I







                            V s L)




      alifornia
            rnittee
        orn

           clion
        Re " al
          lwedical
           Prograrns
   A IL MAR         NFEREN E




   OCTOBER 28=30,1970 PROCEEDINGS































                                                 NEIL C. ANDREWS' M.D.
                                                     General Chaiman





                                                 CHARLES H. WHITE, Ph.D.
                                                     Proceedings Editor





                                  CALIFORNIA REGIONAL MEDICAL PROGRAMS REGIONWIDE CONFERENCE
                                                    ASILOMAR CONFERENCE GROUNDS
                                                     October 28,  29,  30,  1970


             We
                 4:00  -  6:00  p.m.     Registration
                 6:00  -  7:00  p.m.     Dinner
                 7:80  -  9:00  p.m.     orientation -  Neil  C.  Andrews,  M.D.
                                         Presentations of Area Activities - Merrill Hall
                                             Area   I     Cancer Program
                                                             @Sam Sherman,  M.D.
                                             Area  VI     Perinatal   Monitoring
                                                             Richard  Walden,   M.D.
                                             Area VIII    Stroke Volunteer Program
                                                             Mrs. Emily Hackler, R.N.
                 9:00  -                 Meeting of Workshop Chairmen at Podium immediately after presentations

             Thursday, October 29
                 7:00  -  8:00  a.m.     Breakfast
                 8:30  -  9:00 a.m.      HSMHA and Health Care - Vernon Wilson, M.D.
                 9:00  -  9:20 a.m.          Area III     Multiphasic Screening
                                                             Jeanne LeBrun
                 9:20  -  9:40 a.m.          Area  II     RMP - CHP "B" Relationship
                                                             Charles  White,   Ph.D.
                 9:40  - 10:00 a.m.          Area  IV     Northeast Valley Project
                                                             Barton Fischer, M.D. - Louis Garcia
                 10:00 - 10:20 a.m.          Coffee   Break
                 10:20 - 10:40 a.m.          Area   V     East Los  ngeles Cares and Concerns
                                                             Frank Aguilera, M.P.H.
                 10:40 - 11:00 a.m.          Area VII     Physician Continuing Education Through a Resident
                                                          Physician Sabbatical Exchange
                                                             Marion  Mykytew,   M.D.
                 11:00 - 11:20 a.m.          Area  IX     The Use of a Community Task Force in Planning a School of
                                                          Allied Health
                                                             Charles  Buggs,   Ph.D.
                 11:20 - 12:30 p.m.      Lunch
                 2:00  -  3:20 p.m.      Workshops
                 3:20  -  3:40 p.m.      Coffee Break
                 3:40  -  5:00 p.m.      Workshops
                 6:00  -  7:00 p.m.      Dinner
                 7:30  -  9:00 p.m.      Workshops
                                                        WORKSHOP SCHEDULES
             1.  Area-Region     Relationships                     William A. Markey
             2.  Category  Disease  Planning   vs.
                 Comprehensive Medical Care Planning               Sam Sherman, M.D.
             3.  Regional  Medical  Programs   and
                 Health   Manpower   Education                     Richard T. Walden, M.D.
             4.  Regional   Medical   Programs-
                 Comprehensive   Health   Planning                 Michael Shimkin, M.D.
             5.  The   Committee                                   Charles White, Ph.D.
             6.  Regional  Medical  Programs   and  Voluntary
                 Health  Agencies  and   Other   Non-Federal
                 Agencies                                          William Fowkes, M.D.
             7.  Core Staff Structure and Function                 Al   Torribio
             8.  Regional  Medical  Programs  and   Medical        Jane    Malmgreen
                 Schools                                           John Stroessler, Ed.D.





                                                                   1.







                                                   WORKSHOP ASSIGNMENTS


                                 MEETING
        GROUP                     ROOM              2:00-3:20 p.m.  -   3:40-5:00 p.m.       7:30-9:00   p.m.
           A                  Scripps Patio        (1) Markey           (8) Stroessler      (7)  Torribio
           B                  Scripps Lounge       (2) Sherman          (1) Markey          (8)  Stroessler
           c                  The   Lodge          (3) Walden           (2  Sherman         (1)  Markey
           D                  Marlin               (4) Shimkin          (3@ Walden          (2)  Sherman
           E                  Viewpoint            (5) White            (4) Shimkin         (3)  Walden
           F                  Merrill              (6) Fowkes           (5) White           (4)  Shimkin
           G                  Tide Inn             (7) Torribio         (6) Fowkes          (5)  White
           H                  The Dolphin          (8) Stroessler       (7) Torribio        (6)  Fowkes

        Friday, October 30
            7:00   - 8:00  a.m.      Breakfast
            8:30   - 9:30  a.m.      Workshop  Reports
            9:30   -10:30  a.m.      Discussion
           10:30   -10:45  a.m.      Mack Smith, M.D., Regional Health Director
           10:45   -11:30  a.m.      Paul Ward





                                            WORKSHOP PARTICIPANT ASSIGNMENTS

        GROUP A  (Scripps Patio)                             GROUP C (The Lodge)
           Area-Region Relationships - Markey                   RMP &  Health  Manpower  Education  -  Walden
           RMP & Medical School         -  Malmgreen/           Categorical Disease Planning vs.
                                           Stroessler               Comp. Medical  Care  Planning  -  Sherman
           Core Staff                   - Torribio              Area-Region Relationships         - Markey
           --------------------------------------               ----------------------------------------

           Max Miller, M.D. - IV                             Sheila  Cadman  -  IV
           Mitchell  Covel,  M.D.  -IV                       Marion Mykytew, M.D.     VII
           Mrs. Jean Ralph - VII                             Keith MacGaffey, M.D.     VII
           Marcy Braiker - I                                 Dr. Gerald Shaw - IV
           Mrs.  Jack   Dohmann   I                          Dr.  Marcella   Davis  I
           Marge Heafey    I                                 James Von Tellrop     I
           Wilfred Lee    I                                  Henry  Dishroom  -  I
           Frank Jones    II                                 Joanne Reed - II
           La Verne Westerlund     III                       Helen Blood - III
           Marge Crump    V                                  Mrs. Carlee Spencer - III
           Wilson Mizener,  M.D.     V                       James Knight - IV
           John S.  Lawrence,  M.D.  - VI                    Clyde Madden- V
           Emily Kander - VI                                 Lee Cady,  M.D.  -  V
           Bert Tesman, M.D.  "   VIII                       Lois Friss - VI
           Mrs. Catherine Germany      IX                    Valarie Vance, Ph.D. - VIII
           Mrs.  Betty  Frazier  -  IX                       Mrs. Patsy Kelson - IX
           Robert-A. Brook.- CHP                             Mrs. Florence  Wyckoff  -  CCRMP
           Mrs. Virginia Greer                               John V. Naish - CCRMP
                                                             Charles K. Guttas, M.D.     II
















                                                             2.





            GROUP B  (Scripps Lounge)                              GROUP    D    (Marlin)
                Category Disease Planning vs.                          RMP - CHP                           - Shimkin
                   Comp. Medical Care Planning - Sherman               RMP & Health Education Manpower     - Walden
                Area-Region        - Marke                             Categorical  Disease   Planning   vs.
                RMP & Medical School -  y Malmgreen/Stroessler           Comp. Medical Care Planning       @ Sherman
                -------------------------------------------            -----------------------------------------

            Satoshi  Hayashi  -   IV                               Marlene  Checel  -   V
            George Packard, M.D. - IV                              William Schmalhorst, M.D. - IV
            Dr.     David     Miller VII                           Dan Sullivan        IV
            Dr.    Leslie     Gaelen VII                           Paula Liska        VII
            Dr. Melvin Scheinman - I                               Alice  Johnson,   R.N.   VII
            Judy          SchuknechtI                              Mrs.  Florence   Stroud     I
            Maurice    Dawson      I                               Sandra      Halldorson
            Joseph   Cosentino,    M.D. - II                       Brian  Dobrow   -   II
            Jeanne LeBrun          III                             Virgil Gianelli, M.D. - III
            Lorraine    Brown      III                             John  Simmons,   Ph.D.   IV
            Grace          Carpenter IV                            Dorothy  Anderson  -  V
            John Lloyd, Ph.D. - V                                  Mrs.  Celia   Mittleman     V
            William  Monroe   -   VI                               Edwin  McGhee   -   VI
            Claire Adams, R.N. - VIII                              Harry Hunt - IX
            William   Green   -   IX                               Mrs.  Marion   Grindell     IX
            Alfred Haynes, M.D. - IX                               Lyndall Birkbeck
            Mrs.  Pat  Alexander  -  IX                            Gregory Lewis
            Elma  Plappert  -   TARDAC
            GROUP   E    (Viewpoint)                               GROUP  G  (Tide   Inn)
                The        Committee               - White             Core Staff                          - Torribio
                RMP - CHP                          - Shimkin           RMP & Voluntary Health Agencies
                RMP & Health Manpower Education    - Walden               & Other Non-Federal Agencies     - Fowkes
                                                                       The Committee                       - White

                -----------------------------------------              ------------------------------------------

            Nat  Feder  -  IV                                      'Lee  Horovitz  -   IV
            Jack   Cheever   -   VII                               Derek  Price   -   VII
            Helen  Randall   -   VII                               Eileen  Innis  -   VII
            James   Rogers    -    I                               Marjan van  Overbeek  -  I
            Juapita   Stone   -    I                               Mr. Lardja  Sanwogou  -  I
            Mrs: Josephine Williams - I                            George  Lowrey,  M.D.  -   II
            Mrs.  Jean  Filer  -  11                               Stanley G. Parry - III
            Herbert   Bauer,    M.D. II                            Phyllis  Hall  -   III
            Thomas   Elliott,   M.D.  III                          Mrs.  Juanita  Dudley  -   IV
            Mrs.  Ruth  Kaiser  -  III                             Jane Z. Cohen        V
            V. M. Farrell          IV                              John Traband      VIII
            Louis Garcia           IV                              Marcelina  Kalmbach  -   VIII
            Kay  Fuller  -  V                                      Mrs.  Lillian  Mobley  -   IX
            Miss  Pat  Spartnicht  -  V                            Miss Carolyn Phillips       IX
            Paul   White   -    VIII                               Gary Affolter       VI
            Mariano        Contreras IX                            Liz Bernheimer       I
            Ronald     S.     Currie RMPS Rep. HEW                 Al Parham    I
            Jack Long    State Health
















                                                                   3.





       GROUP F  (Merrill)                                  GROUP  H  (The  Dolphin)
          RMP & Voluntary Health Agencies                     RMP & Medical School - Malmgreen/Stroessler
              &.Other Non-Federal Agencies    Fowkes          Core Staff            - Torribio
          RMP - CHP                           Shimkin         RMP & Voluntary Health Agencies
          RMP & Health Manpower Education     Walden             & Other Non-Federal Agencies - Fowkes


          -------------- -----------------------------        -------------------------------------------
          James Ricketts  -  IV                            Walter Graf, M.D.  -  IV
          Frank Forbes  -  VII                             Mrs. Elaine Bogan - VII
          Donald Sherman  -  VII                           Miss Audrey Massey  -  I
          Dennis McGee  -  VII                             Joseph Calamusa - I
          Marilyn Griffin  -  I                            Rev. Cyrus S. Keller, Sr.
          Mrs. Elizabeth  Oakley  -  I                     John Beljan, M.D.    II
          Dorothy Dunning  -  II                           Mrs. Mary Alderson    III
          Frank Harland  -  II                             Miss Eleanor Stittich - IV
          Clifford  Carpenter  - III                       Elsie McGuff    V
          Jackie  Reinhardt  -IV                           Leon C. Hauck    V
          Nils  Bolduan,  M.D. - IV                        John Conner - V
          Frank Aguilera  -  V                             Diane Affolter - VI
          Mrs. Loris G. Phillips -   V                     Sue Ungermann  -  VIII
          Mary Jane Bromley - VIII                         Mrs. Edris Burroughs - VIII
          Erline Williams  -  IX                           Dr. Harris Peck  -  IX
          John White  -  State  Health                     Charles W. Buggs, Ph.D.    IX
          Bob Porter  -  State  Health                     Edna Chapman  -  CCRMP
          Martin Schickman, M.D.     ix                    Mrs. Caffie Green    IX




































                                                           4.






                                                           GREETINGS
                                              Neil C. Andrews, M. D., Chairman
                  Welcome to Asilomar and to the Regionwide Conference of California Regional Medical Programs.
            This is really a birthday party for RMP and Public Law 89-239  --  They  are  five  years  old  this
            month of October.
                 This meeting grew out of a suggestion in March of this year by Don Petit  of  Area  V.  He  had
            observed that all Areas of the California Regional Medical Program  had  established  a  variety  of
            activities which needed to be displayed to other interested parties.
                 Secondly, he observed that ther? is a vast array of people working with Regional Medical Pro-
            grams on various operational activities who are not visible outside their Area or perhaps not even
            outside the project itself.
                 It seemed appropriate to discuss the possibility of a Regionwide  Meeting,  therefore,  of  one
            or two days duration at which time we could present in a scholarly fashion  the  productive  activi-
            ties that are now going on within California.
                 As a result of this suggestion which was presented at the April Meeting of  the  Staff  Consul-
            tants, a Planning Committee was formed.  At their first meeting on May 21st, this group quite
            logically raised the questions why, what for, when, and  how  of  a  statewide  California  Regional
            Medical Program Meeting. The Committee was able to agree that there was a  need  for  such  a  meet-
            ing and that it would be wise to talk about some of the  new  directions  of  the  Regional  Medical
            Programs and to have a discussion between the staff and the Area Advisory  Groups  about  activities
            that have been accomplished in the past and are now ongoing at this  time.  A  title  was  suggested
            which was California Regional Medical Programs Past, Present, and  Future.  Another  title  suggest-
            ed was RMP-Expo, but that didn't survive.  The original notion that this Conference should be
            relatively formal and should consist of a number of brief  sci entific  papers  solicited  from  each
            Area was soon discarded by the Committee who felt that such  an  approach  represented  more  nearly
            a scientific society approach which would not  allow  enough  appropriate  interpersonal  communica-
            tions among staff and volunteers of RMP.
                The eventual result, as you can see from the program for the next day and a  half  is  a  combi-
            nation of techniques beginning with the presentation from each Area of the  description  of  an  on-
            going project. We hope the Area presentations will enable those  of  us  attending  this  conference
            to have greater insight into the actual happenings within the California Region.  The meat of
            the program, however, will be the workshops.  These will take place on Thursday afternoon and
            evening and are ably chaired by representatives from each Area. It  is  the  hope  of  the  Planning
            Committee that each of those subjects explored in a workshop will be discussed thoroughly from
            all points of view so that the chairman can bring a true summary of those discussions.to the
            Friday morning report period. Thus the thoughts, insights and conclusions  of  all  eight  workshops
            can be made known to the total conference and perhaps Provide focus and  direction  for  our  future
            activities.
               We are most fortunate to have with us during this session,  Mr.  Paul  Ward,  the  Executive  Di-
            rector of the California Regional Medical Programs, and Dr. Vernon Wilson, the  Director  of  Health
            Services and Mental Health Administration of the Department of Health, Education  and  Welfare.  Dr.
            Harold Margulies, who is Acting Director of the Regional Medical Programs Service, regrets  that  he
            will be unable to be here as originally planned. These able men will be most  helpful  by  providing
            input from Administrative and Legislative attitudes towards Regional Medical Programs.  I  sincerely
            hope that the next few days are busy and fruitful, that they add to your  understanding  and  stimu-
            late your interest in the Regional Medical Programs. Further,,I trust this  is  not  all  work,  but
            that during your stay here you will enjoy the beautiful scenery and have fun,  but  don't  skip  the
            workshops.






                                                       AREA PRESENTATIONS



                                                AREA I REGIONAL CANCER PROGRAM
            SAM SHERMAN, M.D.

            1.     GENESIS OF THE PROGRAM

                   As recognized in the creation of  the  Regional  Medical  Program  for  heart  disease,  cancer
            and stroke, cancer is one of  the  major  diseases  causing  morbidity  and  death  among  the  population
            of the United States. While loss  of  life  from  infectious  diseases  has  lessened,  the  incidence  of
            the degenerative diseases  and  cancer  has  increased.  Cancer  afflicts  approximately  330  people  per
            100,000 population per year. The  death  rate  is  approximately  200  per  100,000  per  year,  which  is
            almost 20% of all deaths. Based on  the  population  of  Area  1,  it  would  be  expected  that  an  area
            containing about 4.5 million persons would produce a total of 15,000 cancer cases per year.

                  Because cancer represents a broad  spectrum  of  diseases  originating  in  a  wide  variety  of
            sites from a number of histologic structures, treatment is complex.       The proper management of
            cancer patients requires not only  one  but  multiple,  highly  trained  and  experienced  specialists
            working in close cooperation.  Comprehensive medical care of the cancer patient in Area I of
            Northern California is further  complicated  by  the  great  distances  between  medical  facilities,  the
            population concentration varying from  the  metropolitan  San  Francisco  Bay  Area  to  the  small  North
            Coast communities, and a shortage of physicians and paramedical specialty skills.

                At least 50% of  cancer  patients  require  radiation  therapy  at  some  time  during  their  manage-
            ment; probably 50% require chemotherapy,  and  an  equal  number,  surgery.  Although  the  supply  of
            general surgeons in the Area was reasonably adequate, there was only a small number of surgeons who
            specialize in, or devote a majority of their practice to cancer surgery.  Further, it was estimated
            that there were less  than  20  fully-trained,  practicing  chemotherapists  and  only  15  trained  full-
            time radiation therapists  in  Area  1.  It  was  estimated  that  approximately  50  chemotherapists  and
            50 radiotherapists would be required  for  optimum  care.  In  addition  to  the  limited  personnel,  the
            necessary physical facilities in this Area  were  also  insufficient;  for  example,  in  radiation  ther-
            aPY and there were only 11 supervoltage  and  megavoltage  radiation  therapy  units,  yet  the  need  has
            been estimated to.be at least 42 such units.

                Within Area I, two medical  facilities,  the  University  of  California  Hospital  and  Medical  Cen-
            ter; and Mount Zion Hospital and Medical  Center,  an  associate  hospital  of  the  University  of  Cali-
            fornia, possessed  broad-based  oncology  programs.  The  University  of  California  Hospital  and  Medi-
            cal Center and the Zellerbach Saroni Tumor Institute  of  Mount  Zion  Hospital  and  Medical  Center,
            while  geographically  and  administratively  separate,  have  previously  cooperated  in  joint  programs
            in cancer education and research.   Their  programs  in  cancer  education,  research  and  patient  care,
            including but not limited  to  radiation  therapy,  chemotherapy,  and  surgery,  were  being  offered  to
            several peripheral institutions.   These two centers therefore  agreed  to  be  involved  in  a  regi.onal
            cancer program to  utilize  existing  resources,  personnel,  equipment,  and  expertise  to  the  maximum
            extent possible, and to permit  extension  of  their  present  services  to  additional  peripheral  medi-
            cal groups. It was recognized that other  medical  centers  and  groups  in  this  region  also  possessed
            excellent resources and it was expected that  those  who  wish  will  be  incorporated  into  the  program
            as the details can be worked out.

               A climate of  cooperation  exists  between  the  two  named  institutions.  Joint  appointments  of
            the Mount Zion Hospital and the  University  of  California  clinical  radiotherapy,  physics  and  radio-
            biology research staffs existed.  Only  these  two  institutions,  in  Area  I,  possessed  a  full  range
            of ongoing programs and functioning resources, including radiation therapy personnel, straight
            radiation  therapy  training  programs  and  trainees,  radiation  physics,  and  radiobiological  staffs.
            The objectives of the program  are  to  provide  an  in-depth  oncologic  service  to  peripheral  facili-
            ties, to incorporate  into  the  program  the  professional  personnel  currently  supplying  services  to
            these areas, and to supplement the  peripheral  facilities  wherever  necessary  with  the  more  complete
            resources of the University of California and Mount Zion.     This proposal was  in  response  to  an  in-
            creasing demand to broaden the scope and  increase  the  depth  of  the  service  already  being  provided
            on a small scale. As other institutions  in  the  region  are  able  to  contribute  to  the  program  and
            can be assimilated, they will be encouraged to participate.


            II.  PROGRAM DEVELOPMENT

                 That physicians practicing in the cancer field have certain unmet needs became apparent
            through: 1) existing  bilateral  consultation  and  cancer  care  programs,  2)  personal  contact  between

                                                               6.





            members of the staffs of the University of California Medical Center,  San  Francisco  (UCSF),  the
            Zellerbach Saroni Tumor Institute of Mount Zion Hospital and Medical Center (ZSTI) and other hos-
            pitals, and 3) multiple refresher courses given by the University's Division of Continuing Educa-
            tion.  Because of these general observations and in order to evaluate specific local requirements,
            the planning staff of the Area I Regional Medical Program involved itself  extensively  in  conver-
            sations with physicians in communities in the Northwestern part of California  and  in  surrounding
            areas. Many portions of the program to be offered were  suggested  by  prospective  participants.
            The RMP planning staff and members of the cancer teams at UCSF and ZSTI actually contacted repre-
            sentatives and/or members of the medical staffs of the following California Hospitals:
                   Alta Bates  Hospital,  Berkeley
                   Brookside Hospital,  San  Pablo
                   Children's Hospital and Adult Medical Center, San Francisco
                   Concord Community Hospital, Concord
                   Contra Costa County Hospital, Martinez
                   Eden Hospital, Castro Valley
                   Franklin Hospital, San Francisco
                   Fresno Community Hospital, Fresno
                   Harkness Memorial Hospital, San Francisco
                   Highland Hospital, Okaland
                   Kaiser Permanente Hospital,Oakland
                   Kaiser Permanente Hospital, San Francisco
                   Marin General Hospital, San Rafael
                   Merritt Hospital, Oakland
                   Peninsula Hospital,  Burlingame
                   Queen of the Valley Hospital, Napa
                   St. Joseph's Hospital, Eureka
                   St. Francis Memorial Hospital, San Francisco
                   Santa Rosa Memorial Hospital, Santa Rosa
                   San Francisco General Hospital, San Francisco
                   Sonoma Valley Hospital,  Sonoma
                   U. S. Naval Hospital, Oakland
                   U. S. Public Health Service Hospital, San Francisco
                   Veterans Administration Hospital, San Francisco
                   Veterans Administration Hospital, Martinez
                   Through these discussions, it became evident that many of the hospitals i n the Area  have
          problems in cancer management.which could be helped by a  consultation  and  planning  service.  Some
          medical groups had definite strength in certain areas such As cancer surgery, chemotherapy or radi-
          ation therapy, but few had strong representation in all fields  of  cancer  management.  It  seemed
          that a cooperative arrangement, in which the talents of all hospitals could  be  used  to  aid  and
          strengthen those lacking certain aspects of knowledge or equipment, would be of value.


          III.     RESOURCES AND PRESENT ACTIVITIES

          A.       Resources

                   The resources and programs of the University of California, San Francisco  Medical  Center
          and Mount Zion Hospital and Medical Center are extensive. Both  medical  centers  are  equipped  with
          the latest diagnostic and therapeutic equipment and both have active teaching  programs  in  all  as-
          pects of medical care. According to the California Tumor  Registry,  approximately  3500  new  cancer
          patients are seen per year in these institutions. Of these, it  is  estimated  that  1600  patients
          per year are seen by the radiation therapy departments of the two institutions.
                   1.  University of California Hospital and Medical Center
                     The UCSF Medical Center has been serving for years as a regional  educational  and  refer-
          ral facility. In the Radiotherapy Department approximately 75% of  patients  treated  are  from  out-
          side of San Francisco County; they are derived from all counties  within  the  northern  two-thirds
          of the state as well as from Oregon and Nevada.  Informal consultative arrangements exist with
          physicians within all counties of the northern part of the state.  The  chemotherapy,  medical  and
          various surgical specialty clinics have similar long standing consultative  arrangements  with  the
          physicians of Northern California and adjacent areas. Within  the  institution  are  numerous  multi-
          disciplinary cancer clinics (Visible Tumor Clinic, Consultative Tumor Board, Gynecology Tumor
          Clinic, Head and Neck Tumor Clinic, Ot6laryngology-Radiotherapy Clinic, etc.) some  of  which  have
          been in operation for several decades and which serve to integrate cancer care  at  the  institution.

                                                           7.




                The radiation therapy  department  of  the  University  of  California  is  a  well  established  and
           widely known department, pioneering in supervoltage radiation therapy.       It  is   equipped   with   or
           has on order, two supervoltage units,  an  orthovoltage  unit,  a  radiotherapy  simulator  and  a  hyper-
           baric oxygen chamber.   A megavoltage linear  accelerator  is  ordered  for  delivery  during  the  coming
           year.  There is a full time  radiotherapy  staff  of  four  qualified  radiotherapists  and  three  radia-
           tion physicists.   The physics  section  has'routine  access  to  all  the  modern  equipment  which  must
           be used in the operation of the regional program.
                The chemotherapy service has a separate ward    and  out-patient  clinic  area  under  the   auspices
           of the Cancer Research Institute.    In addition, the  CRI  conducts  the  Consultative  Tumor  Board  and
           extensive research activities in the field of cancer.     There is  a  chemotherapy  staff  of  four  full
           time physicians.
               The laboratory of Radiobiology is involved in  cancer  research  activities  and  has  a  very  diver-
           sified program in radiation biology, genetics and biochemistry.      It  has  a  staff  of  eight   profes
           sional investigators plus supporting laboratories and personnel.
               The Social Service Department has long been  active  in  the  management  of  cancer  patients.
           Faculty of the School of Nursing have been engaged in  teaching  aspects  of  care  of  the  patient  with
           cancer.

                 2.  Mount Zion Hospital and Medical Center
                     The Mount Zion Hospital is an acute  general  hospital  of  450  beds,  serving  San  Francisco,
           the Bay Area, and portions of rural California and neighboring states.     The  hospital  has  acquired  a
           reputation as a center for education and research.    There are  fully  accredited  intern  and  residency
           training programs, and a well regarded post graduate course for general practitioners.      There  are   a
           variety of lectures and visiting professorships scheduled throughout the year.      Research  in   oncolo-
           gy, both at the basic and clinical  levels  is  an  important  part  of  the  hospital  research  program.
                     The hospital  maintains  extremely  active  oncologic  services  including  surgery,  chemother-
           apy and radiation therapy.  There  are  approximately  1,000  cancer  admissions  yearly  to  Mount   Zion
           Medical Center, and the Saroni Tumor Institute  is  presently  treating  approximately  8,000  new  cancer
           patients yearly. Mount  Zion  Hospital  and  Medical  Center  participates  in  the  State  of  California
           Tumor Registry, and keeps accurate records of all cancer patients.
                    In order to fill the need  for  a  community  cancer  center,  the  Saroni  Tumor  Institute  was
           established with the utilization of private funds matched by Federal  and  State  funds  under  the  Hill-
           Harris Plan. For maximum efficiency,it was constructed as  part  of  a  general  hospital  to  utilize  the
           existing hospital beds, laboratory facilities, diagnostic x-ray facilities etc.
                    The Saroni Tumor Institute is 14,000 square feet in size.      Space  has   been   allotted   for
           clinical practice', teaching, and research. A  full  time  staff  of  35  is  headed  by  three  radiation
           therapists, a specialist in nuclear  medicine,  two  radiation  physicists,  a  radiation  biologist,  and
           a social worker. The radiation therapists, the  specialist  in  nuclear  medicine,  and  one  of  the  rad-
           iatl'on 'physicists hold academic appointments in  the  Department  of  Radiology  at  the  University  of
           California Medical School. Similarly, members of the radiation therapy staff of the Un    iversity      of
           California serve, through joint appointments, as consultants at Mount Zion Hospital.     Oncologic
           consultants in the various subspecialties who have  been  appointed  to  the  Tumor  Institute  staff  see
           patients on an individual basis as well  as  conduct  regularly  scheduled  formal  and  informal  patient
           conferences.
             The radiotherapeutic equipment in the Tumor Institute includes:       25meV  Betatron   for   production
           of electrons and x-rays, 6 MeV Linear Accelerator installed in 1968, Rotational Cobalt-6   0     Telether-
           apy Unit, Cesium-137 Teletherapy  Unit  250  KV  X-Ray  Unit,  Simulator,  brachytherapy  Sources  (radium
           and strontium), hyperbaric Oxygen chamber (as an adjunct to radiation therapy).
                   The  Tumor  Institute  is  presently  carrying  out  an  approved  four  year  residency  training
           program in "straight" radiation therapy. Eight trainees are  currently  enrolled  in  the  program.
           Residents in general radiology from Mount Zion Hospital, St. Mary's  Hospital  and  Letterman  Army
           Hospital receive training in radiotherapy at the Tumor Institute.  This includes a three month
           course in the basic principles and clinical applications  of  nuclear  medicine.  Didactic  lecture
           courses in oncology, radiation biology,  radiation  physics  and  nuclear  medicine  given  by  the  Tumor
           Institute staff are attended by residents in radiology from training programs throughout the Bay
           Area.




