there were differences in methods,-and techniques in each
              locale, there were also some significant similarities. For  the  most  part,
              the development of demonstration grant proposals to be funded by Regional
              Medical Programs was only one staff function.  The Regional Medical Programs
              at the local level helped meet acute medical care needs through financial
              support, technical support, educational activities, and systems organization.
              RMP staff members familiar with the intricacies of the health care system
              were frequently able, in the course of a short term commitment-, to  enhance



                                               -47-






          the capability of communities to meet their own health needs.

               The RMP program staff members appear to function as a  "skills  bank"
          readily available to communities.  Where a specific skill Is needed but
          Is not possessed by anyone on the program staff,  competent  consultations
          may be possible with members-of voluntary committees or  with  consultants
          specially hired by RMP on'behalf of a community. Since  many  of  these  ac-
          tivities do not involve expenditures of money, and, in fact,  become  part
          of routine day-to-day program operations, much of the activity  Is  not  re-
          flected in annual progress reports,
               In Seattle, Washington, the Model Cities health director said his
          organization had received only a few thousand dollars through RMP, but
          that his relationship with the Washington/Alaska RMP  was  invaluable.  Data
          for the original model neighborhood health plan were provided  by  RMP.  The
          director had always been able to call upon RMP for help  with  evaluation
          methods, data collection, and the preparation of alternative  models  for
          consideration by community committees. Personnel from  a  prepaid  health
          plan and a dental plan located in the model neighborhood  indicated  that
          RMP had helped them prepare documents, provide information and data, and
          develop operational plans. These programs had received  $9,000  and  $11,000
          limini grants" which had enabled them t@ begin programs to train  community-
          based allied health personnel who were then supported with Model Cities
          funds.
               In Washington, D.C.,the RMP responded to a need expressed by the Mayor's
          Health Committee for nurs6-midwives to serve in neighborhood health centers.
          The curriculum developed through RMP Is now being Implemented at D.C.-General
          Hospital. In Philadelphia,a medical school RMP coordinator was  a5ked  by  a
          hospital administrator to attend a community meeting called to discuss  an

                                           .-48-





                0E.0 health center application.  The RMP responded by providing technical
                assistance in the preparation of a $2.5 million Health Network proposal
                which was funded.
                     Staff from several of the RMPs mentioned that In addition to eliciting
                participation by members of medical school faculties in the health affairs
                of their communities, they.had frequently been able to mobil.-ize other mem-
                bers of university communities to joi.n in dealing with these problems.
                Faculty members and students of urban planning, educatiort,..,social work,,
                economics, engineering, architecture, and law were thus mobilized.  In the
                Tennestee/Mid-South RMP, students and faculty from the School of Medicine,
                a School of Nursing, School of Social Work, and College of Law were pro-
                viding services for poverty communities.  In Philadelphia the Lincoln-
                Davies School of Health Economics, the School of Social Work, and the
                Department of Urban Planning joined RMP In developing health programs for
                an assigned target population.
                . I In every Region visited there was evidence of skillful utilization of
                non-RMP, non-university resources, most of them local and committed to con-
                tinuing activities after RMP funding was discontinued.  These were usually
                cost-sharing arrangements Involving many different types of local organiza-
                tion.  For example, In Birmingham, Aipbama, RMP provided funds to the Roose-
                velt City Community Corporation for-a health survey and screening program in
                four separate, incorporated small cities.  The survey involved cooperation
                with the areawide CHP Agency, the County Health Department, the Medical
                School, and professional 'and community volunteei's.  From this project, a full
                fledged prepaid comprehensive health plan has evolved to provide for the medi-
                cal-care needs of a target population of about 22,000 people, 60% of them
                black.  The bulk of the funding for this project now comes from DHEW and from
                the Appalachia Regional Comission, but each of the towns has made a small cash

