DEPA@RTI-IENT 07f IIFALT!:,, l-,DTJC2@TIO'4, AND ;-IELFARE, PUBLIC 1-ir-ALTH SERVICE National Advisory Council on Regional Medical Prograris Minutes of the rA,7ent-,?-eighth l@leeting L/ 2/ October 16-17, 1972 life National Advisory Council on Regi.onil Medical Prograrts convened for its twenty-eicihtli meeting at 8:30 on Monday, October 16, 1972, in Conference PoDni GIII of the Parkla@@,,ri i-5uildinq, Rockville, Maryland. Dr. Tiarold Margulies, Director, Regional Medical Prograns Service, presid- ed over the meeting. The Council Members present were: Michael J. Brennan, M.D. Clark H. Millikan, M.D. Bland W. Cannon, 14.D. Ilt. Sewall 0. Milliken t'irs. Susan L. Curry Mrs. Mariel S. Morgan Michael E. DeBakey, M.D. Marc J. Musser, 14.D. Mr. Edwin C. lliroto Alton Ochsner, M.D. Anthony L. Yomaroff, M.D. Mr. C. Robert Ogden Mrs. Audrey l@l. l@lars Russell B. Roth, M.D. Alexander M. llcphedran, M.D. George E. Schreiner, M.D. John P. '@lerrill, i-I.D. Benjariin !,I. lqatkins, D.P.M. Gerhard A. Mever, MiD. Mrs. Florence R. V4,vckoff Drs. DeBakey, Millikan, Musser, and Poth were present on October 16 only. Dr. DeBakey was present only during the afternoon session. Dr. Merrill was present on October 17 only. A listing of P34PS staff members and others attending is appended. 1/ f4eetinas are conducted in accc)rdiilcr-- with Executive Order 11671 and the Determination of the Secretary of Health, Education, and Welfare, k-hcreunder, dated Sel@toT@i:,er 27, 1972. Proceedings of the closed portions of meetings, and ,,,.aterials st@,nitted for discussion during such closed portions are restricted unless cleared by the office of the Administrator, 2/ For the record, it is noted that r,.ip-71.@ers absent themselves front the r@.eeting when the Council is discussing applications: (a) from their respective institutions, or (b) in eihich a conflict of interest might occur. This Procedure does not, of course, apply to en bloc actions--only when the application is under individual discussion. 2- I. CALL TO ORDER AND OPENING RE@ The meeting was called to orde r at 8:30 a.m. on October 16, 1972, by Dr. Harold ilargulies. Dr. @larguli'es called attention to the conflict of interest and confidentiality of meetings statements in the Council books. Dr. Margulies specifically pointed out that the confidentiality statement applies only to the closed portion of the meeting involved with the review of applications. He also called attention to Executive Order 11671 and its requirements for announcement of meetings and provision for pub- lic attendance and observation. IT. REPORT BY DR. IIARGTJLIES 1. Completion of Council Terms Dr. Margulies noted that Dr. Ilillikan and Dr. DeBakey were both completing their maxim= feasible terms on the Council. Both have served since the beginning of the Program. 2. Quality of Care Conference A Quality of Care Conference has been set for St. Louis during the week of January 22. The meeting will deal with quality.of care and quality assurance from a professional standpoint. It will consist of @-,iajor presentations and panels, rather than a series of The meetinq is designed to develop a common base of understanding on quality of care issues. Attendance will he kept limited to facilitate moving through the agenda effectively. 3. Policy Statement The Regional Advisory Group/Grantee Relationships Policy, which the Council considered and endorsed at its June rqeetirici has been sent out to all Coordinators, RAG Cliairiien ind Crantees. I-I,hile this has stimulated so.-ne further questions where grantees had not appreciated limitations on their actions, the policy has been generally accepted as reasonable. A "larch I target date has been set for Regions to make adjustments in accord- ance with the new policy. P,,@i7i?S will provide advice as needed, but does not expect to approve interim drafts generated by the Regions. 4. Discretionary Fundina Policv Another policy statement which has been distributed is that on discretionary funding,wh.ich describes the freedoms with whi-c.-i can develon new activities N-iithout fornali---ed revi(@-.i anci indicates when @@@Ps @IT-;T@roval is re@,uired. '!'he Discretionary Funding Policy involves a transfer of responsi- bility and of jud@,,ent which is consistent with the -3- decentralization of RMP functions. Under-the policy a Regional iledical Program, which has set out what it pro- poses to do, is given a degree of flexibility during the course of the year and the course'of the triennium to pursue its interest-without having to stop in every stage of the process for a pro forma endorsement of activities which have already been endorsed by a previous review. In actual operation, the Discretionary Funding Policy will require discretion both on the part of PIIPS and the individ- ual Regional medical Programs. At this point one Council mei-iber suggested that discretionary funding authority possibly should be limited to a specific dollar amount. In response, Dr. M@rgulies indicated that the new policy provides adequate control over the kind of rebudget- ing that occurs. He further indicated that any amounts rebudgeted inappropriately would be brought to the Council's attention. At a future meeting of the Council, there will be a report on how the Discretionary Funding Policy is being carried out, and the Council can decide then whether shifts being made under the policy are reasonable. 5. Kidney Guidelines At the June 1972, meeting of the Council concern was ex- pressed about the language in the R@IPS Kidney Guidelines, specifically with respect to what it meant by a "full-time transplant surgeon." The Council directed RIPS to clarify the point by indicating that we were talking about a kind of commitment on the part of transplant surgeons, rather than something verv tigi.-IL-ly definecl as "full-time." A clari.fi- cation has been developed and sent to all the Regions. 