                                                           8.







          IV.    PROPOSED PROGRAM
                 The long range goal of the Regional Cancer program  is  to  improve  care  for  cancer  patients.
          The more immediate program goal is to  provide  comprehensive,  in-depth  consultative  and  educational
          services in oncology that will supplement and improve existing resources in the area.
                 The basic philosophy of the program  is  to  provide  assistance  to  peripheral  medical  groups
          building on their existing strengths and resources, and then  to  aid  these  groups  into  an  ultimate
          position of self sufficiency in cancer management.    The  program  described  here   includes   certain
          aspects of clinical oncology, data retrieval, and education; and  it  involves  many  of  the  hospitals
          in the  area. As the program is further implemented,  it  is  intended  that  both  the  scopes  of  the
          program and the number of participating hospitals will be expanded.     Further,   it   is   anticipated
          that as programs are developed in other aspects of  cancer  management  they  will  be  integrated  with
          this program.  For example, a  program  in  chemotherapy  designed  to  supplement  and  strengthen  the
          chemotherapeutic aspects of this program was developed as a second phase to this grant application.
               Overall policy in the implementation of the program is to  be  set  by  a  Coordinating  Committee.
          This Committee initially consisted of  three  representatives  of  the  University  of  California,  San
          Francisco Medical Center (Glenn E. Sheline, M.D., Ph.D.,  Theodore  L.  Phillips,  M.D.,  B.  Ralph
          Worsnop), three representatives of the Saroni  Tumor  Institute  of  Mount  Zion  Hospital  and  Medical
          Center (Jerome M. Vaeth, M.D ., Jerold Green, M.D.,  Mary  Louise  Meurk),  and  one  representative  of
          Regional Medical Programs (Roy R. Deffebach,  M.D.)  The  Program  Coordinator  is  an  ex-officio  mem-
          ber without vote.   This committee has assumed the following responsibilities:     1)   insuring    that
          the expenditure of funds for the program is in accordance with  the  stated  budget;  2)  insuring  that
          program activities are carried out as stated in the  grant  application;  3)  insuring  coordination  of
          activities and provisions of adequate service to all participating hospitals; 4) establishing poli-
          cy for the operation of the program; 5) preparing periodic  reports  as  required  by  Regional  Medical
          Programs; and, 6) selecting the Program Coordinator.     The  composition  of  this  committee   changed
          during the implementation and future expansion of the Regional Cancer  Program  to  allow  for  the  in-
          tegration of all aspects of cancer management and any    supplements to this grant.
                 A Coordinator for the Regional Cancer Program,    Samuel R. Sherman, M.D., was  selected  by  the
          Coordinating Committee and assumed the responsibility    of the daily  administration  of  the  program.
          He is an ex-officio member of the  Committee  and  is  responsible  for  the  implementation  of  policy
          set by the Committee.   His office is located within the  local  Regional  Medical  Program  Office  and
          he is a part of the RMP staff. He  is  specifically  responsible  for  coordination  of  activities  be-
          tween hospitals and the development of adequate communications with them.

          SUMMARY OF PROGRAM ACTIVITIES
               In order to meet the needs of  the  patients  of  our  Area  with  current  resources,  four  major
          subprograms were proposed to enable more effective  utilization  and  extension  of  the  presently
          available resources.   Other programs will be submitted  as  the  needs  are  identified  and  resources
          become available.   The first is  the  Clinical  Cancer  Consultation  Service  which  provides  consul-
          tant teams to participating hospitals.    If a hospital does  not  feel  that  it  requires  a  complete
          cancer management team, it will have  the  option  of  receiving  aid  from  any  particular  specialist
          desired.   These include radiation therapy, chemotherapy,  surgery,  nuclear  medicine  and  social
          sciences.   Physicians and paramedical consultants  are  available  to  attend  local  tumor  boards  on
          a biweekly or monthly basis and/or to attend  clinics  and  treatment  sessions  in  their  specialties.
          Members   of the Cancer Consultation team will also  assist  personnel  at  the  participating  hospitals
          to   develop their own program, particularly programs in cancer chemotherapy and radiotherapy.         The
          members   of the team provide advice  oh  the  construction  of  facilities;  architectural  consultation
          will also be made available.    The educational opportunities accessible  to  local  personnel  are
          stressed; these teams will actively attempt to attract  prospective  trainees  to  the  ongoing  precep-
          torship programs at  the  established  cancer  facilities.
             .  The second portion of the program is a radiological physics service.     This   program    assists
          the available radiotherapy resources to use their present  equipment  in  an  optimum  fashion  applying
          the modern radiotherapeutic techniques.    Because of  the  extreme  shortage  of  radiation  physicists
          and equipment, it was evident that a regional effort would lead  to  a  more  rapid  and  adequate  pro-
          vision of these services.    Certain installations  cannot  afford  to  employ  a  full  time  radiation
          physicist; this, can be solved by the use of a regional program.     In addition,  the  pooling  of  re-
          sources did enable the use of sophisticated computer  techniques  to  solve  many  problems  which  pre-
          viously required hours  of  laborious  hand  calculations.
                The third program is a computerized data retrieval service.  This system is provided to parti-

                                                              9.




           cipating hospitals on request and will serve as a memory bank of information about individual
           patients  treated  by  means  of  radiotherapy,  chemotherapy  and  urger'y. It will be possible to
           put many informational items  about  each  patient  into  computer  tapes  and  on  short  notice  to  retrieve
           current information on  the  results  of  a  given  treatment  technique  in  one  hospital  as  compared  to
           the region as a whole.    This  service  will  enable  the  individual  hospital  to  evaluate  its  own.per-
           formance in the cancer field.    The  data  retrieval  service  will  also  act  as  an  important  part   of
           the overall evaluation of this regional program.       It  is  anticipated  that  both  the  data   retrieval
           and the  regional  medical  physics  programs  will  serve  to  meet  continuing  needs  for  many  years  to
           come.
                  The fourth  portion  deals  with  an  educational  program  for  medical,  paramedical  and  lay  pub-
           lic.  Educational aspects  are,  of  course,  included  in  each  of  the  other  three  subprograms  and  it
           is probably  within  those  portions  of  the  program  that  the  greatest  opportunity  for  education  occurs.
           With respect  to  training  of  radiotherapy  technologists,  a  program  has  been  organized  with  the  City
           College of San Francisco.  The  initial  year  of  didactic  study  will  be  at  City  College  with  the  prac-
           tical aspects being  given  at  the  University  of  California  Medical  Center  and  Mount  Zion  Hospital.
           The first class was opened in 1970.
                  It is  hoped  that  one  or  two  students  graduating  from  the  program  each  year  will  continue
           for two additional years during  which  they  will  be  given  credit  courses  at  the  Medical  Center  and
           will be qualified for a Bachelor's Degree.
                The additional schooling will include detailed teaching of Physics and Dosimetry and will
           qualify  these  persons  to  become  dosimetrists  and  chief  technicians   in   Radiotherapy   Departments.
           This type of person  would  then  provide  the-major  and  most  important  link  between  the  central  phy-
           sics service of the Regional Medical Program and the individual radiotherapy department.

           CONCLUSION
                  The first  major  step  in  meeting  a  number  of  the  California  RMP  objectives  for  cancer  manage-
            -t is being  accomplished  in  the  first  phase  of  the  Regional  Cancer  Program  that  is  now  operational
           Ten
           in Area I.  This  program  has  been  well  accepted  and  widely  endorsed  by  communities  throughout  the
           entire Area.    Phase  I  was  developed  through  a  cooperative  arrangement  between  two  medical  facilities
           in  Area  I  that  have  broad  based  oncology  programs.  These  facilities,  the  University  of   California,
           San Francisco  and  Mount  Zion  Hospital  and  Medical  Center,  serve  as  the  principal  provider  institu-
           tions  for  the  program.  This  arrangement  provides  participating  institutions  with  1)   clinical   can-
           cer  consultation  by  medical  specialists,  @)  radiophysics  consultation  and  treatment   planning,   3)
           computerized data retrieval service, and 4) other specialized education services.
                   In addition, there  was  a  defined  need  to  develop  further  services  in  medical  oncology  and
           cancer  chemotherapy,  and  to  establish  a  nuclear  medicine  bank.  The  nuclear  bank  has  just  recently
           been approved by-the Division of Regional Medical Programs, but not funded.
                   Phase II has  been  designed  to  supplement  and  enhance  Phase  I;  the  two  will  be  integrated
           both functionally and administratively.       Innovative  educational  aspects  of  the  Phase   II   Program
           include  its  emphasis  on  local  community  chemotherapy  clinics,  model  multidisciplinary   team$   infor-
           mal  telephone  communications,  and  an  individualized  in-service  tutorial  program   rather   than   conven-
           tional  didactic  programs.  Cooperative   arrangements   between   institutions   and   health   professions
           have been developed to  a  high  degree  throughout  the  Area  to  ensure  that  the  program  can  be  imple-
           mented   rapidly.
                   This proposal  is  an  attempt  to  provide  more  comprehensive  care  to  cancer  patients  and  in
           the process to define gaps in services which indicate further program development.
                   Once Phase  II  becomes  operational,  the  components  of  the  program  will  no  longer  be  described
           or though  of  in  phases.  They  will  rather  be  the  necessarily  interrelated  activities  of  a  single
           comprehensive program designed for optimal care of the cancer patient in his own community.
           AUDIENCE  QUESTION:  What  is  being  done  by  the  Cancer  Program  to  bring  services  to   disadvantaged
                                 and ghetto areas in Area I?
           DR. SHERMAN:    The Cancer Proqram is educational in its thrust.         No direct  services  per  se  are  in-
                           cluded in compliance with the original proposal's        goals  and  objectives.  These   ed-
                           ucational activities are centered in institutions        and  communities  which   have   the
                           facilities  and  resources  to  provide  cancer  management.  Some  of  them   are   adjacent
                           to  disadvantaged  areas  and  consequently  render  upgraded  care  to  cancer  patients  of

                                                                 10.







           DR. SHERMAN:  of those areas.
                          If the Phase II Program becomes funded, additional and more comprehensive attention
                         can be focused on the areas having high concentrations of poor and minority groups.





                                          AREA VIII STROKE VOLUNTEER PROGRAM
          MRS. EMILY HACKLER, R.N.
               Area VIII of the California Regional Medical Programs has designed a pilot project  for  volun-
          teer training in an attempt to provide a more comprehensive approach to meeting total  health  needs
          of the stroke patient. It has become apparent that volunteer services in the  community  could  con-
          tribute positively to the continuity of care in rehabilitation and re-socialization of  stroke  vic-
          tims. Under professional guidance and supervision this vast area of "hidden  talent"  may  help  to
          broaden the spectrum of stroke care.

               The volunteer training program is aimed at the patient who has survived the  stroke  and  will
          re-ehter the community with a physical or communication disability. Upon discharge  from  an  acute
          hospital a patient is sent either to an extended care facility, his own home, or on some occasions,
          to a board and care residence. It is our contention that this  is  a  critical  transition  because
          the patient and family (if there is one) are confronted with the difficult task of  readjusting  to
          life with a disability. All too often, little consideration is given to  the  need  for  continuing
          rehabilitation and help with the patient's re-socialization;  planning  for  the  patient's  future
          care is neglected either because the need for a supportive program is unrecognized or  the  service
          is unavailable. An aggressive rehabilitation program may  help  an  individual  regain  or  relearn
          tasks of daily living, but a continually stimulating environment over an extended  period  of  time
          is essential if he is to maintain the level of activity with the realm of his  physical  abilities.
              The volunteer, under professional and supervision, may be able to provide  the  patient's  con-
          tact with the outside world as well as reinforce rehabilitation programs which have  been  tailored
          to meet the specific dimensions of his physical and communication handicaps. We believe  that  con-
          tinued interaction with the volunteer, who is a member of the outside world, may help  prevent  re-
          gression of relearned skills in activities of daily living and help alleviate the feelings of  iso-
          lation that the easily fatigued and often depressed  patient  experiences.  In  observing  tensions
          of the immediate family, the patient is apt to sense that he has altered many  living  patterns  of
          the persons for whom he has the highest regard. This basic concern,  combined  with  the  multitude
          of personal restrictions, very often results in a persistent desire for complete social  withdrawal.

              Our initial program will be geared toward the exploration of the needs of stroke victims
          with emphasis placed on stimulating their communication abilities and assisting them in  re-social-
          ization. The course will be conducted over a period of ten weeks and will consist of  40  hours  of
          lecture  on the causes and treatments of stroke. The students will  observeregularly  scheduled
          patient care conferences presented by the stroke team at the hospital in addition  to  field  trips
          to rehabilitation centers and observations of speech retraining.

              The pilot study will be conducted at St. Jude Hospital in Fullerton, one of  the  first  insti-
          tutions in Orange County to implement the concept of a stroke team. It has approximately 250  beds,
          with plans for a-n additional 80-bed rehabilitation unit scheduled to be completed in the early
          fall of 1970. The project has been given overwhelming endorsement by the  hospital  administration.
              The Women's Auxiliary of the California Medical Association has  voted  to  sponsor  this  pro-
          gram as their project of the year, Project Re-Entry. We shall draw volunteers from  the  Orange
          County branch of the Women's Auxiliary of the CMA, the Guild of St. Jude  Hospital  and  interested
          members of the community. Many of these women are highly motivated, intelligent  and  dedicated
          people who have impressive backgrounds in community activities.
            I All patients who will be followed in the pilot project must  be  referred  by  their  attending
          physicians. Periodic reports will be given to the physicians by the public health  nurse  coordina-
          tor. She also is responsible for supervising and evaluating  the  effectiveness  of  the  volunteer
          placement. Of course, the patient and his family must consent to  this  type  of  follow-up  before
          a volunteer assignment is made. The volunteers will be  expected  to  coordinate  their  activities
          with other community agencies that are providing care to the patient, such as  the  Visiting  Nurse
          Association or the Easter Seal Rehabilitation Center.  The volunteer Will be a visitor to the
          patient in the extended care facility or his home; she will be a driver when  necessary;  she  will
          be a link with the community; but most important, she will be a friend.  Hopefully,  by  mobilizing
          volunteers to provide services to the lonely, frightened and often-times aged members of  our  com-
          munity we shall begin to meet some of the needs of the chronically ill population.

          SIGNIFICANCE

             As a result of the pilot project we hope to evaluate the effectiveness  of  the  trained  volun-
          teer in meeting the long-term needs of the chronically ill individual.  The volunteers will


                                                        12.




              function within the perimeters of care plans established  by  the  health  professionals  and,  hope-
              fully, will be able to reinforce the rehabilitation program  in  the  patient's  home.  She  will  be
              able to maintain an ongoing relationship with the family  and  patient,  yet  have  consultation  and
              supervision available from the public health nurse at all times.
                  We believe that the inclusion of the volunteer,  as  an  informed  and  significant  member  of  the
              health team, will demonstrate that her level  of  dependability,  creativity  and  adaptability  will
              increase commensurately with her assignment.    Hence, from those who are capable of continuing
              assignments with chronically ill individuals and their families and  can  relate  in  a  healthy  man-
              ner to both patients and the professionals  responsible  for  the  planning  and  continuing  assessment
              of patient care programs, we anticipate being able to  develop  a  profile  of  volunteers  most  suite
              to responsible, long-term commitments.
                   In addition, we are hopeful that there will be not only  a  continuation  of  the  service  to  the
              chronically ill in the community, but there will be an expansion  of  it  throughout  the  county  if
              this project demonstrates that stroke patients benefit from volunteer placement, and if the volun-
              teers feel this type of responsibility is a reasonable assignment.     The duty  of  coordinating  and
              supervising the volunteer activities, logically, would be placed on a knowledgeable health profes-
              sional in the community; she could be the home care coordinator in  the  acute  care  facility  or  a
              nurse in the local home care agency.    At this time it appears that the person responsible  or
              training and supervising the volunteers should be a nurse  who  has  a  strong  rehabilitation  back-
              ground.  The cost of such a program is nominal, in contrast to  the  vastly  rich  rewards  one  might
              anticipate for the strong patient.
              AUDIENCE QUESTION:  What is the age range of the stroke volunteer?
              MRS. HACKLER:  The  volunteers range from ages 20 through middle 50.
              AUDIENCE QUESTION:  Is the volunteer program open to men?
              MRS.HACKLER-  Yes.   I would like to include men on this program.     However, at the  present  time,
                            I do not have any male volunteers.     (Mrs. Hackler mentioned that Dr. West, an ortho-
                            pedic surgeon who has had a stroke, is  quite  interested  in  the  volunteer  program.
                            He has addressed the volunteers.)
              AUDIENCE QUESTION:  Do you have any sounding of patient acceptance?
              MRS. HACKLER:  So far the patients and their families have accepted the volunteers well.
              AUDIENCE QUESTION:  How do you locate the patients?
              MRS. HACKLER:   Every time a stroke patient is admitted to a hospital  the  patient  is  attended  by  a
                              stroke team for the purpose of  therapy  treatment  at  that  particular  hospital.  The
                              attending physician and/or the stroke team attendant refers these cases to me
                              (Mrs. Hackler) for follow-up treatment by a volunteer worker.













                                                                13.






                                                      GENERAL SESSION
                                           Thursday, October 29, 1970 8:  30 a.m.


         DR. ANDREWS: We are very fortunate to  have  with  us  this  morning  Paul  D.  Ward,  Executive  Director,
         California Committee on Regional Medical  Programs  and  Vernon  Wilson,  M.D.,  Director  of  Health  Ser-
         vices and  Mental  Health  Administration  of  the  Department  of  Health,  Education  and  Welfare.  Mr.
         Ward will introduce Dr. Wilson.
         PAUL WARD: Thank you  Neil.  It's  a  pleasure  to  introduce  a  very  unusual  gentlemen.  When  he  was
         past the age of 35 he earned a BS, MS and MD in two years.       Anybody who can  do  anything  after  the
         age of 35 is a great man.    He graduated  from  the  University  of  Illinois  Medical  School  in  1950.
         Almost immediately upon graduation he  received  an  appointment  to  the  faculty  as  assistant  profes-
         sor and assistant dean. I don't know  how  he  accomplished  this  and  a  set  of  guidelines  should  be
         written because I know a lot of students who  would  like  to  do  the  same  thing.  He  became  Dean  of
         the University of Missouri Medical School  in  1959;  he  served  as  Coordinator  of  the  Missouri  RMP;
         he left that position to  become  Vice-President  for  Health  Affairs  at  the  University  of  Missouri.
         His publications and writings have  been  essentially  in  the  field  of  medical  administration  and  I
         wish to add this comment about  Dr.  Wilson  and  his  present  position.  He  can  have  a  great,  great
         impact upon health care in the United States.
              As you know, our own  Rober  Egeberg  became  Assistant  Secretary  for  Health  and  Scientific  Af-
         fairs.  That position is essentially a policy position.  We've often described it as a rather
         dangerous position and Roger knew it when he took it, because you sit up there virtually naked
         to the world. Sort of the focal point  but  with  hardly  any  staff  esentially  to  protect  you.  Vern's
         position is one which commands great resource strength in terms of highly trained, highly educated
         personnel which can  put  together  programs  and  affect  those  programs  because  of  their  tremendous
         staff backing.   I Personally believe that Vern will  do  a  tremendous  job  in  this  regard  because  I
         watched him build the Regional Medical Program in  Missouri  which  did  some  fantastic  things  in  terms
         of the kinds of programs he created.    In spite of  the  politics  of  Missouri,  he  accomplished  early
         in the game a great many advances.  He knows the RMP backwards and forwards and it is my very
         great pleasure to introduce Dr. Vernon Wilson.


                                                         REMARKS

                                                   DR. VERNON WILSON

                                                        DIRECTOR
                                  HEALTH SERVICES AND MENTAL HEALTH ADMINISTRATION


         DR. WILSON:  Thank you Paul and Neil.    If I were as wise as you've just attributed me to be I
         probably would accept an introduction and sit down while I'm ahead.  Perhaps one of the things
         we ought to clarify on the beginning is that  I'm  not  really  a  public  speaker.  I  am  an  individual
         who takes a great deal of interest and gets a  great  deal  of  pleasure  as  well  as  education  out  of
         meeting with groups like this.   I would have preferred to discuss the kinds of things that will
         be presented here to you in seminar fashion so that you would have a fair and equal opportunity
         to respond.  Constraints of time are not going to  allow  that  so  I  begin  simply  by  saying  that  if
         .I speak with some degree of certainty on some of  these  points  it's  with  a  complete  sense  of  humi-
         lity knowing that if I had all of the available  wisdom  to  bring  to  bear  on  these  points  what  I'm
         about to say would surely have been modified somewhat.     Nevertheless, there are some issues to
         which we must address ourselves with some clarity.
             in the few minutes we have here it's  my  hope  to  place  some  of  those  issues  into  perspectives
         to give you some feeling of how we are progressing and to invite you as a collective group to
         respond to us in the national responsibilities we have.     I'd like to talk for a few moments not
         in the negative sense, but in a realistic  sense  about  the  constraints  under  which  planning  in  the
         health fields now must operate and this seems  to  me  that  constraints  are  not  necessarily  negative.
         I'm not one who believes in raising children that constraints are bad, I think they are a good
         point from which to start to work out a meaningful and coherent activity.
            One of the constraints under which we  operate  is  that  most  of  the  health  money  we  receive  is
         categorical in one nature or another. We  start  from  the  point  of  view  that  Congress  has  substan-
         tially an interest in voting money into the health field from a categorical point of view.           Those
         of you who have worked-with United funds know that communities  also  favor  this  kind  of  an  approach.
         The second constraint that's probably most misunderstood at  the  moment  is  that  there  are  some  very
         teal budgetary constraints and the approach of the Federal government to -the  handl  i  hg  of  the  bud-
         get for health has undergone some change in the last two or three years.      Let me give you three
                                                           14.






               or four of these in rapid succession and if there's  some  of  this  you  would  like  to  discuss  a
               little bit later I would be happy to provide additional insight  into  it.  (1)  of  the  $20  billion
               plus that's being spent for health in the national scene  at  the  moment  out  of  the  Federal  Budget,
               some $16 billion of that is in what are known as uncontrollable items.       In this  case,  Medicare
               expenditures.   Roughly $4 billion is spent in what is considered  to  be  controllable  -  NIH,  VA,
               Health Services and Mental Health Administration and this group of activities.
                    Now there is a new Federal approach to how one  balances  the  books  that  Paul  McCracken  has
               described in newspaper releases. Some  of  you  who  have  been  reading  with  care  recognize  that
               there will not be deficient spending  in  the  Federal  government  unless  the  gross  national  product
               is equivalent to that which would be expected if there was a 96% employment level.       If   under   96%
               they will deficient spend; if at 96% or  possibily  above  there  would  be  no  deficient  spending.
               Since there is no real intent to change the tax structure so  far  as  any  of  us  can  perceive,  since
               if you are in a deficient spending time you don't raise  taxes  and  if  you  are  in  surplus  time  you
               don't need to raise taxes.   The taxpayer, I think, gave a clue to  this  some  time  back  and  most  of
               you have watched this phenomenon through the eyes of taxpayers.      In the  face  in  this  somewhat
               stable relationship between gross national  product  and  tax  structure,  health  is  still  showing
               some slight increase in the percentage of expenditure, but this is  not  going  to  have  the  same  kind
               of percentage increase in monies through controllable funds  as  it  has  had  in  the  past.  The  third
               item I think that functions as constraint, and I'm leading really  to  the  basis  for  the  sort  of
               planning we need to do together, is that there is still  a  rather  sharp  imbalance  between  the  capa-
               city of the health care system to make its services available and the demands.       In fact,  there  are
               still enough resources coming in that our costs are  going  up  in  an  economic  response  to  the  sup-
               ply and demand phenomenon more than basic costs.     Finally, in the list  of  constraints  on  planning,
               take into account that there are no real agreed upon  national  priorities  by  which  you  can  start
               to talk about an orderly distribution of funds  in  the  face  of  a  shortage  of  potential  funds.
                    Let me quote a few of these for you  quickly.  There  is  equity  of  access.  Some  people  have
               greater access than others to the health care system which  may  be  affected  by  geography  in  the
               rural areas or a number of other  things  including  unwillingness  of  professionalsto  serve  in  a
               given area.  There is the emphasis on age of children.     There is an emphasis on disease categories,
               heart, stroke, cancer, and others.    There's an emphasis on  manpower  addressed  to  the  capacity.
               There's an emphasis on economic issues per se; OEO;  there's  an  emphasis  on  social  issues,  drug
               abuse, and alcoholism and then there's an emphasis on ethnic issues; Indian Affairs.       This  is   not
               an exhaustive list, but it gives you some idea of the  various  attacks  that  are  being  taken  upon  a
               system which has very few established priorities and it  is  rapidly  becoming  evident  that  if  you
               do not have enough resources and you do not  have  comparable  items  against  which  you  can  make  de-
               cisions that you either do not have a planned process or else  you  reorder  the  way  in  which  you
               approach planning.
                    It is clear to me as I observe what's going on in  the  national  scone,  not  only  in  Washington,
               but I think among groups across the country, that there  is  a  growing  agreement  that  equity  of  ac-
               cess  the ability to get into a health care  setting,  is  rapidly  becoming  sort  of  the  first  order
               of P;iority and that right along with that goes  a  tremendous  emphasis  on  one  of  the  major  blocks
               to equity of access which, of course,  is  the  economic  setting  within  which  care  takes  place. Now
               if you turn to planning from an RMP point of view,  and  here  I  am  volunteering  to  you  my  thinking
               and this is not a mandate in the sense that  someone  has  decided,  it  rapidly  becomes  apparent  that
               if in fact you have roughly $100 million a year in  a  nation  which  is  spending  $60  billion  on  the
               health care system and you wish to affect that system, a  frontal  attack  on  health  care  as  such  is
               probably going to net you relatively little.    This says.that if  you  are  going  to  deploy  these
               funds in a way that gives you a chance, you  must  continually  introduce  innovation  into  the  system.
               You must be very careful that you do not fall into the trap that  I  think  has  engulfed  some  by  try-
               ing to take on the direct care of health needs as such,  or  you  will  wind  up  without  an  ability
               to work with the !ystem which so badly needs attention, and, I think, some reordering.
                    There are a few things I would like to leave with some  of  you  who  may  not  understand  about
               Health Services and Mental Health Administration (HSMHA).  This  is  the  two  minutes  to  be  paid  for
               having brought me out here.   You know you've got to learn  a  little  about  my  hobby  too.  There  are
               11 programs in that interesting organization, operating  under  16  pieces  of  legislation  at  a  level
               each year of about $1.6 billion.    It operates in several thousand locations  and  there  are  a  number
               of programs from different points of view that relate to it.      It has a full  range  of  health  acti-
               vities all the way from comment and sort of reporting  ,  i.e.,  the  National  Clearinghouse  for  Smok-
               ing down to the Indian Health Service where we actually  give  virtually  all  of  the  health  care.
               The list of groups that are in that  constellation:  National  Institutes  of  Mental  Health,  including
               St. Elizabeth's Hospital: Maternal and Child Health, including Crippled Children's Service:
               National Center for Health Statistics;  National  Center  for  Health  Services,  Research,  Development:
               Regional Medical Programs;  Community  Health  Services  with  Comprehensive  Health  Planning  including
               Migrant Health and OEO activities.    Now as we are beginning to pick  up  some  of  those  clinics,  the
               Federal Health Services,  including  U.S.  Public  Health  Service  hospitals;  Family  planning;  Center

