Justifications of Appropriation E:stanates for Committee on Appropriations Fiscal year 1973 DEPARIMENT OF LABOR, AND HEALTH, EDUCATION, AND WELFARE, AND RELATED AGENCIES VoLume | HEALTH SERVICES AND MENTAL HEALTH ADMINISTRATION Mental Health - Through Health Services Delivery U.S. DEPARTMENT OF HEALTH, EDUCATION, AND WELFARE MEM TAL MPOAL ITT DEPARTMENT OF HEALTH, EDUCATION, AND WELFARE HEALTH SERVICES AND MENTAL HEALTH ADMINISTRATION Appropriation Title Mental health........ once weeee Saint Elizabeths Hospital...... Health services planning and development......c.eeee0. Health services delivery....... 1973 Appropriation Estimate Pos. Amount 2,178 $612,170,000 4,132 28,271,000 757 329,596,000 7,678 745,657,000 Page 78 96 184 DEPARTMENT OF HEALTH, EDUCATION, AND WELFARE HEALTH SERVICES AND MENTAL HEALTH ADMINISTRATION Mental Health Page No. Appropriation language..... wee w ener e newer eeenee Seow ees 3 Amounts available for obligation. ....cc ccc ee secre eee cece wees 4 Obligations by activity........ cence rece enccee se eeee enews . 5 Obligations by object.........- ie ras Teese ees esses esas 6 Summary of changes........... Sewer ec eee ee ere erate sereoenes 7 Authorizing legislation....... semen e ee eee e eee eenes wae eee . il Explanation of Transfers... cee csc cece resents Sone ee sesssues 17 Table of estimates and appropriations........eeseees a eee ences 18 Justification: A. 1. General statement........ cece cece eee e eee r enc eeeene 19 2. Activities: (1) Research: (a) Grants. cece ce cecccse es ne rere ee eens cerenees 20 (b) Direct operations...........5. see eeeeeees 28 (2) Manpower development: (a) Training grants and fellowships........+6. 31 (b) Direct operations....ccccseeees seveees cee 39 (3) State and community programs: (a} Community mental health centers: 1. Construction.......... eee cee eee eee ke 2. Staffing......s.eeee Seasessueece eee 43 (b) Narcotic addiction....... sees e rene eeeeeees yy (ec) Alcoholism Le. Project. .ccccecccecesevceeucveereveves 48 2. Grants to states. .cccccscccsercssccecs 51 (d) Mental health of children.............200- 52 (e) Direct operations... ..ccscescecscceeceeces 53 (4) Rehabilitation of drug abusers........csceeeees 54 (5) Program support activities: (a) Field activities... ... ccc cece ec eee eee cane 56 (ob) Scientific communication and public ]AUCACLON. cores cesar ecssesnenscesncesesees 57 (c) Executive direction & management services. 59 3. Items of Special Concern: (a) Narcotic addiction... ccccc ecu e nse neceveeeneen 21, 30, 33, 44, 54,57, 66, 71 (b) ALCOHOLISM... .. cece eee cece eee cence ete eeetes 22, 2h, 33, 48, 51, 58, 68 B. Cc. D. Program purpose and accomplishments. ....ssscsceveecscecs State tables. ccc ecrcrerececscevecnesscersssveeevesecess New positions requested. ......seseeesees se neee ween eee 60 73 TT Appropriation Estimate MENTAL HEALTH For carrying out the Public Health Service Act with respect to mental health and, except as otherwise provided, the Community Mental Health Centers Act (42 U.S.C. 2681, et seq.), the Comprehensive Alcohol Abuse and Alcoholism Prevention, Treatment, and Rehabilitation Act of 1970 (Public Law 91-616), and the Narcotic Addict Rehabilitation Act of 1966 (Public Law 89-793) ,['($612, 201,000) ](80 Stat. 1438), $612,770,000 of which [575,000,000] $141,491,000 shall remain available until June 30, [1973]2974 for grants pursuant to parts A, C, and D of the Community Mental Health Centers Act. RS RnB aan Be Be meee ae DEPARTMENT OF HEALTH, EDUCATION, AND WELFARE HEALTH SERVICES AND MENTAL HEALTH ADMINISTRATION Mental Health Amounts Available for Obligation Appropriation... see eeecee eee eeeees Real transfer to: "Operating expenses, Public Building, General Services Administration". Comparative transfer to: "Departmental management".......... "Saint Elizabeths Hospital"........ Subtotal, budget authority...... seeee Receipts and reimbursements from: Non-Federal SOUrceS...cseereseerees Other accounts....cccecesceeers rar Unobligated balance, start of year... Unobligated balance lapsing.......... Unobligated balance, end of year..... Total, obligations.......-.. L972 1973 $612,201,000 $612,170,000 -4 ,000 --- -115 ,000 --- ~1,600 ,000 --- 610,482 ,000 612,170,000 9,000 5,000 155,000 155,000 196,000 9,800,000 -223 ,000 an ~9,800,000 --- 600,825,000 622 ,130,000 i q ? Ro 4 ‘ ‘ : F Obligations by Activity 1972 1973 Increase or Page Estimate Estimate Decrease Ref. Pos. Amount Pos. Amount Pos. Amount Research: : 20. Grants........00.-- --- $97,400,000 --- $101,400,000 --- +$4,000,000 28 Direct operations.. 1,170 41,699,000 1,184 43,268,000 +14 +1,569,000 Manpower development: 31 Training grants and fellowships... --- 120,050,000 ---= 105,050,000 --- -15,000,000 39 Direct operations... 135 7,741,000 135 1,779,000 --- +38 ,000 State & Community programs: Community mental health centers: he Construction...... n= 5,200 ,000 --- 9,800,000 --- +4,600,000 43 Staffing........-- --- 135,100,000 --=- 135,100,000 --- ~-- 4h. Narcotic addiction.. --- 76,390,000 --- 91,298,000 --- +1h,908,000 Alcoholism: 48 Project Grants.... --~ 40,297,000 --- 50,193,000 --- +9,896,000 51 Grants to states.. --- 30,000,000 --- 30,000,000 --- --- 52@ Mental health of children........... --- 10,000,000 --~- 10,000,000 -~- --- 53 Direct operations... 187 6,816,000 194 7,239,000 +7 +423 ,000 Rehabilitation of 54 drug abusers........ 157 13,323,000 164 13,926,000 +7 +603 ,000 Program support activities: 56 Field activities... 152 3,729,000 152 4,015,000 --— +276 ,000 57 Scientific communi- cation & public mtrcation....eceee 90 7,298 ,000 90 7,293,000 --- -5 ,000 59 Executive direction & management SEYViceS... 2s eeee 259 5,762,000 259 5,769,000 -~- +7 ,000 Total obligations.... 2,150 600,815,000 2,178 622,130,000 +28 +21,315,000 Nh E Obligations by Object oy 7 Pot a ‘ i9T2 1973 Increase or Estimate Estimate Decrease Total number of permanent POSILIONS. cc. cece cose eeeeoes 2,150 2,178 +28 Full-time equivalent of all other positions....csssesseee yoy oy -+- Average number of all EMPLOYEES. cc eee cersecccscecce 2,485 2,538 +53 Personnel compensation: Permanent positions......... $31,006,000 $32,415,000 +$1,409,000 Positions other than PEYMANENE. cc eee eececnseevas 1,973,000 1,973,000 --- Other personnel compen- sation...... See e eee eeweeees 1,324,000 1,324,000 -+- Total personnel compensation. ....seeeoees 34 , 303,000 35,712,000 +1, 409,000 Personnel benefits...csececees 3,045,000 3,201,000 +156 ,000 Travel and transportation of PETSONS see ccecccescccececcces 1,954,000 1,981 ,000 +27 ,000 Transportation of things...... 255,000 255,000 --- Rent, communications and utilities. cc... cece weer covee 1,843,000 2,001,000 +158 ,000 Printing and reproduction..... 1,094,000 1,094,000 --- 4 Other Services... ...ceceevccces 9,621,060 10,471,000 +850 ,000 Project contracts......+eee. 31,436,000 31,436,000 --- Supplies and materials........ 1,946,000 1,958,000 +12 ,000 Equipment... csecevcesvececnees 893,000 1,192,000 +299, 000 Grants, subsidies and contributions......cccc eee eee 514,437,000 532,841,000 +18 ,404 ,000 Subtotal. ..... cece cecc ences 600 , 827 ,000 622,142,000 +21 ,315 ,000 Quarters & subsistence charges -12 ,000 -12,000 --- Total obligations by ODJECE. cece cccesecesecevnce 600,815,000 © 622 ,130 ,000 +21 315,000 E 7 7 ‘ Summary of Changes 1972 estimated obligations............ een $600 ,815,000 1973 estimated obligationS..cccsceeseccercreseseeces 622 ,130 ,000 Net change. .ccsccscscccvcsssevessseces +21 315,000 Base Change from Base Pos. Amount Pos. Amount increases: A. Built-in: 1. Within-grade increases...... --- --- ++ +850 ,000 2. Annualization of 1972 new POSIFTLIONS ... cer ee wcescccaes -—— -—— --- +1,021 ,000 3. Equipment replacements...... --- --- --- +283 ,000 4, Annualization of 1972 in- crease of benefits for commissioned officers...... --- -~- --- +72 ,000 5. Increase in Federal Tele~ communications service CHAP BES ccc cece reece rece eene . --- ~-- --- +153 ,000 6. Holiday pay......cseceeeeees coe --- --- +6 ,000 {. Increased payments to other accounts: a. NIH Management Fund..... -~~ a moe +676,000 b. DHEW Working Capital Fund. ccc ccccssoeevcecs --- --- --- +46 ,000 c. HSMHA Service and Supply Fund........e00. --- a = +102 ,000 8. Payments to Bureau of Employees' Compensation.... --- --- --- +17 ,000 Total, increases....... 0 --- --+ ne +3 ,226,000 B. Program: 1. Direct operations: a. Child mental health..... --- oe 4 +40 ,000 b. Minority mental health.. --- --- 5 +50 ,000 c. Crime and delinquency... --- --- 5 +50 ,000 d. Alcoholism... cccccccesee --- --- T +70 ,000 e. Drug abuse....cccceceees --- -——- T +70 ,000 f. Upward mobility program. --- --- -~+- +147 ,000 2. Grants: Research... Community mental healt centers construction.. Narcotic addiction community assistance... Alcoholism projects..... a. b. Decreases: A. Built-in: i. Two less days of pay... 2. Annualization of 1972 employment. reductions...... B. Program: 1. Training grants... Total, net change.. Total, program increases Total, increases.. Total built-in Total, decreases... Base Change from Base Pos. Amount $97 ,400 ,000 5,200 ,000 76,390,000 40,297 ,000 120,050,000 +28 +28 Amount +h 000,000 + ,600,000 +14 ,908 ,000 +9 896,000 +33 ,831 ,000 +37 ,057,000 -169 ,000 ~5 13,000 -742 ,000 -15,000 ,000 -15 ,742,000 +21 ,315,,000 Explanation of Changes Increases: A. Built-in: 1. Within-grade increases: An increase of $859,000 will provide coverage for escalations in the cost of personal services resulting fron normal periodic within-grade advances, to the extent that they are not offset by savings result- ing from employee turnover. 2. Annualization of FY 1972 New Positions: An increase of $1,021,000 will provide full year funding for 153 new positions established in 1972 to support the Institute's. expanded narcotic addiction and alcoholism programs. 3. Equipment Replacements: Additional funding is required to cover the larger cost of research equipment items requiring replacement in 1973. 4, Annualization of FY 1972 Increase of Benefits for Comnissioned Officers: An additional $72,000 will cover the full-year costs of continuation pay increases approved for Public Health Service officers in December of 1971. 5. Increase of Federal Telecommunications Service Charges: An increment of $153,090 is requested to cover increased costs of telephone services provided to the Institute. 6. Holiday Pay: Premium pay costs related to Inauguration Day, a legal holiday, are estimated at $6,000. 7. Increased Payments to Other Accounts: A total increase of $824,000 is requested to provide for central service costs provided to the Institute by the Department ($46,000), Health Services and Mental Health Administration ($102,009), and National Institutes of Health ($676,000). 8. Bureau of Employees' Compensation: Payments to the Bureau of Employees' Compensation will increase from $38,000 in 1972 to $55,000 in 1973. B. Program: 1. Direct Operations: A tctal of $427,009 is requested for program increases in direct operations. Of this amount, $140,000 will provide first- year funding for 14 new positions in the research activity for programs in Child Mental Health (4), Minority Mental Health (5), and Crime and Delinquency (5). An additional 7 positions and $70,000 are requested to support the Institute's expanded alcoholism programs, and an equal number of positions and dollars is requested for support of narcotic addiction and drug abuse activities. An increase of $147,000 is requested to finance services provided to the Institute by HSMHA in connection with the Upward Mobility Program. 2. Grants: a. Research: The increase of $4,000,000 is requested for expanded research efforts in drug abuse ($500,000), child mental health ($1,500,000), alcoholism ($500,000), minority mental health problems ($1,000,000), and crime and delinquency ($500,000). b. Community Meatal Health Centers Construction: Using funds carried over from 1972, obligations for coastruction of Community Mental Health Centers will increase by $4,600,000, to $9,800,000 in 1973. This will provide funds for 10 construction of approximately 24 new centers in 1973. No new appropriations are requested for centers construction in 1973. c. Narcotic Addiction Community Assistance: An increase of $14,998,000 is requested for narcotic addiction and drug abuse community assistance projects. This will bring the 1973 funding level to a total of $91,298,000 for this budget activity. Priority will be given to funding programs serving metropolitan areas with a high incidence ot drug addiction. d. Alcoholism Project Grants: An increase of $9,896,000 is requested for alcoholism community assistaace projects, bringing the total 1973 progran level to $50,193,000. The increase will be used to support projects previously funded by the Office of Economic Opportunity, Decreases: A. Built-in: 1. Two Less Days of Pay: A decrease of $169,U0U is included to reflect two less working days in FY 1973. 2. Annualization ot FY 1972 Employment Reductions: A reduction of 52 filled positions in 1972, will result in annualized savings of $573,000 in 1973. B. Program: 1. Training Grants: A total program decrease of $15,000,000 is proposed for mental health training prograns in 1973, including $7,000,000 for the psychiatry residency program and $8,000,000 for other training programs. Authorizing Legislation Legislation Public Health Service Act, Section 301: Research grantS.cccccssccsasesaee eee e eee Training grants..wesesscccees Ses eteessuee Direct operations............eceee eens Community Mental Health Centers Act: Part A, Section 201--Construction of Community Mental Health Centers......... Part B, Section 22h--Staffing of Community Mental Health Centers: Initial grants. .ccccceccscccseneceeeses Continuation grants... cssesevccsccseee Parts C and D, Alcohol Abuse and Alcohol- ism, Narcotic Addiction, Drug Abuse, and Drug Dependence Prevention and Rehabiii-~ tation: Section 247--Grants and contracts for the prevention and treatment of alcohol abuse and alcoholism.......... Section 253-~Drug abuse education...... Section 256--Special projects for narcotic addicts and drug dependent PETSONS ee ccecerecnceccsccccevenesenss Section 261--Construction and staffing of alcoholism, narcotic addiction, and drug abuser rehabilitation facilities, training and evaluation, and direct grants for special projects: Initial grants. ...ccecceescessceces oe ContinustionS...ccscccssneccecerevece Part E, Section 264--Grants for consulta- tion services: Initial grants. ...... ccc cece cece eeeeeee Continuation grants. ...ccs cece eeeecner Part F, Section 271--Construction and staffing of child mental health treat- ment facilities: Initial grants..ccccccsccccesescecceens ContinuationsS....cccccccsescccerecenece Comprehensive Alcohol Abuse and Alcoholism Prevention, Treatment, and Rehabilitation Act of 1970: Title III, Part A, Section 301--Formula BVANES. cece ecw cece enn enscrsnescececncs 11 Appropriation Authorized requested Indefinite $101,400 ,000 Indefinite 105,050,000 Indefinite 89 ,129 ,000 $100,000,000 --- 60,000,000 9,131,000 Indefinite 125 ,969 ,000 50,000,000 26,490,000 14,000,000 1,732,000 35,000,000 35,000,000 80,000,000 24,616,000 Indefinite 58 ,043 ,000 5,000 ,000 100,000 indefinite --- 30,000,000 1,515,000 Indefinite 8,485 ,000 80,000 ,000 30,000,000 12 Authorizing Legislation for Grants I. The following Sections of the Public Health Service Act authorize grants under the activities "Research" and "Manpower Development." Sec. 301. The language of this Section will be found under the tab "Preamble Paragraph” in Volume II. Section. 302. (a) In carrying out the purposes of Section 301 with respect to narcotics, the studies and investigations shall include the use and misuse of narcotic drugs, the quantities of crude opium, coca leaves, and their salts, derivatives, and preparations, together with reserves thereof, necessary to supply the normal and emergency medicinal and scientific requirements of the United States. The results of studies and investigations of the quantities of crude opium, coca leaves, or other narcotic drugs, together with such reserves thereof, as are necessary to supply the normal and emergency medicinal and scientific requirements of the United States, shall be reported not later than the ist day of September each year to the Secretary of the Treasury, to be used at his discretion in determining the amounts of crude opium and coca leaves to be imported under the Narcotic Drugs Import and Export Act, as amended. (vb) The Surgeon General shall cooperate with States for the purpose of aiding them to solve their narcotic drug problems and shall give authorized representatives of the States the benefit of "his experience in the care, treatment, and rehabilitation of narcotic addicts to the end that each State may be encouraged to provide adequate facilities and methods for the care and treatment of its narcotic addicts. Sec. 303 (a) In carrying out the purposes of Section 301 with respect to mental health, the Surgeon General is authorized-—- (1) to provide training and instruction and tc establish and maintain traineeships, in accordance with the provisicns of Section 433 (a); (2) to make grants to State or local agencies, laboratories, and other public or nonprofit agencies and institutions, and to individuals for investigations, experiments, demonstrations, studies, and research projects with respect to the development of improved methods of diagnosing mental illness, and of care, treatment, and rehabilitation of the mentally ill, including‘ grants to State agencies responsible for II. ee oO administration of State institutions for care, or care and treatment, of mentally ill persons for developing and establishing improved methods of operation and administration of such institutions. (b) Grants under paragraph (2) of subsection (a) may be made only upon recommendation of the National Advisory Mental Health Council. Such grants may be paid in advance or by way of reimbursement, as may be determined by the Surgeon General; and shall be made on such conditions as the Surgeon General finds necessary. Sec. 507. Appropriations to the Public Health Service avail- able for research, training, or demonstration project grants pursuant to this Act shall also be available on the same terms and conditions as applied to non-Federal institutions, for grants for the same purpose to hospitals of the Service, of the Veteran's Administration, or of the Bureau of Prisons of the Department of Justice, and the Saint Elizabeths Hospital. Community Mental Health Centers Act Part A--Construction of Community Mental Health Centers Authorization of Appropriations Sec. 201. There are authorized to be appropriated, for grants for construction of public and other nonprofit community mental health centers, $35,000,000 for the fiscal year ending June 30, 1965, $50,000,000 for the fiscal year ending June 30, 1966, $65,000,000 for the fiscal year ending June 30, 1967, $50,000,000 for the fiscal year ending June 30, 1968, $60,000,000 for the fiscal year ending June 30, 1969, $70,000,000 for the fiscal year ending June 30, 1970, $80,000,000 fer the fiscal year ending June 30, 1971, $90,000,000 for the fiscal year ending June 30, 1972, and $100,000,000 for the fiscal year ending June 30, 1973. Part B--Steffing of Community Mental Health Centers Authorization of Appropriations Sec. 224. There are hereby authorized to be appropriated $19,500,000 for the fiscal year ending June 30, 1966, $24 ,000 ,000 for the fiscal year ending June 30, 1967, $30,000,000 for the fiscal year ending June 30, 1968, $26,000,000 for the fiscal year ending June 30, 1969, $32,000,000 for the fiscal year ending June 30, 1970, $45,000,000 for the fiscal year ending June 30, 1971, $50,000,000 for the fiscal year ending June 30, 1972, and $60,000,000 for the fiscal year ending June 30, 1973, to enable the Secretary to make initial grants to community mental health centers under the provisions of this part. For the fiscal year ending June 30, 1967, and for each of the thirteen succeeding years, there are hereby authorized to be appropriated such sums as may be necessary to make grants to such centers which have previously received a grant under this part and are eligible for such a grant for the year for which sums are being appropriated under this sentence. Parts C and D--Alcohol Abuse and Alcoholism, Narcotic Addiction, Drug Abuse, and Drug Dependence Prevention and Rehabilitation ALCOHOL ABUSE AND ALCOHOLISM Authorization of Appropriations Sec. 247. (d) To carry out the purposes of this section, there are authorized to be appropriated $30,000,000 for the fiscal year ending June 30, 1971, $40,000,000 for the fisc&l year ending June 30, 1972, and $50,000,000 for the fiscal year ending June 30, 1973. DRUG ABUSE EDUCATION Authorization of Appropriations Sec. 253. (da) To carry out the purposes of this section, there are authorized to be appropriated $3,000,000 for the fiscal year ending June 30, 1971, $12,000,000 for the fiscal year ending June 30, 1972, and $14,000,000 for the fiscal year ending June 30, 1973. SPECIAL PROJECTS FOR NARCOTIC ADDICTS AND DRUG DEPENDENT PERSONS Authorization of Appropriations Sec. 256. (e) ‘There are authorized to be appropriated to carry out this section not to exceed $20,000,000 for the fiscal year ending June 30, 1971, $30,000,000 for the fiscal year ending June 30, 1972, and $35,000,000 for the fiscal year ending June 30, 1973. CONSTRUCTION AND STAFFING OF FACILITIES Authorization of Appropriations Sec. 261. (a) There are authorized to be appropriated $15,000,000 for the fiscal year ending June 30, 1970, $40,000,000 for the fiscal year ending June 30, 1971, $60,000,000 for the fiscal year ending June 30, 1972, and $80,000,000 for the fiscal year ending June 30, 1973, for project grants for construction and staffing of facilities for the prevention and treatment of alcoholism under Part C, or the prevention and treatment of narcotic addiction, drug abuse, and drug dependence, under Part D and for grants unler Section 252 and Section 246. Sums so appropriated for any fiscal year shall remain available for obligation until the close of the next fiscal year. (bo) There are also authorized to be appropriated for the fiscal year ending June 30, 1971, and each of the next nine fiscal years such sums as may be necessary to continue to make grants for staffing with respect to any project under Part C or D for which a staffing grant was made from appropriations under subsection (a) of this section for any fiscal year ending before July 1, 1973. mo oo oe ok oe oe ee ee ee ee 15 Part E--Grant for Consultation Services : Authorization of Appropriations Sec. 264. (c) For purposes of making initial grants under this section, there are authorized to be appropriated $5,000,000 for each of the fiscal years ending June 30, 1971, June 30,.1972, and June 30, 1973. There are also authorized to be appropriated for the fiscal year ending June 30, 1972, and for each of the next eight fiscal years such sums as may be necessary to continue to make grants under this section for projects which received initial grants under this section from appropriations authorized for any fiscal year ending before July 1, 1973. Part F--Mental Health of Children , Authorization of Appropriations Sec. 271. (a) (1) There are authorized to be appropriated $12,000,000 for the fiscal year ending June 30, 1971, $20,000,000 for the fiscal year ending June 30, 1972, and $30,000,000 for the fiscal year ending June 30, 1973, for grants under this part for construction and for initial grants under this part for compensation of professional and technical personnel, and for training and evaluation grants under section 272. “(2) There are also authorized to be appropriated for the fiscal year ending June 30, 1972, and each of the next eight fiscal years such sums as may be necessary to continue to make grants with respect to any project under this part for which an initial staffing grant was made from appropriations under paragraph (1) for any fiscal year ending before July 1, 1973. III. The following sections of Public Law 91-616, the Comprehensive Aleohol Abuse and Alcoholism Prevention, Treatment and Rehabilitation Act of 1970, establish within NIMH, the National Institute of Alcohol Abuse and Alcoholism and authorize the award of formula grants to the States. P.L. 91-616 also amends the Community Mental Health Centers Act to authorize grants and contracts for the prevention and treatment of alcohol abuse and alcoholism. The amendatory language is set forth below. The dollar authorization appears in the appropriate section of the Community Mental Health Centers Act (Section 2uT). Title I - National Institute on Alcohol Abuse and Alcoholism Establishment of the Institute Sec. 101. (a) There is established in the National Institute of Mental Health, the National Institute on Alcohol Abuse and — Alcohoiism (hereafter in this Act referred to as the "Institute") tc administer the programs and authorities assigned to the Secretary of Health, Education, and Welfare (hereafter in this Act referred to’as the "Secretary") by this Act and part C of the Community Mental Health Centers Act. The Secretary, acting through the Institute, ghall, in carrying out the purposes of section 301 of the Public Health Service Act with respect to alcohol abuse and alcoholism, develop and conduct comprehensive health, education, training, research, and planning programs for the prevention and treatment of alcohol abuse and alcoholism and for the rehabilitation of alcohol abusers and alcoholics. 16 (b) The Institute shall be under the direction of a Director who shall be appointed by the Secretary. Title III - Federal Assistance for State and Local Programs ’ Part A - Formula Grants Authorization of Appropriations Sec. 301. There are authorized to be appropriated $40,000,000 for the fiscal year ending June 30, 1971, $60,000,000 for the fiscal year ending June 30, 1972, $80,000,000 for the fiscal year ending June 30, 1973, for grants to States to assist them in planning, establishing, maintaining, coordinating, and evaluating projects for the development of more effective prevention, treatment, and rehabilitation programs to deal with alcohol abuse and alcoholism. For purposes of this part, the term "State" includes the District of Columbia, the Virgin Islands, the Commonwealth of Puerto Rico, Guam, American Samoa, and the Trust Territory of the Pacific Islands, in addition to the fifty States. Real Transfer to: "Operating expenses, Public Building, General Services Administration" Comparative Transfer to: "Departmental Management" "Saint Elizabeths Hospital” —d Explanation of Transfers 1972 Estimate - $4,000 -115,000 -1,600,000 Purpose Rental of space, Seattle, Washington Regional Office. For DHEW central service and support in the following areas: 1. Upward Mobility Program (1 position, $13,000) Model Cities Program (2 positions , $30,000) Executive Secretariat (1 position, $16,000) Public Affairs (2 positions, $55,000) Central personnel office improvement ($1,000) Transfer of resources which support clinically based training and research activities at the hospital. i. Training (35 positions, $1,250,000) Research (17 positions, $350,000). Year 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 Budget estimate to Congress 126,899,000 190,096,000 224,085,000 278,669,000 305,115,000 346,909,000 364,939,000 357,904,000 346,656,000 499,451,000 612,170,000 Mental Health House Senate Allowance Allowance 133,599,000 148,599,000 177,288,000 190,096,000 223,273,000 223,273,000 278,669,000 283,169,000 310,119,000 315,619 ,000 296,909 ,000 346,909 ,000 342 5439 ,000 364 ,939 ,000 360,302,000 385 ,000 ,000 371,738,000 456,738,000 581,201,000 658 ,201 ,000 Appropria- tion 143,599,000 183,288,000 223 ,273 ,000 283,169,000 315,619 ,000 346,909,000 350,439,000 360,302,000 389 ,238 000 612 ,201 ,000 18 pos co General Statement The basic mission of the National Institute of Mental Health is to develop knowledge, manpower, and services to prevent mental illness, to treat and rehabilitate the mentally ill, and to promote and sustain mental health. Underlying the great diversity of studies and projects supported by the National Institute of Mental Health is a clear unity of purpose, which is to increase understanding of the forces within and around man which affect or dictate his emotional and mental health, and to apply this knowledge in effective treatment and prevention services. A total approach to the problem of mental illness must also provide for focusing upon acute, critical problems. For this purpose, the Institute has established several centers which focus on specitic high-priority areas such as alcoholism and drug abuse. The organization of the Institute and the distribution of its resources, as reflected in this document, are intended to optimize support among research, training, and service activities. Research is carried out by the institute's intramural research program and is also supported by grants and contracts awarded to investigators in universi- ties, hospitals, and other institutions. Training programs to develop skilled manpower in the mental health professions and allied fields are supported through training grants to institutions and through research fellowships. Financial and technical assistance to States and local communities aids the development of community mental health services. 20 il. Research a. Grants: Included in this subactivity are the Institute's research grant and hospital improvement programs, each of which is described below: : RESEARCH GRANTS Increase or igfe 1973 Decrease Grants......... cence eees $90,500 ,000 $94,500 ,000 +$h ,000 ,000 To find better ways to treat, control, and prevent mental illness, many types of research are supported. Besides the clinical research to study this illness in patients, basic research is conducted to discover how genetic factors, the environment, and our social systems affect thought and behavior. In services development, research investigators test new methods and concepts in care and prevention of mental illness which have been suggested by the results of basic research. Support is provided to individual investigators on a project basis for basic applied and clinical research, throughout the broad areas of mental illness as well as areas of special interest such as drug abuse, pshcho- pharmacology, alcoholism,child mental health, minority mental health, crime and delinquency, and services development research. Tables 1 and 2 show the distribution of research grant funds by type of grant and by program. fable 1. Distribution of Research Grants Increase or i972 1973 Decrease No. Amount No. Amount No. Amount Continuations....... sees Tl $49,851,000 655 $49,851,000 -86 --= Competing renewals...... 153 9,943,000 iTh 11,927,000 +21 +$1,984,000 New Projects............ 628 20,804,000 656 22,820,000 +28 +2016 ,000 Supplementals........... (78) 1,500,000 (-78) 1,500,000 -- --- Total.....ecceeeee21,522 82,098,000 1,485 86,098,000 -37 +4,000,000 Table 2. Research Grants Program Distribution el Increase or 1972 1973 Decrease Narcotic Addiction & Drug Abuse.......... $10,549,000 $11,049,000 +$500 ,000 AlCONOLISM. ccc ccc cece eee r cece cree asvens 7,543,000 8,043 ,000 +500 ,000 Crime and Delinquency........ Deas eee es 3,643,000 4,143,000 +500 ,000 Minority Studies. ..... ccc eee cece eecnceree 1,135,000 2,135,000 +1,000 ,000 Suicide Prevention. ..cesssssccscvccaveees 1,744,000 1,744,000 --- Farly Child Care...csccecssesseccssesvens 2,000 ,000 2,000 ,000 --- Metropolitan Problems... ..ccceusvceeceees 2,183,000 2,183 ,000 ---+ Mental Health Services.......seeeeee: see 7,589,000 9,089 ,000 +1,500 ,000 Psychopharmacology....secessecvsecesssees 10,110,000 10,110,000 --- Behavioral Sciences.......-cecvevreseeee : 17,713,000 17,713,000 --- Applied Research....ssssesevevcceeecneecs 8,563,000 8,563,000 --- Epidemiology. ..cssccccecsccsecsseeevseens 1,120,000 1,120,000 --- Clinical Research. ....cscc cee ee reer enens 8 ,206 ,000 8,206,000 --- “B82 098,000 86 ,098 ,000 +h 000,000 Scientific Evaluation. ......ccceeneeeeees 375 ,000 375 5000 --- General Research Support.......ccerscracs 8,027 ,000 8,027,000 --- Total Regular Research...... seceesesesess 90,500,000 94,500 ,000 +4 000,000 Narcotic Addiction and Drug Abuse: The Institute requests an increase of $500,000 for research in narcotic addiction and drug abuse in 1973 to expand the intensified research program conducted in 1972. Among the areas of this broad and complex field requiring the development of new knowledge are: the mechanisms of drug action; the metabolism of abused drugs; the identifi- cation of drugs of abuse in body tissues and fluids; the development of narcotic substitutes and antagonists; the psychological and behavioral effects of drugs; and the genetic effects of abused drugs. One objective of the research program is to investigate the bio~ chemical basis of drug tolerance and physical dependence to gain an understanding of the processes that underlie drug addiction in man. For example, one investigator has found that protein synthesis in the brain is altered biphasically by narcotics. This effect is now being explored in the rat brain using several avenues of research: (1) measur- ing the change in the rate of protein synthesis after a single injection of morphine using the in vivo amino acids into brain proteins; (2) by assaying tyrosine hydroxlase, an enzyme, in six areas of the rat brain after morphine treatment; and (3) by studying the binding of morphine to nucleic acids. The cognitive effects of chronic marihuana and/or hallucinogenic drug usage on the intellectual and adaptive abilities of a young male undergraduate population are being studied on one campus, utilizing students who voluntarily report various levels of usage over a defined time period. Results of a variety of standardized tests will be compared with those made by students reporting no usage to determine if verbal intelligence, spatial orientation, concept formation and ability to abstract have been adversely affected. In another study, an investigator is attempting to determine the effect of marihuana on the cell nucleus and its relationship to gene transcrytion, metabolism of chromosomal protein, and energy metabolism. This study utilizes the in vivo study of rats injected with radio- actively labeled marihuana constituents, which are then traced in the 22 Brain after various time intervals. Important studies are being conducted to determine the potential of marihuana extract to produce damage to chromosomes in both human and animal systems following dosages of varying strength and over differing periods of time. Research is also being conducted in the area of amphetamine abuse. For example, the effects of methamphetamine on the cerebrovascular system in Rhesus monkeys is being studied. This may be of particular importance in view of the number of clinical reports describing cerebro- vascular changes in drug abusers who take amphetamines. Following intravenous dosage of varying periodicity, all animals will have arterial catheterization and arteriograms to determine the extent of changes in the arterial wall, arterial occlusions, and damaged arterioles. At the conclusion of test periods, or earlier if fatalities occur, the animals will be killed and both gross and microscopic histopathological examin- ations will be conducted to determine the form and extent of cerebro- vascular damage. One aspect of the work in progress on effective narcotic antagonists involves the development of a sustained release vehicle for their adminis- tration. To this end, several projects are being supported to dissolve or suspend narcotic antagonists in a variety of potential depots, including glycogen, cholesterol, polyvinyl alcohol and others, The investigators are also considering the possibility of administering the antagonists in tooth fillings or dental prosthetic devices. The acceptability and the effectiveness of methadone as a treatment agent is being studied under a grant to a large metropolitan muiti- modality treatment facility. This study is examining (a) the client's initial concerns and feelings about. methadone, (vo) the impact of orientation on his attitudes, (c) the attitude of staff and patients undergoing other forms of treatment, and (d) the response of clients to the methadone maintenance program. Both behavioral and personality measures will be made, and follow-up data will be collected to show changes in functioning of clients in maintenance, abstinence, and other treatment programs. In view of the increasing use of methadone and the dearth of informa- tion on the fate of methadone in the pregnant state, a project is being supported to determine the distribution and effects of methadone and its metabolites in pregnant rats and sheep, following acute and chronic administration of the drug, information about its nature, causes, treatment and prevention. Aleoholism: Since alcoholism is the product of a complex and as yet unexplained interaction of biological, psychological and sociological factors, researchers in a number of different fields seek answers to a broad range of questions about the nature of alcoholism and its antecedents. Only as knowledge in the field grows will the capability develop to apply these research findings to treatment and prevention programs. The 1973 budget request provides an increase of $500,000 for alcoholism related research. The material below provides examples of existing activities that will continue to receive support and, where necessary, be expanded. 1. Clinieal research: This area continues to be an important part of the grant program, and ongoing projects are concerned with the effects of aleohol on the stomach, and the identification of different patterns of alcoholism. Research has also been conducted on hemodialysis, the rapid removal of aleohol from the bloodstream. Although this process is not currently practical, it has been accomplished without serious complications. More study on a practical means of channelling alcohol from the bloodstream is planned for 1973. 23 2. Prevention and education: Studies concerning the youth and young adult are needed. In a large scale study of high school youths it was demonstrated that parental rejection, deprivation and impulsivity are factors which can predict problem drinking in youth. Research is being planned to categorize and evaluate the major characteristics and effective- ness of existing preventive programs to develop theory~-based programs of public education. Although primary emphasis will be on observing the develop- ment of problem drinking, the investigators will also study drug use, delinquency, and antisocial behavior in school. 3. Behavioral and psychological studies: Two studies have been done in an attempt to differentiate between subtypes of alcoholic patients to optimally match specific treatment modalities to particular patients. One of these has identified "essential" and "reactive" types of alcoholic persons and the other has described four subtypes based on the relationship between social factors and drinking patterns. Studies such as these will provide information about the perceptual motivation of the alcoholic person, differences in personality characteristics of non-drinkers and drinkers, and other factors associated with the preference for alcohol. 4, Studies of alcohol and driving: The effect of alcohol on driving skills is another area requiring considerably more development. It is estimated that at least 50% of the 56,000 annual highway fatalities are alcohol-related. Experiments are being conducted to determine the effects of alcohol on attention in performing such tasks as driving a vehicle. These experiments suggest that attention is seriously impaired by relatively low doses of alcohol, in contrast to its effects on such functions as vision where relatively high doses are required to produce impairment. Under the effects of alcohol, subjects attempted to cope with the divided attention task by restricting their attention increasingly to one type of task. While the subjects maintained performance closer to normal on the preferred task, nearly all the performance impairment occurred on one of the two tasks. ‘The subjects were generally unaware of any impairment in their own performance. Other aspects of the drinking-driving area in great need of research include the identification of population of of high risk drivers and the specification of its demographic characteristics in order to implement an effective program in driver education. 5, Evaluation of physiological effects: Grants which investigate the physiological effects of alcohol will continue to receive emphasis. Increasing the rate of metabolism of alcohol or preventing its absorption in the body may facilitate the care of acutely intoxicated persons by rapidly inducing sobriety or as a preventive measure against intoxi- cation. Further research needs to be conducted to determine the validity of these findings and to explore in greater depth the similarities and differences between the addictive processes of alcohol and other substances. Child Mental Health: Activities directed at improving the mental health of children carry the highest priority for NIMH. The foundation of the Institute's efforts in child mental health is research--an effort to understand both normal and abnormal behavior. The goals of the current program are to (1) develop and demonstrate new approaches to prevention of learning and behavioral disabilities in children through family-centered programs; (2) stimulate innovative approaches to the improvement of early child care services and education through existing community institutions, and (3) foster the development of a famiiy and child advocacy system based on control by community organizations of parents rather than by professionals in order to improve and integrate family and child services. The 1973 budget request includes an increase of $1,500,000 for Child Mental Health research programs. This increase will be used to stimulate research in the following six priority areas. 24 --- Coordination of children's services with allied delivery systems: these projects will be concerned with services extended by community mental health facilities as they relate to welfare, medical, educational, correctional, and rehabilitation programs for the handicapped. --- Expansion and upgrading of preventive programs for children in community mental health centers contacts and other settings: research activities will include the development of models of children's services in centers and related facilities, with particular attention directed to consultation and education services among community agencies with parent groups. _ oe Developing methods of reducing hospitalization of children and youth: projects will test innovative approaches to alternative care programs as well as to such direct intervention techniques as family crisis intervention. -~~ Supporting models of mental health oriented day care, nursery, and kindergarten programs: special emphasis will be placed upon the role of mental health centers staff in providing technical assistance to partnership agencies providing programs for young children. --- Development of adequate services for minority children: aspects to be stressed are helping parents and referral sources utilize the availability of services in manners that are acceptable to them, the design of services to meet special needs of minority children, and intervention in community conditions which militate against the mental well-being of minority children. --- Developing special services for the adolescent who is likely to drop out of school or to resort to drugs: efforts will be made to develop subtle assistance that will not require labeling of the students to receive help--a factor that has been found to be a deterrent in referral of students for help. Mental Health of Minority Groups: The Institute's Center for Minority Group Mental Health Programs focuses its attention on the special mental health problems of the almost 40 million minority group members in the United States. The general conditions of the life of many minorities are associated with high levels of schizophrenia, alcoholism, drug usage and other mental health probiems and institutioalization in mental health facilities, though it is inaccurate to generalize for all minorities since there are inter-group and intra-group differences. Research is supported to understand the causes, results, and mechanisms of prejudice and discrimination, and to evaluate methods of correcting the attitudes and conditions which place minorities in a disadvantaged position. This is done with minority groups themselves playing a major role in design, administration, and conduct of the research. The 1973 request includes $1,000,000 to expand research programs related to improving our under- standing of the mental health problems of minority groups. Areas of emphasis will include (1) continued study of causes and methods of combatting prejudice, discrimination, stereotypes and racism with emphasis on the aged and institutional change; (2) the relation of social class and minority mental health problems; (3) effective organization and delivery of mental health services for minorities; and (4) ways of building on the strengths of minority groups. The research program will also focus on the connection between residential segregation and assimilation; the factors that affect economic and occupational placement of minority group members as well as studies of minority group institutions and services such as churches and colleges. Crime and Delinquency: The risk of becoming a victim of a serious crime has more than doubled since 1960. Five million serious crimes were reported during 1969, representing 12 percent increase over 1968. Between 1960 and pu BeSeeeeeeeeaes@a8ssB Sas 25 1969, arrests of juveniles for serious crimes increased 90 percent, while the number of persons in the 10-17 year age group increased only 27 percent. Work in this field is based on the premise that effective prevention, treatment, and control of social deviance will depend largely upon a sound knowledge base. Some projects currently receiving support include improving the capabilities of the public schools to deal effectively with emotional, interpersonal and academic problems presented by adolescent boys; and studies on the effect of the "soctal climate’ of correctional institutions on inmate behavior and on the relationship between the personal experiences of institutional inmates and the organizational structure and function of the total institution. In an effort to help determine and reduce the causes of crime and delinquency, the 1973 request provides an increase of $500,000 for the study of various forms of deviant and maladaptive behavior, including development of a sound understanding of its etiological factors; development of means and technology for prevention; and development of adequate methods of intervention. Other Research Programs: In addition to the fields of investigation just summarized, the Institute plans to continue the following programs in 1973 at their current-year funding level. --- Clinical research will emphasize studies leading to improved treatment methods, and the study of the complex of factors from which mental illness and emotional distress arise. -.