DEPARTMENT OF HEALTH, EDUCATION, AND WELFARE

” PUBLIC HEALTH SERVICE
’
HEALTH SERVICES AND MENTAL HEALTH ADMINISTRATION
ROCKVILLE, MARYLAND 20252 ca

AU G 6 1971 . REGIONAL weotcat

PROGRAMS SERVICE

we

°

It is a pleasure for me to be able to provide you with the

highlights of the meeting of the Rational Advisory Council on

Regional Medical Programs which took place in the Parklawn

Building in Rockville on August 3-4, 1971. The meeting opened

with the introduction of four new members of the Couneil who

were present: Anthony L. Komaroff£, M.D., John P. Merrill, M.D

Mr. Sewall O. Hilliken and Benjawain i. Watkins, DPM. Two other

recently appointed members of the Council, Mr. C. Robert Ogden

and Mrs; Audzey M. Mars, were unable to be present. They ar ay
expected to attend the next meeting in November. ; oa

r

In accordance with usuel practice I opened the meeting with a
discussion of the number of topics general interest to RMP.

I began by summarizing the Ney 24 ting which we had with the-
Secretary, reported to you previously. I pointed oul that this
meeting, in my estimation, signaled a turning point in the
Secretary's appreciation of Regional Hedical Programs. There
vere three points of special interest with respect to the
weeting with the Secretary. First, the assemblage was able

to identify all the strengths which characterize Regional
Medical Programs. Second, the meeting was significant in that
RMP elicited especially strong support from the Secretary's
professional staff. Third, the Secretary himself indicated

that RMP will be a key element in developing mechanisms through
which the Department will carry out new initiatives relating to
health maintenance organizations, arca health education centers,”
regionalization, and other facets of Federal health programs
directions. ,

ae)

Dr. Roth stated that it apparently also had the effect of
correcting sone prior misconceptions about, RMP which the
Secretary had held as a result of much earlier experience,

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With respect to RMP appropriations, 1 reported to the Council
members that the House and the Senate had reported marked
increases in funds for fiscal year 1972. Late in fiscal year
1971 a supplementary appropriation was passed that added $10 .
million to the $34.5 million already in reserve for fiscal year
1972, making the total reserve $44.5 million. Senate action

for the fiscal year 1972 appropriation added $40 million to

$30 million additional passed by the House making a total of

$70 million added to the $75 million requested to be available
in fiscal year 1972. While it is difficult to foresee what the
ultimate appropriation will look like, the marked increases

plus the larger reserve indicate that there is a possibility
that greater amounts will be available for grants in fiscal

year 1972, (See Table, Attachment.) There is no Administration

action to date, however, to indicate any change from their pro-

posed funding level. Dr. Pah] had attended recent Senate appro-
priation hearings and also reported that the atmosphere was very
friendly. He indicated that the Chairman wes particularly
gracious and expressed his determination that budget procedures
not block expenditure of all money appropriated.

There were some suggestions from the Council that we take a look
at the possibility of making use of Section 910, particularly in
the light of prospects of increased appropriations. In response
to this, I indicated that the first consideration in allocating
any additional funds would be the strengthening of strong KiPs
that have been hurt by cuts in the past. In the past we had

not implemented Section 910 because of restricted availability

of funds. It would have been imprudent to implement Section 910
under the circumstances (incidentally, this might have been taken
as a Signal that additional monics were available when in fact
they were not). If additional funds become available, hovever,
we should consider using the Section 910 authority as suggested
by the Council, oo

With respect to other legislative activities, I discussed the

status of Area Health Education Centers. As you know, the

Area Health Education Center concept was introduced in the

Carnegie Report and has become a part of the Administration's
program, The AHEC would combine in one community health delivery
mechanism and health manpower educational activities, It would
‘depend on affiliations of hospitals, nursing homes, junior colleges,
etc., linked with a university health science center, and give first
priority to underserved rural or inner-city populations.
 

ed

Page 3 = ,

“+ called attention to the fact that. AHECs were still being con-
sidered by Congress, that is, it was as yet uncertain whether they
would be placed in Nill (BEMT) or RNPS. Whatever .the outcome,

RMP will have great involvement with Area Health Education Centers
in coordination with BIT. . :
Also in connection with Area Health Education Centers, I called
attention Co the fact that the Veterans Administration is con-
ducting a series of eight site visits to areas needing greater
medical services. The purpose of these site visits has been to
move promptly to develop the Area Health Education Center concept.

