I so B&B ImFoRmAkriom & lm^nr- M^m^mEmEmT 300 @oftoe lt=z-m ROULXVMM UfmfmCft IN4^99LMDItC, MA &40 Z077Z 0 USA * C301) 3949-01 1 0 I' A l@ M I," N I- 0 F If I-" A 1. EI)UCA'I'fON A N D W E L F A R E Health Services and Mental Health Administrati on Division of Regional Medical Programs National Advisory Council on Regional Medical Programs Minutes of the Meeting February 2-3, 1971 Parklawn Building Conference Room G/H 2 111. A.NNOUNCi-,@iriN i,) Dr. Margulies made@general announcements, and called attention to the statement, on, "Conflict of Interest," in the information folder. He reported that @li7. Curtis Treen has resigned from the Council and that we are workinc, on the appointment of new Council members to increase the @mcrnbe@ship to twenty, not including the Ex Officio. member from the Veterans Administration, in accordance with Public Lat,, 91-515. IV. CONFIRMATION OF F"4@'--- 'EETINC, DATES ; .@r .-@- v The Council r affirfned the following dates for future meetings: may@ II.-I.2. 19 71 November 9-10, 1971 August -i@4, 1971 February 8-9, 1.972 V. CONSII)ERATION!OF MI@N-UTES OF THE NOVEMBER 9-10. 1970, MEETING With the addition of Dr. Hunt to the list of Council members present, I i the Council unanimously recommended approval of the Minutes of the November'9-10@ 1970' meeting as written. Dr. Brennan, Cliai- -of a Council subcommittee on automated multi- phasic screening,;. @@mounced that the subcommittee had met the day before for six' hcur@ and that they are developing a working conference to be held in@April.1971. The meiibers of the subcommittee are: Dr. Michael J.1 Brennan, Chairman; Dr. Alexander M.:McPhedran, i In, and Dr. John E. Kralewski o,L' the Review Dr. Clark H. @lill Committee. The working conference in April will be held in Detroit and will report its@findings to the Council at the May meeting. VI. LEGISLATION, AIPPRUL'KIA'L'IUNS PMPS BUDGET A. 'Termination of @ts At the November Council discussed project renewal and termination ofiIt', Lding for those that seek such support I)cyond the dates at WIliL'.. they originally proposed to terminate or become self-sustainin '@g At this meeting Mr. Roland Peterson, Assistant Director for Planning and Evaluation, presented salient findings from experience in six regions with 99 p-,-,)jects that became operational three or more years ago. In most of L@2,9@e projects, three or more years of @IP support was requested inil-,. j. Thirty percent of the group terminated f*IP support on scheduled .'i.,.l,.some regions this happened with 60-70/". of the projects. On tlie'o'tt'ier hand, many individual projects expanded -ai-)nc their biLidget., In s.onio instances project seem-ed t(@ di,, -ar from 3 @IP listings, but tlle-activities continued to receive P@IP support I r through the buogets'of core or other project activities. PL@IP support tended to pcrs@st longer for medical school than for community projects. Yftis kind of analysis will continue to be reported. Additional regions I' i will be included as !they reach appropriate ages. B. Over- @uation to Requirements of New Legislation The ongoing process f adaptation to the program review" and triennial d with adjust le must be int@ ment to features added to the legislative base b P.L. 91-515. Regulations and guidelines are being I! y re-examined for tliis@purpose. It is hoped that the formallregulations can be kept sii !le and straight-forward. Publication of guidelines pp should take a form-tiiat will facilitate both their development by Council and their application to @ffl operations. New legislation p features of particular interest include: .1. Reviewlof RMP plans by CHP "b" agencies that have plans in I being: @IPIS is hopeful of broadening the RMP-CHP working relation- ships beyond th,-':letter of the law, to improve the combined effect of the ageftciest platning-on health services. 2. DIJEW rc",-. -.idations for changes in the scope of the program: Modificatio of he disease on@@ t -categorical targeting of the legislation might be esuch proposal that R.IIEPS and Council should examine. Council maylwlsh@to express its opinions on any proposals concerning the scope of PMP@or CHP legislation that go to the Secretary. 3. Annual eport on PM effectiveness:, The first report, already prepared byiRi@S; was essentially a status, or baseline report. Council may@wish@'to contribute to these reports regularly. The schedule fo@ such reports suggests that Council's input should be presented in thelfall of the year. Rudgetary Ou tlnnk l'ians for the fi,- @y'ear 1972 budget will have a considerable impact on the final apportionment of funds for the remainder of fiscal year 1971. At preselt the out'-ook is for level funding of RMP grants at $70 million for each@of the two years. this woul.d be accomplished by reserving a large part of the 1971 appropriation to be carried over for obligation in 1?72. 'This presents two kinds of problems. First, because it requi.res a major @eduction in current commitments to Regional Medical 1r.-')grams for both rs, the planning and persuasive aspects of the RL-gional @ledica'l Prograrn@ becomes more important, with less emphasis on thei.