- Behavioral sciences research will cover a variety of subjects, encom- passing a range of biological and social sciences. Studies will be conducted into the processes whereby the personality, motives, emotional and intellectual characteristics of children are shaped by the family and social environment. --- Psychopharmacology, one of the most successful of. the Institute's research programs, will continue to support studies to assess the pharmacological properties of new compounds; to analyze the physiological and behavioral effects of drugs on animal and human subjects; and to evaluate the efficacy of new chemotherapeutic agents in the treatment of specific disorders such as schizo- phrenia, depression, drug abuse and alcoholism. --- Applied research will continue to pursue one of its primary aims: the prompt and effective application and evaluation of research findings. The program also seeks to test pioneering approaches and new concepts, such as the use of a mobile wit to provide mental health services to children and. their mothers in a deprived urban environment. --- Studies of metropolitan problems deal with the mental disorders and emotional distress that are most prevalent in the inner cities and decaying fringes of our urban areas. The Institute will continue to support studies that attempt to delineate the causes, determine why some are stricken while others are unaffected, and improve existing measures for prevention and. treatment. . : \ ’ . f 44 > ; AN : a4 . 26 2. Hospital Improvement Grants Increase or 1972 1973 Decrease No. Amount No. Amount No. Amount Continuations.......... 44 $4,100,000 57 $5,400,000 +13 +$1,300,000 Competing renewals..... 17 1,500,000 8 701 ,000 -9 -799 ,000 New projects....eseee.- 15 - 1,300,000 9 799,000 -6 -501,000 Total.ceescceseees TO 6,900,000 74 6,900 ,000 -2 --- The major emphasis of the Hospital Improvement Program is directed toward improving the treatment, care, and rehabilitation of the mentally ill in the 302 eligible state-supported mentai hospitals throughout the Nation. The program specifically focuses on the use of latest techniques and knowledge in demon- strating improved services for patients. Programs are planned in response to the hospitals' highest priority needs, and directed to the long-range goal of improving patient care throughout the Institution. In 1972 the Institute decentralized the administration of the Hospital Improvement Program to the Department of Health, Education, and Welfare Regional Offices. As a result of the close proximity of the Regional Offices to the State hospitals it is felt that they can be more responsive to the needs of the hospitals and can provide improved monitoring of those institutions which have received grants. As part of the program, hospitals are encouraged to move toward the develop- ment of cooperative relationships with comprehensive community mental health programs and by the close of 1971, 162 State hospitals reported the start or growth of cooperative relationships with local groups and agencies. Within this number 134 are directly affiliated with community mental health centers and have demonstrated the crucial value of State hospitals as back-up or special resources to newly developing mental health centers. They have assisted in providing a range of services not available in mental health centers and provide component parts of center programs such as inpatient care, emergency care, aftercare, outpatient care, diagnostic services, rehabilitation, consultation and education. As a result of improved delivery of services achieved through a Hospital Improvement award, six state hospitals have received staffing support through the Community Mental Health Centers program. At the end of 1971 a total of 249 Hospital Improve- ment grants had been awarded to 179 of the 302 eligible State mental hospitals. There are a number of noteworthy examples of progress in the Hospital Improve- ment program that illustrate its success in improving patient care. In one typical program, the project was designed to bring together approximately 72 back ward chronic schizophrenic patients into a single ward for resocialization and rehabilitation in preparation for community placement, gainful employment, and to provide them with opportumity to assume the major responsibility for their own conduct and activities. The protocol involved a five step operant conditioning program with each higher step representing an increase of income (the range of income was from $3 to $12 per week) and a commensurate degree of increased responsibility and privilege. In the final stages the patient was permitted to spend his own money and assume almost full responsibility for his activity and actions of others in the group. After a period of time patients were moved in small groups to a rented furnished home in the community under supervision of a community coordinator. During this period, appropriate job placements were made and the income used to help pay for rent, food and other items. About 165 patients have been discharged through this project with a return rate of only 10% as compared to 30% in most hospitals. Another program was developed in response to the rapidly growing number of admissions in the 12 to 18 year old age group. During the first years of operation of this program admissions more than doubled. Educational recreational and occupational programs were extensively used and individual attention and psychotherapy was provided. Of the 272 patients admitted to the program about 84% have been released. The average stay of patients in the program was reduced from 26-months to 13 months.. 28 b. Direct Operations Increase or i972 1973 Decrease Pos. Amount Pos. Amount Pos. Amount Personnel compensation and benefits..... wee 1,170 $18,903,000 1,184 $19,169,000 +14 +$266,000 Other expenses.....e.- --- 22,796,000 --- 24,099,000 --- +1,303,000 Total..eseceeeees 1,170 41,699,000 1,184 43,268 ,000 +14 +1,569,000 This activity supports 1) staff who are responsible for the planning, develop- ment and administration of the research grant and contract program; 2) funding for the intramural research program which is conducted in the Institute's own laboratories and clinics; 3) the Clinical Research Center at Lexington, Kentucky; and 4) a limited amount of research performed on a contract basis. The Division of Extramural Research Programs plans and administers research programs in the areas of behavioral science, clinical research, applied research, psychopharmacology and epidemiologic studies. Included in this Division is the Center for Studies of Schizophrenia which serves as @ coordinating unit to analyze current research to avoid unjustified duplication of effort and to stimulate promising new avenues of scientific investigation. The Division of Special Mental Health Programs administers programs directed toward problems of special significance such as crime and delinquency, metro- politan problems, mental health of children and families, and minority group mental health problems. These highly responsive centers were established to coordinate and focus grant and contract funds on specific problem areas. Intramural Research: The NIMH Intramural Research Program conducts basic and clinical research on the problems of mental illness and related pathologies. Strategically located on the campus of the National Institutes of Health where opportunities for fruitful exchange abound, its scientists pursue the new knowl- edge without which we cannot hope to alleviate the scourge of mental illness for millions of Americans or to reduce the enormous economic toll it exacts. These scientists are members of a research cadre whose excellence is esteemed throughout the scientific world, a fact evidenced by the honors which continue to be bestowed on them in this country and abroad. Dr. Julius Axelrod, 1970 Nobel Prize winner, together with a team of collab- orators, is currently engaged in a search for enzymes involved in biogenic amine biosynthesis and metabolism in the blood. The measurement of these enzymes makes it possible to determine the activity of the sympathetic nervous system in stress and in a number of diseases, (e.g., manic depression and familial dysautonomia) and after drug treatment. Other members of the research team.are working on development of the adrenergic neurones in the fetal brain. Their findings have given considerable insight into the development of these important nerves as the brain grows to maturity. Still another team is engaged in clinical studies of drugs which are frequently abused, e.g., amphetamine and tetrahydrocannabinol (THC), the active ingredient in marihuana. They have found that although tetrahydrocannabinol is partly metabolized, a considerable residue is stored in the tissues and is released so slowly that it can be detected in the blood for several days after its administration. Chronic users of marihuana metabolize it more rapidly than controls who had never used the drug. Another aspect of the THC story concerns the role of an enzyme which induces metabolism of the drug in the lung but which is not present in the liver. Data from another Intramural study suggest that since marihuana is usually smoked, this lung enzyme may play a significant role in determining biochemical patterns of drug distribution in abusers of cannabinols. 23 A team of intramural scientists is now reporting their findings from data collected over the past several years on early family development. The sequence begins with the newly wedded couple, examines their adjustment to marriage, the birth of their first child, the newborn infant in the first few hours of life, mother-infant interaction, the same infant when he becomes 2 1/2 years old and attends nursery school, the pre-school period and later, the early school period. The findings clearly demonstrate relationships between newborn and later behavior, and between pre-school behavior and that of the school-age period. For example, vigorous and goal-oriented behavior (assertiveness) in the pre-school period has proved to be related to later verbal intelligence and use of imagination in the early school-age period, as well as to social ease, lack of fearfulness and more adequate coping with strange new situations. These findings are important for parents, educators and others concerned with fostering the development of learning capability in the young child. Thirteen years of planning, designing and building became a reality this past year when the Institutes' Laboratory of Brain Evolution and Behavior was dedicated at the National Institutes of Health Animal Center in Poolesville, Maryland. The new facility will help Institute scientists conduct brain function and behavior studies on animals living in semi-natural habitats thus eliminating some of the obvious difficulties inherent in behavioral studies of animals con- fined in laboratory cages and living under largely artificial conditions. In an engrossing study of overcrowding in caged mice, one scientist has witnessed what he terms "the dissolution of social organization", the end result of which is an incapacity on the part of the subjects to replace themselves through reproduction. Even when some of the mice were removed to less crowded quarters, their capacities for carrying out the complex behaviors (social relating, courtship, mating and motherhood) which are requisite for survival of the species, were impaired. Although these studies were conducted with mice, the findings may have application for other species, including man. In other studies of the brain, investigators have shown that cerebral vessels are remarkably sensitive to oxygen and that concentrations no higher than those commonly used therapeutically for premature and newborn infants with cardiac or respiratory diseases cause as much as 35% reduction in blood flow in most parts of the brain. These findings suggest that oxygen inhalation therapy should be used cautiously during the peri-natal period lest it lead to retarded brain development and other deleterious effects in the nervous system. Alcoholism: The Intramural research portion of the National Institute of Alcoholism and Alcohol Abuse, carried out in special research facilities at Saint Elizabeths Hospital in Washington, D. C., is particularly concerned with the nature of the addictive process in alcoholism. The research model that is used allows the investigators to study both the behavior and bio- chemistry of alcoholic individuals in all phases of experimentally-induced intoxication. An important reason for studies of the drinking pattern and behavior of chronic alcoholics is the need to examine the many untested assumptions about how and why an alcoholic drinks. These assumptions are based on retrospective reports of alcoholic individuals made during periods * of sobriety and their validity may be affected both by deliberate and unintentional distortions or by the patient's inability to recall and adequately state his attitudes toward alcohol. The program uses experimental animals to test hypothesis developed from intensive study of the alcoholic individual. For more than a decade, much _ effort has been expended to produce alcoholism in an animal in order to facilitate the study of the development sequence and the actions of possible neurochemical, neurophysiological and metabolic factors which are concomitants of alcohol addiction. Data obtained from analyzing the development of such addiction will ultimately help to clarify the biological mechanisms of alcohol addiction and suggest ways to stop or reverse the disease process. 30 The Narcotic Addiction Research Center, is the intramural research arm of the Division of Narcotic Addiction and Drug Abuse, carries out the continuing responsibility for producing laboratory and clinical data on the effects of drugs. This includes studies which assess the psychic dependence producing properties of new non-narcotic drugs prior to their entry into the commercial market, the continued research into new methodologies for improved research on drugs and diagnosis of drug usage, and pharmacological studies of drugs and their action on the nervous system. The center is the only facility which can be called upon to do human assessment of narcotic and non-narcotic drugs. With positions and funds provided in the 1972 budget amendment the Addiction Research Center will expand its existing efforts to assess the dependence pro- ducing properties of narcotic analgesics to include studies of non-narcotic drugs to determine their abuse potential prior to their entry into the commercial market. Clinical pharmacological research on new non-narcotic drugs often reveals the presence of addictive properties which had not been. discovered in animal testing. Moreover manipulation of dose range in clinical testing brings about variances in subjective reactions which are invaluable in understanding the nature and assessing the danger of drugs. This determination is necessary so that the Secretary can carry out his responsibilities under the Comprehensive Drug Abuse Prevention and Control Act of 1970 (P.L. 91-513), which requires that he make recommendations to the Attorney General on the control classification of a drug. Efforts are continuing in order to develop, assess and validate methods for the determination of narcotics in the urine. One method which shows great promise as a practical means for the diagnosis of drug abuse uses thin layer chromatography applied to the urine. This detects the presence of certain drugs and differentiates them from one another. Clinical Research Center: In recognition of its primary research orienta- tion, funding for the Institute's Clinical Research Center at Lexington, Kentucky has been transferred to this activity from the "Rehabilitation of Drug Abusers" account. The Center will continue to provide services to addicts committed to the care of the Federal Government under the Narcotic Addict Rehabilitation Act of 1966, by the courts, from cities that do not have adequate facilities sustained either by local funds or with Federal grant or contract support. Research at the Lexington Clinical Research Center focuses on the followup of the discharged patient. Post hospital services are provided in collaboration with community agencies, and a controlled evaluation of these activities is being completed. Directed Research: Included in this activity is $6,000,000 in 1973 for research contracts. Although a large majority of the drug abuse research is supported under grants to independent scientists, some promising fields of research are not represented by sufficient numbers of investigators to achieve an acceptable rate of progress through the normal grant procedure. These funds will be used to carry out extensive controlled clinical tests with presently available antagonists such as naloxone and cyclazocine; begin a research and development program to develop substitutes for opium derivatives; study the receptivity of prescribers to adopt non-opiate drugs. in their medical practice; develop educational programs to assist physicians in making the switch to synthetics as soon as they become available; and to fill gaps in knowledge identified through surveys and assessment of progress during 1972. Funds are also included to continue the marihuana research contract study which is designed to determine the effects on humans of the prolonged use of marihuana. A total of 14 new positions is requested under. this activity in 1973. Four of these positions will provide additional staff support for programs related to the mental health of children. Five positions will be directed toward studies of minority group mental health problems, and the five remain- ing ‘positions will support research in the field of crime and delinquency. 31 2. Manpower Development a) Training grants and fellowships Increase or 1972 1973 Decrease Training grants and fellowshipsS...ccsseseccvee $120,050 ,000 $105,050,000 +-$15,000,000 An adequate supply of trained manpower is essential to sustain the Nation's efforts to increase mental health services, to obtain new knowledge through research, and to develop and improve methods of organizing and delivering mental health services. Training Grants Institute efforts related to the training of mental health manpower are supported through a variety of programs including: (1) Professional Training: Grants are awarded to training centers and educational organizations for support of training programs in psychiatry, psycho- logy, social work, and psychiatric nursing. This support covers teaching costs and enables institutions to offer financial assistance to students, including stipends, tuition, and dependency allowances. (2) Experimental_and Special Training Projects: Grants are made to eligible institutions and agencies for innovative, experimental training projects, These may include the development of training programs for new types of mental health personnel, programs for persons whose roles or functions may be related to mental health, or. the development of new and experimental methods of training. Support is provided for teaching costs and for full-time training, for student support as well. (3) Continuing Education in Mental Health: Grants are awarded to eligible institutions which develop strong continuing education divisions within profes- sional schools and training centers for the mental health professions, make continuing education an integral component in implementing community and State mental health planning and programs, or provide for program development directed to the needs of a specific group of potential trainees, as opposed to offering isolated courses for whomever can be recruited. Programs are supported at both the professional and nonprofessional levels and are primarily for support of teaching costs only. Although the NIMH supported programs have contributed to the growth in the supply of manpower providing mental health services to the public, the demand for such services has also grown at a rapid rate. The following table summarizes the unmet need for mental health personnel, by comparing budgeted positions in public mental health facilities (Manpower Demand) with filled positions (Manpower Supply): Discipline Pasychlatry.cccccrevcscsenes Psychology......ceccecs Psychiatric social work.... Nonprofessionals......-eee0. Total...cscceees Ce 32 Manpower Demand Manpower Supply Unmet Needs 20,612 18,588 2,024 13,190 11,350 1,840 21,153 18,133 3,020 17 ,039 16,241 798 71,994 64,312 7,682 Within this data, Community Mental Health Centers and State and county mental health hospitals show the greatest need for increased professional and nonprofessional workers to meet the increasing demand for services. fables 1 and 2 below show the distribution of training grant funds by type of grant and by functional program respectively. following the tables describes the training grants structure on a programmatic The narrative material basis. Table 1. Distribution of Training Grants by Type of Grant Increase. or 1972 1973 Decrease . Now Amount No. Amount No, ‘Amount Noncompeting continuation......1,670 $90,500,000 1,334 $73,000,000 -336 ~-$17,500,000 Competing continu- / Ations..csescoes ,.. 179 11,734,000 216 15,314,000 +37 +3,580,000 New Projects......- 155 8,080,000 134 7,000 ,000 -21 -1,080 ,000 Supplemental Awards (27) 700 ,000 (27) 700 ,000 --- --- Scientific Evalu- ation. ...ceesesece 16 336 ,000 16 336,000 --- --- Total.....e+-+-2,020 111,350,000 1,700 96,350,000 -320 -15,000,000 Table 2. Training Grants Program Distribution Narcotic addiction and drug abuse... Alcoholism. .cscsscccsccccee Minority Training........++ Psychiatry. .sccccsecccscecs General Practitioner........ Behavioral Sciences......+6 Psychiatric Nursing......+. Social Work. ......cscercece Experimental and Special... Continuing Education....... Hospital Staff Development... Crime and Delinquency...... Metropolitan Problems....... Suicide Prevention......... Scientific Evaluation....... eeecoeres re ee eeeevenen Ce eoeeeees Increase or 1972 1973 Decrease $1,700,000 $1, 700,000 o“- 4,013,000 4,013,000 oon 1,300,000 1,300,000 --- 32,433,000 20,473,000 -11,960,000 5,533,000 5,533,000 --- 24,279,800 24,279 ,000 “oo 10,299,000 7,259,000 +-3,040,000 12,678,000 12,678,000 --- 7,743,000 7,743,000 oo: 4,264,000 4,264,000 woo 3,800,000 3,800,000 o- 2,204,000 2,204,000 --- 374,000 374,000 --- 394,000 394,000 one 336,000 336 ,000 coe 96,350,000 -15,000,000 TOCAL. cc cs sccevccvccccccevcceves 111,350,000 33 Narcotic Addiction and Drug Abuse: The purpose of these programs is to assure an increased supply of trained professional and paraprofessional manpower to provide treatment and rehabilitation services and to obtain new knowledge through research. Some new awards planned in this area include grants providing students in health fields with training in the drug abuse area. A grant funded jointly with the National Institute on Alcohol Abuse and Alcoholism provides support to medical schools to develop courses of instructions on drug and alcohol abuse and a career teacher award intended to train medical school faculty members in the field of drug addiction. Alcoholism: Currently the Institute is emphasizing the development of training programs which concentrate on the training of individuals who will work with alcoholic employees, drinking drivers, American Indians, public intoxi- cants and other identified target groups. In 1973 the Institute will continue these programs and support programs to provide manpower for after-treatment. care of the alcoholic persons. Finally, efforts will be intensified to develop a cadre of well trained individuals who can develop alcoholism training programs which will increase the number of persons receiving training and at the same time reduce the period of training, with no expense to the quality of the students graduated. Disciplines in which such efforts should be successful are sociology, psychiatry, social work, psychology, nursing, and rehabilitation counseling. Minority Training: Support will focus on the development of techniques for the recruitment and training of minority students in graduate, post-graduate, and baccalaureate programs and in community college human services associate mental health worker programs. Additionally, the Institute will maintain and expand its interest in, and recruitment of minority members in teaching as a career. It will also foster training researchers, as well as programs designed to enable trained minority group members to enter Federal and private decision and policy-making positions in mental health and health related agencies. Further, there will be a concerted effort in training professionals to work in the area of psycho-somatic illness prevention, especially in those most preva- lent among minority group members. Psychiatry Training Program: Support is provided for the training of physicians and medical students in the broad concepts of mental health and in the delivery of mental health services. Every medical school and school of osteopathy and almost all accredited psychiatric training programs in the country receive support through one or more of the ten types of grants administered and funded under this program. Highest priority for support is given to applications in the areas of child mental health and minority mental health services, drug abuse prevention and treatment, and health manpower deficiencies. Support provided by this program may be grouped into two different grant categories: Pre M.D. Psychiatry Training, and Graduate Psychiatry Training. 1. Pre M.D. Programs - Medical school training in psychiatry not only serves to increase the number of persons entering the mental health field, but also enhances the knowledge and skills of persons who may be involved, directly or indirectly with the care and treatment of mental health problems. These grants provide faculty support and student support in order to introduce the principles of psychiatry and mental health into the curriculum of the medical student early in his training. This program will be reduced by $4,960,000 in 1973. It is intended that financial assistance be funded in the future through the student assistance programs administered by other Federal agencies. 34 2. Graduate Psychiatry Training - Support is provided to medical schools, hospitals, and clinics for programs of residency training at the graduate level in psychiatry, including child psychiatry, and for training in special areas such as community psychiatry, student mental health, and others. In community psychiatry training, interdisciplinary programs have been encouraged which involve jurists, attorneys, penologists, and other law enforce- ment officials, in addition to professionals and lay personnel involved in problems of drug abuse, suicide prevention and alcoholism. The 1973 President's Budget contains a decrease of $7,000,000 for psychiatry residency training. Substituted for the present system will be an expanded institutional support grant program. Behavioral Sciences Training Programs: Support of training in the behavioral sciences include grants to institutions for the training of psychologists, for the training of biological and social scientists for research in mental health, and for the training of mental health specialists in the biological or social sciences. In each instance, grants include funds for both institutional costs and for a limited number of stipends. Psychiatric Nursing: This program produces. the manpower for training addition-~- al graduate, undergraduate and non-professional nursing personnel to meet the increasing demands for psychiatric nurses in community mental health centers, hospitals and their service agencies, as well as in teaching roles. The graduate and undergraduate components of this program are discussed below. 1. Undergraduate training: This program provides an opportunity to strengthen the teaching of community mental health and behavioral sciences content through- out the curriculum in baccalaureate and associate degree nursing programs. In addition, it serves to increase the number of graduate nurses continuing their education in the mental health field and provides a sound basis for advanced training and specialization at the graduate level. This program will be reduced by $3,040,000 in 1973. It is intended that financial assistance be funded in the future through the student assistance programs administered by other Federal agencies. 2. Graduate training: This program produces the highly qualified manpower for training additional graduate, undergraduate and non-professional nursing personnel to meet the increasing demands for psychiatric nurses in community mental health centers, hospitals and their service agencies, as well as in teaching and consultation roles. All programs are heavily focused upon training for the delivery of community mental health services, with program content in the areas of community crisis and systems theory, community organization and planning with supervised field training. This training takes place in a variety of community agencies and institutions including mental health centers, in-patient services, out-patient clinics, schools, churches, courts, prisons, nursing homes and housing developments. 35 Social Work Training: Training support in the field of social work is designed to augment the supply of social workers trained in mental health and to improve the quality of social work training relevant to mental health. With these objectives, grants are made to graduate schools of social work and other training centers or institutions for support of graduate training programs in any area of social work relevant to mental health. These grants provide both institutional support and to a lesser degree, student support. High priority in 1973 will be given to projects with the general objectives of improving and extending training capabilities to produce more manpower in community mental health, in minority group development, in innovative educational efforts and in child mental health. Continuing Education Training: This program supports efforts to improve and increase the skills of mental health specialists so that they can keep abreast of the most recent advances in theory, practice and technology. In addition, the program assists training institutions by increasing their capacity to make established mental health personnel more effective and supports con- tinuing education courses for general practitioners. _ The continuing education training program will be used extensively during 1973 as part of a multi-faceted approach throughout the training programs to stimulate paraprofessional training activities. In addition to upgrading the skills of the existing cadre of mental health workers and to provide them more meaningful roles on a total health service team, continuing education will also focus on training professional mental health personnel in the effective use of mental health workers, and on a restructuring of roles and service functions to capitalize on the potential contributions of these workers. Emphasis in the training will be placed upon providing specific mental health skills in response to expressed needs of individuals and service agencies. Hospital Staff Development: The Hospital Staff Development Program is designed to improve the quality of patient care in public mental health hospitals included in state systems of care through inservice training of staff personnel. It encourages hospitals to provide staff development programs at the subprofessional and professional levels through a variety of courses, such as orientation, refresher and continuation training, as well as through special courses for those who conduct the training. The difficulties encountered in securing and retaining adequate mental health personnel in state mental hospitals has leng been recognized, The Hospital Staff Development Program is directed toward alleviating these difficulties by providing a source of funds for some 300 eligible state- supported mental hospitals to initiate or expand new training programs. Of these eligible hospitals, 214 have received staff development grants providing training to an estimated 60,000 persons. Crime and Delinquency: A major emphasis in this area is placed on the development of training models and programs for both professional and: non-pro- fessional service personnel, and behavioral and social science researchers. In addition to the development of innovative training models for professional service manpower, the Institute is devoting more effort to the expansion of work opportunities in this field for various non-professionals--including ex-offenders-) Narcotic Addiction (Community Mental Health Centers Act, as amended: Sections 261 and 256) 1973 1972 Budget Available 1973 Estimate Pos. Amount Authorization Pos. Amount --- $76,390,000 $134,000, 000 --- $91,298,000 Authorization includes the following section of the Community Mental Health Center Act: Section Description Authorization 253: Drug abuse education.......++++.6 $14,000,000 A/ 256: Special projects...... sees eeeeees 35,000,000 A/ 261: Construction, staffing, training, evaluation, special projects..... 80,000,000 B/ C/ 26h; Consultation services......-eeeees 5,000,000 B/ D/ A/ Includes continuation costs. B/ Excludes continuation costs, which are authorized as "sums necessary." C/ Authorization is shared with alcoholisn. D/ Authorization is shared with alcoholism and Centers staffing. Purpose: This activity supports Institute efforts to develop and conduct compre- hensive health, education, training and planning programs for the prevention and treatment of drug abuse. Explanation: This activity provides funding for all the programs authorized under Part D of the Community Mental Health Centers Act, including: Staffing grants which provide for a portion of the salary costs of professional and technical personnel to staff comprehensive community centers for the treatment of narcotic addiction and drug abuse. Special Projects finance treatment and rehabilitation programs which demonstrate new or relatively effective or efficient methods of delivery of health services. Service grants provide partial Federal support for programs of treatment and rehabilitation which include detoxification services, institutional services, or community based aftercare services. Training grants support specialized training programs or materials for the prevention and treatment of narcotic addiction and drug abuse. Education projects provide for the collection, preparation, and dissemination of educational materials dealing with the use and abuse of drugs and the prevention of drug abuse. Plenning and Initiation Grants are awarded to plan or develop narcotic addiction PO ee ee eh nt nn iuoie nartinniar aren. GT Accomplishments: In the area of narcotic addiction and drug abuse, funds have been allocated in the following areas in 1972: 1. Treatment Programs: Funds were used for a broad variety of narcotic addiction and drug abuse treatment services to meet the general and particular needs of the communities across the Nation. Emphasis in this fiscal year was on targeting fimds so as to extend the opportunities for treatment and rehabili- tation to those drug abusers and narcotic addicts who have a strong motivation for recovery, but for whom community services were not available. By the close of 1972 approximately 162 treatment programs will be supported which, when fully operational, will provide treatment services to 33,600 individuals. 2. Training: Funds were utilized for specialized training programs for prevention and treatment of narcotic addicts and drug abusers. These programs train physicians, social workers, psychologists, other professionals, and sub- professionals to cope with expanded narcotic addiction and drug abuse prevention, treatment and rehabilitation programs throughout the Nation. In 1972, an estimated 45 training projects will be supported under this program. 3. Planning: Funds will be provided for planning grants to states, metro- politan areas, cities and small towns to stimulate coordinated, adequately focused programs at the state and local levels. An estimated 44 grants will be supported in 1972. Objectives: Efforts in this area will continue to be directed towards developing treatment and rehabilitation services at the community level. A major portion of the increased funds will be used to support the continued development of compre- hensive treatment centers. on co HEALTH SERVICES AND MENTAL HEALTH ADMINISTRATION Mental Health Program Purpose and Accomplishments Activity: State and Community Programs: (c) Alcoholism Projects and Grants to States (Community Mental Health Centers Act, as amended, Section 261 and the Comprehensive Alcohol Abuse and Alcoholism Prevention Treatment and Rehabili- tation Act of 1970 - PL 91-616). 1973 1972 Budget Available 1973 Estimate Pos. Amount Authorization Pos. Amount --- $70,173,000 $215 ,000 ,000 --- $80 ,193 ,000 Authorization includes the following: Community Mental Health Centers Act Section Description Authorization 2u7 Prevention and treatment.........00- $50,000,000 A/ 261 Construction, staffing, training and evaluation, special projects.. 80,000,000 C/ 264 Consultation serviceS.......eeeeeee 5,000,000 B/ c/ D/ Comprehensive Alcohol Abuse and Alcoholism Prevention, Treatment, and Rehabilitation Act of 1970 Section Description Authorization 301 Formula grants........ pesseaue a $80 ,000 ,000 A/ Includes continuation costs. B/ Excludes continuation costs which are authorized as C/ Authorization shared with narcotic addiction. D/ authorization shared with narcotic addiction and centers staffing. ‘sums necessary.” Purpose: Communities are assisted in establishing "centers" to help prevent and control alcoholism through awards for the support of construction and/or staffing of facilities, development of new services in poverty areas, and special projects. Public Law 91-616 authorizes formula grants to states for the planning, establishment, maintenance, coordination and evaluation of projects for the development of alcoholism prevention, treatment and rehabilitation programs. Explanation: The project grant program included in this activity is authorized under Part C of the CMHC Act, as amended. These programs include: Staffing grants which support a portion of the initial salary costs for professional and technical staff to enable communities to initiate facilities for the prevention and treatment of alcoholism while longer term sources of financial support are being developed. 69 Special projects provide support for training programs or materials for the pre-~ vention and treatment of alcoholism and treatment and rehabilitation programs which demonstrate new or relatively effective or efficient methods of delivery of health services. Grants and contracts for the prevention and treatment of alcohol abuse and alcoholism. Includes support for demonstration, service, education and training programs in cooperation with schools, courts, penal institutions and other community-based public agencies. Planning and Initiation grants are awarded to plan or develop alcoholism treatment and prevention services in a particular area. Accomplishments: In 1972, an estimated 75 staffing projects were funded which, when fully operational, will provide services to 109,000 individuals. In addition the Institute funded a series of projects to provide treatment services for the Indian population as well as a number of special projects to develop innovative ways to deliver services to alcoholics. Objectives 1973: The 1973 request will provide continued support of the treatment and rehabilitation programs established in 1972. A major portion of the increase in 1973 will provide continued support for alcoholism projects transferred from OKO. Funds provided for the formula grant program will permit the states to plan, establish and maintain projects for the development of alcoholism prevention, treatment and rehabilitation programs. These funds will be allotted to states on the basis of relative population and financial need. 70 HEALTH SERVICES AND MENTAL HEALTH ADMINISTRATION Mental Health Program Purpose and Accomplishments Activity: State and Community Programs: (a) Mental Health of Children (Community Mental Health Centers Act, Part F). : 1973 1972 Budget Available 1973 Estimate Pos. Amount Authorization Pos. Amount --- $10,000,000 $35,000,000 (new) --- $1,515,000 --- -+- Indefinite (continu- --- 8,485,000 ation) Purpose: This activity supports grants which will improve the quality and quantity of services to children through staffing and training grants. Explanation: Funds will provide staffing support to existing comunity mental health centers for establishment or expansion of mental health services to children. Accomplishments: This program received its initial funding in FY 1972 and provides partial support of professional and technical staff in community mental health centers providing initial or expanded mental health services to children. The funds were used to stimulate innovative approaches toward expanding the range of services for children with an emphasis on prevention and early treatment. A total of 28 new awards were made in 1972. Objectives: In 1973 the Institute will continue to utilize existing resources for staffing grants to initiate or expand children's services. in community mental health centers. It is anticipated that the funds requested will provide continu- ation support for the 28 grants initially awarded in 1972 and provide support for i new awards. TI HEALTH SERVICES AND MENTAL HEALTH ADMINISTRATION Mental Health Program Purpose and Accomplishments Activity: Rehabilitation of Drug Abusers (Public Health Service Act, as amended: Narcotic Addict Rehabilitation Act). 1973 1972 Budget Available 1973 Estimate Pos. Amount Authorization Pos. Amount 157 $13, 323,000 Indefinite 164 $13,926,000 Purpose: This activity supports the administration of the Narcotic Addict Rehabil- itation Program, authorized by the Narcotic Addict Rehabilitation Act of 1966, which provides for the rehabilitation of narcotic addicts through contract arrange- ments with community agencies and in the Clinical Research Center located at Lexington, Kentucky. Under this program individuals addicted to narcotic drugs may volunteer for civil commitment for treatment (Title III), or those addicted individuals charged with violating certain Federal criminal laws may apply for civil commitment in lieu of prosecution (Title I). The staff supported under this activity also administer the marihuana research contract program and the community narcotic addiction treatment and rehabilitation grant program, both of which are funded under a different activity. Explanation: This program provides (1) contract funds for the community "aftercare" of addicts upon their release from inpatient treatment at the Clinical Research Center and (2) salary and related support for the staff who administer the Institute's over-all drug abuse program. Accomplishments: The development and administration of the civil commitment pro- gram has continued to be a major activity in response to increasing numbers of commitments by the U. S. Courts. In 1972 the Institute transferred the Fort Worth Center to the Bureau of Prisons, Department of Justice, who will operate it as a medium security general medical facility for narcotic addicts. The services which had been provided at Ft. Worth are now provided by local health agencies in the addicts community under contracts with NIMH. Objectives: In 1973 the community assistance program is being expanded to provide community based treatment. to addicts formerly treated under the aftercare contract program. This action will reduce the Federal Government's involvement in direct care programs and is in keeping with our goal of supporting the development of State and local capabilities to deal with narcotic addiction and drug abuse. T2 HEALTH SERVICES AND MENTAL HEALTH ADMINISTRATION Mental Health Program Purpose and Accomplishments Activity: Program Support Activities (Public Health Service Act, as amended). 