RMP, NIH, and HSMHA were all represented at the VA site visits.

Mr. Friedlander, representing Dr. Musser of the Veterans
Administration, noted that the President's Health Message called
for closer cooperation between VA and HEW and indicated that VA
regarded Area Health Fducation Genters as ideal areas for coopera-
tion involving both HSMHA and National Institutes’ of Health.

Mr. Friedlander indicated that VA intends to invest only in ©
activities that will improve quality of care and that show a
prospect. of continuation when ANEC legislation is passed.

I then reported to the Council on the Equal Employment Opportunity
plans of Rips which seek to assure greatly impreved employment. and
career development for minorities and. women.

We have agreed to meet the following goals by January 19723: !

J. A 6% gain in minority employment (an increase of 16
minority employees).

2. 60% of the minorities gaining employrent will enter
in the professional scric¢s.

°3, 50% of all vacancies at or above the medium grade for
RMPS will be filled by minorities. (The first one of
every two vacancies will be filled by a minority group
person.)

4. 40% of all vacancies’ in professional .positions will be
filled by females (minority or non-minority).

- -{ also reported that we have an ERO Council made up of RMPS eaployces
which meets weekly and which is by no means hesitant to discuss where
we have been deficient in meeting our goals. :
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In calling particular attention to our own internal policies
with respect to the employment of minorities and woren, I
reaffirmed to the Council that we expect similar efforts to

be undertaken on the part of RHP grantecs and affiliates. I
specifically stated to the Council that EEO cannot be separated *
from other factors which affect the viahility and effectiveness
of RMUPs. In the future the Council will be provided with
specific data regarding the performance of RMPs. in relation

to EEO so that grant review considerations can be wore realistic
prior to making recommendation to the Director, RPS,

Dr. Pahl reported to the Council on an orientation session that
had been held the day before for the benefit of new Council

_members. As I indicated to you in the beginning of this letter,

six. neu Council members have been eppointed since the last
meeting. ‘hey were joined at the orientation by three others,
Dr. Ochsner, Mrs. Wyckoff, and Dr. Schreiner, who have only
recently been appointed to the Council.

The orientation session is a new procedure designed to give new
members of the Council a co.umon base of knowledge about RiiPs,
The session included a general discussion of how RMPs are
organized and what they do, presented by Mr. Peterson. A
review of RMPS organization was presented by Dr. Pahl, an
overall picture of HSMHA and department programs was presented
by Mr. Baum, and I presented some general remarks concerning
the direction in which I see RNP programs going.

I thought you would appreciate knowing about our efforts. to

give new Council members some general background and common
understanding about the PMP program ir. a formal and systematic
fashion before assuming their duties. In general the staff who
participated felt that the orientation session was quite useful,
If the new Council members who participated concur in this view,

-we will undoubteiiy continue this procedure in the future.

