OF R .1 0 p 0 D 0 rC, @l Tf---S -file fk PEPOF?'F !)Ir.@Plr,,P'D FO'? liEP@LTII 'fli- pSSISTP..!-!T APRIL 5, 1973 AC I-\'I IO If LEDG'[-i'.!ifL7 t@TS o aci,iio,..,,Iedge -lie important contributio@,is The l,iloi-k, Group t.,,islies t of several persons. Elvin Ilil Office of the Adriinistrcitoi,, IISI,IHA, @.,,oi,,@ed clos.-l@, wi tli the uroup throughout study and .,,,as of invaluable assis!@,,-rce. i,ti-,it Elden, Co:-,,.-,,,@uiilty Health Service, provici -sta!i,li ng lla ed out typing and secretarial support. iic@ael Street, Office of tl-ie Regional Ilealth Director, Region X, gave substcintial assistance on -I' -Lhe study. Gc -i-fi:@e porr-ioll o -,oroe Scl,-o@-rhors+ the ll,cgional 0 national Center for Toxicolocical Resecii-cli, FD,@, prepared higli'y professional visual aides on extreirely Short notice. In addi+Llioii, rK, a II a.;!iri c, a 'fice of the Ad,-iiinisti,,-)@ot,, I'S'.'!13 y tid Dorothy Trol.':,-i-, O.i L I and fifth Vicker%,, Center for Disease Control, HSI"Ii..fk, carried out numerous essential tasks for the ',,,fort, Group. TA['ILE OF CO,@ l@l'E ;T S I Study Perspective ................................. 5 II. Study Findit,igs ....................................... 26 III. Recom;iiendations .................... ............ 47 IV. Next Steps ......................................... A pendix A. Perso?)s,Ititerv,ic,@..,ed Dui@ing study Of p 52 [lSt.',HA Proclraris and Oi-canizatioll ............... 56 1@,tiA Oi-(,,,inization .................... Appendix B. Current HS,t of Appendix C. Ai 'ys 57 Altern,itiv.es .................................. @CT.1 V@L STUDF Str r_ -d by On February 21', 1973, aspecial %@iorl, group ,,as conven@ the Assistant Secretary for Health %,,,Iio delivered the follc),,@iii,,g charg-.: ... undertake a broid-revic-@-i of HS,@@'i,@A's programs and organization, and their interrelationships i@iitli the other health agencies. ... submit to the Secretary, by April 15, 1973, an organization plan %,ihicii iiill- (1) reflect recent and projected changes in programs ctd[iiiilislc-red by (2) be designed to help achieve the Depar'Lnient's goals in-the field of health services Keith maximum managem-Int-effectiveness and efficiency." 1. EXTE14SIVE It,%!T!-TRV-,-E';S CO','Di-'CTED. Also explicit in the c!iarge i-ias the desire to achieve broad input into the study through extensive interviewers. During the course of the st@dy, ri-,,.)re than 80 officials and staff inside and outside [IS@'.'ilLIJA @,iere interviewed b,./ the task force. The list of intervieiiees is stio,.,in in Appendix A. -D T[I'z BASIS p@, p P.@ 2 TI iE OPDTI@,T!7 i[7AI-TH PROVID"-, 0 -,.!-')'S 1 S -.---Ttie ap[)ropria'L-.c- federal role in health has been sur@.rnarized in recent s4L,.ateii,,eg@s by SecrL-@LFry Weiiil)-,,rger and Uno.-r Secretary Ca'rl LICCI Tiii s role is: 1 F ii Et n c i ti,,i, o f H e a I t li S.-i-vices to reduce financial barriers ,affecting access to health care. The current vehicles for accoriplisiiii,,g this are Irlil-d-icare and 1',!,r-,dicaid. A, iriore comprehensive approach to na@Lional health insurance is I i I,,ely. r) 'es 2 I t h a. r -i I,, - cl 4 4 gll broad nzitic,.ial benefits but whose hi investment difficult for the private sector or costs.nial,,e it -ate and local govert,@,,.@-rts to-m@lle an adeqL,,ete S'L. annual investment. Preventive and C@,i--Isiipler P)-,-)'L-ecti-n dctiv4ities that can be achieved bC!S'- till'OLIO' _,,I collective action, SLIcii as reguiai-lion of. t@ie manufacture and sale of -s; and pie,.icr,4tlve foc,ds, drugs and t,,iedicF.'l product health and sa-l@e-ty activities, such as the coi-itrol of colli-im.Linicabl,, diseases. -(4) 1-im-@i-ted-l'echn-ical Assis+larice and SD@,cial S'L-art-Up cl, Fun.Iiii,q for of @@ I'll I* k the'system, to introduce new types of facilities or P,,,anpo,.,;er, or to dc-i-,@oiis'L-Irate near 't-,,?pns ol delivery j systems. (5) ti,,2altli i.-il-@,n@jcl@,.,,,2r Education Proqr;',,,-,,-.s as part oi' a general educational initiative that will place principal reliance for accomplishing this role on the institutions of higher education with Federal support throuch general student assistance programs administered by the Office of Education. Limited Federal assistance riiy be needed to overco-,,e especially difficult supply and geographic distri bUtion problems, or to dentonsti-,@tr-, @Ltip validity of now types oi' health professionals. (6) DirecL- Provision of @ll--,alth Care Only as a Last Resor'L. Tlie Federal gov-ern..-@,e.nt's responsibilities to provide health and medical services directly +o certain poplila- tion'groups, such as reservation Indiaiis and -;..erchan'L. seamen, %.,,ill continue until these groups are provided 04- for adequately under Llier mechanisms. 3. T[iE STUDY @iAD TO BE @iLED BEYO@'D JUST Til,--- @1,E,,,LT[i SECTOI,.,, OF D@ With the study requirements to reflect actua.1 and rrojec@.,-d r pi-ogi,arii Chances and achieve the Departnient's goals in the field of health services with maximum management effectiv@- ness and efficiency, the scope of the study could not be limited to program--, the .1,1111, FP;k, and HS',"-.1k. l,'ia i or decisions have been made by.the Administration tfia@z have, Widespread im@,act ,-ind iitiplicitions bo,,,ond the present health services organizatio,,ial,structure. Therefore the issues identified and roccrr,,-ii-.nda+.ions developed cut across agency lines. STUDY Fi@',DIt.,"-)S The-findings in this study fall into three general categories: those impacting health services across ageiiry lines; t'liose -ith the hS!,i; (leal i ng @,i lil@ organization as presently structured and those pertaining to regional operations. 17 H L17ALTII D TO l)@- -@E"ff7LO@'D @ilo T X'F 0 A L !I: -1@ i ADtllf,'ISTERED CC;' Medicare and I-led-icaid togejl-, li e.i, represent the largest sinole Federal influence oil the natioi-@'s health care delivery system. Together they pay for almost one third of the inpatient hospital bills in the U.S. Expenditures for these progra,-il,@ are estimated at $17.4 billion in 1974, or almost of the HEI,,L heal '-Llh budget. Because of their uncontrollable nature, outlays for health financing and their share of Federal health outlays can be expected to increase. An important factor in the rapid r-i--zp- in health ca@.-e expenditures is the failure to achieve changes in -L-1-ie supply and organization of health services that are consistent iiitli tile increased demand gp-iie,-B-Led-by the -y of fi,tiaticirg. -P;ccLuse availabili4t, of tile impact financing progr-.iis have had oil inflation in health car,,' costs, new methods are being d@vised to at@Leript to uti-lizb Federal financing pro!-,rati-is to contain these rising. costs. In line @..,ith these efforts, 4ion op.-is and i.;icf@iciencies of needs to be paid to probl providers and to financing Decisions that affect provider activities and costs. In addition, plans and programs that affect the financing of health services need to be integrally related to activities aimed at the development and modification of systei.-is of health care delivery resources. Currently, the major Federal health financing programs are he substantive operated by agencies @,,,hose concei@iis are not t issues of financing insurance programs' ir,,ipact upon health care delivery, but rather managing large scale payment programs and determining eligibility of beneficiaries. Although some HSt'HA programers are attC,-,Dting to capture third party reimbursement for -services, and have provided professional advice regarding standards for participation in financing programs, the health agencies of 11,El@.1 have not been in a -Posltioli to significaii+.I,J, affluence Medicaid and Medicare. 14orcover, the Assistant Secretary foi,@Heal@Llh, even Keith nominal "policy guidance" responsibility for health financing, has not been able to affect the financing programs in an appreciable .@iay. The effect of a broad national lic-al@Lh iisLir,@nce -program upon -,ire delli,@er@y systen' the nation's health c @,,,i I be t.1,;, t of 1.1.14 even more profound than 'lil-@iid end It is critically important that the present and future health financing. programs be integrated other 'ties. Federal health activi following are exl,-,Iples of the integral relationships The beti,,,een future health activities and the financing programs that can be achieved most successfully through single leadership: The benefit package for national health insurance Sliould be designed i@iith a vice to@,iard medical necessity and efficacy of services covered rather than their similarity to other insurance plans. The continuing Supply and distribution of health care resources need to be integrated %,,rith the demands for services Generated through financing. The development and administration of national health insurance si-iould embody the experience gained from I!iedical-e, Medicaid and ','IH Of CCt4VitieS bionledical,researci-, in a viliole range such as treatments for specific diseases, and efficacy of giedical care. The determination of @-ihcit constitutes the essential mental health servic-es to be covered under national health insurance should be i)as(,d On the expertise of NII,'ili. The effective development of preventive health activities should consider viiietiic-,i, preieiii@,io,-i iiould be accomplished more effectively through coverage of preventive services Linder financing or through collective action. Coverage of preventive health services under national health insurance should be based on the experience of [ISI@,'il]A as to their efficacy. Reimbursement of Fedc@ral service projects through national health insurance can be accomplished i@,uch niore easily and quickly under single leadership that could mandate, for instance, reimbursement of frpp-standing clinics under l@edi(,aid or i-eii,,,ibui-se- ment of N@ISC personnel by I-ledicare. There is presently no single-focus to effect this integration. Research priorities for both health services and biomedical research should be developed with a View towards the health py@obleillis encountered through the financing system. Economic considerations of providing' and influencing distribution of ,health resources through reimbursement policies faced to -be fully explored. These examples illustrate niaior issues iii Federal health programs that can only be fully explored and'resolved if all health programs are considered integrally and if the financing programs are fully utilized to determine the ou+.cc@,,ies. Such issues can most successfully be resolved, solidation of all heal t[i I)i-ogrFi,-,is including financ- by con r ing programs, under single leadership and responsibility. The present operations of health financing programs are- not integrally r,--Iatcd to the other program activi'L.-i es within SRS and SSA. Both t@iSA and BHI receive adminis- trative support and overall policy direction from their parent organizations. Eligibility determination for Medicare is the only function that @-jould have to be maintained %,iithin the current context of the inco,-,ie L-cnan-.e Pr cn a r. @zz i r.41 cgi-ariis, but il- could @e ,crf crme@ service basis by SSA, @iith reimbursement fro.