*. * DEPARTMENT OF HEALTH, EDUCATION AND WELFARE PUBLIC HEALTH SERVICE National Advisory Council on Regional Medical Programs Minutes of the Twenty-fifth Meeting 1/ 2/ November 9-10, 1971 The National Advisory Council on Regional Medical Programs convened for its twenty-fifth meeting at 8:30 a.m. on Tuesday, November 9, 1971, in ~. Conference Room G/H of the Parklawn Building, Rockville, Maryland. Dr. Harold Margulies, Director, Regional Medical Programs Service presided over the meeting. Lo The Council Members present were: Dr. Bland W. Cannon a Mr. Sewall 0. Milliken Dr. Michael E. DeBakey Dr. John P. Merrill Dr. Bruce W. Everist - — Dr. Alton Ochsner Mr. Harold H. Hines: Dr. Russell B. Roth Dr. Anthony L. Komaroff Dr. George E. Schreiner Dr. Alexander M. McPhedran _ Dr. Benjamin W. Watkins Mrs. Audrey M. Mars , Mrs. Florence R. Wyckoff Dr. Clark H. Millikan Dr. Mare J. Musser Dr. Roth and Dr. Musser were present on November 9, only. Dr. DeBakey - was present on November 10, only. Dr. Brennan was present beginning on the afternoon of November 9. A listing of RMP staff members, and others attending is appended, I. CALL TO ORDER AND OPENING REMARKS a The meeting was called to order at 8:30 a.m. on November 9 by Dr. Harold Margulies. Dr. Margulies called attention to the "Conflict of Interest" statement in the Council books. He then introduced two new Council members, Mrs. Audrey M. Mars and Mr. C. Robert Ogden, who were attending their first Council meeting. Dr. Margulies then introduced Dr. Vernon E. Wilson, Administrator, Health Services and Mental Health Administration. i 2 “1/Proceedings of meetings are restricted unless cleared by the Office of the Administrator, HSMHA. The restriction relates to all material sub- mitted for discussion at the meetings, the supplemental material, and all other official documents, including the agenda. 2/For the record, it is noted that members absent themselves from the meeting when the Council is discussing applications: (a) from their respective institutions, or (b) in which a conflict of interest might occur. This procedure does not, of course, apply to en bloc actions-- only when the application is under individual discussion. , « © Il. REMARKS BY DR. VERNON E. WILSON The new organizational structure for HSMHA has been approved by the Department. Under this arrangement, the 15 HSMHA programs will be grouped under four Deputy Administrators. RMPS will be under the Deputy Administrator for Development, Mr. Gerald R. Riso. Mr. Riso's immediate Deputy will be Dr. Jack Brown. The Deputy Administrator for Development will be responsible for | “change agent" type programs. In addition to RMPS, other programs ~< grouped under the Deputy Administrator for Development include: (1) Comprehensive Health Planning; (2) the National Center for Health Services Research and Development; (3) the Hili-Burton Hospital Construction Program; and (4) the Health Maintenance Organization Service. ‘Dr. Wilson next turned to the subject of improving the. use of advisory groups. About two thousand people provided advice to HSMHA through Councils, Committees or consulting: appointments. In order to improve the utilization of this resevoir of talent, HSMHA is trying to develop a "skills inventory." Staff is now developing a short questionaire designed to catalogue the skills, interests and availability of ad- visory group members and consultants. If HSMHA is able to establish the prospective skills inventory, it will be able to utilize more effectively the resevoir of consultative advice available to it, parti- cularly as new "crash programs" materialize. , Next, Dr. Wilson discussed his participation in a White House study on the applications of technology. The study is under the direction of the Federal Council on Science and Technology, and it involves six different panels. These groups are charged with determining those - fields in which technology can now make the greatest economic contri- butions. Each panel deals with a service area or industry which uses much labor and little automation. Dr. Wilson, chairs a twelve-man panel on Health Services. The panel consists of outstanding individuals of National stature including, among others, representatives of the American Medical Association, the Veterans Administration, the Departments of Transportation and . Defense, etc. It is expected that each of the personal services ori-~ ented fields will make its own case for the advantages of technological investments in its particular area. The final report will probably identify those fields in which technological improvements will have the greatest economic impact. It will most likely identify those fields which can make the best use of investments in technology rather ' than how technology can be applied in each field - health, housing con- struction, etc. a fe Tit. 3 Personal service oriented activities tend to become self-defeating un- less provided with a certain amount: of technological assistance. At present, 20 percent of the Nation is underserved in relation to health services and promised improvement cannot be made without appropriate technological assistance. There are a great many places, Dr. Wilson stated, where without at all interfering with the position of the pro- fessional-patient interface, we can still do things a lot more effec- tively. Dr. Wilson indicated that he had some "considerable feeling" that in the future there will be a