Probably one of the high spots of the meeting, and indeed one in
which I am certain you will have an interest, was a very, very
lively discussion of the quality of medical care. This came up in
two contexts, one in relation to what Regional Medical Programs

is expected to do in connection with the Health Maintenance
Organization activity and second in connection with our plans

to implement Section 907 of the Act which requires development

and annual publication of a list of hospitals providing the best
techniques for treatment of heart disease, cancer, stroke, and
kidney diseases.
Page 5 :

Let me first take up the consideration of quality of care in
relation to Health Maintenance Organizations which consisted
largely of a report from me to the Council. I called attention
to the fact that a nuaber of contracts (52 I believe) have been
let by HSMHA to assist various kinds of sponsoring organizations
to do the groundwork for organizing HMOs. I called attention to
the fact that a number of Rips have a very active interest in
these projects. More than this, however, I pointed out that RAP
has been given specific responsibility to establish guidelines
for quality care in His and to develop methods for monitoring
the quality of care provided by IIMOs. Our mission in this
regard is to find out whether the quality of care paid for from
Federal funds meets the subscribers! health needs. This involves
criteria, data, relationships between hospital and non~hospital
practice, incentives for remedial action when quality is less
than adequate, and question of whether quality should be measured
in terms of outcome relating to individual patients or relating
to the entire community. Naturally, attempts to measure and
control quality have been undertaken in the past, and I particu-
larly called attention to recent experience with utilization
review in connection with Medicare and Medicaid.

I reported to the Council that we are working with Social
Security, NIH, and other organizations on the quality issue,
and that we will be setting up a-series of meetings with RMPs
and medical and health grovps to get their help. In addition,
I specifically called on members of the Council for their
thinking end advice and for contributions of their special
skills in helping us to develop useful quality standards and
controls. ,

’ The quality discussion really became animated, however, when

we discussed future plans relating to Section 907. I indicated
that RMPS is required to produce for the Secretary the list of
facilities stipulated by Section 907. While we have spent a
number of years doing preliminary work under contracts to
establish criteria, the final end product has not really been.
forthcoming, but we are now taking steps to produce the required _
list of institutions.

I indicated that listing of an institution. under Section 907 will.
be based on criteria that can be established to identify institutfoas
with special qualities so that they would tend to be the most out=
standing. ‘The refinement of criteria would be done under contract
by the appropriate professional organizations. Actual listing under
Section 907 would be based on voluntary response by hospitals toa
questionnaire which would reflect whatever criteria were developed
with hospitals being given an opportunity to respond.

-“"
We are all well aware of the difficulties which may arise in
developing the list required by Section 90/. Some Council
members expressed great concer with the proposed creation

of the jist which they felt might be more harmful than helpful.
Nonetheless, the Council clearly understood that the guidelines,
‘which we have produced so far have not been completely responsive
' to Section 907 and that we have to do further work in this regard,

I suggested specifically that we can produce 4 select list by
setting appropriately high standards. .1t was agreed that only
competent professionals can render 2 valid judgment of the quality
of care, and a specific proposal was made to ask appropriate pro-
fessional organizations to not only develop standards, but Lo
compile actual lists of the best institutions in their particular
- . fields. Another suggestion proposed that we assemble a group
_of experts to develop a resource List, which would show where
various services vere available as opposed to yhat is superior.
Jt was suggested that such a list would be useful to designate
those {nstitutions where constructive, ywell-oriented work is
being, done. Other suggestions releted to whether it would not |
be better to list more, rather than fewer, {nstitutions, for
example: ° those hospitals where good quality care can be given,
© not just those which are Noutstanding,” oF Wcupersor." As you —
can see, there are many unresolved issues and we will have to
9 take all of these views into account in determining our next
move with respect to Section 997.

 

Pr. Wilson was unable to attend the meeting and was represented

by Mr. Benny Bob Hall, Deputy Aeministrator of HSMHA, who spent

about an hour with the Council. Mr. Hall, who recently came to
HSMHA from HASA, 4s an engineer by training. Prompted in pert
by some recent discussions with the President's science Advisory chy
Committee in which Hr. Hall anc-I both participated recently, he
initiated a discussion of the application of technological develop

_ ment Co the health field. The discussion which followed jadicated

- that the Council and the health field penerally had for a long rine

recognized the potentialities of computer technology and fall-out
from the aerospace progran jn the provision of health care. However s
the Council quite strongly gndicated that money was the fuel needed
to turn interest into practical results. .