-,I the operating health agencies as appropriate for the services provided. In the case.of f,',edicare, eligibility for all social security benefits is determined uniformly by SSA staff, and records ol'-eligibility are maintained centrally in SSA for each beneficiary. Records on utilization of I,iedicare are maintained by the carriers and iii@Ler,i,@edi ari es. Records on beneficiaries' payr,.2nt of the required @,'iedica-,,e- deductible.ai--- Vept centrally in SSA, but are not a part of the larger record sys-Lo-pi on social security beneficiaries' utilization of other social security benefits. These activities are routine and do not@iti@.,oact significantly on the health delivery system and could, therefore, be continued in the current fashion and paid for by DIII on service basis. -'Tiie. operation of the Medicare program and its p-,i,lin.-ent i system are relatively self-contained %.iitliin B.111. The activities conducted in B@ll -- the certification of providers for participation in Medicare, contracting @-iitli the fiscal iiitc@rii,,ediaries and II)tate health agencies, an determination of reimbursement policies in teri,,is of reasonableness of cost and appropriateness of care received -- are the ones that have a i-i.iijor influence on the health care delivery system. The removal of B@iI from SSA would not seriously disrupt either thcse activities or the other ongoing operations of SSA. For I.'iedicaid, both eligibility detei-i-iiinations and the payment of individual claims are the responsibility of the States. The Federal functions with respect to loth eligibility and reimbursement policy are limited to developing regulations a-tid Cl Llidelines. Federal payments to the SL-lates for Medicaid are made centrally it) ')RS, but the operation is a relatively siml)le one of determining th,@-allo%qable Federal share of the total States' i@tt-,dicaid costs The par' of the payment operation in S,O.S that relates to 'il,'iedi cai (I coul d easi ly be i de,,-t'L-, I @i ed and run by MSA. Although @.';cdicaid admittedly has less infllj,-.nce on. the health care delivery sys@Le;ii than l,'iedica-e, it is the development by "iSA of Federal guidelines to the States for reimbursement poli cy that is critical to influencing the system. In addition, these guidelines need to be consistent %.iith Medicare i-eimburseii,,,-tit policy in order IL-lo achieve the maximum ir,,,,)act on the health care delivery sy8tei-,I. lliSA could be reiioved from SRS without disrupting either the I,Icdicaid program or the other-operatitig programs in SRS. -/'.nNt t7 Ti'E OFF'10r'- O.- Ti2,f@- t".Sr,jTS-,rtA,,k!T 2. '@O E STP,': s L r -iksslj@@",E ITS i-"" D Although the Assistant Secretary for Health has been .identified as the principal official responsible for the Departflient.'s health policies since April I-Q63, his -office@has never been staffed or aligiied to carry out this responsibility effectively. ,irth-2rnioi-e, tic has not been in a-position to direct or to be li,-"id accountable for the implementation of established policies. The Assistant So;,_-rotary, fo, instance, has budgetary respo,.is-i- bility for only about 20,"i cf the health LI-L.,,jget. Tlic! result has been lack of an integrated health s'Lrateg@,,. The author i ties.a iid c apibi Iities di@' the Assis'L-arit Seci-@i-@Lry. for Ilealth t:,-,u-.t be cn,,i@,!-.,ceci @o resolve these i-,i-oblems. There has been increFs-i@-.,,j overlap and dLIPI i Cat4iOil Oi' and activities bet,.,,,eeii tire various health pro-,-t-ar@,,s of Department especially in'@Lhe areas ol' reseai,cj@i, and financing standards. The current" fragn,.eiitation'6-i- leadership and accouiitability'n,,eans duplication and of staff as %.fell as lack, Di' any effective focus for activities that bridge the financing and service programs, such as PSRO'S. This lacl,,.of focus has resulted in coiisiderE@i)le confusion of responsibility and activity not only @,iithin but also throughout the private sector i.iliicil trust i,e.late to the fc-clei-al health financing programs. The Assistant Seci-etary's responsibilities should be defined so that he can be held accountable for the planning and iriplcTentation of all the Department's health programs. 3. Tllr CHARACT!!D 0!7 ST DI",,-@,STIC l'O POLE I The present cliaracter-of HS,'.'.@IA reflec-L-.s the devl-lopq,.eii'L- of a variety of categorical grant programs during the 1950's. It is composed of 16 categorical programs %Keith defined missions, each operating relatively I tilout a definition of th eir i,c, I ci tc) n - and argely %-Ii ship to an overall health strategy. These prograr's and -Liol-is must be reoi,@,?,,iized and redirected to contribute fuiic more effectively to the D-.,partni-2nt's health leadership s must be established responsibilities. tl ew - re I a t i o ii s I i i p to relate HSMHP, programs Tore effectively l@lith the Current health financing programs and to a future program of .national health insurance. 4. TtlE Plc-SPLur-TIVE ROLES OF TPE [IFP.,LTII PGEi,'CIES, ESPR@CIALLY IN lo\ . Since tllt establishment of IISI,',,@IA and the realignment of the other health agencies in 1968, the major tf-end in health scrvices programs has been to,,,iard the delivery o health services in a comprehensive nianiier. Bio,-iiedica -or,disease-oriented research has been maintained in a categorical setting. The Cancer and Heart and Lung Disease Acts of 1971 and 1972, ho,@iever, call for initiation of or--i ca I "control" programs in categ c o,-iiiiiu ii i @Ly settings to expedite the translation of the results of research into medical practice. The reintroduction of categorical service activities in a research setting his coniL,sed both the role of research programs %earth respect to delivery of health Services and the role of service L t, -ippr p@ogi,ai-@s %,,,ilh- respcc' to coi-,,.prehensi,,,.o oacho, to service delivery. ibly In addition, aOi)lied res(-,,ai,ch tyiat is ostens relevant to many 1-icalth activities lids up in vii-tually,every [i.,@altil ageric,f of 'I'lle question arises, then, of @-,,,'-iet'tier this research is more effectively -cl-is carried out in an indepetir!-nt reseal -,ttitig, or sho,,il(I be integrally related 'o 'he p,,-c;,ii-ans whether it L it Supports. p O! E 5. T 1-1, E 7AT I O' Ti r; [iE,@! Tl,' I-,'POI,"Q Z, j i-,.- L) The health niaiipo,,.,,-@,r develol),,,i nt activities of the Dc-partri-ieiit were organized in a Bureau of the Public Health Service in January 1967. The organization provided policy focus for maiipca@,for education; unified of a nui-pbcr of special educational support progrei,-@.s for health professionals and a focus for developing innovative ri,,etlicds in health education. The Bu)-eau i,ias r@,,oved to -IL-h,, 11-11H in IO.'OS in recognition of the overall ii@,lpact of research it-id educational support pi,oyr8nis on medical and of higher education. Until recently, the programs in the have been concerned primarily %-iitli ti-,2 education of health and have therefore focused on academic institutions. Questions of utilization, dis@Lli-ibution, and p-ay;-i@,ent l'o-t- [iian,n'c,@.:oi, fare considered by. health services and f4,iia,,icing progro.;i,,S. t,lost of ti-ic health sor,.,ic,2 established separate i@ii,-lripo,,.,,er cievelopiiient activities to 'S relate to their address these issue as they -rvice. mission. particular health se 01- c@ducatiolli viill be provided Federal support f tudent assistance rather primarily through general s .than categorical Support for educational institutions. ut many of the Thc budget request for 10,74 phases 0 .,Iii 1 e institutional support programs of the Bureau, S to Stimulate development increesin special program 9 of iievi and flexible methods to train and utilize personnel. These activities and the manpower efforts that have proliferated among II.S@,','IiA progra,,,Is need to be cor,-,@@irie to eliminate the duplication and confusion @,,,Iiich currently exist. A focal point is needed that vie%.is the provision of trained m-atipot,,ier for the delivery of health care services as a form of resource develop,-,icn@Ll to be @-iith a view to',,,iards 4.ts- ultimate utilization and reiri-,bL.! I- Se P,-. en 6. Pi S I? 'ILIA IS A CO! 1.0:.'!@-RATE OF SPECIT,,I-'-7c"D CATEC-. I C f@, L P R 0S C,l U T created in 1 9 C", 3 p r i,, iia r i I y @k-o bring together a I I[St'.'iA vias procit-ams concerned %,fit!-, tiie.pro,iis.ior, of care. It cur 'tly economists of 16 separate ot@2ratiiin, --ograpis, ren i most of %.ihich have a separate and uniq,,io'legisla,tive mandate to address a nai-y-o,.,ily defined problem the health care deliver-,,,,,, system. [iSill@IA as a vihol.,2, there. is a 1.)i-oc-id range of diverse activities that has evolved as each program established separate co:i-,pDnetits desigiie@l to ,,eet -71 ts unique objectives. These range from direct deli@,ery of care to technical assistance and basic research. t@'iany of the functions established in the separate progra,@s are similar. Most programs:have developed a technical assistance and grants management capability, for instance, and hall' of the programs have specialized training and research activities. There have been attempts, through special projects and committees in such areas as data mancigr-,Tetit, third party financing, and services integration to involve api,,i-oi-,riate programs and co5ibine resources in a [IS;"i.',,;A-%,iide e-i'l@or-@, to 'diiiated approach to a particul a cooi- achieve ar health services delivery issue. These efforts appear to have been limited in scope and effectiveness to bleiid li'S,@-ii@IA efforts under a broad health services s-Llrateny. HSIIHA planning has traditionally been done on pi-ogrc-,rii- by-program basis rather 'than in support of agency-,,.tide goals. '[iS@','[iA-viidc, g als fici e been st 0 v ated in general terms of improving access, ef'icib,-,cy, quality and T effectiveness of health.services. This general approach to goals is a best attei@,-t to su,,i,,,nat-ize potential 4OUS programs, lillpac I I t o' the var bull- unfortunately these generalized goals have been beyond the aggregate ability of to achieve. In fi'ovei-,,@bcr' 1971, IISI@','f!A programs i,iere grouped into four clusters, each under a separate Depu4L-ly Ad,-@iinisti-atoi-. These clusters represented the major areas of activity within IIS,f@',Hj@, namely Prevention and Coiisu;-,l--i- Services-, llcaltl, Sorvi--cs De!4.,.'--ry; Dc,,elcpi,,,n-:,.t; ard I-ic.,ital lieal th. (See Appendix B for current organiz@L- tion chart.). From interviews i-iith the 16 Progra,-i Directors, it appears that @,,,Iiere clusters served any purpose iL- ..,,as to improve the interaction among progra,-,is, but only those within the cluster. Nevertheless, IL-lie interviewers a so revealed that pi-ogr,-ris Britain th,-- cluster still d,,,plica@Lle efforts and maintain separate staffs; that the r,,ost effective program. interrelationships are still at the operating level; that there is little joint planning, operation and evaluation. Half of the Pi-ogra:,,,. D@ii-I,cl@.oi,s felt the cluster had no effect on their pronraT., and i@our felt the cluster system had even hindered their efl'o,-ts. J- C) y of pei-cc[) -ici Intervie,is revealed a variet t is on.the role' of the cluster Deputy P%d.