                                                                 15.







          for Disease Control in Atlanta; Indian Health Service; and the Hill-Burton.
              It turns out that many of those acts have the same authorities in them and  that,  as  a  matter
          of fact, we have some internal planning to do of our own so I'm much interested in what you're
          doing here today from more than an academic point of view.  I hope that you will understand as
          we begin to look at the various programs. We're interested in being sure  that  what  we  do  is  in
          fact in concert and is sufficent from the point of view of getting the most  effect  from  your  tax
          dollar.
            Let me read one sentence from the announcement going into the Federal  Registry  saying  "Regional
          Medical Programs serves as the focal point in health services and mental health  administration  for
          improving personal health care to development of the quality of  performance  by  the  providers  of
          care placing special emphasis on continuing education of established professional  health  personnel
          and on cooperative arrangements among providers of care."  That's  not  the  whole  description  but
          for purposes of abbreviation I'll leave some of the other out. But  I  think  that  gives  you  some
          part of the context in which we work.
              Let me address in a few minutes another issue with which you  will  be  coming  in  contact  and
          which I think bears on the issues of planning from your point of view and  the  future  of  RMP.  We
          are very much involved in what has been called decentralization. It is  a  very  much  misunderstood
          process. As a matter of fact, you should like it and I hope you do. The only  shift  that  is  going
          on in decentralization which would, I think, be a possible source of  concern,  at  least,  as  I've
          talked to RMP groups, really does not relate to any removal of perogatives  in  the  RMP  itself  in
          the regions, but rather a transfer of responsibilities, from the national  office  to  our  regional
          offices of some of the authorities that we have posed at the  national  level.  It  is  our  intent,
          in fact, to go out of project by project review within the RMP's themselves and to  give  increasing
          responsibility to the local advisory group for making that kind of decision. We  view  our  role  at
          the national level as being increasingly that of reviewing whether or not your local  decision  mak-
          ing apparatus is fair, is equitable and that the general quality of the way in which you're  attack-
          ing the national guidelines and the national goals that have been set out is, in fact, an  effective
          one. We are, I think, in that process looking relatively intensively  at  the  mechanisms  by  which
          we can be of most help to you and none of the decentralization indicates any  lack  of  interest  at
          the national level. Let us know if you find that something is going on  that  keeps  you  from  get-
          ting a good job done. There is a difference  between  delegation  and  abandonment.  This  is  dele-
          gation, but by no means an abandonment. If you find things  that  are  not  working  correctly,  our
          office and the national office is always available to review this.
               Another issue that I'm sure is going to be coming to you, and again related  to  our  topic  of
          this morning, has to do with the fact that we are now undertaking an intensive study of  the  inter-
          relationships between Comprehensive Health Planning, Parts A & B particularly,  and  Regional  Medi-
          cal Programs and the National Center for Health Services, Research  and  Development.  They  have  a
          tremendous number of overlapping authorities and responsibilities. We  are  beginning  to  come  out
          with some hypothesis that will be under test over the next few months and which  will  be  discussed
          finally with your advisory groups, your coordinator and obviously with  the  Councils  involved.  It
          would appear that perhaps that a simplistic description of the role of  Comprehensive  Health  Plan-
          ning might well be that it has an obligation to deliver in an equitable manner, health care
          through the planning process obviously, not directly, in some geopolitical  area,  to  a  particular
          group of people. It has a continuing service obligation to that group  of  people  in  relating  and
          planning to the services they receive and that is primarily  consumer  and  public  oriented  as  it
          were even though it must work with the whole system.
               RMP as a complementary role begins to look as an activity which perhaps  has  a  slightly  dif-
          ferent cast. It presents opportunity to a given area  for  innovation  and  affecting  planning.  It
          addresses itself primarily in its efforts to those people who have a responsibility for  giving  the
          health care, the professionals, the institutions, and the relationships between them and  that  fin-
          ally it has a heavy responsibility because of this for educational programs addressed to  that  par-
          ticular group. A National Center for Health Services  Research  and  Development  then  becomes  our
          study and evaluating am and cooperative area where the research is perhaps more  on  the  theoretical
          side, but nevertheless directly concerned with quality of health care.
               As I look at the future then of RMP and for the purposes of this particular assemblage  as  you
          attack yourtasks in the next hours, by definition I think we have to come up with  clarification  of
          the relationship, not only between RMP and CHP in the national center, but with  those  other  parts
          of Health Services and Mental Health Administration which is the national  arm  of  health  planning
          in one sense. Second, it seems to me that we are going to have to look very carefully  at  the  kinds
          of authorities that have been delegated in these several areas and make sure that we are  not  dupli-
          cating in what we delegate to you, the regions or the programs .  There is an agency-wide group  that
          is looking at this process at the national level and I would hope that that example might  extend  in
          orther areas as well as it has in California to the fine cooperative work that  has  been  going  on
          here between particularly, the "b" agencies and RMP. We are going  to  be  looking  to  RMP  as  the
                                                           16.




                            ichest  contact  with  professional  and  with  academic  communities  as  the  real  re-
              agency with the r                                       ey make  to  the  planning  process,  be  the
              source of individuals who will, by the contribution th   nal Council and I say    it  to  this  group
              catalyst force, in change. I've said this to the Natio    ole  to  be  assumed  by  the  RMP  as   an   organ-
              that there are many reasons why there is need for this r
              ization. It should not be placed  in  any  kind  of  an  advantageous  spot  because  I  think  equally
              important that someone should be engaged in  intensive  study  on  the  consumer  and  on  the  public.
              Only then can you have a meaningful dialogue.
               I've  asked the national council  to  begin  to  think  about  all  of  the  HSMHA  consultation  in
              that kind of light. They looked a  little  dubious  when  I  invited  them  to  do.that  but  they  will
              find out sooner or later we really meant that invitation.     Now, let me say two other things
              that you need to keep closely in mind when you think about RMP.      There  isn't,  in   my   opinion,   going
              to be any sizeable increase in funds in the immediate future.      We  have  just  been  going  through
              the business of the '72  budget  and  all  I  have  to  say  is  that  after  seeing  what  happened  to  some
              of the other groups, I've almost decided that holding the line is a gain at the moment.           The
              crunch between the uncontrollables, which are coming up  to  a  ceiling  and  it  really  is  a  very
              sharp ceiling, across the top of available funds, says that  if  you  stay  even  in  that  kind  of  a
              decreasing space you are really  ahead  of  the  game  and  I  think  that's  sort  of  the  way  we  look  at
              i t. I'm not a pessimist.  If we understand the  ground  rules  we  ought  then  to  be  bright  enough
              to  decide  how@we  order  our  priorities  and  keep  moving  even  though  there  may  be  some  disappoint-
              ments in not being able to do  all  those  things  that  we  have  started  out  and  thought  we  might   do.
                RMP is the best model    yet  developed  for  the  incorporation  of  community  action   at   the   profes-
              sional level into a change instrument for society.     Its  success  or  failure  is  qoing   to   depend   on
              your willingness to look at whether that glass is half empty or half full.        Ana  I   would   hope   that
              a measure of increase  and  resources  is  not  going  to  be  the  only  measure  you'r@  goingtto  apply  to
              whether or not you have been successful.    It is my personal opinion that we     will  go   hrough   a
              plateau period,and that this is somewhat  a  testing  period  to  find  out  whether  or  not  RMP  has
              found its  place  in  concert  with  community,  with  the  professional  qroup  and  can  develop  an  under-
              stood national voice  that  speaks  very  clearly  to  a  wide  number  of  people  in  high  places  who  are
              still a little confused about what RMP is.     I  think  your  planning  efforts  need  to  focus  in   fairly
              rapidly on what  RMP  is  and  rather  than  focus  on  the  business  of  all  the  global  things  it  would
              have been nice to have done if you had had the money.      I  think  it'll  be   much   more   profitable   to
              look at the  money  you  have,  the  need  to  keep  that  money  fluid  for  innovative  purposes  then  come
              up with the kind i;f solution that says very  clearly  to  anyone  and  evidently  to  everyone  we  do
              have a role, it is important and we need your support.      I  volunteer  to  answer  a  few  questions
              if there are some.
              A           TION:   I would  like  a  clarification  on  the  special  bulletin  for  the  $1.9  million  dol-
                          eamarkea Tor the Model Cities program that correlates with RMP.            l  haven't   got   that
              squared away yet in our program  and  we  need  this  type  of  information  to  know  where  we  can  go  from
              there since RMP  is  the  closest  thing  we  can  get  to  community  groups,  universities,  and  hospitals.
              This type of information needs  to  be  explained  now  so  we'll  know  what  type  of  relationship  we  can
              work with RMP.
              DR. WTLSON:  Are you speaking from the point of view of the Model Cities group?

              ANSWER:  Yes.
              DR. WILSQN.- Let me respond to that.     This  is  very  much  in  discussion  at  the  national   level   and
              m not going to give  you  as  much  of  an  answer  as  you  would  like  because  there's  still  substantial
              discussion going on.   There  are  two  issues  at  stake  here,  one  appeals   to   Model   Cities   program
              has been given the  task  of  working  with  a  particular  geographic  area  and  with  a  geographic  group.
              The  RMP  mone  comes  from  the  national  appropriation  with  certain  restrictions   and   guidelines   on
                          y
              it and certain inherent responsibilities for  the  quality  of  and  the  type  of  activity  to  go  on  this
              that resides in the National Council.      Now the  real  question  that's  under  discussion  at  the  moment
              between Mr. Page,  myself,  Pat  Hitt  and  others  is  "how  do  we  keep  the  quality  and  consistency  of
              use of that money which comes for  a  specific  purpose  at  the  national  level  at  some  kind  of  an  un-
              derstandable  relationship  with  RMP  and  at  the  same  time  serve  the  needs  of  the   Model   Cities?" It
              would appear  that  the  resolution  is  going  to  come  out  something  like  this:  That  as  a  matter  of
              fact these perogatives will need to stay in the hands of the N@tional RMP Council , the Model Cities
              will be encouraged to  and  helped  in  the  process  of  turning  in  applications  which  will  be  competi-
              ti ve. The money wi I 1 not as far as I can tel I , be turned i nto a sum of money  that  wi  1  1  be  turned
              over  to  Model  Cities  decision-making.  That  is  a  prediction  on  MY  part,  not  a  settled  fact.  We,
              in fact, were just  discussing  this  again  within  the  last  two  days,  but  that's  as  close  as  I  can
              get to it for you at the moment.
              AUDIENCE QUESTION:    I don't think that my question was directly answered.  Will the money be turn-
              e  @@@tO  Model  Cities  Programs?  Weire  talking  about  some  means  of  coordination  where  it   can   be
                                                                   17.




                                                          being   given   to   indigenous    communities$    geographical    or
              evaluated to the point that services are     Cities   and   RMP   work   together   toward   accomplishing   this
              however you want to Put it. How can Model
              oal?
              @R-. WILSON:  Apparently, it didn't come through, let me try one more time.           I'm   saying    that    the
              Mod 1 Cities group may function as applicants for this money.         In   that   process   one   would    assume
              they would not  apply  for  money  that  wasn't  in  concert  with  what  they  are  trying.to  do  locally.
              If,  in  fact,  that  application  meets  the  national  guidelines  and  requirements   that   should   put   it
              into cooperative relationship to which your addressing yourself.          The  money   that   is   earmarked
              for the Model Cities program  is  available  only  for  use  in  those  programs  and   the   Model   Cities
              people  can  apply  for  that  as  any  other  applicant  which  is  the  way  it  looks  like  it'll  work  out.
              We hope you won't apply for it in any way that is not consistent with your overall planning
              effort.
              AUDI           N:  What  can  Model  Cities  expect  from  RMP  in  the  way  of  help  in   the   health   plan-
              nin(             e  present  time,  I  represent  San  Francisco  Model   Cities.   We   have   one   person
              ass,@          ia  Greer,  who  is  also  assigned  to  Oakland  Model  Cities,  and   Richmond   Model   Cities.
              As @           h  are  going  into  their  action  year.  We  are  presently   scheduled   to   move   into   our
              act,on year an yet we have not been able to get any help from RMP.            It  would  seem  to  me  an   awful
              lot to expect one person to cover such an area.       Are  you  planning  to  expand  this   role   to   have   a
              meaningful effect into the Model Cities program?
              DR.  WILSON:  Following  the  request  that  comes  to  us  from  the  Office  of  Management  and   Budget,   we
              re  assigning  people  out  into  the  regional  offices  as  rapidly  as  we  can  consistent  with   the   fact
              that we have had  a  restriction  on  the  number  of  people,  in  fact  a  reduction  in  the  number  of  peo-
              ple  overall.  The  only  way  that  we  see  that  there  can  be  some  relief  is  through  the  RMP   itself,
              which  has  some  money.that  in  concert  with  the  other  responsibilities  they  have  could   be   made
              directly  available  by  the  RMP  region  that  coincides  with  the  Model  Cities  activities.  Out   of   the
              regional office  I  do  not  see  any  relief  within  the  next  year  as  I  look  at  the  personnel  ceiling,
              that would be of the substantial size to which you are alluding.
              AUDIENCE COMMENT:  It  would  seem  to  me,  with  the  charge  to  RMP,  there  should  be  some  kind   of
              meanin fu  role to get involved with the Model Cities program.           As  I  presently  understand   the   role
              of RMP this  is  the  role  that  is  supposed  to  be  effective  at  the  moment.  Now   what   is   your   role
              with Model Cities?
              DR. WILSON:  Ours  in  Model  Cities  is  quite  like  our  role  elsewhere  and  that  is  while  we  have  auth-
              rizations,  I  would  guess  if  we  could  handle  all  the  authorizations  we  have  we  probably   would   be
              a 6 or 7  billion  a  year  program.  As  a  matter  of  fact,  we  have  very  real  restrictions  on  any  kinds
              of new money.  Now  the  charge  to  work  with  the  Model  Cities  is  quite  like  our  charge  to  work  with
              Heart,  Stroke  and  Cancer,  with  Kidney  Diseases,  which  has  been  added,  and  others.  We  do  not   have
              any  massive  new  initiative  which  we  can  invest  in  this  from  either  the  regional  or   the   national
              level.  This  is  going  to  have  to  be  worked  out  with  the  RMP  groups  who  have  also  other  responsi-
              bilities and  none  of  us  are  going  to  have  enoguh  to  satisfy  all  of  the  needs  which  we  think
              ought to  be  met.  That's  where  I  started  and  I  think  we  have  to  face  that  pretty  head-on  and  re-
              alistically.  Yes,  one  more  and  I'm  going  to  quit;  Ilm  running  into   the   next   program.   I'll   be
              happy to talk to any of you individually after we finish here.
              AUDIENCE  QUESTION:  What  did  you  mean  by  saying  the  RMP  had  to   avoid   becoming   involved   in   the
              c;i s-of direct health care services?
              DR. WILSON:  I  am  alluding  to  the  fact  that  there  are  $16  billion  dollars  being   spent   on   direct
                                                          that Rmphas 100 million of it.  Theref re it had to be very
              earth care services at the moment and                                                     or
              careful  about  addressing  any  of  its  dollars  to  those  things  which  provided   directly   for   the
              health care.   It  had  to  work  with  the  system,  with  the  planning   and   the   innovative   things   and
              work with  it  in  a  way  so  it  can  withdraw  that  money  and  use  it  again  for  other  innovations.
              That's all.  Time limited projects are really what I'm talking about.
              A              ION:  So you didn't mean to imply that the provision of direct services was
              DR. WILSON:   I  meant  to  imply  that  it  needs  to  work  with  the  mechanics  and  the  system  for  getting
              t done and it needs to do it in time limited projects.            It  does  not  get  itself  into  the   position
              where its money is continually absorbed for the same thing over a period of time.                      Continuing
              education being the one exception.       If  it  doesn't  work  in  time  limited   projects   it   will   suffer
              the  fate  of  the  old  chronic  disease  monies  which  finally   became   expected   every   year   and   were
              spent  before  they  arrived  and  innovation  sort  of  became   tough   to   handle   under   those   programs.
                                                                     18.




          I'm sorry, this is helpful to me, but I think I had better let the chairman move on with his pro-
          gram.
          DR. ANDREWS:  Thank you, Vern.  Dr. Wilson has agreed to react at the end of the program this morn-
          ing.  He  as very graciously agreed to carry on his discussion in private with you and I hope you
          will take the opportunity to do this.  We must hurry on with our program to stay on time this
          morning.  Area II will present a discussion of their project concerning Multiphasic Screening to
          be given by Mrs. Jeanne Lebrun, the Associate Coordinator of Area III


































                                                           19.





                                            AREA III MULTIPHASIC SCREENING


             VIRGIL GIANELLI  M.D.
                Those of us in private practice of medicine have been well aware of the fact  that  in  spite
             of our good intentions which include working far beyond the 40-hour week, society nevertheless
             seems to be disappointed in results produced as far as medical care is concerned. We, in San
             Joaquin County, in trying to analyze the problem, have for many years conducted dialogue with
             the consumer community. We started with the inception of the Foundation for Medical  Care  prin-
             ciple in 1954. The following year the Medical Society involved itslef in the health  care  prob-
             lems of the migrant poor, which to us seemed to be the most disadvantaged medical grpou in the
             central valley area. Our philosophical thought is best expressed as far as I am concerned by
             Harvely Wheeler of the Center for the Study of Democratic Institutions, when he stated that a
             mark of a professional is he who does what ought to be done rather than what can be  done.  This
             then distinguishes a physician as a man of ethics.
                We in San Joaquin have long been aware that medical care of migrants reached only  those  who
             considered themselves ill with no attempt to unveil occult disease. Little attempt was  made  to
             provide preventive care except in the field of sanitation and immunizations for children.  Out of
             this arose the thought that perhaps Multiphasic Screening could serve as a vehicle to accomplish
             better health care of the rural poor who live in the sprawled ghettos of Stockton so that logical-
             ly we could not distinguish between rural and urban poor. Accordingly, a Pilot Study  of  Multi-
             phasic Screening was condcuted by the Foundation for Medical Care through an RMP grant from Stan-
             ford, Area III.
                 This Planning Study screened two poverty areas of Stockton both in the urban area,  although
             migrants living in the area were screened right along with the urban poor. A total of  151  peo-
             ple were screened.  Of the total number screened, 20.5% were found to have occult diseases, i.e.,
             the screening produced findings that revealed new disease to the examining physician.  An  addi-
             tional benefit was that 34.7% of the total screened were considered to be healthy.  It  was  the
             recommendation of the Board of the Foundation for Medical Care that the major grant "A Program for
             Multiphasic Screening of the Urban Poor and Migratory Agricultural Workers in San Joaquin County"
             be approved. This Board also recommended that "services" be rendered. In this  context,  it  was
             the intent of the Foundation to assure follow-up medical care to the  individuals  treated.  The
             major program for Multi-phasic Scroenihq was indeed approved by D.R.M.P. and in fact  was  given
             priority over many other projects.  The program is now in operation.
                 The purposes of the Multiphasic Screening Project are:
                    1. To identify the health needs of disadvantaged grouDS in San  Joaquin  County,  and  to
                         determine the extent and type of conditions requiring medical care.
                    2. To demonstrate that mobile multiphasic screening can be the  energizing  link  between
                         health needs and health services in a poverty community.
                 Some of the objectives of the project are:
                    1.   To use mobile Multiphasic Screening for early detection in identification of pre-clinic
                         abnormalities of cancer, heart disease, stroke and other major diseases.
                    2.   To identify individuals requiring medical attention and refer them to the  organized
                         medical community for follow-up, diagnosis and care.
                    3.   To use Multipha@ic Screening as a portal to medical care and to actively engage  the
                         urban poor in a neighborhood health program, and the agricultural poor in a  similar
                         program centered in migrant camps.
                  To date over 1100 people have been screened.  We have established a follow-up health center
             where screenees with positive findings may go for follow-up care. It is presently staffed  by  a
             full-time nurse coordinator whose duties will include the insuring of follow-up of all screenees
                                      This follow-up is to trace the screenee through the  medical  community
             with positive findings.
             and all the various avenues of health care. The follow-up health center was  combined  with  the
             established Pear Sifford Foundation in South Stockton and the combined operation now carries the
             name "Pearl Sifford Health Center".  Many years ago some of us developed the concept of a mobile
             medical volunteer task force that would deliver health care to those most in  need  of  it.  The
             Pearl Sifford Foundation, named after the relative of the principle donor,  provides  funds  for
             medical supplies and has been in a Southeast Stockton ghetto for a period of four years prior to
             the Multiphasic Screening Project.  The San Joaquin Foundation for Medical Care provides physician
             staffing and administrative support to guarantee adequate follow-up care.
                  We have strong feelings regarding community,involvement.  A Consumer Health Council has been
             incorporated and it is our desire that it become fully as strong as the Medical Society so that
                                                            20.




                                                                ch a Council produces  a  major  problem  in  that
            equals can deal with equals.  The organization of su             in the City of  Stockton,  a  commun-
            it has become apparent that of the 48 minority groups organized
            ity of 100,000, there is very little inter-group  communication.  The  organization  of  this  Council
            has been and is one objective of the Director of  Health  Facilities,  the  Foundation's  sub-contrac-
            tor responsbile for'screening. It must be emphasized that it is extremely difficult to develop
            an organization truly representative of a poverty constituency.  The  need  of  a  common  denominator
            was obvious. As an example of our problem, as far as the chicanos are  concerned,  there  was  a  time
            when the church represented an area of agreement.  But this no longer holds true.    We would  propose
            that interest in good health is a concept that is acceptable to all groups and  as  such  can  act  as
            a unifying catalyst. It is interesting to note that the Consumer Health Council presented the
            Medical Society with three requests in the Health Check-up.  These were:
                1.  Sickle cell trait determination
                2.  Blood typing
                3.  Pregnancy Test
                After considerable interaction between the physicians and  the  Consumer  Council  it  was  agreed
            that only the Sickle Cell determination was pertinent to the  objective  of  the  program.  This  type
            of Consumer Health activity and interest we consider to be a valuable  contribution  to  this  screen-
            ing. The necessary laboratory procedure, Sickle Cell, has been incorporated as  part  of  the  screen-
            ing.
                If the physicians are to be professional, then it logically follows that  they  must  be  involved
            in the problems of the city.  We have come a long way from  the  Aristotelian  concept  that  the  aim
            of the city is to make men happy and safe.  Health as an apolitical issue gives medicine a strategic
            opportunity to be deeply involved in the reconstruction of our cities.    Although the new  Pear  Sif-
            ford Health Center was opened just October 12, 1970, we now are furnishing nurse coverage for
            eight hours a day, physician coverage for three hours an evening,  a  Drug  Abuse  Program  for  young
            people, including a training of street people to conduct rap sessions and  to  furnish  crisis  inter-
            vention by a 24-hour telephone service. O@erational by next month  will  be  a  program  of  follow-up
            social work and medical service for the Order of the Good Shepherd.  This Order counsels girls
            recently convicted of a felony as well as those who have completed their time  at  the  San  Francisco
            facility and have been returned to the area but who without proper counseling frequently return
            to their old habits.  Also operational are legal services to the poor, the  service  of  a  nutrition-
            ist on a part-time basis; partly operational are the activities of  the  Welfare  Rights  Organization
            and in the planning a Center for the Elderly and also a program through the County Agricultural
            Department to provide development of family gardens under the concept that food production by
            the poor can partially return the concept of dignity to the disadvantaged.
                 As can be seen from the above, a simple procedure such as Multiphasic   Screening   expanded   to
            include services has led to the establishment of a center that is able to fulfill the needs of
            a community and has given the Medical Society the opportunity for physicians to be leaders in
            the reconstruction of social order.



















                                                             21.






                                           AREA II RMP - CHP "Bff RELATIONSHIPS
         CHARLES WHITE, PH.D.
                In its wisdom, the 89th Congress created  the  Regional  Medical  Programs  to  make  available  the
            best possible patient care for Heart Disease,  Cancer,  Stroke,  and  Related  Diseases.  As  a  compan-
            ion piece, the Partnership for  Health  Act  authorized  agencies  to  conduct  programs  of  Comprehen-
            sive Health Planning for sub-state areas.   The majority  of  these  proved  to  be  voluntary  associa-
            tions  of  interested  organizations  and  individuals.  Regional  Medical  Programs  were  directed  to
            encourage and assist  the  establishment  of  creative  evolutionary  partnerships  through  cooperative
            arrangements among medical schools, research institutions, and hospitals.     At  no  point  in   either
            piece of legislation was there mention of the  other  program,  nor  were  there  any  instructions  di-
            recting one program to relate to the other.   For the first few  months  the  programs  did  not  relate
            to each other, in fact.  A.noticeable shift  in  emphasis  began  to  be  felt  following  the  election
            of the Nixon  administration  and  a  series  of  formal  and  informal  relationships  have  developed.
            From a prospective which is only slightly historical, I will consider  the  posture  of  the  two  agen-
            cies at the National, State, and Local arenas.
                Prior to the  enactment  of  89-749  Community  Health  Planning  in  the  United  States  had  been
            largely non-prescriptive in nature, limited  to  restricted  segments  of  health  problems  or  special
            population groups.  Vested  in  non-governmental  health  planning  groups,   individual   elements   of
            this system were dealt  with  selectively.  Hospital  Planning  Councils,  for  example,  were  involved
            with  facilities  planning  related  to  federal  funding;  Health  and  Welfare  Councils  indulged  in
            some health  planning  and  ad  hoc  citizen  groups  carried  out  one-shot  health  planning  studies. His-
            torically, the voluntary planning agencies carried  out  their  functions  without  any  formal  regula-
            tory authority or facilities and without  control  of  government  funds.  The  only  notable  exception
            was the franchising law of New York State which  vested  area  hospital  review  and  planning  councils
            with a strong legal review function  over  facilities.  Since  1966,  a  number  of  these  pre-existing
            voluntary  agencies  have  been  recognized  or  have  applied  for  recognition  as  the  Comprehensive
            Health Planning Agency for their area; in other areas,  new  or  autonomous  voluntary  planning  groups
            have been established and recognized; in still other areas,  governmental  units  have  been  recognized
            as the Comprehensive Health Planninq Agency.  I  In  general,  the  majority  of  the  funded  area-wide
            health planning agencies are  non-governmental  though  the  interests  of  the  government  are  repre-
            sented as  required  by  law.  Theoretically,  the'  determination  of  the  most  suitable  agency  for
            Comprehensive Health Planning  has  been  based  on  general  agreement  within  the  community  that  a
            particular organization is  appropriate  to  conduct  the  activity.  There  are  a  number  of  reasons
            why the voluntary or non-authoritarian model was used  for  the  organization  of  Comprehensive  Health
            Planning Agencies rather than a governmental  model.  Historical  precedent  is  one  important  reason.
            Congress, in  its  report  accompanying  the  legislation  noted  the  successful  area-wide  facilities
            experience of the Hill-Burton Program which was  largely  a  voluntary  approach  and  hope  that  area-
            wide Comprehensive Health Planning would extend and expand this success.     In  most  areas,   however,
            a more  compelling  logic  lay  behind  the  creation  of  voluntary  rather  than  governmental  health
            planning agencies. The health "system" is  composed  of  sectors  fragmented  in  terms  of  vested  in-
            terest, ideological concepts, expertise  , and  functions.  This  complex  structure  is   believed   to
            make it impossible for planning technicians to  plan  unilaterally  for  health,  and  the  governmental
            authoritary  approach  was  rejected.  A  voluntary,  non-authoritarian  model  was   believed   to   be
            more appropriate in relating  the  multiple  sectors  since  it  emphasized  participation  in  partner-
            ships; it would  promote  expansion  and  major  alterations  in  systems;  it  would  achieve  resource
            reallocation; and it would stimulate entrepreneurial response to health needs.
                 In section 314-B of PL89-749, the function  of  the  "b"  Agencies  was  described  as  "developing
            plans for coordination of existing  and  planned  health  services including  the  facilities  and   per
            sons required for provision of such services."  This  mandate  lacks  a  clear  concept  of  the  opera-
            tional steps which Comprehensive  Health  Planning  Agencies  should  take.  Many  organizers,  partici-
            pants, and communities assumed that these new  agencies  would  continue  to  operate  through  coopera-
            tion and advice without any particular coercive powers or regulatory functions.      Indeed,        most
            operational area-wide planning agencies have acted in advisory capacities.  They     seek    to     play
            major roles in planning through the collection of data, developing a broad-based           constituency,
            assembling a competent and capable staff, through the  assessment  of  needs  and  the  bringing  toget-
            her of groups to discuss problems. This  process  has  been  hampered  by  unclear  agency  goals,  con-
            flict and lack of cooperation among the consumers  and  providers  as  well  as  conflict  and  lack  of
            cooperation within each of these groups and the ever present political expediencies.
                 The original legislation which created both programs expired on June 30, 1970.      It  was  there-
            fore necessary for the present Congress to pass  new  bills  if  the  programs  were  to  be  continued.
            One of the important preliminary steps  in  the  legislative  proc'ess-is testimony  before  congressional
            committees.  During much of 1969 and all  of  1970,  this  process  of  testimony  has  continued.  From
            it has arisen several broad streams of thought which I wish to summarize.