                                                -49-






             contribution and large in-kind contributions.  Local business firms have

             provided $18,000 In cash and additional in-kind contributions.  The

             marketing committee and finance committees are chaired by vice presidents
             from Blue Cross-Blue Shield and from the banking industry.
                  Every Region visited had been involved  in  providing  assistance  for  com-
             munity groups applying for.Federal  grant  funds.  Typically  these  were  appli-
             cations to [Comprehensive Health Services,_Family Health Center grant applica-'
             tions], and OEO Office of Health.Affairs grant applications..  Some of the
             Regions had also been Involved with other  Federal  programs  and  agencies  such
             ,as the Departments of Labor, Housing  and  Urban  Development,  Transportation,
             and Agriculture. Ohio Valley RMP  program  staff  had  worked  extensively  with
             both OEO and Model Cities Including the Hunter Foundation In Lexington, an
             ambulatory-patient-care OEO project In Cincinnatti, the Pilot Cities OEO pro-
             ject, and Dayton Model Cities.  Again, many of these efforts are not described
             in the Ohio Valley annual progress report since they  do  not  result  in  funded

             RMP projects.

                  The components of RMP, as related to the  development  of  new  or  improved
             health services for underserved communities, consisted of people, skills,
             money, and Intangible resources.  In trying to characterize the personnel in-
             volved in this process the inadequacy of the brief interviews which were

             conducted throughout the study must be realized.  However, some common
             characteristics of both the people and -the program were identified.  First of
             all, successful RMP staff members were intimately  known  in  the  local  and/or
             regional community.    7hey were  extremely  knowledgeable  about  the  culture,
             the political forces, and the broad local power forces within their areas.
             They were very well versed in the language and the programs of-other local and
             federal health programs as well as those other programs with a significant
             Impact on the health care scene.  .They came from a variety of academic

                                                -50-





             backgrounds: education, liberal arts, social w'ork, behavioral sciences, basic
             science, and medicine.  All were college graduates with at least a bacca-
             laureate degree, and most had earned a Master's degree.  Virtually all could be
             described as generalists rather than specialists.  They had the ability to
             look at the total scene In acommunity and synthesize solutions to the health'
             care problems they encountered.  They were able to cope with overall problems
             while locating adequate technical assistance to solve specific operational
             problems.  Invariably they had the total commitment of the-program coordinator
             and the senior staff and were permitted to exercise independent judgment in
             operating within their own milieu.  Finally they all appeared to be extroverted,
             wam, self-confident, accepting, and articulate.  Above all, they seemed to be
             completely unafraid when operating within whatever community was involved.
                  During the course of several site visits, members of the team were accomp-
             anied by program staff personnel Involved in commdnity-based medical programs
             connected with the local RMP.  They noted that these staff people appeared to
             be widely known and greatly respect@d from the halls of-,the university to
             the streets of the poverty neighborhoods.  Warm interpersonal.relationships
             between the RMP staff and providers and consumers at all levels made It pos-
             sible for the team to be warmly and openly received in ghetto clinics as well
             as In establ ished Institutions of learning.
                 A wide range of skills was demonstrated in the RMPs site visited; some.
             skills were common to all of the RMPs-and others seemed to 'have been de-
             veloped In response to specific local needs and priorities.  For example,
             skills In management, health services systems, data collecting, information
             gathering and proposal writing were-present In most of the RMPS.  Education
             skills were also common throughout most of the RMPs visited. -These Included
             academic skills in the training of a wide variety of new health professionals
             and other skills useful to the community, such as skills In training members