1973 1972 Budget Available 1973 Estimate Pos. Amount Authorization Pos. Amount 501 $16,699 ,000 Indefinite 501 $16,977 ,000 Purpose: There are three Institute programs included under the Program Support Activity. These are: (1) Field Activities - which provide central office coordi- nation of regional programs and mintain Institute relationships with other Federal agencies and State and community organizations. (2) Scientific Communi- cation and Public Education Activity-which supports the National Clearinghouse for Mental Health Information, a public education program on the dangers of drug abuse and alcoholism and the National Clearinghouse for Drug Abuse Information. (3) Executive Direction and Program Management Services—-which supports the program planning and evaluation, biometric and legislative services, and adminis- trative management of the Institute. Explanation: The funds requested support salary and related costs of employees who work in the activities described above. Accomplishments: The Institute's drug abuse information and education program has been expanded with development of the National Clearinghouse for Drug Abuse Infor- mation to full operational status. An alcoholism public information program was expanded in 1972 to include an information and education campaign in the public media, including television and radio spot announcements, newspaper and magazine advertisements, posters and other materials. Aliso, the National Clearinghouse for Alcohol Information was established to provide support for programs of educa- tion, prevention, treatment, rehabilitation, research and training in the areas of aicohol abuse and alcoholism. Objectives: As a resuit of increases in the size and number of decentralized pro- grams, the Institute will increase coordination and collaboration between head- quarters and regional offices. Collaboration with other Federal and state agencies and citizens groups will be increased. The Information programs of the Institute will continue its efforts to disseminate information on mental health as well as its public information programs to educate the public on the dangers of drug abuse and alcoholism. Allocation of Funds for Construction Grants of Community Mental Health Centers AY KANSAS... cee ee eee ete nene .. Colorado.....sseees Pe ra Connecticut. ..ccsecesscescere DELAWALC. .. ecw e ec ence cen eevee District of Columbia........ Georgia... ccc ccc c eens veneee Hawaii. ccc ccc ce cnccaves oe TOWRA. ce caer eee ev venne aseeee KANSAS... cc cseccsccee deve wcce Kentucky. ccc ccccccccccccvcccs Louisiana.... cece ess cesessves Maryland......... eee escaee Massachusetts. ...csecesese eee Michigan.........ceeccceeees Minnesota........ were nee cease MiSSiSSIpPL......-.cceeeeeeee MISSOULL. ccc cee w er eee c ene enee Montana. .cccrcseseses so nenens Nebraska....,.... emcee ere naee Nevada... ccsceveccnscsccnens New Hampshire......cseceenees New Jersey..ccsssscccevcsesee New Mexico...secrcccccssccaces New York. ccc cece cere seen caae North Carolina........ eee North Dakota........cccceeeee (0) es 0 Oklahoma........ paver ee ees ees OPEB. wee e cece rater sevevecces Pennsylvania... .ccssccccnce eee Rhode Island......-e-e.sce00- oe 1971 Actual 195,984 1,846,971 105,816 Woh ,655 100,000 535,021 728 123 255,742 124 ,286 1,349,474 383,725 322 5488 542 ,608 608,795 217,933 483,890 690,826 295 4500 510,518 470,160 652,870 175,343 335 523 75,320 100 ,365 1,142,141 68,520 1,024,251 8h2 016 88 500 1,430,990 392 ,420 1,598,712 54,867 1972 Allocations 291, 445 100,000 125 ,829 163,258 1,222 ,364 151,104 179,172 100,000 100,000 480 5427 340,56) 100,000 100 ,000 675,977 352,254 196,013 152,031 254,479 288,161 100 ,000 248, 865 355,061 567,915 258 226 206 ,300 322,783 100,000 101,508 100 ,000 100,000 432,711 100 ,000 1,068,452 392,012 100,000 699 ,835 191,803 12,684 789,652 100,000 73 1973 Allocations South Carolina. ....ceceesseeee South. Dakota....... peer eeceens TENNESSEE. cece vscceacvesnsesee TOXOS. cc rece weet ese ecccenaces Utan er csccscvccscsccese weve ewes Vermont.......ee0- eee cee ces eee VAP Zinia. cc cscccevccneccssenns Washington. .....cccce ccc eceees West Virginia. ...ceceeeeeneees WisconSin. .....eewc cess ecccees WYOMUNG.. cee see c eee e ee encens oe GUAM... cece ec e cece reece anaes Puerto Rico... .cececresccesacee Virgin Islands..i..scceeecsees American Samoa........ -eeeee ee Trust Territories..... wee e eee 1971 Actual 472,334 184,608 1,751,086 161,544 100,000 TLT THs 106,568 314,971 86,087 98,405 548 ,4h6 TObAL. ce seeceevecesesenss 23,421,768 1972 1973 Allocations Allocations 211,914 --- 100,00¢ eee 311,555 --- 806,493 -e 100,000 --- 100,000 --- 329,800 — 219,394 --- 141,281 a 305,001 --- 100,000 --- 7,480 --- 2h9 342 ~~ 35150 --~ 2,344 — 9,361 --- 1h ,850,000 -0- Allocation of Funds for Alcohol Formula Grants 1971 i972 1973 Actual Allocations Allocations Alabama.......5. Cece e newer aees a --- 589 ,488 589 ,488 AlASKO. cee cece cece ees see eeees --- 200,000 200,000 AVAUZONA. cece cece cence ene eeeenens --- 254,507 254 507 ArKanSaS...ccecseeeecese ran --- 330,212 330,212 California.r.ccccccscesaes weeeee ee 2,472,403 2,472,403 COLOPAdO. cesses eucveccsccnceeees --- 305,630 305 ,630 Connecticut. reccescscecevecevecs ~-- 362,402 362,402 Delaware. ccececccscccecace ene eee --- 200,000 200,000 District of Columbia........eee. a+- 200,000 200,000 PLOVida. weccseceecencccceeneeres --- 971,731 971,731 GOOF TIA. cee ee sce eteceveeeeenees --- 688 ,838 688 ,838 HAWALL. coe ccc ecw tee ee sense eees --- 200,000 200,000 Idaho....... eee eee see eeeeee --- 200,000 200,000 Tllinois..... peewee eee eecusees ~-- 1,367 ,259 1,367,259 Indiana....... eeeeae eee eee +. = 712,484 712 48h TOW. ccc veces ce ccrcnececreseeene --- 396 , 464 396,464 KANSAS. . cc scce nc ceseecvenceneece --- 307 5503 307 ,503 Kentucky sees eeescscceces se eeeee -—— 514,720 514,720 LOUiSiANa. .. eee eee eee ee ween eens --~ 582,846 582 , 846 MALNG. ccc r ees e reserve necreseces . --- 200 ,000 200 ,000 Maryland......eeeeee Lecce ceeeee --- 503,365 503,365 Massachusetts........ cece eee ee --- 718,161 718,161 MiChigan.cescccccscccvevcsceeces --- 1,148 ,688 1,148 ,688 Minnesota........eeeeee0- see nwoee --- 522 5299 522 ,299 MiSSIiSSUpDi.sssscersceccncantees --- 417,271 417,271 MISSOULA... cece eee eee e eee eeees — 652 ,873 652,873 Montana. ....eeseeeeceees Leceeeee --- 200,000 200,000 Nebraska... ceesenceccceceeccvens ~—- 205,314 205,314 NOVAGa. cee cece w cr eecnencnterene --- 200,000 200,000 New Hampshire........... wees oeee --- : 200,000 200 ,000 New Jersey... sseeees rrr --+ 875,219 875 ,219 New Mexico. .ccsccccsvvecvcccenee --- 200 ,000 - 200,000 New York. .ceccccececcwcesenecens --— 2,161,096 2,161,096 North Carolina... ....ceecvecceces --- 792,901 792,901 North Dakota... cccccccvcesccnaere --- 200,000 200 ,000 Oh1O. ss. cr sccevnsresvecs se cececes --- 1,415,515 1,415,515 OKLANOMA. . eee eee rere s eee cece --- 387 ,949 387 ,949 OPE BON... recs c cee vescucencrerees -—- 288 ,598 288 598 Pennsylvania. .csccccscscsncveces ---+ 1,597 ,184 1,597,184 Rhode Island.....sceececesvcsces -—-- 200,000 200 ,000 16 1971 ig9fe2 1973 Actual Allocations Allocations South Caroling..cccsecseeeeseees --- 428 ,626 428 ,626 South Dakota. ..ccr creer vecccece ae --- 200,000 200,000 TENNESSEE. cece cece eee eeeerr eens ao 630 ,165 630 ,165 Texas..... se eeaee veces see eeeee --- 1,631,247 1,631,247 Uta. cvvscavcncvcvcvvccscsene wees --- 200 ,000 200,000 VErMont. cc cece v cs ceveseccrcenens --- 200,000 200 ,000 Virginia. .cccsccceecervceeceeees --- 667 ,066 667 ,066 Washington. .seceecscceccenceces . --- 443,755 43,755 West Virginia... ..cssece cee eenes “= 285,760 285 ,760 WISCONSIN. . cee eeveeeeetccecs cee --~ 616,909 616 ,909 Wyoming. .ccecescecccece See ree eas --- 200 ,000 200,000 GUAM. sc esenarecvercvccreccvenece = 15,130 15,130 Puerto R1icd.seccccsesvccccsceace --- 504,331 504,331 Virgin Islands..... ee ee eee ecees --- 10,418 10,418 American Samoad......eee cece eeees --- h74o 4, 7hO Trust Territory....sseseees sees --- 18 ,933 18,933 TOCAL. ccc cc awe esses navces eae -O- 30,000,000 30,000,000 New Positions Requested Fiscal Year 1973 Grade Research Psychologist. .ccccccccucccecsrsccvetce GS-15 Anthropologist. .ccscccccceseecenceenne GS-14 Child Psychologist......... eee eee ees GS-14 Sociologist........ eee cence renew eeeee GS-14 Psychologist....... sce e ee eee aceesenes GS-14 Anthropologist. ...ceccee cece ecercns GS-13 ECONOMLSt. ccs eee eee ccccecerene wee eeeae GS-13 Political Scientist............. seas GS-13 ECOLOZist....c ccc ccceecccvecce ween eeeae GS-12 Public Health Analyst......... Ser GS-11 Public Health Analyst..... weer ee eee eee GS- 9 Secretary. ..ccccseeee seen ween ence ry GS- 5 State and Community Programs Public Health Advisor...... eee eee nees GS-14 Public Health Advisor... .ceeseees sees GS-13 Public Health Advisor.....-...-0- wenn GS-12 Secretary. ccc ccceccccecccncsecssconce . GS- 5 Rehabilitation of Drug Abusers Public Health Advisor.......c cece reese . GS-13 Public Health Adviscor........... ee eeee GS-12 Program Analyst. ..rsesvecssececsevceee Gs- 9 Secretary ...... sees seeuss See ee eas GS~ 6 Clerk—tbypist .. cece cc eccrererenerccene GS~ 5 Clerk-typist....cceseeoeeees vaeesseees GS- 4 Total new positions, all activities “I “I Annual Number Salary $24 ,251 20,815 20,815 41,630 20,815 17,761 17,761 17,761 15,040 12,615 10,470 13,876 233,610 FINE RPP BPP EEN PPP i 41 5630 35,522 15,040 13,876 106,068 Ayr Mm % 17,761 15,040 10,470 1,727 DPPH 12,404 70 , 340 =~ 28 410 ,018 6,938 . DEPARTMENT OF HEALTH, EDUCATION, AND WELFARE SAINT ELIZABETHS HOSPITAL Appropriation language POCO H OEE ESEHEREEHHHOSEHOHED Amounts available for obligation cecccssecscccccesesecs Obligations by activity ceccccsccccsccvcvcccsvveseceses Obligations by Object csccsccereccsevovccsovesescovcces Summary Of Changes ccvecsecsescocsssssccvosescososseses Explanation of transfers eovsecceccsceresccccscerocsee Table of estimates and appropriations eeccecsccocccceces Justification: A. General statement waccacccseccccccecceoccesoscoss Le Hospital programs csccvcccccccesccsscvscccces 2. Reimbursement detail coccccccccoveccevccseese 3. Statement of average daily patient population B. Program purpose and accomplishments .reccessssoce Page No. 19 80 80 81 82 83 85 86 86 93 94 95 Appropriation Estimate SAINT ELIZABETHS HOSPITAL For expenses necessary for the maintenance and operation of the hospital, including clothing for patients, and cooperation with organizations or individuals in the scientific research into the nature, causes, prevention, and treatment of mental illness, [$23,144,000] $28,271, 000 or such amount as may be necessary to provide a total appropriation equal to the difference between the amount of the reimbursements received during the current fiscal year on account of patient care provided by the hospital during such year and [$49,709,000] $55, 860, 000 (Department of Health, Education, and Welfare Appropriation Act, 1972). DEPARTMENT OF HEALTH, EDUCATION, AND WELFARE SAINT ELIZABETHS HOSPITAL Amounts Available for Obligation Appropriation sccsescscvevcscvces Comparative transfer to: "Departmental Management" 2... Comparative transfer from: "Mental Health” seccccccccseses Subtotal, budget authority Receipts and Reimbursements from: Federal funds cecscceccsccvcccce Trust TUNdS cevscvecescvencoces Non-Federal sources weccccccece Total obligations eascacce 1972 1973 $2h.,936,000 $28,271,000 -13,000 --- 1,600,000 a 26,523,000 28,271,000 721,000 807,000 300,000 300,000 23,826,000 26,482,000 51,370,000 55,860,000 Qbligations by Activity 1972 1973 Increase or Page Estinate _ Estimate Decrease Ref. Pos. Amount Pos. Amount Pos, Amount 86 Clinical & Com munity Services: Total obliga~ tions secccoeee 45132 $51,370,000 4,132 $55,860,000 ~== +$4,490,000 Obligations by Object 1972 1973 Increase Estimate Estimate Decrease Total number of permanent POSItLONS ..ccecccsceccccvece 4,132 4,132 one Full-time equivalent of all other positions .eeccsscccee 195 220 +25 Average number of all employees 4,016 420k +188 Personnel compensation: Permanent positions seccesees $36,451,000 $38,921,000 +§2,470,000 Positions other than permanent 1,388,000 1,657,000 +269 ,000 Other personnel compensation . 2,277,000 2,395,000 +118,000 Special personal service payments ceccoccsccccssesses 41,000 41,000 = Total personnel compensation 40,157,000 43,014,000 +2,857,000 Personnel benefits cscccsecscese 3,472,000 3,709,000 +237, 000 Travel and transportation of PEYSONS cececrcccccacccccccces 151,000 165, 000 +14,000 Transportation of things «csccee 107,000 107,000 mae Rent, communications and utilities 658,000 734,000 +76 ,000 Printing and reproduction ...6.. 35,000 35,000 ——- Other SeErviceS sesccsscovsecsees 1,195,000 1,899,000 +704,,000 Supplies and materials ..e.eeee. 4,751,000 5,114,000 +363, 000 Equipment ..ccccccccccscccscsece 764,000 937,000 +173 ,000 Lands and structures sessceccece 110,000 176,000 +66,000 Insurance claims and indemities 2,000 2,000 oo- Subtotal sceccccecccccsccccess 51,402,000 55,892,000 +4,490,000 Deduct charges for quarters ..° =32 000 ~32 000 -o= Total obligations by object .. 51,370,000 55,860,000 +4,490,000 82 Summary of Changes 1972 estimated obligations SeCeoeeeeeeeeseeeeeeesesenveseooa $51,370,000 1973 estimated obligations POPC OCC O CER OD Eres eee EEE LOO EOS 55,860,000 Net change CHK O HPCC ER ER EET OOHRS OBE REHEEEOE +h ,4.90, 000 Base Change from Base Pos.. Amount Pos. Amount Increases: A. Built-in: 1. Annualization of employment and related support to effect unit- ization Pee CeP ORE Soe ReeHeerEese “ao meen om 1,804,000 2. Average salary and wage grade adjustments plus additional holiday POS e ever oeseseereooos —_——_ aon —- 1,236,000 3 Other (including FIC, DHEW Working Capital Fund) ..seceee =m “= woe 400,000 B. Program: 1. Equipment replacements ..csceses === 874,000 ann 239,000 2. Restoration of Interns and Residents staffing eeoccccceeee Om —_ 280,000 3. Scheduled support for Upward Mobility Program Oasveeeseseon — == —— 523,000 hk, Scheduled support for WOW Program PEC COOS EH OO EHO SEO OREO ——— ae _—= 107,000 Total, increases Caeroocesees = “_—— we 4,589,000 Decreases: Ae Built-in: 1. One less day of POY sevccccccses =@™ ee =99,000 Total, net change Peeonevreveoreesseceneceeos ™™™ ace 4,490,000 33 lanation of C es Increases: A. Bulit-in: 1. Full year funding of 300 additional positions (291 man years) authorized in 1972 for necessary programmatic changes including the initial implementation of the unit system of organization which has been widely adopted by other progressive, psychiatric hospitals. Funds are also needed to make necessary alterations to patient care facilities and to support required community related activities required for unitization and other service improvements. 2. Increases in the pay costs for within grade increases, quarters allowances for PHS officers, wage grade reclassifications and adjustments, and holiday pay for the Presidential Inauguration. 3. Additional fimds are required for increased telephone costs, working capital fund assessments, increased electricity for air conditioning and supplies for patients. B. Program: 1. Additional funds to cover the larger cost of equipment items requiring replacement in 1973. 2. Restoration of funding support for Intern and Resident positions to be transferred at the beginning of 1973 to NIMH's Division of Man- power and Training. These participants in the Hospital's clinical training program provide a valuable source of recruitment for scarce- category medical officers and other related professional staff. 3. Full year costs with increased enrollment in the Upward Mobility College, which was established for the purpose of providing educational opportunities and career development to primarily dis- advantaged minority employees. Requested funds will also support required Hospitel participation in other Upward Mobility Program efforts. kh, Funds to cover 10 additional treinees and increased costs for 26 trainees completing program requirements under the Washington Opportunity for Women program, a social service for subeprofessional indigenous workers, Decreases: A. Built-in: i. One less day of pay below 1972 base. 84 Explanatio of Transfers 1972 . Estimate Purpose Comparative transfer to: Departmental Management = $13,000 Central services pro= vided to Saint Elizabeths Hospital for administration of Upward Mobility Program. Comparative transfer from: Mental Health 1,600,000 Transfer would align fiscal responsibility with organizational changes re- sulting from the disestab- lishment of National Center for Mental Health Services, Training and Research. As a result of these changes, research and training pro- grams integrally related to clinical operation of Hospital were transferred to Saint Elizabeths. Year 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 Budget Estimate to Congress $5,974,000 10,178,000 9,429,000 10,084,000 9,073,000 9,044,000 11,077,000 10,405,000 14,823 ,000 23,144,000 28,271,000 House owance $6,332,000 7,816,000 9,216,000 10,217,000 9,906 ,000 9,028,000 11,077,000 10,405,000 14,823,000 23, 144.000 SAINT ELIZABETHS HOSPITAL Senate Allowance $6,332,000 7,816,000 9,216,000 10,217,000 9,906 ,000 9,028,000 11,077,000 10,405,000 14,823,000 23,144,000 85 Appropriation $6,332,000 7,852,000 9,620,000 10,290,000 10,171,000 10,749,000 13,380,000 16,883,000 23,796,000 2,936,000 4/ L/ Difference between estimated appropriation and House and Senate allowances is due to changes in estimated patient load. Justification SAINT ELIZABETHS HOSPITAL 1972 1973 Increase or Estimate Estimate Decrease Pos. Amount Pos. Amount Pos. Amount Personnel compensation and benefits .oesveeo4,132 $43,629,000 4,132 $46,723,000 -- +$3, 094,000 Other Expenses eoentoe “— 7,773,000 -_ 9,169,000 cae +1,396,000 Deduct charges for quarters OO oneneeeee -—— = 32,000 —— «32,000 == o TOtAl cesccscccceettyl32 $51,370,000 4,132 $55,860,000 -~ +$4,490,000 General Statement This appropriation supports the operation of the Saint Elizabeths Hospital - Division of Clinical and Community Services. Saint Elizabeths provides treatment and rehabilitation for approximately 3,300 inpatients and 2,650 outpatients and operates a community mental health center which serves District of Columbia residents in the southeast quadrant of the city, south of the Anacostia River, commonly referred to in this context as "Area D’. The 1973 budget request of $55,860,000 includes $1,600,000 to support Saint Elizabeths' clinical research and training programs which, in previous years, were budgeted under the "Mental Health" Appropriation. Saint Elizabeths Hospital. - Division of Clinical. and Community Services The Hospital provides treatment, care,and rehabilitation services for a variety of patient categories including District of Columbia residents, persons charged with or convicted of crimes in the United States or District of Columbia courts, U.S. Nationals who become mentally i11 while abroad, residents of the Virgin Islands and U.S. Soldiers’ Home, and other categories of Federal beneficiaries. Facilities of the Division include a forensic psychiatry and security unit for the examination, treatment and rehabilitation of patients referred by the courts under various types of criminal proceedings, and a comprehensive community mental health center. The Hospital conducts a clinical research program for the purpose of obtaining a better understanding of the causes of mental disorders, and the factors bearing upon their development, treatment and possible 87 prevention. Saint Elizabeths also provides mltidisciplinary clinical training for professional and ancillary personnel engaged in or interest- ed in mental health activities. It also provides administrative and logistical support to NIMH activities located at the Hospital. Major Accomplishments Since its organizational placement within NIMH, the Hospital has given its highest priority of effort to the reduction of its inpatient resident population. This has been accomplished by careful screening of the patient population to ascertain sound alternatives to hospital- ization. Patients no longer in need of hospital psychiatric care and who are not dangerous to themselves or others are being returned to normal commnity living. Since this intensive program has been in operation, the inpatient population has been reduced by almost 2,000, This accomplishment has materially assisted with upgrading of patient care by elimination of much of the dehumanizing aspects of residing in obsolete and substandard Hospital areas. Success in reducing the necessity for inpatient hospitalization is evidenced by the average daily outpatient load increasing by approximately 500 to an average of 2,650 in 1972, primarily due to the Community Mental Health Center. Over 10,000 patients were treated at Saint Elizabeths last year, with admissions rising from 3,650 in 1970 to 4,012 in 1971. In its continuing effort to provide better services to its patients, the Hospital made the following programmatic improvements: (a) Unitization. With the additional staffing authorized in 1972, the Hospital began the initial implementation of unitization of services to patients. Actions were taken to begin reorganizing the Hospital into a number of semi-autonomous patient services, each having treat- ment teams with the necessary staffing to provide a full range of mental health services and continuity of care for patients within its own geographic catchment area. Selected patient services were reorganized internally into units and teams, and some organizational components within the Hospital are being consolidated to reflect proper alignment with the health area served, Decentralization was initiated in medical service functions such as nursing, psychology and social service with related personnel now being directly assigned to clinical directors. (bo) Special Programs, The narcotic addiction program, a drug-free therapeutic community known as Last Renaissance, was expanded to serve approximately thirty patients. There have been 105 admissions into this program in nineteen months, with a current waiting list of seven- teen addicts, Sixteen patients have graduated, with seven graduates now employed in drug rehabilitation centers throughout the country. The program also provides a variety of consultative and educational services to neighborhood drug programs, schools and medical societies. A mental health program for the deaf was established, including inpat- as dent, outpatient, partial hospitalization and full emergency services. This pioneering effort integrates services, training, research and combined commmnication methods to provide comprehensive mental health services to deaf people. It also provides consultation, education and rehab- 4litative services, and serves as a resource in training and research. There is an average of 47 patients receiving treatment under this program, of whom an average of 24 are outpatients. A special alcohol program was also established for women. (c) Services to Children. Another ward, with a capacity of 30 patients, was opened to serve a selected group of children. (4) Medical and Surgical Support. Intensive care units are being developed to strengthen these services which are seriously overburdened. (e) New Admission Service. A new admission service for nonresident and no-fixed-address patients of all ages was established in the Geriatrics Division. This is in keeping with the modern practice of aduitting patients to age-integrated wards. (f) Forensic services. This program, under which the number of cases to determine competency to stand trial has rapidly increased, was reorganized to separate pretrial from treatment patients, and maxima security from minimum security patients. (g) ‘In-service training. ‘The Hospital reassessed its in-service training and staff development efforts in order to increase staff productivity. ‘The Upward Mobility College, which currently has 150 students, was established in coliaboration with Federal City College for the purpose of previding educational opportunities and career development to primerily disadvantaged minority employees. A collab- erative effort was also undertaken with Washington Opportunities for Women for training indigenous social work aides. Gontinued efforts to improve treatment, especially for new patients, and to speed the return of patients to the community have sustained the sharp reduction in the average length of hospitalization experienced in recent years, ‘The median time spent on the Hospital rolls by patients who were discharged during 1971 was slightly more than three months, in contrast to a comparable stay period of nearly @leven months only «ix years ago. The median time since admission for those patients on the end of year rolis has dropped during the Last etx years from nearly 9.5 yeais to 5.3 years at the end of 1971. A concentrated effort has also been made to place patients in the commmity after hospitalization is no longer necessary. The unprecedented reduction in the resident patient census during recent years reflects the accelerated return to the commmity of those patients who could most readily make the transition back to the community environment. The residual patients having an outplacement potential include those presenting medically related (not psychiatric) problems and those whose long period of institutionalization make such action more difficult. ‘The lack of suitable, alternative living arrangements and adequate financial support for the indigent patient will also have an inhibiting influence on further outplacements. Because efforts must now be directed toward the movement of the more chronic patients, of whom fifty-eight percent are over 54 years of age, it is anticipated that the markedly slower outplacement rate currently being experienced will continue and result in an average daily load of 3,150 during 1973. Area D Community Mental Health Center A major step in the conversion of Saint Elizabeths Hospital into a modern community-based mental health facility was the establishment of the Area D Commmity Mental Health Center (CMHC) in 1969. The CMHC serves approximately 175,000 residents of that southeast portion of the District of Columbia designated as Area D, and which has the massive social problems associated with urban localities. The Center offers all the elements of a model community center including con- tinuity of care, a complete range of children's services, consultation activities and commnity involvement. Specialized programs are offered in alcoholism, drug addiction, and suicidology, including the clinical and comunity media for a psychiatric residency program. In addition, five satellites have been developed in Area D to service immediate neighborhoods. Through close involvement with the residents of the commnity, mental illness can be detected earlier, thus reducing the probability of inpatient hospitalization. The policy has also been established to treat the patient in his community environment until such time that the degree of illness passes the threshold whereby inpatient hospitalization becomes essential. The Area D CMHC now has on its rolls an average of 1,400 patients, of which 1,160 are out- patients. From its inception, 5,267 patients have been admitted for treatment in the Center. Commmnity Relations Saint Flizabeths continues to expand its participation in commmity activities, such as the vocational rehabilitation program which is operated jointly with the D.C, Department of Vocational Rehabilitation. During the past year, the Hospital accepted 600 referrals with 191 patients being successfully rehabilitated (i.e. the patients were working and no longer needed the group's services). The District also cooperates with the Hospital in the operation of a transitional work- shop for patients, The Hospital also supplies the clinical base for the provision of accredited course work for students from local schools and universities in the fields of medicine, social work, psychology, hospital administrat- ion, vocational rehabilitation, chaplaincy and nursing. Saint Elizabeths also provides formal orientation in mental health concepts to such community groups as police officers, probation officers, Secret Service and FBI agents, and the clergy. In addition, the Hospital has oriented over 25,000 college and high school student visitors to its operations during the past eight years. Members of the professional staff, both officially and individ- ually, provide consultative and educational services on request to D.C, commnity agencies and personnel. The Hospital also cooperates with local mental health associations in finding jobs for former patients. Patient Population The average daily outpatient load will increase to approximately 2,650 in 1972, and to 2,750 in 1973, primarily due to the operation of the Area D Community Mental Health Center, and will offset the gradual decrease in the average daily inpatient load. Consequently, the average daily load for all patients is expected to remain relatively stable, going from 5,950 in 1972 to 5,900 in 1973. With a planned average daily inpatient load of 3,300 in 1972, it is estimated that an average of 3,150 will be experienced in 1973. The number of patients treated will approximate the 1971 level of 10,100. Since the Hospital's growing outpatient population is requiring the diversion of increasing amounts of scarce time for services to outpatients, the total number of patients is considered in determining staffing levels. Based on the projected level of employment and the average daily load of all patients, the staffing ratio would be sixty-eight employees per one-hundred patients in 1973. Clinical Research and Training The 1973 request includes $1,600,000 to support clinical research and training programs which, in previous years, were budgeted under the "Mental Health" Appropriation. This change in funding is proposed for the purpose of aligning fiscal responsibility with the organizational changes effected in May, 1971, wherein the National Center for Mental Health Services, Training, and Research was disestablished. In the deactivation of the National Center, those research and training programs which were integrally related to the clinical operation of the Hospital were transferred to Saint Elizabeths. The goal of the Hospital's research activities, which are . intimately linked with related programs of clinical care and training > is to better understand the causes of mental disorders and the factors bearing upon their development, treatment, and prevention. Research studies in 1973 will be conducted primarily in the areas of operant behavior, criminal behavior, clinical psychology and psychiatric sociol- ogy. The principal objective of the training program is to increase the number and improve the skills of persons serving medical, nursing «2 is and allied medical and mental health disciplines concerned with the treatment and rehabilitation of the mentally i11. In 1973, the Hospital will provide: training to 120 medical students; graduate and postgraduate programs in mental health such as those for intern- ships and psychiatric residency training; training for mental health professionals, counselors and technicians; and special workshops for Community Mental Health and other community groups. The training program serves as a valuable source of recruitment for scarce- category medical officers and other related professional staff. Unitization During 1973 the highest priority of the Hospital will be to proceed towards the full implementation of the unitization of services to patients. Unitization is considered the most essential step in the conversion of Saint Elizabeths Hospital into a modern community- oriented facility. Under the planned Unitization of the Hospital, the clinical services will be decentralized into smaller treatment units within which a basic unit team will provide patient-centered treatment and continuity care to an individual patient, Each unit will provide comprehensive care and treatment services to all patients within its catchment area including diagnosis, inpatient treatment, rehabilitation, evaulation, outpatient and outplacement services. Training will be provided to aid many employees whose work activity will be shifting from primarily a custodial orientation to that of a commnity-oriented active treatment effort. The Unit system will stimulate extensive interchangeability and jointness of fuctions among staff members in a constructive team approach, This should produce better staff and patient morale and will improve communication between staff, the patient, the patient's family, and the community. The morale of the ward staff should also improve because, after becoming more therapeutically oriented, their feeling of contribution to the effectiveness of the total program should be enhanced, More community involvement can be expected with the added participation by the staff in consultation activities with local. health, welfare and other institutions. The Hospital will also continue to make such needed improvements in medical and surgical support services, services to geriatric patients, forensic services and improved services to children, Continuing efforts will be made to reduce the necessity for inpatient hospital~ ization, and to speed the return of patients to normal community life. The requested increase of $4,490,000 includes $1,804,000 to cover additional costs to continue with the implementation of the unit system of services to patients, including full year costs of additional employ- ment authorized during 1972. An additional $1,776,000 is required to cover built-in salary and wage adjustments, increased operational support costs such as Working Capital Fund assessments, plus necessary equipment replacements. Full year cost with increased enrollment in the Upward Mobility College, together with scheduled support for the Washington Opportunities for Women Program, will require an additional $630,000. The remaining amount of $260,000 is requested for the restoration of Intern and Resident trainee positions. Reimbursement Detail Reimburserents for services performed (patient care): Veterans Administration ..ses U.S. Soldiers Home .cccccccce Public Health Service (Indians) Seteovceooeteoeceeoee U.S. Nationals Covecconsecrose U.S. Prisoners @eeeovaeeeneeoneoee Soc. Sec. (Medicare payments) Subtotal COCKER ECOSECBECHEEEOCE Payment received from Non- Federal sources: Patient care: District of Columbia ..ceces Cafeteria sales ceccccccccee Gale Of SCYAD coccccsccceces Washington Opportunity for Women @eseaseevesovacesaeoen Subtotal seeeneneroeeoeonecos Total reimbursements .cccccese Per diem rate: District of Columbla weccoce Ovex OCC COREE O EEOC OO HEC HOR 1972 1973 Increase or Estimate Estimate Decrease $15,000 $17,100 +$2,100 90,200 85,900 ~4 300 30,100 34,300 +4,,200 450,200 515,300 +65,100 135,500 154,400 +18, 900 300,000 300,000 one 1,021,000 1,107,000 +86,000 23,667,000 26,372,000 +2,705,000 82,000 68,000 ~14,,000 3,000 2,000 -1,000 74,000 40,000 = 34,000 23,826,000 26,482,000 +2,656,000 24,847,000 27,589,000 +2,742,000 i972 2973 Change $22.8. $26.38 +$3 254 41.09 47.10 +6,01 Statement of Average Daily Patient Population 1971 1972 1973 Actual Estimate Estimate Reimbursable Public Health Service (Indians) 2 2 2 D.C. (Residents) ...cccccccsese 2,376 2,173 2,078 D.C. (Vol. and Non-Protesting). 361 366 370 D.C. (Prisoners) oeaeseccsereceos 303 290 285 D.C. (Jury Trial) @eeevsscervecse uA 38 37 U5. Soldiers Home eeeveaenecenee 6 6 5 Veterans Administration .eceses 2 1 1 U.S. Nationals COOH ORESC SEH BOAOE 32 30 30 U.S. PrISONErS sesoccsecvccvcere 10 9 9 Reimbursable Totals .e.e. 3,133 2,915 2,817 Nonreimbursable Military Ootneceoeeoseeeseaneosesene 92 85 70 D.C. Non-residents eeerveseennes 205 190 16 Public Health Service secccsess 6 5 5 Virgin Isiands e@e@eeoeoeoaneaneaes eevee 85 80 72 Miscellaneous s#@eeoaooveeeceneeevase 26 25 21 Nonreinbursable Totals .. kik 385 333 Total In Hospital Patients 3,547 3,300 3,150 SAINT ELIZABETHS HOSPITAL Clinical and Community Services Program Purpose and Accomplishments Activity: Clinical and Community Services 1973 Budget 1972 Estimate Pos Amount Authorization Pos. Amount T5132 $26,523,000 Indefinite 4,132 $28,271,000 Purpose: Saint Elizabeths Hospital provides treatment, care, and rehab« itation services for approximately 3,300 inpatients and 2,650 outpatients. The Hospital operates a security treatment facility and a comprehensive mental health center which services District of Columbia residents in the southeast quadrant of the city. Saint Elizabeths also conducts a clinical research program and provides multidisciplinary clinical training for professional and related personnel. Explanation: The Hospital operates with an indefinite appropriation, which fixes a total operating ceiling and provides that direct Federal appropriations will make up the difference between the total authorized ceiling and the amount of reimbursements received during the year. Virtually all reimbursements received are for inpatient care. The principal reimbursing agency is the District of Columbia. Prior to 1973, the clinical research and training programs were funded from the Mental Health appropriation. Accomplishments in 1972: The Hospital began the initial implementation of unitization of services to patients, with initial actions being taken to reorganize the Hospital into a number of semi-autonomous patient services. Medical and Surgical intensive care units are being set up. Special programs in narcotic addiction, alcohol and services to children were expanded. Over 10,000 patients were treated and, due to the emphasis placed on the early return of patients to productive community life, the average daily patient load was reduced by 247. The Upward Mobility College, with 150 students, was established to provide career development opportunities to primarily disadvantaged minority employees. Objectives for 1973: To continue further implementation of the unit plan, including closer working relations with community agencies, active treatment with early return to the community and effective follow-up, and provision of treatment efforts to avert the need for inpatient care. To be able to offer comprehensive care and treatment services within a catchment area, including the acute and chronic patients, the none psychiatric special care patients, and special groups such as children, drug abusers, alcoholics and geriatric patients. Other needed improve- ments are the. strengthening of medical and surgical support services, improved services to geriatric patients, strengthening of forensic services and improved services to children. It is hoped that the unitizetion of patient services will enable the Hospital to further reduce the inpatient population. ee ee DEPARTMENT OF HEALTH, EDUCATION, AND WELFARE HEALTH SERVICES AND MENTAL HEALTH ADMINISTRATION Health Services Planning and Development Page No. Appropriation language....ccceceerccecrseresescesserecneeusens 98 Explanation of language changes..... See eee eae ee nnseccesone 101 Amounts available for obligation........seccsccesacvccscsrsces 102 Obligations by activity... ..ceeceecne reese nearsneraveenssncene 103 Obligations by Object... cescccccecre neces cesrsrarescesececces 104 Summary of changeS....scceccseccecsaacrsersreessscccverseseuces 105 Significant items in House and Senate Appropriations Committee Reports... cescssscvccervccccccccvescecescsrescness 109 Authorizing legislation... ccccesecrecrcnereseereveceseccsens li Explanation of transfers... sceceresccercrvecesvecne cer erecees 118 Table on estimates and appropriations.......cscerescereccceees 119 Justification: A. General Statement... ccsccrccccvccecvccvensensessevrenstes 120 1. Health services research and development: (a) Grants and CONtractS...ccceeuencceccecenseesece 123 (b) Direct operationS.......ccsvrccceerecesceatecas 135 2. Comprehensive heaith planning: (a) Plamning grants......ccccccececrccccteeesesusees 136 (b) Direct operations... ..ccsccccccaccceeseeesesnne 140 3. Regional medical programs: (a) Grants and ContractS......scecssccereveeeancscns 142 (b) Direct operationS.....scccscceccccssrecevsctecs 147 4. Medical facilities construction: (a) Construction grantS....cccerccsrecececsscsesene 149 (b) Interest subsidies......cccec acer ceesecevsesees 149 (c) District of Columbia medical facilities........ 149 (d) Direct operationS.....cc.ccecescenccececeseces 150 5. Program direction and management services........... 151 B. Items of special concern: 1. Regional medical programs......sceseacssccecesscccce 109, 120, 142, 159 2. Nursing home improvement... ccccecsccvescccccrescenes 130 SE DEPARTMENT OF HEALTH, EDUCATION, AND WELFARE HEALTH SERVICES AND MENTAL HEALTH ADMINISTRATION Health Services Planning and Development C. Program purpose and accomplishments........cccessecees D. State tables... ccc cece cece rcncvsncsssvesesvesessoee E. New positions requested. ....scecccsnccccsssccscecccece Page No. 152 169 182 7 38 Appropriation Estimate HEALTH SERVICES PLANNING AND DEVELOPMENT To camry out tithes VI and 1X, sections 314[a} through 314(c}), and except as otherwise provided sections 301, 304, 311, 402(q), 403(a) (71), and 433(a) of the Public Health Service Act; $329,596,000, of which $85,000,000 shall be available until June 30, 1975 for grants pursuant to section 601 of the Publica Health Service Act for the construction or mod- eranization of medical facilities, and $2,500,000 shall remain available without fiscal year Limitation for payment of interest on guaranteed Loans as authorized by section 626 of the Act. ! [HEALTH SERVICES RESEARCH AND DEVELOPMENT] 2 [zo carry out, except as otherwise provided, sections 301 and 304 of the Public Health Service Act, with respect to health services research and development, $62,070,000. [REGIONAL MEDICAL PROGRAMS] ” [to carry out title IX, sections 402(g), 403(a)(1), 433(a} and, to the extent not otherwise provided, 301 and 311 of the Public Health Service Act, $102,771,000.] [meptcaL FACILITIES consTRUCTION]? [ro carry out title VI of the Public Health Service Act, and, except as otherwise provided, section 304 of the Act for administrative and tech- nical services under parts B and C of the Developmental Disabilities Services and Facilities Construction Act (42 U.S.C. 2661-2677), the District of Columbia Medical Facilities Construction Act of 1968 (Public Law 90-457), and the Community Mental Health Centers Act (42 U.S.C. 2681-2687), $306,704,000; of which $197,200,000 shall be available until June 30, 1974 33 for grants pursuant to section 601 of the Public Health Service Act for the construction or modernization of medical facilities, of which $41,400,000 shall be available only for grants for the construction of pub- lic of other nonprofit hospitals and public health centers; $8,300,000 for grants and $6,700,000 for loans shall remain available until expended for hospital experimentation projects pursuant to section 304 and section 643A of the Public Health Service Act; $50,300,000 shall be for deposit in the fund established under section 626, and shall be available without fiscal year limitation for the purposes of that section of the Act of which $30,000,000 shall be available for direct loans pursuant to section 627 of the Act; $24,052,000 shall be for grants and $16,575,000 shall be for loans for nonprofit private facilities pursuant to the District of Colum- bia Medical Facilities Construction Act of 1968 (Public Law 90-457); Provided, That there are authorized to be deposited in the fund established under section 626(a)(1) of the Act amounts received by the Secretary and derived by him from his operations under part B of title VI of the Act which shall be available for the purposed of section 626(a)(1): Provided further, That sums received by the Secretary from the sale of loans made pursuant to section 627 of the Act shall be available to him for the pur- poses of that section,] [For an additional amount for "Medical facilities construction", $1,500,000, to remain available until expended: Provided, That these funds shall be available only for loans for nonprofit private facilities pur- suant to the District of Columbia Medical Facilities Construction Act of 1968 (Public Law 90-457): Provided further, That the funds appropriated to carry out that Act in the Departments of Labor, and Health, Education, and Welfare, and Related Agencies Appropriation Act, 1972 (Public Law 92- 80) shall remain available until expended .] ; . ‘ " ‘ a 100 Appropriation Estimate MEDICAL FACILITIES GUARANTEE AND LOAN FUND Thene are hereby authorized to be deposited in the "Medical facilities guarantee and Loan fund" amounts neceived by the Sec- netary snom operations under part B of tithe VI of the Public Health Service Act and such amounts shall be available to the Secretary without fiscal year Limitation for carrying out his functions under section 626 (a) (1) of the Act: Provided, That sums received from the sale of Loans made pursuant to section 627 of the Act shall be available to carry out the purposes of that section. 1 101 Explanation of Language Changes HEALTH SERVICES PLANNING AND DEVELOPMENT / 1. A new account is proposed as a result of the consolidation of three HSMHA appropriations, "Health Services Research and Development", "Regional Medical Programs", and "Medical Facilities Construction". This consolidation creates a new appropriation which not only reflects a functional grouping of the accounts, but also provides for better admin- istration by making the appropriation structure consistent with the current HSMHA organization structure. 2. Language formerly used for the three consolidated accounts is deleted. . MEDICAL FACILITIES GUARANTEE AND LOAN FUND 1. The proposed language provides authorization for the Secretary to use monies received from the sale of direct Hill-Burton loans to make additional loans. DEPARTMENT OF HEALTH, EDUCATION, AND WELFARE HEALTH SERVICES AND MENTAL HEALTH ADMINISTRATION Health Services Planning and Development Amounts Available for Obligation Appropriation.......-e.eeee cee ceeee Real transfers to: "Operating expenses," Public Buildings Service, GSA........ "Medical facilities guarantee and loan fund".......e0eseeeee Real transfer from: "Nursing home improvement"....... Comparative transfers to: "Departmental management"........ "Preventive health services"..... "Office of the Administrator..... Comparative transfers from: "Health services delivery"....... "Office of the Administrator".... Subtotal, budget authority.......