                                                              22.





                  Granted that there are exceptions and what I am about to say is open to  quibbling,  these
             generalities are nevertheless true in the main:
                  1. The position of the Nixon administration has consistently been that  the  two  agencies
             should merge under a common National Advisory Council, which would have reduced authority.
                  2.  Comprehensive Health Planning has developed a public or consumer constituency.
                  3.  Regional Medical Programs has developed a constituency among health service  providers.
                  4.  Comprehensive Health Planning is regarded as a planning-oriented agency.
                  5.  Regional Medical Programs is regarded as an action-oriented agency
                  6.  Decentralized decision-making should reside in the P.H.S. Regional offices.
                  During this period of testimony two very different philosophical positions  emerged  which
             could be described briefly as an Administrative position and a  Senate  position.  The  administra-
             tion wished in general to merge the two programs under a common budgetary  authority  with  Compre-
             hensive Health Planning as the more dominant of the two. The senatorial  position  maintained  that
             the two programs should continue relatively unchanged. A general drive was oh during  these  months
             to consolidate many of the programs within HEW and the Public Health Service; Regional  Medical
             Programs and Comprehensive Health Planning were not being singled for vengeance, punishment,  or
             special attention. They simply were caught in the web of a larger game being  played  which  was  a
             larger degree of administrative control in Washington, plus a greater degree  of  decentralized
             agency control within the States and areas.
                  Finally, the period of debate was finished, and in the main the senate position has prevailed.
             Very few of the provisions the Administration wished to include were finally  incorporated  in  the
             measure signed into law only earlier this month. The categorical emphases of  Regional  Medical
             Programs were maintained with the addition of kidney diseases. Whereas,  the  original  legislation
             was focused on making available the latest advances in the diagnosis and treatment of Heart, Cancer,
             Stroke, the new legislation focuses on making available the latest advances in the  prevention,
             diagnosis and treatment and rehabilitation of persons suffering from these  diseases.  In  addition
             to the functions included in the earlier legislation, the reasonable linkages promoted and fostered
             under Regional Medical Programs are to "strengthen and improve primary care  and  the  relationship
             between specialized and primary care."  The RMP's original mandate to "improve generally the
             health manpower facilities available to the nation" has been further specified to  "improve  gener-
             ally the quality and enhance the capacity of manpower and facilities." For the first  time  then
             there seems to be a mention of quantity as well as quality. RMP's are to  work  to  improve  health
             services for persons living in areas where such services are limited. These ends  are  still,  how-
             ever, to be accomplished without interference with patterns or financing of  professional  practice
             or institution operations. This is a continued contribution to the lobbying power  of  the  profes-
             sional organizations which supported Regional Medical Programs and  their  accomplishments  without
             surrendering these prerogatives. Regional Advisory Groups now will be required  to  include  repre-
             sentatives of the State level Comprehensive Health Planning agencies and ex-officio  representation
             from the Veterans Administration. It is suggested that sub-regional organizations such  as  the
             California Areas should include area-wide "b" Agency representations from their Advisory  Councils.
             The reverse of the representation mandate is true for Comprehensive Health Planning.
                  The authority for grants and contracts has been substantially expanded from multiprogram  ser-
             vices for conducting demonstration projects of control methods; the collection and  study  of  epi-
             demiological data; the conduct of cooperative clinical field trials; the development of  special
             training programs; and special project grants for developing new means of  developing  health  8er-
             vices with the diseases covered. On the financial side  the  administration  requested  $79,500,000
             for RMP and the authority recommended by the Congress was almost $98 million.
                  The Comprehensive Health Planning Bill has not changed to any  great  extent.  The  specifica-
             tions for membership in the State Health Advisory Council have been amended to include  Federal
             as well as State and local agencies, such as the Veterans Administration and the  Regional  Medical
             Programs. State Health Planning agencies are directed to provide Comprehensive  State  Planning
             for health services, including Home Health Care.  Fu rther, the State's planning process  is  re-
             quired to include environmental considerations as they relate to public health.  Several  interest-
             ihg changes have been made in the area-wide health planning portions, although none of them  are
             drastic. Area-wide agencies are required to consider Home Health Care services  in  their  planning
             process. Increased funding was authorized for the next three years, although  congressional  appro-
             priation and bureau of budget expenditures have never equaled  authorizations.  To  summarize  this
             laborious recital: various programs that would have been combined in a single title  remain  separ-
             ately authorized. Multi-funding for programs in expanded data studies have been  pasted  into  law.
                  The lines of responsibility among the three programs have been blurred  without  clarification
             on relationships to each other. However, the department has  sufficient  authority  to  consolidate

                                                            23.






           programs in the absence of such legislation.      The  best  illustration  I  have  been  able   to   devise
           is that of gazing down a set of railroad tracks to the horizon.       The  tracks  appear  to  come   closer
           together without ever  definitely merging before they cross the horizon.

                 On July 1, 1970 there were  55  Regional  Medical  Programs,  only  one  of  which  has  not  achieved
           operational status.    At the same time, all  50  States,  the  District  of  Columbia,  and  5  Territories
           had State Comprehensive Health Planning Agencies.      One  hundred-thirteen  Area-wide,  or  "b"   Planning
           Agencies, had  received  grants  by  that  date. Thirty-five of  those  have  achieved  operational  status.
           Still undefined are the relationships between the two programs.       In   California,   however,   a    new
           ingredient  to  the  mix  has  been  added.  Assembly  Bill  1340  provided  the  power  for  area-wide  "b"
           Agencies to become the  kind  of  regulatory  bodies  they  were  not  intended  to  be  in  their  original
           conception.   We are thus  presented  with  the  anomaly  of  a  Federally  created  planning  agency  which
           is supported equally by Federal and local funds  being  directed  by  State  law  to  perform  a  regulatory
           duty.

                 So now in considering the two programs from  the  State  level,  we  must  consider  that  the  volun-
           tary  area-wide  health  planning  agencies  have  been  invested  with  decision-making  authority  on  all
           applications  to  construct,  expand,  or  alter  health  facilities  for  the  purpose  of  increasing  bed
           capacity or changing license or category.      Is  it  desirable  and  feasible  to  combine  planning   and
           authoritary or regulatory functions in a single agency?  Is it legitimate to vest regulatory
           responsibilities  in  a  nonpublic  agency?  Will  voluntary  planning  remain   a   valuable   concept   in
           an increasingly regulatory environment?

                 Five responsibilities have been commonly  assumed  by  area-wide  "b"  Agencies  and  their  committee
           structure reflects these concerns.     They are:   environmental  health,  health  facilities,  health  man-
           power, personal health services, mental health and mental retardation.        It is apparent that the reg-
           ulatory function will begin to consume  increasing  amounts  of  time,  energy  and  resources  of  the  "b"
           agencies, possibly as high as 80 percent.      If the health facility  function  becomes  80  percent,  does
           that mean the  other  four  committee  functions  must  compete  to  divide  the  remaining  20  percent  in
           time, money and staff resources?

                 Area II is a geographic entity affecting 20 counties in Northern        California  and  three   coun-
           ties in Western Nevada,  composed of 47,000 square miles of territory, with a population of
           1,510,000 people. The area  is  largely  mountainous,  primarily  rural  in  character  with  several  clus-
           ters of population and several identifiable medical communities.       Sacramento  is  the   largest   urban
           center, including in its sphere the University of California School of Medicine at Davis.         The   city
           of Reno is the urban hub of  Western  Nevada,  including  Washoe  Medical  Center  and  the  new  School  of
           Medicine at the University of Nevada.  Other  medical  trade  areas  focus  around  Travis  Air  Force  Base
           in Upper S61ano  County;  the  Woodland  area,  Yuba  City  -  Marysville;  Chico  and  Redding.  There  are
           73 hospitals in Area II with a total of  4,000  beds,  this  number  is  approximately  14  percent  of  the
           state total.   Area II has 12 percent of those hospitals  under  50  beds,  15  percent  of  those  from  50
           to 100 beds, and 21 percent of those from 100 to 149 beds.  There are 1,963 physicians, 7,700
           nurses, and several thousand allied health workers.      In the  past,  referrals  of  certain  health  con-
           ditions were made to San Francisco or Palo  Alto.  As  the  School  of  Medicine  at  Davis  and  the  medi-
           cal facilities of  the  Sacramento  Medical  Center  continue  to  expand  in  size  and  sophistication,  a
           new service will be  rendered  to  physicians  and  citizens  in  Northern  California  and  Western  Nevada
           through the opportunity for consultation and referral to the new center.        In  the  publication,  "Uti-
           lization  of  Treatment  Facilities  for  Heart  Disease,  Cancer  and  Stroke  in   California   Hospitals"
           prepared for CCRMP in June,  1969,  overwhelming  numbers  of  patients  residing  in  Area  II  are  hospi-
           talized within their county of residence.      Clearly they do not  leave  Area  II  in  large  numbers  for
           other  hospitalization  and  the  most  numerous  transfer  is  to  Sacramento,  the  nearest  urban   area.

                 Planning  studies  and  educational  programs  in  Area  II  have  been  hospital-based  and  involved
           extended learning activities transported to the hospital locations.       In  an  attempt  to   serve   each
           hospital within each county within  each  district  of  the  area,  large  staff  commitments  of  time  and
           travel are  necessary  for  field  visits  which  are  undertaken  on  a  regular  basis.  These  boundaries
           of Area II are approximately continuous with two Comprehensive Health Planning area-wide "b"
           Agencies.  The  Superior  California  Comprehensive  Health  Planning  Association  located  in  Chico   in-
           volves the Northern Sacramento Valley to the Oregon border.      Included  are  Siskiyou,   Teham   Trinity,
           Shasta, Lassen and Modoc Counties which  comprise  RMP  Sub-Area  District  I,  and  Butte,  Glenn,  Colusa,
           Plumas, Yuba and  Sutter  Counties  which  comprise  Sub-Area  District  II.  The  Golden  Empre  Comprehen-
           sive Health  Council,  located  in  Sacramento,  includes  El  Dorado,  Nevada,  Placer,  and  Sierra  Coun-
           ties and are in  RMP  Sub-Area  District  III;  Sacramento  and  Yolo  Counties  in  RMP  Sub-Area  District
           IV. Therfore,  of  the  20  counties  in  Northeastern  California  which  comprise  Area  II,  18  are  in-
           cluded in the area  served  by  Golden  Empire  and  Superior  California.  Only  Amador  County,  which  is
           not a member of any "b"  Agency  Council,  and  the  eastern  tip  of  Solano,  which  belongs  to  the  Bay
           Area CHPI are not covered.

                                                              24.





                  Through the last several months, numerous planning meetings have  been  held  among  various
             persons within the three organizations as they have attempted to develop understanding  and  agree-
             ments. The discussions have centered around the merits of expanding  the  staff  capabilities  of
             both the RMP and CHP programs. It has always been clear that both programs can  do  a  more  effec-
             tive job by expanding staff capabilities in two ways: by adding personnel to  serve  specific  pro-
             grams in planning areas; and by welding a close working relationship  between  the  personnel  of
             the  programs - a relationship which avoids overlapping and takes the greatest  advantage  of  the
             divisions  of labor. Although the three agencies involved in Northern  California  have  supported
             the  building of cooperative relationships and deploying limited manpower resources  as  effectively
             as  possible, it is still evident that the staffs are not quantitatively adequate  to  handle  the
             jobs in  view of the regulatory function which must be undertaken by the "b"  Agencies.  The  state-
             ment will  be particularly true in planning for personal health services  and  health  manpower.  In
             view of the background of the legislation at the national scene, we feel  that  the  illustration
             of the railroad tracks directing towards the horizon is increasingly  appropriate.  The  programs
             are obviously going to be pushed closer to each other by pressures from  the  national  administra-
             ion.  Political reality weighs heavily upon our thinking.  For that reason Area II suggested
             that CCRMP should apply for an increase to support the core staff personnel budgets  of  each  of
             the areas to prevent disastrous delays in the planning of programming for personnel  health  @er-
             vices and health manpower.  If such funding is supplied to the RMP Area offices, it will not
             necessitate the raising of local matching funds -- a task which  continually  saps  the  strength
             of CHP agencies. Interagency staff personnel are perfectly cap@ble  of  staffing  committees  with-
             out forcing changes in the legal requirements of advisory council representation.  The  quality  of
             interagency working relationships has been such that the organizational location of  new  personnel
             is immaterial. I am impatient with those pettifogging arguments about the location  of  the  offic-
             ing and responsibilities of reporting, etc. If you are trying to build an  empire  this  will  be
             an uncomfortable arrangement, but if you are sensitive and responsive to the goals  and  missions
             of both programs, then the system is workable. If we are  unable  to  solve  such  administrative
             problems such as personnel supervision, we deserve to fail in any case. Such  increase  in  staff
             assistance and support is needed for the RMP District Councils I and II, which  will  incorporate
             representatives of the Comp Planning County Councils. Staff assistance  will  support  the  area-
             wide Personal Health Services Committee and the nine active County Personal  Health  Services  Cbm-
             mittee, the area-wide Health Manpower Committee, and the nine County Manpower Committees.  Further
             development of manpower concerns involves a merged committee from Superior California Association,
             the Golden Empire Council, the Division of Allied Health Sciences of the School  of  Medicine  UCD,
             the State and Community Colleges, and Area II. Program and multi-area  planning  has  already  been
             initiated through this mechanism. Area II does not have a separate manpower  committee  because  of
             the existence of the other groups. Staff assistance is needed to help support  the  area-wide  Per-
             sonal Health Services Committee of the Golden Empire Council, the  five  active  County  Personal
             Health Services Committee, the area-wide Health Manpower Committee, and the  five  active  Manpower
             Committees. Golden Empire Council is concerned with the problem of delivering health  care  to  a
             metropolitan center as well as to rural areas. Sacramento contains  all  the  health  problems  .
             typically identified with delivery of care in cities since it serves the hub of the  great  central
             valley as well as the State Capitol. The Superior California Association has  a  primary  concern
             for the problems of the delivery of health care in rural areas.  As a planning agency.in an entire-
             ly rural setting'it must be responsible for developing ideas, exploring  alternatives  and  testing
             solutions. Established patterns of staff and committees of the three agencies  will  need  to  be
             supplemented by these new staff resources as well as special groups and  new  combinations  of.pro-
             viders and consumers grappling with the twin problems of evaluating quality and quantity of health
             care.




             iHealth Planning Issue Paper #3 "Areawide Health Planning Agencies: Can They  Remain  Voluntary?"
             New York:  Community Health, Inc., May, 1970.











                                                            25.






                                              AREA IV NORTHEAST VALLEY PROJECT

              LOUIS S. GARCIA - BARTON L. FISCHER, M.D.

              I.  BACKGROUND

                  The Northeast San Fernando Valley Project commenced operation in January, 1969.  It was funded
                  under the auspices of UCLA, Area IV, of the California Regional Medical Programs.

                  A.  Target Area

                      The area chosen contains approximately 250,000 residents in 6 communities that exist in the
                      Northeast corner of the San Fernando Valley which is located approximately 25 miles from
                      the Los Angeles Civic Center.  These communities include, Sylmar, San Fernando, Pacoima,
                      Sun Valley, Sunland, and Tujunga.

                      The people vary greatly in ethnic concentration, years of education, annual incomes per
                      family and in sophistication about health.  Because of the high concentration of Mexican-
                      American and Blacks in the "inner cities" of Pacoima and San Fernando (approximately 50%)
                      the large number of welfare recipients and medically indigent persons, plus the lack of
                      availability of health resources to a significant percentage of the population, the area
                      has been temed a Health Ghetto.

                  B.  The Objective

                      The objectives of the Project were to identify the health needs of the consumer, identify
                      the health resources, identify facilities and amount of their utilization, to develop a
                      viable medical, professional, and consumer Community Advisory Board, to promote health
                      education and Health Career programs and to scientifically document and record the data
                      collected.
                  C.  The Approach

                      1. Preliminary Data
                         Data'@as collected by conducting approximately 30 Koffee Klatches with residents in
                         the six communities representing the various ethnic groups.  These groups were also
                         selected to reflect different levels of economic and educational attainment.  The ques-
                         tions asked at these Koffee Klatches resulted in clusters of health problem areas that
                         the consumers were most interest in seeing resolved.

                      2. Questionnaire Design

                         The'Soft Data collected at the Koffee Klatches was utilized to develop a Community
                         Household Survey which was further pretested and finalized into what is considered
                         to be the largest community household survey ever conducted in the County of Los An-
                         geles.  A professional consultant and bio-statistician were contracts  to inc u e
                         the scientific design of the survey.

                      3. Sample Size

                         .The sample size was selected at random utilizing the 44 census tracts that compose
                         these 6 communities.  It was designed to survey 3% of the residents in the inner
                         cities of Pacoima and San Fernando and 2% of the other 4 communities.  The reason
                         for utilizing the above formula was due to the predominately Anglo population of the
                         other communities.

                         This design provided 1460 homes to be surveyed of which. 1139 were completed.  When
                         the business address and empty lots were deducted, the refusal rate was less than 8%.

                      4. Surveyers

                         Approximately 27 indigenous consumers from the 6 communities were hired and trained to
                         conduct the survey.  They represented the three major ethnic groups and were assigned
                         to their specific communities.  Because of the large number of Spanish speaking resi-
                         dents in the inner city, a team of bilingual interviewers were specially trained to
                         handle all households requiring that skill.  This approach proved to be very successful.


   .i                                                       26.
   i
   i







            II.   RESULTS OF SURVEY

                  The results of this Community household survey clearly indicates the need for.a health  educa-
                  tional system for improvement in'the delivery of health services and for  the  development  of
                  a comprehensive health care system.
                  It dramatically points out the problems faced by the residents in three specific  communities.
                  (I.  In San Fernando, the problems are compounded by cultural and language barriers.
                  (2.@  In Pacoima, the problems are exacerbated by the large numbers of welfare recipients,
                  high unemployment, And high concentration of ethnic low-income minorities.  (3.)  In  Sunland,
                  the problem is lack of facilities and services in the immediate area and  isolation  from  any
                  major hospital.

                  The results of our data has been further substantiated by other surveys which have  been  con-
                  ducted.  Pacoima has been designated one of the 8 needy communities in Los Angeles County.
                  The best and latest survey was conducted by the American Public Health  Association  Community
                  Health Action Planning Services for the County of Los Angeles* known as the "Merrill  Report."

           III.   PROJECTED IMPLEMENTATION PLANS

                  The proposed Health Care System envisioned by the N.E.V. Project is composed of 6  components.
                  These components will be implemented in stages and will require funding from a variety of
                  public and private resources which are being negotiated at the present  time.  The  components
                  consist of:

                  A. The Census Tract Captain is the first component of the system. Research experience  in  many
                     neighborhoods revealed that radio and television in general, the efforts-of the Heart  Asso-
                     ciation and the Cancer Society, and other public education endeavors do not reach very  many
                     people. In fact, only about 3% develop a reasonable level of the education in  health  mat-
                     ters that is available to the public today. This deficit is compounded in  bilingual  area.
                     The position of 'Census Tract Ca    , an intelligent, concerned and trusted  individual  of
                     the neighborhood, who will conduct face to face programs on health education and health
                     careers is proposed as at least a partial solution to this problem in the Northeast  Valley.
                     This individual will also act as the liaison person or health "ombudsman" for  his  commun-
                     ity, thus expediting the communication of the sick of the neighborhood with physicians  and
                     hospitals.

                  B. Two Census Tract Health Stations, the second component, are envisioned as  oriented  toward
                     preventive care.  Each will be manned by allied health personnel such as public health
                     nurses, registered nurses, licensed vocational nurses, census  tract  captains,  indigenous
                     health workers and, perhaps, "physicians' assistants."  The Health Station will be  capable
                     of providing simple emergency care, immunizations, multiphasic health testing,  computerized
                     health histories, and health education. It will also be a training base for  the  San  Fer-
                     nando Valley Health Consortium (see below).  The necessary professional back-up must be
                     arranged with the private medical community,with a core medical group, or  with  the  emer-
                     gency rooms of a hospital near the station, or with a combination of these resources.

                  C. HMO is the third and probably the most important item for both physicians and patients.
                     We have contracted with experts in the field of insurance.  A  Health  Maintenance  Organi-
                     zation (HMO) is planned which will utilize prepaid health insurance  for  patients  without
                     insurance, and will contract with MediCal and Medicare for  comprehensive  health  coverage
                     of their patients if and when it becomes legal to do so. This plan  is  designed  to  reim-
                     burse physicians and hospitals for their part in the provision of  efficient  comprehensive
                     health care.

                  D. The Multipurpose Health and Welfare Center, the fourth component, has been studied for
                     five' years.  If this components is to be realized, the Project organization believes it
                     should be situated in the "inner city" -- San Fernando or Pacoima, it  should  contain  the
                     headquarters for all agencies that contribute to the total welfare of a family  or  indivi-
                     dual (including social, legal, employment, housing, health, and other  community  services)
                     and it should be bilingual.


                   Merrill, Malcolm H., M.D., M.P.H., Future Directions for  Health  Services,  American  Public
                   Health Association Community Health Action Planning Services, County of  Los  Angeles,  1970.


                                                            27.





              E.  There are six hospitals in the Northeast Valley; they are the fifth component of this
                  system as currently envisioned.   It is hoped that the public hospital, Los  Angeles  County
                  Olive View (and perhaps San Fernando Veterans Hospital), can become  oriented  toward  acute
                  care rather than limited to chronic diseases.   It can then share in the medical care of
                  lower middle-income families with limited resources, and perhaps can be encouraged to pro-
                  vide long term rehabilitation services.  The four private and nonprofit hospitals may
                  be incorporated into the prepaid health plan if they wish to do so.
              F.  The San Fernando Valley Health Consortium, the sixth component and  final,  encompasses  the
                  ove@all allied healt education lan being developed by  San  Fernando  Valley  State  College
                  and the San Fernando Valley Regional Medical Programs.  The appropriate delivery of health
                  services is predicated upon the availability of adequate numbers of  health  care  personnel
                  to do the required job.  The Northeast Valley Project has pioneered this program because
                  of this fact and because it is believed that allied health careers offer upward social and
                  financial mobility to minority groups.  Also, the greatest lack of health services is in
                  the disadvantaged.areas in which these groups reside.







































                                                          28.






                                       AREA V EAST LOS ANGELES CARE$ AND CONCERNS
            Frank Aguilera , M.P.A.
                 Area V became involved in a stimulating and exciting project between February 1969  and  Febru-
            ary 1970. The purpose of the project was to collect information on the health  care  patterns  and
            needs of East Los Angeles --- a Mexican American community. The exciting element was that  community
            health needs were to be identified from the point of view of the recipient of  health  services.
            Furthermore, the survey was to be conducted by persons from the community. As part  of  the  method-
            ology, the Welfare Planning Council of the Los Angeles Region, a non-profit planning  agency  sup-
            ported by United Way, was given a contract to conduct the statistical research and  data  analysis
            required. Technical support and administrative coordination was provided by the staffs  of  Area  V
            and Welfare Planning Council. Policy for program development was established by  a  locally  gener-
            ated steering committee. Representation expressing the point of view but not  speaking  for  the
            diverse components which make up East Los Angeles was obtained on the steering committee  from  the
            providers of medical services, health-related agencies, community based organizations,  youth  or-
            ganizations, consumers at large, and religious organizations. The end product of  the  project  was
            the publication of "East Los Angeles Health - A Community Report."
                 The report represents one year of conserted effort during which concerned  individuals  with
            diverse backgrounds collaborated to develop an action oriented project whose impact  would  extend
            beyond its publication. The report was seen as the beginning and not the conclusion  of  RMP,  pro-
            fessional, and community involvement working together to improve the health status of  East  Los
            Angeles.
                 Very briefly and without becoming involved in the politics of implementation, I  would  like
            to describe the major activities of the project, the main recommendations made by  the  community,
            the reasons why Area V approached the situation in the way it did, and the  major  accomplishments
            of the project.
                 Following preliminary organizational efforts to include community and professional  input  in
            the planning and implementation of the project, the first step was to determine the  health  needs
            of East Los Angeles, primarily as seen by the person using the health services. In  order  to  ob-
            tain this viewpoint, a questionnaire was developed with the assistance of the  steering  committee
            which would be acceptable and relevant to the residents of East L.A. It was  felt  that  traditional
            survey approaches would be ineffective. For this reason two bilingual East  Los  Angeles  residents
            familiar with the community were recruited and trained in open ended  interview  techniques.  Inter-
            viewees  inc'luded over 150 community leaders and persons involved in the delivery of  health  ser-
            vices in East Los Angeles. They were selected because of their involvement  in  community  affairs
            and because it was felt that they would reflect the viewpoint of large numbers of  residents  in
            East Los Angeles .  Interviews of patients and clients were also conducted at various medical
            and health related facilities in East Los Angeles.  The results of the survey and the health
            statistics compiled by the research staff of Welfare Planning Council and RMP staff  members  were
            incorporated into a preliminary report.
                 The preliminary report formed the basis for an open Community Health Workshop held  on  Octo-
            ber 25, 1969, at East Los Angeles College. Over 400 residents and providers of  health  care  ser-
            vices attended. The primary objective of the workshop was to validate the points  of  view  collect-
            ed during the interviews.
                 Based on the results of the Community Health Workshop, the preliminary reports  were  revised
            and sent to key policy makers in the health field with an invitation to attend a  Community  Health
            Conference. They were requested to react to the preliminary report which  contained  health  needs
            and recommended solutions offered by the East Los Angeles community. The  primary  objective  of
            the second Health Conference held November 22 in Los Angeles County/USC Medical Center,  was  to
            stimulate action toward implementing solutions to meet the identified health needs.
                 The recommendations which continually appear in the thirteen categorical sections of the
            report include the following:
                 1) More community control and participation in the planning of actual  health  facilities  in
            the East Los Angeles area.
                 2) The establishment of local 24-hour multipurpose clinics which  would  provide  diagnostic
            services, initial medical care and referrals.
                 3) The development of a bilingual information service or center to inform  East  Los  Angeles
            residents of available health services.
                 4) The recruitment of more bilingual Mexican American people in health  and  paramedical  posi-
            tions of health delivery services.
                 5)  The provision of low cost medical care.
                                                           29.