           of community boards to run new health service organizations.  Skills essential
           to the development of categorical programs were very much In  evidence,  parti-
           cularly with regard to the newest categorical disease focus assigned  to  RMP--
           chronic kidney disease.  Expertise In Emergency Medical Services systems de-
           velopment was also beginning to develop in response to local as well as na-
           tional priorities.  In Georgia, EMS development had been singled out as a very
           high priority Item by both the Regional AdvLsory Group and other public service
           organizations.  Working Jointly with other provider groupst-the Georgia RMP
           had embarked on a program to systematically cover the entire state, particu-
           larly rural and small town communities, with Emergency Medical Service sys-
           tems linked to existing provider Institutions.  In many cases this complex
           operation involved crossing community and political boundary lines and re-
           gionalizing services. Similarly there were RMP staff members  developing  cost-
           containment systems through cooperative purchasing arrangements, record keep-
           Ing, and other costly services essential to health care institutions.  Other
           Regions had employed a cadre of professionals skilled in the development of
           neighborhood health centers within urban communities.
              A number of RMPs used similar methods to assist in the development  of  per-
           sonal health services for scattered and isolated ru.ral population groups.  For
           example, the Rochester RMP, serving a ten-county, predominantly rural area,
           populated by scattered farm owners and a-large number of migrant farm  workers,
           addressed the problem of inadequate manpower and facilities oh two fronts.  The
           RMP joined other groups to assist In the development of a new rural compre-
           hensive health care clinic'(The Tri-County Family Medicine Program) which is
           now active and expects to be self-sufficient within another year.  The  Roches-
           ter RMP also provided funds to train nurse practitioners who are-currently pro-
           viding care In a second rural clinic, thus enabling local physicians to see

           many more patients.

                                            -52-





               ,A different approach was discovered in the course of a visit to the
            Illinois RMP which had organized a health center for senior citizens in
            the Flannery Homes Housing Project.  Skillful use of physician assistants
            and sound administrative and management practices were demonstrated in
            this project.  This Is particularly significant since there are thirty-
            six similar senior citizensl.housing projects in the city and-there is
            a potential for replicating this project at P-ach housing site.
                During the site visits it became apparent that the characteristics of
            the program staffs were undergoing metamorphosis.  People with substantial
            experience in dealing with categorical disease programs and continuing edu-
            cation of physicians were no longer on the staff in most places and seemed
            to have been replaced by people with a different array of skills relating
            to new program directions and new federal health Initiatives.
                As the Task Force looked at continuation applications and discussed
            with coordinators their plans for the coming year, It appeared that rather
            substantial changes would have occurred in the composition of program staff
            as additional people were employed to work with community groups in develop-
            Ing new and improved health services.  There was obviously a much greater
            emphasis-on employment of minority group professionals who might be able to
            relate more effectively to the ethnic monorities who had become high priority
            target groups.
                It appeared that the allocation of.RMP funds was also undergoing
            transformation.  Many staff members reflected on the days of the large grants
            to major institutions related to categorical illness programs.  By contrast,
            new project grants, in general, were in smaller amounts, for a substantially
            shorter time, and frequently were funded through new or emerging health-in-
            terested organizations.  Since many of these grants went to locally-supported


                                           -53-





           Institutions, cost sharing was usually built fri.  The Regions used a variety
           of techniques to provide quick turnaround on project applications Including
           pilot projects, contracts, and especially Developmental Component funds where
           possible.  Many of the operational projects in which RMPs joined with local
           governments to provide for the development of new health care services ex-

           emplify this trend.

                In some cases relatively large amounts of RMP funds have been committed
           to programs with an Impact on minority groups and/or underserved communities.
           Large grants were made by the Metropolitan Washington RMP on a continuing
           basis to the Howard University/Freedmen's Hospital complex; apparently this
           has had a rather substantial Impact on the quality and the amount of care
           available to residents of the area immediately surrounding  Howard.  Thus
           the Freedmen's Stroke Project and Howard University Cancer Project were
           Included in the Metropol'itan D.C. site visit.  The director 'of the Cancer
           Project indicated that this RMP-funded project paved the way for a $5.1
           ml )lion cancer research center grant from the National  Cancer  Institute.
           He said quite emphatically that without-initial RMP seed money this center
           could never have been developed and would not be available to the Washington
           community.  Even before the cancer center money had arrived, Freedmen's Hos-
           pital had developed the largest radiotherapy department in the District and
           had also developed the only approved radiotherapy program and school  for
           radiotherapy technologists In the District.  The Stroke Project has Influenced
           the general level of care within the hospital since it was one of the first
           attempts to institute the team approach to medical care with regard to  a
           categorical illness.  There are also some medical audit elements built into
           the program which have resulted in rather substantial changes In-the quality
           of care rendered In the hospital.  Medical students and students of other