@,inistrat'o:. Of the resr)oiises r from the Prograi,,i Dii@ec-t,)rs,. three consi(,Ict-ed the cluster deputy to be a line ni-ap,,-.'c:er, four a coordinator, i.;@,-Il,e eight- tliouc@@lit h, served as both. I'@,.ei-e %.,,as agrec-n,.cnt -i-,g the Prooram Directors that clusters %,,ei-e orig!r),@lly estpblislied, 'Llh-, cluster deputy @.ias intended to coordinate prograris'and act as a crisis solver; but, in some iiisL@atices, depci,ding on the deputy's personality, his' role Gr'd,,tally a became that of a line supervisor. t In sLIlilTary, the Clusters appear to have offered a convenient way to conceptualize the broad array of programs and to have reduced the direct spaii of control o-F the Adii-iiiiisti-a@Llot-; but not to have [)con effective in coordiiiz,,'-ing proci- an resources to achieve broader health services goals. 7. THE If@ITE,",FACE PROr'l@@",!S 'ri'S tA onlv Di s cti s s i ons %qi tti Prog -,-am D i rectors revealed .@-,ha4L few steps had been talen at o,,)eratitig levels to assure 'that adequate relationships exist be@Ll,@,i--,en liS!.',IL'IA-financed service activities and SSil and SRS financing proni-ei,"Is. -In addition, the relationship of the health s--.riice and health 'inanc-ing programs- in the processes of policy d-lvoloi-,-,,,@,nt and program planning is not-cotisistent oi- adequate. As a result, OPPOrtLilli ti es or an integrated policy ,.,,ith respecL-1 to health cl a 2 nati orii Iheal til i nsu,@lailicl@ n t a t i on. and operation of ubste,,ntive input f- "Om program deserve a more thorough and s ealtli of@icials. q.-fic Dc-p-3i-tr.,,,(-@nt's h health I,,Iith increasing dependence on finaticing.progranis foi 'ise from the lack of a coo)-cliiiated services, many questions ar health services policy: fferetit benefit Should grant programs provide a di package from financing programs? Are soi-..c' of these services medically desirable, irid -,Yi-uijld 'L-"iiey bn covered under f4,nancing? l@lliat necds to be done to bring the Iiidiin @iealth system tip to standards of participation for financing. '14hat is the maximum potential for reimbursement of project grant activities through existing and future -firtar'loing prbg'ra,-,ls? Ansvi-.rS to Such questions are essential to developing a unified health strategy, and they are possible only through a close integration' of all IIEI,-.1 service activities -0 C TIIE I-','L--I-f@TIO!@!iS!IIP OF )'F !'E 11 ACTIVITI'LS or,@,,iized, in At the time t@ie- Public I:ell'fl Servic(2 @,jas re had enveloped sizable service delivei'Y 1967 and 1968, program elc-i,,ien-L-s in addi Lic)n @Lo. its @)asic I-ese@it-cli activities. It had bcco!,@c a disease-ot,iented, vertical oi-g,@,rization, b"c-i-,,,s Through a vai-ic-i-y of approaching health pro i activities. The placement of in [iS,',,'r',A i@-) 1,0'08 appears to have iiiad6- sc,@nse as Oi"c@L-1 iiiza-Llioii-,l and because I,,Ili.'IH had many functions in otliei- [IS[.'itiA programs. Its size, variec,,, of activities, and spangle focus, ho@.,,,cver, riiake it unique. As is divested o,' its i-esporisi- bilities to finance the operation of cogimuriity ili@-ntal health centers and other mental and services, it begins to asSL,,@-i-- the chcii-E,,@.r@tei-istics of the ol@-hei- research institutes at 9. T@IF 171-,,TTO.',@' 'r,i'JST 1,I),O',IIDE F@,,r) Tril.7 PI-IAS!' OtiT OF The' 1974 budget calls ioh and redirection -1 S of several niaioi pi-ogr c-i ii dactivities in line i,,,itli a redefinition of the Fed o,,-a I' role in 1),2altli.A reorganization tiici-L-1-lool,,,s Lc)@,.,ai-d the future roles in health i',lLlst at the same t i @,! i -L' provide for the o,-dei-ly transition of ongoing operations. Wi'tliin [ISi,l@IA,. the Regioii,?.l 1,;,-,dical Ili,cgr,Eiiii, +,lie flill-Bui-ton Co-is-'u-'L!Cti-n SuP!),')'-t for co"-' @l' ty be terminated by the end of FY 107@i:. n,,ental li(-@al @Llh ceiite-i-s, alcohol abase projc-,ts and long r2 r,@l training viill be gradually phased out beginning in F'I' 1974. St'. Elizabeth's Hospital viill be transferred the District of Columbia, and contracts @,iitli and other Federal facilities %,fill replace (!4ii,ect provision of inpatient care in PHS hospitals. Project grant support for 14a-tcri-ial and Child Ilealtli Service @,iill.be ,-epl-ced. I-,,y I formula grant funding. Although no specific action i.,,as requested in the budg(@lk-, several o-ic programs anticipate significant changes in response to the to,.,iard health services fiti,)nrino )tid the discoiitiii!jatice of activities.best Supported at the S@Late and local level. In the Bureau of @lealt',i f,ianpo@.,,ei, Educatiott, the bud,,-e,t-, calls i'O@, termination of categorical support in allied and public health, and for schools of ,iursii-,C,, veteriri:--i-Y P.,,edicii,e, podiatry, pharmacy and optometry. Funding is increased for special projects and educlat4loi,,-al in order to focus health training SL!rdpor'k-, in areas of spt-2cial need. 10. TtiE c ti.11, p F!@! ,-.,T RCLE 0'7 R":GT-C.@II."311. CI'F-TCES S! 'sis O'l A I- '7 r i T,.L,,-i s i o,,,. national categorical proc-iro,,-iis. Tli@ regional offices are ally concerned @-iith helping develop integ",a,,,,ed g(-ner br-@alth service systems to meet State end local needs and priorities On the other lia d, national programs are n generally concerned @,iitli specific objectives under more categorical missions specified in legislation and appropriations. The integration of these categorical programs in supporting comprehensive health service developpieiiL-1 has been define as a responsibility of tiie-regional offices. Recent decisions to accelerate the decentralization of programs to the region,,.stress the need to I)iece decis-ion-P,@al-ling authority closest to -L-lie point of pro@ii-am iii,,pler,,.,enta- tioii in order -IL-lo improve the effectiveness of programs and the coordinated use of all resources in meeting local health care needs. DecetitralizatiGri of HS,','@"IA grant programs to the 'i-egions has proceeded to the point @,,,here 25 grant programs have been decentralized, representing 60i@3 of the total IIS,'.',@IA grant dollars. Additional grant programs have been partially decentralized finite another 20 remain centralized. 14ost of this latter gl-OL;p have been determined appropriate for centralized.operatioll. Alcohol and drug abuse service grant programs (-Ire presently ceiitr.a I i, --7od, although ai-c not b;-,Ifig 23 l@,lhilc@ consider,@i@le pi-ogress has been in the (Jecen- --.--tt-alization of grant the have ex,F,,-essed.' difficulties in achieving program integration. During interviews the Pegional Directors sta-L-led the following cop,,.i-,,,on problc-,riis: There are serious differences bet@,;een regional ol@fices r and h--adCi Li i 1-ters staff i, C, i JL-h respect to the of achieving objectives. I',--adquartei-s procj@ans liFve v i e,,,,, c, d some efforts at integration as obstacles to the achieve- niciit of national progr@ir,.,:Ii,.a, ic objectives. Inadeotiate integration of p,-ograT-,I--, @,t lleAdqtlai-i--i's lplv--- too much responsibility for coordination a+, the regional level. The fact that regional offices receive separate allocations tied to individual,Eippi-opria@Liotis instead of a consolidated opei--,u-ing budget is vic-,..,,ed as a constraint to their ability to integrate activities. There is inadecluiate stl'U C tLli-ed regional office input into national poli-cy and budget development. RelatiQns i@iitli Medicaid and t!,edicare staff are generally episodic and unstrLICtU)-ed. To@ PS TO. REFLECT -FIIE -fliE ROLE Ot@ TIIE PEG, 0.17FICE [,El IL L LES PIT F- u I heal th the prip,,.ar,l role of the regioiil'l I presents -,ri oL.,s staff is to iRipleiT-.ent ar."I integrate v, i 4 region. Llhin the JILF-" categorical grant progi-z@.-,@; orgaiiization-,it the regional level is a reflection of lloztdqiiai-ters orc-lonizci-L-.ioi-i alo,-ig cluster and categorical t4oll @.litll program lines. Coordina the health activities of other agencies is liiiiii,@2d in the regions just as it is ill headquarters. As the health agencies respond to change s in the federal roles in health, the RO health staff i-iill be expected to Etssu.-ne the follo,.,,,ing responsibilities Ai,iai-ding. funds to and r.,,@,,)nitoritig performance oi in surveillance organizations established to i-,iiii,.4L, i of professional standards. Monitoring performance of agencies k,@iiich have roles ii -heal th i:nSLI-,-ance f i ii@.iici ng syste,-,is. Certifying facilities for participation as providers in health fir,,-tiicing Providing technical assistance to I)I'CPE'.I@e I-evel heal -L-li care deliv('@i,y projects for financing through reimbursements -e Pro tcF community or Sta' viditig technical ass level. authorities for the prevention of co@in@iiiica")Id diseases. SS4 Coordinating and a isting in collection of data on health tare resources and health status. Awarding funds for State-@-jide and con,@riunity level planning and coordination efforts. Assisting in the implementation of programs to provide care for bcne-riciii-ies through direct delivery activities. Assisting programs for safeguarding liealth'throuch eiif ol,cericn4L,, of la,,.is governing tare manufacture and sale of food, drugs, and other substances. f- u 3s Tile a-ency str,,ictlil,'e for service nani zed act i,,, i t i e sof IIE@,,' contains @t'@ree net,.i agencies or,) ;,-Iii-,g and z,@. r ',),u, id 'L li f Li c -Libiis of I ILI L sei-vi ces, devel ol);l,,,@nt o' th resources and prev,,@ti'ioii a 11, rj c O,-i o Iof health litl)in each oi'.tliese functions, the fed,,i--rtl role @,-&i-ies from one of direct action to oi-,,@ of serving as a -@oc,us foi- ind advice. Four otli-@i- orgai,.izat;,-, , , n;-, I o p @Llions @-,?,Iiicli i.lc.,,-e considered are discussed in fkppetidi>, C.. linpleiientitig these three agencies i-iotild result in a health s Lrucju-,,ir.,-- consisting oil l'ivc- a-,,ncies, c-acl-, specific hca'.tli mission: Food and Drug conSL@'@,,-,Ier protection Ila-Lioiial Insti-L-lut(-@s of liecil'Lh--' bio,-,-,--dical research Center foi- Disease Coti@Lli-ol - prev.-njG-ive and n!,;'ulic health -tfeaith Pesou,,-ces, fkd:@linisti,atioti - Iica'th care resources Health Services Ac!i,.,,inistrZ,,4-4 uion fiea'['L-l-, set-vices The purpose of tiii.s s@,,,-Idy has been to create a structure that facilitate -, the dcvelc)o;,-eiit and iriplc-!,@c-n T@- 2, -L-ion of coisisl@-ert health policy. The functions of t,io tl,,i@ee ne@,,, ag,-@.nc-ies provide a continuing focu-. on t,ie ele;,,,ei,,ts have to t I i I- "i . be considered in the of o,.,e,".'l hoalt!i )-@ii-ly. I 0 I f' Since the est(-,I)Iisil,9'.cllt O' CDr" Ds a scl)ziratc- a(j(,ncy reqtiii,Cs s o-" very little e I C,! 2 o c C) 1'. s o 1 io, e . i n t o E), g c- ti c i c F, j o rIE I. a v i t i s 1 1 C) t -ovision o-l' I L ,Iipj he pi h set-,.lic:os and '-fie d.-velop:-.l-@,.it I,!itliiii a nc-,@-i agency foi- hec@l!',,i scr%,-ices, all no,.-: financing oi- dii-ec@Lly sL,,i)pc),,-tiiig tii.2 cl(--.@livei-y of care %,,Iou 1 cl I)e co,-soli(la'Lled. T@;,,@@ n@,ed to I)','i!lg the fitiaiici,,i- prog,,o@i-iis o-i' i,,,iici uiic!2r health pol@icy has been discussed eai-liei-.in tli.is report. In addition, the current health s(,i,%,ic'c 1)1-cnl,-El.!Ils %@,,oule! 1),@, cons6licl@"L-ed to facilitate a coordinates approach in redirecting tliesc activities to@.!ai-d sup-ort t@,.,rou,@.ih i-Ili@ finciiicit--,g si@tc,,,.l ti-iati direct Fed,@,i-al assistance. Tl-iesc, currciit se,,-%,icc@ programs are SL@ppoi-'Llcd through a vc-ii-'$,,,ty of r!r-,c[iatliSl-.IS, foi-riiula and p'-,,-oiQct gi-oiijL-.s., coriti-ac's, ciiid d i i- c.,t federal assistance for beneficiary, care. is r c-,,-, o i e cl th@a@L t ii -.icfective ot)2i-a t i on c o n s o 0 1 1 and 'redi -ir these activi-LLics 1 pl arm o,.,tersive rcction o adininistrativ-- burdens o-ii 'a net cigo-ii.