@,capabilities to sxiijport projects.. Secondly, it presents a very low appropriation base for the 1973 budget, so that maintaining the same 4 $70 million level through that fiscal year @,7ill. require a significant I I appropriation increase. The 1973 budget presentation is.essentially a technical problem that must be solved by @IPS within the DHEW structure. The, adjustipent of MiT awards to the proposed reduction would affect everyone and requires Council's attention. One possible route would belto fi@d the necessary reduction by cutting awards to the less effective re'- gions, and retaining levels cl.oser to-existing commitments in!tiie more effective regions. This and alternative policies will be theisubjects of intensive study over the next few' x,Teeks. D. Progress in!Adminfistrative Adjustment to Legislation, the Triennial Cycle and National Emphasis on Programmin Council's policy statements arc being examined for possible review and updzitin@,.' l@(-,vi,ew criteria leave been updated, but are subject Lo modifl- catioii irid refinement as necessary. Council.'s parti.cipit@lon Oill I)c- sought as pl,,insi drafts become available. ,and lhien completed,@these, materials will be given not only to Council and staff, but alsoito the Regional Medical Programs as well, as aids to program developments Meanwhile the RMPS is developing a comprehensive review system integrated with a new Management Information System. The objectives of these de- velopments are to effect economies in time, integrate @IP activities-with the total HSMIA!Prog@am surveillance, and improve RMP performance. These developments are@-intended to potentiate the formation and implementation of our human judgment's. 1. The current status of the RMPS Management Information System was presented by Mr. Frank Ichniowski, Acting Chief, Office of Systen-Ls Management,@@IPS. During liIis presentation he highlighted some of i:.Iie most recent a@Ccomplisliments of the MIS team and then proceeded to tie ii-i these current activities with the MIS implementation plans. In line wit@ tlies@ plans, lie announced a planned reorganization of the Office of S steris Management to better reflect the demands of the y Management Information System and to more optimally utilize available personnel. This reorganization provides for separate branch activities within OSM dealing with: MIS Design and Analysis, Programming,.and MIS Data Base Co ntrol. It was pointed out that at least five major sources will be providing I inputs to the MIS,. Iliese inputs include the Anniversary Review Application,@ the 1,@eglonal Reporting System, Site Visits, and other reports on contact, R-'-TS Staff and the Regional Office. Certain other efforts currently! underway by the MIS team were identified, namely- Development of an@MIS liaison team, use of MIS consultant, and MIS II t L@ II, (le (I tilesc (--xLra curri.culir a(.Llvlti(-s wl]] @;ln(.1 more Iccflr,,it(-,Jy guide tllc, plan being dc!velol)(2d. Mr. Iclillio,,Tlski tl ien linked these various ongoing activities to a series ofiprop6sed outputs which could reflect the needs and demands of the system users. This output plan categorized outputs as emanating 'from combinations of four major groupings: Financial Iiiformation@, R@g@onal Characteristics, Performance Records and Control, and Ilistorical Records. Ultimately, tlic@ IIIS willprovide usage, via retpote teletype or I video displ@y units, to RMPS, Review Committee, National Advisory Council, lislfHA, the Regional Office and the Regions themselves. riie Review Ccle and its l'ools. Mr. Ken 13aum presented a y ci(-@ser I)tj.on@ of tire plirp- oscs, phases and Lools of LI)c- propQs(!d triennial c cle of review and -iurvc@.til.ance. .1. ouncil ])is CU-@3sion ... On efficiency of operation: Development of such systems always risks over-elaboration of'the Management Information System;@the m@anualizing of procedures, ritualization of site visits and of'application reviews can result in ever-increasing demandsion staff and advisors' time. ... Danger of@over-simplifying a complex multi-disciplinary operation lik@ the management of RMP; observance of rigid pro- cedurallspeci@ications may conceal real probl.ems and forestall application of important professional judgments. ... Couricil-spaff responsibilities: Need full understanding of Council'@s responsibility for program and financial judgments. In some,reseatch programs councils have concerned themselves with content,'left funding to staff discretion. Some councils control initial funding and commitments; others concern them- selves w@itli other funding decisions. Staff discretion In approvin program changes without Council review also needs definition. ... Regional @,ledical Program development and progress: Council needs toiobserve conformance with guides, quality of project desi ns @ 9 nd operations, not only to maintain program direction, but also to evaluate its own guidelines and policies. I I -I I L, r i I I I I t I 6 I)c,ve I op! niuti Ls, in do not alwayf-; present on fixed iiinive@s;ii-y or Lri(@nnlal- dates'; sometimes it is highly .desira6le to@ review and activate new departures as soon as their virtueF8 become apparent. Cross communication between regions could be impeded at considelrable@loss in effectiveness if concepts had to await I fixed dates of Council review. Counci@i,s job is.primarily policy determination, but both' cyclical and interim reviews of operating and proposed changes contribute to Council's judgments. Perhaps Council and @ta@f action responsibilities could be enumerated, with staff pre- senting@a list of its actions for discussion at each Council meeting@.. I'he position of.the Regional Advisory Croup needs very clear specifi @e@ation@ i'n documentation of the review process @nd the assignm nt of responsibilities. 