substantial investment in the field of technological improvement. He asked the Council to keep this in mind when considering opportunities for sponsoring new activities through RMP. REMARKS BY .MR. GERALD R. RISO Mr. Riso indicated that he had only been with HSMHA for a few weeks. He outlined a number of matters, however, which are expected to command his special attention during the next several months. These include (1) improving HSMHA's ability to identify health care needs; (2) de- veloping better relationships among research activities within HSMHA; (3) identifying health delivery practices of significant value; (4) pro- moting the introduction and practical application of such practices; and (5) promoting relationships between HSMHA programs. Very great interest in HMOs has developed as a result of the Department's efforts in this area, A very practical and pragmatic approach will be taken with respect to providing assistance and stimulating HMO develop- ment. Among other things, an attempt is being made to correct several widely held misconceptions about HMOs. First, there is and will be no element of compulsion in HMOs. Second, HMOs are not intended to be a substitute for health insurance, and third, the responsibilities of HMOs will not actually be as broad as the term "health maintenance" would seem to imply. . While the Government does not-have the ability to respond to every ex- pression of interest in developing an HMO, HSMHA is in a position to provide modest financial assistance to some HMO developers. It is pre- pared to provide advice to developers concerning (1) whether they should _ proceed further (2) reevaluate what they already have done, or (3) desist from their efforts to organize an HMO. The Department ddes not contemplate insuring continued operation of all HMOs. Some are expected to fail and we will learn from their experiences. 4 © Tt is the Department's intentions to syphon off those groups which should not be encouraged, to encourage those which show truly good propects, and to improve those which appear to have good prospects, put marginal performance. At the present stages of HMO develop- ment, it is expected that a number of HMO's currently in the plan- ning and development stage will reach a decision within the next six months on whether or not to proceed further. The initial grants and contracts for planning and developing HMOs .. were made between May and July 1971. A second round of applications was submitted in July. Awards on the basis of these applications are expected to be made before the end of the calendar year. Two more application cycles are planned prior to the close of the fiscal year in June 1973. The original set of grants and contracts made between May and July of this year are currently being examined in relation to geographic spread and types of sponsorship, and this will have some effect on the future pattern of awards. , The average planning grant for HMOs has been $100,000 to $150,000. In the future some more modest grants in the neighborhood of $25,000 to $50,000 will be made to prospective HMO developers to explore whether they should proceed further. Some of these smaller grants © will probably go to rural areas. - At the close of his presentation, Mr. Riso made the following points in response to questions raised by various members of the Council: 1. The definition of the quality of .care within the confines of the HMOs is the responsibility of the RMP Program. 2. HSMHA has not developed an "ABC of eligibility" which might be a good idea, but, if there are churches or other small groups which would like to be involved in HMO and have questions con- cerning their eligibility, they should contact the HMO program Director within the appropriate HEW Regional Office. '.3, Funding levels for the November HMO review cycle will be modest and the magnitude of activity in the February and June review — will be determined by legislation, and the geographic and spon- sorship pattern that evolves from earlier awards. , IV. ANNOUNCEMENTS A. Appointment of Dr. Hinman Dr. Margulies introduced Dr. Edward J. Hinman, the new Director of the Division of Professional and Technical Development, RMPS. © ‘ Vv. VI. VIT. 5 Dr. Hinman has had a very distinguished career, most strikingly as Director of the Public Health Service Hospital in Baltimore. Loss of Dr. Klieger Dr. Margulies next announced the sudden passing of Dr. Phillip Klieger, who for many years has been part of the Regional Medical ‘Programs Service. Dr. Klieger most recently served as Chief of the Office of Committee and Council Affairs. The condolence of... RMPS has been expressed to Dr. Klieger's widow and his family. Responsibility for Committee and Council Affairs will now be picked up by Mr. Kenneth Baum. CONFIRMATION OF FUTURE MEETING DATES The Council reaffirmed the following dates for future meetings February 8-9, 1972. May 9-10, 1972 Council then set the following subsequent meeting date: August 15-16, 1972 For the information of the Council, Dr. Margulies indicated that con- sideration was being given to the idea of reducing the number of Council meetings to 3 a year, rather than 4. CONSIDERATION OF MINUTES OF THE AUGUST 3-4, 1971, MEETING The Council considered and approved the minutes of the August 3-4, 1972 meeting. REPORT BY DR. MARGULIES A. RMP National Meeting in January, 1972 There will be a National Meeting of Coordinators in St. Louis on January 17-20, 