6. San Francisco Yidn y r-leeting At the'June Council meeting some concern was also expressed over how kidney consultants were to be made available. The Review Committee had expressed some doubts about the use of a National Panel. These were not shared by the Council. The Council did, however, express a view that there should be a good level of understanding among the consultants as to how they were going to carry out their review functi.ons--both from the technical point of view, and i@iith.respect to the overall principles of a network of dialysis and transplant centers to which R!AP and the Council are committed. A two-day meeting was held early in September for over 70 kidney specialists who are on the PI,,,PS Consultant list. The Conference -4- was also attended by,Dr. Schreiner and Dr. Merrill, representing the Council. Dr. Schreiner indicated that a significant group of specialists attended the meeting and that it provided an opportunity for then to anal,,zf-- the guidelines and get a common base of information at one time. 7. National Kidney Foundation Award The Regional I-ledical Progrms Service has been selected by the national Kidney Foundation to receive that group's Annual Health Achievements Award. The award will be presented in Ilew Orleans on iloveirber 18. 8. Review Connittee Functions For the last several months the P@'.IPS Review Committee has had extensive discussions about its functions, vis-a-vis the Council and Staff Anniversary Review Panel. These kinds of questions arise naturally in all review grouses as changes occur both in their membership and the patterns of program operation. In order to clarify the situation, FIIPS staff has developed a paper on the role of the Groun with respect to the other R..IPS review bodies. The Paper %;as discussed with the Review Co,.@ittee, which found it acceptable. One Coi-cqittee member felt that a chart of the P@IPS Review Process would be helpful, but that is a mechanical @eature rather than a sul)- stantive comment on the functions of ',.he Comittee. The Comittee does analyze applications in great depth and spends considerable tine on site visits and subsequent discussions. In addition to the neir functional c-tatcT-,.ent, i@'IPS has done other things to nake them feel Tqore secure in their role. Co.,@I i-ini- cations has been improved -,iarkedly, for exa,-iple, by feeding back actions of the Council to the Review Committee. This enables the ne.@ers to know ,7hen there are differences, and understand why those differences occur. 9. Status of R!,PS Policv Ilanu@,l It has been reported to the Council in the past that TU.IPS is in the process of Preparing a looseleaf, cross-indexed nolicv manual. This has Proven to be a rather arduous, tir@,,e--consillincr task, which has been frequently interrupted by the exigencies of day-to-day operations. The Manual has now been comleted. It will be circulated for coi-@.ient to Coordinators, RAG Chairmen, grantees, Members of the Council, and members of the Re-view Conmittee. It will also be announced as available for co,-.rient in the Federal Register. -5- Revised regulations for the program are under consideration. They will be redrafted, but they have been held back until the manual could be completed. One of the items that will be included in the manual is a full discussion of section 910 which, among other things, provides for activities of a National or interregional interest and otherwise broadens the scope of Regional Medical Programs in the fields of health manpower education delivery systems, etc. V,'e have not developed a policy statement on Section 910, largely because this might create the illusion that there is a separate pot of money available for carrying out the authorized activi- ties, which is not the case. 10. Progress on Section 907 Section 907 is that part of the Act which requires the Secretary to prepare a list of hospitals having the most advanced capacity for dealing with the categorical diseases. RF,IPS is now in the process of developing a list of such hospitals through a contract with the Joint Commission on Accreditation of Hospitals. Under the contract a list of questions and a questionnaire has been developed by a groun of e-,Perts. The questionnaire covers equipment, personnel, teaching programs and volin,es of service deemed to be needed to assure quality of'care. No final decision has been made on the nature of the list or its distribution when complete. The final list will not be one that depends up-on minimum standards, and this will make it unique. The nature of the final list, however, has not 'yet been determined. it conceivably could be restricted to an "unique" group of institutions. it could be a more extensive list associated with professional requirements for patient referral, or it could be a much larger list showing the. characteristics of institutions. It is anticipated that information in the questionnaire will also be useful for planning, allocation of resources, and attempts to achieve regionalization. The list, as put together, should be maintained, modified as needed, and made broadly available. As a consequence, P.@IPS expects to be working with other aopronriate HR@IHA offices to develop arrangements for the monitoring and continuity of the list. There was considerable discussion bv the Council with respect to the need for judgemental invut by Regional Advisorv GrouDs in the Section 907 activity. -6- It was moved, seconded and carried that: "After the list is received by this Council, it be distributed to the local Regional Advisory Groups for review and comment, and modification, and returned to this Council before the final list is passed an to the Secretary." (Transcript Vol. 1, page 34.) In subsequent discussion it was made clear that the above action of the Council referred only to the list of facilities and not to the raw data from the questionnaires. 