. Probably the most interesting part of Mr. Hall's discussion from
your point of view concerns reorpenization of HSMHA. Mr. Hall
‘stated that the so-called "Willard Report" is still confidential. ne
Ye indicated, however, that a reorganization of HSMHA activities :

could be expected during the Fall. He pointed out that there are
now 14 program directors reporting directly to Dr. Wilson and that

@ a regrouping of HSMNA programs can be expected which will probably

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Page 7

take the form of a consolidation of like programs under a senior . .
official reporting directly to Dr. Wilson. ‘

With respect to reorganization of RMPS, Dr. Pahl reported to the
Council that the long ewaited restructuring of our own reorganization
was announced to the Staff shortly before the Council meeting.

There will be two principal Divisions in addition to those such as
Planning and Evaluation, Systems Management, and. other units

attached directly to my office.

There will be an Operations Division which Dr, Pahl currently heads
as Acting Division Director. Nr. Chambliss is currently acting as
Deputy Director of the Division. The Operations Division will
contain an office of Grants Review under Mrs. Kyttie and a Grants
Management Office under the continued direction of Mr. Gardell.

The major change will consist of Four Overational Branches or "Desks"
organized on a geographic basis. The Fastern Desk will be under

Mrs. Silsbee, the South Central Desk will be under Mr. Ven Winkle,
the Mid-Continent Desk will be under Mr. Posta, and the Western

Desk will be headed by Mr. Russell, Staff assignments have been

‘announced and it is our intention to have these operaticnal by early

September. .
It is my hope that the new RUPS Organizational set~up will provide:

(1) better liaison between RMPS and the various Regional Medical
Programs; (2) better communication within RHPS; (3) a fuller unfrag~
mented picture of what is going on in the Regions; and (4) a smoother
working relationship with HEW Regional Offices. oe

Under the reorganization, the Professional end. Technical Division

will also take on a new complexion. Instead of being geared ta

ad hoc problems, this Division will now concentrate on producing
finished products relating to specific professional issucs which

are of critical importance to the RiPs, ranging from technical
problems to health delivery methods. The Professional and Technical
Division will also be responsible for developing stronger relations
with the National Center for Health Services Research and Development,
the Health Maintenance Organization operation, and ether related pro-
grams and agencies, It will also have a more systematic input into
the review of grant applications through appointments of individual
staff to work in a joint capacity with specific area desks in thes.
Operations Division. I also announced to the Councs) that the
Professional and Technical Development Division can be expected in |
the very near future to have greater staff strength than it has had”
in the past. - an :
within high, medium, and low groupings. -

Page 8

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Next the discussion turned to the rating system which was tested
with the current applications by the Review Conmittee, You will
undoubtedly recall that the new RMPS Mission Statement approved
by the-Council at its previous meeting included 17 criteria for
the assessnent of Regional Medical. Programs. Since that tine a
staff committee has put extraordinary effort into developing,
clarifying examples relating to cach of the criteria, a weighting
system and a simple rating procedure for each criterion patterned
after the NIH 1-5 model. The evaluation of the rating system
based on the initial trial was extensively described to the Council -
by Dr. Pahl and Mr. Peterson. In general, it was pointed out that
the actual ratings tended to confirm the validity of the overall
professional judgments traditionally. made by Council, Conmittee
and other reviewers, . a
Since the rating system is still in its trial stages and in ordéy”
to preserve objectivity, actual priority ratings and scores
derived from the Review Committee exercise were net provided to
the Council. They were, however, provided with ‘the general results
jn the form of a chart showing the regions in alphabetical order

i
t

I indicated to the Council, that in ny estimation the rating

system will be an eficctive tool for use by the Office of the

Administrator of HSMHA and by my office in making and explaining
administrative decisions.
|

;
I think you will be pleased to know that at this meeting of 1
the Council we finally clarified some questions about the new
triennial review process. For quite sone time, there has been
a ueed for a statement on exactly what the Council's recommendations
mean and which kinds of requests require Council approval and which
do not. I know there have been questions on these points among
ovr own staff and I am sure that you, too, have felt the need for.
more specific information. Ve have discussed these matters vith
Council at previous meetings and at their request have developed
a statement outlining the Council's responsibilities in the
triennial review process. A copy of the statement which was
formally adopted by the Council is attached for your information.
It is.self-explanatory. .