-. Unobligated balance, start of year. Unobligated balance, lapsing....... Total, obligations........ 1972 $473,045 ,000 -3,000 ~30,000,000 1,000,000 -27 ,000 ~2,189,000 -55,000 25,935,000 27,000 467,733,000 44,500,000 -109, 000 512,124 ,000 1973 $329,596 ,000 329,596,000 329,596,000 102 103 Obligations by Activityl/ 1972 1973 Increase or Page Estimate Estimate Decrease Ref. Pos. Amount Pos. Amount Pos. Amount 122 Health services research and development: 123 (a) Grants and contracts... <-- $56,118,000 --- $58,018,000 --- +$51,900,000 135 (b) Direct operations.. 218 5,898,000 230 6,325,000 +12 +427 ,000 Subtotal... 218 62,016,000 230 64,343,000 +12 +2,327,000 136 Comprehensive health planning: 136 (a) Planning grants...... --- 25,000,000 +-~ 39,800,000 --- +14,800,000 140 (b) Direct operations 24 935,000 49 1,833,000 +25 +898 ,000 Subtotal... 24 25,935,000 49 41,633,000 +25 +15,698,000 141 Regional medical programs: 142 (a) Grants and contracts... —--- 139,300,000 --- 125,100,000 --- ~-14,200,000 147 (b) Direct operations... 169 4,602,000 194 5,051,000 +25 +449 ,000 Subtotal... 169 143,902,000 194 130,151,000 +25 -13,751,000 148 Medical facilities construction: 149 (a) Construction grantS....6. --- 197,200,000 ~--- 85,000,000 -~- -112,200,000 149 (b) Interest subsidies... --- 20,300,000 --- 2,500,000 -+- ~-17,800,000 149 (c) District of Columbia medical . facilities.. -~--- 42,127,000 --- --- --- -42,127,000 150 (d) Hospital exper- imentation project..... <--- 15,000,000 --- --- --- +-15,000,000 150 (e) Direct operations 135 3,058,000 135 3,259,000 —--- +201,000 Subtotal... 135 277,685,000 135 90,759,000 -—-~ -186,926,000 151 Program direction and management services.....+.. 149 2,586,000 149 2,710,000 --- +124 ,000 Total obligations. 695 512,124,000 757 329,596,000 +62 -182,528,000 L/ Amounts included for Medical facilities authority. construction activity are budget 104 Obligations by objectL/ 1972 1973 Increase or Estimate Estimate Decrease Total number of permanent POSLCLONS... cece ce cer eaeeee 695 757 +62 Full-time equivalent of all other positions........... 90 96 +6 Average number of all employees........-2..2-- soeee 710 797 +58 Personnel compensation: Permanent positions....... . $10,045,000 $10,915,000 +$870,000 Positions other than permanent...... tee eeseeee 654,000 728,000 +74 ,000 Other personnel compen- SAtion...cecccsecccovecee 72,000 72,000 -—~ Subtotal, personnel compensation........ 10,771,000 11,715,000 +944 ,000 Personnel benefits........... 1,069,000 1,209,000 +140,000 Travel and transportation of PETSONS..seevecccsees cones 1,126,000 1,271,000 +145 ,000 Transportation of things..... 99,900 114,000 +15,000 Rent, communications and utilities. ..... ccc eee eeeee 688,060 810,000 +122,000 Printing and reproduction...- 293,000 333,000 +40,000 Other serviceS.....ccsereceee 2,544,000 2,961,000 +417 ,000 Project contracts.......... 27,888,000 28,133,000 +245,000 Supplies and materials....... 127,000 145,000 +18,000 Equipment... ..cecceecrcercoce 130,000 143,000 +13,000 Investments and loans........ 24,775,000 --- ~24,775,000 Grants, subsidies and contributions. ....ccceec eee 442,614,000 282,762,000 ~159 852,000 Total obligations by object 512,124,000 329,596,000 -182 ,528,000 i/ Amounts included for Medical facilities construction activity are budget authority. Summary of Changes 1/ 105 1972 estimated obligations... ... cece cess cence ceunecsvenes $512,124,000 1973 estimated obligationsS.......scceusscccscncecvessveeees 329,596,000 Net change...-..eccccreccecccesccesceceseees 182,528,000 Base Change from Base Pos. Amount Pos. Amount Increases: A. Built-in: 1. Annualization of positions new in 1972... .ccceccvceee --- --- --- +330,000 2. Within grade and longevity ANCTEASES... cc cecvecccvace oo ~-- --- + 325,000 3. Annualization of uniformed services pay increase (PL 92-129). 2... ccc eee eee --- ~~~ —_ +19,000 4. Increases for DHEW Working Capital Fund, HSMHA Service and Supply Fund, and FTS CHAT ZES. se cccccreccsccces ~~ --- ~—— +168 ,000 5. Increase in continuation costs for area-wide plan- NIng Srants..cccesceccsoee --- --- zo +2,900,000 B. Program: 1. Health services research and development : a. Grants and contracts.... -—- 56,118,000 --- +1,900,000 b. Direct operations....... 218 5,898,000 +12 + 251,000 2. Comprehensive health planning: a. Formula grants to States for health planning... --- 7,675,000 --- +2,325,000 b. Project grants for area- wide planning......... --- 13,200,000 --- +9,000,000 c.- Project grants for train- ing, studies, and demo- StrationsS....cccseeees -—— 4,125,000 --- +575,000 d. Direct operations....... 24 935,000 +25 + 890,000 3. Regional medical programs: a. Emergency medical— emSELVICCSs sr crececectes Om --- +25 + 350,000 4. Program direction and management services....... 149 2,658,000 -- +68,000 Total, increases........ +62 +19,101,000 1/ = Amounts included for Medical facilities construction activity are budget authority. 106 Base Change from Base Pos. Amount Pos. Amount Decreases: A. Built-in: 1. Two less days Of PAV. ceceecesecceceecsnee TTT --- --- ~$74 ,000 2. Decrease resulting from employment cut-back during ho) ee --- --- ~204 ,000 3.. Non-recurring equipment and change of station costs.... --- -—- -- -24,000 B. Program: 1. Regional medical programs: a. Tue. === 139,300,000 —- C5,200,000>> 2. Medical facilities construc- tion: a. Construction grants...... ~-=- 197,200,000 ~-- -~112,200,000 b. D.C. medical facilities construction.......500. <-> 42,127,000 --- -42,127,000 c. Hospital experimentation PLOJECE seve cere vceeeee OH 15,000,000 --- -15,000,000 d. Interest subsidies of guaranteed loans....... =--~ 20,300,000 ---___-17, 800,000 Total, decreases......... ---__-201, 629,000 Total, net change......ccececccssvccnae +62 -182,528,000 A. Explanation of Changes Increases: Built-in: An increase of $3,742,000 is for mandatory items. Of this $330,000 is for full-year costs of positions new in 1972, $325,000 is for net additional costs of within grade and longevity increases, $168,000is for DHEW Working Capital Fund, HSMHA Service and Supply Fund, and FIS charges, and. $2,900,000 is for an iner®ase in continuatien costs for area-wide planning grants. Program: Grants and contracts~-The increase of $1,900,000 will support an expanded R&D effort in the development of a cooperative Federal-State-local health services data system. This system is the tool by which the Federal Govern- ment can measure progress in reaching its health goals. Direct operations~~An increase of 12 positions and $251,000 is requested in 1973, The increased program effort in the development of health services data systems requires personnel with capability to develop health status sur- veys, monitor data systems for ambulatory care, and to collect and analyze the national data resulting from this program. 107 Explanation of Changes--continued Formula grants to States for comprehensive health planning--The increase of $2,325,000 would allow State agencies to increase professional staffs by 25% and in addition provide for an increase in special studies and consulta- tion to support effective planning at the areawide level; a crucial under- taking in FY 1973 due to the substantial increase in the number of new area- wide agencies. Project grants for areawide comprehensive health planning--The increase of $9,000,000 includes $5,100,000 to establish approximately 100 new area- wide agencies and 20 new State assisted local councils and $3,900,000 to increase the average Federal share to avoid financial dependence upon organizations whose activities must be reviewed and commented upon by 314(b) agencies. Project grants for training, studies and demonstrations--An increase of $575,000 is requested for 1973. This amount would enable the graduate pro- grams to increase the level of technical assistance to be provided to the operating agencies and would be directed in part to further emphasis on the development of planning for innovative systems for the delivery of health care. Direct operations--An increase of 25 positions and $890,000 is requested for 1973. Twenty (20) of the additional positions and equivalent funds will be placed in the Regional Offices to enable the staff to be more responsive to both the State and Areawide agencies in providing technical assistance and consultation. Emergency medical services--25 positions and $350,000 are included for the new Emergency Medical Services Program. These resources will be used to provide planning and evaluation, professional and technical assistance, standard setting, project review, project grants and contracts management and data system development. Program direction and management services--Includes $68,000 to support the Upward Mobility Program. Decreases; A. B. # Built-in: The decrease of $74,000 represents non-recurring salary costs resulting from a reduction of two days of pay in 1973. The decrease of $204,000 results from position reductions in line with the Administration's economic policy. The decrease of $24,000 is due to non-recurring equipment items and change-of-station costs associated with positions new in 1972. Program: Regional medical program grants and contracts—-The decrease of $14°700-000 Ta 1973 SEPT eer STREETS Een ccurcing tens in 1972 of $21,000,000 and an increase of $7,000,000 for a new program of grants and contracts for emergency medical services. These funds will be used to support 5 projects in addition to the 5 funded in 1972. 108 Explanation of Changes~-continued Medical facilities construction: Construction grants--A decrease of $112,200,000 in construction and modernization of hospitals and long-term care facilities is a result of the continued redirection of Hill-Burton activities from a grant program to a program of loan guarantees with interest subsidies for inpatient health facilities. Ambulatory care facilities do not have the same revenue pro- ducing potential as do general and long-term hospital beds and therefore the capital costs of construction for these facilities will continue to be supported through Federal grants. District of Columbia medical facilities--A decrease of $42,127,000 occurs in the construction or modernization of medical facilities in the District of Columbia because the full amount authorized by the Statute has been appropriated. The statute expires on June 30, 1972. Hospital experimentation projects--A decrease of $15,000,000 occurs in the construction of hospital experimentation projects because appropriated funds are sufficient for currently authorized projects. Interest subsidies--A decrease of $17,800,000 is due to the avail- ability of $20,300,000 brought forward from prior appropriations. Gat | 109 Significant Items in House and Senate Appropriations Committee Reports Item 1972 House Report Research and demonstration grants Committee directed that the Pediatric Pulmonary Program be con- tinued in 1972 at not less than the 1971 level. (page 16 of the report). 1972 Senate Report Research and demonstration grants 1. Committee expressed keen interest in a long-range plan to develop interrelated kidney pro- grams aimed at providing therapy for the 8,000 to 10,000 Americans who fell victim to kidney disease annually. (page 25 of the report). 2. Committee directed that a portion of RMP increases be used to prove out HMO programs. (page 25 of the report). 3. Committee concurred with the House and further directed that ail pediatric pulmonary projects ongoing in 1971 were to be funded in 1972. (page 26 of the report). 1. 2. 3. Action taken or to be taken Eight Pediatric Pulmonary proj- ects were funded at a $1,000,000 level in 1971. It is anticipated that the 1972 and 1973 levels will be approximately the same. Recent studies have begun to develop long-range plans for combat-— ing end-stage kidney disease. There will be much greater emphasis on placing each project in the context of both regional and national needs. In keeping with expanded plans, funds invested in these activities will increase from $4,800,000 in 1971 to an estimated $8,500,000 in 1972. Up to $16,200,000 will be used to fund the planning and development of HMO's in 1972. All projects ongoing in 1971 which have been included in their applications by the RMP's affected have been approved for 1972. At the same time, final funding decisions have been left to the individual regions within their own systems of priorities. 110 Significant Items in House and Senate Appropriations Committee Reports - (Cont'd) Item 1972 Senate Report (Cont'd) 4. Committee directed HSMHA and the National Advisory Council to zidress themselves to questions .drrounding the flexibility and individuality allowed RMP's which could impair their effectiveness. (page 25 of the report). 5. Committee directed that increased funds be targeted to a review of the availability of and access to special surgical teams in open-heart and coronary artery surgery, especially in the District of Columbia. (page 25 of the report). 1972 Conference Report Research and demonstration grants Committee agreed that no exist- ing regional medical program is to receive a lesser amount in FY 1972 than it received in 1971. (page 6 of the report). Action taken or to be taken 4. Over the past year specific cri- teria and policy have been developed and issued to the RMP's. There has been a marked increase in efforts of staff to meet with Regional Advisory Groups. In January, 1972, a National Coordinators Conference was held. It brought together all coordinators, RAG members from every region and Council members to discuss with staff issues, policy, etc. 5. A new survey of cardiovascular surgery facilities in the District of Columbia is currently in progress -under the auspices of the Metropoli- tan Washington RMP. A report will be available before. 6/30/72. In addition, Regional Medical Programs Service, in order to carry out Sec. 907 of the Public Health Service Act, contracted with the Joint Commission on Accreditation of Hospitals to develop the Secretary's Lists. One of the criteria which will be used in identifying eligible institutions for those lists will be their par-. ticipation in a regional plan for the optimal development and utiliza- tion of specialized facilities and services. All RMP's will, where consis- tent with National Advisory Council approved funding levels, be funded at or above the FY 1971 level. 111 Authorizing Legislation 1973 Appropriation Legislation Authorization requested Public Health Service Act Section 301 Indefinite $22,726,000 Section 304 $94,000,000 41,617,000 Public Health Service Act Research, Research Training, and Fellowships Section 301 of the Act provides legislative authority for the award of grants for research, research training, and fellowships. Research and Demonstrations Relating to Health Facilities and Services Section 304. (a) (1) The Secretary is authorized-- (A) to make grants to States, political subdivisions, universities, hospitals, and other public or nonprofit private agencies, institutions, or organizations for projects for the conduct of research, experiments, or demonstrations (and related training), and (B) to make contracts with public or private agencies, institutions, or organizations for the conduct of research, experiments, or demonstrations (and related training), relating to the development, utilization, quality, organization, and financing of services, facilities and resources of hospitals, facilities for long-term care, or other medical facilities (including, for purposes of this section, facilities for the mentally retarded, as defined in the Mental Retardation Facilities and Commu- nity Mental Health Centers Construction Act of 1963), agencies, institutions, or organizations or to development of new methods or improvement of existing methods of organization, delivery, or financing of health services, including among others -- (iv) projects for research, experiments, and demonstrations dealing with the effective combination or coordination of public, private, or combined public- private methods or systems for the delivery of health services at regional, State, or local levels. "(c) (1) There are authorized to be appropriated for payment of grants or under contracts under subsection (a), and for purposes of carrying out the provi- sions of subsection (b), $71,000,000 for the fiscal year ending June 30, 1971 (of which not less than $2,000,000 shall be available only for purposes of carrying out the provisions of subsection (b)), $82,000,000 for the fiscal year ending June 30, 1972, and $94,000,000 for the fiscal year ending June 30, 1973. "(2) In addition to the funds authorized to be appropriated under para- graph (1) to carry out the provisions of subsection (b) there are hereby authorized to be appropriated to carry out such provisions for each fiscal year such sums as may be necessary." 112 Authorizing Legislation 1973 Appropriation Legislation Authorized requested Public Health Service Act Section 314(a)--Grants to States for Comprehensive State Health Planning............e0ee+e0+4-+920,000,000 $10,000,000 Section 314(b)--Project Grants for Areawide Health Planning............... 40,000,000 25,100,000 Section 314(c)--Project Grants for Training, Studies, and Demonstrations....cssesseceees eeeeeveveneees 12,000,000 4,700,000 PUBLIC HEALTH SERVICE Title III--General Powers and Duties of Public Health Service Part B - Federal-State Cooperation "Grants to States for Comprehensive State Health Planning "Sec. 314. (a) (1) AUTHORIZATION.--In order to assist the States in comprehen- sive and continuing planning for their current and future health needs, the Secretary is authorized during the period beginning July 1, 1966, and ending June 30, 1973, to make grants to States which have submitted, and had approved by the Secretary, State plans for comprehensive State health planning. For the purposes of carrying out this subsection, there are hereby authorized to be appro- priated $2,500,000 for the fiscal year ending June 30, 1967, $7,000,000 for the fiscal year ending June 30, 1968, $10,000,000 for the fiscal year ending June 30, 1969, $15,000,000 for the fiscal year ending June 30, 1970, $15,000,000 for the fiscal year ending June 30, 1971, $17,000,000 for the fiscal year ending June 30, 1972, and $20,000,000 for the fiscal year ending June 30, 1973. "Project Grants for Areawide Health Planning "(b) (1) (A) The Secretary is authorized, during the period beginning July 1, 1966, and ending June 30, 1973, to make, with the approval of the State agency administering or supervising the administration of the State plan approved under subsection (a), project grants to any other public or nonprofit private agency or organization (but with appropriate representation of the interests of local Govern- ment where the recipient of the grant is not a local Government or combination thereof or an agency of such Government or combination) to cover not to exceed 75 per centum of the costs of projects for developing (and from time to time revising) comprehensive regional, metropolitan area, or other local area plans for coordina- tion of existing and planned health services, including the facilities and persons required for provision of such services and including the provision of such services through home health care; except that in the case of project grants made in any State prior to July 1, 1968, approval of such State agency shall be required only if such State has such a State plan in effect at the time of such grants. For the purposes of carrying out this subsection, there are hereby authorized to be appropriated $5,000,000 for the fiscal year ending June 30, 1967, $7,500,000 for the fiscal year ending June 30, 1968, $10,000,000 for the fiscal year ending June 30, 1969, $15,000,000 for the fiscal year ending June 30, 1970, $20,000,000 for the fiscal year ending June 30, 1971, $30,000,000 for the fiscal year ending June 30, 1972, and $40,000,000 for the fiscal year ending June 30, 1973. 113 "Project Grants for Training, Studies, and Demonstrations "(c) The Secretary is also authorized, during the period beginning July 1, 1966, and ending June 30, 1973, to make grants to any public or nonprofit private agency, institution, or other organization to cover all or any part of the cost of projects for training, studies, or demonstrations looking toward the development of improved or more effective comprehensive health planning throughout the Nation. For the purposes of carrying out this subsection, there are hereby authorized to be appropriated $1,500,000 for the fiscal year ending June 30, 1967, $2,500,000 for the fiscal year ending June 30, 1968, $5,000,000 for the fiscal year ending June 30, 1969, $7,500,000 for the fiscal year ending June 30, 1970, $8,000,000 for the fiscal year ending June 30, 1971, $10,000,000 for the fiscal year ending June 30, 1972, and $12,000,000 for the fiscal year ending June 30, 1973." Authorizing Legislation 1973 Appropriation Legislation Authorized requested Public Health Service Act: Section 601 -- Construction grants........$417,500,000 $85,000,000 Section 626(a)(1) Interest subsidies...... Indefinite 2,500,000 PUBLIC HEALTH SERVICE ACT Title VI--Assistance for Construction and Modernization of Hospitals and Other Medical Facilities Part A--Grants for Construction and Modernization of Hospitals and Other Medical Facilities Appropriation "Sec. 601, In order to assist the States in carrying out the purpose of section 600, there are authorized to be appropriated-- "(a) for the fiscal year ending June 30, 1965, and each of the next eight fiscal years-- (1) $85,000,000 for grants for the construction of public or other nonprofit facilities for long-term care, "(2) $70,000,000 for grants for the construction of public or other nonprofit diagnostic or treatment centers; (3) $15,000,C00 for grants for the construction of public or other nonprofit rehabilitation facilities; "(b) for grants for the construction of public or other nonprofit hospitals and public health centers and for grants for modernization of such facilities and the facilities referred to in paragraph (a), $150,000,000 for the fiscal year ending June 30, 1965, $160,000,000 for the fiscal year ending June 30, 1966, $170,000,000 for the fiscal year ending June 30, 1967, $180,000,000 each for the next two fiscal years, $195 ,000,000 for the fiscal year ending June 30, 1970, $147,500,000 for the fiscal year ending June 30, 1971, $152,500,000 for the fiscal year ending June 30, 1972, and $157,500,000 for the fiscal year ending June 30, 1973. ; "(c) for grants for modernization of the facilities referred to in paragraphs (a) and (b), $65,000,000 for the fiscal year ending June 30, 1971, $80,000,000 for the fiscal year ending June 30, 1972, and . $90,000,000 for the fiscal year ending June 30, 1973. 115 Title VI--Assistance for Construction and Modernization of Hospitals and Other Health Facilities Part B--Loan Guarantees and Loans for Modernization and Construction of Hospitals and Other Medical Facilities Appropriation "Sec, 626. (a)(1) There is hereby established in the Treasury a loan guarantee and loan fund (Hereinafter in this section referred to as the 'fund') which shall be available to the Secretary without fiscal year limitation, in such amounts as may be specified from time to time in appropriations Acts, (i) to enable him to discharge his responsibilities under guarantees issued by him under this part, (ii) for payment of interest on the loans to nonprofit agencies which are guaranteed, (iii) for direct loans to public agencies which are sold and guaranteed, (iv) for payment of interest with respect to such loans, and (v) for repurchase by him of direct loans to public agencies which have been sold and guaranteed. There are authorized to be appropriated to the fund from time to time such amounts as may be necessary to provide capital required for the fund. To the extent authorized from time to time in appropriations Acts, there shall be deposited in the fund amounts received by the Secretary as interest payments or repayments & prinicpal on loans and any other moneys, property, or assets derived by him from his operations under this part, including any moneys derived from the sale of assets. fut 116 Authorizing Legislation 1973 Appropriation Legislation Authorized requested Public Health Service Act Title IX -~ Education, Research, Training, and Demonstrations in the Fields of Heart Disease, Cancer, Stroke, Kidney Disease, and other Related Diseases..... $250,000 ,000 $120,800 ,000 PUBLIC HEALTH SERVICE ACT The Public Health Service Act, Title IX, Education, Research, Training and Demonstrations in the Fields of Heart Disease, Cancer, Stroke, Kidney Disease, and other Related Diseases. "Sec. 900. The purposes of this title are-- (a) through grants and contracts, to encourage and assist in the establish- ment of regional cooperative arrangements among medical schools, research insti- tutions, and hospitals for research and training (including continuing education), for medical data exchange, and for demonstrations of patient care in the fields of heart disease, cancer, stroke, and kidney disease, and other related diseases; "(b) to afford to the medical profession and the medical institutions of the Nation through such cooperative arrangements, the opportunity of making available to their patients the latest advances in the prevention, diagnosis, and treatment and rehabilitation of persons suffering from these diseases; "(c) to promote and foster regional linkages among health care institutions and providers so as to strengthen and improve primary care and the relationship between specialized and primary care; and "(d) by these means, to improve generally the quality and enhance the capacity of the health manpower and facilities available to the Nation and to improve health services for persons residing in areas with limited health services, and to accomplish these ends without interfering with the patterns, or the methods of financing, of patient care or professional practice, or with the administration of hospitals, and in cooperation with practicing physicians, medical center officials, hospital administrators, and representatives from appropriate voluntary health agencies." Sec. 901(a) There are authorized to be appropriated $50,000,000 for the fiscal year ending June 30, 1966, $90,000,000 for the fiscal year ending June 30, 1967, $200,000,000 for the fiscal year ending June 30, 1968, $65,000,000 for the fiscal year ending June 30, 1969, $120,000,000 for the next fiscal year, $125,000,000 for the fiscal year ending June 30, 1971, $150,000,000 for the fiscal year ending June 30, 1972, and $250,000,000 for the fiscal year ending June 30, 1973, for grants to assist public or nonprofit private universities, medical schools, research institutions, and other public. or nonprofit private institutions and agencies in planning, in conducting feasibility studies, and in operating pilot projects for the establishment of regional medical programs of 11.7 research, training and demonstration activities for carrying out the purposes of this title and for contracts to carry out the purposes of this title. Of the sums appropriated under this section for the fiscal year ending June 30, 1971, not more than $15,000,000 shall be available for activities in the field of kidney disease. Of the sums appropriated under this section for any fiscal year ending after June 30, 1970, not more than $5,000,000 may be made available in any such fiscal year for grants for new construction. For any fiscal year ending after June 30, 1969, such portions of the appropriations pursuant to this section as the Secretary may determine, but not exceeding 1 per centum thereof, shall be available to the Secretary for evaluation (directly or by grants or contracts) of the program authorized by this title." "MULTIPROGRAM SERVICES "Sec, 910. (a)To facilitate interregional cooperation, and develop improved national capability for delivery of health services, the Secretary is authorized to utilize funds appropriated under this title to make grants to public or non- profit private agencies or institutions or combinations thereof and to contract for-- "(1) programs, services, and activities of substantial use to two or more regional medical programs; "(2) development, trial, or demonstration of methods for control of heart disease, cancer, stroke, kidney disease, or other related diseases; "(3) the collection and study of epidemiologic data related to any of the diseases referred to in paragraph (2); "(4) development of training specifically related to the prevention, diagnosis, or treatment of any of the diseases referred to in paragraph (2), or to the rehabilitation of persons suffering from any of such diseases; and for continuing programs of such training where shortage of trained personnel would otherwise limit application of knowledge and skills important to the control of any of such diseases; and "(5) the conduct of cooperative clinical field trials. "(b) The Secretary is authorized to assist in meeting the costs of special projects for improving or developing new means for the delivery of health services concerned with the diseases with which this title is concerned. ig authorized to support research, studies, investigations, "(c) The Secretary the utilization of manpower in training, and demonstrations designed to maximize the delivery of health services." Explanation of Transfers 1972 Estimate Real transfers to: Operating expenses Public Building Service, GSA....... ~$3,000 Medical facilities guar- antee and loan fund......+.. -30,000,000 Real transfer from: Nursing home improvement..... 1,000,000 Comparative transfers to: Departmental Management....- -~27,000 Preventive health services.. -2,189,000 Office of the Administrator. -55,000 Comparative transfers from: Health Services Delivery.... 25,935,000 Office of the Administrator. 27,000 Purpose Transfer to GSA for rental of space. To establish the "Medical facilities guarantee and loan fund" to provide funds for direct loans to public agencies for the construction of health care facilities. Transfer to the research and development elements of the nursing home improvement program (National Center for Health Services Research and Development). Funds for a Department-wide nursing home initiative were appropriated in the Supplemental Appropria- tions Act, 1972. Subse- quently, the entire approprie tion was transferred to the appropriate agencies for implementation. Transfer to support the departmental public affairs activities. Transfer of National Clearing house for Smoking and Health. Transfer of 3 positions to the Office of Financial Management to establish a loan accounting section. Transfer of planning grants and related direct operations due to reorgani- zation of HSMHA. Transfer of Deputy and staff due to reorganization of HSMHA. Year 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 Health Services Planning and Development Budget Estimate to Congress $176,220,000 184,589,000 247,057,000 328, 304,000 358,568,000 372,671,000 327,290,000 319,548,000 266,029,000 249 ,653,000 329,596,000 House Senate Allowance Allowance Appropriation $188,672,000 $226,220,000 $226,220,000 182,981,000 233,281,000 231,287 ,000 44,407,000 267,057,000 266,907,000 259,089,000 1/ 328,304,000 328,304 ,000 358,529,000 358,529,000 358,529 ,000 347,671,000 357,671,000 342,171,000 273,368,000 1/ 388,489,000 335,275,000 327,748,000 351,748,900 351,748,000 358,229,000 400,430,000 393,717,000 437,480,000 542,480,000 498 ,980,000 113 1/ The Regional Medical Programs activity was not considered by the House. 120 Justification Health Services Planning and Development Increase or 1972 estimate 1973 estimate Decrease Pos. Amount Pos. Amount Pos. Amount Personnel compensa- tion and benefits. 695 $11,840,000 757 $12,924,000 +62 +51,084 ,000 Other expenses...... ~~~ 500,284,000 --- 316,672,000 --- ~183,612,000 Total........... 695 512,124,000 757 329,596,000 +62 -182,582,000 General Statement EPEAT This budget proposes a consolidated appropriation, Health Services Planning and Development, for HSMHA's health services planning and develop- ment programs which were supported previously by four separate appropriations: Health services research and development, Comprehensive health planning and services, Regional medical programs, and Medical facilities construction. The proposed appropriation is consistent with the recent internal reorganization of the Health Services and Mental Health Administration. It. reflects a functional grouping of the health services planning and develop- ment programs and as such provides for improved coordination and administra- tion of these activities. Research and Development The National Center for Health Services Research and Development will continue major studies designed to improve the way in which health care is delivered in this country. Special emphasis will be placed on cost, dis- tribution and quaiity of health care. The budget includes $64,343,000, an increase of $2,327,000 over 1972. The increase will support the continued development of a cooperative Federal-State-local health sta- tistics system. This project is designed to produce the most compre- hensive data base yet developed for assessing the Nation's health. Comprehensive Health Planning For Comprehensive health planning, $41,633,000 is requested. The in- crease of $15,698,000 over the 1972 appropriation would permit the funding of 100 new areawide health planning agencies and 20 new State assisted councils in rural areas for a total of 272 and 28 respectively. This in- crease is a further significant step towards the development of a compre- hensive, Nationwide health planning system. ¥ Regional Medical Programs The 1973 estimate for the Regional medical programs includes $130,151,000 a net decrease of $13,751,000 below the 1972 obligations (but an increase of $30,882,000 in actual appropriations), consisting of increases of $7,449,000 offset by decreases totalling $21,200,000 for non-recurring construction and 4 Y 121 transfer of planning projects for the health maintenance organization effort to that activity. The additional funds, together with the substantial increase in 1972, will provide for a special initiative in emergency medical services and will strengthen the 56 RMP's and will permit new and increased efforts associated with (1) manpower development and utilization programs, such as Area Health Education Centers, (2) emergency medical service and rural health care systems aimed at improving the accessibility, efficiency, and quality of health care for all Americans, (3) a systematic approach to the treatment of end-stage kidney disease patients through the sharing of facilities, manpower and other resources, (4) the development, demonstration and application of the latest advances in biomedical and management tech- nology as they relate to the delivery of health care. Medical Facilities Construction The 1973 estimate for Medical facilities construction reflects a balanced program of loans, guaranteed loans and grants. Over $600,000, 000 in loans will be made or guaranteed in 1973, adding over 12,000 new or mo- dernized hospital beds to the health care system. In addition to the loan program, $85,000,000 in grants is included for construction of outpatient and rehabilitation facilities, $2,500,000 for interest subsidies and $486,000 for direct operations. 122 Health Services Research and Development Increase or 1972 1973 Decrease Pos. Amount Pos, Amount Pos. Amount Personnel compensation and benefits...esesee+s 218 $3,675,000 230 $3,968,000 +12 +$293, 000 60,375,000 -- _+2,034,000 Other expenses,.......... -- 98,341,000 - Total....ceecceeees 218 62,016,000 230 64,343,000 +12 +2,327,000 Introduction The primary national health goal is the provision of the highest level of health attainable for the entire population of this country. In keeping with this goal, special attention must be directed to the persisting inability of the health care system to meet the demand for high quality health services, the continuing disproportionate rise in medical care costs and the unequal distribution and uti- lization of health services. As the health services delivery arm of HEW, the Health Service and Mental Health Administration has concentrated most of its R&D effort in the National Center for Health Services Research and Development. The National Center stimulates, supports and manages research, research and develop- ment, demonstration, and related training activities which will lead to increased efficiency and effectiveness in the organization, delivery and financing of health services in the United States. The National Center's role, working with both the public and private health sectors, is to develop and test innovations to determine their effectiveness, acceptability, and applicability on a large scale. The collective impact of the R&D program should be increased efficiency in the public and private delivery of health services and increased effectiveness of publicly funded service programs in meeting national health goals and in responding to the public's needs. Priority has been given to innovations which appear to offer the greatest potential for improving access, moderating cost increases and assuring quality. These include: 1. new types of health manpower, especially development and evaluation of physician-extenders like physicians’ assistants, including MEDEX and their civilian counterparts, pediatric and family nurse practitioners, and mid-level dental workers; 2. evaluating the effectiveness of various HMO models and monitoring their fiscal impact; 3. cost containment in health care institutions through all-inclusive rate reimbursement and common claims forms, mergers and shared services; 4, methods for objectively assessing health care needs and adequacy of manpower, facilities and services for communities and states; 5. experimental medical care review organizations to provide operating prototypes for Professional Standards Review Organizations; 6. cost-effective health care technology; 7. Experimental Health Services Delivery Systems to optimize the use of Federal, State and private dollars in bringing comprehensive health care for the total population of communities or entire states, sweeeeeenrReeeeaeeeewasesasn Ss & 123 Health Services Research and Development . Increase or 1972 Estimate (a) Grants and Contracts 1973 Estimate Decrease Pos. Amount Pos. Amount. Pos. Amount Other expenses...sseeceeee ~— $56,118,000 -- $58,018,000 -- +$1,900,000 Subactivities: Research and develop- ment grants and CONELACES.s co. ceseesecee ~—- 51,118,000 ~- 53,018,000 -- +1,900,000 Research and develop- ment training....eee.. << 5,000,000 -- 5,000,000 -- --- Total.sesccccesesse —_ 56,118,000 —_— 58,018,000 — +1,900, 000 (1) Research and Development Grants and Contracts: 1972 1973 Increase or Estimate Estimate Decrease No. Amount No. Amount No. Amount Research, Development and Demonstration Grants: Non~competing continuations. 90 $18,559,000 103 $22,045,000 +13 +$3,486,000 New and renewal grants...... 40 9,291,000 33 7,705,000 -7 -1,586,000 Supplementals....sesseeeeee+ (15) 200,000 (15) 200,000 -- = Subtotal....ceeseeesees 130 28,050,000 136 29,950,000 +6 +1,900,000 Contracts: Continuations--.......e00-0¢- 61 16,150,000 61 16,150,000 -- ~me New ContractB....eccsccceses 38 6,918,000 38 6,918,000 —--+ --- Subtotal. .ccecvcoescese 99 23,068,000 99 23,068,000 -- ~~ Totalrcccaccccccccccccseeces 229 51,118,000 235 53,018, 000 +1,900, 000 Distribution by Program Increase or 1972 Estimate 1973 Estimate Decrease Research and Development: Health services manpower...cecscesece $5,000, 000 $5,000,000 ~-- Health maintenance organizations ~— evaluation.....cees 2,000,000 2,000,000 --~- Health care institutions, costs, . and Financing. .ccccccscscscccccssne 9,518,000 9,518,000 — Federai-State-local health services data System. ..secseccncens 1,600,000 3,500,000 +$§1,900,000 Performance accounting... .ccccsoscsses 11,000,000 11,000,000 -—— Health care technology...csscecsecsee 7,000,000 7,000, 000 -—- Health care SyStemS..ccoccrccescecces 15,000, 000 15,000, 000 -——- Totals cocescenccccecccssecceocee 51,118,000 53,018 ,000 +1,900,000 Be eaeneBe ReBeeeDpDeaeseweaep&@wvwQus SS & 124 Building on previous health services research, the National Center has estab- lished a research and development program directed to creating, introducing, testing and evaluating the essential components of comprehensive community health care delivery systems that will increase the supply, improve the distribution, and moderate the cost of health services. The problems and approaches of the R&D program are developed through consul- tation with private and public health care providers, both institutional and indi- vidual, third-party payers, consumers, and university-based specialists and re- searchers in health care organization, delivery or financing. The Center also maintains working liaison with other programs of HSMHA, DHEW, and other federal agencies concerned with health services. By these means, program areas, major projects, and other principal aspects of the program are defined, focused, and kept under continuous critical review and appraisal. The National Center's strategy for carrying out its R&D program consists of the development of prototype community health services systems. The systems approach calls for identification and examination of the inter-related components which constitute community health care and modification of these components in order to maximize their individual and joint contributions. The major components which have been identified for special attention are new types of health manpower; evaluation of health care financing mechanisms; cost containment through innova- tive institutional arrangements and insuring quality of care; the development of a cooperative Federai-State~local health statistics system; cost effective tech- nology; and community health services R&D. In addition, in 1973 the Center will begin to develop its second generation R&D programs, Building upon its current R&D program and the commitment of HSMHA to integrate its service and development programs, this will lead to the HSMHA R&D strategy for systematically introducing at State and regional levels the tested organizational, manpower and technological innovations that predictably will bring about constructive reform in health services delivery. This national implemen~ tation strategy will provide the mechanisms needed to assure the attainment of the intended purposes of financial entitlement legislation. Data from the various studies will be combined in designs for R&D projects, which will put into effect and test the new planning and development methods. It is expected that several alternative patterns of planning and development will be offered for evaluation to States, regions, and localities. Both the planning studies and the implementation studies will emphasize the development of cost/ effective preventive heaith services through the creation of HMOs and similar health services organizations. Planning and implementation studies will be carried out with involvement of CHP and RMP agencies and personnel, and the Regional Offices. ‘The National Center will design and guide studies and provide technical assistance and financial support for key R&D projects. To support the R&D effort, the National Genter is requesting a budget of $53,018,000 for grants and contracts in 1973, an increase of $1,900,000 over the 1972 level. The increase will support the continued development of the coopera~ tive Federal-State-local health statistics system. Specifically, the following high priority R&D programs will be supported in 1973. I, Health Services Manpower It is estimated that some 200 physician's assistant programs of the widest possible range of types may now be in existence or in some stage of development. The proliferation of many different and uncoordinated programs may cause great confusion and be disruptive to the attempts to use these new types of health manpower effectively. Moreover, few of the current physician's assistant programs address themselves to anything but the numerical shortage gf physicians. It is not clear that physician's assistants, who must functf@n under the supervision of 125 licensed practitioners, will be able to relieve the shortage. This cannot occur if requirements for supervision cause them to distribute themselves in accordance with the existing pattern of physician distribution, which re~ flects over-concentration in certain medical specialties and in affluent population centers. : In addition, the kind of training now being given to physician's assis- tants tends to assume that established patterns of medical practice and organization will remain unchanged. Little attention is given to coming technological developments and new forms of health care organization, which will undoubtedly have a pronounced influence on the duties to be performed and the skills required by the physician's assistant. A climate of accept~ ance of the physician's assistant unquestionably now exists. But answers to these basic questions must be found before we can move effectively to develop the potential which the physician's assistant appears to offer. Several projects currently supported by the National Center are devel- oping and evaluating physician~extender manpower which can be used in normal practice settings, group practice clinics or remote health care centers linked to medical supervision by radio, television, or special telephonic connections. These demonstrations are being evaluated by use of procedure which will permit direct comparisons of results. The Uniform National Evaluation Protocol includes the effects of introducing physician's assis- tants in various sized medical practices on the costs and quality of care, patient and physician satisfaction, delegation of tasks, and relationships with other health professionals. Recruitment, selection and curriculum are also being studied. This evaluation is now under way with six MEDEX projects as well as with the