11. MIS and Evaluation Committees Dr. Margulies called on Dr. Pahl t@ discuss two newly established internal @l-DS staff corinittees--one concerned with Management Information and the other concerned with RMPS Evaluation activi- ties. Both of these groups are composed of RMPS senior staff. The establishment of the two steering committees indicates the very real interest of @IT)S'in setting a high priority on the better ennlovyient of the @@lanager@ient Information System and in improving the usefulness of P14PS Evaluation activities. ",he MIS group will lool: closely at the data being collected and its usefulness to site visitors, the Review Committee and the Council. Illith respect to evaluation, the Council has fror,.i time to time been advised of evaluation contracts that have been let and has periodically been informed of results. As the program matures, however, it becomes more ind more important to develop an understanding of the acco.@irl.ish,-n@-@,-its both of head-r-,iarters staff and the individual Regional Medical Programs. The establishment of the evaluation committee is designed to.give the evaluation function a considerably higher priority in the future than it has had in the past. It is hoped that increased emphasis on the evaluation function will enable P,24PS to involve both the Review Com-n@ittee and the Council more fully in the formulation of plans. The stepped up evaluation effort is expected to improve the understanding of the program. within the Department, and HS!IIHA, and among the general public. 12. Review Com@mittee Membership Dr. Margulies also called upon Dr. Pahl to discuss changes in the composition of the Review Coruiittee. Three new members have been appointed to the FI,4P Review Committee. They are: Dr. William Luginbulil, ilirs. Maria Flood, and Dr. Grace James. In addition, there have been three recent resignations from the Review Cormittee: Mr. Jeanus Parks, Sister Ann Josephine and Dr. Edmund Lewis. At this point there was considerable discussion by various members of the Council, princit)allv Dr. Brennan, with respect to the need for greater represe ntation of the categorical disciplines on the Review Committee. As a result of the discussion it was moved, seconded and carried that: "The Council expresses, through the Administrator, its conviction that authoritative scholars, a-uali- fied in neurology, oncology, and cardiology be included in the menbersiii-o of the Review committee." (Transcript Vol. 1, pages 55 and 57.) III, STATI!@@IEINT BY DR. ST014E Dr. Margulies introduced Dr. Frederick L. Stone, Interim Deputy Administrator, HS@lliA, who read a statement for the Administrator. The statement primarily concerned two subjects: (a) developments relating to categorical disease control programs within the Denart- ment, and (b) the desirability of continued funding by @',,IPS of certain types of activities. A copy of Dr. Stone's statement is attached. Dr. Margulies asked !.fr. Peterson, Director, office of Program Planning and Evaluation, MIPS, to discuss recently developed statistical data relating to the matters discussed by Dr. Stone. Mr. Peterson stated that roughlv two-thirds of the project activi- ties for which P@'IP support has been discontinued are being picked u,i,i at a reduced level by other local funding sources. In addition, many discontinued projects have been phased out for thoroughly valid reasons. Such projects (1) mav have been time limited, (2) may have proved to be undesirable, or (3) may have been determined to be of low prioritv in relation to available funds. With respect to the funding of categorical activities, there has been a marked Percentaqe decrease in single categorical disease activities and a slight increase in dollars devoted to these, largely as a result of the increase of total funds available to PI,.IPS from 1971 to 1972. In addition, many activities related to the categorical diseases in general are submerged in the "multi- categorical" classification. There was extensive discussion of Dr. Stone's remarks bv var ious members of the Council. The follo@4inq key points were brought out: 1. Firmness in phasing out T@IPS funding for particular activities Iias largely resulted from limitation on the amounts of funds available. 2. M.-4P staffs need to develop capabilities for economic planning, argtnent, and presentation to funding bodies. 3. If NIII controlled programs do not work along with the P14P structure a new organization similar to RMP will have to be invented. 4. Earmarking of funds for specific categories of activi- ties can be detrimental. to the administration of the total program of an P.',IP. Dr. John R. F. Ingall, Chairman of the National Steering Committee of Regional l@iedical Progr&,n Coordinators, was recognized by the chair-,ian. Dr. Ingall endorsed the Coijncil's comments concerning the need for assistance of RAC, and P:-IPs in the development of control p?7ogra,.@. Ile also stated that Regional Advisory Groups had strong categorical. protection built in, and indicated that the problem of many R,lPs is relating categorical interests to the general delivery -of health care. He stated that manv projects have been continued by other agencies aid requested (re: FL,,IS) that liSiIIIA keep P@4Ps informed on relevant contracts. In closing, Dr. Stone indicated that he would advise the A(Lministrator of the Council's an(-'I others' Ile also stated that 14III cldarlv would not try to stimulate another set of net@qorks--tlaat the creation of "control" orograms would be a TIS,'-IIIA-wide activit, in which the Council could expect to take the principal load. Finally, he pointed out tjiat ot,-er IIS-11-@IA programs have a certain e-xnf@rience in dealing with the t-ird Party nal-,ient problem and can furnish technical assistance- to Keeps a,-id other organizations %.,,here required. IV. SPECIAL R"-POPTS 1. P@',!P Relationships with I-,ealth Care Institutions Dr. Margulies called.on Lir. Sam 0. Gilmer, Jr. to discuss P@IP Pelationships with Health Care Institutions. Mr. Gilmer pointed out that recently a number of small and informal conferences have been held with hospital oriented P,I,IP/program staff and with individual hospital administrators. These indicate, as in the past, that there is little institutional commitment to P..!P on ti-,e part o@- hospitals. There are exceptions, however. There is a real need to strengthen r@IP and %!.IPS relation- ships with hosoitals. Hospital governing bodies genera lv have not adopted Dolic ics clearly statinq t.,,.e relationship of the hospital's service T.)ro-Tr,-.n to the'activitics of the R-IP serving the area. Likewise, there is no commitment on the part of hospital administrators, as a whole, with respect to the importance of @IP or commitment to working with ElPs even though a niu-iber of hospital administrators are involved with the programs as individuals. In addition to the informal conferences,, a survey of hospital administrative competence within PI.lPs is now being conducted. Returns indicate that about two-thirds of the iLkiPs have designated astaff person to handle hospital liaison functions. In closina, Mr. Gilmer cited a number of activities in which hospitals and Regional I-Tedical Pro- grams could profitably participate and particularly called attention to the TILP procTraLm of the Joint Cor4,nissi.on on the Accreditation of fTosT)itals. 