-y tliit is cil.so. che,,.-gc-ci @,ii th operating iiici it-itegratiii,, -'I-ie iierilti) s-2i-vic- fin:%i-tc:rig L 14evcrtli--Iess, i@L- is stroii-ly that ti,CSO I'LIIICJLiO!!', bl -j L L in a single agency to a sti-ofi,@,, lolity l'or services, to ii,,cet.trie i-icccl for i,-Iol-c Cfi,cctivc., -vice and fiiia,.i-@iiig pi-ogr,-ti-,,is, (Ind -L-o (,Iinlirat(-' costly (iii,ect sei -ItiOll Of L L,;-q Coll'JiCtilly C:L!PliC, e-rfot-I s at , I L The of a.C'L',iv4,-'--@'es si.ipl)oi-ting the clevelo5,@-.,.@@rit o-F i-escL.!-,ccs is 'L-t..2 sccoi-id P.@ajoi- pi-o@,!isioii. propose Hi@\A- i;i-ill 're@,,, ire i!!@,@ediate z,.iid c-x'L(@ns -i ve redirection and into(-,-o,'-ion of oiicoii-,g pror@i-,@,@is. A grc,,-,Itei- :.-etence n,,L@st be develor)cd to pi-ovid- the degree of c@ stii-veilli,t,,-.e and rese@i-cli activities ii-,-cessai-@f for 0-ir a coordinated rLsOL@l-CC-S Stl'a'L-,C','@Jy. In addition, this agency reqtiii-c ii-itc.,grajL-,ic,@i of ongoit,g resoii,ce dc,velopiiil-ii'L-, F@-i-ogran,,s ,.!-itriin a coordinated resOL11-ces sti-a'L-e.9i/ 'flie long tci-,Yi llocus of this ageiic,@, i,,-,-,ist be provision o-j- i ii l'o ri-,q:i t i on ,,iialysis and advice o@,-i the overall suppl, c!,-i-.1ati,,d and effective utilization of health c&,.i-e i-csc,,,ii-ces. Resource development has been articulated as a Federal responsibility in,the pE,,s@L, and hills been the general -goal-of I)LIl..@'I'OUS, scattered efforts. Conc-o'lidation of these activities %.iill facilitate more effec-Li@.,e Utili7,1- tioii of Iii;,iited Federal l'uiiding @kl;]I-CL,'-h JL-la i,g e ti i-i 9 of activities. Problciiis should Lie idet,,-Li l'i cc', in a broader co-,,.-Lcx-L. of ti-ic overall vi',l,-,, of resources in the 'U.S. -Ttie iilz)Ect of this viill@ iio'L- depend as iii0cli On tli,2 o,n,,,ratioii of direct pi-ogi-cip,-,Is, as on their indirect role i@n ini"Itic@ncing the policies'ard programs of TIIE FO! S @'I S -F n T'I' 1, o; oil s -i I-, of Serv-icc,s 'cl@-11 I C c-, s be to ,)rovic@n aiici f i -,,a I I c c-, II c de I i very c f 1', c@i i d , (,rciiits vc, i-y, a, i I -d u i i I!:,a e -1 y r, i ri s e,.,- i i-i gtile '-[I cEti,e f L@ is C LI Ci C' Z:. (,I -i toi-i iig prog -z@ris ec, i ca. i-e and t.'i-dicaid); d ve'oi)ing and P..,@ o n i 'u i I s t a i I d ---@ r d so 1) i, t i c i o n o f p o i I tile of cai-c, ri f i iiaii,-i i,,g; revi i,ec-ei vc- teri-ns of cost, qLiality, prelial--ii,,,. existiiiri he a l 'L-,Ii service I' 0 I- S LI 1) p 0 I' t 11 C; L@ -'L-'Il i I'Cl -i@"LY financi!ir,i f)y cclt)-@,I)ility alid enSLII' I iig i,-,cet ciccef)@L,@i't)l(-, for and providing h.-@ii't-,h sei,v-icc@s to specific -1@edei-c@l t-latitig coii\,ei-sio-,i of tile, L t@ihile facili4 @e actvities "C' SL)i)rort t-hrouch financing The Heiltli Scrvicc.,-3 i Oil k,:OUId i!lClLde 1 1 health c i- e I' I' c i i-I q e c t s the B'@l"t-eEiLl Of III 0 'I 'L-, 'II 4 the SC)CiZIl SC-CLI I Ly l'i,-,dical, Sci-viccs froii @@,-,cial 2,114c@l [ZehabilitLition 'zc,,%,ice 'L-lh(-, Pro-I' n-- s s c) il Af-i'a-i i-s fro!n tile 01@l'ice c),@ 'L-ho Pssist@,ii'Ll for Ic, 11 'LI r aiicl '.Iic,,Iical Care Standards 1-tcLivi'L-.ies )'o;ii il C' C C,; L! 1 '-L Y 11 --Sey,vic(-,. In additioi-i, 311 ,icti\,ili@s: f,-riily Ilrojec-L n,@ (-:cii'ei-s, and liealt,,i projects; Centers iric! Child 4 f S Cil 4 11 I 1,@ -1 I11 ai@d I I I - CI S j- V i C e ii. ii d ci Federal Ileali--Ii Pi-oir@-ji,,.ls Service (FIIPS). llithin this egc-.,icy, the financing activities eight be integi-a-Lp-d 3 r;izijoi, tl,-2 B!'I and .-I to L, ilar,Ci ng C C. @.!OUI -1 be pol 4 Cy substructure. These three fi u -Lion, (.i ri dr) i, oii I dc-vr:,@lol-,lll,-2tit, progrciin li'@o 11 to 1, r, The service did l'Ol-l-,-,Llla gi-ciiit activities r..i i (j [,,'L-. co,,,.@),,,ise a self-contained con-i-ooti,-iit of liSA that has it functions comparable to the l'iiiaricit,.g SLII)'.trLIC'I,-Llt-e. (!rated sc,,rvice@s t4ol@S, oll..2 co,T,poiien t could contain a uiiit for polic,, cind i-eit,,Ia for technical assistelicc and ai-@d a 'L-hii-d for program Monitoring (Ti-aining of gi-zi,.itee s'Llai@l's is co,-isi@-ei-.--d-- a forni of technical assistance.) The Correct care ectivil@,I'CS aC,-4 V4 +-'(-..S nliglil- colilpris-2 the f@ll'th of lici,@,,. These L. t, II @ I are relatively Self-coiit-Diiied @,,Ig,,iiiisti-(itivelv b.@cEiuse of river r distinct operating requii-c,,,,,,2iits, and could retain rich of t!-, e i r present organizational Stl'Llc@Llui,e. L 'for 1),,@ograiii ei,,'cction Ttic, Z,d;l-iiiiistl'otiVe Stl'Uc.,tii-c- SUI)POI-T ill l@,,Sii% @,,,Ould Lci, cl(-@i,iv.ed f,,,o!',,i- Sc-,Al, and @i S 1, -ti i n' "I t s addi4L-lioti to tilo integral "[I and I-ISi'i COP',i@0, cei a(li-iiiiistrat-ivc@ Support @tl@-ICt ons -LICII as Pet-SCI:--i@el and f-n--,iicial ei-it, are no,..i out ill S@'S and @S[@,, ar!d a ij 11 a g c ir,, proportion of ti-,c)se s'L-a.-l'-I's should bo identified Eiiii trz,,iis-,rE!-@-i-cd to [ISA. Tliei,e care, as soiiic policy suppoi,JL-. activities in SSA that i@'ela'L-e to f,'ic-clicEire. Thc@ relevant portions of 'L-Ihese activities -- i.e. SU[)-Lilli'LIS of ti-,c@ Office of tlic-- Actuary, 0-iri@ice of Researcii and Statistics, 01'1'ice of Progi-zii,,i EvcilLiatiOl, E@iid Planning, and tfl,,' Bureau of Hearings and should be identified and transferred to O@NSII Bid HSA. The liec -il th S-i-vicc-s Acliiii-iisti,a'Lioi, i-!ill serve as a policy I'C?SOLII'Ce ior issues concerning tli--, cic-,livery of' 'Health so,,-vices. Information on utili7-,tic)'ti of all feclcrally-fiiiaiced servi'ces be col'lcctc(t throlicl'ii I-ISA, alth.,)Li@,:Ii all others dcita.-ga'Llhei-iti@i activities k','ill be COt",-]LlCtCd in ti@"A. T h c s,,- operational v.,i'll iiicl L,-de of sel-ViC6S till-OLIC,"'l reiil,,bui-sei-1--@iit, gi-an-L-1, and Jirect service I)rfio)-i,l!s and i,,n-ed .1 ... to I).2 clos,,@l@, relates' to.L-,,3seliiie an(] oth(--,i- cl,7tta develoi)cd in HPP,. All research be co:-l,,!Licted -'In including I-ese@ii-cli L- i@d c,xperi k;i 'h -Liie '-i ii,@ki-ici n@ s 'L L- I -1@ [IS[@ s' @k@ 4 til -in.--ii-ig sys'ei-i t'(,,it licivc, I)c)'-icy i io s, .ns i,, I i@ c f i ii L L probl c,. c 11 and they %.!i I 1 c 1 o s c, I i th I! s c a r c !I c@ survci I I staff to dck!clop expei-i;ii,-:!iits tl,.at Trip resolve -Lliese poli@,, 32 I"r", T 1 2. S I S. of the c,)n I II -@iiiic L I sui-vei'll@,111-e of tl-le status o-@ l@.riilth cE,i-e in the tiii-otig!) Stz,@te anc; local plz@t,@ri-iiig ci c @L- i v -'I i eas i..;el Ias collection a@-icl analysis 01 dDta on i-eso,,irce SLIIJ,!-.Iy all(i Vital StL-tiStiCS, z;.nd disease --i)icideiice; c'---velopitig i.,i,,d testing (in ,cr,c),.-diiicitioi,. ,.iith Fe,lici@@tl health sct,vice activities) iim,i -,I),,)roaci-i,2s 1-1r) the provision, ei!is'L-.ril,)tit-iO'.I, &Ild LI'L-IiliZatiC)II -iltli faCili.L-iC C lie( S -al th care o and he systell,.s; pi--o-,,4,ding special support foi- de,,elop- tiii-ou@i'ti sci-vicc@ -l'itiancirig or c,,c-iieral CdL.Cat@.on This .igency brings the entire set of IIS'.',Ii'A organizations iio@.,, Cc-,.'itcf- for Sei-vicos -.Cluster P\c-seat-cli D@-@velop:.@,n- I,. jL-. Ilea]-tli C;,,-[-e Facilities SC-.)-vice, Co;,,@.- Itli Pl,il-@iiiiij Sei-@Y,ice, [,,co on,;il i) I i,.sive l.leo, I.'ieclical Pro@.-,-E::i,,s Sci-vice, ii-id I?jec-31tLi l@@iaititeiignce Oi-gaiiizatiot-i c,--,,vice -- @,iiLl the Sol-,v,ices ai-@ci' Ce,.iLt@i- for S'Lla'L-listics 1'ro?-Ii the [IS!.'it.-]A Ot"-f-ice of the Tlic- BL!r-(!ciu of -he i!,itional 1, Iltll L Sc,,i-vi-IC! Ccii-ps, Ut!IL'I- sei-,,,-ice i, search training acti,,,itic2- tii;llt are loca'- iii various fiS"@-IA Le c:, t) i- o i.ij i -c a T pi-ogri;ii,,s ai P, C!;o -Cos Z'IICI O' oiir i- e@ n ziciditic,@",I, a d-,i,,-I,2iision access to be cl.@,,,clcpcd to provide ci l@@,'L-,icn-al polir-.,v focus fit),, )-aspect to resources da'L-.a. niajoi @-i i I I be @Lhn 'i-i-st step iii ci-ea'Liii,r,l E, strong, Collt4 activities. oi' /t,@i @-'!-;Cy Si-iOLild clearly e coiitii-ititi,n of res,:)u.-i-cc, ng: fi-oiii of V,"IlEtt i.s happening ii) "-12altil systc@'i cind its coi'@",Poilellts; to rc@s,,,arcii at,.d evcalllucal-@on of speci i@i C etid iSSL18S L to d related to the li@,al '-.ii L, -@2 o i.,.; -2 i-i t a i-.. d o t i o ii .Y d@;i,otisti-atio!@s ard t, of i-esoLii-c,- dCVCI Oi,);,,loll,L a. c -,I v i t I 0- s The surveil l@;f,,c@ is etivisioi,,ec! to i n c I L,'@l h e I 4Li o I, L@ C i- e r, s v c I t h P 1 @. r,@ i n g Set,vice, t.)-ie Ceiii-ei- for SI,-atistics, r the @,,-Iiice utii t i ii e@i).d CLI' C'tlt I-!IS!-i;' A acti %!i -Li C-IS rc@l -.ttc (I to th(-, dc:l@-iriition of f@,,-@,ilth scai-(.-it,, ai,ea,3. T'tie Cen-'L-ei- @i -o r- Pealti-i. St,-i'vices Reseorcli and 1).-vclc),')ii-,ent and tire i-c@seai-cii o-,' take otlic,,,, progi-iii;,.@-,. Ti-ic ai-io' .--o!-Iir)ozi-@@nt -ii!c:lude,, file CIC-1.@,o,-ISJL- a JL- 1, C) 11 and 'L the @l'ationc:, I t !I Service Coi-ps, l,ilaintcr@atice Organization SC-i-vice,' and Emerg@-.,ic:y i%',--dical Devices; @ii,,d the opcr,-,-'L-1 -ioiial o-F Pegiati,,,! i,@lf-,dical I)i-c;gi@cipis Scrvice, and [@ln-altli Care FElcili-ties S-,rvic,,,. It is to ei-,iphasizc- 'the need foi-.collsolicl@'t-lif-ig rl i-,-LSeiircii JL-li-ain-ii,,ri Eci-livitic@s. l@!iiere s,.;cli IIC,Olli- ongoi i-,,g @..,c)rr, goes be@,ond ng the n2.-.@cis of sp,.%ci fc 9 r a n t o i- c o ii JL- r,@ C t o,.,@ i--! -a -LL e d p i-- oEtri st 11 Y S 1. 0 LI I d 'L) included in li'PA. Pi-og,-ani direction and s o i- for this n-,-%.,, agency sl,.o,.ild obtained BIL '(,',@IE and '3. T I I E C i@, FO..@ Di FOCIJS F C.' S Co,,,,r7-,r i. I-'T!-L P) E T!'@ .... ........ P.- OU'f tl!l'!'iiii@, I ;S. 1.1 be to Pi-ovide ii;,>, -t i Tiie Diissi--- nal lc,--ic'-@rship 11 the I);,-. 0 v e I of coil,,,i,@Liiiic(ible anc,' \,cctor- fo -itic)il a.",(i COI]TL, bo,-iie diseases ii-ici co;i@'-I@Lic)tis- I;aj c)i- functi(,,iis I-, c I L:t p I- L, Vi' 1 colil-i-ol I I lig g anc L i iig St@t 'C,@ -ai-id COli!ll!lll')'icable discl--,@s by @L CC)il!"",tl ii i t3i c -oviding .11-iical I L action, L o C C. @j effect4@,.Ie t 0 c II!, i 0 heal tii -s s @ie ns; s t c, r i ri?, safe etirj [ICalt@l-rL[l co::(! 0 d 4 11 I t progi-'ai,is relatiiiri to cl-i-,,I-L-lh c) -@, (i I c@ a,@l -!) a -, cP) S,@, and i-Eit coii-L,.-,ol ; directii-ig @oi-,eigii (-ad L quaraiitii-:c activities; (iiid i[-@@i)-i-oviiig of- cl i Ili Ca I aborztjL-o,-ics. -in 'I-,e This i,,,oulci coittL,L I Pr I I cvc-ii'-@oii ConSLIP,@er S,-@-vic-s ClLlStOr -- CCIltel- -fOt, [),,,as- Coi-@,--,.-c@l (C")(-) Bui-e(iu o Co:,-Ii,,iuii iEnv i 1. I !I n ;.I (j 2 iC E! c.1 IN'ati ona.1 I,,,,sti tu-L'e f 01- OCCLI!I-,-;.'L- Sci f,, a tid I-le@-.1 0,S.". The ag@,t-icy %.,,olilci tiic, Disease Control, since tile s i s 4- ,C Continue to be on the cLii,i-ent, Livi-L-@ics. T lie I c- d - based pa-iii'L-. and i-o,,.eiit control &.ssoci which rci.,,ain in the FY 1974 z@ s(I -Cn- -into ti,o CDC structure, ,c staildii,,,., 'ilTIOSill,. llo-.,:2ver, s i; I -@l r c@, I i 'I @Ls indepc-ri@l,.@iit orgc-iiii-iii'L-ic),,ial S"%-,Z'@'l-LiS ill cl@ I t-S trans-ror to the Presi(li,,@i-,,t' s ri. c;; I ill I T l@' Z,, C4 ',ni, 'Ca S llevlei! sio@ild bc. dL ol all trans-i7ei- to DEA, to (!eLeri,,iinc,. ,-.c) i)e transferred and to es,-Z,,blisil arcl rL)@,ii-i ng Spec-iii e to b2 ii-,adr- if l@,'IOS',! 