Center-sponsored demonstrations of the family nurse practitioner, school nurse practitioner, the pediatric nurse practitioner, the nurse midwife, and the dental auxiliary. Data is being gathered in 25 states from 200 coop- erating medical practices which range in size from solo-general practices to large-scale urban group clinics. Ways in which physicians productivity is being increased is being documented: Preliminary findings, based on a random sample of 3,000 cases from 20 solo family practices show a potential savings of approximately 20% of physician time through assignment of patients in certain diagnostic categories to primary contact with only the nurse. In 1973, demonstrations and uniform evaluation of mid-level medical workers will be extended to a total of 35 states. Comparable data will be available in sufficient quantity to permit assessment of the cost effec- tiveness of mid-level workers. By the end of 1973, the licensure and cre~ dentialing issues will be sufficiently analyzed to suggest guidelines for national policy, which will supplement and expand those transmitted to the Congress by the Secretary in June 1971. (Report on Licensure and Related Health Personnel Credentialing) In 1973, R&D emphasis will shift to problems of multiple alternative staffing patterns in regionalized delivery programs and in group practices, including HMOs. An estimated $5,000,000 will be used to support manpower studies in 1973. é % | we. | ww IT. Iil. Health Maintenance Organizations - Evaluation The National Center is supporting a variety of projects related to research, development and evaluation of Health Maintenance Organizations (HMOs). HMOs will be studied with respect to such factors as enrolled pop- ulation, benefit structures, utilization patterns, monitoring of services, costs and quality of care and financing mechanisms. A provisional HMO data monitoring plan is being developed in 1972 and will be ready for installation and evaluation in 1973. The uniform national evaluation protocol under development can be used by Federal and private agencies to evaluate the benefits of the HMO form of health services delivery. The protocol will bring together in one technique the several different types of measurements needed to assess the net effects of HMOs, such as the breadth and continuity of services delivered to people, the quality of the services, the resources required by the HMO, and the costs to individuals and families and to supporting public and private programs, This will make possible a comparison of HMO costs and efficiency with other forms of medical practice organization. In 1973 an estimated $2,000,000 will be used to support the evaluation of Health Maintenance Organizations. Health Care Institutions, Costs and Financing A. Costs and Financing The cost of medical care continues to increase at a fast pace; by the end of fiscal 1971 the bill for the Nation's health care had risen to $75.0 billion, 7.4 percent of the Gross National Product. On the average, each man, woman and child in the United States was paying $358.00 annually for medical care, an increase of $31.00 per person over the previous year alone. As a result, consumers have difficulty purchasing comprehensive health care coverage, or even worse, they are completely denied medical care because of its costs. It is obvious that costs must be effectively controlled if significant progress is to be made in the improvement of the delivery of health services to the population. An ongoing study of Title XIX in the State of California is comparing the quality, use and costs of care among six different forms of physician organization. The use and costs patterns differ depending upon the degree of physician responsibility actually exerted in maintaining surveillance over the appropriateness and quality of care. The provision and utilization cf medical services often requires sub- stantial costs to patients which are not reflected in dollar expenditures, e.g. waiting times, travel times and costs, and time and effort involved in patient participation. These costs are likely to increase in the event of a substantial increase in insurance coverage, resulting in little net change in access to many population groups. Research and development is being under- taken in these non-monetary costs including the magnitude of such costs, their effect on patient behavior, and possibilities for reducing the level of these costs, ‘ The National Center is supporting a major study of the efficiency of alternative organizational forms for the delivery of ambulatory care, in- cluding prepayment plans, fee-for-service group practices, and traditional solo practice. The study focuses on economic aspects and implications of medical organizations, use of non~physician personnel in new ambulatory care systems, and problems in the definition of price and productivity indices for such systems. It is expected that preliminary data will be available in the summer of 1972, These analyses will serve as a basis for fundamental deci- sions affecting government support of various modes of practice, including the . ‘ 127 development and implementation of HMOs. B. Institutions 1 The costs of hospital care continue to rise more rapidly than the costs of any other component of the health care industry and twice as fast as the overall cost of living. The National Center is deeply involved in research and development directed to cost containment projects which are intended to produce nationally applicable results. It is the nationwide installation of the new procedures that will moderate cost increases, improve interinstitu- tional relationships and reduce unnecessary hospitalization. The R&D pro- jects encompass hospitals and other care institutions. Simplifying administrative procedures in hospitals has great potential for reducing costs of health care. Two approaches to simplification, each of which is being evaluated on a national basis, are: 1. Implementation of an all-inclusive rate charging and reimbursement procedure in hospitals. Instead of charging for each specific item, hospitals will establish average costs in typical patient categories and then bill each carrier or agency or patient the appropriate standard daily rate. 2. Establishment of a nationally accepted uniform hospital discharge abstract and common insurance claim data. This project, currently being tested in five communities, will facilitate analysis of hospital costs in relation to the number and types of patients served and to the size and type of hospital. This will for the first time permit nation- wide comparisons of hospitalization experience by length of stay, diagnosis, medical procedures, age, sex, size of hospital, and other variables. In time, it will provide useful data for determining community needs for additional hospital beds and for other types of services, such as nursing home beds and outpatient facilities. Previous studies of both approaches to cost moderation, indicated potential savings of hundreds of millions of dollars annually if the pro- cedures were adopted by ail hospitals and accepted by third-party payers. Savings can also be realized by reducing management overhead, better utilization of skilled manpower in short supply, avoiding the duplication of facilities, equipment, or services through shared services among similar or diverse types of facilities; mergers of facilities into one common corporate identity; agreements among different types of facilities to insure appro- priate placement of patients relative to their needs; and formal relation- ships between ambulatory care facilities and hospitals. 1, A major national study of hospital mergers and shared services is being made by the Health Services Research Center jointly sponsored by the American Hospital Association and Northwestern University. The Center is supporting an evaluation of the integrated health care facil- ities established by the Samaritan Health Service, Phoenix, Arizona. Special attention is given to the efficiencies resulting from common management of groups of hospitals and sharing of medical services such as obstetrics, pediatrics, radiation therapy and the like, Economies resulting from centralized purchasing, laundry, food services, computer services, billing, laboratory testing and maintenance are being demon- strated. The potential impact on quality of care resulting from sharing of clinical services will also be evaluated. In addition, insights gained in the Samaritan study have been incorporated in two publications dealing with hospital mergers and shared services which have been made available to the hospital community on a national basis. IV. 128 Although studies of the different forms of arrangements have been com- pleted or are in progress, available reports do not permit a precise estimate on a national scale of the magnitude of potential cost reduction. The evi- dence is clear, however, that cost savings will be achieved. The results of these analyses will be published in the form of R&D guide- lines for communities, systems or institutions who wish to test these methods of implementing interinstitutional arrangements. In 1973, an estimated $9,518,000 will be used to support studies in the area of health care institutions, costs and financing. Federal-State-Local Health Statistics System Rational decision making for any substantial investment requires reliable baseline and trend data. This is particularly true of the health care system, which has been undergoing tremendous expansion in recent years without atten~- dant refinement of its data-gathering and handling mechanisms. In an era when the health care system has investments from all sectors, and, particu- larly, when there appears to be great merit and emphasis upon decentralization of as much decision making as possible, a cooperative Federal-State-local health data system is imperative. Lead responsibility within the Health Services and Mental Heaith Admini- stration for the research and development phase of the program is located in the National Center for Health Services Research and Development. This pro- ject is being developed jointly with the National Center for Health Statis- tics which has responsibility for the implementation of the system. Consistent with current national priorities, the cooperative system gives priority attention to data needed for the planning, operation, manage- ment, and evaluation of health services delivery. If individual access to health services is to be improved, while maintaining quality and containing costs, the health care system cannot continue to operate without adequate knowledge of its effects upon the health of the population. The Cooperative Federal-State-Local Health Services Data System must serve to coordinate data~collection activities at various levels, from individual patient care to local, State, and national decision making. Emphasis, therefore, is placed on developing an intimate working relationship between the data system, health services delivery systems, and local, State, and Federal governments. The system wili be developed through the use of standard definitions, standard measurements for quality of performance, and standard precedures for the collection, processing, and analysis of health data. The system should provide data which will accurately and adequately reflect (1) the physical and mental health of the people, (2) the use of ambulatory, hospital, and long- term care services, including preventive, diagnostic, curative and rehabili- tative services, (3) the cost of these services, (4) the available health resources--facilities, manpower, and services, (5) the character and quality of the environment as it relates to health, (6) the basic demographic characteristics of the population, including patterns of family growth, births, deaths, etc., and (7) the knowledge, practices, and attitudes toward health and health care. In 1973, an estimated $3,500,000 will be used to support the R&D phase of this cooperative project, an increase of $1,900,000 over the 1972 level. v. 129 Performance Accounting A. Quality Assurance and Review The National Center, working in cooperation with the Regional Medical Program, has supported basic research and development on the quality of medical care and on improving methods of measuring and monitoring quality. In 1971, the National Center began support of experimental medical care review organizations (EMCROs) by eight State and county medical societies to review the quality of health services delivered by all providers in specified geographic areas. In 1972, these experimental organizations are being ex- tended to 10-12 sites. The purpose of the EMCRO is to develop and test alternative methods for conducting objective peer review of the content, appropriateness and quality of medical care. Those which prove successful will be prototypes for implementation of Professional Standards Review Organizations legislation. Review mechanisms will encompass office and hos- pital care, nursing home drug use, drug utilization review, criteria for admission to hospitals and long-term care facilities. Health professions other than medicine are to participate and establish review mechanisms. The public is to be appropriately represented in the review process at a suitable level. The elimination of medical care and pro-~ cedures which are unnecessary, without compromising quality of care is a necessary objective in the effort to contain costs. The quality assurance program seeks to achieve this effect while also impacting on the delivery of care to insure an acceptable level of quality. In 1973, the Center will expand research and development in two parts of the future quality assurance system which have as yet received little at- tention, These are measures of outcome of medical care, and methods for developing and installing in office practice and hospitals the patterns of medical practice which reasonably assure high quality outcomes. The results of the basic research previously supported and of these new studies will provide the methods for quality assurance in HMOs, as well as in all other forms of provider organizations. B. Health Services Data System Developmental projects have been initiated and will continue in selected communities with the goal of establishing continuing and flexible systems for making available and using health services data in the planning, operation and evaluation of health services delivery programs. In the short-run, these efforts will be focused on providing information for evaluating Experimental Health Services Delivery Systems and Health Maintenance Organizations. Data collection activities within the experi- mental community systems and the HMOs occur concurrently with the planning and development of these new organizations and will relate specifically to their activities. Comparison and evaluation of the various data efforts produced during the development of these activities will be carried out with a view to determining the most useful and least costly means of gathering and evaluating health care data. Initial attention is being given to developing a community profile from census and other data. The first components of the data system are the household survey, hospital discharge abstract data and methods for obtaining information on cash flow. At a later time, attention will be given to de- signing an encounter form for ambulatory care data and for methods of col- lecting data for quality assessment. The basic data elements will include descriptive information such as demographic information, community surveys and data on manpower and facilities; ambulatory care data; hospital discharge data; quality assessment data; and financial data. The hospital discharge abstracts and ambulatory care surveys, together with other utilization data, are being developed for further implementation and evaluation within the context of the Federal-State-local health services data system, which is being jointly developed with the National Center for Health Statistics. Iv. 130 These prototype health services data systems are being developed and evaluated in four locations. Two, Rhode Island and Colorado are statewide; two others are local efforts at Livingston and San Joaquin in California. Timetables for component development, implementation, evaluation and modifica- tion have been established at all four locations and the expectation is that health services data systems, including survey, ambulatory, funds flow and uniform hospital discharge components will be in operation by May 1973. Tech- niques for demographic analysis of existing census data will be available by December 1972, A similar data collection effort will be undertaken in order to monitor and evaluate the performance of Health Maintenance Organizations. Standard- ized data systems will be installed in experimental HMOs and HMO-like instal- lations. These. will be more formal management information systems, for inter- nal management and control within the HMO. as well as providing for effective and objective review by outside authorities. The data collected will provide for the continuous monitoring and periodic evaluation of performance within individual HMOs and for comparison between HMOs. , C. Nursing Home Improvements . In 1972 the DHEW received a supplemental appropriation to implement the President's request that new initiatives be taken to improve the general con- ditions of the Nation's nursing homes and extended care facilities. The National Center received $900,000 to support a new R&D effort with respect to nursing home standards and quality. The R&D approach will: (1) improve the techniques of quality performance assessment of nursing homes to enable inspectors to detect deficits in patient care and environmental hazards; (2) introduce new types of mid-level manpower such as nurse clinicians and physician extender personnel to augment the phy- sician's care and provide medical management supervision; and (3) design a data system that would provide a systematic inter-agency data/report sharing and implementation. plan, The latter would achieve a uniform minimum core data set compatible with data used by other agencies. In 1973, an estimated $11,000,000 will be used to support studies re- lating to quality assurance and review, EMCROs, data systems development, and other evaluation activities. Health Care Technology The projects undertaken by the National Center's Technology Division are directed to the issues of cost-containment, efficiency and productivity in the delivery of health services. These projects employ state of the art computer techniques to: Automate certain service functions; process data to improve the clinical management of patients; and provide management information to im- prove the operation of health care facilities. Health care technology research and development is directed to four areas: 1. Medical information technology includes work in hospital information systems and medical signal processing. The current strategy is to sup- port two approaches to the development of hospital information systems. One capitalizes on the sizeable public and private monies already inves- ted in achieving a workable total hospital information system (HIS). _This evaluation assesses the impact of HIS on manpower requirements, ‘level of skills, length of stay, quality of care, cash flow, inventory and fiscal controls. The second is based on time shared computers which make feasible a shared, modular hospital information system. This ap- proach supports a group of cooperating hospitals to implement modules of the system and share cost based on computer time utilization. Both of these approaches are currently undergoing the test of demonstration and ReeeaearmageaeeaeaeneaeeaeeeEneataw#Etegm w& objective evaluation in operational settings. The hospital information system at the Massachusetts General Hos- pital utilizes in a modular fashion small computers and the MUMPS lan- guage (a high-level language interpreter). Several examples of economies achieved with individual modules are available. For example, the Census and Bed Control Module at Framingham Union Hospital in Massachusetts, re- quiring daily physician updating of estimated length of stay, resulted in a 14% increase in bed utilization for the 150 medical/surgical beds of this 288 bed hospital. With daily charges at $75 per day, this module thus resulted in an increased cash flow of $1,500 per day, which calcu- lated on a yearly basis, produced $500,000 of income to offset fixed operating costs. Other modules, such as radiology and pharmacy, may achieve cost savings through rationalizing information flow within these departments and thus facilitate optimal resource allocation. 2. Automated health maintenance systems R&D include projects in labora- tory automation and screening and disease detection and screening. Two projects are currently being supported which successfully demonstrate the use of computers in improving the operation of the clinical laboratory. The new activity planned in this area is to explore the feasibility of extending automation techniques into the microbiological laboratory. Developmental work on mass screening devices will continue for white cell differential counts, sputum cytology and ECG analysis. These are clini- cally important, high volume activities that are labor intensive. Auto- mation of these tests would result in significant cost reduction and con- servation of skilled manpower. Private enterprise has moved in to further development and expansion of many of the Technology Division's projects, For example, the automa— ted ECG program developed by the Division is the focus of an ECG Data Pool supported by more than one hundred members, largely from the private sector. The studies show that a 75% savings in physician manpower may be achieved by using a computer assisted ECG analysis program. On a national scale, this would free an estimated 1,300 cardiologists for direct patient care. Equally important, this system improves patient care by providing rapid access to a correct ECG interpretation in medi- cally underserved areas. This project has progressed to the point where it is providing a valuable service to a community of hospitals within the city and the outlying regions surrounding Denver. This activity which was initially funded for three years as a demonstration will be complete~- ly self supporting in 1973. 3. Technology for Logistics and Data Systems. Data System activities are directed toward the design and development of computer systems for handling medical transactions and claims data. One such contract is a pilot study for the On-Line Medicaid Claims Processing for the entire State of Alabama. In the area of medical logistics, the delivery of health services to remote areas has been identified as a problem of significant scope in which existing technology offers possible solutions. One such possible solution is the use of picture-phones and closed circuit television to extend medical support to health services personnel and facilities oper- ating in remote or isolated locations. An activity to explore these possibilities has been initiated. 132 4, Ambulatory Services. Priority is given to increasing productivity and efficiency of the physician in the individual office, group practice, or clinic settings, where in fact the majority of health care in this country is delivered. Significant gains in ambulatory care management can be made through automating medical record systems, medical history acquisition, and providing physician consultative support. Major pro- jects in these categories will be subjected to a nationally-based assess- ment in order to concentrate R&D on those approaches which promise the best pay-offs in savings of physician time and increasing productivity. The automated history is considered the most probable cost-effective vehicle for bringing the time-shared computer terminal into the physi- cian's office. This versatile communication device will permit such innovations‘in the office as computer aided diagnosis; drug interaction warnings; educational materials and treatment plans; special instructions in diets; patient scheduling to hospitals, clinics, and laboratories; communication with hospital information systems that will allow entering of preadmit data, review of patient charts, and entering of medical orders; and record, billing, and accounting functions. In 1973, an estimated $7,000,000 will be used to support health care technology research and development. VII. Health Care Systems The National Center for Health Services Research and Development supports the implementation of model health care delivery community systems which stress preventive measures, ambulatory care, improved financing methods, and improved use of manpower and technology. A. Experimental Health Service Delivery Systems. The “health care delivery system" in the United States consists of practitioners, administrators, financers, consumers, and private and public agencies at ali levels and fre- quently having overlapping jurisdictions. It is often impossible for a commu- nity to allocate resources for maximum community benefit because conflicting or competing programs may provide multiple sponsorship for some services o1 beneficiary groups, while other desirable services and needy beneficiaries are not covered by any program. In response to this situaticn, the Health Services and Mental Health Administration, through the National Center for Health Services Research and Development, is supporting the creation of experimental health services delivery systems for entire communities. In 1971, the Center served as lead agency for the cooperative initiation of Experimental Health Services Delivery Systems (EHSDS), in 12 urban and rural communities across the United States, including the States of Vermont and Arkansas. Up to eight new EHSDS will be started in 1972. These are voluntarily established projects covering entire communities or states whose purposes are to: 1. Establish a voluntary management capability reflecting a balance of control between the providers, third-party payors, political ele- ments, and the public. Assure access to the system by all inhabitants of the area. Assure the quality of care in the component organizations. Evaluate performance of the system in terms of community needs. Combine public and private funds to increase access, moderate cost increase, and insure adequate quality of care. WU & Ww Ph eo 8 6 The NCHSRD is evaluating the EHSDS program and assisting EHSDS communi~ ties in developing a: uniform health services data system. Innovations, 133 developed through research and development elsewhere, will be installed and tested in EHSDS. Examples are new manpower types, financing arrangements, quality assurance techniques, and cooperative arrangements among health care facilities, The EHSDS program reflects, at the national level, a common effort by all HSMHA programs. It includes the development of joint funding of these large-scale projects to improve community health care delivery. The EHSDS program also involves coordination with other HEW agencies and with other Federal departments, At the community level, the EHSDS projects first establish and then determine whether a management structure can improve performance of the health services delivery system in improving access to care for the entire community at reasonable cost and of assured quality. Major consideration is given to redirecting private and public (Federal, regional, State and local) sources of funds more efficicntly, and to initegialing community services. The R&D will be supported for a limited period only. More efficient use of existing dollar flow will enable each system to support the necessary staff and special activities, The service money flowing through the community in- cludes medicare, medicaid or private insurance as well as HEW funds. B. Community health services research and development, Community health services R&D projects are carefully selected laboratories within which the separate manpower, institutional, financing and other R&D programs of the National Center are given final test of effectiveness. Each such laboratory analyzes the health care requirements of the population.in relation to existing resources. On the basis of this, R&D is conducted in installing new kinds of manpower, financing, ambulatory care services, interinstitutional agreements and the like. Their effect will be evaluated in terms of increased access to, and utilization of, health services, costs, and patient and pro- vider satisfaction. One of the first prototypes to emerge under this strategy is Rhode Island Health Services Research, Inc., a non-profit corporation which in- cludes in its membership the major health provider, payer, and organizations in the State. The development of this health services corporation is the first step in the creation of a statewide comprehensive health services system which will incorporate results of the Center-supported research and development. The Corporation is presently considering revised programs of ambulatory care in the community, establishing a health services information system, and experimenting with hospital reimbursement mechanisms in which all hospitals will participate. Each of these changes, if instituted, will be scientifi- cally evaluated. Several other innovations are under discussion. The cor- poration has completed an analysis of its needs and is now studying its health services resources. The survey of health care needs will be refined and re- applied periodically, In 1973, an estimated $15,000,000 will be spent on 1) the development of experimental health services delivery systems; and 2) community health service research and development. In summary, the National Center is requesting $53,018,000 for support of its research and development activities in 1973, an increase of $1,900,000 over the 1972 level, The additional $1,900,000 is requested to support the continued devel- opment of a cooperative Federal-State-local health services data system. 493 134 (2) Research and Development Training 1972 1973 Increase or Estimate Estimate Decrease No. Amount No. Amount No. Amount Training grants: Non-competing contin- UAtLONS. .cccccecseves 43 $3,771,000 43 $3,771,000 -- --- New and renewal grants.. 1 67,000 1 67,000 -- =o" Supplementals.....secees (&) 150,000 (8) 150,000 -- -“-- Subtotal..vescecees 44 3,988,000 44 3,988,000 -- --- Fellowships: Non-competing contin- UATLONS. crceccccccers 62 574,500 62 574,500 -- --- New grants...scccecceece 5 71,500 5 71,500 == “<< Supplemental....sscceees (8) 30,000 (8) 30,000 -- --- Subtotal...secccoss 67 676,000 67 676,000 -- -—~ Contracts: ContinuationsS..ccscceres 2 166,000 2 166,000 -- --- New COMCTacts...serereee 2 170,000 2 170,000 -- --~ Subtotal. .cocsseces 4 336, 000 4 336,000 -- --- Total. .cccscccscecevervesvs 115 5,000,000 115 5,000,000 -- --- As the development of new systems for the organization, delivery and financing of personal health services evolves, the focus of training activities within the National Center is shifting in anticipation of the research and management capa- bilities which will be required. In 1972-1973, a major emphasis of the training program will be the develop- ment of training in health services management and evaluation. Implementation of the innovations in health services delivery systems resulting from the Center's R&D. program will require training of new types of managers and administrators. These new types, including physicians, hospital administrators and others from non-health backgrounds, must be prepared to plan, implement, operate and evaluate evolving systems, Experience in health services R&D is essential in training pregrams geared to produce these skilis. This training, while it may be conducted in an academic setting, will not be entirely degree-oriented. It will emphasize the development of quantitative, analytical skills for existing health services administrators to provide in- creased managerial and executive capabilities. It is not intended solely to develop independent health services research personnel, but will focus on mid- career experience designed to produce improved capacity for planning, more rational allocation of scarce resources, and knowledge of processes for syste~ matic, objective evaluation of the impact of innovation on the health care delivery system. The 1973 level of $5,000,000 will support 48 awards to institutional programs and 67 individual fellowships. This is the same level as in 1972. 135 Health Services Research and Development Increase or 1972 1973 Decrease (b) Direct Operations Pos. Amount Pos. Amount Pos. Amount Personnel compensation and benefits......sseee+++-218 $3,675,000 230 $3,968,000 +12 +8293,000 Other EXPENSES... +e +e eeeeeree —H 2,223,000 -- 2,357,000 -- +134,000 Total..cccceccecceceeee218 5,898,000 230 6,325,000 +12 +427 ,000 The National Center for Health Services Research and Development is responsi- ple for the appraisal and evaluation of the effectiveness of health services opera- tions and for developing a research and development program that is geared to im- proving health care nationally. The staff of the National Center devoted major effort to designing and direct- ing the strategic program of research and development. The staff obtains high- level evaluation of all proposals, closely monitors contracts, reviews results, in- forms the professional community of significant progress and identifies the next steps in research and development. Considerable time and effort is devoted to close collaboration with the investigators, providers, payors and major national organizations. The staff of the Center is organized into three major programs: 1. Special Projects R&D, addressing highest priority problems through short-term research and development. 2. Secial and Economic Analysis with programs in the social sciences, economics, epidemiology, and legal medicine; addressing fundamental long-term issues in health care. 3. Health Care Technology which encourages applications of advanced instrumentation and automation to improving the delivery of health services. The National Center is requesting a program increase of 12 positions and $251,000 in 1973. The increase is essential for the National Center to further de- velop the managerial and technical capability to carry out its large-scale R&D efforts. The increased program effort in the development of community-wide health services data systems requires additional personnel with statistical and computer capability to develop health status surveys, to monitor data systems for ambulatory care, and to collect and analyze the national data resulting from this program. The additional increase of $256,000 provides for built-in changes, which is partially offset by a decrease of $80,000 due to non-recurring program costs. Comprehensive Health Planning 1.3 Increase or 1972 estimate 1973 estimate Decrease Pos. Amount Pos. Amount Pos. Amount Personnel compensation and benefits.......2.06+ 24 $546,000 49 $872,000 +25 +$326, 000 Other expenses.....-+e.0+- —~ 25,389,000 -- _ 40,761,000 --_ +15,372,000 Total.........+6e- 24 25,935,000 49 41,633,000 +25 +15,698,000 Planning Grants Personnel compensation and benefits.....eeesees —7 38,000 -- 38,000 - ~_ Other expenses........-++6 ~~ 24,962,000 -- 39,762,000 -- +14,800,000 Total...secesessee ~~ 25,000,000 -- 39,800,000 -- +14,800,000 Subactivities: (a) Formula grants to States. for comprehen- sive health planning.. 7,675,000 10,000,000 +2 ,325,000 (b) Project grants for areawide comprehensive health planning....... 13,200,000 25,100,000 +11,900,000 (c) Project grants for training, studies and demonstrations........ ‘ 4,125,000 4,700,000 +575 ,000 Total... .sceseees 25,000,000 39,800,000 +14 , 800,000 (a) Formula Grants for State Comprehensive Health Planning Agencies The Partnership for Health Program introduced the concept of comprehensive health planning as a mechanism through which the planning activities of health and related elements can be linked together within the States. Formula grant funds are awarded to the 50 States, District of Columbia, and 5 Territories based on population and per capita income. The funds support up to 75% of the costs associated with conducting State comprehensive health planning. The 1970 amendments to Title III of the Public Health Service Act contained in P.L. 91-515 have led to expansion of State advisory councils to include repre- sentatives of the Veterans Administration facilities and Regional Medical Programs operating in the State. State agencies have continued to be involved in planning, priority setting, and special studies that in many cases have led to recommenda- tions to improve provisions of health services. For example, two State agencies recently accomplished studies that led to recommendations for expanded and improved services to crippled children. Both of these recommendations led to legislation expanding and improving these services. Other State agencies have recommended environmental programs such as solid waste disposal, emergency medical care pro=- grams, certificate of need programs to assure effective review of proposed health facilities, and a variety of other programs. Many have been implemented. 137 States will be continuing to place emphasis upon the setting of priorities for health within their jurisdictions and making recommendations for the imple- mentation of these priorities within the State. Comprehensive Health Planning is a continuous process which requires not only the participation of both providers and consumers, but also is equally dependent upon close cooperation of State and local planning bodies. Thus, in 1973, many State agencies will become increasingly involved in coordinating the efforts of areawide health planning agencies within their jurisdiction and working with them toward a joint accomplishment of mutual objectives. The continuing close ties of the State comprehensive health planning programs to the State political, economic and social systems will, in 1973, facilitate the adoption by the States of recommended planning priorities and recommended alternatives for the solution of their problems. More and more of the States will be drawing together the categorical programs in health for the purpose of attacking health problems through joint efforts. As they accumulate more knowledge and experience, States will be in a better position to modify or realign health resources in order to more effectively combat problems. State comprehensive health planning organizations will review and comment on a wider range and variety of health projects. The increase of $2,325,000 will allow State agencies to increase professional staffs by 25%, from just over 300 persons to over 400. In addition, there will be an increase in consultation and special studies to support effective planning. These increases will enable agencies to increase not only their manpower but also their breadth and scope of skills. A primary emphasis will be for State agencies to become substantially more involved in assisting the development of new area- wide planning agencies. (b) Project Grants for Areawide Comprehensive Health Planning It is essential to the health planning process that every area identify its health needs, inventory resources, establish priorities and goals, and recommend courses of action. To assist public or nonprofit private agencies in this vital effort, project grants will be awarded in 1973 which will comprise about 60% of the total amount spent for the purpose. The remaining funds will be obtained from a broad range of community or local sources. The Federal share may reach as high as 75% if the area has been designated as a peverty area. During 1970 and 1971, the number of areawide agencies increased from 93 to 158 agencies. The number of these agencies which have finished organizing and have launched active planning programs has increased to 110 and is expected to reach 125 by the end of 1972. Recommendations from areawide health planning agencies have had important consequences. For example: Hospital mergers have been effected with more efficient services at lower cost resulting, unnecessary facility construction has been avoided, modernized facilities have been developed, neighborhood health centers have been introduced into communities, immunization and screening programs have been started, lead poisoning prevention programs have been designed, ambulance and other emergency care programs have been operationalized, city water and sewage systems have been improved, and a vast array of other services have been improved. As these examples suggest, comprehensive health planning agencies work across the whole range of health concerns with attention paid to personal health, mental health and environmental health, as well as health facilities. Emphasis is placed on the cost, availability, and accessibility of health care. While each agency defines its own agenda in relation to the needs of its own communities, there are 138 commonalities. For example, more than half of the operational areawide agencies were active in drug abuse and alchoholism in 1972, and similar percentages would be true of other health problems of current concern. In 1973 there will be increased emphasis on review and comment of proposed health programs and facilities. Such review and comment is now required by law for Hill-Burton, RMP, and 314(e). In addition, there are administrative require- ments for review and comment by 314(b) agencies on local applications under 314(d) and migrant health applications, and various States have laws requiring additional review and comment, certification of need, or even approval of some applications by the areawide comprehensive health planning agencies. The increase of $11,900,000 will provide $2,900,000 for continuation costs of the 172 agencies expected to be receiving grants by the end of 1972. Of the balance, $5,100,000 is included to establish approximately 100 new areawide agencies and 20 new State assisted local councils. In addition $3,900,000 is included to increase the average Federal share to avoid financial dependence upon organizations whose activities must be reviewed and commented upon by 314 (b) agencies. The following table reflects the actual/estimated number of 314(b) agencies: AREAWIDE COMPREHENSIVE HEALTH PLANNING UNDER SECTION 314(b) 1969 1970 1971 1972 1973 1. Number of Areawide Planning Agencies 93 127 158 172 272 (a) Planning 7 36 90 127 158 (b) Organizational 86 91 68 45 114 2. Number of State Assisted Local Councils — -— ~ 8 28 % of Population covered by” Not Areawide Agencies Available 55 65 67 80+ (c) Project Grants for Training, Studies and Demonstrations for Comprehensive Health Planning Effective health planning is dependent on skilled health planners - a resource in short supply. To help remedy this situation, about 400 graduate students were trained in the principles, concepts, and techniques of comprehensive health plan- ning through grants to 22 graduate institutions. Further, about 400 local elected officials, health professionals, administrators, planners, consultants and policy level personnel were trained through ten continuing education programs aimed at "upgrading" individuals already involved or connected with health planning in 1972. The improved ability of consumers to participate in comprehensive health plan- ning is extremely important to its success and to foster that objective about 1,500 consumers were trained in thirteen consumer education programs during 1972, The 1973 request will continue support of the graduate programs with about 240 expected to graduate with advanced degrees in the spring of 1973. It will also 139 support about ten continuing education programs which will reach about 600 individuals already involved or connected with health planning. Consumer educa~ tion programs will be continued and will reach approximately 1,750 people. The success of State and areawide planning will depend to a large extent upon the availability of personnel skilled in health planning and on constructive con- sumer participation in health planning. The increase of $575,000 for project grants for training, studies and demon- strations will enable the university programs to provide an increased level of technical assistance to the planning agencies. It will also allow greater emphasis on the development of health planning methodology. 140 Direct Operations ‘Increase or 1972 estimate 1973 estimate Decrease Pos, Amount Pos. Amount Pos. Amount Personnel compensation and benefits.....sesee0e. 24 $508,000 49 $834,000 +25 +8326,000 Other expenses......sseeeee = 427 ,000 -- 999 ,000 -~ +572 ,000 Total... cecseeseres 24 $935,000 49 $1,833,000 +25 +$898,000 The efforts of Federal, State, and local governments and the private sector to improve significantly the health status of the individual have fallen below expectations, in part due to the lack of a planning process which links health needs to health resources at the various levels of community health organization. This lack results in an inability to identify such organizational problems as gaps in health coverage, deficiencies in financing, and rational alternative arrangements for patient care as opposed to our presently fragmented health system and subsystem. The development of comprehensive health planning agencies at the State and areawide levels provides a focus where planning and analysis can be undertaken and those interested, both as providers and consumers of health services, can participate in reaching mutually satisfactory decisions. Through the operation of this planning process, more systematic attention can be given to problems, community health goals, relationships, the development of alternative solutions, and evaluation. One possible outcome will be a more integrated use of Federal, State and local resources to improve the health of the people. The Comprehensive Health Planning Program develops national policies and criteria for use by the Regional Offices and provides guidance and technical assistance to 56 State and territorial Comprehensive Health Planning Agencies as well as the 172 areawide agencies expected to be in operation by the end of 1972. Section 314(a) formula grants are supporting 56 State and Territorial Comprehensive Health Planning agencies. In 1973, Section 314(b) project grants will support 272 areawide comprehensive health planning agencies, 100 of which will be new with about 28 special grants made to States to help provide planning assistance to sparsely populated areas. In addition, the Program develops and provides assistance to projects, supported under Section 314(c), which train participants in the comprehensive health planning process. Program emphasis in 1973 is on the provision of developmental assistance to aid the large number of new 314(b) agencies to achieve successful operations, and to meet the increasing demand from both 314(a) and 314(b) agencies for Federal help and guidance. 