2. Management Survey Activities Dr. Margulies called on Mr. '@"liona,; Simonds, of the P-i'LIPS Grants i@lanagemcnt Branch, to discuss @.1anagem(--nt Survey activities. Mr. Simonds stated,that the ?Ianacement Survey Prociram was first organized in 1969. At that time surveys were only conducted at the r--cruest of the Coordinator or with his agreement. A,)I?ro.,tinatp-J.y two ,fears ago the !Iariagenent Survey Proqra--.i was reorganized so that all @.ections are surveyed by staff on a regular basis. Management surveys cover such items as the adequacy of a Region's written nolici-es, payroll and leave procedures, the adequacy of financial management and records procure- ment and inventor,, control, as well as personnel policies and procedures. On completion of each survey, preliminary findings are discussed orallv with the. Region and the final written report includes only material which has been discussed in advance. Survey reports are distributed internally to appropriate units of r-@IPS, IIS,'.IIIA and including the TIEW Audit Agency. Copies are furnished to the coordinator, RAG Chairman and grantee institutions Recommendations of management Survey reports are used to correct identified deficiences, to assist the operations desk and the Director, and to ntovide information for con- siderat.ion by site visitors and other reviewers. By the end of @lovember 1.972, Management survey visits will have been conducted in 35 iZeqions. Eighteen additional surveys have been scheduled for the 1973 calendar year. -10- 3. Third Party Reimbursement Dr. Margulies called on Mr. Roger Miller, of the Grants management Branch, R4PS, to discuss a draft of a proposed new IISMHA policy concerning the phasing-in of funds from sources outside the progr@,.--- Mr. Miller reported that the proposed policy would require that, to the maximum extent possible, all projects should become self-sustaining cormilinity-based operations within a given time frame. in order to accomplish this the proposed policy would require a plan for the phasing-out of T)rogram funds ancl'the r)liasing-in of other support. V. CONFIRMATICII OF FTITURE @IEETILIG D,%TES The Council discussed,but too)-, no action on, future'meeting dates. Several members had conflicts with the dates proposed. VI. CONSIDrP.ATICI-1, OF THE MINIJ-LFF, CIF T,iF 14rFTITIG OF JT@T'F 5-6, 1972 It was m6ved3seconded and carried that the minutes of the June 5-6, 1972, meeting be approved. (Transcript Vol. 1, page 134.) VII. CURIZEIIT STP@TF,'!E@IT IIIT-@"@IN T@'T,' I)rPA-7lc7@LF@IT OP @@Dll,,G 704D LEGI'-zLATIV.r:, ACT.R Ilr@,11:,S Dr. Margulies renorted that the ITE14 Labor Appropriation Bill was passed and vetoed. Since then a second appropriation bill was passed and again vetoed. There is still no final action on the appropriation or on spending controls. The Department is running on a continuing resolution and there is no basis for speculating on funding levels for RPIP. There is, however, very persuasive evidence that in an effort to limit the spending in the Federal budget, restrictions will be placed, wherever possible, on expenditures. There is a good possibility that the level of funding available for RIP during the 1973 and 1974 fiscal years will be reduced. The R-IP legislation-expires on July 1, 1973, and there are a number of organizations developing ideas about what future @,IP legislation siould contain. @@le have no knowledge, however, of any final position developed by.the administration with respect to legislative extension. C! II-PTEE DATA PRT'@rl@IT,%TIO@l VIII. REVIT:l@l C A-%I Mrs. Silsbee presented a n@-er of slides that had been utilized on an e.,merinental basis to s@,,narize background information from the MIS for the Review Ccini"tee. She pointed out that RMPS has considerable information in the Management Information System as well as extensive institutional memorv on the part of staff and older Committee and Council members. Membership in these groups changes, however, and the visual materials were developed in an attempt to bring background information to reviewers in a matter that can be quickly grasped without slowing down the review process. After viewing the visual charts at the September 1972, Committee meeting, Committee members expressed the view that the presenta- tion had been helpful. They suggested, however, that the information in the charts would be even more useful if made available to site visit team members prior to site visits. Committee members also expressed 'the opinion that canned visua s could be misleading and that information should be tailored to individual applications to bring out the salient points. Council discussion following Mrs. Silsbee's presentation likewise sounded a note of caution. The Council members expressed the opinion that such material might be presented in a capsulated form which could be misinterpreted by the uninitiated. Several examples were cited of hoii data accumu- lated in broad categories could Tiask important details. Program staff functions, for example, include both administrative activities and activities of a Professional and program nature. IX. RFPOTIT 0111 tIOU'@ITAII@T STATES, Il@,Tr@-IOUNTAIN 2\1,TD COLO-PADO Dr. Margulies called on Dr. !Iilliken, who had participated in a site visit addressed to the question of territorial overlap bet@,?een the Mountain States, intermountain and Colorado/tlyom- ing @!Ps. Dr. Milliken stated that the purpose of the site visit was to decrease the friction that had aT)T)arentl,y developed between the P@lPs. The three Regions decided to create an interregional Executive Council designed to reach joint decisions regarding programming in overlanned areas. in addition, a policy and procedures document has been developed for coordinating the activities of the three programs. X. REPORT OZI DE'v'ELOPIl-@'LTTAL C(i@IIPO:I,EI4@@ Mrs. Silsbee was called uT)on to report the results of a staff study concerning the develqnmental component and proposed action. At the present time, 35 Regions have been an roved for a .