1). Stalff Response ... Efficienc@ of operation: Staff projections for the Codes of operation@in the management information and review procedures now envisioned indicate that the new approach will save time on routinelbasic processes and leave more time available for sub- stantiv6 tasks. ... Over'-simp'lification: The general aim of the plan is to emphasize h@lan professional judgments at all points of decision. ... Council-sitaff responsibilities: Council's responsibilities for grant decisions are fixed by law; the purpose of this pro- cedural development is to give Council a choice of ways in which its res onsib,@l,ities can be carried out efficiently. pi Staff wi@ll prepare a list of Council-staff responsibilities and Councilichoicies for next meeting. Regional Medical Program development and progress: Cross- communication bet,,7een regions occurs naturally through direct region-t 0-rcg on exchange and through region-staff-region routes. i Staff plans to bring Council a report on cross-communication at the next!meeting. ... Council action: Staff was requested to circulate for con- siderati n at,tlic next meeting a description of the proposed review process and the types of judgments that would be reserved to the Councii. 7 Vii. RE@IARKS-BY DI@. @VFI@NON E. WILSO!I, AU@AI ISTRATOR, HEALTH SERVICES AND ,IIENI'Al, lll,AL'rif At)"ITNI@TPATION A. AI)T)o:tntm(-n@, of Director: Dr. Harold @izirgul.ic@.s has been confirmed -is Director, @IP.S; only the paper work remains to be completed. 11, Iteconimendatlions of the Willard Task Force: Completion of tlic-, task force report isIexpeLted sooii. Unfortunately a draft could not be developed in ti@ime 'fo@r this session. C. Health Maintenance Organization: The Health Maintenance Or&anization (HMO) concept is a broad flexible one that has strong HEW support. The term now refersito organizations providing comprehensive health care to r enrolled popiila@tions,and financed by capitation. Prepayment and carefully defined packages of-p@ervices to represent comprehensive care are important elements in cur:vent Considerations. HEW is very act,, e in implementing the concept and in stimulating the formation of Hmb's. Late in November the@Secretary appointed the following four task forces. I i to examine inipo tint aspects of HEW 'posture toward the concept: Policy l@@lationslilps with non-fil?,W agencies Financing Technical Assistance The Administrator, HSMHA, heads the technical assistance group. However, heads and members of'the groups were selected, not to represent their constituent agencies,,, but to explore concepts of the Department's in- Ult 1. volvement imate@assignments for implementation of HEW policies and responsibilitie for@HMO's are by no means obvious and certainly are not decided. There is a high probability that IIS@FHA as the Department's technical agent in healtli'care'ldel:!.very will have an important role in technical I assistance for HMO propagation. CIIP agencies undoubtedly will have review and comment responsibilities I 11 concerning proposed l@10 activation. RMP as a channel for provider expression will@t)c, fully involved. It seem.,; c hzit-IIEW will actively support promotion of HMO activation. lear t I I Ilie Department will offer technical assistance and the planning and coordinating capabilities of its field arms and associated agencies. There is no plan to replace existing forms of health care with the HMO; the objective is to oDen access to health care as broadly as possible and Funding of IIEW activities is as yet unresolved. $2.25 million may be- available' from @CIISR@ 1971 appropriation; somc amount might be taken from reserved funds-; other amounts may yet be found elsewhere. Technical assistance @@fuiiding might well become a IIS@MA responsibility. Whatever is decidc@d fpr fiscal. year 1971 activities will. affect planning for 1972 appropriations for other programs as well as for the IIS@IRA total. D. Questions and Answers: Q. What are the '@Characteristics of a desirable IDIO? A. It has taken !from September to January to arrive at the fol.lowing list of@ichara'cteristics: An orga@izecl-'system of contractually related healthcare facili- I ties; an organized 'multi-disciplinary group of health care pro- fession.ils; an enrolled group of clients; a sound insurance plan. No rigid prescriptions have been adopted for accommodation to the insbrance!plan or for minimum enrollments. Q. What islthe D.epartment's view.on coverage of enrollment? A. Broad. ilf ac!Cess to health care is to be extended through the fMO devices, s@ome groups will require' assistance. SSA and SRS are loo ling at this. A Family Health Insurance Plan might be a vehiclel,for eXtending coverage. Q. Looking,beyond the problems of initiation and establishment, what I i will provide ong-term support? A. A soundly planned HMO should be supported by the revenues from its operations. Q. Will Federal contributions on behalf of Federal beneficiaries be uniform? A. It seems logical Lo believe that Federal IIMO's will expect uniformlor at'least minimum packages of individual or family cAre, but wil'I "regionalize" the prices of the standardized packag@ . Q. Could allarge,' employer set up a "house" f]Mo? A. Some ire alre@ady studying the idea. It seems likely that three or four! iwill @appear soon. Labor organizations also are interested. i 11 !- i I I - I I i i I t I - t I I I I 9 Q. Is legislation expected? A. Propos @ls on[ financing loans and insurance are being considered. Notliin'g new@is needed for program administration. Q. ikliat rate of, progress does the IIEI@' visualize - how many I-DFO projects mig.lit be established in a year? A. Many q@estio,ns must be investigated in order to organize,an li@to, c@s'.tablish the necessary contractual relationships, specify and price service pacl