1973 Increases A net increase of $898,000 is requested for these activities. It includes 25 positions and $495,000 to increase staff capability to respond to State and areawide agencies'requests for technical assistance and consultation. In addition, $395,000 is included for project contracts aimed at determining various patterns of effective on-going comprehensive health planning and making information about them available to all 314(a) and 314(b) agencies. The total also includes $10,000 for built-in items, partially offset by a decrease of $2,000 for two less days of pay. 141 ane Regional Medical Programs Increase or 1972 Estimate 1973 Estimate __ Decrease Pos. Amount Pos. Amount Pos. Amount Personnel compensation and benefits........ 169 $3,157,000 194 $3,523,000 +25 + 366,000 Other expenses........ -- 140,745,000 ~- 126,628,000 -~-__-14,117,000 Total........6- eee 169 143,902,000 194 130,151,000 +25 -13,751,000 Introduction The Regional Medical Programs Service provides a major mechanism and supports activities required to enhance the capacity of the health care system to furnish services of satisfactory quality to all Americans. Regional Medical Programs Service: (1) supports grants and contracts which on a regional basis bring together in a common effort the local medical centers, hospitals, and other health care facilities, health care providers and other resources to systematically identify health problems, commitments, and undertake the solutions; (2) furnishes professional and technical assistance and advice to the Regional Medical Programs, States, local communities and other relevant health agencies: (3) conducts programs through voluntary commitment of regional resources to bring about an increased, effective use of medical knowledge, make more efficient use of physical and human medical care resources and help remove barriers which impede entry of patients into the health care system, maintaining major focus on those diseases which are the greatest causes of morbidity, disa- bility, and death in the United States and (4) facilitates and provides professional guidance at the regional level to other governmental and private efforts aimed at improving the organization and delivery of health care. 142 Regional Medical Programs: Increase or 1972 Estimate 1973 Estimate Decrease (a) Grants & Contracts... $139, 300,000 $125,100, 000 -$14, 200,000 The Administration's proposed national health strategy is as follows: 1. There must be assurance of equal access to our health care system. 2. Supply and demand for health and medical services must be brought into balance. 3. A purposeful organization of our efforts to improve efficiency must be implemented: first, by emphasizing preventative services and health maintenance on a prospective and systematic basis; second, by maintaining a reasonable and understood relationship between expenditure and care rendered. Cost conscious- ness and economy need to be introduced by direct incentives. 4. Finally we must build upon our present strengths in the Nation's pluralistic health enterprise. It is specifically these goals that Regional Medical Programs have been organized and geared to accomplish. Regional Medical Programs have been organized as functional consortiums of health care providers, each with special and specific resources which can be made responsive to health needs. They are also structures deliberately designed to take into account local resources, patterns of practice and referrals, and needs. As such they have been important forces for bringing about institutional reform through changes in the provision of personal health service and care. This merger of providers has already produced systematic approaches to the major diseases of the heart as well as cancer, stroke and kidney disease. Several regions have accomplished the pooling of training resources to more effectively meet the manpower needs of each region. In some areas, health maintenance projects are being supported in a variety of ways. For example, a prepaid health care insurance program for the residents of Milwaukee's inner city has been developed with the assistance of the Wisconsin Regional Medical Program. The Cream City Community Health Center has been established by nine physicians who organized into a group practice to provide medical services for the health center clientele. Technical and financial assist- ance were provided by the Wisconsin Regional Medical Program for early planning of the Center. Grants funds were obtained from the Office of Economic Opportunity, with Wisconsin Regional Medical Program assistance, to help support the first year of operation. The Center is working with Medicaid, Biue Cross-Blue Shield and the Milwaukee County Medical Society to develop a completely self-supporting experi- mental health maintenance organization. During 1971 and 1972 the affiliated health providers with the aid of the Regional Medical Program mechanism, have promoted and demonstrated at the local levels, new techniques and innovative delivery patterns that lead to improved accessibility, efficiency and effectiveness of health care. For instance, five community hospitals on the north shore of Massachusetts have begun home care programs through the efforts of the Tri-State Regional Medical Program and the Massachusetts Hospital Association. Such programs will provide continuity of care for hospitalized patients after discharge, as well as reduce the length of stay in the hospital. To date, one hospital has achieved a fully coordinated. 143 home care program with excellent multi-disciplinary input. Three hospitals are planning to hire full-time nurse coordinators and have opened a much improved information interchange with the local Visiting Nurse Association. One hospital moved the Visiting Nurse Association right into the hospital building and also appointed a full-time qualified nurse as coordinator. In the rural and inner city areas and in concert with related Federal, local State, regional officials and programs, specific efforts have been directed to encourage the providers of health care to make care available and accessible to those areas where there is a distinct scarcity of resources. As an example, in the State of Washington, because of a physician manpower shortage, the isolated community of South Bend and surrounding areas were about to lose their hospital until the Washington/Alaska Regional Medical Program stepped in to organize community, State, and Federal interest and resources to save it. Not only are new physicians locating in South Bend but additional services beyond those formerly offered are now available. In 1972 a grant has been made for a regional cancer center in Seattle, Washington. Health Maintenance Organizations ~ Assuming that authorizing legislation has been approved, there are likely to be about 350 Health Maintenance Organizations in either planning or operational stages by June 30, 1974. Nearly every Regional Medical Program already has been involved in the development of professional activities at the local level. Because of their provider linkages, Regional Medical Programs, act as catalytic agents to bring together the various elements of the health care system, provide an environment conducive to planning, and give staff support and professional guidance, when necessary. In this way, Regional Medical Programs support professional organizations which have the potential for becoming Health Maintenance Organizations. In addition, subsequent to the establishment of Health Maintenance Organizations, Regional Medical Programs have actively engaged in the professional aspects of planning for manpower programs, mechanisms for monitoring the quality of care, ambulatory and emergency medical care services, centralization of laboratory facilities, data systems, etc. Regional Medical Programs is, within present legislative authority, also pro- viding funding through grants and contracts to support the planning and develop- ment of Health Maintenance Organizations in 1972. Experimental Health Service Delivery Systems - Regional Medical Programs are playing the same catalytic role with respect to Experimental Health Service Delivery Systems. Some are providing staff support even after an Experimental Health Service Delivery System contract has been signed. For instance, the interim director of the project in Boise, Idaho also is an area coordinator for the Mountain States Regional Medical Program. Program for 1972-73 Although Regional Medical Programs have been moving away from the narrow categorical disease approach and the emphasis on continuing education projects, the substantial increase in funds in 1972 has provided the impetus to substan- tially speed up that redirection. Goals 1. Manpower Development and Utilization - Programs aimed at enabling exist- ing health manpower to provide more and better care and training and more effec- tive utilization of new kinds of health manpower. New funds will be used to plan and develop Area Health Education Centers. These programs which focus on improved patient care services, depend on affiliations of hospitals and other treatment 144 facilities, nursing homes, junior colleges, etc., usually linked with a university health science center, to improve manpower distribution and to provide the missing link between manpower education and patterns of delivery. Area Health Education Centers will be a source of manpower for Health Maintenance Organizations, Experimental Health Service Delivery Systems and other comprehensive health care systems. Area Health Education Centers and other Regional Medical Program funded projects will emphasize improved utilization of new kinds of health manpower, particularly physician extenders, who can take over many of the traditional functions of the physician.enabling him to see more patients while, at the same time, lowering the cost of ¢are. Another important aspect of Regional Medical Program efforts will be to encourage the expansion of existing family practice programs and the establishment of new ones. One important specific contribution will be to assist in identify- ing intern and residency training sites (e.g., preceptorships, group practices) and setting up such graduate training programs at the community level. In addition, Regional Medical Programs will seek to favorably influence the distribu~ tion of family practitioners ~- that is, to get them to locate in areas of greater need -- by strengthening the professional linkages between family and speciality practice, between small community hospitals and larger hospitals and medical centers. They will attempt to minimize or remove the sense of isolation and enhance the professional growth of these individuals through such efforts as. the partial support of circuit-riding Directors of Medical Education serving several small hospitals and the outreach programs of medical centers providing speciality consultation to family practitioners. 2. New Techniques and Innovative Delivery Patterns - Activities aimed at improving the accessibility, efficiency, and quality of health care. They provide opportunities to increase the rate of implementation of systems innovations, new technologies including automation, and changes in delivery patterns, particularly those developed through the efforts of the National Center for Health Services Research and Development. Rural Health Care Systems New techniques and innovative delivery patterns have allowed Regional Medical Programs to improve access to quality health care and provide emergency services to Americans in urban and suburban areas. Thus far, however, no one has found a way to adapt the same techniques and patterns of care to rural areas. Geography has been the stumbling block. For example, a rural area of South Georgia and Northern Florida which has a staggering number of serious auto accidents has round-the-clock emergency service for the first time under a Georgia Regional Medical Program Project. In a typical year, December 1, 1968 to December 31, 1969, there were 1,618 motor vehicle accidents on the section of Highway I-75 which passes through this Florida resort area. At that time, all hospitals in the area were relying on practicing physicians to be called on a rotating basis for emergencies. Virtually the only ambulances available were those from local funeral homes, which, in most cases, did not meet medical standards. The population of 200,000 in land area of 3,800 square miles is served by 96 physicians (the national average is 141 physicians per 100,000 population) and ten hospitals with a capacity of 838 beds. The project staffs and equips round-the-clock emergency rooms in two of the larger hospitals and provides emergency ambulances with intensive care capabilities. In addition, Moody Air Force Base has agreed to provide helicopter ambulance service in dire emergencies. 145 Although projects like this are worthy, they are not comprehensive nor do they begin either to provide adequate emergency services or to touch the majority of the residents of rural and remote areas. For the first time, rural health care systems will be developed which will have as their long-range goals: a. The same quality of care enjoyed by those Americans fortunate enough to reside in areas where favorable distributions of health care resources exist. b. Primary and emergency care within a reasonable travel time even under the poorest of weather conditions. c. Care that is not only available and accessible but also care which is provided in such a way as not to encroach on the dignity of the consumer. Comprehensive rural health care systems will include (1) health education for the consumer, (2) primary/preventive care, (3) emergency care, (4) secondary/ tertiary care, (5) rehabilitation services, (6) extended care, and (7) home care. Emergency Health Services Systems Today more Americans require hospitalization for accidents than for any other diseases except cancer and heart disease. In the last decade the mortality rate for males has been rising with increasing changes in younger age groups primarily due to external causes including accidental death. Yet we spend less than 1% of the amount spent on cancer or heart disease in alleviating this problem. It is not surprising, then, that adequate emergency care systems are sadly lacking. What is needed are systems which bring together better transportation services, communication which would tie hospitals, transportation facilities and other emergency organizations into rapid response systems, and emergency medical centers with specially trained doctors and nurses. This will require a very carefully designed plan of coordination which includes firemen, police, highway safety officials, mayors, governors, as well as those who must provide the professional and technical services. There is also an urgent need for effective public education. Emergency Medical Systems at a cost of $8,000,000 will be funded in 1972. An additional $7,000,000 is requested to allow the funding of additional projects totaling $15,000,000 in 1973. These will be implemented in major cities, medium size cities, combinations of cities and adjacent areas, rural areas, and entire States. In all cases they will be linked to adjacent systems and will address the larger question cf ambulatory services for those who do not require emergency care. Demonstration projects should clearly show the improvement in health which can be obtained by such systems. An improvement of only 10 percent in emergency care would save 15,000 lives and more than 3,000,000 hospitalizations and would return $3 billion to the economy. 3. Regionalization Activities - Provider-initiated activities leading to greater sharing of health facilities, manpower, and other resources. End stage kidney disease is one area in which the development of integrated regional systems could prevent the duplication which has characterized certain other specialized resources. These regional systems provide the opportunity to show how scarce resources can be linked together efficiently. 4. Development and Implementation of Quality of Care Guidelines and Performance Review Mechanisms - Such guidelines and mechanisms are necessary to the development of the new and more effective comprehensive systems of health services such as Health Maintenance Organizations, rural health delivery systems, and emergency health systems. The development of these guidelines and mechanisms is carried out in conjunction with the efforts of the National Center for Health Services Research and Development. 146 5. Development, Demonstration, and Application of Biomedical and Management Techniques ~ Activities aimed at increasing productivity of providers and extend- ing specialized services to areas not currently covered. 6. Strengthening Regional Medical Programs - Thus far, this discussion has emphasized the direction of resources toward meeting new national objectives. One must not lose sight, however, of the overriding purpose for Regional Medical Pro- gram organizations which purpose is to bring together local resources in such a fashion as to create efficient and effective solutions to local health problems. While the new initiatives will contribute significantly to those solutions, they do not constitute a panacea. It is equally true that some Regional Medical Programs have not well served that overriding purpose. Accordingly, the selective funding policy has sought to reward the effective regions and to provide a sufficient base from which new initiatives could be launched. At the same time, concerted efforts are being made to improve the ability of the lesser Regional Medical Programs to attack the problems in their regions. Some have already made good progress. At some stage in their improvement, new funds must and will be made available to these Regional Medical Programs for new project activity. In exercising the current authority to use funds for the purpose of program planning and evaluation, in addition to exercising this authority through grants and contracts, these funds will also be used to finance consultative and other services required to prepare, monitor, and review various forms of evaluation. Such consultative services would be performed under contract or through the use of part-time or intermittent consultants. 147 Regional Medical Programs: Increase or (b) Direct operations 1972 Estimate 1973 Estimate Decrease Pos. Amount Pos. Amount Pos. Amount Personnel compensation and benefits..... eae 169 3,157,000 194 3,523,000 +25 +8366,000 Other expenses...... oe -—~ 1,445,000 7 1,528,000 -- +83,000 Total... ......ceee 169 4,602,000 194 5,051,000 +25 +449,000 This activity supports staff for reviewing, processing, awarding and adminis- tration of grants; provides health data required by the 56 local Regional Medical Programs in the implementation of their activities; develops and maintains appro- priate relationships with government and private agencies concerned with improving the organization and delivery of health services. This activity also provides technical assistance to the regions in the plan- ning, development and implementation of their programs. Three of the many areas of assistance have been (1) development of professional concensus on regional programming for long-term control of hypertension, (2) development of regional information services to promulgate each region's experiences to the other regions, and (3) a study of the cooperation in trials and observation of experimental services such as "Physician Assistant" programs. The rapid expansion of Regional Medical Program activity and the movement into new areas of emphasis carry with them additional requirements for development ef policy guidance and criteria for project development. More finished products relating to specific professional issues of critical importance will be needed. They will range from technical problems to health delivery methods. ‘he most outstanding example of this is the new emergency health services program. The 1973 increase includes 25 positions and $350,000 to develop and carry out this important health initiative. It also includes a $99,000 net increase partially offset by both program and mandatory decreases. 148 Medical Facilities Construction Increase or 1972 1973 Decrease Pos. Amount Pos. Amount _ Pos. Amount Personnel compensation and benefits........ 135 $2,223,000 135 $2,300,000 ~-- $77 ,000 Other expenses........ ~~~ 275,462,000 --- 88,459,000 --- ~187,003,000 Budget Authority Total....ssseaee 135 277,685,000 135 90,759,000 --- -186,926,000 Obligations 135 134,091,000 135 201,280,000 --- 467,189,000 Introduction A request for $90,759,000 is submitted for 1973. This amount provides $85,000,000 for construction grants, $2,500,000 for interest subsidies on guar- anteed loans and direct loans for construction and modernization of hospitals and other health care facilities, and $3,259,000 for direct operations. The 1973 budget for medical facilities construction reflects a shift in the Federal role in financing hospital construction from a purely grant basis to a balanced program of direct loans, guaranteed loans and grants. With the recog- nition of depreciation as an integral part of hospital costs by Medicare, Medicaid and private insurance carriers, financing of hospital construction can be put on the same basis as other capital investment. In effect, the purchaser of the medical service bears the cost of the capital investment. With this change in concept, medical facilities are now able to compete in the mortgage market and do not have to rely upon grants and contributions for capital investment. The 1973 budget reflects this shift in emphasis away from outright grants as a financing mechanism to direct Federal loans and guarantees with interest subsidies on loans made by the private money market, Maximum flexibility in the use of construction support funds will be further encouraged by applying them to projects which will serve other HSMHA and Depart- ment programs. Hill-Burton grants will be used to construct community mental health centers, for facilities to house health maintenance organizations and for comprehensive health care centers which include programs in maternal and child health, family planning, drug abuse prevention and care, and alcoholic rehabili- tation. The administrative barriers between these several programs and the de- finition of those areas in planning and structural requirements which might re- quire waivers of policy or regulations is already being explored at the staff level between a number of HSMHA programs. 143 Construction under Title VI, the Public Health Service Act (Hiil-Burton) 1972 1973 Increase or Estimate Estimate Decrease Other expenses (B.A.)....$217,500,000 $87,500,000 -$130 ,000 ,000 Other expenses (Oblig.). 92,192,000 198,021,000 + 105,829,000 The $87,500,000 requested for 1973 under Title VI of the Public Health Ser- vice Act will provide $70,000,000 for grants for outpatient facilities, $15,000,000 for grants for rehabilitation facilities, and $2,500,000 for interest subsidies on guaranteed loans to private nonprofit organizations and direct loans to public agencies for construction and modernization of hospitals and other health care facilities. 1. Construction grants---The construction of health care facilities for ambulatory patients would be supported with the $85,000,000 requested for con- struction grants, The $70,000,000 requested for Outpatient Facilities would assist in the construction of an estimated 194 projects. The $15,000,000 re- quested for Rehabilitation Facilities would assist in the construction of an estimated 49 projects. 2. Direct loans---Construction of health care facilities owned by public agencies (States, cities, counties, hospital districts, etc.), which are pre- cluded by local laws from borrowing mortgage funds from commercial lenders, is supported by a program of direct loans. Loans would be made by HEW and the resulting debt obligation sold to the Federal National Mortgage Association and other investors. Proceeds from these sales would bé used to provide capital for additional direct loans. 3. Interest subsidies---Under the redirected Hill-Burton program, Federal support for construction of inpatient health facilities such as hospitals and long-term care centers would be available through guaranteed loans with interest subsidies for private, nonprofit hospitals and direct loans for facilities owned by public agencies. These types of facilities generate the income from fees for services and third-party payments necessary for repayment of mortgage loans. The $2,500,000 requested for 1973 would, when added to $20,300,000 carried forward form previous appropriations, subsidize over $600,000,000 worth of guaranteed and direct loans. District of Columbia medical facilities 1972 1973 Increase or Estimate Estimate Decrease Other expenses (B.A.)....++ $42,127,000 ---- ~$425127 ,000 Other expenses (Oblig.).... 38,967,000 woe - 38,967,000 $40,052,000 has been appropriated for grants and $40,575,000 for loans to assist in meeting the cost of projects in the District of Columbia for the moderni- zation of public or nonprofit hospitals and in meeting the cost of projects for the construction or modernization of public health centers, long-term care facilities, including extended care facilities, outpatient facilities, rehabilitation facili- ties, facilities for the mentally retarded, and community mental health centers. Legiglation for this p¥wgwvam expires on June 30,1972. _ Hospital experimentation projects 1972 1973 Increase or Estimate Estimate Decrease Other expenses (B.A.)...+.+++- $15,000,000 ---- ~$15 ,000 ,000 Other expenses (Oblig.)....... w--- w--- aane Grants and loans are authorized to provide for construction of medical facilities which involve experimental designs or methods of construction to serve as demonstrations relating to delivery of health services. No funds are being requested for this activity in 1973, Direct operations 1972 1973 Increase or Estimate Estimate Decrease Pos, Amount Pos. Amount Pos. Amount Personnel compensation and benefits............025, 135 $2,223,000 135 $2,300,000 --- $+77,000 Other expenses............ coe 835 ,000 ==» 959,000 «-- +124,000 Total..(B.A.)....0ee 135 3,058 ,000 135 3,259,000 ~-- +201,000 (Oblig.) ...e. --- 2,932 ,000 ~-= 3,2594:000 ~-- +327,000 The estimate of $3,259,000 and 135 positions requested for 1973 are neces- sary to continue the Federal Governments' role of providing national leadership in the planning, programming, design and functioning of all types of medical facilities. The funds requested will support the staff necessary to provide technical assistance and consultation to project sponsors and State agencies regarding all aspects of program administration: to develop and revise guidelines for the design, construction, and equipping of health care facilities; to develop regu- lations, procedures, and policies for operation of the program; to review and approve basic documents, such as State plans and project applications: to compile and analyze data pertinent to health care facilities: and to assist health facility construction programs with the above activities. The operation of this program requires a variety of specialized and highly technical skills relating to the planning, design, equipping, functional layout and construction of all types of health care facilities as well as the prereq- uisite talent necessary for administration of a significant Federal program of national scope. The professional staff includes deciplines such as medicine, nursing, hospital administration, architecture, engineering and public adminis- tration. rent & 151 Program direction and management services Increase or ‘. } 1972 estimate 1973 estimate Decrease Pos. Amount Pos. Amount Pos. Amount Personnel compensation and benefits........ 149 $2,239,000 149 $2,261,000 --- +$22,000 Other expences.......+ --- 347,000 --- 449,000 -~- +102,000 Total, ..-ccceeoes 149 2,586,000 149 2,710,000 --- +124,000 This activity includes program leadership and direction and staff services including administrative management, program planning and evaluation. The immediate office of the Director is responsible for planning, directing, coordinating, and administering the Health services planning and development programs. Administrative management is responsible for the development, coordination, direction, and assessment of management activities. It directs such services as financial, personnel, and contract management. Planning activities focus on annual work plans, the longer-range goal- oriented planning system and encompasses efforts in program analysis and evaluation, as well. The increase of $124,000 includes a program increase of $68,000 for the Upward Mobility program and a net increase of $56,000 for built-in items. ye mm ma 152 HEALTH SERVICES AND MENTAL HEALTH ADMINISTRATION Health Services Planning and Development Program Purpose and Accomplishments Activity: Health services research and development ~- Grants and contracts. (PHS Act: Sec. 301 and 304) 1973 Budget 1972 Estimate Pos. Amount Authorization Pos. Amount -- $56,118,000 Sec. 301 ~ indefinite -- - $58,018,000 Sec. 304 $94,000,000 Purpose: The National Center focuses on national priority problems in health services such as rising costs of medical care, unequal distribution and utilization of health services, inadequate methods for health services planning and decision- making at local and national levels and shortages of professional health personnel. Explanation: The scientific programs of the National Center are carrted out through research, development, demonstrations and related training. Research grants are awarded to organizations and individuals to perform studies and to con- duct and evaluate demonstrations. Contracts are used to support research and development projects. Under the training program, grants are awarded on a competi~ tive basis to institutions and to qualified scholars for research and managerial training programs in the health services field. Accomplishments in 1972: In 1972 the National Center made progress in primary com- ponents essential to involving and increasing comprehensive and effective health services for total communities. Major projects involved new types of manpower, ambulatory care, automation of hospital services, methods for assessing and main- taining quality of care, methods for limiting hospital costs, and the launching of community-wide health services systems. For example: 1. To pave the way for using much larger numbers of physician's assistants and nurse practitioners in physician-extender roles, the Center designed a method for determining how and where these new types of manpower should be used. This method will provide data for future national health manpower policy and is being applied at first to the evaluation of the Medex type of physician's assistanta and now to nurses such as pediatric nurse practitioners, nurse midwives, and family nurse practitioners. 2. The Center is supporting the first automated hospital patient care Management ‘system in the United States. This computer-based system controls the admission of patients, the scheduling of medical, nursing, and auxiliary services according to highly sophisticated. patient care plans; reports and records services actually performed; measures patient changes in response to services, and feedback data essential to update the system as a whole. Other projects played major roles in creation of automated clinical hospital laboratories capable of producing the thou- sands of quality-controlled tests required daily in the operation of all large hospitals. 3. The 1972 budget is supporting research, development and evaluation of HMOs which were funded by HSMHA in 1971 and are now in the planning and organizational phase of development. The HMOs will be studied with respect to such factors as enrolled populations, benefit structures, utilization patterns, monitoring of servicea, and legal and market factors. 153 R&D is being carried out, in close cooperation with the National Center for Health Statistics, on the Cooperative Federal-State-local Health Statistics System. This work will begin in 4-6 communities, States and regions. The cooperative system will provide information about the health of the nation, its health resources, and the utilization of these resources. It will furnish the data needed to make rational de- cisions at all levels about health care delivery problems and ways of meeting these problems. In 1971, the Center initiated and supported the development of Experimental Medical Care Review Organizations (EMCROS) by 8 States and county medical societies. In 1972, these experimental review organizations which are intended to be prototype Professional Standard Review Organizations (PSROs) will be extended to 10 to 12 sites. Objectives for 1973: In 1973 the National Center will continue and expand its priority R&D in new types of manpower, HMOs, health care institutions, cost effec- tive technology, experimental medical care review organizations, and health service delivery systems. The 1973 budget includes an increase of $1,900,000 for the con- tinued development of the cooperative Federal-State-local health statistics system. Out of this project will come the most comprehensive data base yet developed for assessing the Nation's health. 154 HEALTH SERVICES AND MENTAL HEALTH ADMINISTRATION Health Services Planning and Development Program Purpose and Accomplishments Activity: Health services research and development - Direct operations. (PHS Act, Sec. 301 and 304) 1973 __ Budget 1972 Estimate Pos. Amount Authorization Pos. Amount 218 $5,898,000 Indefinite 230 $6,325,000 Purpose and Explanation: The National Center for Health Services Research and Development is responsible for the appraisal and evaluation of the effectiveness of health services operations and for developing a research and development pro- gram that is geared to improving health care nationally. Accomplishments in 1972: The staff of the National Center devotes major effort to designing and directing the strategic program of research and development. The staff obtains high-level evaluation of all proposals, closely monitors contracts, reviews results, informs the professional community of significant progress and identifies the next steps in research and development. Considerable time and effort is devoted to close collaboration with the investigators, providers, payors and major national organizations. The 1972 budget provides additional specialized staff which are essential for the National Center to further develop its capability for mounting largé-scale R&D projects. The increased program effort in the development of cooperative Federal- State-local statistics systems requires personnel with statistical and computer capability to develop health status surveys, to monitor data systems for ambulatory care, and to collect and analyze the national data resulting from this program. Objectives, 1973: An increase of $251,000 and 12 positions is necessary to support the expanded R&D strategy. Nine of the positions would be used to support the con- tinued development of the cooperative Federal-State-local health statistics system. Parallel to the R&D studies and projects, a number of internal studies by staff would move ahead. These studies would identify political, legal, and organi- zational barriers to large-scale adoption of new policies, and program formats suggested by the R&D. An additional increase of $176,000 will provide for mandatory increases. HEALTH SERVICES AND MENTAL HEALTH ADMINISTRATION Health services planning and development Program Purpose and Accomplishments Activity: Comprehensive health planning - Project grants for training, studies, and demonstrations for comprehensive health planning (PHS Act, Section 314(c)) 1973 Budget 1972 Estimate Pos. Amount Authorization Pos. Amount ~- $4,125,000 $12,000,000 -- $4,700,000 Purpose: To train people in health planning skills. To improve the art and skills of comprehensive health planning. Explanation: Grants are awarded to public and nonprofit private agencies, institutions, or organizations to support graduate education, continuing education, and training of consumers to participate in comprehensive health planning. Accomplishments in 1972: In 22 graduate programs, over 400 students were trained in the principles, concepts, and techniques used by State and areawide compre- hensive health planning agencies, preparing them to practice effectively in this field. Ten continuing education programs aimed at upgrading individuals already involved or connected with health planning reached approximately 400 local elected officials, health professionals, administrators, planners, con- sultants and policy level personnel. Consumer education programs reached approximately 1,500 persons. Objectives for 1973: To increase the level of technical assistance provided by university programs to the planning agencies. To increase emphasis on the development. of health planning methodology. To support short-term training for about 1,750 health professionals and consumers and long-term training for over 400 graduate students. 156 HEALTH SERVICES AND MENTAL HEALTH ADMINISTRATION Health services planning and development Program Purpose and Accomplishments Activity: Comprehensive health planning - Project grants for areawide compre- hensive health planning (PHS Act, Section 314(b)) 1973 Budget 1972 Estimate Pos, Amount Authorization Pos. Amount -- $13,200,000 $40,000,000 -- $25,100,000 Purpose: To provide a mechanism for the development and coordination of a strengthened planning capacity for solving the health needs of our citizens at the community level. Explanation: It is essential to the health planning process that every area identify its health needs, inventory resources, establish priorities and goals, and recommend courses of action. To assist public or nonprofit private agencies in this vital areawide comprehensive health planning, project grants are awarded according to a matching fund formula. Federal funds will average 60% of the project with the additional remaining funds coming from a broad range of community groups and local governmental funds. The Federal share may reach as high as 75% if the area is all or partially designated as one of poverty by the Department of Commerce or if the Agency supports projects for poverty areas, Accomplishments in 1972: The number of agencies which have finished organizing and have launched active planning programs is expected to reach 125 (of 172 total agencies) by the end of 1972, Agencies in the planning phase help set priorities for their communities and establish a framework of comprehensive health planning. Against that framework, they review and comment, as required by law and policy, upon a variety of proposals for health services and facilities. A broad range of health problems are addressed in these efforts; in 1971 and 72, for example, a majority of all agencies in the planning phase were involved in drug and alcohol abuse issues. Building cooperative relationships with other federal health programs is an essential element in 314(b) work. For instance, assistance may be provided in the development of health maintenance organizations, OEO Health Centers and Experimental Health Delivery Systems. Objectives for 1973: Improve the effectiveness of the 172 agencies and 8 State assisted local councils expected to be in operation at that time. Increase Federal share of individual agency budgets to avoid financial dependence upon organizations whose activities must be reviewed and commented upon by 314(b) agencies. Establish approximately 100 new agencies and 20 new State assisted comprehensive health planning councils in rural areas. Agencies will be located in areas in which approximately 80% of the population reside. 157 HEALTH SERVICES AND MENTAL HEALTH ADMINISTRATION Health services planning and development Program Purpose and Accomplishments Activity: Comprehensive health planning - Formula grants to states (PHS Act, Section 314(a)) 1973 Budget 1972 Estimate Pos. Amount Authorization Pos. Amount -- $7,675,000 $20,000,000 -~ $10,000,000 Purpose: To assist the States in comprehensive and continuing planning for their current and future health needs. Explanation: Formula grants are awarded to States, the District of Columbia, and five Territories, according to a formula based on population and per capita income. Federal financial participation cannot exceed 75% of the costs. Accomplishments in 1972: Formula grants were awarded to the States, the District of Columbia, and five Territories and supported up to 75% of the costs of their programs. New Federal legislation led to expansion of State advisory councils to include representatives of the Veterans Administration facilities and Regional Medical Programs operating in the State. State agencies were involved in planning, priority setting, and special studies that in many cases led to recommendations to improve provision of health services. For example, two State agencies accomplished studies that led to recommendations for expanded and improved services to crippled children. Both of these recommendations led to legislation expanding and improving these services. Objectives for 1973: To increase professional staffs of State agencies by 25%, from just over 300 persons to over 400. To upgrade capability of State agencies through increased consultation and special studies. RBaReae we@eaewnwsweainsmRtnBeeagn& ww 158 HEALTH SERVICES AND MENTAL HEALTH ADMINISTRATION Health services planning and development Program Purpose and Accomplishments Activity: Comprehensive health planning - Direct operations 1973 Budget 1972 Estimate Pos. Amount Authorization Pos. Amount 24 $935,000 Indefinite 49 $1,833,000 Purpose: This activity supports the comprehensive health planning staff that provides national leadership in the development and operation of programs to provide grants to States and local agencies for the conduct and improvement of comprehensive State and areawide health planning. In addition, the program develops and provides assistance to projects which train participants in the comprehensive health planning process. Explanation: This activity provides consultation and technical assistance to States, communities, providers of health services, medical and health services, medical and health organizations and other Federal units. Also, develops national policies and criteria for use by the regional offices and provides leadership in the health planning field. Accomplishments in 1972: Guidance and technical assistance were given to State planning agencies in each of the 50 States, the District of Columbia and 5 Territories, 172 areawide health planning agencies, and training institutions for health planning. Objectives for 1973: To improve staff capability to respond to State and areawide ‘agencies’ needs for technical assistance and consultation. To devise ways to help State and areawide agencies to learn from each other's successes, BmeEeeeeBQtnesemeReeeneeeeeseeknma 139 HEALTH SERVICES AND MENTAL HEALTH ADMINISTRATION Health services planning and development Program Purpose and Accomplishments Activity: Regional medical programs ~ Grants and contracts (PHS Act, Title IX, Secs. 301, 311, 402(g), 403(a) (1), 433(a)) 1973 Budget 1972 Estimate Pos. Amount Authorization Pos. Amount Budget Authority -- $94,800,000 $250,000,000 -~- $125,100,000 Obligations ~- $139,300,000 -- $125,100,000 Purpose: Funds are used for grants and contracts which on a regional basis encourage common efforts of health providers at all levels to systematically identify health problems, and develop programs which provide solutions to these problems. Explanation: Applications for grants are submitted by each regional medical pro- gram. Applications are received in Review Committee and by Council for approval of funding. Contracts are reviewed by a Contracts Committee and approved by the Director. The final contract is negotiated, in accordance with prescribed regula- tions, by Health Services and Mental Health Administration contract officers. Accomplishments in 1972: Regional Medical Programs have been organized as func- tional consortiums of health care providers, each with special and specific resources which can be made responsive to health needs. The merger of providers has produced systematic approaches to the major diseases of the heart as well as cancer and kidney disease. In 1972, the affiliated health providers with the aid of the Regional Medical Program mechanism, are promoting and demonstrating at the local levels, new techniques and innovative delivery patterns that lead to improved accessibility, efficiency and effectiveness of health care. Efforts at both regional and national levels are being directed to encourage providers of health care to make care available and accessible to areas where there is a distinct scarcity of resources, particularly in the rural and inner city areas. In 1972, a construction grant has been made for a regional cancer center in Seattle, Washington. Objectives for 1973: Funds will be provided for programs to enable existing health manpower to provide more and better care and training and more effective utilization of new kinds of health manpower. New funds will be used to plan and develop Area Health Education Centers, which will be major sources of manpower for Health Maintenance Organizations, Experimental Health Service Delivery Systems and other comprehensive health care systems. 