                                         -54-






               health professions now have an opportunity to observe continuity  of  care
               from the onset of acute stroke through progressive stages  of  treatment.
                     In the Tennessee-Mid/South region, a multiphosic screening  project
               at Meharry University-has had a number of Interesting results.  First
               of all, since it Is the only multiphasic screening program  available  to
               residents throughout a large geographic area, It has provided  a vital
               service.  Second, it has linked the services of the screening program
               with local out-patient and In-patient institutions and with..private pro-
               viders of care from the surrounding community.  Third, It has provided
               a basis for the development of a working relationship between the Meharry
               Medical College and Vanderbilt University School of Medicine which has
               continued and which has borne. a great deal of fruit including the design
               and Implementation of a number of student activities with an important
               Impact even on parts of the South outside the Tennessee-Mid/South  region.
                    The Metropolitan New York RMP$s Harlem Stroke Project is another pro-
               gram which has affected a minority-group, underserved community.  In addition
               to its categorical focus, this program has had a significant outreach effect
               Involving the participation of a variety of community groups in Its  case-
               finding and follow-up activities. Fourteen community health  workers  have
               completed a six month training course and screened over 2,000 persons  in
               1971 as part of this project.
                   The diversity of the -roblems and problem-solving techniques encountered
                                        p
               In the course of the site visits nearly defies generalization and  summary
               analysis.  As we have noted, Individual staff members whose efforts have been
               amt successful are united more by a common style than by common substantive

               skllls.

                  Similarly, certain common problems and problem-solving approaches were









           demonstrated both in heavily populated urban ghettoes, In sparsely popu-

           lated rural areas, and sometimes even In recently settled suburbs.  These

           commonalities have important Implications for the approach originally adopt-

           ed In this project and for the approach which ought to be adopted in further

           projects of a similar nature.

















































                                            -56-









                                            APPENDIX A


                                            METHODOLOGY



                   In an effort to develop.information that would be both reliable and
              useful in shaping future efforts to structure health care programs for
              medically underserved people, data for this-study were compiled through
              site visits and through systematic reviews of certain documents.  The site

              visits, carried out by a team of four staff members from the California
              and New Jersey RMPS, were made to twelve regions chosen as a representa-
              tive sample in terms of geography as well as of the types of problems en-
              countered and the ways in which these problems were managed.  In the meantime,
              staff from the New Jersey and California RMPs reviewed the most recent annual
              applications submitted to RMPS by each of the fifty-six regions along with
              data on the funding history of each region generated from the RMPS Manage-
              ment Information System.

                   In addition, an extensive array of legislative documents, conference
              proceedings, Presidential statements, draft position papers, correspondence,
              Departmental/Regional communications media, press information releases,
              journal articles, news clippings, and similar or related material was re-
              viewed.  Through these documents, the-developrbent of RMP was traced within
              the context of the Program's evolving legislative mandate and shifting
              national health care priorities.  This phase of the investigation was carried
              out by -someone with prior professional experience in both health care and
              legal research who had had no previous involvement with RMP.
                  The regions visited were: Washington/Alaska, Rochester (upstate New York),
              Greater Delaware Valley (centered on Philadelphia), New York Metropolitan,



                                             -57-






          Tri-State (Massachusetts. New Hampshire, and Rhode Island), Ohio Valley
          (southern Ohio, southern Indiana, Kentucky and western West Virginia),
          01-State (principally greater St. Louis), Tennessee/Mid-South, Georgia,
          Illinois, Metropolitan Washington (District of Columbia and adjacent

          counties In Maryland and Virginia), and Alabama.  To some extent the in-

          formation gathered on these site visits was supplemented by the' first-
          hand knowledge of team members based on'theii own experience with the

          Now Jersey and California RMPS.

             The site visits were made over a period from May 7 to July 17, 1973.