1972. Members of the Council will be invited to attend. The Conference will cover a number of topics about which there is a ligh level of interest such as: Area Health Education Centers, Health Maintenance Organizations and improved utilization of health manpower. . B. Cc. RMPS Reorganization The RMPS reorganization previously announced to the Council has been put into effect and the geographic operations desks have in fact, been put into action. Status of. Revised RMPS Regulations RMPS has for some time been developing an updating of the Regula- tions for the program. Some new material has been prepared in draft by the Office of the General Counsel. The Council will have the opportunity to study and make recommendations on any proposed new. Regulations. Among other things, the Regulations being developed will deal with some issues which have been troublesome, particularly the proper relationships between the grantee agency, Regional Advisory Group, Coordinator and core staff. These have now been defined with some clarity, but as with all regulations there will remain room for in- terpretation which is going to be the responsibility over time of the Council, Participation of Minorities and Women on. Advisory Groups The Department has expressed a desire to increase the participa- tion of women on advisory groups and it is anticipated that the two ladies presently on the Council will be joined by others as the present vacancies are filled. Some reflection of the RMPS's hope to create a better balance in terms of minority membership and the balance between the sexes can be seen in the present make-up of the Review Committee. This group is now at full strength and new members include: Miss Dorothy Ee Anderson, Assistant Coordinator, Area V,. California Dr. Gladys Ancrun,. Executive Director, Community Health Board, Seattle Mr. William J. Hilton, Director, Illinois State Scholarship ' Commission, Chicago Dr. William G. Thurman, Professor and Chairman, Departmént of Pediatrics University of Virginia, Chartorrevilles Virginia Mr. Robert E. Toomey, Director, Greenville Hospital Systen, Greenville, South Carolina . . E. F. G. 7 Current Status of Area Health Education Center There appear to be three possible developments with respect to area health education centers: (1) that there will be no legis- lation; (2) that the primary responsibility for AHECs will be placed in the National Institutes of Health; or (3) that the primary responsibility for AHECs will be placed in RMPS. The Regional Medical Program legislation contains all of the necessary authority for AHEC development. Regardless of the legislative outcome, it is quite clear that RMP will be in- volved with AHECs and in any event, will be working closely with the Bureau of Health Manpower Education at NIH, and the Veterans Administration. There appear to be two concepts of Area Health Education Centers: (1) an expansion of the activity revolving around a university health science center, and (2) a community based.activity pro- viding service with educational activities playing an essential but not dominating role. The second model in which the certifi- cate, diploma or degree is subordinate to the service performed has the best chance of becoming a viable and effective institu- tion. . Dr. Endicott, Director of the Bureau Health Manpower Education at NIH, does not believe that AHECs should be a mere extension of the university health science center or a satellite thereof. RMPS and NIH will be working on AHEC in any event, and there is no significant difference in their respective goals. | Status of Section 907 Section 907 is that part of public law 91-515 which requires RMPS to develop a list of hospitals that can provide the most recent advances in the treatment of heart disease, cancer, stroke, and kidney disease. The Guidelines for heart disease, cancer and . stroke have been produced under contract previously. These _ either provide or serve as a basis for developing the appropriate institutional criteria: In addition, a small group is now working on criteria for kidney disease. The most important recent develop- ment with respect to section 907 is the completion of a contract with the Joint Commission on Accreditation to produce a‘’series of reports that will enable physicians or the public to have. a wide range of choice on where they receive help. Review of Kidney Proposals In the past kidney projects have been handled in a manner different from the rest of Regional Medical Programs. In the future, they 8 will continue to be handled separately but, in the somewhat modified manner described below: 1.‘ Kidney projects will be brought before the Review Commit- tee and Council having had a technical review. 2. Kidney projects will also be reviewed with respect to how they relate to the total program of the sponsoring RMP. 3. Kidney projects will be reviewed with respect to the size of the budget for the kidney project in relation to the total budget of the RMP. The Counedl was next asked to take into consideration four questions forwarded by the Review Committee. 1. Whether Council recommends that money apportioned for renal disease be considered in a proportional ratio to the total amount of money of the RMP's budget? 2. Whether the total amount of money spent in a given region for renal disease should be in proportion to the total amount of dollars being spent in that region? 