160 Activities aimed at improving the accessibility, efficiency, and quality of health care will provide opportunities to increase the rate of implementation of systems, innovations and new technology. Rural health care systems will be developed that are compatable with needs of rural areas; development of emergency health care systems and development of integrated regional systems which will prevent duplications of specialized resources. The provider-initiated activities leading to a greater sharing of health facilities, manpower, and other resources will provide the opportunity to show how scarce resources can be linked together efficiently. 161 HEALTH SERVICES AND MENTAL HEALTH ADMINISTRATION Health services planning and development Program Purpose and Accomplishments Activity: Regional medical programs ~ Direct operations (PHS Act, Sec. 301) 1973 Budget 1972 Estimate Pos. Amount Authorization Pos. Amount 169 $4,602,000 --- 194 $5,051,000 Purpose: Evaluates, processes and awards grants; provides the principal point of contact between the service and the individual Regions for assisting in the development and implementation of cooperative program arrangements. Develops and maintains appropriate relationships with government and private agencies concerned with improving the organization and delivery of health services. Explanation: Applications from Regional Medical Programs are reviewed by special consultants, other Federal agencies and Service staff and are then analyzed and integrated for presentation to Review Committee. A written Summary of Committee review is provided for presentation to the Council. Technical assistance is provided in the development and coordination of programs aimed at improving the availability and quality of health care. Accomplishments in 1972: The Anniversary Review process has been refined and the review and award process is being accomplished through a triennial review by the National Advisory Council. Additionally, this activity continues to provide Health Services data to the 56 Regional Medical Programs as required for their planning and operational programs. This activity provides technical assistance to the regions. In 1972 the primary emphasis will be on local health requirements and needs. Some major studies associated with the coordination and execution of continuing education are those associated with the coordination and training programs such as: (1) development of professional consensus on regional programming for long-term control of hypertension; (2) development of regional operational information services to promulgate each regions experiences to the other regions and (3) a study of the cooperation in trials and observation of experimental services such as "Physician Assistant" plans. Each of these programs and studies are designed to develop criteria for evaluation and to assist in the development of effective regional systems of health. Objectives for 1973: To provide the strong leadership to the Regional Medical Programs, particularly the weaker ones, required by the expansion and redirection of Regional Medical Program activities. The rapid expansion of Regional Medical Program activity and the movement into new areas of emphasis will require additional development of policy guidance and criteria for project development. Increased technical assistance will be needed for new projects in areas involving new techniques and innovative delivery patterns, more effective use of new kinds of health manpower, and the quality of care guidelines. 162 HEALTH SERVICES AND MENTAL HEALTH ADMINISTRATION Health services planning and development Program Purpose and Accomplishments Activity: Medical facilities construction~-Construction grants, (Public. Health Service Act,Sec,601) 1973 Budget 1972 Estimate Pos. Amount Authorization Pos. Amount Budget Authority -_—- $197 ,200,000 $417 ,500,000 -— $85,000,000 Obligations --- 87 ,192,00 “<- 175,221,000 ' Purpose: Formula grants, matched by local funds, are used for construction of new buildings, for expansion or remodeling of existing buildings, for moderni- zation of obsolete facilities, for replacement of obsolete equipment, and for the purchase of initial equipment for new, expanded or modernized facilities. Explanation: Applications for grants are submitted by public bodies or private nonprofit organizations to the designated state agency and selected for funding based on points established in the State plan. Applications are reviewed and approved by the DHEW Regional Offices. Accomplishments in 1972: In 1972, the $197,200,900 appropriated for construc- tion grants will assist in the construction of an estimated 445 health facility projects, Of those, 232 will be outpatient facility projects, 47 will be re- habilitation facility projects, 42 will be long-term care facility projects, 57 will be hospital projects and 67 will be modernization projects. Objectives for 1973: The Health Care Facilities Service will encourage max- imum flexibility in the use of construction support funds by applying them to projects which will serve other HSMHA and Department programs. Hill-Burton grants will be used to construct community mental health centers, for facilities to house health maintenence organizations and for comprehensive health care centers which include programs in maternal and child health, family planning, drug abuse prevention and care, and alcoholic rehabilitation, Of the $85,000,000 requested for construction grants in 1973, $70,000,000 will be invested in 194 outpatient facility projects and $15,000,000 will be used to support 49 rehabilitation facility projects, 163 HEALTH SERVICES AND MENTAL HEALTH ADMINISTRATION Health services planning and development Program Purpose and Accomplishments Activity: Medical facilities construction--Direct loans, (Public Health Service Act, Sec. 626) 1973 Budget 1972 Estimate Pos, Amount Authorization Pos. Amount --- $30,000,000 «sen nw nw nw nnnnn we eee Purpose: Construction of health facilities owned by public agencles (states, cities, counties, hospital districts, etc.), which are precluded by local laws from borrowing mortgage funds from commercial lenders, is supported by a program of direct loans. Explanation: This mechanism of assistance enables public agencies to partici- pate in the loan guarantee and interest subsidy program. Loans would be made from a revolving fund capitalized with a $30,000,000 appropriation in 1972. The debt obligations, usually in the form of bonds, received for the loans would be sold by HEW to the Federal National Mortgage Association and other investors. Proceeds from these sales by HEW would be used to provide capital for additional direct loans. Accomplishments in 1972: Program regulations have been published and agreements with the Federal National Mortgage Association and private bond investment con- cerns regarding procedures for committing and transferring bond obligations are being negotiated. Approximately $30,000,000 in direct loans will be com- mitted in 1972. Objectives for 1973; Additional experience and streamlining of procedures will permit extensive utilization of the program in 1973. Depending on the volume of loan applications, it is anticipated that committments to use revolving fund capital several times will be made. 164 HEALTH SERVICES AND MENTAL HEALTH ADMINISTRATION Health services planning and development Program Purpose and Accomplishments Activity: Medical facilities construction-~Interest subsidies (Sec. 626 (a) (1) of the Public Health Service Act) 1973 Budget 1972 Estimate Pos. Amount Authorization Pos. Amount Budget Authority Such amounts as --- $20,300,000 necessary --- $2,500,000 Obligations -—< 5,000,000 --- 22,000,000 Purpose: Loan guarantees with interest subsidies provide another form of Federal assistance to private nonprofit and public agencies for hospital construction. Federal participation in debt service costs is authorized to reduce the rate of interest paid on approved projects by 3 percent. Explanation: Interest subsidies are paid on guaranteed loans made to private nonprofit and publicly-owned hospitals, The subsidy serves to reduce the rate of interest paid by the borrowing institution by three percent. In the case of private non-profit hospitals, subsidies are paid only on loans guaranteed by Hill-Burton. Hospitals owned by public agencies are eligible for direct Hill-Burton loans paid out of a revolving fund, The fund is replenished by selling the obligations received for the loans to the Federal National Mortgage Association and other investors at 4 higher, taxable interest rate. Interest subsidy appropriations are used to supplement the higher interest rate. Accomplishments in 1972; Approximately $170 million worth of loans will be guaranteed or directly made in 1972, requiring $5,000,000 in interest sub- sidies. Twenty-three projects, building or modernizing facilities for 3,300 inpatient beds, will be supported. Objectives for 1973; $605,000,000 worth of loans will be guaranteed in 1973 resulting in 83 projects adding or modernizing over 12,000 beds. The program will require $17,900,000 to subsidize current loan guarantees and $4,900,000 to subsidize prior loan guarantees for a total of $22,800,000. Of this amount $2,500,000 is requested in 1973 with the remainder carried. forward from previous appropriations. «* 165 HEALTH SERVICES AND MENTAL HEALTH ADMINISTRATION Health services planning and development Program Purpose and Accomplishments Activity: Medical facilities construction--District of Columbia medical facilities (Sections 2 and 3 of the District of Columbia Medical Facilities Construction Act of 1968) 1973 Budget 1972 Estimate Pos. Amount Authorization Pos. Amount Budget Authority —_- $42,127,000 Expired were Obligations mo 38,967,000 a ecto Purpose: Funds for grants or loans are for the construction and modernization of hospitals and other medical facilities in the District of Columbia. Explanation: Grants and loans are awarded on a project basis. Federal payment made under this Act for the construction of long-term care facilities, including extended care facilities, outpatient facilities, or rehabilitation facilities, may not exceed 66-2/3% of cost of such project. In the case of any other pro- ject (including a modernization project), the Federal payment may not exceed 50% of the cost of such project. Loans shall bear interest at the rate of 2-1/2% per annum and shall be repaid over a period not to exceed 50 years. Accomplishments in 1972: In 1972, 5 loans totaling $16,575,000 and 4 grants totaling $22,167,000 will be awarded to the following hospitals: Loans Grants Rogers Memorial Hospital Georgetown University Hospital Childrens Hospital Washington Hospital Center George Washington University Hospital Childrens Hospital Georgetown University Hospital Rogers Memorial Hospital Washington Hospital Center Legislation for this program expires on June 30,1972 166 HEALTH SERVICES AND MENTAL HEALTH ADMINISTRATION Health servicea planning and development Program Purpose and Accomplishments Activity: Medical facilities construction--Hospital expermentation projects (Public Health Service Act, section 304 and 643A) 1973 Budget 1972 Estimate Pos. Amount Authorization Pos. Amount o-- $15 ,000 ,000 weer een Purpose; Funds for grants or loans are for the construction of hospitals or Stet medical facilities which demonstrate experimental hospital design. Explanation: Grants and loans are awarded on a project basis. Grants are awarded to provide construction of hospitals, facilities for long-tern care, or other medical facilities which involve experimental designs or methods of construction to serve as demonstrations relating to delivery of health services. Loans are awarded to provide up to 66 2/3% of the increased cost of projects for the construction of demonstration of experimental hospitals. Loans shall bear interest at the rate of 2 1/2% per annum and shall be repaid over a period not to exceed 50 years. Accomplishments in 1972: The $15,000,000 appropriated in 1972 will be placed in reserve in order to reduce Federal outlays. Objectives for 1973: No funds are being requested for 1973. 167 HEALTH SERVICES AND MENTAL HEALTH ADMINISTRATION Health services planning and development Program Purpose and Accomplishments Activity: Medical facilities construction--Direct operations 1973 Budget 1972 Estimate Pos. Amount Authorization Pos. Amount Budget Authority 135 $3,058,000 = sewer enenen 135 $3,259,000 Obligations 135 2,932,000 135 3,259,000 Eurpose: fo provide national leadership in the planning, programming, design and functioning of all types of medical facilities, and to provide State agencies with technical assistance in determining additional facilities re- quired and developing programs to meet the indicated needs. Explanation: State plans are reviewed for conformance with planning criteria and guidelines. Assistance is provided to the States and communities in the planning, programming, designing and functioning of hospitals and other health facilities, and proposed projects are reviewed to determine eligibility and compliance with the law and regulations. Accomplishments in 1972: Technical assistance and consultation to project sponsors and State agencies regarding ell aspects of program administration were provided; guidelines, regulations, procedures and policies were developed and revised; basic documents, such as State plans, project applications and de- sign drawings were reviewed and approved: surveillance over bid awards and construction of facilities was maintained; statistical data regarding health facility planning was compiled and analyzed; and several other facility con- struction programe were assisted with the above activities. In addition, implementation in 1972 of the loan guarantee and direct loan program was undertaken. Objectives for 1973: The staff will update and revise regulations and guide- Tines as changes occur in the planning, design, equipping, functional Layout and construction of all types of health facilities and will continue to pro~ vide national leadership in all aspects of health facility construction. Considerable emphasis will be placed on completing implementation of the Loan guarantee and direct loan program begun in 1972. 168 HEALTH SERVICES AND MENTAL HEALTH ADMINISTRATION Health services planning and development Program Purpose and Accomplishments Activity: Program direction and management services 1973 Budget _ 1972 Estimate Pos. Amount Authorization Pos. Amount 149 $2,586,000 Indefinite 149 $2,710,000 - Purpose: This activity provides for the overall planning, direction and administration of the broad scope of programs of the Health services planning and development appropriation. Explanation: It includes program planning and evaluation activities which focus on program, operational, and legislative planning. Administrative management is responsible for the development, coordination, direction, and assessment of management activities. It directs such services as financial, personnel, and contract management. : Health Services Allocations of Grants to States Planning and Development 1 for Comprehensive State Health Planning 1971 1972 1973 Actual Allocation Estimate Alabama..scecsccensccevccesccres $151,600 $143,500 $180,000 Alaska. scccsscccccseccvceccsvces 76,800 76,800 100 ,000 ATIZONAs ceercaccccccsccevenceecs 76,800 76,800 100,000 ArkanSaS..ceccccccsscsccsecscces 86,200 83,200 102 ,800 California.sccccccscccssccccscese 491,500 500,500 674,500 Colorado. ..cccscsccccececsesenes 76,800 76,800 100,000 Connecticut..c.cccccccesesecvions 76,800 76,800 100,000 Delaware. .cscscaccccescessovsses 76,800 76,800 100,000 District of Columbia... ..eccesees 76,800 76,800 100,000 Florida...cccesccsssvesssccseses 199,700 207 , 300 285,400 Georgiasccccscsscecccccccceceees 167,400 160,800 206 ,600 Hawailecccccccscccncevseevessaes 76 ,800 76,800 100,000 Tdaho.eoceccovccrsscccccecsccces 76,800 76,800 100,000 T1LANO1S. coe caccceseerccesecees | 278,400 279 ,000 367,100 IndLanacccccecssecssccscceeesees 150,500 151,600 205,900 LOWas se vecscnenccccesvsvncsvesees 85,400 85,700 114,200 KanBaBsccscscccccccccescvsvesers 76,800 76,800 100,000 Kentucky. scocccccscccescoscoenss 122,600 121,700 157 ,600 LOuLsiandsesccccessenesccecscers 142,600 141,000 178,200 Maines cacccverncccvccesevececes 76,800 76,800 100,000 © Maryland. ..ccscccccvcsnenscesecs 100,900 103,600 138,800 Massachusetts. scsccevsccscccece 143,000 147,300 194,900 Michigan. cssscessscoeccsecesves 239,300 239,100 327,200 Minnesota. .ccccssessescesseceses 111,100 112,600 149,800 Mississippl..cccscesccccsccseoes 113,800 107,500 127,600 MISSOUTL. cco vcccccvccssvosesnces 143,300 145 ,500 189 , 300 Montana. .ccscccccccccsvcsecccncs 76,800 76,800 100,000 Nebraska...ccscccscccsvcevccvers 76,800 76,800 100,000 Nevada. ..sscocccesscccccccvcsene 76,800 76,800 100,000 © New Hampshire..cccccccssvcecvecs 76,800 76,800 100 ,000 New Jersey..cscscsnsccesceecsees 181,300 181,900 234,400 . New Mexico. .ccccossccevceccssces 76,800 76,800 100,000 New York. vcsccsscccccccccevesees 442,800 440,700 569,200 North Carolinasc.scccccecccceses 196,000 189, 300 236,900 North Dakota. .ccccccscccecennece 76,800 76,800 100,000 169 170 Health Services Planning and Development Allocations of Grants to States for Comprehensive State Health Planning (cont'd) 1971 1972 1973 Actual Allocation Estimate OL, ccccccccccccverccccssevecss $307,000 $306 ,600 $400 ,600 Oklahoma. ...ccecscvsccccsrecoecs 89,400 90,400 116,300 OLE ZON. ccacceecaccevecevevsccces 76,800 76,800 100 ,000 Pennsylvania. .coscccscceescesces 346, 300 346 ,800 446,500 Rhode Island. ..ssersevcecsecccee 76,800 76,800 100 ,000 South Carolina....cccssevcceeecs 113,500 106,900 132,100 South Dakota..cccccceccecsecsece 76,800 76,800 100,000 TENNESSEE. cer sssccccaccncccceee 155,000 150,400 190,900 TOXAS. casccnsccuveccscenccureres 370,500 369,700 479,100 Utah. wccccccecsascccccsccscssnes 76,800 76,800 100,000 VeErmont.rsscsccsccavecssesscvess 76,800 76,800 100,000 Virginiar.s.ccccvccccoenscvevenes 152,700 151,200 192,900 Washington... cccccccccccvnsscees 92,500 95,300 127,500 West Virginla...csscesvesccevess 76,800 76,800 100,000 WISCONSIN, cc. ceccccrcccereeveres 126,300 130,900 178,900 Wyoming. ccccscevccccereeresecers 76,800 76,800 100,000 GUAM. .occcccccccvesesseveseecess 76,800 76,800 100,000 Puerto RicO.sccuccerveresescoves 224,000 234,600 294,800 Virgin Islands...eccesssecscesacs 76,800 76,800 100,000 American Sam0d..accccscesevseces 76,800 76,800 100,000 Trust Territory of the Pacific Islands. .ccscccccssccccesesecs 76,800 76,800 100,000 TOTAL. ccc cccceevccccsscccees 7,998,200 7,598,200 9,900,000 Evaluation Amount2/......06. 76 , 800 76,800 100 , 000 Grand Total.ssscccscececeees 7,075,000 7,675,000 10,000,000 1/ Allocations are awarded to States based on population weighted by per capita income, and a requirement that each State receive a minimum of one percent of the amount available for allotment. 2/ Authorized by P.L. 91-296 Health Services Planning and Development ALLOCATIONS TO STATES For Construction and Modernization of Hospitals and Related Health Facilities Fiscal Year wo T1 1973 1971 1972 Totals $171,720 ,000 $194,900 ,000 $85 ,000 ,000 Alabama 3,583,851 4,188,571 2,280,880 Alaska 1,200 ,000 1,200,000 300 ,000 Arizona 1,750,396 1,819,715 869,221 Arkansas 2,310,311 2,521,617 1,305 ,875 California 8,715,388 10,969,161 5,381,676 Colorado 1,966,225 2,149 ,437 927 , 368 Connecticut 1,967 ,408 1,967 ,424 650,977 Delaware 1,200,000 - 1,200,000 300 ,000 District of Columbia 1,200,000 1,200,000 300 ,000 Florida 5,042,959 6,013,391 3,062,420 Georgia 4,124,611 4,723,773 2,485,192 Hawait 1,233,723 1,227,026 329,177 Idaho 1,317,315 1,334,854 438 ,668 T1linois 6,005 ,622 7,226,850 2,965 ,145 Indiana. 3,906,922 4,639,957 2,024,093 Lowa 2,608 ,846 2,927,735 1,170,640 Kansas 2,345 ,838 2,463,324 947,392 Kentucky 3,201,234 - 3,669,239 1,910,800 Louisiana 3,857,231 4,400,140 2,143,059 Maine 1,454,903 1,475 ,010 541,781 Maryland 2,295 ,896 2,573,699 1,246,392 Massachusetts 4,351,125 4,794,952 1,667 ,528 ‘Michigan 5,248 ,395 ; 6,367,206 2,922,847 Minnesota 3,153,688 3,580,635 1,548,980 Mississippi 2,785 ,582 3,078 ,736 1,667,695 Missouri 3,940,580 4,536,710 2,013,164 Montana 1,278,915 1,294,566 396,023 Nebraska 1,492,746 1,523,755 626,199 Nevada 1,200,000 1,200,000 300,000 New Hampshire 1,254,586 1,262,946 367 ,454 New Jersey 4,527,306 5,150,828 1,986,719 New Mexico 1,466,199 1,489,209 588 ,587 New York 10,344,755 11,642,494 4,435 ,453 North Carolina 5,128,165 ‘ 5,907 ,674 2,950,461 North Dakota 1,281,757 1,288 ,394 387 ,355 Ohio 6,538,653 8 ,067 ,855 4,010,144 Oklahoma 2,567,115 2,870,251 1,370,029 Oregon 1,838 ,826 1,967,281 872,141 Pennsylvania 9,538,650 11,341,528 4,599,219 Rhode Island ~ 1,273,925 "1,276,467 375,220 ALLOCATIONS TO STATES - Continued For Construction and Modernization of Hospitals and Related Health Facilities Fiscal Year 112 1971 1972 1973 South Carolina 2,996,889 3,342,108 1,703,903 South Dakota 1,298 ,046 1,299,489 396 ,855 Tennessee 4,233,766 4,886,243 2,370,731 Texas 9,504,132 11,333,449 5,512,489 Utah 1,454,762 1,478 ,323 589,072 Vermont 1,200,000 1,200,000 300 ,000 Virginia 4,125,804 4,702,248 2,210,385 Washington 2,461,557 2,747 ,025 1,156,791 West Virginia 2,450,982 2,627,584 1,108 , 238 Wisconsin 3,265,948 3,879 ,886 1,765,555 Wyoming 1,200,000 1,200,000 300 ,000 American Samoa 750,000 750 ,000 150,000 Guam 750,000 750,000 150 ,000 Puerto Rico 4,028 ,467 4,671,235 2,320,007 Trust Territory 750,000 750,000 150,000 Virgin Islands 750,000 750,000 150 ,000 ALLOCATIONS TO STATES FOR CONSTRUCTION AND MODERNIZATION OF HOSPITAL AND HEALTH RELATED FACILITIES TOR FISCAL YFAR 1971 AS OF JULY 1, 1971 Hospitals and Long-Term Rehabili- . Moderni- Public Health . Care Outpatient - tation State Total zation Centers Facilities Facilities Facilities Total $171,720 ,000 $57,609,575 $19,252,623 $18 ,583,846 $62,179,897 $14,094,059 Alabama 3,583,851 1,286,706 600 ,000 581,445 818,645 297 ,055 Alaska 1,200 ,000 1,000 ,000 - - 100 ,000 . 100 ,000 Arizona 1,750,396 300 ,000 300 ,000 300 ,000 707 ,O61 143,335 Arkansas 2,310,311 498 ,327 790 ,000 110,000 780 ,816 131,168 California 8,715,388 2,325,744 300 ,000 867,725 4,341,761 880,158 Colorado 1,966,225 526,417 300 ,000 300 ,000 698 , 258 141,550 Connecticut 1,967 ,408 874,739 83,000 - 900 ,000 109 ,669 Delaware 1,200 ,000 300 ,000 300 ,000 300 ,000 200 ,000 100 ,000 Dist. of Col. 1,200,000 300 ,000 300 ,000 300 ,000 200 ,000 100 ,000 Florida 5,042,959 1,210,984 300 ,000 503,278 2,518,208 510,489 Georgia 4,124,611 1,020,000 326,492 434,998 1,976,564 366,557 Hawaii 1,233,723 220,325 379,675 300 ,000 233,723 100 ,000 Idaho 1,317,315 300 ,000 300 ,000 300 ,000 317,315 100 ,000 Illinois 6,005 ,622 2,431,271 300 ,000 466 ,568 2,334,529 473,254 Indiana 3,906,922 1,392,815 300 ,000 315 ,492 1,578 ,602 320,013 Iowa 2,608 ,846 920,196 313,921 300 ,000 905 ,157 169,572 Kansas 2,345 ,838 150,096 1,148 ,333 738 ,200 209 ,400 99,809 Kentucky 3,201,234 630,159 300 ,000 323,609 1,619,219 328 ,247 Louisiana 3,857,231 1,012,706 216,960 410,000 1,843,793 373,772 Maine 1,454,903 300 ,000 300 ,000 328 , 282 426,621 100 ,000 Maryland 2,295 ,896 477,365 300 ,000 , 300 ,000 1,013,147 205 , 384 Massachusetts 4,351,125 2,075 ,926 300 ,000 300 ,000 1,392,843 282,356 Michigan 5,248 ,395 1,676,086 300 ,000 466,277 2,333,073 472,959 Minnesota 3,153,688 925 ,870 1,653,914 - 320,451 253,453 : Mississippi 2,785 ,582 364,414 900 ,000 2,249 1,312,339 206 ,580 5 ww Missouri 3,940 ,580 1,319,049 300 ,000 330,799 1,655,193 335 ,539 Montana 1,278,915 378 ,477 194,091 300 ,000 278,915 127 ,432 Nebraska 1,492,746 300 ,000 307 ,018 300,000 | 492,746 92,982 Nevada 1,200,000 1,184,265 -— , - - 15,735 New Hampshire 1,254,586 300 ,000 300 ,000 300 ,000 254,586 100 ,000 New Jersey 4,527 , 306 1,980,923 300 ,000 ' * 320,091 : 1,601,614 324,678 New Mexico 1,466,199 771,764 155 ,000 36,800 404,500 98,135 New York 10,344,755 4,563,297 300 ,000 781,063 3,908,140 792,255 North Carolina 5,128,165 3,500 ,781 300 ,000 516,811 386,356 424,217 North Dakota 1,281,757 300 ,000 300 ,000 300 ,000 281,757 100 ,000 Ohio 6,538 ,653 1,638,075 300 ,000 655 ,545 3,280,095 664,938 Oklahoma 2,567,115 1,029, 364 175,000 - 1,133,058 229 ,693 - Oregon 1,838 ,826 423,943 300 ,000 300 ,000 677,534 137 , 349 Pennsylvania 9,538,650 3,929 ,849 300 ,000 756,461 3,785 ,040 767 , 300 Rhode. Island 1,273,925 300 ,000 "300 ,000 300 ,000- 273,925 . 100 ,000 South Carolina 2,996,889 594,310 300 ,000 300 ,000 . 1,498,753 303,826 South Dakota 1,298 ;046 300 ,000 300 ,000 300 ,000 298 ,046 100 ,000 Tennessee 4,233,766 2,327,741 977,277 241,016 380 ,012 307 ,720 Texas 9,504,132 2,656,156 300 ,000 ‘ 1,418,733 .. 4,277,059 - 852,184 Utah 1,454,762 900 ,000 - : 200 ,000 254,762 100 ,000 Vermont 1,200 ,000 300 ,000 600 ,000 , - 200 ,000 100 ,000 Virginia 4,125 ,804 1,174,806 300 ,000 377 ,746 1,890 ,094 383,158 Washington 2,461,557 766,321 300 ,000 300 ,000 910 ,633 184,603 West Virginia 2,450,982 717,316 300 ,000 , 300 ,000 942 ,586 191,080 Wisconsin 3,265,948 1,010,923 300 ,000 , 300 ,000 1,376,069 278 ,956 Wyoming 1,200 ,000 705 ,397 31,942 200 ,000 252,161 10,500 American Samoa 750,000 200 ,000 200 ,000 200 ,000 100 ,000 50,000 Guam 750,000 — 200 ,000 200 ,000 200 ,000 100 ,000 50,000 Puerto Rico 4,028 ,467 916,672 300 ,000 400 ,658 2,004 ,738 406,399 Trust Territory 750,000 200 ,000 200 ,000 200 ,000 100 ,000 50,000 Virgin Islands 750,000 200 ,000 200,000 200 ,000 100 ,000 50,000 HLT FISCAL YEAR 1972 GRANT ALLOCATIONS TO STATES FOR CONSTRUCTION AND MODERNIZATION OF HOSPITALS AND OTHER HEALTH FACILITIES Hospitals and Long-Term Rehabili- Public Health Care Outpatient tation States Total Modernization Centers Facilities Facilities Facilities Total $194,900 ,000 - §50,000 ,000 $40 ,250 ,000 $19 , 650,000 $70,000 ,000 $15 ,000 ,000 Alabama 4,188,571 526,566 1,014, 369 355 ,837 1,904,969 386,830 Alaska 1,200,000 300 ,000 300,000 300 ,000 200 ,000 100 ,000 Arizona 1,819,715 300 ,000 374,222 300 ,000 702,783 142,710 Arkansas 2,521,617 330,126 580 , 330 300 ,000 1,089 ,852 221,309 California . 10,969,161 2,357,609 2,385 ,384 836,785 4,479,716 909 , 667 Colorado 2,149,437 536,814 402,727 300 ,000 756,316 153,580 Connecticut 1,967 ,424 717 ,225 300 ,000 300 ,000 540,453 109,746 Delaware 1,200 ,000 300 ,000 300 ,000 300 ,000 200 ,000 100 ,000 Dist. of Columbia 1,200 ,G00 300 ,000 300 ,000 300 ,000 200 ,000 100 ,000 Plorida 6,013,391 1,224,471 1,326,522 465 , 340 2,491,189 505 ,869 Georgia 4,723,773 757,180 1,098 ,739 385 ,434 2,063,416 419 ,004 Hawaii 1,227 ,026 300 ,000 300 ,000 300 ,000 227 ,026 100 ,000 Idaho 1,334,854 300 ,000 300 ,000 300 ,000 334,854 100 ,000 Illinois 7,226,859 2,453,126 1,322,313 463,863 2,483 ,284 504, 264 Indiana 4,639,957 1,407 ,044 895,511 314,142 1,681,757 341,503 Iowa 2,927,735 929 ,882 520,920 300 ,000 978 ,280 198 ,653 Kansas 2,463,324 781,623 423,921 300 ,000 : 796,118 161,662 Kentucky 3,669,239 625 ,092 841,934 300 ,000 1,581,141 321,072 Louisiana 4,400 , 140 960 , 342 952,820 334,245 1,789,376 363,357 Maine 1,475,010 330 ,596 300 ,000 300 ,000 444,414 100 ,000 Maryland 2,573,699 484,261 549,019 300 ,000 1,031,050 209,369 Massachusetts 4,794,952 2,082,480 740,173 300 ,000 1,390 ,034 282,265 Michigan 6,367,206 1,691,057 1,295,285 454,382 2,432,525 493,957 Minnesota 3,580 ,635 1,056,987 682,240 300 ,000 1,281,236 260,172 Mississippi 3,078 ,736 346,767 746,155 300 ,000 1,401,268 284 ,546 ay aad Missouri 4,536,710 1,321,257 890 ,675 312,446 1,672 ,673 339,659 Montana 1,294,566 300 ,000 300 ,000 300 ,000 294 ,566 100 ,000 Nebraska 1,523,755 300 ,000 300 ,000 300 ,000 518 ,472 105 ,283 Nevada 1,200 ,000 300 ,000 300 ,000 300 ,000 200 ,000 100 ,000 New Hampshire 1,262,946 300 ,000 300 ,000 300 ,000 262 ,946 100 ,000 New Jersey 5,150,828 1,986,963 876,385 307 ,433 1,645 ,838 334,209 New Mexico 1,489,209 300 ,000 300 ,000 300 ,000 489 ,209 100 ,000 New York 11,642,494 4,527,098 1;970,952 691,403 3,701,418 751,623 North Carolina 5,907 ,674 1,182,071 1,308 ,984 459,187 2,458 ,251 499,181 North Dakota 1,288 ,394 300 ,000 300 ,000 300 ,000 288 ,394 100 ,000 Ohio 8 ,067 ,855 1,640,149 1,780,463 624,581 3,343,682 678 ,980 Oklahoma 2,870,251 603,422 603,445 300 ,000 1,133,260 230,124 Oregon 1,967,281 429 ,874 379,650 300 ,000 712,977 144,780 Fennsylvania 11,341,528 3,935 ,804 2,051,372 719,615 3,852,446 782,291 Rhode Island 1,276,467 300 ,000 300 ,000 300 ,000 276,467 100 ,000 South Carolina 3,342,108 581,376 754,980 300 ,000 1,417,840 287,912 South Dakota 1,299,489 300 ,000 300 ,000 300 ,000 299 ,489 100 ,000 Tennessee 4,886,243 1,104,934 1,047,416 367,430 1,967,031 399 ,432 Texas 11,333,449 2,598 ,329 2,419,612 848 ,793 4,543,996 922,719 Utah 1,478 ,323 300 ,000 300 ,000 300 ,000 478 ,323 100 ,000 Vermont 1,200 ,000 300 ,000 300,000 300 ,000 200 ,000 100 ,000 Virginia 4,702,248 1,167,546 979,105 : 343,467 1,838 ,748 373,382 Washington 2,747 ,025 772,880 513,646 300 ,000.- 964,620 195 ,879 West Virginia 2,627,584 712,289 495 ,591 300 ,000 : 930,711 188 ,993 Wisconisn 3,879,886 1,028,172 782 ,894 300 ,000 1,470,263 298 ,557 Wyoming 1,200 ,G00 300 ,000 300 ,000 300 ,000 200 ,000 100 ,000 American Samoa 750 ,000 200 ,000 200 ,000 200 ,000 100 ,000 50,000 Guam 750,000 200 ,000 200 ,000 200 ,000 100 ,000 50,000 Puerto Rico 4,671,235 908 ,588 1,042,246 365,617 1,957,323 397 ,461 Trust Territory 750,000 200 ,000 200 ,000 200 ,000 100,000 50,000 Virgin Islands 750 ,000 200 ,000 200 ,000 200 ,000 100,000 50 ,000 Sif TENTATIVE ALLOCATIONS TO STATES FOR CONSTRUCTION AND MODERNIZATION OF HOSPITALS AND OTHER HEALTH FACILITIES For Fiscal Year 1973 Rehabili- Outpatient tation State Total Facilities Facilities Total. $85,000 ,000 $70,000,000 $15 000,000 Alabama 2,280,880 1,895 ,822 385 ,058 Alaska 300 ,000 200 ,000 100 ,000 Arizona 869,221 722,479 146,742 Arkansas 1,305 ,875 1,085 ,417 220 ,458 California 5,381,676 4,473,142 908 ,534 Colorado 927 , 368 770,810 156,558 Connecticut 650,977 541,079 109,898 Delaware 300 ,000 200 ,000 100 ,000 Dist. of Col. 300 ,000 200 ,000 100 ,000 Plorida 3,062,420 2,545 ,422 516,998 Georgia 2,485,192 2,065 ,642 419,550 Hawaii 329,177 229,177 100 ,000 Idaho 438 ,668 338 ,668 100 ,000 Illinois 2,965 ,145 2,464,569 500 ,576 Indiana 2,024,093 1,682,386 341,707 Lowa 1,170,640 973,013 197 ,627 Kansas 947 ,392 787 ,453 159,939 Kentucky 1,910,800 1,588,219 322,581 Louisiana 2,143,059 1,781,268 361,791 Maine 541,781 441,781 100 ,000 Maryland 1,246,392 1,035 ,976 210,416 Massachusetts 1,667,528 1,386,016 281,512 Michigan 2,922,847 2,429,412 493,435 Minnesota 1,548,980 1,287,481 261,499 Mississippi 1,667 ,695 1,386,155 281,540 Missouri 2,013,164 1,673,302 339 ,862 Montana 396,023 296,023 100 ,000 Nebraska 626,199 520,484 105,715 Nevada 300 ,000 200 ,000 100 ,000 New Hampshire 367 ,454 267 ,454 100 ,000 New Jersey 1,986,719 1,651,321 335 ,398 New Mexico 588 ,587 488 ,587 100 ,000 New York 4,435 ,453 3,686,560 748 ,793 North Carolina 2,950,461 2,452,364 498 ,097 North Dakota 387 ,355 287 ,355 100 ,000 Ohio 4,010,144 3,333,152 676,992 Oklahoma 1,370,029 1,138,741 231,288 Oregon 872,141 724,906 147,235 Pennsyivania 4,599,219 3,822,779 776,440 Rhode Island 375,220 275,220 100 ,000 South Carolina 1,703,903 1,416,250 287 ,653 South Dakota 396,855 296,855 100 ,000 Tennessee 2,370,731 1,970,504 400,227 Texas / 5,512,489 4,581,871 930,618 Utah 589,072 489 ,072 100 ,000 178 ‘TENTATIVE ALLOCATIONS TO STATES FOR CONSTRUCTION AND MODERNIZATION OF HOSPITALS AND OTHER HEALTH | FACILITIES (Continued) Rehabili- Outpatient tation State Total Facilities Facilities Vermont 300 ,000 200 ,000 100 ,000 Virginia 2,210,385 1,837,228 373,157 Washington 1,156,791 961,502 195,289 West Virginia 1,108 ,238 921,145 187 ,093 Wisconsin 1,765,555 1,467,494 298 ,061 Wyoming 300 ,000 200 ,000 100 ,000 American Samoa 150,000 100 ,000 50,000. Guam 150,000 100 ,000 50 ,000 Puerto Rico 2,320,007 1,928,344 391,663 Trust Territory 150,000 100 ,000 50,000 Virgin Islands 150 ,000 100 ,000 50,000 ma m wa @ es a ma ; | | a || @ m | a 72 = a a FY 1971 Loan and Loan Guarantee Allocations to States for Modernization and Construction of Hospitals and other Health Facilities TOTAL Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Dist. of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Towa Kansas Kentucky Louisiana Maine Mary land Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire $500,000, 000 8,236,500 456,500 3,247,500 4,992,000 26,721,000 5,432,500 6,509,500 1,659,500 1,355,000 14,470,500 10,460,000 1,323,000 1,888,500 23,163,000 13,792,000 8,813,500 7,577,000 8,198,000 11,224,500 3,369,000 5,748,500 18,478,000 17,534,500 10,527,000 5,987,500 13,408,000 2,703,000 3,202,500 912,000 1,894,500 New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming American Samoa Guam Puerto Rico Trust Territories Virgin Islands 18,222,500 2,151,000 42,450,500 14,544,000. °1,919,500 19,301,000 6,954,000 4,624,500 37,465,500 1,613,500 7,670,500 2,496,500 12,642,500 29,653,500 2,509 ,000 1,098,500 12,842,000 7,679,000 7,383,500 10,508,500 759,500 79,500 435 ,500 11,167,000 235,500 309 ,000 Saab ~~ . ‘ . : t i : P r . 2 i AK ’ i F 4 : E 1 FY 1972 Loan and Loan Guarantee Allocations to States for Modernization and Construction of Hospitals and other Health Facilities 500 ,000 , 000 TOTAL Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Dist. of Columbia Florida Georgia Hawaii Idaho ILlinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missourl Montana Nebraska Nevada New. Hampshire 8,041,500 460,000 3,255,000 4,815,500 27,244,500 5,633,000 6,509,500 1,720,000 1,353,500 14,506,000 10,101,500 1,294,000 1,936,000 23,637,500 14,114,500 9,039,500 7,542,000 8,075,000 11,021,000 3,423,000 5,836,000 18,512,500 17,853,000 10,641,500 5,613,000 13,456,500 2,746,500 3,286,000 937,000 1,924,000 New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginla Washington West Virginia Wisconsin Wyoming American Samoa Guam Puerto Rico Trust Territory Virgin Islands 18,354,500 2,221,500 41,715,000 14,119,000 1,938,500 19,445,000 6,944,500 4,743,000 37,638,500 1,629,500 7,396,000 2,501,500 12,482,000 - 29,176,000 2,579,000 1,102,500 12,671,000 7,841,000 7,317,000 10,836,000 794,500 68,000 389 ,000 10,999,000 244,500 325,500 180 Tentative FY 1973 Loan and Loan Guarantee Allocations to States for Modernization and Gonetruction of Hospitals and other Health Facilities TOTAL Alabama Alaska Arizona Arkansage California Colorado Connecticut Delaware Dist. Of Columbia Florida Georgia Hawaii Idaho I1linots Indiana Towa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire $500 ,000 ,000 8,009,500 466,000 3,329,000 4,800 ,000 27,216,500 5 ,689 ,000 6,512,000 1,722,000 1,333,000 14,711,500 10,109,500 1,303,000 1,949,500 23,557,500 14,117 ,000 9,020 ,000 7 5509 ,000 8,100,000 10,992,500 3,413,000 5,856,500 18 ,496,000 17,840,500 10,665 ,500 5,561,500 13,458,500 2,752,500 3,294,000. 947 ,000 1,941,000 New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginta Washington West Virginia Wisconsin Wyoming American Samoa Guam Puerto Rico Trust Territory Virgin Islands 18,377,500 2,219,500 41,650,500 14,098 ,000 1,934,000 19,403,500 6,964,500 4,789 ,000 37,523,500 1,624,500 7,390,000 2,491,000 12,494,500 29,317 ,000 2,618,500 1,112,000 12,665,000 7,829 ,000 7,283,000 10,825 ,000 798 ,500 67,500 "385 ,000 10,903,000 240 ,500 323,500 181 * ‘ f | » ‘ ‘ : . : q ; New Positions Requested Fiscal Year 1973 Health services research and development Direct operations Public Health Analyst.......sesceeesees Health Science Administrator.....ccceeee Social Sctence AnalySt.....scoseseceecs Public Health Analyst.....cscesccseceas . Program Analyst.....ccccccccnscsccscces Health Statistician.....ccscseveccscres Statisticdan. ....cccccvcssccssvscsccens . Staff Assistant... rsccscccsccccsecers SECTECATY. cece rercocsccsvcrcecesasecens Clerical Assistant... ccccsveccvccuvves Comprehensive health planning Direct operations Public Health Advisor........... a seeeee Health Planner... .ccccccsscccccccceone Public Health Program Specialist...ccccscccsscccucsssncenins Health Planner... .ccccscccseccccssenece Public Health Program Spectalist...crcccccccvccsvaccsccsvece Public Health Advisor... ..eccesseseress Public Health Program Specialist... cccwcsrcvcsacccccesceace . Program Management OLLACET. ccc s cee scevcerseccnce ce eeenes Administrative Assistant......ssceseees Clerical Assistant.......ccccevseeseens Clerical Assistant....cscccscsccccsvees Clerical Assistant.....ccccccccccvscces Commissioned Officers: Director Grade...ccccscccccsccccveees Full Grade... ccccccccccsccscsensecece Regional medical programs Direct operations Supervisory Public Health Analyst...... Supervisory Systems Analyst...........- Public Health Analysts. ..cccccecrercues Systems AnalySt..ccccccesccccnscvcecese Public Health Advisors.....sesceesscees Systems Analyst... .ccecececsssecccssecs Administrative Assistant......cscseecene SECTEEALY. cccccccscvccccccscressesescce Annual Grade Number Salary GS-14 1 $20,815 GS-14 1 20,815 GS-12 1 15,040 GS-12 1 15,040 GS-11 1 12,615 GS-11 1 12,615 GS-9 1 10,470 GS-7 1 8,582 GS-6 2 15,454 GS-5 2 13,876 12 145,322 GS-15 l 25,583 GS-14 1 21,960 GS-14 2 43,920 GS-13 1 18,737 GS-13 3 56,211 GS-12 2 31,732 GS-12 1 15,866 GS-12 1 15,866 GS-11. 1 13,309 GS-6 3 24,459 GS-5 3 21,957 GS-4 2 13,088 2 46,048 2. 26,964 25 375,700 GS=15 1 24,251 GS-14 1 20,815 GS-13 3 53,283 GS-13 1 17,761 GS-12 7 105,280 GS-12 1 15,040: GS-3 1 10,470 GS-6 1 7,727 182 Secretary/Clerk-Typist....ssscccecee “ Clerk-Typist..cccccscoesesccccoccers Total, new positions, all activities GS-5 GS-4 27,752 31,010 "313,389 ‘834,411 184 DEPARTMENT OF HEALTH, EDUCATION, AND WELFARE HEALTH SERVICES AND MENTAL HEALTH ADMINISTRATION Health Services Delivery Page No. Appropriation language... .csccscscccccsccsceccsecserucesecsescuses 186 Explanation of language changeS......ccsccccvccccvccccsevessssseeses 189 Amounts available for obligation........cccscccccccncncnecccuscnees 190 Obligations by ACAVILY...ceceeeeeeneceeecceeceesueeeceesceecesecs 191 Obligations by Object. ..ccecsececeeccrccceccson reer eenetnerensesees 193 Summary Of cChangeS.....scccererecaccercccccrcsenecesssesesesevecece 195 Authorizing legislation....... cece eee c cece nese tc cere ce eeseceeeeues 199 Explanation of tranferS.... ccc ccc ce rece rcncn teense cecescserscsenes 206 Table on estimates and appropriationsS.......ccccccccncceccccssevens 208 Justification: A. General Statement... ccrccccccrecccnccrvecrecssececesseesenne 209 1. Comprehensive health services: (a) Grants €O SEACCS..rrcccrccvcversvevecssnsevecesseses 212 (b) Health services grants... .ceccosercccccseccacvcsensee 214 (c) Migrant health grants....cccccccccccvevessccssesvese 215 (d) Direct operationg.... cece ccc cc cece see varececseeanes 217 2. Maternal and child health: (a) Grants to StateS..crccccvcsecccccccsecesesesssceseus 224 (b) Project grants. ..ccccccvcccereceessassssnecessceneses 227 (c) Research and training... .cscccseccccsaccnncsnnecvves 231 (d) Direct operations.....scscvcccecccccscvcensuarsceces 233 3. Family planning: (a) Project grants and contractS.......scecccccccaceveas 235 (b) Direct operations... ..cscccccccncccesevecesvacsseseees 242 4. National health service COrpS......ssesscercceccuercucves 244 5. Patient care and gpecial health services: (a) Inpatient and outpatient Care... .cccrscccccccnecenece 248 (b) Coast Guard medical services... ..ccccccescccccesces 249 (c) Federal Employees... cccccsccsccccscccccersvectcveaes 250 (d) Payment to Hawali....cccccc ces ccccccerecccsenseccees 251 6. Regional office central staff... ccc cc cence wees cccnecnes 252 7. Program direction and management services....ccsccscscces 253 185 DEPARTMENT OF HEALTH, EDUCATION, AND WELFARE ’ HEALTH SERVICES AND MENTAL HEALTH ADMINISTRATION Health Services Delivery Page No. B. Items of special concern: 1. Family planning.........ccsseccccceesceneseveees 210, 234, 264 2. Nursing home improvement......ssecccsseecececces 218, 257 3. Migrant health. .....cccsccvec recs reccssceeneenes 209, 215, 256 4, Status of conversion of PHS Hospitals. .ccccc cece eee eee ences seeeneresees 210, 248, 268 5. National health service corpS....ccseeseeeeaeecs 210, 244, 267 C. Program purposes and accomplishments........sceeeees 254 D. State tables...cssccccccccecccccrcseressestesteseees 274 E. New positions requested...ceceeessecceeceseecncrence 280 186 Appropriation Estimate HEALTH SERVICES DELIVERY 1 For carrying out, except as otherwise provided, sections 301, 310, 311, 314(d), 314(e), 321, 322, 324, 326, 328, 329, 331, 332, 502, 504, title X of the Publie Health Service Act, the Act of August 8; 1946: (5 U.S.C. 7901), section 1010 of the Act of July 1, 1944 (83 U.S.C. - 763e) section 1 of the Act of July 19, 1963 (42 U.S. C. 253a), and title WV of the Secial Security Act, $745,657,000, of which $1,200,000 shall be availablé only for payments to the State of Hawait for care and treat- mene of persons afflicted with leprosy: Provided, That any allotment to a state pursuant to section 503(2) or 504(2) of the Social Security Aet shall not be included i in computing for the purposes of subsections (a) and (b) of section 506 of such Act an amount expended or estimated to be expended by the State: Provided further, That when the Health Services and Mental Health Admints tration operates an employee health pro- gram for any Federal department or agency, payment for the estimated cost shall be made by way of reimbursement or in advance to this appro- ‘priation: Provided further, That in addition, $4,719,000 may be trans- ferred to this appropriation as authoriaed by section 201(g)(1) of the Social Security Act, from any one or all the trust funds referred to therein: Provided further, That anounts received for services rendered. under section 329 of such Act shall be credited to this approprtatton.. {compREHENSIVE HEALTH PLANNING AND SERVICES]? [to carry out sections 310, 314(a) through 314(e), 317, and 329 of the Public Health Service Act, and except as otherwise provided, sections 301 and 311 of the Act, $320,703,000: Provided, That - $4,519,000 may be transferred to this appropriation, as authorized _ by section 201(g) (1). of the Social Security Act, as amended, from . 187. any one or all of the trust funds referred to therein, and may be ex- _ pended for functions delegated to the Administrator of the Health Services and Mental Health Administration under title XVIII of the Social Security Act.] [MATERNAL AND CHILD HEALTH}? [For carrying out, except as otherwise provided, sections 301, 311, and title X of the Public Health Service Act and title V of the Social Security Act, $330,151,000: Provided, That any allotment toa State pursuant to section 503(2) or 504(2) of such Act shall not be included in computing for the purposes of subsections (a) and (b) of section 506 of such Act an amount expended or. estimated to be ex~- " pended by the State. ] [crants made during the current fiscal year for any project under section 508, 509, or 510 of the Social Security Act may be for periods ‘ending prior to July 1, 1973.} [PATIENT CARE AND SPECIAL HEALTH SERVICES ]9 [For carrying out, except as otherwise provided, the Act of August 8, 1946 (5.U.S.C. 7901), and under sections 301, 311, 321, 322, 324, 326, 328, 331, 332, 502, and 504 of the Public Health Service Act, section 1010 of the Act of July 1, 1944 (33 U.S.C 763c) and section 1 of the Act of July 19, 1963 (42 U.S.C. 253a), $85,700,000, of which $1,200,000 shall be available only for payments to the State of.. Hawaii for care and treatment of persons afflicted with leprosy: Provided, That when the Health Services and Mental Health Administration establishes or operates a health service program for any department or agency, payment for the estimated cost shall be “made by way of reimbursement or in advance for deposit to the credit of this appropriation. ] 188 ‘appropriations, “Comprehensive Healt 189° Explanation of Language Changes as a result of the consolidation of three |. h Planning and Services", "Maternal and. Child Healch", and “Patient Care and Special Health Service". This consolida- tion not only reflects a functional grouping of the accounts, but also provides for. better administration of the programs by making the appropriation structure consistent with the current organization of HSMHA. 1. New language is proposcd s been added for the National Health Service Corps which be returned to this appropriation. d for services. would be deposited 2. Language ha would allow funds collected for services to Under existing authority, any amounts receive in migcellaneous receipts of the Treasury. This proviso is requested in order that fees from third-party payers and individuals who are able to pay may be collected and "re-used" by the program. Also crediting reimbursements to this appropriation would reduce the amount of direct appropriations required. 3. ‘Language formerly used for the three consolidated accounts is deleted. DEPARTMENT OF HEALTH, EDUCATION, AND WELFARE HEALTH SERVICES AND MENTAL HEALTH ADMINISTRATION Health Services Delivery Amounts Available for Obligation Appropriation....cceecerrsecsecers Proposed supplemental.....-s+ee+es Subtotal, appropriations....-s+e+> Real transfers to: "Operating expenses, Public Buildings Service," General Services Administration.....- "salaries and expenses,” Economic Stabilization Activities..... Real transfer from: "Nursing home improvement"....«-+ Comparative transfers to: "Departmental management ,"....++ "yealth services planning and development”. .ssesceresseeees "Preventive health services".... "Office of the Administrator”... Comparative transfer from: "Office of the Administrator"... Subtotal, budget authority....