                                       and the preceding activities certainly  sound  somewhat  removed
            The major recommendations              lated diseases. How did Area V  become  involved  in
          from heart disease, cancer, stroke, and re                        e Area V concerns  in  late
          such a project?  What was the climate like and.what were some of th
          1968 that led to such a project?
             In a general way, the staff of Area V  was  aware  that  East  Los  Angeles  had  specific  health
          needs characteristic of an economically deprived areain a  central  city.  East  Los  Angeles  covers
          an area of approximately 45 square miles  and  has  a  population  close  to  400,000.  Approximately
          70% of the residents of East  Los  Angeles  bear  Spanish  surnames.  The  problems  associated  with
          poverty are often accentuated by a language barrier and a cultural  background  which  often  is  in-
          consonant with the prevailing health system planned and  operated  by  members  of  middle  or  upper
          class Anglo America. In 1965, almost one-quarter  of  all  families  in  East  Los  Angeles  had  in-
          comes below the "poverty level" index developed by the Social  Security  Administration.  The
          median income was $5,100 compared to $7,100 for the County of  Los  Angeles  as  a  whole.  Unemploy-
          ment in East Los Angeles was 7.7% compared to less  than  5%  for  Los  Angeles  County.  One-quarter
          of all families did not own a car. Thirty-five percent  of  all  housing  in  East  Los  Angeles  was
          either deteriorating or dilapidated. The median education  of  the  East  Los  Angeles  resident  was
          8.4 years of school compared to 12.2 years for the County. The dropout rates  in  local  high
          schools were as high as 57%. Based on this information, East  Los  Angeles  became  a  high  priority
          target for Area V.
             Operating on the generally accepted approach to  community  involvement  according  to  RMP  1968,
          the staff of Area V made repeated attempts to involve the  medical  professionals  in  the  East  Los
          Angeles area. These  efforts  met  only  limited  success.  The  concepts  of  continuing  education,
          physician involvement and the RMP categorical approach to  improved  patient  care  were  inappropri-
          ate in the barrio. it became necessary,  therefore,  to  re-read  the  guidelines  and  redirect  em-
          Ohasis to the development of cooperative  working  relationships,  not  only  among  providers,  but@
          also among health related agency personnel  and  community  based  groups.  It  became  necessary  to
          begin to consider ways to assess the specific health needs of  East  Los  Angeles  to  determine  how
          RMP might best approach the situation.
              In the-process of obtaining documentation on the health  needs  of  East  Los  Angeles,  however,
          it became obvious that no substantive data existed on the health needs of  the  barrio.  No  complete
          documentation could be obtained from which a profile on community health  needs  could  be  extrapol-
          ated.  Moreover, health as a concern for the East Los Angeles community , received   low    priority.
          Any effort to survey only the medical needs, or  specifically  the  catastrophic  diseases  would  be
          doomed to failure. The strategy adopted was for RMP  , through  the  Assistant  Coordinator-Community
          Programs, to become involved in issues of concern to the community  and  eventually  motivate.      it
          toward the problems of health. As some of the  more  basic  concerns  such  as  employment,  housing,
          clothing, etc., were resolved in the comunity's  hierarchy  of  needs,  attention  could  then  focus
          on health-related problems and eventually oh  the  catastrophic  diseases.  Based  on  this  analysis
          and the situation in East Los Angel es, Area V applied for  and  received  $20,000  from  CCRMP  to  .
          contract with Welfare Planninq Council to conduct a survey  to  document  the  health  needs'of  East
          Los Angeles. Because of previous inability to motivate  participation  by  East  Los  Angeles  physi-
          cians, a decision was made to conduct the survey from the point of view of the consumer.
               East Lot Angeles is a community which like-other economically  deprived  areas  has been  studied
          and surveyed with no visible positive follow-up. Community support  for  the  project  was  therefore
          begrudgingly given, but only after assuring all concerned that  the  survey  would  be  more  than  a
          report to collect dust on some agency bookshelf.- The report  would  be  by  and  for@all  concerned.
          The entire project was oriented away from the concept of planning  for  planning,  and  emphasis  was
          placed on planning for action.
               The major accomplishments resulting from the project include the following:
               1) Publication of "East Los Angeles Health - A  Community  Report."  The  report  is  documenta-
          tion of the health needs of East Los Angeles as perceived by  the  community.  It  includes  original
          statistical research on the health needs of the East Los Angeles study  area.  The  report  has  been
          used by both community-based organizations and  official  health  agencies  in  developing  proposals
          to implement specific solutions. In  the  process  of  conducting  the  project,  comunity@0'rganiza-
          tions and official agencies have worked together to focus on  the  health  needs  of  the  community.
               2) The recommendations contained  in  the  report  were  reviewed  by  the  Los  Angeles  County
          Board of Supervisors. Subsequently, the Board of  Supervisors  direct7ed  all  departmenIts  concerned,
          namely, the Department of.Hospitals, County Health Department, and the Department 'of Mental Health,
          to implement the recommendations  requiring  only  administrative  decisions  and  to'return  to@@the
          Board of Supervisors the recommendations requiring policy changes.  As  a  result,@both  the  Depart-
          ment of Mental Health and the County Health  Department  now  offer  evening  clinics.  An  alcoholic
                                                            30.






             rehabilitation clinic is operating two evenings a week in East Los Angeles.        A drug  abuse  clinic
             has been established at the Northeast Health Center in the East Los Angeles area.
                  3)  The Board of Supervisors has announced  plans  to  construct  a  $4  1/2  million  neighborhood
             health center in East Los Angeles.     Plans are currently  being  developed  with  the  cooperation  of
             the Citizens Advisory Council to the East Los Angeles Health District.
                  4) Area V has partially  funded  a  project  to  develop  an  integrated  health  care  system  for
             senior citizens in East Los Angeles.     The idea originated  with  the  senior  citizens  of  East  Los
             Angeles and was submitted  to  Area  V,  Regional  Medical  Programs  through  the  Los  Angeles  County
             Health  Department.  The  project  will  involve  voluntary  health  agencies,  physicians  in   private
             practice and local medical facilities in East Los Angeles.
                  5) The position of Special  Assistant  on  the  Health  Needs  of  Spanish-Surnamed  Americans  has
             been developed by Dr. Egeberg in  the  Department  of  Health,  Education  and  Welfare  in  Washington,
             D.C. This appointment was a direct  result  of  a  commitment  made  by  Dr.  Egeberg  during  the  East
             Los Angeles Health Conference. The  screening  and  recruitment  process  was  delegated  to  a  commit-
             tee composed of representatives  from  community  health  organizations  and  the  district  health  of-
             ficers from the two health  districts  in  East  Los  Angeles.  Area  V  staff  provided  administrative
             coordination and technical support to  the  committee.  Similar  positions  have  been  created  by  the
             Department of Hospitals and the County Health Department in Los Angeles County.
                  6)  "East Los Angeles Health - A Community Report" has been circulated among Federal agencies
             by Congressmen Brown and Roybal resulting  in  an  increased  awareness  by  federally  funded  programs
             about the health needs and problems in East Los Angeles.      In short, the project has produced
             visible community oriented changes in local as well as national institutions.
                  Currently, we are concerned at Area  V  with  evaluating  the  future  role  of  RMP  in  East  Lot
             Angeles. Budget constraints and lack  of  staff  prohibit  direct  RMP  follow-up  of  project  recommen-
             dations.  Efforts are being expended, therefore, to enable RMP to continue its role as a catalyst.
             The next logical step is to increase the  involvement  of  medical  professionals  in  East  Los  Angeles
             and develop a bridge between professionals and  the  recipients  of  medical  care  involved  in  health
             activities. We also hope to  develop  closer  working  relationships  with  other  Federal  programs  in
             East Los Angeles. Although the staff  of  Comprehensive  Health  Planning  in  Los  Angeles  County  has
             been kept informed of  RMP  activities  in  East  Los  Angeles,  no  cooperative  working  relationships
             have as yet been developed specifically for the East Los Angeles area.  A closer working relation-
             ship is being developed with Model Cities in the Northeast/East Los Angeles area.
                  As a member of the staff at Area V, I am  particularly  concerned  by  what  a  participant  in  the
             East Los Angeles Health Conference  described  as  "the  cancer  in  the  East  Lot  Angeles  comunity."
             I am concerned because if not properly  treated,  the  patient  will  die  and  the  cancer  will.spread
             becoming even more virulent and with increasing potency will engulf our entire society.
                  In closing, I would like  to  quote  from  the  Report  of  the  National  Advisory  Commission  on
             Health Facilities, published in December, 1968:
                  Health needs originate in  people  and  in  the  community.  Health  facilities,  inescapably,  must
                  relate to the people in the communities they serve.
                  There should  be  community  responsibility  with  both  consumer  and  provider  participating  in
                  decisions.  The  consumer  must  be  involved  in  planning,  policy  setting,  and  assessment  of
                  adequacy of the services provided.
                  These are statements  made  almost  two  years  ago.  At  that  time,  they  were  recommendations.
             Today, in East Los Angeles, they are closer to becoming reality.















                                                               31.




            AREA VII PHYSICIAN CONTINUING EDUCATION THROUGH A RESIDENT PHYSICIAN SABBATICAL EXCHANGE
         MARION MYKYTEW, M.D.                    ion of Area VII and of our proposal in Physician Contin-
         .1  I would like to give a brief descript                          The Sabbatical Exchange Pro-
         uing Education which is presently under review in Washington, D.C.
         gram is one portion of this physician education proposal.- A list of activities of Area VII, in-
         cluding pilot and study proposals, has been duplicated and is available for distribution.
            Area VII consists of the two southermost counties in California, San Diego (the 2nd most pop-
         ulous county in the State) and Imperial, a sparsely populated predominantly desert area.  The
         counties are about equal in size (4200 square miles) with a total population of 1.5 million, but
         95 per cent of the population reside in San Diego County while 5 per cent, about 80,000, are in
         Imperial County.  This area, adjacent to Mexico is bilingual and multicultural including a substan-
         tial representation of American Indians.  The area has 33 acute hospitals, 20 of which have less
         than 100 beds.  There are 4 community hospitals in Imperial County, all under 100 beds and located
         15 minutes apart and about 150 miles from the University Hospital in San Diego.
            There is a severe shortage of physicians in Imperial County as well as of nurses, dentists
         and other allied health personnel.  Forty_ six physicians practice in Imperial and of these, about
         20 are in general practice, 3 are internists and 1 is a pediatrician.  The trend in Imperial Coun-
         ty over the past ten years has been a gradual decline in the number of practicing physicians.  There
         is one group practice of four physicians, several partnerships, but most are in solo practice.  Fif-
         teen physicians have practiced in Imperial County over 20 years. Many of the younger physicians  who
         do come'stay a few years then usually leave for residency training.
             Early in 1969, members of our Area VII Continuing Education Committee held a series of  meetings
         with medical staff members from community hospitals in the two counties.  Hospital staffs expressed
         their interest in "problem oriented" continuing education programs which could be integrated with
         their practice at the community'hospitals.  The medical staffs of hospitals most distant from the
         University Hospital were particularly interested in resident and sabbatical programs which might
         be developed with the new UCSD School of Medicine.  A proposal was developed for Physician Continu-
         ing Education in Community Hospitals which included the following components:
             1.  A major educational technique of the proposal is medical auditing.  Medical Audit Commit-
         tees at community hospitals will identify needs for continuing education and will also evaluate
         the effectiveness of the subsequent educational experience.  The program will provide consultants
         to assist community hospitals in establishing and utilizing the medical audit.
             2.  Cooperative arrangements will be developed among groups of hospitals to share one Director
         of Medical Education.
             3.  Consolidation of hospital staff meetings will be developed in order to decrease the large
         number of meetings attended by many physicians who may be members of 5 - 10 hospital staffs.
             4.  A Guest Resident Program will be established, modeled after the Bingham Associates Pro-
         gram at Tufts-New England Medical Center which pioneered in regional medical programs 30 years
         ago.  A resident or fellow will spend one week per month at community hospitals where he will
         transmit information and demonstrate how certain clinical problems are handled at the UCSD Medi-
         cal Center.
             A pilot project was begun in September of this year when a Fellow in Pulmonary Disease from
         University Hospital was sent to Imperial County.  The program includes didactic lectures (for
         physicians and allied health personnel), walking rounds, demonstrations and consultation clinics.
         At the end of the week, Grand Rounds are presented.  Allied health personnel and faculty from
         the Department of Medicine also participatedin these one-week programs.  Programs are planned
         with the Chiefs of Staff, nursing directors and hospitals administrators following recommendations
         made by the hospital staffs.  The Director of this Project is the Professor and Chairman of the
         Department of Medicine at UCSD.
              5.  A Sabbatical Exchange Program is proposed Which will allow the community physician to
         leave his practice and come to the UCSD Medical Center for a 2-6 week period for intensive work
         in an area of his interest.  Arrangements will be available for a resident from the UCSD Medical
         Center to serve as locum tenens for the physician during his sabbatical period.  The training
         program is planned 3oi-ntIT by-the physician and his faculty supervisor.
              A pilot sabbatical program was initiated this past summer when a letter from the Dban's
         office was sent to physicians in Imperial County inviting them to participate in a Sabbatical
         Program at the UCSD Medical Center.  Funds were not available to enable locum tenehs arrange-
         ments or to cover travel or per them costs for the participating ph3ysiciins-.  There were no
         charges for participation in the program but it is recognized that the loss of income durin@
         this time is significant.  Nine physicians (seven specialists and two general practitioners
         have so far participated or are scheduled to participate in this program.  Some tried to use
                                                         32.






             their vacation time for the program but  found  this  detrimental  to  themselves  and  their  families.
             To date the response of participants have been most enthusiastic.  Most physicians have spent 1-2
             weeks at the University  Hospital.  One  physician  spent  4  weeks.  The  two  general  practitioners
             have arranged one day per week programs on a continuing basis.  We believe that locum tenens
             arrangements will facilitate the participation by more community physicians.

                  Coordination for the program will be  achieved  by  a  joint  RMP-CHP  Health  Manpower  Committee.
             In Area VII, CHP has the same boundaries  as  RMP.  Early  this  spring  the  RMP  Continuing  Education
             Committee merged with the CHP Health Manpower  Committee  in  order  to  eliminate  duplication  of  ef-
             forts. Merger has also occurred of  the  CHP  and  RMP  Committees  in  Imperial  County.  The  merged
             RMP-CHP Health Manpower Committee has three Task  Forces,  one  of  which  is  on  Physician  Continuing
             Education .  Members of this Task Force constitute the same members as the Continuing Education
             Committee of the San Diego County Medical Society, again eliminating duplication of effort.

                  Administrative responsibility for the program will  be  in  the  Office  of  Health  Manpower  of
             the UCSD School of Medicine. The Associate Dean  for  this  office  is  the  Coordinator  of  Area  VII,
             Dr. Michael Shimkin.

                  The Guest Resident and Sabbatical Programs were developed in particular response to the needs
             of the more rural communities in our two  counties.  The  pressures  of  patient  care  lack  of  many
             specialists for consultation and the  geographic  isolation  of  physicians  in  Imperial  County  are
             obvious.

                  Faculty of the UCSD School of Medicine, pressed by the demands of a developing school have
             recognized a responsibility to serve as a  resource  for  the  continuing  education  of  the  medical
             profession in our community.

                  The program is mutually advantageous to the participants:
                  1.  The practicing physician gains access to a source of new knowledge.  He has first hand
             observation of tested techniques.  In  addition  to  the  specific  clinical  training,  an  ancillary
             benefit is in acquainting the community physician with the new personnel and developing capabili-
             ties of the Medical Center.  He learns at first hand what is available to him and his patient
             and he meets on a personal basis with many of the  specialists  to  whom  he  may  have  referred  pati-
             ents.
                  2.  For the faculty and students of the Medical School, continued contacts with the realities
             of daily practice are necessary if our  teaching  is  to  be  relevant.  As  the  community  physician
             returns periodically for the sabbatical experience, he will become more comfortable in the academ-
             ic environment and assume more of a  teaching  role  during  rounds  and  conferences,etc.,  basing  his
             comments and observations on those of the community practitioner as contrasted with the specialist
             or subspedialist in a teaching hospital.
                  The aim of the program is to establish close and continuing contacts between community physi-
             cians and the Medical School, enable the  physician  to  resume  his  professional  education  and  keep
             the practitioner under the influence of the medical school throughout his active career.




















                                                               33.




         DR. ANDREWS: While Doctor Wilson is coming to the podium,  I  want  to  take  this  opportunity  to
         thank the presenters, both last night and today, for the insights  they  have  given  us  into  the
         activities in the various Areas in California.  The  presentations  have  been  good  and  I  think
         we've all profited by virtue of them.
                                                  SUMMARY REMARKS
         DR. WILSON: There is very little that one can add to this kind of  a  program  that  I  think  will
         provtde-you with additional input. Mrs. Wycoff was regaling me this  morning  with  something  that
         I don't think she expected to turn up here. Apparently, the  YWCA  group  whose  initials  appeared
         on the podium dates back to the early days when this auditorium was built.  It  was  called,  as  I
         understand, the"Ground Gripper Group." That was apparently in contrast  to  the  flapper  group  at
         that time. As I listen to the several presentations made by this so-called  Grass  Roots  organiza-
         tion if you'll allow me to push this analogy a bit further, it seemed to me that  the  Grass  Roots
         organization indeed had a pretty firm grip on the ground and that  promises  very  well,  I  think,
         for sound growth.
              Let me react, if I may, to several threads that seemed to  run  through  what  was  said  this
         morning without making any attempt in this brief seven  or  eight  minutes,  to  critique  each  of
         the presentations. Over and over again it  appeared  very  clearly  that  cooperation  is  truly  a
         personal matter. It's not mandated, it is not forced, and as a matter of fact,  is  only  a  result
         of mutual confidence and trust between individuals who are  really  accomplishing  the  task.  It's
         not sent in from a distance -- it-'s a part of what individuals are doing on  behalf,  usually,  of
         @omeone else rather than themselves. The future of RMP as an organization so far  as  I  can  tell,
         is going to be dependent on your ability to build on what we have heard  today.  I've  been  to  so
         many conferences and in so many discussion groups that I always approach this with  a  great  sense
         of hope but also with a sense of caution because I do know  that  even  though  you're  in  relaxed
         clothing, in a way we're presenting our Sunday appearance. I hope that  what  we  have  heard  here
         this morning is the core of your intent -- that it is, in fact, in evidence of  what  you  do  when
         you return to the several places where you are serving because if,  in  fact,  this  is  California
         Regional Medical Programs, the country will have but no alternative but to  support  this  kind  of
         activity and our plateau in funding I think will be Only temporary.
              Now there is one thing that I want to repeat, because as I listen  to  the  several  programs,
         in some of them run the threads of the possibility that individuals become so  impressed  with  the
         importance of what they're doing that they'll put more and more funds  into  the  central  activity
         and a smaller percentage of funds into the periphery and into those things  which  will  run  their
         course and be renewed. May I ask again the question that, if you  want  to  be  a  leverage  group;
         if indeed you want to deal with self-renewal in RMP and in  the  system  in  the  same  sense  that
         John Gardner, I think, intended in his book on the general  issue  of  self-renewal,  you  must  be
         very careful that you don't become so impressed with the  importance  of  what  you're  doing  per-
         sonally in'your own group with these kinds of monies that it becomes caught up in  your  activities
         and perhaps begins to exclude the start of the very basic and very  important  things  we've  heard
         from several of the projects.
              Let me give two other brief notes and stop this part.  I  don't  believe  I've  ever  heard  a
         more eloquent exhortation than two of the papers that so demonstrated the forcefulness of         the
         community involvement. I was particularly attracted to the  last  one  with  community  involvement
         of the youth. You will find Secretary Richardson has talked rather forcefully  to  all  the  agency
         heads on Tuesday of this week and said, "The next two members of every Advisory Group in  HEW  will
         be individuals who are to be classified as youth." And if any agency head wishes  to  deviate  from
         this, he'll have to explain to me why he was deviating." That's an interesting  sort  of  a  state-
         ment.  The other comment is that I would hope that as we go through the process of sending respon-
         sibility and authority to the Regional offices that you will  intensively  and  positively  explore
         the way in which they can use their new responsibilities and their new authorities to  assist  you.
         One must always look forward in this kind of process, and this is a process of change.
              The HEW Regional offices are themselves undergoing change., If  they  aren't  responsive  yet,
         they @ill be responsive to the problems that  may  come  from  these  centralizations.  I  do  hope
         you will use this heavily and as you work on these problems you will  call  upon  them  for  advice
         and consutlation and something that may be a little more  readily  available,  their  personal  at-
         tention to the issues with which you are struggling. Now I promised  I'd  deal  with  any  kind  of
         question you might wish to pose. I savedhalf time for you. I took  half  and  you  have  half,  and
         I'd be glad to respond to leftovers or challenges which I didn't respond to  the  first  time  that
         you'd like to bring up now.-
         AUDIENCE QUESTION: I wonder if anyone in HSMHA, the RMP, or CHP is looking  at  the  various  bills
         in Congre@s for restructuring the health care delivery system?

                                                        34.







            DR. WILSON: The restructuring of the health care delivery  system,  interestingly  enough,  has  been
            tosse in the lap of HSMHA. Now you asked if we were looking  at  it  and  yes  we're  looking  at  it
            with concern, a little bit of horror and considerable apprehension about  the  time  constraints  un-
            der which we're functioning.   As we look at the health options  which  were  recently  requested  on
            a three-week deadline period we had all of the agencies throughout the federal government.together.
            This included the Department of Labor, OEO, and the Veterans Administration.     The whole group  met
            to talk about these options and in turn to talk about their  implications  as  related  to  both  the
            pending legislation and potential new legislation. We,  I  think  are  not  sure  and  I'm  a  pretty
            new arrival in Washington to be at least personally assured that we  comprehend  all  of  the  impli-
            cations of these interrelationships,   The direct answer to  your  question  is  yes,  we're  trying,
            we're doing the best we can and we will in a relatively early period of  time  be  turning  to  vari-
            ous kinds of community groups who are struggling with problems and  asking  them  to  participate  in
            these discussions as well.

            AUDIENCE QUESTION: What role do you see for RMP in the  development  of  health  maintenance  organi-
            zations if the amendments to the Social Security Act pass?

            DR. WILSON-  I wish you hadn't asked that.   I'm going to tell you a little bit more about penguins
            than you asked to know.  The Health Maintenance Organization activity is probably  one  of  the  most
            over-described and least understood of activities I've ever witnessed.    The  17-550  amendment  ad-
            dresses itself to a very specific issue and that is "Is there a way you can take the payments which
            come from Medicaid and Medicare and address them into a new kind  of  organization  that  would  pro-
            vide cost reduction in the Medicaid-Medicare Program?"    I  hope  we  haven't  overlooked  the  fact
            that there are 6 million people in this country who are   already  getting  their  health  care  from
            what could be very generall termed Health  Maintenance  Organizations  and  have  done  this  without
            any help from HEW, Thank You.
                 Now within that kind of a set of limits,  there was a group of very interesting young gentle-
            men, none of them from health fields, who worked for several months on what  they  considered  to  be
            health maintenance organizations and did it on what I  rather  crudely  called  the  filling  station
            theory: if you build more of them to compete, you'll get gas at a  lower  price.  Now  I  would  sub-
            mit that that's not the way the health care system works.    One of  the  leadership  gentlemen  went
            to help in a campaign in one of the states and  HSMHA  inherited  the  health  maintenance  organiza-
            tion activities about three weeks ago. There's  sort  of  a  feud  on  this  now  long-discussed  but
            little-clarified issue.  We have a task force working on it.    I have  a  notebook  with  200  pages
            of briefing which I read all the way from Washington to San Francisco last night.     I'd   have   to
              that it's a pretty good encyclopedia of the issues, but I  wish  somebody  would  tell  me  ekactly
            how to resolve it. There will be, I think, a resolution  of  at  least  the  initial  attack  on  the
            Health Maintenance Organization thing at our level fairly quickly now and proba      restricted    to
            just this Medicaid-Medicare packet at that moment.   As soon as that's  done,  the  issues  that  are
            descending upon us may wel I be evolved by January I. And we have  -to  get  some  general  community
            involvement in that set of discussions.  There  are  a  great  many  professions  organizations  w  o
            have a right, a responsibility, to be as much part  of  this  as  they  can  before  the  regulations
            come out.  We obviously are working intensely with Social Security and the others.  A direct
            answer to your question is that I think that in this particular  phase  we  probably  will  not  have
            the kind of time it takes to get a meaningful interaction with RMP and the  others  in  this  initial
            cut at the regulations response to 17-550.  That is simply the opener.    It  seems  to  me  when  we
            begin to deal, as we must, with the general impact on the health  care  system  and  health  mainten-
            ance organizations in the generic sense, then RMP will be very  much  a  part  of  this  and  that'll
            be on a slower time table.

            AUDIENCE QUESTION:  I have a feeling and I want to get your  reaction  to  it.  My  feeling  is  that
            all of a sudden this will become law and all of a sudden there will  be  a  frenzied  need  for  pro-
            duction in regard to it and then all of a sudden somebody will start  looking  around  for  money  to
            put it across and then all of a sudden RMP and its funds might loom as a  possible  source  and  then
            priorities change.

            DR. WILSON: That's sort of an "over my  dead  body."  We  went  through  that  discussion  some  time
            ack and everybody gracefully backed off on that one but  there  will  be  8  million  dollars  placed
            in the treasury of the National Center for Health Services Research and  Development  to  be  expend-
            ed by my office directly for the pursuit of HMO and that's the expenditure.    For   the   next   two
            years, as I think I was implying less directly earlier, we  can  keep  the  momentum  going  in  some
            of the strong programs like California.   I don't think there's a danger of anyone wanting to
            obliterate this kind of a program or detract from it for other purposes.




                                                             35.




          AUDI NCE QUESTION:  About continuing education function in RMP.  Iwonder if you  would  elaborate
          on t             reassuringly.
          DR. WILSON: Well, my allusion to continuing education was in the context of my sort of  admonition
          or urging or whatever you want to call that gentle pushing I was doing to be sure that you don't
          get your funds all tied up in service. But I said that there was one area where you would  have  a
          continuing obligation and that was in continuing education because that's another kind of change
          agent. It is quite clear that at the national level there are even substantial people  that  think
          that should be the prime and almost only activity of RMP.  This I think would be disappointing
          and selling far short. It is very evident that it will always be a substantial part of  the  acti-
          vities of RMP insofar as the current legislation and I read to you an abstract from the  Current
          Register that will be going in that deals with continuing education as a major part of the acti-
          vities. I hope we don't get caught, of course, in the trap of traditionalism when we're  dealing
          with continuing education.  I'll take one more question and I think we'd better quit.
          AUDIENCE QUESTION: You spoke of decentralization in RMP - I wonder if this applies to HEW in  gen-
          ral? I'm referring specifically to last year's policy of direct funding to  the  migrant  health
          project without going through the state agencies.
          DR. WILSON: Decentralization applies to HEW generally. I'm most knowledgeable  about  HSMHA  acti-
          ities.  Roughly one-third of our deployable funds   the ones that aren't caught up in some  kind
          of a grip like the public health service hospital  are now being expended with the primary author-
          ity and responsibility in the regional office. We have tended in those instances to keep  research
          grants and training at the national level and to look at health service as something that  would
          be deployed by the regional offices. The migrant health worker program is coming out of the  Regi-
          onal not the national office. Any migrant funding is coming from the Regional.  We're  still  in
          the process, and I'm pretty new at this business of finding out exactly how it is that  you  get
          the right communication between the Regional office and the "b" agency and the local  professional
          group and if there's any one extra-curricular in the loose use of that word where I've spent a lot
          of time it's on California either by telephone or personal visit where some folks forget about some
          of the common amenities of courtesy in doing this sort of thing. You know these  are  inexcusable,
          in personal or official relationships. I hope we're getting to that issue somewhat. We  will  con-
          tinue to be making the grant as such from the regional office for the migrant health worker projects
          and others.  That does not mean, however, that this won't be subject to substantial discussion
          with the "b" Agency group and with the local professionals and those people who have who have  a
          right to be involved because they finally wind up doing the work. Does that speak for  your  ques-
          tion?  This is decentralization.
          AUDIENCE COMMENT: I just wanted to mention one thing, that Dr. Wilson felt they had  their  Sunday
          lothes on and he wouldn t have to chance to critique their papers . We did that for Dr.  Buggs  on
          Monday just so he wouldn't have.his Sunday clothes on. He thought we wouldn't have time to do  it,
          but we took care of that.
          DR. WILSON: I was sure someone would. I one time heard a speaker use something which  I  will  rob
          nd repeat now, that "You've been an excellent audience.  If you have another chance to be an
          audience, don't miss it."



