3. Whether renal programs funded by the regions will come out of their total budget or out of a separate budget? 4. Whether renal programs should be considered outside of the total regional activities or not?- It was moved by Dr. Everist and seconded by Dr. Roth that the answers to these questions in order, are "no, no, yes, and no," with the additional comment in relation to question number 4 that on the assumption that funds will be greater and that more money will be put into kidney disease, the utilization of section 910 for kidney projects is perfectly reasonable. , At this point Dr. Margulies called upon Dr. Hinman to outline the manner in which kidney project will be handled in the future. Dr. Hinman outlined the following procedures: 1. Inmediately upon receiving a kidney proposal, the Regional Medical’Program will be asked to contact RMPS to determine whether the proposal is within the scope of RMP National priorities. At this point RMPS will advise the Regional Medical Program on whether it is desirable to proceed fur- ther. The Regional Medical Program is free to either accept . or reject this advice. 9 2. Each Regional Medical Program will be expected to establish a technical review group for kidney projects. This could either be.an Ad Hoc or.a standing group. RMPS would have a list of appropriate review consultants throughout the country who could be called upon by Regional Medical Programs to serve on such review panels. 3. Once an appropriate review group has been established at the local level, RMPS will be in a position to certify through ~<- the Council that an appropriate technical review has taken ‘ place. It is at this point that the larger question of the relationship between the. kidney project, the total function- ing of the RMP and the relationship the kidney budget to the total RMP budget would be taken into consideration. Dr. Hinman also discussed other proposed kidney activities of the Division of Professional and Technical Development. He cited plans to develop a coordinated federal strategy on certain issues, parti- cularly that of-anti-lymphocyte globulin. H. Distribution of Advice Letters to Regional Medical Programs Ordinarily after the Council reviews a Regional Medical Programs grant. proposal, an advice letter is prepared which goes only to the Coordinator and the Regional Advisory Group Chairman. This letter ordinarily contains rather detailed advice. Both the Steering Committee and the Review Committee have proposed that Committee members and Consultants who have served as site visitors get a copy of the advice letters as well as the regions to whom they are addressed. . It was moved by Mrs. Wyckoff and seconded by Mrs. Mars that fur- ther distribution of the advice letters as suggested be authorized. The motion was approved unanimously. Dr. Margulies stated that RMPS would also make all advice letters available to Council members including those who have not been reviewers or site visitors. VL. STAFF REPORTS + < A. Reorganization and Functional Directions of the Division of Pro- fessional and Technical Development. 10 Dr. Hinman reported on the reorganization and functional direc-. tions of the Division of Professional and. Technical Development.- The Division's objective is to find and implement solutions to identified problems. In doing 80, the Division will use a task force approach rather than the traditional Branch and Section form of organization. Some of the current issues being dealt with by the Division include: 1. quality of care standards for HMOs 2. area health education centers , 3. rural health care 4, manpower utilization 5. experimental health service delivery systems In view of Dr. Hinman's remarks there followed an extensive dis- cussion of the importance of medical records in maintaining quality of care. Several types of records systems currently being tried in Indian Hospitals and VA Hospitals, for example, were discussed. Other items included: (1) the need to develop a satisfactory re- trieval system; (2) medical passports, and (3) the patient's right to know what is in his medical records. Procedures for Reviewing Anniversary Applications Dr. Pahl reported on further progress in reorienting RMPS review mechanisms. Dr. Pahl announced that a "Staff Anniversary Panel" has been formed and met for the first time in August. The panel reviews applications from Regions which have not yet received triennial support, and anniversary applications from those regions which already have been approved for three years. The new review system is designed to better utilize the time of staff, Review Committee, Council members and outside consultants. Local RMP Review Process - Status Report Mr. Baum reported to the Council with respect to the current status 7 of activities for insuring that the review mechanisms of the fifty- — gix RMPs comply with the RMPS "Review Process Requirement and Standards."' These standards constitute requirements to which the ‘local review process must conform as a quid pro quo for decentral- izing project review to_the individual RMPs. > RMPS is now in the process of conducting site visits to verify that each of the RMPs meets the review process requirements. The first two site visits have already been conducted. and the results will be forwarded to the appropriate coordinators shortly. These pilot visits have helped to develop a standard site visit procedure and have helped to crystalize some troublesome issues. In order to