Also in line with clavifying PMPS policies, I asked Mr. Boum of
our staff to develop a short presentation cn where we stand in-
our efforts to revise R4P policies and regulations. He indicated
that because of changes brought about by the last amendment of the
Statute and changes in operational procedures as reflected in the
Mission Statement, Criteria, Standards for Local RNP Review Proces:
Developmental Components, etc., ¥e have been advised by the HER
Ceneral Counsel's Office to completely rewrite the Programs

“ee
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Regulations. The General Counsel's Office fs of the opinion that
the regulations should reflect both the statute and the actualities
of the way the Program operates. Under the ectreumstances they felt
that an attempt to revise the original regulations written: five
years ago would be undesiy ble. Therefore, the General Counsel's
Office, in cooperation Sieh our staff, is.developing an snitial
draft of new Regulatioas for the Progra,

Mr. Beyum also indicated that cc aeiderable progress has been made

in developing policy materials that can be Included in a loos 3e~-Leaf
manual that we plan to issue. The manval will be designed for
convenient use by our own-stzff as well as grantees and affiliates. 5
He indicated that a small number of individuals on our staff have
done a monumental job in pulling together applicable Depar frente 1, a
HSMHA, and RMP policies as well as developing new material a

necessary. However, considerable editerial work stiil needs to
be done. It is estimated that an initial draft will probably be .
ready for review and comment by the R4PS professional staff. in

about four weeks. ,

p cr

Another staff report was presented to the Council by Dr. Farrell
and Dr. Gimbel cn the subject of "A Computer Assisted ENG Analysis."
An extensive report oa this subject wes prepared at the Council's
request.

ibel noted that five Regional Medicad
ipu uter Assisted EKG Analysi

vproaches. He stated that, techno-
logically, fully operational EXG Analysis requiring no further
reading by a physician has not been achieved. He stated that
development of a fully automated system of that level of sophisti-
cation is problematical.

In summarizing the report, Dr. Gin
Programs which have undertaken "Coz
have each developed different app

It was further pojnted out, however, that computers have accurately

and xeliably been used for screening normal and abnormal EKS's with
less than one percent error. In response to questioning, Dr. Ginbel
indicated that the cost of automated EKG screening. is estimated at Le
two to four dollars per cardio: ‘ram exclusive: of the cost of rereading —
by a cardiologist and assuming a certain minimym aunual volume of
“input. In none of the pron rems in question, however, has this cost

or the required volume of business been approached.

In effect the conclusions reached were: (1) that computer assisted !
EKG analysis is an effective and reliable sercening technique; (2)
that definitive diagnosis must be done by a cardiologist; end (Ze.
‘that while the computer can speed up the work of the cardiologist, |
at least in the present state of the art, it can not replace hit.

While we did not ask the Council to take a stand on this issue, I
think the findings discussed above should raise some red flags with
respect to funding new and additional computer assisted EKG activities.
by Regional. Medical Programs, at least until the existing activities ©
have been evaluated fueehee with respect to the usefulness of the .
technique, whether it's worth the cost, how jt can contribute to

rontanstigatian ana dimnroawe arroce fA earitecas
.o@

‘both interesting and helpful. |

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Page 10 .

Certainly one of the high spots of the meeting, especially from

¢ . . .
the point of view of those who were there, was the slide presentation
by a guest speaker, Dr. Al Haynes, concerning progress on the Watts-

Willowbrook Project in Los Angeles. Dr. Haynes brought with hin a

very informative slide show outlining the development. of the project.