                                                         36.






                                                      GENERAL SESSION
                                                 Friday-, October 30, 1970
                                                         8:30 a.m.


           DR. ANDREWS:   We will move now into the reports of the workshops which were held yesterday.      This
           shouldi I think, be the highlight of this program, because  it  represents  the  conclusions  of  your
           collective deliberations.


                                                        WORKSHOP 1
                                                 Area Region Relationships

           William A. Markey
                Workshop #1 progressed through three groups. These  groups  brought  forth  a  wide  range  of  in-
           terpretations of the question "What about Area-Region relationships?"
                The range of interpretations was from a formal chart of  organization  in  a  military  type  dele-
           gation of duty from national to Regional to  Area,  through  the  essential  abolishment  of  California
           as a Region, and the making of each Area a Region  in  and  of  itself.  This  latter  interpretation
           brought out that there are similar kinds of difficulties  in  the  Area-Region  relationship  and  the
           District-Area relationship in those Areas  which  are  organized  into  formally  structured  districts.
                By and large, all groups seemed to be accepting  of  mutually  supportive  roles  with  strong
           local participation within the overall Regional framework.     It was felt and agreed  by  most  members
           of the groups that if the mission of the California  Region  were  described  frequently  and  sincerely
           with reference to the Areas, then a total structure which  allows  for  Area  input  could  predominate.
           For example, "The purpose of the California Region is,  through  its  Areas,  to  provide  improved  re-
           gionalization of health care services throughout the  state."  The  phrase  "through  Areas"  should  be
           used frequently in describing the activities and goals of the Region.
                With respect to priority setting, there was  fairly  good  consensus  that  Regional  guidelines
           are needed as a framework within which the Areas should function.     Areas then would  set  their  pri-
           orities within this framework and in keeping with documented needs of the Area.  This, it was felt,
           would provide the highest and best use of the existing  resources,  and  should  point  the  way  toward
           discovery of needs which are not now being served.
                It Was generally agreed that the Region should not  expect  to  impose  specific  priority  goals
           within an Area not ready to accept or recognize these needs  as  being  higher  than  a  locally  recog-
           nized priority.
                Informal priority setting by the Area Advisory Group and core staffs was discussed.       It  was
           pointed out that use of staff time for small studies  and  similar  means  to  achieve  regionalization,
           involvement, or other catalytic activities will  undoubtedly  continue  without  the  laborious  major
           project development and review processes. It was felt that  this  was  an  important  element  in  the
           overall effectiveness of Area activities, and  that  this  informal  priority  setting  should  probably
           receive formal recognition.
                Discussion was held in one group relative to  the  political  influence  from  Washington  or  from
           state officials on operation of a given Area. The example  given  in  this  group  was  the  appointment
           of a person as program director who had once been  a  political  opponent  of  a  congressman.  The
           group was unable to resolve this particular problem; but it  did,  in  discussion,  point  out  ways  in
           which members of Congress might be informed About  RMP  activities  in  their  respective  districts.
                The review process was discussed by all three groups.     Most questions dealt with th  e  forth-
           coming Annual Review process, the developmental  component,  and  the  Region  level  funding  decisions
           which are implied. An important suggestion was  forthcoming  from  one  group,  with  concurrence  by
           another group: The technical review report should be made available  to  CCRMP  as  well  as  to  the
           Area Advisory Group, with a staff summary of discrepancies and changes  made  by  the  Area  to  meet
           deficiencies, and that an abstract of the proposal rather than  a  personal  appearance  by  the  pro-
           poser should be presented to CCRMP.    It was felt that the proposer, who might  by  the  time  the
           proposal is complete have only faint resemblance to his  initial  thought  included  in  the  project,
           would have presented activities to the various technical committees, the technical review, and
           the Area Advisory Group. He would still look forward to  a  presentation  at  the  RMPS  site  visit.
           It was felt that if a written summary, in terms which would  be  easily  understood  by  all  members
           of CCRMP, including community representatives, were  to  be  presented  without  an  individual  "pitch"
           for each proposal, that CCRMP would be able to make a more  sound  judgment  relative  to  the  impor-
           tance and relative position the proposed project would have  in  the  total  scheme  of  California  RMP
                                                              37.






         p I anni ng.
              It was felt an important ingredient in the review process would be  that  CCRMP  should  view
         itself as a defender of any project which it approves for funding.
              Other discussion covered:
              RMP's possible role in the implementation of health  manpower  organizations,  national  health
              insurance, and similar programs.
              RMP's role in expanding basic medical health education capacity of the country.
              CCRMP should provide clear criteria for project and core acceptability.     This would  help
              Areas in the selection of material or projects presented.
              The importance of some fund flexibility at the Area level  was  emphasized.  This  would  be  for
              pursuit of locally important information for studies or public relations  activities  in  a  for-
              mat which is appropriate and to scale for each Area to use.
              Finally, it was emphasized that each Area Advisory Group and CCRMP  should  have  the  internal
              strength to be able to say "no" when indicated.    This was with respect to  the  forthcoming
              Annual Review process, and the need for a more clearly defined program  for  California  in  RMP.


                                                     WORKSHOP 2
                        Category Disease Planning Versus Comprehensive Medical Care Planning

         Sam Sherman, M.D.
              Groups B, C, and D met a nd discussed the question of: "Categorical Disease  Medical  Care  Plan-
         ning versus Comprehensive Medical Care Planning."
              The first issue for this discussion revolved around the original  intent  of  the  legislation
         implementing Regional Medical Programs.   It was agreed that the categorical  approach  in  planning
         was necessary in the early days of the program because of:
              1.  The high incidence of mortality and morbidity of heart disease,  cancer,  stroke  and  the
                  related diseases in this nation.
              2.  The pressures of the professional organizations  and  voluntary  agencies  whose  traditional
                  interests were in these disease categories
              3.  The ease of planning and operational progr@ms concerned  with  educational  activities  de-
                  signed to upgrade dare for a few diseases rather than for  total  medical  and  health  prob-
                  lems.
              4.  Improvement of professional skills in limited disease categories was more readily achieved
                  in a limited program as compared to a more comprehensive one.
              5.  Initial guidelinesand directives specified that this approach was  to  be  followed  using
                  cooperative arrangements with physicians, institutions and communities.
              Initially there was polarization, but finally there were  common  areas  of  agreement.  All
         groups agreed that much has been accomplished by the categorical approach and  that  it  should  be
         retained as a base but it needed broadening and updating.    Many gaps in medical care  have  been
         identified, particularly since consumer input has been added to the professional input.      More
         visibility to Regional Medical Programs is needed in order to  receive  increased  consumer  and  pro-
         fessional support and acceptance. Almost all  discussants  recommended  increased  flexibility  by
         expanding the categorical approach and including comprehensive medical care planning.      Increased
         emphasis on preventive services, social services, continuity of care  and  all  types  of  rehabilita-
         tive services is needed in the future development of programs.    Elimination of  fragmentation  and
         undue duplication should result from this new direction.
              Primary care was defined by all three groups as "any modality which  permits  a  person  to  have
         entry or re-entry into the medical care system." This may be  achieved  by  a  multiplicity  of  meth-
         ods and through any member of the recognized health team.
              It was noted that Regional Medical Programs has been instrumental  in  promoting  the  acceptance
         of the health team for management of diseases, utilizing a multidisciplinary concept for total care.
              All groups agreed that Regional Medical Programs should assume a  role  in  providing  equity  of
         access to health care, increasing quantity of health care, and higher quality  of  health  care  using
         the educational methods which have been so successful in the categorical programs.     With this issue
         resolved, the three groups recommended that Regional Medical Programs should relate to primary care
         particularly where there are gaps in the delivery of health care, be they in  rural  or  urban  areas.
         This role can be either as a catalyst or a coordinator and should be carried  out  when  requested  by
         Model Cities Programs or Neighborhood Health Centers or any responsible  community  or  group  of

                                                          38.







            consumers.
                 Furthermore. in cooperation with "b" agencies of Comprehensive  Health  Planning,  many  needed
            health manpower and personal health services problems could be remedied in the future.      These
            cooperative efforts would possibly lead to innovative health delivery  systems  acceptable  to  both
            the professionals and the consumers-Overlapping and unnecessary duplication  of  the  two  programs
            would be materially reduced if not eliminated by this "collusion course".
                 In conclusion, it was agreed that in order for Regional Medical  Programs  to  remain  viable,
            category disease planning must be expanded and made more flexible.    Health professionals and
            allied health personnel must be offered realistic incentives for creating  new  and  exciting  pro-
            grams with both educational and health delivery components. The  total  health  needs  of  consumers
            should receive primary consideration, and if new legislation or new  guidelines  or  new  relation-
            ships with other agencies will be required for this -- so be it!!


                                                        WORKSHOP 3
                                       Health Manpower and Regional Medical Programs

            William Monroe

                 President Nixon has recently announced a survey which disclosed that there  was  a  shortage  of
            40,000 physicians in this country. He pledged the support of his  office  to  overcoming  this  "medi-
            cal gap." However, Dr. Wilson has told us that there has been no increase  in  the  level  of  funding
            for health services for fiscal years 1971 and 1972, and that he  anticipates  very  little  increase
            for the following year. At the same time, three universities  have  indicated  major  financial  prob-
            lems in keeping their doors open for medical students.  St.  Louis  University,  Marquette  University
            and George Washington University have indicated that they may close the doors of their medical
            schools next f@ll. In view of the lack of priority assignment to  funds  and  the  funding  problems
            of the universities Wthin the United States, what can Regional Medical  Programs  do  to  close  this
            health manpower gap?
                 Insofar as continuing education is concerned, the Regional Medical  Programs'  efforts  in  the
            past have been largely organized around the categories of  heart,  cancer  and  stroke.  Continuing
            education has dealt with training physicians and allied health workers to  man  Coronary  Care  Units,
            to provide stroke teams for stroke units and other categorical approaches.  Some areas have offered
            short seminars but report inconsistent response, some courses being well  attended  and  others  are
            not.
                 The question of the physician-assistant is one that Regional Medical  Programs  must  deal  with
            Physician-assistant training has been organized primarily on a categorical  basis  -  training  physi-
            cian-assistants for pediatric work, expanding the role of the nurse and similar activities.     Al-
            though a new law has been signed into effect in California, the r6le  of  the  assistant  physician
            has not been defined or licensing procedures developed. This is an  area  in  which  Regional  Medical
            Programs can become actively involved and can alleviate the pressures on  the  physicians  by  defin-
            ing the role of the Ohysician-assistant and seeing that he is adequately  trained  to  assume  duties
            wherein lesser than physician skills are required.   In addition, in order  to  effectively  utilize
            the physician-assistant, the physicians themselves will have to be trained  to  work  with  their
            assistants.
                 It has been recommended that Regional Medical Programs utilize its  influence  to  require  at-
            tendance in  Continuing  Edu'cation courses in order that licenses may be  retained.  This  is  current-
            ly being considered as a requirement by the American College of  Family  Practitioners.  A  word  of
            caution, however. The doctor is an hourly worker. When he takes  off  from  work  to  attend  class,
            his income stops.  He is , therefore, required to consider training on a cost/benefit basis.
                 In considering allied health works it should be pointed out that the role  of  the  nurse  today
            is really quite different than that of 20 years ago.   However, there is no  well  organized  re-
            orientation or training courses for older nurses. Regional Medical Programs  has  a  role  in  bring-
            ing together representatives of nursing education and nursing  associations  to  develop  appropriate
            curriculum whereby nursing skills can be updated.
                 Brought out in the workshop on health manpower was the practice  of  physicians  issuing  stand-
            ing orders, permitting nurses to treat patients in  their  absence.  Considerable  discussion  took
            place as to the legality of this procedure.   In the County of Los Angeles, nurses  and  firemen  have
            been identified and trained for rendering emergency medical aid  to  coronary  patients.  In  order
            that they may do so, however, a special law has been passed in the  State.  This  law  permits  the
            cited practice only in counties with populations exceeding five  million  persons  which  automati-
            cally excludes all other counties, except Los Angeles.


                                                            39.





                 Consideration should also be given to  upgrading  the  skills  of  other  health  workers  such  as
           LVN's and Community  Health  Aides.  Well-organized  efforts  such  as  those  being  carried  forward  in
           Area VII (UC-San Diego) should be emulated with CRMP.  It was noted that in some areas medical
           technicians were trained in such  numbers  that  they  cannot  all  be  placed  in  internship  positions
           in their area. It should, therefore,  be  the  responsibility  of  RMP  to  survey  the  total  field  to
          .match skills against requirements. It  will  be  a  matter  of  coordination  to  assure  a  balance  be-
           tween the supply and demand for health care delivery services personnel.
                 The Health Consortium is a new  concept  which  may  be  utilized  to  assure  comprehensive  health
           care.  The difference between the health consortium and an inter-disciplinary medical team is
           that the whole consortium is a group which is  trained  to  work  together  as  a  unit  to  view  the
           patient as a patient rather than to look at him as a set of individual diseases.


                                                          WORKSHOP 4
                                Regional Medical Programs - Comprehensive Health Planning

           Michael Shimkin, M.D.
                 I also sat through three sensitivity groups and they were supposed to react to three questions:
                 1. What should be the relationships between RMP and CHP?
                 2. What should be the  relationships  between  RMP  and  Model  Cities  or  other  Federal  programs?
                 3'. How can the RMP develop multiple sources of funding?
                 All groups decided the answer to  all  three  questions  is  "yes."  I  think  we  all  realized  that
           although we talk knowingly about  sub-segments,  that  the  health  industry  can  be  called  a  non-system.
           It   is'however, far to the  rear  of  another  non-system  in  this  country  called  health  legislation.
           So we find ourselves  talking  in  cliches.  Obviously,  everybody  agrees  that  we  should  work  toget-
           her. Obviously, the goals,  if  not  identical,  are  similar.  Obviously,  the  way  we  proceed  with  it
           is determined by the acts or versions of the Acts under which we work at a particular time.  I
           don't know that we have any alternatives.  It  is  not  in  our  wisdom,  to  decide,  for  example,  that
           RMP related more closely to health manpower and primary health care and the role of providers
           than CHP, whose role is  mostly  planning  and  facilities  and  represents  more  strongly  the  consumers.
           This is the way it was written -- all we are doing is regurgitating and then deciding this was
           our decision. We really had very little to  do  with  it.  As  a  matter  of  fact,  in  most  of  our
           minds, there occurred the sad thought that despite the reorganization of RMP to the so-called
           newly defined goals the only really  viable  act  we  had  before  defined  heart  disease,  cancer,  stroke
           to which kidney disease has been added.  The rest is really our interpretation.
                 What are these legislators trying to say to  us?  Is  it  possible  that  to  them  the  old  flags
           of heart, cancer and stroke  have  more  appeal  andtheretofore  perhaps  have  more  funding  in  the
           future than these overall goals  and  cliche  words  such  a  comprehensive?  I  wonder  whether  this  is
           what is in the legislative process we@have seen before us.
                 All of the groups agreed that  the  RMP-CHP  orientation  alone  is  too  narrow.  Written  into  law
           are many other pieces  of  legislation  which  interpret  Federal  activities  at  the  local  level.  Cer-
           tainly in most areas you'll find that monies, if you want to be so cras       s as to talk  in  those  terms,
           are much fuller in terms of programs under Model  Cities  and  OEO  and  none  of  us  have  developed  any
           meaningful relationships with these  organizations.  There  is  a  lot  of  expression  of  mutual  need  on
           both sides, yet how that mutual need is to  be  fulfilled  is  not  quite  plain.  Most  of  us  were  RMP
           people with a few from CHP and a few from  other  agencies  --  we  all  agree  that  Model  Cities  need
           our help terribly much. I don't  know  that  Model  Cities  is  quite  as  firm  in  that  contention.  The
           point is that we in RMP cannot wait for Model  Cities  to  come  to  us  and  ask  for  our  help.  We
           have to go and talk to them at the people  to  people  level  to  define  their  problems  and  help  them
           without offering the threat  of  taking  over.  So  somewhere  in  this  public  relations  scheme  perhaps
           something can be worked out.
                 We also discussed whether  there  should  be  a  more  formal  relationship  between RMP and  CHP  at
           any level. We came to  a  Solomonic  decision  that  perhaps  we  better  leave  that  one alone  toot   Some-
           times solutions to  the  problems  are  worse  than  the  problems  themselves.  Since  we are  getting  along
           not too badly in our present relationships, let's  try  that  way  rather  than  to  call  for  some  arti-
           ficial mechanism that may or may not work. When I  say  we  I'm  not  too  darned  sure  whether  it  is  me
           talking or any of the people in  these  groups,  but  this  is  sort  of  a  free-wheeling summary.
                 Yesterday, Dr. Wilson told  us  about  a  decentralization  of  these  programs  and indicated   that
           this should occur at the  HEW  regional  level.  Having  had  experience  with  this  kind  of  decentrali-
         ,zati6n in the past, some of us  have  concerns  about  that!  Perhaps  Dr.  Smith  will  talk  about  it,  but
           the recent course of events would indicate  that  the  HEW  regional  offices  do  not  have  the  capabili-
           ties or capacities, and so admit, to  carry  out  any  of  these  functions.  So  often  what  results  is

                                                               40.





           another stop gap in the ladder and some of us would rather deal with Washington directly, if Wash-
           ington is equipped to respond quickly to our needs.        At  any  rate  that's  one  of  the  problems   we
           have to deal with for which I don't think there is any particular solution, at present.
                 So  in  conclusion,  we  sort  of  concluded,  that  we  wouldn't  conclude  anything,  and   indicated
           that the two states we certainly are faced with and have to live with and can live with are:
           1)   keep our options  fluid,  and  don't  come  to  any  cosmic  decisions  too  quickly,  and  2)  maintain
           as good a sense of humor as this pain allows.


                                                           WORKSHOP   5

                                                          The Committee


           Charles H. Whi e, Ph.D.
                 The  total  group  that  came  to  this  conference  is  approximately  60%  RMP  staff;  20%  advisory
           committee  members;  20%  staff  members  of  other  agencies  with  planning  functions.  As  one   attempts
           to  share  skills,  knowledge,  and  understandings  in  the  performance  of  our  staff  roles,  "The  Com-
           mittee" topic was chosen as one of the workshop subjects.
                 The groups varied considerably.      In some  groups  the  subject  itself  was  under  discussion  for
           long periods, but in other groups it served only as a vehicle to get onto other more serious bus-
           iness.   We were able  to  identify  a  number  of  reasons  why  committees  exist:  as  a  way  of  sharing
           responsibility,  of  encouraging  participating,  as  a  division  of  labor,  of   performing   an   indepth
           study, as away of  collecting  expert  knowledge,  as  a  way  of  performing  a  task  in  the  most  effec-
           tive manner, and  in  some  cases  as  a  political  device.  This  discussion  of  the  types,   functions,.
           and roles of committees led us to a thread of consensus that ran through the day that frequently,
           in our own organizations, we  know  these  are  some  of  the  purposes  of  committees.  but  we  also  have
           some committees that don't seem to match any of these committees.          One  of  the  two  of   the   very
           explicit conclusions that were  able  to  be  drawn  is  that  it  may  be  time  to  reorganize  and  re-ex-
           amine our structure.  Remember, the structure of your program may         have  been  built  upon  a   review
           and grant project application building scheme.  That scheme may no longer be a reality.  The
           development of grant proposals may have been able to run its course.           We  may  be  moving,  instead,
           toward fewer standing committees, fewer long-term groups toward more issued-centered, time-limited,
           task-oriented committees which  are  called  into  existence  to  do  a  job  and  then  are  called  out  of
           existence again.    We contrasted this with  a  group  of  a  series  of  traditional  groups  that  just  go
           on and on sometimes long past the point when they have any reason for existence.
                 The other thread which we discussed thoroughly was:        if we are no longer building grant pro-
           posals  that  call  for  a  different  theory  of  staff  roles,  the  staff  work  then  becomes  committee-
           centered  in  a  process  of  being  the  broker  or  catalyst  among  people  or  organizations.  This   re-
           moves some of the tangible ways of dealing with problems.  As long as you can chase a grant
           proposal you have something tangible to work with.  When that's gone, some of the security is re-
           moved for the staff.  They must then try to formulate a substitute set of goals.
                 In  one  particular  group,  there  was  unanimous  agreement  that  staff  members   themselves   were
           extremely  unclear  about  the  purposes  of  their  agencies.  This  seems  to  bear  out   the   suggestion
           that we need  to  re-examine  our  own  structure  and  programs.  We  ought  to  do  some  more  considering
           about what is the role  of  the  staff  person,  in  view  of  the  changes  of  directions  of  the  program
           that were indicated yesterday.


                                                           WORKSHOP   6
                 Regional Medical Programs and Voluntary Health Agencies and Other Non-Federal Agencies

           William C. Fowkes, Jr., M.D.
                 Three  very  informative  and  interesting  workshop  sessions  were  held  covering  the  above   sub-
           ject.   It was the consensus of opinion that the definition of a Voluntary Health Organization was
           any organization that responds to public need and does not as a routine get funding from the Fed-
           eral Government.    In  addition  to  agencies  such  as  the  Heart   Association,   the   American   Cancer
           Society, Kidney Foundation, etc., we can include some hospitals and free clinics.             It   could   be
           stated that a Voluntary Health Organization is a group of people organized to handle a particular
           problem, raise its own money for its own cause, and self-organized by citizens with specific goals.
                 Given the foregoing clearly defined definition, its was concluded that there is literally no
           limitation on the extent to which we might work with Voluntary Health Organizations.  As the goals
           of  these  organizations  continue  to  broaden,  their  importance  to  RMP  will  continue  to   grow   and
           through cooperative arrangements We can address ourselves to specific healthcare problems.
                                                                41.




                  There was considerable discussion as to how RMP should relate to such agencies on a regional
             and on an area basis. It was agreed that this very much depended on the  individual  needs  in  a
             particular area. The association would in all probability be task-oriented and the kind or  scope
             of ties be appropriate to local situations. This is simply a way of  accomplishing  the  ultimate
             goal for which both are aiming. It was a concensus that the relationship of  these  organizations
             with RMP could not be defined from a national,regional or state level, if task-oriented relation-
             ships should be handled on a local basis or neighborhood basis.
                  There was little question of any conflict in any of the areas between Voluntary Health Organ-
             izations and RMP other than the possibility of competition concerning visibility  or  recognition
             between the voluntary agency and RMP. There was some feeling that the Regional  Medical  Programs
             needed considerably more visibility and more recognition for its coordinating function in order to
             accomplish its mission. This is not the case with CHP. There was almost  universal  feeling  that
             the voluntary health agencies and CHP were in direct conflict because of the  necessity  for  CHP
             to solicit funds to raise its 50% share from the same constituencies as the voluntary health
             agencies.
                  The categorical nature of the voluntary health agencies was felt to be  at  some  odds  with
             present goals of the RMP but it was the general feeling that these organizations would adapt
             and that their resources could be mobilized in more comprehensive and broad programs  appropriate
             to local need.  There was general feeling that categorical programs will continue to be developed
             though in a somewhat more limited scope and that we must strive to continue our excellent relation-
             ship with the voluntary health agencies for mutual benefit.
                  There was a tendency in each of the three workshop sessions to move from the association  of
             RMP and voluntary health agencies to the relationship of RMP to Model Cities and there was feeling
             that RMP staffs within personnel and time limitations should work intimately with the Model Cities
             programs and help them develop their health components.

                                                       WORKSHOP 7
                                            Core Staff Structure and Function

             Al Torribio
                  What constitutes a good core staff?
                  In what ways can personnel be shared between Areas?
                  What are the skills of planning? How can they be utilized? Who has them?
                  What is the relationship between core staff and Area Advisory Councils and/or District
                    Committees?
                  A "good" staff requires a frame of reference.  In  RMP  this  reference  is  difficult.  For
             example, a basic RMP concept is                 but planning  involvement  requires  grass  roots
             contacts. For this reason there is a movement toward sub-regionalization, and  sub-area  or  Dit-
             trict development.  The staff's relationships to constituents are affected by:
                  Changes and uncertainties in the law. Changes in  program  relationships,  emphasis,  review
                  and approval mechanisms. Changes and delays  in  funding.  (For  example:  How  long  should
                  a project be carried as a part of core funding when an approved  but  unfunded  project  may
                  never be funded because of changing program emphasis?)
                  The function of core staff may be affected by a change in RMP from  the  role  of  solicitor
                  and/or screener or projects to health system transformer.
                  What constitutes a "good" staff? Good will vary with the  size  of  staff  the  area  to  be
             served, and the expectations of the community and university. With all  the  above  changes,  one
             of the primary skills expected of staff is the ability to function  efficiently  and  effectively
             in the face of change.  Money is a prime need for staff development.  RMP programs with multiple
             staff members can exchange experiences and develop group support of endeavors.  Isolated or
             small staff feel alone and overwhelmed at the magnitude of its tasks.
                  A good staff should develop community acceptance.  This can be accomplished by persons from
             a Variety of disciplines and ethnic backgrounds. Staff should trust and accept  the  sound  deci-
             sion making capabilities of volunteers. Listening skills, ability to draw other  members  of  the
             university out into the community, and their acceptance of new ways to deliver health service are
             important attributes.
                  As a catalyst and idea broker, staff should avoid putting old.wine in new bottles  and  know
             how to tap various funds. Staff should not become emersed in medical care  to  the  detriment  of
             their continuing education responsibilities.
                  Community volunteers are not concerned with  professional  jealousies  and  status  problems
                                                            42.




           but rather with health care needs.  They-expect staff to know who should be involved.  As a
           change agent, staff should encourage RMP organizational  change  when  structure  no  longer  fits  the
           program goals or objectives. In moving  from  project  to  system  approaches,  communities  should  be
           prepared for the wind-up of projects and not left high and dry after project funding ceases.
           Shift in program emphasis may require new team members.
                Few Areas have had experiences in  exchanging  or  sharing  staff.  Some  do  draw  on  the  know-
           ledge and experience of others and have also provided considerable assistance to CHP staff.
                In  regard  to  staff-board  relationships.  The  term  "advisory"  needs  clarification.   Should
           boards develop policy? Should  they  hire  and  fire?  The  workshop  groups  indicated  wide  variance
           in practice.  One Area Board hires and fires all members of the staff, professional and non-
           professional. In another, the Coordinator hires and  fires  and  may  or  may  not  tell  the  Advisory
           Board. In one Area, staff members  assist  committees  only  when  invited  to  help.  In  others,  the
           staff decides when to convene Committees to  seek  their  help.  There  was  some  need  expressed  for
           staff title clarification.  How do planning officers differ from assistant coordinators or
           grant management personnel or project coordinators?
                All staffs should have periodic self appraisals of their role, functions and accomplishments.
           Goals and objectives should be  reviewed.  Volunteers  should  be  involved  in  this  process  because
           in some instances, they change,  and  accept  change,  more  readily  than  staff.  Increased  involve-
           ment Of more consumers in RMP should be encouraged.
                'Finally, staff should develop faith in the future of RMP, hope in RMP goals and its relation-
           ship to other federally related programs. Above  all,  staff  should  maintain  a  charitable  attitude
           toward national and regional administrators who have a most difficult job.