          In each case the Coordinator of the Region proposed to be visited was con-

          tacted, told tho- purpose of the proposed visit, and Invited to have.his
          Region participate.  He was then asked to have the following people present
          to meet with the Urban Health Task Force: the Coordinator himself, RMP staff
          members, a Regional Advisory Group representative, local health leaders,
          and officials Involved In dealing with urban health.

             For the first two site visits, the four Task Force members, John A.
          Mitchell, M.D., Henry Wood, Marlene Checel, and Madeline Thoma, split up
          with two members meeting with the Washington/Alaska RMP and the other two
          meeting with the Rochester RMP.  Following a conference on May 14, 1973
          with Mr. Cleveland R. Chambliss, all four Task Force members visited the

          Greater Delaware Valley, New York Metropolitan, and Tri-State RMPS.  The
          teoms then split up again and went to the Ohio Valley, Bi-State, Tennessee/
          Mid-South, 'and Georgia RMPs and finished on May 24, 1973.  Then, following
          a two-member visit to Illinois and a full team visit to Metropolitan

          Washington, the Urban Health Task Force met with Mr. Chambliss for a de-

          briefing on June 12, 1973.  The final site visit, made after the debrief-
          Ing session because of scheduling difficulties, was made to Alabama on

          July 17t 1973.





                     -in most cases the Urban Health Task Force members began their visit
                 with a briefing by the Coordinator and his staff.  The remainder of the
                 time was usually spent In Interviews with Individuals associated with but
                 not an the staff of the local RMP.  These Included RAG memb*rs; staff mem-
                 bers of RMP-funded projects; volunteers or staff members from other federal
                 programs such as Comprehensive Health Planning, Office of Economic Op-
                 partuni,ty,-@ -Model Cit;es;-and-local officials such as city councilmen,
                 state health commission members, and others concerned with urban health
                 problems.  Information 'obtained In the course of these Interviews was
                 Included in a report developed on each Region visited.
                     In the second phase of the project the most recent progress report
                 and continuation application for each Region. was reviewed by RMP staff
                 members in California and New Jersey at the same time that the site visits
                 were taking place.  Initial. plans had called for a detailed questionnaire
                 to be submitted to each of the fifty7six regions In order to gather the
                 necessary data.  However, this proved not to be feasible.
                     A preliminary Instrument for extracting the Information contained
                 in each application was developed, based In part on official RMPS report-
                 Ing forms, before the first site visits were made.  As this Instrument
                 was being used by the reviewers, a number of problems were discovered.
                 First, and perhaps most serious, were the reporting periods Involved.
                 Since applications were submitted to RMPS at different times during the
                 year and because some of the RMPs had extended program and funding years,
                 some applications were quite recent and reflected the latest developments
                 while-others, submitted up to two years earlier and generally prepared over
                 a period of six months to a year prior to submission, were extremely out
                 of date.  Thus comparisons between regions did not reflect fairly the

                                               -59-






          relative strengths and weaknesses of each program. Moreover,  a  pre-

          liminary review of the most recent applications indicated a  dramatic

          shift In regional priorities dating from about the time that the Advisory

          Committee on Urban Health was formed and the original contract for this

          project was first announced. The  older  applications  were  prepared

          prior to the RMP emphasis on health care for the underserved and did not

          accurately reflect the activities which were being carried out in 1972

          by those RMPs nor the directions in which they would move in 1973.

              Yet a third weakness became evident when information collected through
          the application review was compared with what the Task Force members were

          discovering In the course of site visits.  To a large extent, the urban-
          health-related activities of the Regions visited were not fairly reflected
          in their annual applications. A number of reasons were  noted.  First

          the reporting forms had been developed by HEW before the Involvement of
          RMPs with urban health had become a [major concern.  Thus, the forms were
          not designed to extract this information.. Second, due to the relatively
          recent start of the program and the infrequency of reporting on a three
          year cycle, staff members In many Regions simply were not familiar enough
          with the forms and did not know how to.use those elements of the report-
          ing format which could be adapted to highlight vital activities and ac-

          complishments.  Third, and most dramatic,-was the failure of the appil-
          cation forms to focus on a wide range of program staff activities other

          than those which culminated in RMP-financed projects
              Thus RMP staff members might survey the health needs of a particular
          urban neighborhood; discover an urgent need for primary care facilities;
          work with local community leaders to organize a representative board;