0-r-c-ice s@,a.,.i co@:@' to be Io,-; '-.--d in ti- :c CF)c i IIA I --, II ',- a f o r o v c., I - ap r oI- d i i- e c t i 0!11 ri t-I ',.II p@ I a II;--. -ations coli'd also be su.p,,)ort. I'lic i-c@mainiiig BCI-IL o p,-, I SpeC-i@ i S t t 4 Li;ider -c if it desir-(,i!)Ie to their location at Park]eL@,,fn. It is e>,,,)octn-d tlict the available this z,(,,-.iicy in be stjt@l'icicn'L to ra a g t 1-1 C'@! 0 I- g a 11 7 a'- i o n P@' F i -f-,S I-!It OT[IER -L. f'70!;TD- S@ r'Cl@,L r-.T Preventik,.- In addition fo health sci-vices Health i-e---,r,,L@i-ces, tii,-, thi rd broad compl -v@.1-Y cci,,,,@poncrit of all I oil strategy is fun-' o f p c i I4 r,, c: -o!-, i- r,l 0-1 -1@-14S t@,pL, 4 heal tii pr-obl t@.cti vi 'L-i esI 4Vitie consuii,ip-r pi-O'Lect-ioli cc'Lli 'S o-i@ Foc;c't air,, Dl-u@l Adminisi.t-a't-,ioi, the cr.;ll-,-,-iuiiicablo dise,:isl- r)) o I-, L0 II cl I-ivities o-@ CD,, 'Firici ("CctlDI", control .c' and 1-1 t Z., IS a 4'0 @lelltil -oil C, i,,i ti C_, Cf !,Ilol@l, all I onvi I DCEI.'i. Coiisid-i,Ett-ioii @.ias (@iveii to grol,!I)iiic all [))"vc"'Itive i i, c' s u i, E, s c ri s i o n cl o t h e D,@ Peol'g' -S s D@-p I-l'i z tio,-i I'Iiis Igelicy third- asl)r-,ct of all --@i-,itegy '.-'ould coi,,si cl r b i-o a dCl L! of -Lo frciii L,,D-'L-11 a pc-i-soti,-Zl licaltli a.-Id a public health aspect. Such an agency S C, C I_ -t-sc, 'I-,e VIIDL[ld solve as a C, o f v a rc,,,,i s j) c- v e ii 'Lli,@c- lil,,il-L@li sc,,i-vi,@es that 1,1@o")Osc"l f"))- coverag.2 I-ieal'L.i-i -ic-iti-anc-irig It I-,"O'Llid also %.@,cigli the I-olzitivc-, 0-ic coiiducti:io pi-evert-i%,e activi4Lies h ,,J-Lil 01- ColleC,-4 thro,,tg ci I Li,,le ec-i-lioi-. @,,,,proLi c I I I- i-, -,o @-il I-lezil@L-11 Services than a 1)c@l , -c Ideas gc?ll,. clil-Ilklly felt that consoliclia-bii-,g it --ive activities Li)-idor s-itiglc, le,-)d-c) -s.iip cl@rify tli,, of -preventive ac-Livitie,.; ho,-,flvei, i'L-1 @-.,@)s also y .,,4 recogni zed' tl----,,t the of all ci,, 'orcei@ agl--ncy i-ias ,,iitli Sig;lilriCallt SLIC",@C-@ss oil c O!-,., D at i v e and technical assi'--,-'L-l a r,, c e ci p p i- o,,@ c 1 i c- o Li 1 d ri o 'L-1 s,L-11-otig'(-.i-.,@ll -1y's abili'L-.%,, to Tlit,,,s, a i:;,qve to eitlic@r @,geri L in this The [:D,@ CD,,' is not a - -OU',)S c tioii gi IC-,-ii-ly Iii-c-veri@-iv.-, activi'U-ies 'L-"riat ai-e in IISI.'ii'll'k LiijfJ,,2r CDC.1cL-,,,Ic,.i-sliip, ii,,cl sei)ai,@iti(,!l ol' Ff)A. calls c i, c i, f" - c; I 1) i-e v ti t i v a, c'-' s 'Li I fi their @Ll)-l-tiOnS frcrf,-i tfiose e Livit-ies, to C) c e s f) i- c s o!.i c;@ s p 1, C- eT@for-ts I L I c i--i a. ri @i tile o-f or @,,o@d L to iiii'ec-tious or uiic.afe or coti,-@i'Lliciis that F,,,ay have a care nor slio@ild -@li,--y ov(?I-Ial,) (I 4 to ii,;,-rove of (es to I)i ces D -I I' tl,.-I c I'l t s L by State 11,3al a P, 1.1-itl.,,ouL c, clc-,.c -,:,,i-ca'ioii o' OLit for I-',-ay tii Is II, t . I L i e@ L I cei-e service-,. 'Le I S L I 'C'--, S 0 0 1 PI acei in the 'L-.!-,,-se b,, c i -'L-, actio,-is co,,-,sis'Lc -i t ,,-i jLli -vice tli e ii o@-i F @l I o I e i n I,,2 zi I jLli i..-iiicli s:,- i (lel-ivev-y t i- -i i,i i I- r) (I 1- O!@l -,L i ' 'C (I I I I'.' g c-iiii@ll-iasis oil as t!ie Li I I- C@ I- 0 C' 0 II- and tl', 0 L! 1-1 C -'L-, "I 0 1I i ii 't- 'Lion 4111 jL-I-i,@ recoi;:iii,--iided -irive--areii%--y l,pi)rc)@icii rcsoi,,)-ce@, services, S Tli@re z@i"c Of pl-0 4 C.Ct Statistic,al to ard ser%!icc, del-i,,e)-@, and to ,-!.SA. I!-,is aci-,ieve a c o ,I I- collr>olic'a-'-ioi-i of -@Llie services and -ind tlic, i-,Lccssary conversion to o-L@ii,,,- financing mecliai@ii si;-is along activities in than ricl-! It %,,,ould !-,,ol ic@; for -@Licii 1),,,OgrE:;-iis. In odd4i'L-, -'Ioii, tl,,e expertise @,-,C)Llld facili'L. itIC:]L!SiOl. 0-1: Co,,,e-,,acle for Iie-cilth services in 'Llic p,(-ogi-ai:is. Urid-et- -LI,, i s 4 4 4 would Lie moved to the 'rile 2,1@oliol aiic?l di-L@,g ob,,ise sc@i,vice ic-Livities, require lcg@lslEi-,L-.icii @Llb be sc@P,7-,rateci -i'7rori Si tice feasibili'Qi of consicic-i-c@4L-ion., 4,-.Il,-- sc-pe,-t-atio!i o-F alcol,,oi d-,,-,,;g s .2 services fi-oi-,,i not -Tjiis decision Se,-ViCe aCtiV4 i@S -e'-ciitic)i-i of cit le;,st science implies the i Witllifi i-iill a research pi-ograr,,I. At tfie is iilei,-it to placi@',-,! -Ill^irial-y L- 0 11@ Lt L eltll)IIE@SiS I)Y 01-C -.t I-L, -e role 0.1' .is a I-csc,,I-Cii-ol,ieiitccl or@i II i i-.@i @Lli Oil ic,ivii-,i--, 1-n vic)ttld result in ci o -,r disruption ,.titliin SSi@ , 1, I Of C :,.i. @'li tj t I Sion ol s c@ tlic,, future co;il 'I )-vice a rid e r ,s Gi veii these cc)i,,sicleratioiis, i-L is be retained is a free-stot@,,,rJing Insti'L-.L!tC and be p"l@(-ed ,,,eii ii,,ore a CO wi ti IIH. P Tile-,nt of '!!!@ll in 11,1111 I @',cs i t inlt,)Ol,taiit to give attention to resolutioti.0-ic tile issues coricci-iiii-ig i-el,-A@-ioiisliips the se-l,vicc, cl-2livel,@, par-iculzirl aspects of NIII progra,,iis L those i i-i '-fie l@atioi,.@,l Cancer Itistit@l@Lc End 'LI-,-, i@',@ttioral a@--iul LL,'YI!L! institute and -L-lic proposed Health Services ResOL, i'CCS o rc ..,s He?.Itli Sci-vicn @-eli,iery of Pi q i@@ -f s Li en b@-sic bi ci@.c-di cal i-esear,c' n s i-@ - Thc,, acc t,.,: -2 tioti, and direct dc@livei-,f are co,,,.i,,)Ie,<. I ii t I,, specific ai-c@a of de: 'I'V I CC r,,@o s ,,l,onstrati,@,@i and direct @-live,,y ok S C. --S ,L L obvio!is area of concern is o@@ con',-rot in ti,.,-! ','a'Llio.-icil C'--iicer IIIS@L-li-!'.Ll'tp- and tl,,,@ 'L, i c.,,i,.-, I He(ir4' and LL!I-i@l, 'institute. It I,,,as )lot possible ill t!14.,j C--,Lf@,@dy give full r to clo-')7ii-iing I)t).,-iatc, -I-C.!, 0. @Li -,,rise) ia ITT! patterns bet@,:,-@@ii health set-vice (le'livil---t-@., and L)ic,',i rll,,i :Ical arch. Control programs and other li @al @Llh service rese acti vi ti es of vii tli thci r categori cal focus zi@L, e;;-, p t to bridge from research to services through tile es'Labl i sii,-i@n-n@. of disease-oriei-ited syste,-is ol- health I t ,.,,as tile general -assL,,@,,i,,)tion o' this study these services ri,,, s + in the long run, be tied to health @.!hi I e no recon-@-ilendatibn is being iflade for oi-ganiza@Llioii,:,l -changes -L-o address the relationship of-service delivery and research the area requires further study and resolution. prog -Legislative, pi-ograi.-,,-natic, and pi-ac@.a@Llic concerns should be in corpo,-,--ted into an analysis of alternative steps the Assistant Secretary for llc@ilth could tall,,., to clarify these relationships. Ti-@ese coiisiclc-,ratioi,,s have on the H---A service delivery program policy and ir,,,pleir,.eiitatict-1, 0 11 S i rc-s decentralization actions, regional office progi p and the futj're role of research programs. Lpl i ed H,2p-lth Peseprch 11 i s During the study, it @.ias evident that applied i-eseei-c, being carried out in virtual .ly every @i'E',,! health agency. Applied research both biomedical and health -services research is needed to develop rieails of -'ii-.-,.pi-c,@4ing the health @et-vice delivery s@,steni and preventive health se,-vices and to provide a Sound scientific basis for regulatory action Th initially the responsibility o f '! T.,@ , 0 by FDA. is research @-ias c i L -esc but has gro,,.,,n ul) else,,,,,iierc@ la)-gely. because the "Ili i r c h has be lisive to olier pt-ogr@,rl needs. en unrespo Environl,.iental health is probably the r,,Io s t diffuse area of applied research. ',!i thin enviroti;iiental health research is carried out -ir, by the f,ationa'i Cancer Institute, the National IIISti'L- L,t C for Eiiv'roniiiental Ileal'Llli Sciences, the radiational Institute of Child 'iiealth ei-id Human Developr7,ent; in FDA i L' the tlcitioiial Center for Toxicological Research; and in 1-isil-lil,j.A @%/ BCE,"I, t!IOS'i'!5 and CDC. The primary need for this research is as a scientific basis for FDA's regulatory decisions, yet Piost of the research Lli@tti that aL i,@CTR is not influenced appreciably by FD,"@'s needs. In addition, the applied research problem includes touch research that falls into the "gap" be'L,%-,,een t\'IH and This research @-iould be useful both to the financing ,nd delivery of health se,-vices and to th-- de,/eloprilen@L- o I' -health resources, but @ilif considers i-L.-too service-ot@ technology-orieiited and liS,'@',Hf@ considers it too bio-,,Iedical- oriented. This research could be i,-,,,de i-iiore res .ponsive to the program, needs either by placing it organizationally i It,- 11 i 1-: the -pi,ogripi that I-IOLild use 'the research results, or by establish a iiiecliiiiis:,l for the progi-a,-,,, that needs ttie results of the re@.ep.1- to -i nf I LI,-IlCe the priorities for and the Plays the research is li3 It was i-ccognizc@d@'liat neither of the,t,,,,,o possible sol titi L oils to the appl i ed research pf-obl eiii ,,,ias liapreni tig in HS,,'.'I[!P@. , It @i-ias also recognized that the solution to the environ,-,,,olita.1 heal4L-I;i research pi-oblei,,i probably did not lie in since the. problem concerned primarily FDA and Illq. To cittei,i,,,)t to address that problem through an applied health research organization in HS,?.IFIA i-iould tend to complicate rather than siiii,-,)Iify it. l@,lhile the problem req@iii-es early attention, it was considered more appropriate for StLidy and resolution outside the context of this StL;dy. searcn p IIH, the In general, the applied re roblem arises because t, agency those primary mission is research, has o-ici@-en been unresponsive to other programs needs for this research. The solution lies either in devising %-Jays to make this research responsive while leaving it in its present research setting or to place the research activities in the respective prog)--,Pl settin(is @,-,ihere it can be responsive. The former alternative appeared more attractive because the direction @,i,,cl se-L t'i tig of research priorities, including )polied research, is considered an appropriate aiid a necessary acjt-livi@1-y for ,'Resistant., S c- -L-ai@y for Health. -ALT[I S't!Cl@l-D BE TI!,- I-Cp HE!@t-T.", 5. TIIE REGIO CF17T'C, T,' I ff -ly .-Cf II i. The major future resl)o:isibli'tics o l@ the regional o'i'ficc-_, (PO) health staff @,iill be to help z).(I!- ' ister and P,.onitoi- national iii n health insurance activities, provide surveillance of the health delivery system, and assist in resource de%,elopr,;nlnt and public health activities at the State and local level. Tl'ie overall mission includes the following major functions. Standards Com This %qill be a niajoi- activity in tfie administration of f,'Icdicare and I,'iedicaid and in future national health insurance and revenue sliai-4,ng pi-ograi,.,,s. Standard setting and compliance activities relating to health pi- ovidei- participation influences the mci nner in %,i!iicii those se-,,,vices are organized and delivered. 'Fliis function ii,.ust be conducted in cl,o se cooperation Keith the designated State and local agencies. Surveillance. Regional Offices @-iill play an ir,-iportaiiL-1 role in. the health intelligence net,..!oi-',,,. Infoi-i,-atio-.i on health care needs, co,,i,@itions, and program effectiveness must be gathered and analyzed on a State and regional basis to monitor ni,ogi-ai-,s and problc,-ts; to predict 4L-.i-ends; to assess resource utilization and to provide the b,,sis for developing strategies for change i health fii-i@i,,icing aii,,l i-esoi,-rce programs. Resource Develon@eiit. As an oujL-gro,,@itli of surveillance and. s s end r)t@ovilcle support to States'(ind co a.i-)d d e,,io n s tr z). t i o ii dge Died "C-11 devel@')P- altii services 0 for It of research. in science and as a. i,esu d Li 7 C capacities Technical clssistall'@e activ".