                                                        WORKSHOP 8
                                      Regional Medical Programs and Medical, Schools
           Jo            sler, Ed.D.

                In the early sixties public attention was focused  on  the  three  primary  diseases  of  mankind:
           heart disease, cancer and stroke. President  Kennedy  appointed  a  blue  ribbon  committee  headed  by
           Dr. Michael De-bakey to study possible ways to make  inroads  into  conquering  these  deadly  killers.
           The Debakey Committee recommended  the  establishment  of  specialized  clinics  throughout  the  couh-
           try to bring together the  foremost  authorities  in  these  fields.  Following  lengthy  debate,  Coh-
           gress passed Public Law 89-239 and in  October  1965,  President  Johnson  sighed  the  heart  disease,
           cancer and stroke amendments establishing the Regional Medical Programs.  This law provided
           that the R6giohal Medical Programs be  established  within  the  university  environs  rather  than  in
           new SP6cialized medical centersbecause it  was  thought  that  the  knowledge  which  was  centered  in
           the medical schools should be made available outside the cloistered halls to the practicing
           physicians throughout the country.  To date fifty-five Regions have been funded for planning
           activities.
                The California Region operates  through  the  California  Medical  Education  and  Research  Foun-
           dation headquartered in San Francisco. The Region  is  then  divided  into  nine  Areas,  one  at  each
           of the nine'medical schools in the State of California.  This is a unique arrangement for the
           RMP's throughout the country but seems  to  have  worked  well  because  it  permitted  the  California
           Region to get an early start and made available funding for the four newer medical schools in
           the State earlier than would otherwise have been possible.
                There have been, of course, differences of opinion.as to the relationships that medical
           schools have with Regional Medical Programs. It has been  feared  by  some  that  the  medical  schools
           would resist community programs because they would tend to divert the focus of the professors
           from the realm of  academe  and  dilute  their  efforts  through  widespread  cooperative  arrangements
           with many other agencies.  Actually,  through  the  RMP  mechanism,  mutually  beneficial  arrangements
           have been developed between the teaching  physicians,  the  community  physicians,  and  allied  health
           personnel throughout the Region in a way which  has  never  been  done  before.  Some  of  the  general
           questions growing out of this new  relationship  which  We  have  discussed  at  this  conference  are:
                What are the relationships between the RMP and the medical schools?
                What are'the advantages or disadvantages of these relationships?
                How can these relationships be made more beneficial?
                We also directed our  attention  to  some  of  the  "nitty-gritty"  interface.areas  pertinent  to
           carrying on the everyday work of the RMP's under the University aegis.  These included:



                                                             3.






                 1.  Objectives
                 2.  Administrative Policies
                 3.  Facilities and equipment
                 4.  Personnel
                 5.  Finance and accounting
                 6.  Support services
                 7.  Project proposals
                 8.  Public relations                             spirited, sometimes heated, and frequently
                 Opinions expressed during the discussion were         esents a consensus--there is neither
               diametrically opposed to each other.  The following repr             presented.
               space nor time to report every point no matter how eloquently it was
                 Most medical schools adapted smoothly to the new conditions and Phil    0sophies of the RMP
               program. However, those of traditional orientation felt  resistance  toward  expanding  the  medi-
               cal school's dual role of teaching and research to include concern  for  community-oriented  medi-
               cal services. !his resistance was reinforced by theresent'nent felt by socially conservative
               faculty members to anything that smacked of government influence.  It was also held by some
               that the community must come to the medical schools to partake of  any  of  its  benefits.  Conse-
               uently, the early proposals submitted for RMP  consideration  were  academically  oriented,  bene-
               .icial primarily to the medical schools and in many cases basic  research  in  nature.  RMP  cool-
               1 ess to this approach was readily apparent, and these institutions began  the  grantmanship  game
               anew under the qround rule that acceptable proposals were community-oriented.  The pertinent
               questions now b-ecame:  "Should RMP projects be designed to reach the few people who need.the
               most help or the most people who need less?" or "Should RMP efforts be defined by community
               members who define what they want so that medical schools will meet  their  standards  of  patient
               care services?li
                   There is no doubt that these are concerns basic to RMP success with medical colleges.
               People in needy areas are still. distrustful of the medical school 's influence in RMP.  They feel
               that the programs are not sufficiently realistic to their actual care needs.  Many in under-
               privileged areas are troubled by the belief that the medical schools are interested only in
               using them as guinea pigs.
                   But the climate is changing. Medical schools  are  responding  to  the  challenge  of  meeting
               community medical needs, especially when defined by  joint  cooperative  means  between  community
               and medical school representatives. Medical schools feel the  pressure  of  taxpayer  demands  for
               producing treatment-oriented physicians; they are responding to  the  pressures  of  medical  students
               who clamor for instruction which is relevant to the needs of the community.
                   Spurred by this, the medical schools are reaching  out  to  the  community.  They  are  conducting
               projects which bring their personnel and resources to the community.  True  it  is  not  as  wide-
               spread and far-reachingIan effort as many would like, but progress is bein; made.  Medical
               schools are forming departments of community medicine to facilitate bridging the gap      They are
               beginning to consider the employment of non-physicians in  those  departments  and  pers@nnel  who
               may lack academic degrees, but who can measure up to new criteria of  competence  and  make  vital
               contributions  rom a base of rich experience in community life.
                   Medical schools find this new role a  beneficial  one  for  establishing  good  Dublic  relations.
               And RMP has found that affiliation with the medical  schools  has  lent  stability  and  prestige.
               Some RMP groups prefer to be housed on campus to strengthen their identity with the medical
               school.  They value and utilize the supporting services  --  computers,  publications,  etc.,  and
               the access to consultation and professional expertise which the medical school can offer.        Other
               RMP groups place more value on being located  off  campus  in  the  community  neighborhood.  They  do
               not want exposure to the possible risk of  medical  school  domination.  They  do  want  closer  iden-
               tification as a community agency.    (Som6 even get better parking accommodations this  way')  ,  Some
               RMP groups have solved the problem by having both kinds of locations.     For the  medical  school
               which has accepted responsibility for community  medical  service,  what  better  established  vehicle
               for action than through RMP?
                     RMP groups which have made the greatest progress in  developing  fitting  relations  with  medi-
               cal schools are those which have taken active steps  to  surmount  obstacles  created  by  obscurities
               of national policy, unapproachable deans   ,and ivory-tower faculties.    Cooperation and involvement
               are key words in this process.    Cooperation versus  demand;  and  involvement  through  service.
                     In conclusion, the relationship between RMP a d the medical schools can be, and generally is,
               a good one.   It expands th@ medical school's role into an  extremely  relevant  social  one  of  Pro-
               Viding community medical service, it builds a bridqe  between  medical  school  faculty  and  practic-
               in    h         with resultant facilitation of continuing education, and provides a solid resource
                 9 p ysicians.
               Of technical expertise for RMP to draw upon for  the  effective  realization  of  its  objective:  the
               provision of improved health care.
                                                                  44.





                               QUESTION AND ANSWER PERIOD FOLLOWING THE WORKSHOP REPORTS


          DR. BUGGS:  I think this conference would be of a great help in settling area-region relationships
          and core staff structure and function by answering one question. That  one  question  can  be  an-
          swered in two words, either singular or plural. I would like this  from  each  of  the  panelists.
          With regard to the area coordinator, who does the hiring and firing  in  California?  The  governor,
          the Regents, the Board of Trustees in  the private schools, the Board of Directors, the Chancellor
          of the respective campuses or the dean of the Medical School?  I would like that question answered.
          DR. ANDREWS: Are you speaking in relation to the Medical School only?
          DR. BUGGS: Yes, to the medical school in regard to the appointment  of  the  Regional  Medical  Pro-
           ram coordinator.
          DR. SHERMAN: In Area I, I am certain the hiring is through the Office of  the  Dean  with  the  con-
           urrence of the Chancellor and a committee that has been appointed at  the  University  to  oversee
          Regional Medical Programs.
          DR. WHITE: In Area II, a search committee was formed by the  Dean  including  faculty  members  and
           he area advisory council to interview candidates and make  recommendations.  From  that  point  on,
          the answer is all of the people you named. The Dean must recommend to  the  Chancellor  and  to  the
          Board of Regents. All these persons must approve the appointment of  the  coordinator  who  is  a
          member of the faculty and goes through all the normal process of faculty appointment.

          DR. FOWKES:  The Dean in Area III.
          MR. TORRIBIO:  In Area IV, the De an appointed the only coordinator we have had.  I don't know what
          T-he process will be in the future, but I suspect it will be different, because there was  one  area
          council when the coordinator was selected.
          MR. MARKEY: In Area V we have a similar pattern of little experience in this  matter,  but  the  one
           ime that it happened, it was done through the dean's office  and  the  dean's  recommendation.  I
          don't believe that it went on to a board from that point.
          MR. MONROE:   In Area VI I belive that the Board of Trustees of the University was involved  in  the
          choice of the coordinator.
          DR. SHIMKIN:  The usual complicated mechanism affected Area VII.    Somebody nominates and  it  has
          to be approved through channels by faculty members then it goes, after filling out scales of papers
          to at least two faculty committees.   One committee examines whether you are a good  boy  and  have
          had a number of publications.  Then  it goes, really, to where the decision  making  is  important
          @ budget committee which questions whether or not it can afford you and whether  you  are  a  good
          investment for tenure.   Then all of this gets gathered together and the Dean talks it  up  to  the
          Chancellor. At one time decisions were delegated down to each campus,  now  the  Regdnts  must  make
          that stamp of approval. After a month or a year you get  the  appointment  settled.  It  is  a-very
          complicated process.
          DR.  STROESSLER:  I'm not sure how this works in detail in Area VIII, but I would assume it
          would be as Dr. Shimkin indicated for the University of California  system,  originating  at  the
          Dean's Office and progressing on from there.
          DR. ANDREWS:  Dr. Buggs would you like to tell us what your plan is for Area IX?
          DR. BUGGS:  Only that I will see if I can decifer these remarks.    I did not get  the  clear-cut
          answer in two words, but we will try to discover where the authority really lies.     If it has  to
          go to the Chancellor and from the Chancellor to the Board of Regents, then as I  see  it,  we  are
          excluding the democratic process in selecting because you have ruled  out  all  community  input.
          DR. ANDREWS:  As I heard people from Area IX yesterday,   I don't think they are going  to  permit
          this process without being involves.
          AUDIENCE COMMENT:   I'm from Area IX, and I'm not going to deal with the Board of Regents but
          you are here from areas and it could happen to you, too, if you let a  Congressman  throw  an  ap-
          pointment back in the faces of the people.  We have a Dean, but we don't have a school yet.
          We're playing games, never to have anything for the poor.    I'm not about to come here  and  let
          all you learned people make reports without going on board with me by saying  you  support  what  we

                                                          45.




              have tried to do in our area. Now we've kept guidelines so far as that  goes;  but  the  guidelines
              are all over because we didn't bring the Congressman in at that time.  We  have  gone  through  due
              process which was wrong. We had community input, we've given our findings  to  the  Dean,  and  the
              Dean has made his appointment. Now I understand Governor Reagan will  have  something  to  say  about
              it on Monday morning. That's going too far. If he has something to  say  about  Area  IX,  he's  damn
              sure going to have something to say about all the rest of you eight areas.  So you may as well
              throw that out of your minds and Paul may just as well get ready to go home and  all  the  rest  of
              you. When one Congressman can upset the whole RMP program,  you  haven't  got  anything  anyway.  All
              I want is support from you that you understand what we're trying to do and say to  us  that  you're
              willing to work with us in some manner.
              DR. ANDREWS: I don't think you understood the answers. In five  of  the  schools  the  appointments
              o not go further than the Dean. The rest of them do send appointments  to  the  Board  of  Regents.
              There is no policy.
              AUDIENCE RESPONSE: I just wanted you to understand. You  answered  beautifully.  We  will  set  the
              olicy.
              DR. ANDREWS: I think the participants of this conference are  to  be  congratulated  on  the  input
              they a@ve given to these workshop chairmen  which  generated  the  reports  this  morning.  I  think
              we've gained insight into the activities and the level of thinking in the California Regional
              Medical Programs.  Are there any questions you wish to address to the panelists?
              AUDIENCE QUESTION: Neil, I noticed a lack of any comment  during  these  proceedings  about'an  op-
              portuki'ty to explore one of the new manpower models we have been talking about for some  time,  that
              is the physician's assistant. We have legislation in California now that will  enable  us  to  devel-
              op and employ such persons.  The Board of Medical Examiners will try to define these types of
              individuals and establish programs for them.  It seems to me that RMP has a  very  vital  input  in
              the development of that role and the definition of the training and function of a physician's
              assistant.  I wonder if anyone is thinking about this.  I haven't heard any comments.
              DR. ANDREWS:  Does anyone on the panel have a comment?
              MR. TORRIBIO:  In Area IV we had a meeting with the head of the MEDHIC program for returning
              servic men who are looking for jobs and Dr. Fitzhugh of the Watts-Willowbrook-Charles Drew
              MEDEX program which is patterned after the University of  Washington.  Also  there  were  represen-
              tatives of the California Medical Association which has a committee concerned  about  the  role  of
              paramedical people and some representatives of voluntary agencies, and health departments who
              are also experimenting with nurse assistants,  family  care  practitioners,  pediatric  nurses.  We
              have gathered quite a stack of literature and program knowledge of 611 of  these  and  are  gradually
              becoming very sophisticated about the various aspects relating to them.   The question is  a  crucial
              one.  How do you plan for health care in situations as described by an Area II field representative
              such as a three-county area with one dentist; or when the only hospital in the  county  has  22  beds
              with one 66-year-old physician who just had a coronary.   It's a crucial question in  many  of  the
              urban as well as rural areas. A new project has just been started  at  Berkeley  to  train  women  as
              family health practitioners.  I think there are 15 public health nurses in that program.     Is  that
              correct?
              AUDIENCE RESPONSE: I think you are giving the State Health Department  credit  which  it  does  not
              deserve. The-University of California School of Public Health has a  grant  for  a  development  pro-
              gram for a family nurse practitioner.  The first six students were admitted this fall.
              MR. TORRIBIO:  When these girls come out 18 months from now we hope they don't go to another state
              because these kinds of people are being looked for now and we had better  plan  to  utilize  Califor-
              nia-trained people.
              DR. FOWKES:  In Area III we have been involved in a couple of programs.  One is a physician-assis-
              tant program, which was submitted to RMP in a project  called  "Integrated  Assistants"  which  did
              not pass at the division level and was returned. However, the  people  who  developed  the  program
              originally are moving ahead and will probably accept their first students  around  January  1,  1971.
              A lot of work has been expended and the formal B.A. program will extend 18 months.  It will
              accept a variety of applicants with health backgrounds,  including  medical  corpsmen,  nurses,  or
              anyone with an interest in health fields who has appropriate background.    In  addition,  a  comple-
              mentary program will attempt to duplicate in a civilian hospital the training  of  corpsmen  to  feed
              into the formalized physician's assistant program. Also, we  have  a  neophyte  pilot  nurse  practi-
              tioner program that began September 20, 1970. We have five nurses  who  are  going  through  a  four-
              month program centered at Stanford Hospital but which involved  preceptorships  in  the  community.
                                                               46.





            Mrs. Jeanne LeBrun has been the major organizing force behind this program.
            AUDIENCE COMMENT:    We discussed  in  our  group  yesterday  the  area  of  allied  health  professionals.
            This is really what we are talking about today.      One  person  doing  his  or  her  thing   to   produce
            five or six people here or there.     We're  talking  about  meeting  a  demand  which  far  exceeds  this.
            We're  talking  about  a  school  of  allied  health  professionals  which  would  bring  together  all  of
            these types  of  people,  upgrading  professionals  across  the  whole  gambit  to  meet  the  health  man-
            power shortage to free up the physician so he can really do his job.        I'm   not   aware    that    in
            California  we  have  a  school  of  allied  health  professionals,  but  it  is  in  the  talking   stage. We
            also discussed  that  RMP  in  its  affiliations  with  all  of  the  universities  would  be  one  of  the
            greatest vehicles to plan  the  implementation  of  such  a  school  to  meet  the  shortage  we  are  dis-
            cussing today.

            DR. BUGGS:   I wish to clarify something.    I don't want  this  audience  to  leave  with  the  idea  that
            the MEDEX program we have spoken about was developed by the University of California.                   The
            Charles  Drew  Postgraduate  Medical  School  has  an  affiliation  with  both  UCLA   and   USC,   Through
            the School of Allied Health Profession  there  will  be  similar  affiliations  with  state  and  community
            colleges,elementary  and  secondary  schools.  The  MEDEX  program  proposal  was   written   by   Dr.   Al
            Haynes, who is chairman of our Department of Community Medicine.       Because   we   do   not   have    at
            the present time a  functioning  hospital,  the  affiliation  with  the  Medical  School  at  USC  provides
            the clinical and didactic training at the present time.      The MEDEX program  is  a  part  of  University
            of Washington MEDEX program developed by a black physician, Dr. Dick Smith.        At  the   present   time
            four of these programs were funded as one package.      One  of  the  training  programs  to  be  based  at
            the Drew school.   Dan Grindell,  formerly  training  coordinator  for  the  King  Hospital,  modified  the
            MEDEX program and that project is known as the Physician's Assistant Program.        We  are  pretty   sure
            that is going to be funded through Model Cities.     The  training  will  be  done  at  the  University  of
            Southern California.

            AUDIENCE QUESTION:  Gentlemen     I would  like  to  know  if  it  is  possible  for  this  body  since  we
            are sandwiched between two major conventions, the APHA  and  the  AAMC  (Many  people  from  the  RMP  will
            attend both of these     to  give  any  recommendations  to  the  AAMC  in  regard   to   manpower   train-
            ing?       That's what it's  all  about.  Where  are  we,  RMP,  in  terms  of  making  recommendations  to
            the AAMC in terms of training?    I know  some  papers  are  being  presented  by  members  of  this  body.
            This is our best opportunity to   get started in the area of manpower.     Can anyone  say  what  is  plan-
            ned  for  presentation  or  recommendations  in  the  name  of  RMP?  What  is  our  attitude  toward  that
            convention?
            PAUL WARD:  I suppose as a group we  have  a  great  many  individual  ideas  about  it,  but  we  have  no
            synthesized position that has come out of debate on the issue.      Naturally,  from  my   own   point   of
            view, I'd like to see things done  logically,  but  as  I've  said  many  times  I  don't  hold  much  hope
            that this will be the case.   If we were to do it that way, I would like to see RMP have the
            courage, and belive me this would take a great deal  of  courage,  to  say  that  we  should  start  licen-
            sure reform now  before  we  get  into  various  training  courses  with  licensure  and  certification  at
            the end, and before we categorize people.    We don't need more  levels  of  manpower,  what  we  need  i,n
            the health field is the ability to go from one level to another without confusion.        If  we  had   the
            collective courage  to  go  before  the  legislature  and  ask  for  changes  in  licensure  and  make  one
            b@oad  license  available  to  all  personnel  ,  with  certain  qualifications  within  that  one   single
            license, We'd be doing the best thing that can be done.       I tried once as  many  of  you  will  recall.
            Until that time, I had been fairly friendly with nu   rses,  therapists  and   others,   but   collectively
            they were very angry with me when I suggested that procedure to the legislature.        Nothing         was
            done. I don't think anything else is worth doing at this point.       Sure,  we  could  train   more   peo-
            ple to serve  in  the  health  field,  which  will  further  complicate  things.  But  if  we  really  want
            to do  something  worthwhile,  we  take  on  that  questioning  of  licensure  and  we  create  the  ladder
            approach which we've discussed  many  times.  We  would  need  to  fight  many  of  our  own  groups  which
            are involved with us here today -- those that have vested interest.      It  would  be  a   bloody   fight.
            I wonder if we have the courage or the ability to come to that conclusion.
            MR4 TORRIBIO: There are also  some  other  allied  schools  which  are  developing  and  unfolding  besides
            the one at Charles Drew.  One  is  at  California  State  College,  Bakerfield,  one-is  in  the   planning
            stage at Valley State College, San Fernando, one is at Fresno State College.
            AUDIENCE COMMENT:  In our last  discussion  group  last  night,  we  had  a  minority  position  concerning
            PO itica  activism.  If RMP and CHP really have  a  vital  future,  it  must  be  as  political  activists.
            We suffer from a lack of credibility and one  of  the  ways  we  are  going  to  get  credibility  as  part
            of the process  of  bringing  about  change  is  moving  legislatures,  changing  laws,  and  restructuring
            the system as we know it today.  That requires political involvement.

                                                            47.




            AUDIENCE QUESTION:   I have a couple of questions I want to ask.       I'm from  Model  Cities  in  Oakland.
            I've really enjjoyed this conference, working with the groups and playing football.        After     listen-
            ing to the great  White  Father  yesterday,  speaking  about  the  National  policy,  and  the  groups  dis-
            cussed problems that are going on, but  I  haven't  heard  any  recommendation  from  the  group  on  what's
            going to be the local policy.    What are  the  relationships  between  the  model  neighborhood  areas  and
            the health centeTs?-A-nd the rural areas?     It seems to  me  there  has  to  be  a  combined  relationship
            where if it happens in one area does it have to happen all over the state.         I don't think  there  can
            be cooperation unless you involve  the  community  groups  since  that's  where  the  political  power  lies
            to change legislation.   RMP is not  reaching  out  into  the  communities,  it's  staying  in  universities
            and hospitals.   That may  be  the  policy  of  the  Reagan  administration  who  controls  the  university,
            but he'll be leaving soon and then you'll have to rely on the community.         I think RMP  needs  to  put
            more effort and interest into the  community  so  it  can  really  get  some  strength.  There  are  commun-
            ity groups that do  have  money  that  is  available  to  help  strengthen  the  RMP  and  the  CHP  groups. You
            might get a lot if the Model Cities program will fund their allied school of health.          This     could
            happen in 10 or 12 more cities in California.      If RMP will take  that  stand  to  do  something        con-
            structive for the community groups.     It's going to have to  be  done  through  local  policy  --        though
            it's you guys who will be making these decisions.      We  want  to  know  from  the  community  level  "Are
            you going to be making that decision in an effort to help those groups?"
            DR. ANDREWS:   I will answer in part that  not  all  areas  have  Model  Cities  components  within        t em.
            Area II, for instance, does not, but  we  have  been  meeting  with  community  groups  to  provide        input
            into our planning activities.
            AUDIENCE QUESTION; My next  question  is  about  the  fragmentation  since  you  have  nine  areas.        All
            areas do not have Model Cities, but those  areas  that  do  have  Model  Cities  can  set  a  definite  pol-
            icy on how they would like to work with Model Cities groups.       It   would   be   statewide,   so   Model
            Cities would know what they can do and  how  they  are  going  to  do  it.  Today  we  have  three  of  four
            Model Cities directors here.    There has been no effort  to  try  to  get  cooperation  from  these  direc-
            tors.  What kind of input can they put into RMP in  order  to  help  since  the  RMP  is  asking  for  help?
            Or how can  RMP  help  our  comunity?  This  has  to  be  discussed.  As  far  as  I'm  concerned,  I  might
            as well be out playing football because I'm not  getting  anything  out  of  it  if  we  are  not  going  to
            do something constructive for the entire community.
            AUDIENCE COMMENT:  My name is Al Parham, Model Cities Director, Berkeley.         I'm  hot   tuned   in   on
            this whole RMP thing  as  some  Model  Cities  directors  might  be  such  as  Henry  Dishroom  of  Richmond
            and he is here. One thing  that  Mr.  Lee  from  Oakland  did  put  before  you  is  the  very  serious  and
            critical need for RMP to become involved in the community.       I  feel   with   this   limited   knowledge
            realizing that it  is  important  for  me  that  before  Model  Cities  can  get  really  involved  as  they
            would like to be involved, we are going to need assistance.       For   example,   in   Berkeley   at   this
            time,  I  could  use  assistance  in  terms  of  monies  that  could  come  to  fund  the  health  planning.
            One of the things  we  can  do  in  our  Model  Cities  Programs  is  to  partially  fund  the  position  of
            a health planner with  additional  money  coming  from  RMP.  Then  we  begin  to  get  into  the  community
            to do some of the thingsand  move  in  the  direction  of  change  that  I  heard  at  least  one  gentleman
            talk about.   I was really  turned  on  from  the  standpointof  what  Al.  was  talking  about  because  he
            was beginning to know where it's really at.      I  missed  some  of  the  earlier  talks  and   I'm   sorryI
            about that.   But we're going to begin to think  seriously  about  the  change,  about  how  we  use  staff-
            ing, and also how we are going to be able to get representatives in the community.          I   think   this
            is where it starts here. With Model  Cites,  we  will  be  able  to  do  a  shared  kind  of  thing  and  we
            look very seriously at that.     I'm at a disadvantage because I don't know the principals.       We're
            all  important.  The  sister  from  Watts  over  there  --  she's  important.  As  they  say,  she's  heavy.
            You people are important  too.  The  reason  I'm  at  a  disadvantage  is  I  don't  known  exactly  who  to
            go to.  The  assistance  I've  been  getting  has  come  through  Virginia  Greer  who  has   been   working
            in Northern California.  One person trying to reach a whole bunch of people.         I  hope   she   doesn't
            mind my saying this, but if  we  are  really  concerned  about  getting  out  of  the  University  into  the
            community, then there shouldn't  be  one  Virginia  Greer,  there  should  be  more  people  funded  to  get
            out where the people are to  begin  to  get  some  service.  What  good  does  it  do  to  have  one  person
            who must serve a large number of people who only has time to talk.        If  we  had   enough   people   to
            begin to assist with  providing  enough  information  that  can  begin  to  improve  services  --  I  under-
            stand that some words are  dirty  words  and  I  don't  want  to  use  any  of  them  now  because  I  don't
            @aht to upset anybody -- but we  could  use  assistance  in  knowing  when  people  come  into  the  Commun-
            ity what you do need.    I've already said  what  we  could  use.  We  are  in  the  planning  year  of  our
            Model Cities program  'Some assistance will  help  us  plan,  even  if  it  is  a  shared  kind  of  funding
            arrangement. And we will move from that point  to  do  those  other  things  that  we  have  not  been  able
            to do  thus  far  because  of  the  lack  of  staff.  Any  other  Model  Cities  comments  and  it  is  very
            important that we talk about this,  will  have  to  come  from  a  person  who  is  involved  more  directly
            with the program,  like  Mr.  Dishroom  from  Richmond.  Model  Cities  doesn't  plan  to  take  this  over,
            but I just think it is important.
                                                               48.






            DR. ANDREWS: Thank you very much. I think I'll let Mr. Paul Ward respond to  this  and  then  Dr.
            Smith if he would.