                                          -60-




              assist In locating a suitable neighborhood health center site, hiring staff
              members, and negotiating clearances with local zoning boards and similar
              municipal agencies, and give the board members guidance in preparing a
              successful application for funding through some funding source such as OEO;
              and none of these activities would be reflected In the Region's annual
              application since-no RMP funded project.resulted.  They might-simply be
              lumped in with program staff activities.  It-is important to note that all,
              of the activities described above are entirely in keeping wi-t-h RMP's man-
              date to strengthen and Improve primary care, especially In service-scarcit
              a ress, without itself financing the provision of care except In connection
              with a demonstration project.  Yet, not only would these program staff
              activities fall to be highlighted, but by being lumped In with other
              program staff activities they would contribute to the Impression that the
              Region in question was a "bloatecp' bureaucracy with wildly disproportionate
              administrative costs.  At best, the.neighborhood health center and/or its
              governing board might be listed on RMPS Form 8, Program Activities Summary.
              Unfortunately, this form often was little more than a "laundry list" which
              merely Inventoried contacts without in any way indicating the nature or
              quality of the tranactions involved.
                 After completion of the site visits and the record review, the
              Urban Health Task Force reviewed the site visit reports and the record
              review summaries.  In the course of th.is review, the Task Force freely
              referred back to source documents to substantiate unusual indicators or
              to clear up Inconsistent data.  The application and progress report format
              made It fairly easy to describe operational projects but the Task Force found@
              that It was difficult to find much Information on the activities of program
              staff.  Frequently, it was necessary to read the narrative progress report


                                            -61-





           of the program staff or the RAG report to identify a program  Initiative.

           In many Regions, It was difficult to identify activities planned or

           carried out through the Developmental Component.

                The Task Force then turned to financial data available from the RMPS

           Management Information System printouts and looked in detail at the Funding

           History List for each Regiod.  For purposes of this report, information

           was taken from the program year-which contained the most months of  1972.

           For example, if a region received-an award for the periods-Janaury 1971

           through April 1972 and May 1972 through July 1973, the information for
           the later period, which covered eight months of 1972, was used.  No  effort

           was made to reduce the data to twelve-month periods since there was not

           enough information available.  This method was utilized since the report-

           ing periods varied from ten months to twenty months, and additionally,  the

           starting and ending dates were staggered to fit the three times per  year

           cycle of the National Advisory Council.
               The Project Summary (RMPS Form 15), when It was well written,  was  the

           most useful document for the reviewers. Since project  titles  frequently
           failed to Indicate the intent, scope, or direction of a project, they  were

           of little use In an objective review.  The project summaries, however, could

           be related to the funding history preoared through'the Financial Data Record
           (RMPS Form 16) and summarized in the Management Information System printout'.

           When all components of the system were used to report Developmental  Com-

           ponent activities, It was possible to generate for inspection a  concise,

           composite picture of a Region's Developmental Component efforts.

                Regions were required to report on "Core Central Regional Service
           Activities" (RMPS Form 12) for the Immediate past and future funding periods.

           An examination of these reports was attempted but could not be carried  out



                                            -62-





              because same Regions did not report activities and others did not seem
              to agree on definitions of the term.  The most frequently reported
              activities In continuing education for health professionals; but data
              gathering and health surveys were also reported.
                   To the greatest extent possible, only data which could be considered
              valid were used In pre'paring'thii report. Anecdotes, when cite7d, have been-
              offered as examples of incidents'that Were reported and that are con-
              sidered to be part of the tactical'reportoire of many of tKii'RMPs and
              are neither unique nor peculiar to any single Region. In the final analysis,
              It seems safe to say that the data Included in this document are a fair,
              accurate reflection of the underlying reality and these data support the
              conclusions reached.





































                                               -63-