@p developmental component; twenty-one have not been approved. -12- of the latter group, eight Reg@ons have not applied. Two of these are still in the planning stage. Thirteen Reg,-ons have applied and have been disarnroved--eight of them twice. The Developmental Coqponent was initiated at a time when R:.IPS was shifting from a focus on "project". to emphasis on "programs." Among other things, the.developinental component appears to have been useful in helping many Regions to strengthen the RAG, program staff activities, forward planning, budget control, and the project monitoring function. At the same tir,@e, there may have been a detrimental effect upon those regions that were not approved. Some disanvroved applicants misinterpreted the denial of a develo,-)nental c(.),-,,r)onc@nt as sictnifving disenchant- n@ent with specific activities T)roposed, rather than with their goals or processes. in addition, and most important, those P,egions that needed the developmental component most were those that did not meet the standards for approval. Since the develo:),,iental cc7,r.,onent was initiated, P@-1,PS has decentralized nroject review, initiated the triennial svstem, introduced -the review criteria and rating system, and announced the discretionary lundinrl T)OliCy. These changes pro-,.Tide Regions with flexibility and recognition, and do other things that the developmental con,.-2onent was originally designed to accomplish. RI@PS is currently tiii)-il-@ing a..Iol_14- missing out the developmental component in an orderl@l manner and will be seeking the Council's advice on this at the next meeting. XI. @IISSO@TRI SITE VISIT Dr. Ll"cPhedr,@. renorted on a s-)c-ciil site visit to the "Iissouri which too? nlace on Se-.otc@-,.,d)er 18, ]@972. The site visit had been reco--viended previously, bv Council, to relav Council concerns relat-'@ng to the value of sc.)T-,e eyr)cnsive COT'IT')uter projects and - e organization of both the proc staff and Regional Advi- ,h Tr@,in sory Group. Dr. McPhedran reported the following 1. Program staff is beginning to seek solutions to problems in the Fegion, rather't'tian waiting for t)roject Proposals to be initiated by other crrour-;s. 2. Proqram staff is beginning to work on priorities, goals and objectives. 3. The Director of the program has assumed another resoonsi- bilitli, on a nart-tiic basis, and is spending currently onl,,r 54% of his ti-,c@ with t@ic PI.IP. -1 3- 4. The Regional Advisory Group needs to add Veterans Administration,'C.HP and minority representation. 5. The Region needs to create an evaluation section and simplify its review Process. At the conclusion of Dr. !.IcPhedran's report there was some discussion of the relationship between the Missouri @',IP and the Bi-State @@IP in St. Louis. The consensus was that while there were unsettled jurisdictional issues between Bi-State and Illinois, there is no Drolilem between Bi-State and Missouri. XII. REVIEte,- OF A. Albanv Moved: Dr. Oclasner Seccncied: Mr. @den Accept the Reviev7 Co.,@@.ittt--els recort-icndations for three-_ vear funding in the amounts of $1,GlS,Ooo; $1,783,090; and $1,940,723. (Transcript, Vol. 1, Page 165.) B. Bi-State Moved: Dr. McPhodran Seconded- Mrs. Curirr Award triennial status, but no developmental co-,inonent in the amount of $1, 150, 000 for the 04 year with 7% increases for the 05 and 06 years, and conduct a site visit after the next year of operation to review RAG effectiveness, staff relationships, and boundax-,, nroblems with Illinoi's. Pmounts approved include $50,000 in discretionary fund,; to make it POS5-,ible to hire a Deputy Coordinator. (Transcript, Volume 1, Page 171.) C. l@liscons3.n Moved: Dr. Millikan Seconded: Mrs. Wyckoff Accept the recommendation of the Staff Anniversary Review Panel to increase the approved level for the 06 year to $2,153,624, including @?312,881 for kidney activities and a $177,907 developmental component. (Transcript, Vol. 1, Page 173.) -14- D. West Virginia Moved: Dr. Cannon Seconded: Dr. Roth Accept the Committee's recommendation for $1.5, $1.6, and $1.7 million for the first, second and third years. (Transcript, Vol. 1, Page 178.) E. Central New York Moved: Dr. Schreiner Seconded: Dr. Musser Approval in the amount of $889,000. (Transcript, Vol. 1, Page 185.) F. Michigan Moved: Dr. DeBakey Seconded: Dr. McPhedran Approval in the amount of $2.25 million. (Transcript, Vol. 1, Page lb9.) G. Hawaii Moved: Mr. Hiroto Seconded: Dr. Komaroff Accept the recommendations of the Review Committee in the amounts of $1,805,488, $1,839,213, and $1,820,577 for the 05,06, and 07 years, respectively, including kidney and earmarked funds for the Pacific Basin. Kidney funds are subject to satisfactory definition of relationships between Kuakini and St. Francis Hospitals. The request for a developmental component was not approved., (Transcript, Vol. 1, Page 194.) H. New Mexico* moved: Dr. Yonaroff Seconded: Dr. Watkins Approve for triennial status in the amounts of $1.25, $1.30, and $1.35 million for the 05, 06, and 07 years, respectively. A site visit is to he conducted next year, and no funds are to be allowed for basic training in allied health professions. (Transcript, Vol. 1, Page 206.) corin@ittee because of t'ie Region's success in obtaining alternative funding for six of thirteen projects. I. Northern New England Moved: Mrs. 14yckoff Seconded: Dr. @IcPhedran Approved in the amount of $850,000 for the 04 and 05 years, including a developmental connonent and $ 37,500 and $25,400, respectively, for continuation of kidney activities. Triennial status is denied, but should be granted if the Region seems ready for this after a site visit at the end of the 04 year. (Transcript, Vol. 1, Pages 209 and 213.) J. Virginia* Moved: Dr. Watkins Seconded: Dr. DeBakey Triennial status approved in the amount of $1.8 million, including Developmental component for each of three years.. (Transcript, Vol. 1, Page 218.) K. Indiana Moved: Dr. Brennan Seconded: Dr. Ochsner Approve the Review Comriittee's recommendation for $1.2 million for one year. (Transcript, Vol. 1, Page 220.) L. Rochester Moved: Mr. Milliken Seconded: -Dr. Brennan Accept the Peview Co-inittee's recommendation for $935,000, including $35,000 for kidney, and noting specifically the Cornittee's requirement that the bylaws be completed. It was also recommended that the Region be revisited in within six to nine months. (Transcript, Vol. 1, Pages 225-226.) M. Texas** Moved : Mrs. L@lorgan Seconded: Dr. Schreiner Accept the Peview Committee's recommendation for $1,900,000, .$2,10o,ooo and $2,300,000, including the following amounts for kidney: $337,157, $309,640, and $294,640, for the next throe years (with the funding for the second and third years contingent upon greater minority involvement in staff and RAG as determined i-e@7 i-@ ni-7.rN (TrF-nscr,,,.nt, Nlol. 2, Paae 6 Mrs. Mars'not present in meeting room. Dr. Meyer not present in meeting room. Dr. DeBakey absent. -16- N. Mississippi Moved: Dr. Merrill Seconded: Mr. Hiroto Go along with the anoroval of the triennial application at the funding level recommended by the Committee in the amount of $1,926,9,94, $2,200,000, and $2, 445,891 for the 04, 05, and 06 years. (Transcript, Vol. 2, Page 11.) 0. t,,'--@iphis* Moved: Dr. ileyer Se coneied: IIrs. '@,@lvckof f Increase the approved level to $2,000,000, including $100,000 for a develoo,-nental cor:!T)ol-ient. (Transcript, Vol. 2, Page 13.) P. Northeast and Southeast Annlications for Tnterreaional Coor(-Iiiiators- @3nler Secti.on 910. Moved: Mr. O,,-jclen Seconded: Mrs. I-lorcran @ipproval of Southeast for three years, and Northeast for two, with funding of a third yEar for ITorthe@i@t contingent on satisfactory progress. (Transcript, Vol. 2, Page 67.) I-letropolitan 17,t--w York, 910 ridrii--y A-oplication Moved- Dr. Merrill Seconded: Dr. Schreiner Defer consideration of the nresent aonlications P'ending a staff visit to study, evaluate, and honeful.lv to reconcile some of their uncertain aspects. In the interim, the Director, P14PS, is authorized to T--rovide interim funding, if he should find such funding to be ne@essary. (Transcrir)t, Vol. 2, Page 79.) R. SART.) Recommendations Continuation applications from the following Regions which were reviewed by SAPP and nroT)osed actions by the Director were called to the Council's attention: California Colorado liyo,-iing Georgia Maine Dr. Cannon not present in Trecting room. -17- There were no Council comments with respect to these continuation applications, or the proposed actions by the Director. (Transcript. Vol. 2, Page 80.) I hereby certify that, to the best of my knowledge, the foregoing minutes-and attachments are accurate and co-,iplete. Harold @larciulies, i,I.D. Director P,egional @iedical Programs Service ATTENDANCE AT THE NATIONAL ADVISORY COUIICIL MEETING October 16-17, 1972 P14PS STAFF Mr. Norman Anderson Mr. Roland Peterson Mr. Waddell Avery fir. Michael Posta Mr. Charles Barnes Mr. Laurence Pullen Mr. Kenneth Bain Dr. Richard M. Reese Ms. Marilyn Buell Mr. William Reist Mr. Richard Clanton Ms. Leah Resnick Mr. Spencer Colburn Mr. Abraham Ringel Ms. Cecilia Conrath Dr. Jimmy L. Roberts Mr. Joseph De La Puente Mr. Richard Russell Ms. Annie Dicks Ms. Rebecca Sadin Mr. Alex Dobson Mr. Luther Says Ms. Eileen Faatz lis. Patricia Q. Schoeni Ms. Myrtle Plythe Dr. Richard Sclirot Mr. Gerald Gardell Ms. Kathryn 11. Sievers Mr. San 0. Gilmer, Jr. Ms. Sarah J. Silsbee Ms. Eva M. Handal Ms. Shirley Simon Mr. Charles Henson Mr. Thomas Simonds Mr. Charles Hilsenroth Dr. Margaret Sloan Mr. George Hinkle fir. James Smith Dr. Edward J. Hinman fir. Patliew ',;pear Ms. Dona Houseal Ms. Doris Staton Mr. Francis C. J. Ichniow8ki Mr. Jerome Stolov Mr. Joseph Jewell Mr. Calvin Sullivan Mr. A. Burt Kline Mr. William Torbert Ms. Lorraine Yyttle Dr. Clarence Washington Mr. T-lalter Levi iLr. Lee Van Winkle Dr. Joseph Linehan Ms. Glenna 1,731com Dr. Harold Margulies Ms. Constance Woody Mr. Rodney Mercker Mr. Frank Zizlavsky Dr. Bruce Miller Mr. Roger Miller OT-HEP-13 ATTENDTITG Mr. Ted Moore Mr. Bob Morales Mr. Edward Bridgforth, Public, Ms Marjorie Morrill Jackson, '@llississippi Ms: Mary E. Murphy Dr. Margaret H. Edwards, T@ICI-IIIH Mr. Frank Ilash Dr. John R. F. Incrall, Pul)lic, Mr. Eugene Nelson Lakes Area R?,IP, Buffalo, New York Ms. Peggy Noble Ms. Frances Howard, NI24-tllH Mr. Harold O'Flaherty Dr. Frederick L. Stone, OA-HSIIHA Mr. Joseph Ott Mr. Donald N. Young, OGC-HS,",IHA Mr. Chris Ottenweller Dr. William J. Zukel, NliLI-14IH Dr. Herbert D. Pahl Ms. Jeannie L. Parks Presentation by Dr. r. L. Ston@ to i National. Advisory Council, RMPS- Dr. Wilson has asked me to express his sincere regret that he is unable to meet with you this morning, but- t-]-,Is is his day to defend the HSMHA budget before the O@1B, and I am sure you will understand and wish him well. Before proceeding further, I would like to emphasize those specific attributes of the Regional Medical Programs that signalize its progress: 1. Its-decision-making powers have been decentralized to the final level in most cases; i.e., to the states or sub-reaions of states. 2. In a special sense it demonstrates revenue-sh@-iririg at its best. 3. It has evolved, nationally speaking, into the only reliable tool we have which relates to the prof-essioriLil at the community level. 4. In these Programs we have, regionally disbursed, the largest pool of talent addressed to i.i-i otii.- T\Tati.o@i.