Essentially the Watts-Willowbrook undertaking involves the new 700-
bed Martin Luther King, Jr., Memorial Hospital, the new Charles R.
Drew Postgraduate Medical School, and. other community agencies which
have combined in a concerted effort to establish a health services
center for the area and provide quality care to the residents.

The Sinportant point to remember here is that service to the community
in the project is regarded as being equally and perhaps more important
than education and research. Indeed, some of us think of the Watts-
Willowbrook endeavor as being one prototype of the area health
education center, although the preject was begun before the AHEC
concept had been enunciated, vo

I hope you will find the above summary of the Council meeting to be

Sincerely yours,

. “LA me LGPMA ay

  

Director

Attachments
 

 

 

 

 

 

v * . eo : : Attachment No. 1
“ey
: ,
46 . STATUS OF RMP_FUNDS AND APPROPRIATIONS
FOR FLSCAL YEAR 1972, AS OF AUGUST 3,.1971
(In Millions)
a
REQUEST HOUSE SENATE
Original Reserve for Fiscal Year 1972 $ 34.5
. Additional Fund Requested for Fiscal Year 1972  . _40.5°
Yotal Reserve and Request , 75.0 75.0 75.0
Additional Funds in Pending Bills “ 30.0. 70.0
~
Department Request and Additional Amounts
in Pending Bills 105.0 — 145.0
Supplementary Appropriation 10.0 10.0 _10.0
TOTALS . : . § 85.0 $115.0 $155.0
 

seu he ffeevep ea

RYVIEY RESP ONSINILIa IES

UNDER TRE TRIFENTAL REVIEW SYSTEM

 

 

 

Under the triennial review system, each Pepional Medical Program
normally will be reviewed by the National Advisory _ Gounest only
once each three years, The ‘triennial review serves ta recognize -.
* the Region as an "accredited" orpenization and to set a general
level of annual support for the three year period. Thus, the -
Council's favorable recommendation constitutes a time-limited
approval for an RMP as an organization having recognized capabili-
ties, rather than being approval for a specific set of aetivits ies.
In addition to recomaending the general level of support, Council

-actions-on individual applications may include advice to the appli-

cant Resional Medica), Program, or specific conditions for the grant.
‘Prior to review by the Council, each triennial application will be
reviewed by assigned BMPS staff, .a site visit team and the MIPS
-Review Committee. +
Except as specified below, the Director, RHPS, will wake continu-
ation avards, including support for new activities, for second and
third (02 and 03) year support without further Council action insofar
as the proposed activities are consistent with relevant policies.”
The Council will be provided with a sumaary of such awards. Specifi-
cally, the Council's advice will be sought when:

1. Supplenentary funds ere requested in addition to the general

support recommended for the year in question.

2. Anew or increased Developmental Component. is requested,
. . ; i

3, The Council, the Director, RPS, or the Region requests
Council review. : ’

4, The applicant has failed in a material respect to meet the
requirements of the Program or applicable laws, regulations
or formally promulgated policies of the Department, HSNIA
or RHPS.. .

s
.

‘fhe summary to be provided to the Council will include the following

information’ concerning each Region reviewed by staff for continuation
support:
1. The amount pr

revio isly “recorunende .d by the Council for funding,
and the amount at

carded,

2. A list of activities supported during the most recent grant
year, identifying those viich have been completed and those
which have been supported through a developnental component.

.
 

 

rw ey . , . °
ye . - 2
e , oo f :
e le 3. A. summary of the Region's response to any advice specified by
the Council or limitations upon or conditions of the award.
‘ 5
-  °4 A summary of any outstanding accomplishments. .
. 5. A summary of any outstanding problems. 7 .-
i
: ° 6. Annual reports from the Regional Advisory Group and
fem 4 from RMPS staff. (these will be made available on
I. _¥request by the Council.) ‘
‘ . : - .
é - .
. ! ¥
a .
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° f
!
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