-'Os s@loul five central availa@le witi-lill the RO's-, ti-iili the sr alized and elsc@,,;',-ici-e in the Depztrt@,-;-2nt, as %,,,ell as in othe .,,eci resources throughout the nation. Technical assistan-@e'l,esoui,ces I-opi-i ate.. SuPPOI-t O@ this Trust be c-111-1@.liced aiif exp@in--d as IPP U- tYI)e vii I -1 need to be pIi,ovided to co:,,,,@liunity groups and agencies, as 'vicll as ".iealth institutions and c,-icficizil agencies. Preventive iind PLi!)lic ll,,@,:ilth Activities. The Depai-ti,,ient's- ciall c o', c c- c- -d health activities have t)-adi'Lionc-Ally been espe i vtith helping the d-@vclor,@,,,,cnt of State anJ local public liaal'Lh ie through the PO's, al@L-hou-h services. This focus should colitiii,, Lil(@ b' develo@)ed in a cciitex, of concern for a to'--l it stio 0 t health strateay. Effective assistance in this at-ea will i-,2qu-ire ition of pi-ev-ii'-iv,, health activities 'L,iat sh,,-,,il-d a. clezir,--.i- Ct--fi ii L be focused On Pi-oblenis of disease Coi@Li,ol through epide,,Iiology and i ril,i,.IL4, 11 i z,@i Jk,, i o n Given the s-@uat@d nlissio!,-] of- the regional health staff and the related L f LI n C t i o n s I'C C O@,,!.l i@,,J ai o n s on t r,,,, [I 0s a r e Tile Regional 1.1e.al',-,Il Llii-ec'Lloi, (U!D).'.@liould be 'the principal health) official in the PO. This role should include a ii ng n,, -il)assing program leadership, Plan' broad Mandate c irpplepi,,iita'-iori an'! direction Of-' O'@in rc I'l 0 "Is V It also should i IlCl Lide areld'L-lionship i-ii tli the Pegi,Dtial Director as principal health advisor, iiialirg unnecessary the position of Associate Regional Director for Heal',-h. The 'i?.!iD should be responsible for all health progi-an,.s -iii his region. The RHD's should report to the Assistant Secretary for Health thl'O LI g 11 the Deputy Pss'is'Latit Soci-e'Lai@y for Prograni Operations. The capacity of RO staff to provide technical assistance should bc increased as appropriate. Grant decentralization slioLil.d be cor,.t,)Ieted pi,oi-i-.,'ptly. The RIID should develop'meclianisi,-,s for the full integration of the efforts of the regional health staff such as consolidated vior,, plans; consolidated operating budget for salaries and expenses; and flexitility in Litilizcitioii of personnel. IV. tiE):T S'FEPS factors need to be consicloi-cl,l c@'trefLIll" i n the dc\,elolj;,-,,ent of in strategy. is -Irescritly a1-.igh degree of ii-.or,,,entLir,, associated the leadership in i-,,Iiicli could bC,' SLli)i)O@"L-i\,e of i-eoi,gani-,a'L-,i on. Nevi zigency lieicls %@.,i I 1be designated in the near fLItU'f-0 .Reorganization activities should begin as soon as possible to avoid territorial disputes that riay develo-p- i,ii t[i del a,led action . The o@erall impact of the lie,,-/ health leadership to cf-['c@ct the proposed organizational changes will diminish prolonged delay. Tile CLtrrent uncertainty and restlessness thaL-. permeates HS,?.@',Illi,@ cloi-,,,,inds in',@i-@ediate action and 77 -i-otig leadership. st The abolishment of and creation of tl-.,o nei@i'age'ncies (Stealth Services Administration and 1-1caltli Resources Adiiiiiistratioii) co,,,-Id L,., done in@Lc2)@@nally uricle-i- the direction of an acting Acii,,iinistra'L-ot- of @,I)p@arance of this il@proacil, lio,,,,,--ver,. Could viell be construed p ion of carrying i-ocrastiiiation, @@ii tli no intent Cl 4-0 Oli Ltile Tile nee avoid I)i-oloiiged organizational chaos i,:ould arg,,je strongly for -,n iniiiediate br@!a'r,, of HS"li@r,% into @RA and II.SA, %.,,ijL-ii each agency reporting directly to Oi@S@l. iiice all o-' tile reccniiiiiended actions can be c.,ffected 'S within the authority of the Secretat@y, conCLiri@etice in the overall concept at that level will be SLifficient to begin iripleii,.etitatioti under the leadership and d -,tion o L-lant Secr ire f the Assis' etai-y for Healti-i. . 'file development and approval of a co,,Iple-Le ot,.gpnizatiolic-zl pl an containing detailed mission and function s'L-late;,,6-nts for all units is a tii,.il--consuming process. Effective reorganization will be seriously jeopardized if this process Must be completed before implei-nen@Latioii begins. . lininediate ii,,,,,r)lenientation will require iiianageTi,,--nt flcxibilit,,, for mat,,ing operating decisions ;,iitiiin the overall of the reco:@.1,@'i,,cnd,--d plan. DLtails of tile organizational strL,CtL,'i@e can be developed is ii-iiplementotion proceeds. Considei--iiig these factors, it is recorpmeiided that iniplc,;iiiitatio,.i proceed under the- leadership of a rianag.@;i,.cii'L tearn asseri@;',)Ied by 'Ci tiie P@ssistarit rr--cretary for Ilealtii. -I'fic, 'L-ee@i, sl,.,)ijld iriCILi"e: -ion --etai,y foi- /\dFiinis' -a' Del)ut@, P,,sistant @'o, L L and I,', a n i 9 e; i,, @--, n t Depiil,-,%,, Pissistaiit foi- I.',ediccil and Deputy Assistant Secretary for Prograp.-i O',)oi-a'L. oils Adriiiiiistrcitor of 11,Si@ Adi-niiiisi'li-ator of li@'@A Directoi- of IIIH Director of CDC A nucleus of three or foui- managers that can direct dav-t@D-di,f activities areas of the reorg.iiii zciti on ipal issues regarding the rrial,,eu,@) of the There are t@@io priiic a4-i ri-iaiiagei,lent teani. The first, involves the integr LI on of DHI and IISA and tlieii- ulti.-,izite transfei- to @ISA. The responsibility for this Piergor could be cissigiicd to the P-,dmitiis-111-citor of HSA along i-iltli ttie realigni-@,,,,-tit of the service pi-or-.@i-am-s froni [iStill IA. Because of the r@,a,iiitLIde of both tasl,,s, the Assistant Seci-et,iry could elect to retain in his office the P),",I/!,',SA re-.i)oiisibilit,,, until stomach 'L-.iTic- as the details are finalized, thereby CIISLII-itig.aii o,i,derly intc!g,.@,,,U-ion of these programs into IISA. The second issue involves the agency 1-ic,@lles' direct l')ai-tici,,),-@ticil I I-CqLi I ,t2 LI close %.iorting relationsliii) ti,,,c-it might o@llo,,,,,.Iise occur ii ci-ive por@' to i,esp" L. each agency is left on its oil of tile i,eco,,,,i;iieiidatioiis. it is quite i i;, that the entire tea-rii be held accountable for the total reorganization. ta@,en to tile The follo,-Iirig steps should be reorganization: t Step I - Obtain Secrej-,iry and Undc@i- Secre tai-y concurrence pt. Vlitli this concurrence, in overall coii-le te aLi their JL-y and delega responsibility to th e Assistant Secretary for lic-a'l tli.. Step 2 Brief appropriate Congressional and ExeCLiti%,e Of f i ces. It is essential that these briefings be completed before details of the i-coi-ga ii i za ti oil becorie general lno,,-,,leJge. p Appoi ;iageTnent t-@ir Ste 3 ,it the n@a and develop an implementation strategy end plan. 4 Step 4 Transfer Nll,,'.1i to and ii,,itiaL-e further Study Of its internal oi-ganiZ,34- and intei--.relationsliirs. Step@5 Esta.blish CDC as an ageiic@,.;,,,nd transfer 'bCcl"l and ill"I'OSH. 51 - Establish t,,,,o tie,,,i agencies '!S!@) and Stop 6 abolish 'iSi"ii'-!A. Step 7 - Transfer fi-ci,@i to Step 8 - Establish Regional Office liaison st@,-f-ic under eputy Assistant Seci-e@z,@-y for Program tile D Operations and begin to iniplei,l,etit oL-her recoi,.i,,,,endcitioiis relating 'Lo the Regi(",]@il Offices. Step 9 On a prede@L-c i-:,,i i ii c d' date to be established by the Secretary, preferably not later than July 1-5 1973, t,-ansfc-i- BIll (SS,'%) and ','.S" (SILIS) to the direction 'Di@ the Assistant S,-c)@e'Lai@v 4 for I-lealth. '@-litliiii 90 deals of th@s action, the OASI-I and '-L-he ol' and @ilSA fill determine and i,-,,,I)leTei,t the t,,,ecessai-@, actions to integrate @Ippi-,,priaLe u,,i i b r, s a n cl establish their stafi@s in IISA. If implementation is Li-iidertaleii along th-@, @enei,al steps outlined above, the reo.-gani.-ation could reasonably be r 1, 1973. completed by OctoLe Time is of the essence and the deg@,-ee of in large measure depend upon the speed %,Hire!-, iii-@pleir:eiita'(-Iion call pi-occ!?,l in @n T i f, 7 front the Secretary is imperative. 52 D D U R S l'U D Y "S I 'L- , I , @ @ , PERSOii I T r"" f T 01 'I Z'@ T, P R 0 G,"\ PiS@-,"iD O' TT k)i and I,Ic@rital Acting Adiflinistrator: David J. Sencer' Deputy, Associate and Assista r,,,in-sl,,,ator and Frederic!,, L. Sto,,e, iiiterir.,,@ 11,@,T)utY Au i L to,, for Developi@---nt 'I,,Ig Act . peputy f,,@r-inistra@ 'Ice A. Associatc Adplillis@Li,,a t c) r Bever Progre,.rii Planning and Eval@i-,Itic)n John li. Kelso., Associate. Adi-ni ni stratoi- foi- l,i a n a gt 1,1. lohnson, Associate Ad,,miiistrato)' for Re-io:,Ial 01--i@.1ces David v 1L;n@ ca' Gerald [q. I',ui-JL-lz, Associate Ad5',inis@Li'atol' for Cci@l', 'Ons and Publ-ic Affairs Joan F. Bu!-,Iinel@, Assistant Aci,,,,iinistr@,tor for Legic-'iatill.,) Robert J. I-aur, DelDLity Administrator 'or Prevention and Coiisuriier Services Emery A. Johnson, Ac@Litig Det)-u@tly foi- Services Delivery Berti-,iin S. Bro,,.,,n, Deputy Ad.,iiiriisti-atoi- -for t@lp-ntal Program Directors arid Staff: David J. S--ncer, Center foi- Disease Coi-,'L-li,ol L,U L Marcus '@l. Key, National Inst-i'- -e foi- Ocoui)atioral Safety ari@, Robert E. Novick, Bureau of Com.-nunity f,larjorie A. Cos,,-a, National Cei,ter foi- r'c-tn,@ily PI-,Iln4ing Servt.--es Albert B. LauderbaLigh Arthur J. Lesser, @-laternal and Chil--',- Servic2 G.i-ace t,l. Angle and Ralp.h Pii-dee Paul, B. Bataldeii, COi-@,@,-iLiniti Pealth Sci-,,ricc ). - I I 53 Ei-,qery A. Servi-ce Ro!-@,-i-t E. Stroicher, Fectc--al Health Frograms Service il.oland D. ip-ici@ae [I. [-'.,-,Donald Sc-rvice Co,,-Ps 'I tj i) a 'I Y llot@lard G. 11, cxander Robert van tlatio,,,al Irl en t e rfor Health Services Research aid D,,velop@,,eiit Ii. Grz,,ning, Health Care Facilities Service Ruth E. Duniia!-,i Robert P. Jc,,rir,s, Health Planning Service John Capotii@Li, Jr. Harold I'argulies, Regional 't,ledica.1 Programs Service Gordon K. t,'i--cLeod, Ylealt'ri l,,ciintcnEincc@ Organization Service Bertram S. B-i-o,,.,,n, National Institute c)f !,iental Health James D. Isbister and jan,les D. Morris E. Cliafetz, National Itistill-ul--,-, on Alcohol Abuse and t"A'Icoliolis Kenneth L. Eaton and ic),'-jn f@. I-lilliam E. Bunney, Division of Narcotic Addiction and Drug Abuse Karst Bes'L-,c,:@,-@an Theodore D. ',-!c.,olsey, '@,lational Center or Health Statistics Ed,.@.,at-d B. Per-,-in Regional Hea't,, Directors: Gertrude T. ilLinter, Region I C. Robert Dean (Acti.ng), R;-n,,,,-ion 11 George C. G@.i-diiier, Region III Eddie J. Sessions (,@ctii-io) Region IV E. Frank Ellis, Region V ltolmaii E. RLgion VII L Abel G. Ossoi-io, Region VIII cl p David l@l. Johnson, Regi(.