-I, There are several thin s he has asked me to discos,-, with you---aiid ti,.e :Lixst is .9 I. l@rio.-cities: We a-re well aware of the marAy pressures qiic'i have bti.:C-:C-e-t-ed I.,I-ic ]@(-Fi I i7@ Medical Programs ever since they became a part of IIS@RIA in 1968--and n,,,-,.,c,r has the strain been greater than in the last ti@o years. tender they have made the best of very difficult iiituiitiorts, iLiid their contril),tt -i.oil to solving the problems of ac(!ess to pi.,:iliiir.@7 been remarkable. 'Elie.-Lr have been most impressive. Tli(@y have fotiiid it poss-.i.l)lc.@ t.o to ii(-.@w pri(-)rj.-tl@i.c,,s identified by liS@LIIA wl-ip-n these came iiiiLlcr,,;c-,rv(,d, Ti-it:liziric;, la migrant workers, urban and rural poor, young children and the elderly-- and they have been able to place emphasis on ambulant care facilities and the more effective use of allied health personnel. Their ability to enlist the cooperation of the providers and all concerned groups in the regions was most notably displayed in the recent crash program to set up emergency medical services, and I believe no other organizations in the country could possibly have done this so rapidly and so well. However, our priorities are also set by the Congress, which in general reflects the will of the people, and it has been inescapably clear that many members of Congress are just as interested today in improving the care of patients with heart disease, cancer, stroke, and kidney disease as they were when the IZ@IP I.eFi,,latior, passed in 1965. As a inntter of f:ict, the Nqt@iniii@l A(,t c)f 107.1, p-l@il;tld ii.ii 1),irt b(it'-sume Llio It@illil li@l(I ]lot. ftill'i,l I(.(I Llitt of tIlo"lc! %Vllc) for tlie@ RMP legislation in '65 and those. ilieiiii)(@i.-s of Congress who over- whelmingly supported it;.@ol they decided to try again. Those members of the health professions concerned witli..heart disease were not quite so frustrated because they had been deeply involved in the UIPS effort. to develop guidelines for optimal care through the Inter-Society Commission for fleart Disease Resources. Nevertheless, they wer@ deeply distressed as the RMPs withdrew sharply from support i.ii the field of heart disease and urged ec.ual. ti-,ne with cancer on the Ilill. Congress expressed its continuing commitment to iinproviiia the lot o .people with cardiovascular, respiratory and blood diseases by passii,,,, the National Ileart, Respiratory and Blood Disease Bi.,ll of 1972. It.@@o no accident that increasing amounts of $,IO, 30, -ind 40 It were authorized in both bills for control activities ii: .,2oL)I)(?r,,iti-on With other Govc-i:@inierit-, agencies. 3 Mien Appropriation Hearings came around last spring@ members of Congress were hearing bitter complaints from their constituents--doctors and patients concerned about heart disease, cancer, and stroke--who found that many RMP programs in these disease areas were being terminated. They pointed out that the legislation OD the books still makes heart disease, cai-icer, stroke, and kidney disease the major responsibility of the RMP'S. And they are right; it does! Of course, itis perfectly true that if people do not have access to health care at all, they will not have access to care,@or heart disease, cancer, stroke, and kidney disease either, ai-id therefore the recent emphasis on access to primary care is totally commendable. Miat- the R@IP's have been able to accomplish in that direction has served to strengthen the base for all medical care across the country. Now, however, Congress has made it crystal clever that it -,.7,@ints the national effort in the control of heart disease, cancer, strol@e, and kidney disease greatly intensified and that it will no longer tol..ercite diversion of funds appropriated for those purposes. This time it has authorized special fuiidi-ii@s J'c,.c coi-ttrc)l in I)utl,;ct:s c)f the NCI and NHLI and in both cases it has di-i-(.,,cted that tb(@se activities b(, 4 dl6§6st b6s§ible Co6p6tati6li'14ith'6thdt'Gov6rnm6nt carried out'ih'th6 agencies. IThe appropriation committees have been generous with the control portion of the NCI and NHLI.budgets, but at this point we canno tell what funds will eventually be released. Partly as a result of Congressional pressure, partly because of the need to achieve better coordination betiqeen the various parts of @HEW, and because of the crushing magnitude of the problems of heart disease, cancer, stroke, and kidney diseases which constitute at least 70 percent of the content of comprehensive health care, the Secretary has agreed that IIS,@IIIA will work closely iyit:l@i the Institutes in the area of disease control--and specifically in the fields of heart diseases cancer, stroke, and kidney disease. As a forerunner of the kind of intense cooperative effort which will henceforth be coordinated bv trick I,-i@:-.tj.Lutes, the Fecreticy -I.aun(-Iie(I the National Hypertension Progran,, on July '@15. Aimed i-i.i-Ltiall.y at pro- fes8ional education in the field of liypc,.rtc,.nsion, it will later move on to public education and to tiic- I)rep@irc-it@i.on cf the iicziltli @,,L@rvic(@s delivery system to respond to an increased demand for screening, diai.,.- nosis, treatment, and follox4-up. This .act7Lvity is being served by',a National Advisory Committee, an Inter-A"cncy Working Group, and four task forces made tip of members of the kdvisc)ry Committee andi. representatives of the Nlil,l, VA, FDA, @ii-i(i IIS@IIIA. The first will deter- mine the content of the educational. pTo),,-rini, (lefiilll Li-ic- level -il)ove iiliicli treatment is indicated, and recommend what that treatment should be; the second will plan the professional educational program; the third will plan the public education program; and the fourth, chaired by HS@HIA, will evaluate the impact on the health services delivery system and determine the resources needed to respond to the professional and public education programs. Dr. W. McFate Smith, Regional llcalth Director for Region IX, is serving as the chairman of Task Force IV. This has been a very intensive effort',siiice July, and has engaged a large amount of the time of Dr. Margulies, and of Drs. Hinman, S oan, and Greenfield. Eventually, it must en@a5,,c the time and attention of this Council and of all the Regional ltedical Prograim_. Dr. Wilson has made a firm commitment that every IIS@IIIA program which can increase its attention to measures affecting the control of heart disease, cancer, and stroke iiit,iiii tll,,e limits of presc@.