            MR. WARD:  There's no question but that we should be working closely  with Model Cities and  that
             e should be taking a very active part in the planning for the health needs that's  going  on  in
            the overall plans that are being made up by the Model Cities. I will point out that  we  do  have
            a strange situation that six of the Model Cities Programs and that's a majority of  the  programs
            in the state are in Area I. We have had only one person working with those six  projects  and  that
            one person is highly overworked to try to handle what should go on from our  point  of  view.  In
            fact, one person in my opinion, could not handle the planning for one project, let  alone  for
            six.  i4e did make application last month or last week I should say for funds to carry on
            Model Cities relationship as well as "b" agency relationship. This application  will  be  site
            visited on December 7 and 8 and some decision will be made on the award after the first of
            the year. This does not mean that we should wait until then to try to  do  something.  It  does
            mean that we are going to be more limited in what we can do in this area and then we  will,  if
            the application is approved and fun e -

            MR. TORRIBIO:  Neil, I think that Mr. Parham and Mr. Lee have spoken very eloquently of our  need
            to work together. We have no choice because we are serving the same people.  In  fact,  the  people
            that the Model Cities program works with have a larger percentage of health problems  than  any
            other part of our society. We have only one Model Cities Program in Area IV, which  is  in  Fresno.
            The director, James Aldridge, has been a member of our district committee  since  its  inception.
            When he is unable to attend, he sends two community representatives as his  delegates.  We  are
            just beginning in Fresno a preliminary plan involving one of Mr. Aldridge's staff in  terms  of
            a developmental possibility or feasibility study in one of the,poor areas of Fresno  with  his
            staff. It will be a health planning project. We are trying to relate, but  I  sympathize  with
            Area I with so many Model Cities programs.

            DR. SHIMKIN: I just want to express my desire and pledge to do all we can with the  Model  Cities
            rea. I wish we were sure we knew how to do it. We also carry the larger  interest  of  CHP  in  our
            Area as well. Also, I wish to mildly retort to the fact that the University  of  California  is
            supportive of these endeavors. The question is how far we can stretch without losing  sig  t  o
            the main task of educating the providers of health care. We have  organized  an  outreach  clinic
            in San Ysidero area and we plan another in southeast San Diego in the northern part of the
            county.  Unfortunately many of these things are on the drawing board and not funded, but at
            least our heart is in the right place. We welcome opportunities to be  of  mutual  assistance.
            AUDIENCE QUESTION: I think we ought to dispense with the altruism,  of  extending  ourselves,  in
            Model Cities as an act of charity. We need the relationship to the Model  Cities  program.  In  one
            of our groups last night we talked about our increasing role in having an impact upon the  health
            care delivery system. In the fact that in the primary care center; 80% of the demands of  service
            fell into areas other than those which called for the specific skills of the physician  for  direct
            technical intervention. Many of these kinds of functions call for the kinds of  manpower  which  we
            had not been accustomed to thinking of as the traditional health manpower which  are  related  to
            the functions of some of these great other Federal agencies in addition to HEW, OEO, Labor, Housing,
            and I think'it is in our interest as we begin to think of a delivery system which is going to  have
            a substantial impact on the community to look to the one administrative structure w  c   egins   to
            pull together the whole range of human services and that is represented in the Model  Cities  area.
            It has developed in the lower socioeconomic disadvantaged areas, but as in  many  other  instances,
            we have to look to the extremes of illness in our communities to see things that are really  appli-
            cable'to the broad communi   as a whole. I think we find that in the  Model  Cities  program.  I'll
            be most interested when wet@ear from the regional representative of HEW, Dr. Smith @s to  the  role
            that he sees for Model Cities in extending the RMP effort.

            AUDIENCE COMMENT: Maybe I don'tunderstand anything that went on this morning because  I  heard  the
            man ask for@health educator he said he  could  use.  The  areas are all set up  around  universities
            and this is the  k'ind of expertise you have. Now that  was  just so simple -- Ray  Charles  could
            see that and he is blind! Just so simple -- you could say I'll share a health educator  with  you
            in each area and then w6'd go on about our business.  He  asked for that. Don't  tell  him  to  go
            back and write a proposal because we have RMP coordinators  who are supposed to be  experts  at
            writing anything.  The expert is supposed to know what to do.  I don't tell him how to  attack  a
            community problem. I tell him there's one there and  he  better see to it that it gets on  the  way.
            It't time to get out of the great university settings to do something for the  people.  Don't  keep
            talking about educating doctors. To do what? What are you going  to  educate  them  to  do?  What
            You have to do now is find a way for each area then you will have done something  for  these  two
            days you've been here, find a way for each area to say you will give 4 hours of a health  educator.
            That's as simple as it can be. In each area can you share a health educator?  Can  you  do  that?






            Then I will understand what I came here for.

            MR. LEE:  As a director of one of the Model Cities programs in the Bay Area, we would like to
            request a meeting with Mr. Ward or somebody else to get a clear cut kind of definition of what's
            going to be done.  We're talking about coordination and cooperation.  In Oakland, RMP funded
            a West Oakland Health Center for $4,000 for a health planner.  When we looked at it we said what
            will $4,000 do for a community that has 48,000 people in bad health so we give them $150,000
            This type of cooperation is what we are talking about.  You've got the expertise -- you've g@t
            the universities -- you've got all these hospitals that know what to do, just give us some
            cooperation and we'll get on with the business.  You sit up there and waste 4 days when we
            could finish it in 30 minutes.































































                                                           50.







                                                              REMARKS
                                                          DR. MACK SMITH
                                                             DIRECTOR
                                                           HEW REGION II

              DR. ANDREWS:  Dr. Smith, you have heard the problem.
              DR. SMITH: Thank you, Nei I , for the opportunity to come here. Let  me  tel  I  you  some  things  I  am
              and tome things I am not.    I regret now, after experiencing  this  morning  session,  that  I  was  not
              here full-time.   I must say that my reasons for  accepting  the  invitation  were  somewhat  varied.   I'm
              not here to represent Dr. Margulies.    I came here because I am new in  the  position  I  occupy,  a
              scant ten days away from the bedside and instruction.     My background  is  one  of  medical  education,
              clinical investigation and health care administration.     I became regional  health  director  on  Octo-
              ber 19.   I don't pretend to be an expert; I cannot even  pretend  to  be  completely  knowledgeable,
              not only of all the programs we have responsibility for, but  of  all  the  problems  these  programs
              are directed toward.   I would like to make a few remarks  about  my  observations  this  morning  and  I
              will respond to that extent.
                   I began to be concerned about half way through that there had been no minority reports.        That
              changed.  Somewhat facetiously, I was concerned when I observed  that  all  the  men  were  up  here  and
              all the women down there.   I'd like to express to you my  intense  personal  interest  and  previous
              involvement in matters concerning RMP.    As some of you from Area  I  know,  the  hospital  of  which  I
              have been director has been involved in RMP programs in recent years.     Of  course,  the   program   of
              RMP is much broader than my involvement.    You've heard from Dr.  Wilson  about  the  mission  of  HSMHA
              which is the health care arm of the public health service, and  I  am  sure  he  told  you  he  sees  the
              mission of HSMHA as providing the centers of expertise, but he did not  tell  you  that  it  has  centers
              of expertise.  I think he recognizes that in  becoming  centers  of  expertise  to  help  you  with  your
              programs will be a tough row to hoe. Now I'm impressed already  in  the  short  time  I've  been  in  the
              Region IX office that there are some experts there and  I  agree  with  someone's  earlier  comment  that
              there aren't enough of them.   One of the problems we have to grapple with  in  the  regional  office  is
              far more complex than anything I have  previously  concerned  myself  with.  My  background  in  part  is
              in biologic research.  The problems in the laboratory are much, much simpler.     You can define speci-
              fic objectives or specific methods for solving them and things tend  to  line  up  in  a  row  where  you
              can plan appropriately.
                  I'd like to read one sentence of Dr. Wilson's  which  reflects  on  the  difference  between  the
              kind of problem in the laboratory and one in the community.    "By contrast,  the  HSMHA  Center  of  ex-
              pertise will be dealing with questions which are related to the action-oriented world of the
              community. It will be serving action-oriented people with problems whose solutions will pass
              the test of community reality.  The problems  here  require  delineating  demands  and  needs,  needs
              to programs, programs to resources." Believe me, that's a big  order,  but  I  assure  you  that  all
              of us are expecting to achieve those missions.
                  I don't pretend to address myself to the  specific  relationship  of  Model  Cities  to  RMP.  It
              would be presumptions of me to do so in so short a time. One of the  reasons  why  I  came  here  was
              that I hoped to jet some answers about the relationship  between  RMP  and  CHP.  Someone  said  that
              the answer was yes; that didn't help me much. It is  apparent  to  me  that  in  your  program  you  also
              considered some of the changes in the RMP legislation, particularly in regard to CHP.
                 I would like to address myself  briefly  to  the  significance  of  decentralization  in  carrying
              out program goals.  To put it brutally and simply, decentralization is an effort    to   decentralize
              the bureaucracy so as to move a big share of decision making  out  of  Washington  to  the  community
              whore it can be more responsive to needs and more  sensitive  to  these  needs.  I  don't  think  I  need
              to tell you that government has become inefficent,  confusing,  frustrating,  and  it  appears  inca-
              pable of doing many of the things that its citizens expect it  to  do.  It's  probably  fair  to  say
              that it isn't working very well.
                 John Fischer has remarked.that this is government inefficiency in the one area that John
              Gardner, Walter Reuther, and William Buckley can agree upon.  You are aware as I am of the
              events of the last twenty years; of the many new programs of the last five or six years.  And
              for most of them monies -- never enough, but monies nevertheless.  To each of thete programs
              there were certain strings attached. The most  important  string  perhaps  was  that  these  programs
              should develop comprehensive plans. Communities should have a  plan.  It  could  be  seen  by  every-
              one where the program had planned.  This all sounds very fine, but it didn't work out too well
              for a number of reasons. In the first place, the  programs  were  piecemeal  and  were  not  related.
              The programs were administered by scores of different agencies and  each  agency  had  its  own  strings.
              Each agency required different kinds of reports, and there are a  confusing  variety  of  reports  as

                                                             51.





            you know better than anyone. In fact, some areas were  part  of  different  comprehensive  plans  and
            the boundaries of one comprehensive plan overlapped the boundaries  of  another.  The  third  problem
            with all these programs when money became available was that people  looked  around  the  communities
            and said "Whose plan?" There weren't any plans. There was a rush  of  people  from  all  quarters
            and all sectors to get into the planning game. Having  gotten  there  they  had  various  degrees  of
            competence at it. But they all looked around and the first  thing  they  discovered  was  that  there
            was no data to plan with. But the plans came in anyway. They  were  very  imaginative,  in  fact,
            so imaginative that former HUD secretary Robert Weaver called  them  "great  works  of  fiction."  He
            implied that it had been expected by those who sent them in that the  "nuts  in  Washington  wouldn't
            catch them anyway." But the nuts in Washington did catch the works of  fiction  and  they  sent  them
            back for rewrite after rewrite.  Instead of taking three, four, five months to get a program
            through, it took three, four, five years.  So this is the kind of problem we have had and the
            government's solution is decentralization. I could mention an  example  that  came  up  recently  and
            how complicated it can be. The governor of Kentucky  developed  an  imaginative  plan  to  rejuvenate
            the State of Kentucky. He wanted to build houses and schools, urban renewal,  sewers  and  job  train-
            ihg. He found out that housing had to go to HUD, schools  and  other  education  support  had  to  go
            to HEW, five different agencies dealt with sewers and you were supposed to shop around  to  find  the
            best deal. For job training you go to Labor or OEO or both. It turned  out  that  all  these  agencies
            had field offices, but none of them were in Kentucky. For HUD he needed  to  go  to  Atlanta,for  HEW
            to North Carolina, for Labor to Chicago. The Small  Business  Administration  Office  was  in  Phila-
            delphia and the OEO field office for Kentucky was in Washington. As a  result  of  the  Federal  Sys-
            tem Streamlining Task Force (FAST), much of this is in the process  of  improving.  The  regional
            lines have been drawn so that lines coincide for HEW, HUD,  OEO  and  the  Department  of  Labor.  It
            would now be possible for the Governor of Kentucky to go to one location to meet with people respon-
            sible for each of the programs mentioned.
                 Here are a couple of examples of tangible streamlining efforts.  It  used  to  be  that  if  you
            wanted anurban renewal program you went to HUD for dollars.  There were 286 separate items of
            information vou wpre required to submit. One hundred and thirty-seven of  these  wore  determined  to
            be useless and were eliminated resulting in an administrative savings of 800,000 pages  per  year  of
            useless paper work. In Hew 14 reports were dropped and 18 others were revised,  resulting  in  a  sav-
            ings of 51 man years of useless work saved on an annual basis. These are small instances of what the
            thrusA of decentralization i* all about.
                  s I said in the beginning my reasons for coming here were entirely selfish, I am  in  no  posi-
            tion to contribute anything to your deliberations. I wanted to meet some of you;  I  wanted  to  learn
            a little bit about RMP and some of the programs related to it. The other reason  was  that  I  wanted
            you to know who I am. You know where our office is; it's our job  to  make  this  thing  work.  We'll
            do our best.
            AUDIENCE COMMENT: Dr. Smith noticed that all the panelists were men.  Did  he  also  notice  that
            all were white men?
            DR. ANDREWS: When we started this conference, I told you that it  was  designed  for  the  staff  and
            advisory committee members to have an opportunity to get together and to  learn  what  was  going  on
            in their own areas as well as the other eight  areas  throughout  California  Regional  Medical  Pro-
            grams   to gain insight into the projects that were ongoing.  This,  of  course,  has  occurred,  but
            over and above this we had an opportunity to hear from some of  the  other  health  related  agencies
            and groups with concerns. I've asked Paul Ward to draw conclusions to the  meeting  to  see  that  we
            have accomplished what we set out to do.  Paul.
            AUDIENCE COMMENT-. Mr. Chairman, one thing I think there is another question that I  think  needs  to
            be raised an@I would like to give Mr. Ward a chance to speak to  us  because  I'm  relating  it  back
            to something he said before. I think there are two things that I am  very  concerned  about.  Now  in
            this meeting and how things go on here, that is whenever we  talk  about  the  needs  of  communities
            immediately relates it to the fact that there was an application  for  additional  funds  to  try  to
            meet the needs of Model Cities in Area I. Now I've been over to Regional  Medical  Planning  in  Area
            1. There are I'm sure at least 20 people, professionally staffed  people,  at  that  office.  But
            there is only one that is assigned to work with the six Model Cities agencies and the  rest  of  them
            don't even know what we are about. Now I suggested that  the  20  people  and  some  reallocation  of
            resources that there are already enough people there and you don't really need to go and get
            additional money to do the job. But now if you are going to make  applications  for  additional  funds
            it may be some consultation with us that needs the help and so our own capacity  to  help  ourselves.
            It might even have been better. So what I say now is that working with  the  communities  enough  you
            are not taking advantage of the resources that are there and  there's  just  an  assumption  that  if
            somebody would give you additonal money that you would want to be able to do the  job.  Now  I  under-
            stand that the additional funds are supposed to provide an additonal person  to  relate  to  the  six
            Model Cities in Area I. Now 1 don't believe two people can do it and so it's still  out  of  the  to-
            tal complement of staff in the central office. We're getting crumbs and you  can't  serve  the  Model
            Cities with that much of your resources. So the first thing  to  talk  about  is  a  reallocation  of

                                                            52.




           resources with another plan.  Secondly, you have tremendous influence of the University of Califor-
           nia and until the University of California which  is  doing  a  good  job  of  protecting  RMP  or  RMP  pro-
           tecting the University, I don't know  how  it  goes,  but  until  the  University  becomes  relevant  to  the
           communities that it is presumably training  people  to  serve  and  it  is  not  until  the  University  does
           that then there's still a lot of  wasted  resources  so  that  I'm  not  one  to  speak  in  terms  of  addi-
           tional funds that we  can  get  from  the  Federal  government.  I'm  talking  about  what  we  already  have
           from the Federal  government,  we're  talking  about  all  that  money  that  the  University  of  California
           has and making that  money  and  making  those  resources  relevant  to  the  communities  you  are  supposed
           to  be  serving  and  we  applauded;  I've  been  to  three  teleconferences,  three  larges  teleconferences
           recently and invariably the  conclusion  that  everyone  comes  to  is  that  until  we  get  more  help  and
           different health  manpower  we  will  not  be  able  to  solve  the  health  problems  because  of  reduction
           of costs, the cost  of  medical  service  is  absolutely  necessary.  Nevertheless  we  have  hot  been  able
           to get right down to  a  discussion  at  any  of  these  conferences  on  how  we  get  a  meaningful  School
           of Allied Health Sciences, for example, in our  own  area  in  the  Bay  Area,  Number  1  and  Number  2  to
           get over this matter of  licensing  that  Mr.  Ward  mentioned  before  and  I'll  say  this  if  you  really
           mean it we have one step in terms of the first  step,  I  guess  you  would  call  it  a  step  in  terms  of
           the medical assistance  that's  been  approved  by  the  State  of  California.  I  say  let's  get  on  with
           that unless  we  really  want  to  take  on  the  medical  profession  and  get  different  kinds  of  people
           authorized and trained  to  provide  medical  services  and  unless  those  services  are  going  to  be  re-
           lated to the communities they  are  supposed  to  serve,  the  people  who  need  them  really,  then  you're
           not doing us any good whatsoever.  Now  we've  spent  time  up  here  and  I  think  that  for  those  of  us
           who were invited that we  have  started  to  learn  something  about  your  language;  however,  you  do  not
           know anything about  the  language  of  the  people  back  there  in  Richmond,  California  that  need  your
           services and I would  say  that  your  next  meeting  you  have  an  invitation  to  come  to  Richmond.  Now
           in terms of a plan, we  have  a  plan  and  data,  we  have  the  availability  of  space,  for  example,  we
           have a lot of people ready to cooperate to establish an allied health school in Richmond        '    Califor-
           nia. So far  we  haven't  gotten  any  spills  or  any  assistance  from  the  Federal  government  nor  have
           we gotten much from RMP with the exception  of  one  person  who  can't  do  it  all.  So  I  say  that  with
           all those people that Area I has,  I  believe  you  do  not  need  additional  help;  you've  got  enough  to
           start on the job if you will just reach out to the resources and certainly the University of
           California  is  wasting  enough  to  do  everything  that  Richmond  needs  and  I  suppose  everything  that
           most of these.bther communities need too.
           PAUL WARD: There have been a number of points  raised  during  these  two  days  that  need  a  lot  of  com-
           ment.  In that  regard,  it  certainly  has  been,  I  believe,  a  very  good  meeting.  And  as  Henry  and
           others have pointed out so well, we do have  to  get  into  the  Model  Cities  program  and  other  programs
           and do a  good  job  of  planning  with  them.  I  don't  say  this  defensively  because  what's  been  said
           here today about Model Cities makes  me  very  happy.  It  wasn't  too  long  ago  and  I  think  this  is  a
           pretty good indication of progress, that  we  did  make  efforts  to  talk  to  the  Model  Cities  programs.
           It was then that they  pointed  out  to  us  that  they  had  A  great  many  problems  and  certainly  their
           spectrum of  problems  is  greater  than  ours.  When  they  talk  about  these  problems  with  their  advi-
           sory committee ,  health  was  not  necessarily  on  top.  There  were  things  like  employment,  training,-
           housing,  living  conditions  and  other  things,  but  health  was  not  necessarily  a  top  priority.  But
           as we  have  seen  these  programs  develop  health  has  become  more  and  more  a  priority  within  them.
           I think the time is ripe  when  we  should  try  to  rearrange  some  of  our  resources  to  begin  to  meet
           our obligations iiFthis particular field. I  have  no  doubt  of  this  at  all.  I  don't  say  this  defen-
           sively and heaven knows, I can't  speak  for  the  universities,  if  anyone  can,  but  I  would  point  out
           that those people are in the  program  in  projects  for  which  we  have  been  granted  money.  That  money
           was  granted  for  the  specific  purposes  within  those  projects.  Now  apparently  the  money  is   going
           to become a little freer in the  sense  that  RMP's  programs  begin  to  phase  out  we  might  be  able  to
           find new uses for  these  funds  and  to  make  these  decisions  ourselves.  Let  me  point  out  that  they
           won't be easy  decisions  to  make  because  it  is  very,  very  difficult  to  phase  an  existing  program
           out saying you are going  to  divert  funds  to  another  program.  Because  what  was  being  done  in.those
           programs was needed in the  first  place  or  the  money  wouldn't  have  been  granted.  It's  pretty  rough
           sometimes to draw a list of  priorities  and  say  we've  got  to  divert  those  funds  away  from  existing
           projects into other projects. I  think  we  can  do  it.  I  trust  we  can  do  it.  If  we  don't  we  will
           have failed in  the  advantage  and  the  responsibility  that  have  been  given  to  us,  mainly,  that  is
           to make our own decisions. I  think  we  are  extremely  fortunate  in  having  Dr.  Smith  in  the  regional
           office as the health  director.  Dr.  Smith  is  very  aware  of  the  needs  of  this  program  and  how  we
           should  cooperate  with  other  programs.  We've  always  enjoyed  a  good  relationship  with  the  regional
           office and I'm sure  that  relationship  will  go  on.  We  are  more  fortunate  I  think  than  most  other
           Portions  of  the  United  States  where  these  harmonious  relationships  with  the  regional  office  have
           not taken place.
              When Dr. Wilson was here yesterday,  I  felt  a  cringe  of  guilt  although  I  think  I  was  completely
           innocent. He  said  you  put  forth  your  best  Sunday  suit  in  describing  the  presentations.  I  hadn't
           noticed the  agenda  that  morning,  but  it  fitted  so  perfectly  with  the  national  priorities,  as  if
           someone had  sat  down  to  devise  a  program  to  impress  a  representative  of  the  Federal  government.

                                                             53




              He couldn't have done a better job.      I had nothing to do with  that  agenda  after  it  was  put  toget-
              her, not even then did I realize what     had happened.   It was  an  excellent  set  of  presentations,  it
              was an emphasis on meeting the health     care needs of the poor, it was aimed at thosespecially marked
              groups that pertain to the priorities     set forth and I'm sure as he  left  here  he  said  he  was  very,
              very impressed with what had happened.  -  I  think  the  change  has  come  through  loud  and  clear  that
              we are trying to change our direction     and emphasis from one of developing quality (@.r, top of quality
              to one of taking a look at the heztltli   care needs  in  the  less  fortunate  communities  and  seeing  if
              we can't do something about those health care needs.       I say that  because  we  are  at  somewhat  of  a
              strange situation now.    They give us the ability  to  make  our  own  decisions  about  what  we  want  to
              do within the confines of the law and the legal restrictions on that money.          We  have  the   ability
              to turn around and face the national  priorities  set  forth  by  HEW  and  to  meet  them  or  we  can  say
              to hell with HEW priorities and not do anything about them.        But  I  don't  think  circumstances
              would allow us to do that as witnessed this morning, but we could do it if we wanted to.           If    the
              site visit review team came  out  and  said  "how  did  you  spend  your  money?"  and  we  said  "we  spent
              it this way" the site review  team  would  then  say  "that  isn't  necessarily  the  way  we  had  in  mind
              for you to spend it." And  we  would  say,  "but  you  gave  us  the  authority  to  spend  it  the  way  we
              wanted to that we thought agrees with our authorities."       You noticed  that  Wilson  said  that  he
              wanted to be the last one to tell us how we should spend our money.         I  raise  that,  not  because  I
              have any concern about what the site visit team would do, whether it        would  recommend  that  we   get
              less money next year and less after that or more money next year and        so forth.   What  we   must   do
              is to take a look at what's occurring and make our decision based on        that.  I  want   to   bring   up
              one thing that wasn't mentioned during this meeting.       Dr. Wilson pointed  out  very  clearly  that  the
              Bureau of the Budget has said there is going to be level funding for the next three years.           He
              didn't actually say three years, but the  projections  for  the  next  three  years  give  RMP  a  very
              slight increase.   I'm not condemning the Bureau of the Budget, but it isn't God.         We have a tendency
              to overlook  that  sometimes.  There  are  a  lot  of  forces  at  play.  For  example,  the  Senate  raised
              the RMP  appropriation  by  $18.3  million.  The  Bureau  of  the  Budget  asked  for  this  to  be  knocked
              out by the conference committee, but we did get a pretty good increase.         Sure  the  Bureau   of   the
              Budget can keep us from spending that  money,  but  there  are  other  things  involved  besides  the  Con.-
              gress.  To quote Sylvia Porter, a national health insurance program is inevitable.          It   is    going
              to be the main topic of discussion during the next Congress.       No one disagrees that national health
              insurance is coming -- coming more quickly than the Bureau of the Budget would like to see.           When
              National Health Insurance does come it will  make  our  role  more  exciting  and  dramatic  than  we  dream
              of.  It means, regardless  of  what  people  say,  that  there  will  be  more  funds  in  Regional  Medical
              Programs.  Maybe RMP hasn't revolutionized the world, but it's all they have.         They  must  use   what
              they have to try to meet the needs.     People  may  say  its  illogical  to  have  national  health  insur-
              ance before building up the  system  of  providing  the  means  for  delivering  care,  but  in  the  United
              States, it doesn't  function on the basis of logic.      It functions  on  the  basis  of  what  the  people
              want. Let me cite an  example  to  show  that  the  average  person  does  not  realize  that  medical  care
              is poorly organized until he must  wait  in  a  doctor's  office  or  travel  a  long  distance  to  receive
              help. The  average  citizen  doesn't  think  about  the  organization  for  the  delivery  of  health   care
              every day of his life. What does  he  think  about,  every  time  he  feels  a  pain?  "How  do  I  pay  for
              this illness that's coming on  me?"  He  just  hopes  that  he  has  coverage  for  it  and  he  hopes  it's
              not something that will tie him up for $25 or $30,000.      When you have  that  kind  of  a  situation  you
              have a conscious and a subconscious friend  on  the  part  of  people  toward  seeking  some  kind  of  pro-
              tettion against the economic involvement.     That's  why  in  California  we  had  Proposition  1  on   the
              ballot. The people voted  Proposition  1  down,  but  it  would  have  increased  our  capacity  to  provide
              manpower.  They  voted  it  down  for  many  complex  reasons  other  than  not  understanding  the  complex
              health care shortage.   At the  same  time  a  national  poll  showed  that  72%  of  the  people  supported
              national health insurance.   When that  many  people  support  a  program,  Congress  will  vote  that  kind
              of program.  If you look at the money that's been put  up  on  the  providers  side  to  help  us  ease
              into that kind of program, you will  see  that  the  Federal  government  has  put  up  less  resources  'in
              the last three years for the development of  health  care  capabilities  than  it  did  before  we  had
              these problems.  There  is  no  indication  that  Congress  or  the  Administration  will  put  money   into
              the development of manpower for the  easing  of  health  care  problems  until  we  face  a  greater  crisis
              than exists now.  The way to  create  a  greater  crisis  than  exists  now  is  with  the  advent  of  more
              purchasing power for medical care  benefits.  This  is  the  trend  we  will  take.  Logically  and  morally
              then, the RMP has the responsibility of aiding these efforts in that direction.         If  the   HMO   pro-
              vision passes we have the obligation  to  at  last  push  this  development  as  far  as  we  can  with  our
              planning abilities.  We must be  even  bolder  and  create  management  capabilities  in  health  care
              areas in concert with the CHP.   This  is  a  complicated  subject,  but  management  capabilities  in
              dealing with several facilities and providers  in  one  catchment  area  making  sure  of  maximum  use
              from each facility.  In fact, deciding  which  cases  should  be  outpatient,  who  should  have  what  kind
              of services in each facility with  some  kind  of  control  over  the  percentage  of  utilization  and  all
              the rest. This is a tremendous job.     I should  mention  that  we  are  on  the  road  toward  franchising
              of facilities of rate studies as dirty as that word may be, but it is inevitable.  We must be think-
              ing in those terms and making our plans accordingly.      It won't  be  easy.  I hope we  can  accept  these
                                                                54.





          responsiblities and I hope we can come up with wise decisions.  I think we, with CHP have the
          ability to make these decisions better than anyone else.  If we're not perfect, we are all they
          have.  With that in mind, I hope we can start a series of discussionsat the local level built
          around these particular concepts and I think if we do we will see new life, new hope come into the,
          program.  I think you will see rough times, but it will all be worth it.
          DR. ANDREWS:  With that, the conference is ended.  Thank you for coming.









































                                                       55.