-,,,iv A Staff Office of the Associate Vevei-ka and Alv",@ Harvel, L Ad,-,iinistratoi, for Region. Offices -Inistratoi, E. Goldstone, Office -,f the Associate Ad,,ii L lot, P,-ogi-ain PI,-,.nning @,,alua'ioii 0 e I- c -i e sP, E og4 t,ioi-l,is r,,. crinr,,'E2r, Director, tlational'Center for Toxicol cal f",-@-s,--arch, Fooci and Drug Joseph P. Hile, Director, Executive Director of Regional Operations, FDA Ronald T. O@@es John F. Sheri-iiati, Acting Director, National Institutes of Health P,obert Berlii-,er, Thonias J. Kennedy, Leonard D. Fenninger. e.,,,d Leon Ecl,,,,-,!ai,tz -t, Direct Kenneth Il Endico4L or, Bureau of Health l,icitipo,,,ier Education, i',IIH Daniel F. '.','I)iteside and Charles H. Doe'Lltner Calvin B. Bald,..iin, Jr., Executive Officer, tlation,;il Cancer Insti@Lute@ @,IIH Jo,'-iii C. Ballar, III and John 14. Yai-I)i-o Tlieodore Cooper, Director,- Stational lleai-4L-. and Lung Instit-, Li 'Le [,I H I TnSti@U@e of --David P. Rall, Director, Eiivironme 4 L k,L ntal Stealth Services, illH -e of Envii-c,@-.-,2r Williai-i '.-I. Pa,,r).-., Deouty Dir---.ctor, Iiis'Litu4L Heal -L-h ServicC-S, 1'IIH, and Scientific Coordinator of Frederick, Cancer Research Center Commissi-,,,'.ei-, "'iedical Services .1ldmiiistra-tion, Social and Re@iabilita@Lioii Services -Tho,-ilas M. Tierney, Director, Bureau of I!caltli In@-Lit-ance, Social Security P.,,@..-.iinistratio,i Ir@.,.,in I-Ioli,-.tein -lnd .','.oi,i@is B. Levy Office of t,r -2 s i li L t, Richard L. Seggr-,l Deputy issis--ati@ Secretary for Progra,-@i Opei-atio 5 5 S',-Iociil-A,@7sistalit for Drug [\buse Prevention. Acting D-OPuty Assistant Secretary for Rupert F. Adniinistration and il@l-aiiageirlient office of the Secre-F-,rv, Bernard F. Felly, Office of the Under Secretary Eugene Rubel, Executive Secretariat (,Health) Peter B. Ylu-4Lt, Office of the General Counsel Keith Office of the Assistant Secretary for Planning and Evaluation Peter Fox, Office of the Assistant Secretary for Planning and Evaluation Thomas S. t,'icFee, Office of the Assistant Secretary for ttd@clirtisti-atioli ari(i ',ia,,iagc-i-,leiit Joh@,i Pinney, Office of the Assistant Seci@etary.fo,,- Pd@-iiinistratior, and f,ianagenient DrPARTiVENT OF HEALTH, EDUCATION, AND VJELFARE APPROVED: HS HEALTH SERVICES AND MENTAL HEALTli AI)V@INISTRATION DATE: APR O@, ICE O'i7 THE AD@,,', It\!!STRATCR DFPUTY ADTV,INISTRATOR AD.,@l NIST@,ATOR j. F@rc,lcri@k I-, St,,: 0, i,iteriiii Oi'F I CF S P'C-C fAL clrF ICE "liFr E @@c U- 0,7-;CE C,@-r EO-'@'A@ Pr\OjEC'[S E,, I V E S ',7 C ['\ L R 1 AT of, :Ioi@ I U t'i' !'IT D; @R E C T 0 R D I R E C T @) R D I P, E C T 0 R Lon:s C. f3AOIO7) t'\SST. ADPi-@iN!ST,@A- ASSOC. AP,',l I N I S - F"!-' I G-'\ F ('R Tf',A I Oil F t@, @t F IFGISLATIO,4 RE") 1 ri@@A L OFF. Lr@@iEl IT 'IC 'I E V L U A T I r 1)3,id W. I(,Il!llun C;cruld N. lt,rtz (3AI7) (3A35) (3A37) I S 1.@l @Ty !.IT Y 1 i'@ I S I s - REGIONAL HEALTH DI@,.-;'.TO'@S A, n L71 H I t@O.S ION. Nl:%Ss. Ger-,rtik!@ 1: z S TA @'ST is.-RV'. 'D'ELIVFI@Y '@r'%V N.Y. i: V I C E S interim illl:!,Al)ll 1.1'! !IA, PA. IDIRECTO@ l'iitvry A, Acttyi, l@ertrat@i S. Ilrown IV @'I I..,@N 1',\, (;A. V ('Ill('At;O. II-L. V: 1),\I,!;%S.'IL.XAS wall t VI( K @k N S,\ S C': F 0. llotlii.iti I" V;ll I V I! I\, @'O L. o. Alcl(;.(@ c I:; ('O, CA L t!;i !X !@,!ST. L -II,, fo Si, V. DEV. 1:@!@ C r 0 D I l@@ E -Z T 0 R O'@ D 1 R E C r O!, A-@ L A @i H CA t' 'I: '@,@.TL ir'ST. T L. I i'@@ S T. i C 1 L 1 T I @- S ALCii'OL F C-'@-! .1 A - -:i D H--A',-T H S' S 1 S F E - V. A@IUSE D I R E C T 0 P DInEC-1 -Di RE CT C R D!.R@CTO@ L.@s.,cr L. Cltafetz r, r 0 3153) f 3 Cf)) (3NOO) C U,%' I T Y S I VE @!FPLL i@ L7i H S RV. iTY DIRECTOR D I R I C 0 R D I P. E C T 0 R (3QOO) (,@,,'A L :'@AL F-20- ALTI- SRV. -!'@A,'@'@S Sl@V. DlrECTOI@ D I R E C T 0 R 1-iiiery A. I 1 F. A I !i,lie@l li% p2rt of L, 9 1-6! 6. Ti-@."A@ICE 01@'G. !!@"ALT@i P[ZO- "')'@ZA@,,IS Si'ZV. s@@v. ,@fa I;!.,! i% t,ul I,I"t @ctit is DI ?. ECTO R c I R E C T 0 R I:. Streic@ier K. Nl@,cLec@l @3V(",)) AT L. 17 AL7!-l SRV. coi@I PS E C T 0 R .5 7 Appencii-Y C Ai'iALYSIS OF OPGAi@IIIZA'FIC.!I'PiL AL j'i'. i'@,-,AT IV ES Once the broad federal roles in fic,-Ith Caere do'incd, a c,,Tr,-on I)roblem thr@vuaho,,it the ri,.;-,jor issues as descried i,,,as ti,,C-it (the current oi@caniza@Lional st-t-uc@Llui-e ,,,,as inconsistent %,iith these roles and 'Lliei-efore inhibited them . Four oi-o,,ani- z,,.tional options ,,iere ci--@ielooed @@,,hich had as their core the 4- ..,.,need for an organizational based on an artic lived @ederal health mission. The partiCLI lar 'options i,,,ere developed to isolate iSSL12S and contrast -@-,,&ys ol@ addr-@ssina them organizationally. Th,@-,,, @,,,ere not as "eitlier-o)-l' proposals since tilei-c- are innumerable variations and cc:.Tib-ina-Lions possible. A i-evie,.,i oil the current activities of the varioLs heal@Llh corp.Qoneii@Ls of [iEt4 suggested @Lhat there %,iere three iraior I-,Ieali.-h program functions -- health services, prevention of health probl,2,.is, and development o' health resources. The oi-gani.-,-ational options I L were atteii-,p'L-s to "package" various groupings of these oi@ogra,@ii functions iti@-o -,7enci-- 1--h s c@ L c n t !,-, add, -@o@ , 'h@- options a prar-@i,a4L-ic concern for the imnact oil any organizational ch7-nce in oncoina o@@-rations terms of the need to minimize the negative asnects oil disrUDt4,cn and to ze the use of exisL@ing administrative capabilities. 1. DESCRIPTIOi@l OF ,-inq a ne%,i agency, a descriptive For each alternative cre,4, organizational ti@@'le, abl.-revia'Led Fission and Thes,@ fo,,ii- al'err@a'ives major functions ai-e-sho,,i,ii in chart -lorm, on the @oll@-iirig p,.ge. 0 I I I I.. . A C.; CDC s A oriii Gt% tr CDC- c CDC ;I D,i t.i P,I(oliol otir( t :DA T A 11 L I':-' I Al(()Iiol r, c, u D r it Fz,-% c)tj r i, ().I t-. C,i r I o t II): ITY OPTIC,,6.' cn CX) 16 L MSA D t,i ii (l,i r (I,, Al -it( C.,k r I t c 5 Option Center fc..r Dise@ise Control Mission: Prov'l,.'-- leadership for the prevention and coii.'@rol Li --ions. of cor,,-@,,uriicabil- disease a,-id o@i,-@r public -ieaith fuiict. li@a, i cL @@u Ce,.,elop means to pre%,,,.@nt and control co,,.r. r -1 c e d i s C., a s @-' ss t I i a L, e S 4L. C-1 Le F-, i,, d c c, iu n i @L-v action tiiroLi,@-i@i surveil iai-,ce t4otl o@ and educa-Ll'on; pro,,,ic!e technical assistance and de;roiistra 1 1 effective tech@,iiq@ic-s for control of co;,,,,.,,,,unicable diseL)ses; enforce -,,la grant forei@.@n quaran+Uii@@- reat.ila'Lioi-,s; alcol,,c)lisi7,, an programs Tor d d T.-,en'-,al fieL,, I ii servic-,2s, and and heal:'Lh; @-ni! develcr, standards to assure safe and @icai-Llhl@ul i-ioi-Itii-ig enviroi,,;-,@l-nt. e ii'L- or@,aniZ L Curr a@ioiial elem-nnts include the Center for Diseaso OCCUN . at4 Control, the l,la-uionai Ins@Gitut-- -,For. Tonal Sai@ei',y and Heall-Iii, and all formula grant programs. 4 Health Rcsources Ind,-,.Inisi'li@ation Mission: Prepare exis-L-'i,ng fed,--i-ally-assis-@-n-d h e a I -L-Iii services manpo,.-,,,-r proarans for financing through national health insurance or other appropriate sources. Major Functions,: Provide and technical issis'L-lance to existing 'i-iea-itli'service prograri-I for rfie,,tiig financing progr:-,ri I standares- for .t, continue to provide or arrange ,Cor health services to sDn-cific l@ederal beneficiaries ,..,iii'le facili'Lla@Ling conversion of -L-hc-sn- activities -f"-o support, through fitiancira programs; provide s+"L!den.+. and ins'--i-L,,jzi.enol assistance for the education of sp@r4a ! pi-c,'-Ic-ms @-,Iiicfi are not L L) effectively covered un,lier ceiiet-al educational SLIPPOI-'L. @MeCh3niSiIS. a.nd Support demonstrations desigti-2d to i,,i,r,)i,o,,,e the future pro- duction and utilization of he,-!'Ln services ri-,anpo,,.ier. HRfk includes all demonstration, service, and training pi-o4-ct J- grant programs e,@'clusive of those in CDr-; direct care i)rogra!-,Is; ;-i-2 Bureau 01@ @ducotic'n e;,,c-]L@si've of i-es,2circ.@ and !@.n-,c,,,,er ;,,-ont activities. intelligence activities; and the i@ursiiig Iiiiprove,,, Health I 11 S Lirance Adi-,'Lirtistr@tioi-,' Y T Y Mission: AdminiS@Lel' Dresent Title XVIII and Title c c a i d progr,-it-,,.s, i nt-I udi ng devel oprent, iri@l e@ilen'Ll@iti on and of enfoi,cc,-,P-nt standards.' policies -1-r-d i in f i ii;ip'i 1 I" I O.'l 31 ri c- i t @l i 11 S LI on LI for monitoring, evaluating, and testing ne@,@ approaches relating to health insurance proot-ans. @GO I'li--.,! fT -r@@ions: A@iniinister Titl- XVIII and XIX pro-raii,,c" @-,-"ir'-a-i-ds and certify for in fiti,-In-iiig procii-a-,,s; t:,,onitor -lnd ad-c@Li,,@cy of standards; v z-, I u c)-,@-L-rall of stan-@ -ds and financing for Doli,cy i c aDDropri,.'L-,@.-,,-.-@s of cc-ire received in of c o s q,@,alitv and develop and I",,s@Ll ii ' EnDro@chn-s th 4 to i il,,) r o,., c-2 1 i e a I L"ii -1 nsut-anc,@. i ricl udi ng @ I i n,, d -, 1 i v e ry s y sr-I s , a n dI,,ea I th collect data on hem-'Itii Status 1-tc-alti resources; analyze data Policy i services i,-Iiplica.-L@-joi-Is and dissc-,-,,iiiate irl'ol-.-;,.a@Lion to appropriate a c@t'i on agencies. aCt4Vi -the health fitiancitin arid related support ties 4,D, -i and t in the S,,.c-ia'] Security Soc-'icl a,-,@ lehab-'Ii- tation '-z--rvice; activities in medical care s@LI-Clrir,'ia,,-,-4s, research and development, comprehensive liecilth planning, and health I I ,"E; and the statistics; research and r,,,anpo!,:et@ intelligence from fessibiial Standards Revievi Organization from O,"ASH. Pro L Center for Disease Control Mission: Provide national leadership for the prevention and control of o@.,,,,,runicable diseases. or FLn Li?ns: DeielOD means to prevent and control co,-,@,unicable diseases; stimulate S ,-, a 'L, e a n d c o m n i 'Lly action through su-cveillance and educa4L-.ioti-, provide @L,,-,r-linical assistance and de,-;.oristi-.,,tion oT hniQ!je@- for cont!,o'! dis--ases: @nToi,ce effective tec foreign quarantine regulations; and develop standards to C-Is@-ure a safe and healthful ,.,-orking environment. The CDC includes the present Center f'or Disease Control and the 1-4ational Ins'(-Iitu@Le for Oc-cupa@Llional Safety and Health. @lation,@l Inst4,1--,-@-@ of ",-2alth 14i ssi on: Provide national leadership in the field of r..iental T-fO L health, including iii'etisi,,e e r@s director a+,- such -Irobl,-:-,-,s as alcoholism and drug abuse. Maior FLinc tioris: Conduct and SLIr'pOi-t rese arch, training, and -cogi-aNis i -is of general -2n@al he cow.,Punity p n t@ic are, 31 tii 'drug 0 4 n't, c 1 s T-2r c L I dis other rental health plot) I serve as principal focus izot- behavioral' science activities and 'or cultural and social problems relaL-ed to P,,eii'L-al health. The includes the cui,r,2nt activities excep t for St. E I ia L,, s 11 -o s p i 'L, Bene 14ission: Provide or arrange foi, health care for Fpderal beneficiary "ations. popul e 14ajor Fuiicticns: '.I .3 K-ii,rar,,nerents Itoi, oi, Drovide health services facilitate -he convei-sio,,i of Pc,@FFied TC-C! L -beneficiary c@-re prcor-@,,-,is to -,,lnancit,g thi@ough national health insurance or o-@L@i-,i- ri-Lchanisr!,s. BCA includes tire Indian Health Service, Federal Health Prograins Service, and SI-.. IL:-Iizabc-ths @!ospi'Lal [real th Standards and Resoui@ces Ad-7,.iiiiistretio,,i End 41',lDlc- enta-io,,i oil health 14ission: Facili-L, a 'L- ed e v e-2 n t s throuch setting and oi@ standards insurance pi-ogl-z,,,.l LI 4 r,v-illance of health for par-@icil,la-t-lion in il'.SL,,rancc- programs; su- status and system resources; and preparii-ig e\,is@Llitio l@ceierally- assisted health services and manDO.-!