-,it ftiiidi.r.@'Y and personnel will do so. De ending on the level of funds eventually p released, additional contributions will. be made by programs to the.control of tht--sc, disease,-, in c:oc)i)f.2i7::iti.oii -,.Y.i-th tli(@ @ICT . tlie 1,17111, I@.. the NINDS4 The area cf hypertension will take precedence in this cooperative effort, but the others wi:Ll not be far behind. What does this mean for the @[Ps? Somchow they will have to bc' encouraged to put a larger part of their back into the fields oi' heart u"Lsease, ca-ccer,-as-lu s'trc)"-,L-:, but to do this as' an int-epralt 6 of comprehensive health care. We wish to protect the gains they have made in the last two years and to reintroduce some of the categorical disease activities in a very special way which will not adversely affect the current noncategorical program efforts. We therefore wish to seek your reaction to the following proposals: 1) That the RMP's be encouraged to retain or redirect a part of their regular grant program to support those activities which seem most important at the local level in relation to heart disease, cancer, and stroke. 2) That a special fund be designated for control a@tivities--the exact amount to be determined by the level of funds finally released to RMPS by OMB and DHEW--at least a portion of which would be held centrally. Emphasis would remain on getting this to the RAG's as rapidly as possible but with more specific guidelines than has held for some of our past programs. 3) Some part of these central funds be awarded to the regions by contract after review by appropriate coyimi.ttees of expert COTlSl-t't.,tants -f'or activities which will@:Col-loll guidelines developed by RMPS in close cooperation with NCI, NJILI, and NINDS. 4) Quality assurance has been discussed with this council before t:tit ttie issue has never been more urgent. Some of these central funds may als,-.@ be used to support contracts (a) with national professional organizations for @l-lie development of criteria for quality assurance in relation to heart disease, cancer, and stro@-e; (b) with individual :institutions or to groups of institutions to demonstrate various alternatives for I.-Tie (le..,'-@ivL@ry of hif@Lai@i - cTrvj(,,Ps to patients viith these diseases; and (c,-) with @fedic-zil. Ilrograill;@'. or 7 national professional organizations to promote the.regionalization of specialized facilities and services. Review mechanisms would have to be worked out; staff would have to be assigned (any additional positions possible?); and methods of communication of these changes to the regions would have to be developed. In short., RMP's have some new priorities which are really some of the ones they started with, but which now should be integrated into comprehensive health care as much as possible and represent a partnership effort with the NHLI, and NCI, and NINDS. II. Council Policy on Duration of Funding and Phasing Out of Projects The other subject I wanted to discuss with you concerns your Council policy of decremental funding and phaseout at the end of three years. Owe all know the dangers of getting trapped in demonstration projects for which it proves impossible to find other sources of support. Obviously, if these are allowed to become fixed clizir,,es ztiicl continue to proli.ferzAL-0, the situation would resemble Medicar(-, and Medicaid soakiii(i' up ali ev(-,r- increasing share of the R@IPS budget, The Program would tl-ic-ii c(-@asp- to I-;(-, a developmental one and lose the marvelous, initiative cz!tztlytic role it has played so well . But it was this .3-year termination policy also that gave us special trouble in the Congi,ess last spring. Programs we:@i@@ being terminated rigidly because the had had 3-vear funding. I'ii some y cases little effort was made to help. the project directors find othe." sources of financial support. In some, allc,gf:,,cl' 7 proin-,-'si.ncf projects were L3 terminated abruptly when one or two more years @it reduced furid:i.iip, might: haN,e enabled them to bec(.)riic@ of w(@!:Vc! programs or just beginning to fulfill their promise, and it appeared that the reward for success was annihilation. Whatw(3 should like to have you consider are some modifications of your policy which would put emphasis on the following: 1) Continue, as I know you do now, requiring new ipplicants to indicate how funding will be covered from other sources in ecws. 2) Make awards with decremental funding when possible. 3) Ask the R@IP's to take greater responsibility in he lping appliccints find other sources of funds. 4) Apply the policy with flexibility. Not all of our innovations in health care wil-1 be acceptable to the funding organizations. There may indeed be some service projects of such that ]'\@II)S should continue funding them for more than three years. If no other alternative fi-Li-idi.iaf,! can be located then decremental funding should bE,, applied gradually with a maximum of technical assistance to the local. pro,7rrztiii so are not in the position of abandoning patients abruptly. 5) Particularly 3.n progri:tinf, iiivol\?:Ly,,,) children or tli(,@ elderly, it would be better not to get stirted on @i-t- it.-LI. i.f i-io hope other funding at the end. But the J',i4f-lls will surety lay lip credit ill if they can start programs which bring h.21p to these groups and CVeritU."LII7 make them self-supporting! It has been a keen pleasure for me to participate in your di.scussi.4.)jis this 'have found ii@y @l)lcl tti(IU"IIll, morning. I trust you L') 0 .1. Ilieir general thrust will- bci I:o -ct(](l 'to 1-111-s Coun(-!.I,.Is pl,,es(,."It resporisibilit--ies and scope of 1. [IC to I.I.-Y to any que-ittianit'%that'@ari'se:the, eni3uihg discussions. T,. SI-.-on(2-0!1-'I.O--i.0-72