--I- prooi-a,-,,s for financing 'i na throijgt ,ti ori;41 health iiizurance o@- oi-her appropriate so,,jrcl-s. Ilialor Functions: Develop standards and certify providers foi- participation in Financing progra!7.is; it-,oni@Lor compliance and adequacy of standards; revic,,ii of care received tei,pis of cost, quality and el@1'ec4@-iveiiess in ; evaluate over-all irilpact of standards and fiii--iicirg l'oi- pr,,iicy develop and test ne,@i approaches to iii@ldi-ove the insur@,ice Dro-rai-.is, including l'i ii 7-;ncirig, delivery SYS@Lc-ir@s, and health collect nd I-,calk'h services resources; atlaIV7e da-a data on health status a L for policy imolica'Llions and disse7.inE:,@e 11ITor.,.-,c,.@Lion L-o appi-oori,-.te 'de i i'@e to action agenc4ies; --,i--.vi and technical ess-ista!, existirg heal@L.,@i service proQ,,,a,@:,is ioi, r,,,Leting 4in-ai,,,,-inq pror-r@l.-I standards for rei.-..b@irsel-.,-,-nn'L; provide st@dent and institutional assistance for @uiie educaz4iCtl OT -cc) special pi-o-blei-.s -iu-ional which are not effectively covc)@@-d u,,.,er general edjc@ support an.d support de;-,-,onstra-L-,ic,,is desi"ncd to improve the future production and utilization of health services -,,.@,npo,,,,er. The PSPA includes the Bureau of @!eal4.--,h ,!..nnp-.l,.ier Education; demonstration, service anci training projec@L and for,-,,uia programs exclusive of those in and. CDC; riedical care Statistics standards @i-2al@Lli planning and health L. i activities; li,,d the Professional Sta!,,cl--,,-ds Revic-%.i Orcaiiizal@-ion -,nd fl?ljrsin- Option 3 -i,@ti on rice pcl-,Iinist Disease c@, caL-@aci tY tf,.e health and health delivl, et urgent co--mui-.icable and provide assi@, to me disease and nanpo'vlcll- shortage pro@-lei-is. --hc-rina, monitoring or epi- 1-11-ior ns: Conduct data cEi, surveillance of ho.al-'L,.h status and of health delivery to appropriate action aqa ' resources; co-,,riutiicate findings -ncies; c;a'L-la or poi-icv e diseases through s-@:I;;,.Lila4,-ing or selective federal providn health pei,scrr,,21 to I - L critical shortage areas; and develop standards to,assui-e safe and healthful @,.,orking eiivironF,-ien'Ll. CDSA includes the components of Center foi- Disease Control l 4- il (exclusive of S,-,,O'.i@-.g and Hea L ), National Center for I-.'ealtli Statistics, ila4L-.io-ial Institute for Occupational Safety and 11'eal@Li'l, di-id 'rileali--h Service Coi-ps; atid the intelligence activities ro,-,i Substance P.,buse Ad,-,iiiiistration Mission: Provide assistance for the prevention and control of ubsta@ce abuse. Maior FLJ,n@tions: Develop the means to prevent, control and treat at)usc- oi- substances SLICII ZiS alcohol, di-L,,-,s, and tobacco; provide training surpoi-t 'or lic@alth @-.,orl,,Icrs in SL]bs-L@aiic-,- --)@"Use; assi clt States and co-,,@@i,.L:ni '-Li es i q de--, I i rg -L-h @t.hp-se ,)-cobl =-F.S throue,li publ 1 c, ea@,,lcc-t@Li On, '-Llec@,iii c-, I assi stance and cii-an@L. assistance to provide foi, treatment, rehabilitation and other coinidunity action programs. The SPA includes the national 'Institute foi- Alcohol PbLIse, the Di@ug. Abuse Pi-ogra,,.q, and S,-,lol,-,irig and Hc.@@ilt@n activities. Health Stati@,11,,rds 7i-d 'Resourc@s rl%clininistraticn Mission ,rid in,,,)le--,-.entation o-7 health Facilitate develop@,iieiit insurance pi-ccrar,,,s and of SI- for participation in insurance rpi-og,,-aris; aici preserving -existing --ed 1;7--a i. -- - -@-,r pi-og, federall,y-'assis .11@-h services and i,,anDo,., "aii',S tor financii,,g through national health insurance. -or otner al)or,opriate sources. e 11 r F Lj,-i i o I,. s Develop stanil,i-ds and c t, l@Y rrovidl,s s i,cr ii in -or cc,-,-, p a received adequacy of standards-, revirl,@-i aDt-)I-Cloria@Llenr-@s@, of care in terms o-f cost, qualit-ly, and ei@i@-nctiveiess; c,,ialuate overall ar,i 4-4 impact of standards liatic4,lr, joy- i,)Olic," -i 1-,l,) I i c ci t -:i ci s develop aiid iie-,,@i at,)@,-)roacfies to iii-:,i)i-ove ti,,c@ @iealth insurance k; programs, including financing, delivery sys-L-,c2@,-,s, and tiealt'll provide and eclinical assistance existinn health service pro@@r@,r,-,s for r,-.-netinQ fiiia.,,,ic@iig stand-.i-@is -[For -icr-ial assistance reiribursei:nrit; provide sudent and institL]' L L for the education of ril,",nnol.,.ler to special problems that are hot effectively covered under general, educational support rtieciianisr-,,s; support cle-,,,c@istr2,tions desicned (@,,) -ir-,i@rove future ,,-odiction and utilization of@ services and con'Li r,!Ii L, to provide or arraiine for services -Lo specific beneficiaries wiiile.facili'L-.ating conversion of these activities to support through financing programs. The @ISP,4 includes the Bureau of t,lanp@,,,,er Education excluding Lio@i, serve ir.,,,npo!.,.ter intelligence all HS, I'a ce, and training pi-o4ec@L. and i'Or;,l,,,ila aran+-s exclusive of those related to cohol, druo abuse, an h al d CDC: (I-;Ire,-L. -ene@ici,-,-v care pi,ec-r-ams iiicltidina St. ill !r,@dical care standards, co,-,.oi-e plarinirr-!, and research and devel opii,,eiit; and Prol@essional St@-n,@,arG's Revie"i Organization and l@@lursing lioTie Affairs activities.-I-rarii OT@SH. 4 1 Health Protection f\ e. i n 41 s t i o ii Mission: Provide national leadc,;rs!iip for p@,otec+.ion 'rom public health hazards. on. s D@-veloo l'-@lie to preve@,it, control, and treat diseases and other health p,-obie:,,,.s that pose P- threat i-,o public health through in@e--@L-.i, on or safety h-,,-7 ar-'@, zijch as co!-@--,., il"cable U- - I;;"l I s-o',in,). and --,iisai@e ,.--i-king diseases, -llcor,@olis,:,., dr,,ic, abuse, e n v i r o n ii t s @L, i' i,:. i I ----te and cc@:-!,@,-,;un-i e, t i o n +" o d --- a l@Ve4 'I I ar,,r.e with these Pi-obl-2i;-;s SLI I c a a i- i-, - s s a n d t, ti edur-ation; and direct lateral action +.a provid,-- technical assistance S4 and de.-,@on t-Ira-Le effective techniques. HPA iticlullc,,s the Ceiit@er for 'Disease Cont,@ol , e.Ico,',,ol drug abuse activities, and the national iris'Litu'ue'l'or Occupational Safety and Stealth. -ces Ad,,qii iii str@iti on Health Pesotii s s o II: P,["-;)are -C ougli n@i'L-i.,)n,,l health'. insurance a n c i ri g other ii.,,,,;)Y,opriate so,@j-,,ces. or I.i,a@ior FLiricti,,)!@s: and @Llcc-.,',t,.ical assistance to 0 r ri,,eeti i r_, xi s @, i II(@ 11 se r,i, I +0 oil for standards l@oi Coll @ PI" i -I c f;ilci heal th sei-v i ces L-o l@i c fec!r-@i-@t-I i-)enc@f-iciei,ir-@s ,-I' r -i t4 C f-")-', .1 O_c t,[,. r_ , , r I..alicl lig ,2 aCliV S @o L ing convei-sio I ;__, L i _ - - pilogila,,,is,; !)rlvidr-- s4-: and as,:,isl-ance c. r e I v L, ..@, -1 L. I k. L education a-l@ to i,-,eet DI-051@.;-s @.lhici-i ai-e not ectively covered Liricier geiioi-E,,l -d'Llcational suDnoi,t P,,-,z-ciianis,-,,,s; eff I . t, and support cic,,-,,onsti-@j-ion-s desici@,tcd to the fLI'Li.ii-e production and u4 II services i-,cinpo,,.,,or. The HRA includes HS!',!!',,"@ dr-ir,-,ons'Llra IL- i on serv i ce , and tra i air r,- pro -c@ct and forif,,Lilci grant pro.-jr-.-,;.-,s excILISiVe of alcoi,,c)i , drLIO, aL-,use and care pror,,;i-C-ir.,,s iICILICI CDC; direc St. lliy@beths -sP-i JL-.E. I ; the rese- ii c, Bureau of Educ@,-Lic@-i exclusive,, ol :ii-c! and manpoviet, and the l,Lir--,ing 'none iiipi@ovei,reii'L-, activities. I-lealth StanrJLi@@-Is [4ission: Provide oi-ol'essional ii,-,alth gui@,--iiice for a-l@;,,iiiis'Li-ation t T;-'-I.@ YIN' Ff fi-rarici@ig prog,-a.-,,s; edniiniste-i@ t.@,.-esen L, . - , , (. .-,I i -" I i Prograpi; facilitate doieloDT,-ent @,i-;ci of 11,@al+ll S@a4 insurance I)rOC,'I-aF',IS tfll-OL@qh survcill,-,t,,ce of ,-- L L-L@'S end sys'tl,-@@,;l resources; and -set and r,,@bnitor standards for pai@ticipa4L-lion in insurance programs. flalor F6nctions: Develoo standards and cei-til@y pro,iidoi-s for participation in fil,,@,li@Icing pi-ogi-;@i:,,s; adriiiiiistei- Ti@LIc- ",T-X r'rcr-.rp,i; -ID adCOLIaCy - 4L"Ile ove ,. 4-e monitoi CC,,, liance and of standards CV@-lL! r-a I I 'andar-s L u - d financing 'or ooiic,,i, ii,,-,plicatioi,,s; revie!.i impact of s a e received in terms of cost, and appropria'L-,.@-n,,2ss ot c i, effectiveness; develc,,-, and test a,,):)i-oacl,.es to the -,;!nce pi-o,- I L T I n c i .-, ii health ii)sLii @;:is , I iicl ,(,ii rf@l del I and hea.],L-1-i iilanpo,.,iei,; collect data on health status of disease and health services resoui-c-2s; aiiaIN2'c d-a-@ci for policy and dis-.u,,,iiiate infoi-iiia@Llion.'Lo cti)pt,opi-iate action agencies. IISA iticILicics the ,Predict Services support ac'L-.i,vi-L-.ies-iii 'L-,I',,e Sociil @,iici Re@abilit@t@Lion Sc-i-vice-. HS,@.i,i,4 medical COI-C@ s--and,:irds, Dlannirc,, L statistics, End research and devl-lo@,i,,,ent; :--,nd intelligence activities -irroni and the PS'@O active LIOS TI-CM OASli. TLTFi)'IirtTl@!ES. @@TIO@, I OF 2-. EVAI..U"' 'f lie a ItE.,rri atives k,iere e%i@ ItiD-Leci acl@'i r'st six cri tci-i,@ @@!iiich addressed ttic study finrlilIgS, as as tile P-,aCtiCal coiisidcl,atioils of a nc-@-i alirini,,,,ent. rfie ran,,,ist4irig progi-,iris inai iitai tied essentially in'L-.zic'L-1. b.. - Option 3 more effective T h c I I I,,'[ I a n d Bf 1) 1-0 9 I-aE'l S I','C) LI I d b e 's p 1 i t!,,i tii activities assi(ii-.,@rJ to sc,;)arcitc-@ agencic@s. Data C)! and di r,,! g ::-, Liu s e a!-, -a clo Sri activities i.,:oL,,Id li,,.v-. to be -,--laligtied fro;-,i their current organizations. c. Option 4 less effective This op'tion is identical -L-o option 3, in addition to which it would i-,-,q,,iire the transfer of from S!@S. d. Option I least effet'ive This s i e i t i,i o u 1 d i t r i t e t-. E. c i v o t t@,! c u r I- e I I --o sevel-c-il health s,-,)-vices and t. different to r o:,. i [))-Oi cc t g 1-Zl,@ S L.'PnO'("L' ii reSO L@ !'C(-, II d v@lould seDai-a-1--e delta (!-i4l'i 'S Lir,,lc. i r-,, iS Joel] ., , L r,,- r ,i g a I,. t-t I-- - . as healt'fi c-(-v-icc-s ac'L,4,,ti ties 'ro:il (jlr, :n III --@(!r i 1-icn grant ai,,-d c,,-)ntr--:,ct i @.,-ol id L require tlic, ti-atisfe-i- of' both arid bllil t,iL:lir current 1) i-,eilt 3. NEED F02 A COI@iBTiil':D -e As tli2 p) -,editor., z,,r;,-tlysis (,..de i,, e et s c@ P, n t c@ gs L . i L. inherent in each ol' the fo,,@i- options @-iiat ,-iei,e develop,-,d. I,!Iiile 'L-@-ie first option, fo,,- -ii,is'L-aiice, ai,,,),,2-@.rs prefei-6@,[)Ie accot-cli,,-,c., to r,,-.os6 (Di@ it i-l@-ould be the most disrLIPtive to iiiiple;-,,.ei-it. In addition, any of the optio@is contaiii-ii-ig a sep;,ii-a'L-.L, he@,ltli resot@-f-ces age!ic, a hpal'L-!,, inherent prob*l 'Fhey cc-t@ s i ;i) '@ 2 Po IIc@,/ t I-'-!! bet%,i.2c,ii the sei,vice resource ai,!"! "C) z; 1-Y develo:),-I-.,-ni-it activi '(-,-,es in o f a , -i I t c ti@,c of service delivery mecliciiiis,-.is other gran-Ls. i-,e hea'i resources place all curreii,6 resource aC-L-i@,!4, "-,ic-s s,,-.; teriiii ri(@.'L-.ion or cc:i,.ersi-u,,i to l@C).-i-,,S Of SUD@--;C)-t ii-I ;I,-i that ai-ti CLI] 1 o-, ri resioi-l,,i!)i 1 i i@-Y for health i-c-soui-cc-7. i@l 4L-.',, service (1--livc-r), c-ci v -I @.-i es e c c) cil act i v i e s a re s c @i:-% c- o there be a co,-i4--ii-,!.iing 1',,) r ac 'L) i 1 -1 t,v to rl status of h-,altii c;--,,,-e i-esoLji-cos in Li.S. in oi-r,'!@), 'Lo responsive p',)Iicies, incl LI-J 41 1 @LIIOSC- 1-C I -L '-I. i-ia'IC'i I s n;T-1 . L- Upon )-(,c!xciminii,sg tii@- I Flr)pr--"@t'l-,Ol @.esi,-LibIc! -'L-lo the street fea'L'L,",,"@-, of the to i@ Lil,-, role i-c-,spec'L, 'Lci L' O'- g -!!I I "a 'L@ .@t o 1'. a re c o!il@@@,L t i o,,i , tl 1 -,,D @l c resh@il)iii(i of O:,, I f oL,, r op-t@, oi!s as t.'-,,,?y 1,:c).re