---- Receipts and reimbursements from: "Pederal funds"..-.e+-sceceerers ttrust Funds"....cccesercsrences “Non-Federal sources”.....sesees Unobligated balance, start of year Unobligated balance, lapsing.....- Total, obligations.....-e+-+. 1972 $736,554 ,000 5,610,000 742,164,000 ~31,900 ~1, 300,000 4,300,000 -125,000 ~25,935,000 -54,300,000 -20,006 136,000 664,889,000 16,665,000 4,719,000 558,000 9,000,000 -459 ,000 695,372,000 1973 $745,657 ,000 745,657,000 16,559,000 4,719 ,000 6,940,000 773,875,000 1 0 191 Obligations by Activity 1972 1973 Increase or Page Estimate Estimate Decrease Ref. Pos. Amount Pos. Amount Pos. Amount 211 Comprehensive Health services: 212 (a) Grants to States....... --- $90,000,000 --- $90,000,000 --- -—-- 214 (b) Health services grants....... --- 103,913,000 --- 116,200,000 --- +$12, 287,000 215 (c) Migrant health grantS....605. -o7 17,950,000 --- 23,750,000 --- +5,800,000 217 (d) Direct operations... 445 17,981,000 445 18,862,000 --- +881 ,000 Subtotal.-+- 445 229,844,000 445 248,812,000 ~--- +18,968,000 223 Maternal and child health: 224 (a) Grants to States...e+0e. --~ 121,522,000 --~ 125,678,000 --- +4,156,000 227 (b) Project grants. --- 92,008,000 --~- 101,330,000 --- +9, 322,000 231 (c) Research and training..... --- 21,106,000 --- 21,392,000 --- +286 ,000 233 (d) Direct operations... _133 4,078,000 133 4,148,000 --- +70,000 Subtotal.... 133 238,714,000 133 252,548,000 --- +13,834,000 234 Family planning: 235 (a) Project grants and contracts --~ 94,815,000 --- 137,024,000 --- +42, 209,000 242 (b) Direct operations... 70 1,438,000 87 1,987,000 +17 +549 ,000 Subtotal.... 70 96,253,000 87 139,011,000 +17 +42,758,000 244 National health service COFPS.--ee. 637 14,117,000 637 14,803,000 --- +686 ,000 246 Patient care and special health services: 248 (a) Inpatient and outpatient CALC. scceee 55479 95,237,000 5,479 96,303,000 --- +1,066,000 249 (b) Coast Guard medical serviceS...s- 151 4,802,000 151 5,105,000 --- +303 ,000 250 (c) Federal employees.... 260 4,487,000 260 4,498,000 <--~ +11,000 251 (d) Payment to Hawaii....se- --- 1,200,000 --- 1,200,000 --- --- Subtotal....5,890 © 105,726,000 5,890 107,106,000 --- +1,380,000 252 Regional office central staff....... 250 5,287,000 250 5,281,000 --- ~6,000 253 Program direction and management services... 233 Total obligations..7,658 5,431,000 236 695,372,000 7,678 6,314,000 773,875,000 +3 +883 ,000 +20 +78,503,000 Obligations by Object 1 1972 1973 Increase or Estimate Estimate Decrease Total number of permanent POSILLONS .....cecccececer 7,658 7,678 +20 Full-time equivalent of all other positions .......4.. 401 422 +21 Average number of all employees ...cseeceees ae 7,387 7,886 +499 Personnel compensation: Permanent positions....... $80,918,000 $84,029,000 +$3,111,000 Positions other than permanent .....ecsecees 3,956,000 3,918,000 -38,000 Special personal services — 375,000 375,000 —— Other personnel compen- BAation .c.cecvccceevecse 4,529,000 4,527,000 -2,000 Subtotal, personnel compensation....6+. 89,778,000 92,849,000 +3,071,000 Personnel benefits ........ 12,338,000 13,951,000 +1,613,000 Travel and transportation of PETSONS «cc. ecacceeeee ove 4,785,000 4,627,000 - -158,000 Transportation of things ... 2,716,000 2,169,000 -547,000 Rent, communications and UtELLIities .....cecseeeeee 3,117,000 3,333,900 +216,000 Printing and reproduction 537,000 489,000 ~48,000 Other services ...cccceees 15,109,000 15,782,000 +673,000 Project contracts ..e-.- 15,383,000 15,048,000 ~335,000 Supplies and materials.... 11,694,000 12,074,000 +380 ,000 Equipment ...cseesseceeces 4,143,000 3,930,000 -213,000 Grants, subsidies and contributions ......ss6- 536,071,000 609 , 922,000 +73,851,000 Subtotal .....--cceees 695,671,000 774,174,000 +78,503,000 134 Obligation by Object 1972 1973 Increase or Estimate Estimate Decrease Deduct quarters and subsis— tence(-) ccccscccccvcccece -299 ,000 -299,000 --- Total obligations by 773,875,000 +78,503,000 ODJECE.cccesevcvsseves 695,372,600 Summary of Changes 1972 estimated obligations.....cssesees 1973 estimated obligations.....+ssseee- Net change...sesecceeees eoeaoeanceenne 135 a $695 ,372,000 oe 773,875,000 +78, 503,000 Base Change from Base Pos Amount .Pos. Amount Increases: A. Built-in: 1. Annualization of positions mew in 1972. ...ccessvceeee -— -—- —— 755,000 2. Within grade and longevity ANCTEASES. sec cece vees sees --- --- “—- 2,511,000 3. Continuation pay costs for commissioned officers (medical) ..cccceeceeseeeee 7T™ --- --- 547,000 4. Annualization of uniformed services pay increase (PL 92-129). .eseeececees . -- --- ——— 664,000 5. Increases for DHEW Working Capital Fund, HSMHA Service and Supply Fund, and FTS charges....-- eeeee -—-- --- ~o- 249,000 6. Increase in continuation costs for migrant health PLOJECES. cece scecesereces -_—- -—- — 2,800,000 7. Social Security contri- butions ...ccvcceescreeces -_—- “= -—— 36,000 8, Contract medical care and -- supply price increases ... -—~ --- -——— 358,000 B. Program: 1. Comprehensive health services: a. Health service grants: (1) Comprehensive health centers... -—- 88,618,000 --~ 9,287,000 (2) Family health centersS.....eees . --- 13,000,000 -_—~ 3,000,000 b. Migrant health grants... --—- 17,950,000 ——— 3,000,000 c. Direct operations......- 445 18,811,000 -—- 120,000 2. Maternal and child health a. Grants to States for: (1) Maternal and child health services.. --- 59,250,000 -—- 1,528,000 (2) Crippled children's SeETVICES. oes eeeee -~~ 62,272,000 --- 2,628,000 b. Project grants for: (1) Maternity and infant CATE. cee cece eee --- 43,428,000 --- 3,804,000 (2) Comprehensive health care for children and youth.....-.. + 47,400,000 -—~ 5,442,000 136 Base Change from Base Pos. Amount _ Pos. Amount Program (continued) (3) Dental health of children......-. -—- 1,180,000 --- 76,000 c. Training....seecereeees “o- 15,071,000 --- 286,000 d. Direct operations.....- 133 4,078,000 --~ 46,000 3. Family planning: a. Project grants and contracts: (1) Service projects.. oo 88,500,000 --- 42,000,000 (2) Education and information..... --- 700,000 --- 209,000 b. Direct operations.....- 70 1,438,000 17 233,000 4, Program direction and man- agement services....+-ee- 83 2,133,000 3 694,000 Total, increases...... 80,273,000 Decreases: A. Built-in: 1. Two less days Of PAYsrsscceeccenecerees -— --- --- -233,000 2. Decrease resulting from employment cut-back during 1972.....eseseeees ~-- --- --- = --1,514,000 B. Program: 1. Decrease in reimbursable PYOQLAMS . eee ereeceeecrces --- --- --- -23,000 Total, decreases.....-- -1,770,000 Total, net change +78,503,000 A. B. 137 Explanation of Changes Increases: Built-in: An increase of $7,920,000 is for mandatory items. Of this $755,000 is for full-year costs of positions new in 1972, $2,511,000 is for net addi- tional costs of within grade and longevity increases, $547,000 continuation pay costs for medical officers, $664,000 for annualization of uniformed services pay increases, $249,000 DHEW Working Capital Fund, HSMHA Service and Supply Fund, and FTS charges, $2,800,000 increase in continuation costs for migrant health projects, $36,000 increase in Soctal Security contri- — butions, $358,000 contract medical care and supply price increases. Program: Health service grants--An increase of $12,287,000 is requested for this activity. These increases would provide support for additional neighborhood health centers previously funded by the Office of Economic Opportunity and the conversion of several Family Health Centers from planning to operational status. Migrant health grants~-The requested increase of $3000,000 would be used for upgrading existing projects strategically located along the migrant streams to maximize their quality and utilization. Direct _operations--An increase of $120,000 is requested for project contracts to initiate a reporting system to collect information on the extent of health services obtained by migrants and seasonal farmworkers and their families. Maternal and child health services--The $1,528,000 increase will help States maintain the current level of medical care services and partially offset the rising costs of medical care. Crippled children's services--The increase of $2,628,000 will help States in meeting the increased costs of providing the more effective but technically more complex treatment of handicapped children. Maternity and infant _care--The increase of $3,804,000 will support expansion of the 56 existing maternity and infant care projects and extend services to an additional 12,000 mothers and infants, for a total of 205,000, in 1973. It will also assure continuation of intensive care te infants in ongoing projects and new projects becoming operational in 1972. Children and youth--The increase of $5,422,000 will assure comprehensive health services to an estimated 547,000 children. This compares with a total of 504,000 expected to be served in 1972. Dental health of children--The increase of $76,000 will support contin- uation of an estimated 17 dental projects planned to be in operation in 1972. It is expected that these projects will provide comprehensive dental health care to an estimated 22,000 children in 1973. 198 Explanation of changes (continued) A. B.. Training--The increase of $286,000 will provide the continued support of 19 university-affiliated mental retardation centers and for training personnel in health care and related services for mothers and children. Direct operations--The increase of $46,000 provides for added costs of central services, Family planning services-~ The increase of $42,000,000 in obligations for family planning project grants includes $10,000,000 to fund established family planning projects presently funded by the Office of Economic Opportunity. The remaining $32,000,000 will support new or expanded family planning projects with State and local health departments, hospitals, universities, and other public and/or nonprofit organizations. Priority will be given to funding projects serving rural areas, migrants, Appalachia, Spanish-speaking Americans and other hard-to-reach areas and groups. The increase will extend services to approximately 700,000 additional women by the time the funds are totally expended. The total program level for 1973 will provide services to approximately 2,200,000 women when the projects are fully operational. Education--The increase of $209,000 will be used to develop improved educational materials and promote the use of educational methods which have proven their usefulness. Direct operations--The increase of $233,000 will support 17 new positions in the regions and central office to administer the expanded grants and contracts program. Program direction and management services--The increase of $694,000 includes $649,000 to expand the upward mobility program and $45,000 for added costs of central services to administer an expanded family planning grants and contracts program, Decreases: Built-in: The decrease of $233,000 represents non-recurring salary costs result- ing from a reduction of two days of pay in 1973. The decrease of 31,514,000 results from position reductions in line with the Administration's economic policy. Program: Inpatient and outpatient care--The decrease of $23,000 represents a ‘decline in reimbursable program. 139 Authorizing Legislation 1973 Appropriation Legislation Authorized requested Public Health Service Act Section 310--Grants for Health Services for Domestic Agricultural MIgrants... cess cccccnscccecccccereevesesees 6 930,000, 000 $23,750,000 Section 314(d)--Grants for Comprehensive Public Health Services. .cccccecccscccceveceseceseceseseses 165,000,000 90,000,000 Section 314(e)~~Project Grants for Health Services Development..........+.+157,000,000 116,200,000 Section 329--Assignment of Medical and Other Health Personnel to Critical Need Areas....scsccccececcevceveres 30,000,000 8,418,000 PUBLIC HEALTH SERVICE "Health Services for Domestic Agricultural Migrants "Section 310. There are hereby authorized to be appropriated not to exceed $7,000,000 for the fiscal year ending June 30, 1966, $8,000,000 for the fiscal year ending June 30, 1967, $9,000,000 each for the fiscal year ending June 30, 1968, and the next fiscal year, $15,000,000 for the fiscal year ending June 30, 1970, $20,000,000 for the fiscal year ending June 30, 1971, $25,000,000 for the fiscal year ending June 30, 1972, and $30,000,000 for the fiscal year ending June 30, , 1973, to enable the Secretary (1) to make grants to public and other nonprofit agencies, institutions, and organizations for paying part of the cost of (i) estab- lishing and operating family health service clinics for domestic agricultural migratory workers and their families, including training persons (including allied health professions personnel) to provide services in the establishing and operating of such clinics, and (i1) special projects to improve and provide a continuity in health services for and to improve the health conditions of domestic agricultural migratory workers and their families, including necessary hospital care, and including training persons (including allied health professions personnel) to pro- vide health services for or otherwise improve the health conditions of such migra- tory workers and their families, and (2) to encourage and cooperate in programs for the purpose of improving health services for or otherwise improving the health conditions of domestic agricultural migratory workers and their families. The Secretary may also use funds appropriated under this section to provide health services to persons (and their families) who perform seasonal agricultural services similar to the services performed by domestic agricultural migratory workers if the Secretary finds that the provision of health services under this sentence will contribute to the improvement of the health conditions of such migratory workers and their families. For the purposes of assessing and meeting domestic migratory agricultural workers’ health needs, developing necessary resources, and involving local citizens in the development and implementation of health care programs authorized by this section, the Secretary must be satisfied, upon the basis of evidence supplied by each applicant, that persons broadly representative of all elements of the population to be served and others in the community knowledgeable about such needs have been given an opportunity to participate in the development of such programs, and will be given an opportunity to participate in the imple- mentation of such programs. 200 "Grants for Comprehensive Public Health Services "Section 314. (d) (1) AUTHORIZATION OF APPROPRIATIONS.-~There are authorized to be appropriated $70,000,000 for the fiscal year ending June 30, 1968, $90,000,000 for the fiscal year ending June 30, 1969, $100,000,000 for the fiscal year ending June 30, 1970, $130,000,000 for the fiscal year ending June 30, 1971, $145,000,000 for the fiscal year ending June 30, 1972, and $165,000,000 for the fiscal year ending June 30, 1973, to enable the Secretary to make grants to State health or mental health authorities to assist the States in establishing and main- taining adequate public health services, including the training of personnel for State and local health work. The sums so appropriated shall be used for making payments to States which have submitted, and had approved by the Secretary, State plans for provision of public health services. "Project Grants for Health Services Development "(e) There are authorized to be appropriated $90,000,000 for the fiscal year ending June 30, 1968, $95,000,000 for the fiscal year ending June 30, 1969, $80,000,000 for the fiscal year ending June 30, 1970, $109,500,000 for the fiscal year ending June 30, 1971, $135,000,000 for the fiscal year ending June 30, 1972, and $157,000,000 for the fiscal year ending June 30, 1973, for grants to any public or nonprofit private agency, institution, or organization to cover part of the cost (including equity requirements and amortization of loans on facilities acquired from the Office of Economic Opportunity or construction in connection with any program or project transferred from the Office of Economic Opportunity) of (1) providing services (including related training) to meet health needs of limited geographic scope or of specialized regional or national significance, or (2) devel- oping and supporting for an initial period new programs of health services (includ- ing related training). Any grant made under this subsection may be made only if the application for such grant has been referred for review and comment to the appropriate areawide health planning agency or agencies (or, if there is no such agency in the area, then to such other public or nonprofit private agency or organization (if any) which performs similar functions) and only if the services assisted under such grant will be provided in accordance with such plans as have been developed pursuant to subsection (a). "Assignment of Medical and Other Health Personnel to Critical Need Areas "Section 329. (a) It shall be the function of an identifiable administrative unit within the Service to improve the delivery of health services to persons living in communities and areas of the United States where health personnel and services are inadequate to meet the health needs of the residents of such communi- ties and areas. HARKER "(g) To carry out the purposes of this section, there are authorized to be appropriated $10,000,000 for the fiscal year ending June 30, 1971; $20,000,000 for the fiscal year ending June 30, 1972; and $30,000,000 for the fiscal year ending June 30, 1973." 201 Authorizing Legislation 1973 Appropriation Legislation Authorized requested Public Health Service Act Section BBL mm LOpers.cscceseccesccccs Indefinite $1,200,000 PUBLIC HEALTH SERVICE ACT Title III--General Powers and Duties of Public Health Service Part De~Lepers Appropriation Section 331. "xxx when so provided in appropriations available for any fiscal year for the maintenance of hospitals of the Service, the Surgeon General is authorized and directed to make payments to the Board of Health of Hawaii for the care and treatment in its facilities of persons afflicted with leprosy at a per diem rate, determined from time to time by the Surgeon General, which shall, subject to the availability of appropriations, be approximately equal to the per diem operating cost per patient of such facilities, except that such per diem rate shall not be greater than the comparable per diem operating cost per patient at the National Leprosarium, Carville, Louisiana." 202 Authorizing Legislation 1973 Appropriation Legislation Authorized Requested Public Health Service Act: Section 1001 ~ Grants and contracts 1/ for family planning services . . $90,000,000 $111,500, 000— Section 1003 - Training grants and contracts .....4 sees 4,000,000 3,000,000 Section 1004 - Research grants and contracts ....+4.e.s«e-. 65,000,000 2,615,000 Section 1005 - Informational and educational materials ..... 1,250,000 909 ,000 Project Grants and Contracts for Family Planning Services Sec. 1001. (a) The Secretary is authorized to make grants to and enter into contracts with public or nonprofit private entities to assist in the establishment and operation of voluntary family planning projects. (b) In making grants and contracts under this section the Secretary shall take into account the number of patients to be served, the extent to which family planning services are needed locally, the relative need of the applicant, and its capacity to make rapid and effective use of such assistance. (c) For the purpose of making grants and contracts under this section, there are authorized to be appropriated $30,000,000 for the fiscal year ending June 30, 1971; $60,000,000 for the fiscal year ending June 30, 1972; and $90,000,000 for the fiscal year ending June 30, 1973. Training Grants and Contracts Sec. 1003. (a) The Secretary is authorized to make grants to public or nonprofit private entities and to enter into contracts with public or private entities and individuals to provide the training for personnel to carry out family planning service programs described in section 1001 or 1002. (b) For the purpose of making payments pursuant to grants and contracts under this section, there are authorized to be appropriated $2,000,000 for the fiscal year ending June 30, 1971; $3,000,000 for the fiscal year ending June 30, 1972; and $4,000,000 for the fiscal year ending June 30, 1973. Research Grants and Contracts Sec. 1004. (a) In order to promote research in the biomedical, contra- ceptive development, behavioral, and program implementation fields related to family planning and population, the Secretary is authorized to make grants to public or nonprofit private entities and to enter into contracts with public or private entities and individuals for projects for research and research training in such fields. (b) For the purpose of making payments pursuant to grants and contracts under this section, there are authorized to be appropriated $30,000,000 for the fiscal year ending June 30, 1971; $50,000,000 for the fiscal year ending June 30, 203 1972; and $65,000,000 for the fiscal year ending June 30, 1973. Informational and Educational Materials Sec. 1005. (a) The Secretary is authorized to make grants to public or nonprofit private entities and to enter into contracts with public or private entities and individuals to assist in developing and making available family planning and population growth information (including educational materials) to all persons desiring such information (or materials). (b) For the purpose of making payments pursuant to grants and contracts under this section, there are authorized to be appropriated $750,000 for the fiscal year ending June 30, 1971; $1,000,000 for the fiscal year ending June 30, 1972; and $1,250,000 for the fiscal year ending June 30, 1973. 1/ Additional authorizing legislation to be submitted mm a | ‘| a a || mm = ; | mm w , BB a = wa a z= 204 Authorizing Legislation 1973 Appropriation Legislation Authorized requested Social Security Act Section 501--Maternal and Child Health 1/ and Crippled Children's Services........... $350,000,000 $267,400,000 = SOCIAL SECURITY ACT { Title V--Maternal and Child Health and Crippled Children's Services Authorization of Appropriations Section 501. For the purpose of enabling each State to extend and improve (especially in rural areas and in areas suffering from severe economic distress), as far as practicable under the conditions in such State, (1) services for reducing infant mortality and otherwise promoting the health of mothers and children; and (2) services for locating, and for medical, surgical, corrective, and other services and care for and facilities for diagnosis, hospitalization, and aftercare for, children who are crippled or who are suffering from conditions leading to crippling, there are authorized to be appropriated $250,000,000 for the fiscal year ending June 30, 1969, $275,000,000 for the fiscal year ending June 30, 1970, $300,000,000 for the fiscal year ending June 30, 1971, $325,000,000 for the fiscal year ending June 30, 1972, and $350,000,000 for the fiscal year ending June 30, 1973, and each fiscal year thereafter. Purposes for which Funds are Available Section 502. Appropriations pursuant to section 501 shall be available for the following purposes in the following proportions: (1) In the case of the fiscal year ending June 30, 1969, and each of the next 3 fiscal years, (A) 50 percent of the appropriation for such year shall be for allotments pursvant to sections 503 and 504; (B) 40 percent therecf shall be for grants pursuant to sections 508, 509, and 510; and (C) 10 percent thereof shall be for grants, contracts, or. other arrange- ments pursuant to sections 511 and 512. (2) Im the case of the fiscal year ending June 30, 1973, and each fiscal year thereafter, (A) 90 percent of the appropriation for such years shall be for allotments pursuant to sections 503 and 504, and (B) 10 percent thereof shall be for grants, contracts, or other arrangements pursuant to sections 511 and 512. Not to exceed 5 percent of the appropriation for any fiscal year under this section shall be transferred, at the request of the Secretary, from one of the purposes specified in paragraph (1) or (2) to another purpose or purposes so specified. For each fiscal year, the Secretary shall determine the portion of the appropriation, within the percentage determined above to be available for 1/ Includes $19,000,000 for family planning projects. 205 sections 503 and 504, which shall be available for allotment pursuant to section 503 and the portion thereof which shall be available for allotment pursuant to section 504. Notwithstanding the preceding provisions of this section, of the amount appropriated for any fiscal year pursuant to section 501, not less than 6 percent of the amount appropriated shall be available for family planning services from allotments under section 503 and for family planning services under projects under sections 508 and 512. Administration Section 513. (b) Such portion of the appropriations for grants under section 501 as the Secretary may determine, but not exceeding one-half of 1 percent thereof, shall be available for evaluation by the Secretary (directly or by grants or contracts) of the programs for which such appropriations are made and, in the case of allotments from any such appropriation, the amount available for allotments shall be reduced accordingly. ae ma m@ Explanation of Transfers 1972 Estimate Real transfers to: Operating expenses, Public Buildings Service, GSA....... ~$31,000 Salaries and expenses, Economic Stabilization Act... -1,300,000 Real transfer from: Nursing home improvement..... 4,300,000 Comparative transfers to: Preventive health services... -54,300,000 Health planning and development... ccccsccsecseeees -25,935,000 Departmental management...... -125,000 Office of the Administrator.. -20,000 206 Transfer to the General Services Administration for rental of space. Reflects a transfer of funds to the Executive Office of the President, as autho- rized by the Economic Stabi- lization Act. Funds would be used for administrative expenses associated with carrying out provisions of the act. Transfer to the research and development elements of nursing home improvement program from the Office of the National Center for Health Services Research and Development. Transfer of project grants resulting from the reorganization of HSMHA. Transfer of planning grants and related direct operations due to the reor- ganization of HSMHA. Reflects transfers to support the departmental intergovernmental coordina= _ tion functions, coordinated field personnel management, Upward Mobility, and the adverse action and employee grievance examining staff. Transfer of a budget analyst position to HSMHA Financial Management. Comparative transfer from: "Office of the Administrator.. 136,000 207 Transfer of Deputy and staff due to the reorgani- zation of HSMHA, Year 1963 1964 1965 1966 1967 1968 1969 1970 Trust fund transfers 1971 Trust fund transfers 1972 Trust fund transfers Proposed Health Services Delivery Budget Estimate House Senate to Congress Allowance Allowance Appropriation $101,514,000 $101, 477,000 $98,820,000 $98,820,000 116,538,000 116, 462,000 116,462,000 116,462,000 142,536,000 142,436,000 143,064,000 143,064,000 196,616,000 197,480,000 183,480,000 197,980,000 242,521,000 242,271,000 242,271,000 242,271,000 410,599,000 383,406,000 384, 209 ,000 383,806,000 513,476,000 454,847,000 457,847,000 456,347,000 453,507,000 461,297,000 463,207,000 463,207,000 4,320,000 4,320,000 4,320,000 4,320,000 519,798,000 519,798,000 525,940,000 521,248,000 4,320,000 4,320,000 4,320,000 4,320,000 640,851,000 644,869,000 685,750,000 656,319,000 4,519,000 4,519,000 4,519,000 4,519,000 supplemental 5,610,000 1973 Trust fund transfers 745,657 ,000 4,719,000 209 Justification Health Services Delivery Increase or 1972 1973 Decrease Pos. Amount Pos. Amount Pos. Amount Personnel compensa-~ tion and benefits... 7,658 $102,116,000 7,678 $106,800,000 +20 +$4,684,000 Other expenses...... --- 593,256,000 --~ 667,075,000 _--- +738 ,000 Total....sseeee+ 73658 695,372,000 7,678 773,875,000 +20 +78,503,000 General Statement This budget proposes a consolidated appropriation, Health Services De~ livery, for HSMHA's health services programs which were supported previously by three separate appropriations: Comprehensive health planning and services, Maternal and child health, and Patient care and Special health services. The proposed appropriation is consistent with the recent internal re- organization of the Health Services and Mental Health Administration. It reflects a functional grouping of the health services delivery programs and as such provides for improved coordination and administration. Not included in this grouping of health devlivery programs is the Indian health service appropriation which tis presented to the Subcommittee on Department of Interior and Related Agencies and the Emergency health service appro- priation which is heard by the Subcommittee on the Department of Treasury, Postal Service and General Government. Comprehensive Health Services The budget includes $90,000,000 for the States under the Partnership for Health formula grant program and §116,200,000 for 65 neighborhood health centers and 23 family health center projects. The Federal funding of these centers supports the development of primary and ambulatory health services for inner city and rural areas lacking adequate services. Efforts will be continued to assist these centers to collect third party health insurance payments so that they can become self- sufficient. The migrant health activity includes $23,750,000 for Health care for migrant and seasonal farmworkers, an increase of $5,800,000 over 1972. The 1973 program will focus on up-grading at least 50 existing projects strategically located along the migrant streams to improve quality of care and utilization. Maternal and Child Health In 1973, the budget includes $252,548,000 for Maternal and Child Health Services,.an increase of $13,834,000 over 1972. Grants to States for mater- nal and child health services are being increased by $1,528,000 and for the care of crippled children by $2,628,000 to reduce infant mortality and to 210 continue and expand services for crippled children. These funds will pro- vide for physicians' services to more than 500 thousand crippled children, prenatal and postpartum care to more than 400 thousand women, and family planning services to 850 thousand women. The projects grants program of $101,330,000 an increase of $9,322,000 over 1972, will provide comprehensive care services to 152,000 mothers, 53,000 infants and 546,000 children and youth in disadvantaged urban and rural areas. Family Planning Services The 1973 budget includes $139,011,000 for the National Center for Fam- ily Planning Services, an increase of $42,758,000 over 1972. This request will continue progress toward the President's goal of providing family planning services to. women who need but cannot afford them. Project grants to State and local health departments and other public or nonprofit organizations will provide services to an estimated 2.2 million women in 1973 as compared to 1.5 million in 1972 and 700,000 in 1971. Current estimates are that approximately 2.3 million additional women may be receiving services from other providers in 1973, including private physicians and voluntary organizations. When combined with the 2.2 million women to be served by projects funded by the National Center, a total of 4,5 million will be receiving services. This significant national effort will help reduce the dependency of many families presently burdened with the consequences of unwanted childbirth. Patient Care and Special Health Services The 1973 estimate for the PHS hospitals and clinics will maintain the same level of operation as in 1972. The number of primary PHS benefi- ciaries in the hospitals has continued its decline. In 1973 we estimate that 59 percent of the total patient load will represent primary bene- ficiaries as compared to 61 percent in 1971. During 1973 efforts will continue toward converting some of these facilities to community control in line with local health care needs and resources. National Health Service Corps In 1973, the Corps will accelerate placements of health personnel in Nation's health manpower shortage areas. Almost 600 physicians, dentists, nurses and other health professionals will be providing direct health care in these locations. These health personnel will provide support for a total of 175-225 communities with a total population of approximately 700,000 to 900,000 people. 211 Comprehensive Health Services Increase or 1972 1973 Decrease Pos. Amount Pos. Amount Pos. Amount Personnel compensation and benefits. .......065+445 $8,327,000 445 $8,970,000 ~~ +$643,000 Other expenses........+...-~~ 221,517,000 --- _239, 842,000 --__+18, 325,000 Total. ..eerccees ee 2 445 229,844,000 445 248,812,000 = +18, 968,000 Introduction This activity encompasses a number of unique and interrelated programs designed to improve the delivery of health care to the American people. Comprehen- sive health services development, Migrant health, and support of Medicare pro~- : grams - all move toward the improvement in the delivery of health care that we are seeking. One of the highest priorities is the support of 55 comprehensive health care centers and 118 migrant health projects. The centers and projects provide family-oriented primary care to population groups long without basic health services. The comprehensive health care centers provide basic health care primarily to the urban poor. The Migrant health program provides access to health services to migrant and seasonal farmworkers and their families. Emphasis is now on the improvement of the quality of those services. The quality of services provided through Medicare is aided through medical care standard development pro- grams and through counseling and participation in the application of Medicare standards. States and communities are helped in maintaining quality of care in their health institutions through programs of training for their license inspectors and Medicare and Medicaid surveyors through the Nursing Home Improvement program. 212 Grants to States . Increase or 1972 1973 Decrease Pos. Amount Pos. Amount Pos. Amount Personnel compensation and benefits.....sceoeeees =~ $1, 306,000 -- $1,306,000 -- — Other expenses.......50+6.++ -- 88,694,000 - 88,694,000 =~ -~ Total...-.sceeseess ~~ 90,000,000 _-- 90,000 ,000 -- -- The formula grant authorized by Section 314(d) enables the States to provide more direct support to a broad range of public health programs at the State and local levels. The authority provides for flexibility in the use of these Federal funds in response to State needs. The States are using these funds to support communicable disease control programs such as venereal disease, tuberculosis and immunization activities (particularly rubella); chronic disease programs directed toward such major causes of death and disability as heart disease, cancer, diabetes, and stroke; environmental health services, including food and drug, industrial health, radiological health, sanitary engineering, air and water pollu- tion; laboratory services; home health and public health nursing services, com- munity mental health, including treatment of alcoholism, drug abuse, and suicide prevention, A number of States use a portion of their allocation in developmental health activity. California has for some years provided State project support to com- munities for the organization, development, and operation of new and innovative health services, particularly community health services in urban or rural ghettoes and model cities areas. The Missouri Division of Mental Health supports a crisis intervention program in Joplin serving two counties. A 24-hour-a-day program patterned after suicide prevention programs, serves a broader need to assist people with personal and emotional problems in addition to seeking to forestall suicide. The mental health program of Kansas allocated all of its formula and matching funds to support new and innovative programs within the State, such as a thera- peutic day school project, an adolescent walk~in clinic, a juvenile court cooperative group care program, and a famlly life education program. Arizona is supporting the establishment and utilization of a pediatric nurse practitioner program in one county as a method of broadening its maternal and child health effort. In mental health, one of their programs in which State formula grant funds are used is in the prevention of mental illness through the early identification of high risk persons and the application of preventive psychotherapy. One use of formula grant funds in American Samoa has been to extend dental health services into the elementary schools. Another has been to start a post- graduate course in public health nursing--a first in the medical history of American Samoa. The State of Nebraska used some of its allotment to support health pro- fessionals. assigned to local communities to carry out communicable disease and environmental health programs. Pennsylvania uses formula funds to assist in carrying out a student inter project providing services to mental health, mental retardation, and related agencies. Undergraduate college students are placed in an agency for a year. They earn college credit through their universities and are paid a modest stipend for their services. 213 Expanded environmental health services is one of Maryland's uses of, the grant. A sanitation inspection unit for nursing home facilities and expanded sanitary survey section of shellfish waters receive support from this use of the monies. Virginia uses all its funds to assist in the operation of its local health departments for services rendered on the basis of the need of the individual locality. In the District of Columbia these funds have enabled their community health services administration to further the concept of Neighborhood Health Centers which provide comprehensive health services to families within a short distance of their homes. In 1972, funds authorized for evaluation are being used to continue to support a contract with the Association of State and Territorial Health Officers to develop and activate a uniform program reporting system for State health depart- ments. This project will assist the State and Federal governments in planning and evaluation as a result of increased information which will lend itself to evaluation. In 1973 we anticipate that the States will continue to support a broad range of health programs at the local level. No increase is requested in this activity in 1973, 214 Health Services Grants Increase or 1972 1973 Decrease Pos. Amount Pos. Amount Pos. Amount Other expenses.... -- $103,913,000 -- $116,200,000 -- +$12,287,000 Project grants authorized under Section 314(e) of the Partnership for Health Legislation provide means to help upgrade the delivery of health services. First priority for awarding these grants is given to comprehensive health service pro- grams providing primary care and a broad range of ambulatory services to medically underserved urban and rural neighborhoods. In 1973 these programs will provide comprehensive health services for about 1,280,000 persons, an increase of 330,000 over 1972. Comprehensive Health Centers The comprehensive health service program supported 55 comprehensive health centers, including nine neighborhood health centers transferred from OEO, and a limited number of developmental and supportive projects in 1972. These health care programs covered an eligible population of approximately 2,700,000 persons and provided services to an estimated 850,000 persons at a cost of $88,618,000. The centers are organized to deliver all ambulatory health care services and have arrangements to secure most needed specialty treatment. Improved management capability in the 55 comprehensive health centers in 1972 was encouraged through the support of ambulatory health care information systems and accounting systems. In addition, support was furnished to the centers to enable them to develop pro- grams to increase their ability to obtain third party funding. In 1973, $100,200,000 is requested to continue funding the existing compre- hensive health programs, with $20,000,000 of this amount to be available for supporting 10 to 14 additional health centers previously funded by OEO. In total we expect these centers to provide services to over 1,000,000 people. We are assisting health centers to improve their management capability and develop Financial plans so they can recover increasing amounts of their cost of operation through third party payments. Where possible,emphasis is given on conversions to prepaid capitation and increasing the center's potential for be=- coming an HMO or an HMO component. Family Health Centers The Family Health Center Program, initiated in 1972 with $13,000,000, will continue our efforts to increase ambulatory health care resources in medically underserved urban neighborhoods and remote rural areas. These centers provide a basic package of health services on a prepaid capitation basis. Family health centers actively coordinate with other Federal planning and direct service pro~ grams at the national, regional and State levels to maximize the effects of plan- ning, community relationships, funding allocations and staff competencies in a given geographic area. In 1973, an increase of $3,000,000 will provide for funding three new centers and for activating the operational phase of at least 10 developmental projects initiated in 1972. These new centers plus the 10 centers which began operating in 1972 will bring the total to 23 operating centers serving an estimated 230,000 persons. Emphasis will continue to be placed upon efficient and effective methods of managing, organizing and financing health care services. Through these methods the family health center will become an integral part of the community medical care pattern and federal grant support can be released for resource building in other areas of critical health need. 215 Migrant Health Grants Increase or 1972 1973 Decrease Pos. Amount Pos. Amount Pos. Amount Other expenses...+ee.-™ $17,950,000 -- $23,750,000 -=- +85 ,800,000 Projects supported under this activity provide health care services to migrant agricultural laborers and seasonal farmworkers and their families. The purpose of this program is to raise the level of migrants' health to that of the general population, and to assure that migrants have access to ongoing community health services. The problem of providing adequate health services to migrants and seasonal farmworkers and their families is closely related to the problem of insufficient health resources available to all rural residents. As more resources and financing mechanisms become available to support health care services for the general population, one aim of the Migrant Health Program will be to develop adequate services in migrant impact areas to meet the increased demand. In 1972 the program initiated efforts to convert existing projects from their present grant method of financing services to a prepaid capitation system. An additional effort was made to assist projects in substantially upgrading the quality of their services and increasing their scope of service as well as increasing the numbers of persons served. It is estimated that there will’ be 460,000 patient visits in 1972, an increase of approximately 101,000 over 1971. During 1972, 64 of the 118 projects reported the establishment of consumer boards. The remaining projects while having less formal mechanisms at this time are making efforts toward meeting the 1970 legislative mandate to show evidence of consumer participation in project activities. In an effort to extend the concept of using indigenous personnel in the administration and delivery of health services in migrant projects, 90% of the projects have employed migrants or former migrants as paraprofessional staff members to assiat in the delivery of services. In addition, four of the seven comprehensive projects have Mexican’ Americans as project directors. 1973 Increases In 1973, the program will maintain ite efforts toward increasing the capacity and utilization of health services in the areas of major migrant populations. An increase of $2,800,000 is requested to cover increased continuation ‘costs. A program increase of $3,000,000 ia requested to accomplish the following purposes: ---An effort will be designed to provide 1,000 families, from one or more different areas, an appropriate health services benefit package through a prepaid capitation system capitalizing on existing migrant health projects as providers of service. ‘ ». 216 --~This effort will provide an experience base with respect to the ability of established migrant health projects to cost out a service package and to collect third party payments. In addition, the effort would provide specific experience on the ability of migrants to effectively utilize available services provided under a prepaid delivery system spanning the migrants' work areas. ---A Uniform Cost Reporting and Accounting System will be implemented in 15 projects which have developed the potential capability to utilize third party reimbursement payment mechanisms. This effort will be needed in order to provide the framework to begin conversion from grant support to other funding approaches. ~~-In addition, the increase will be used to assist the remaining projects to become capable of converting from a grant method of financing to a prepaid capitation plan for delivering an acceptable benefit package, or to assist them to become a provider component of a prepaid health plan. It will also allow the projects to focus on improving the quality and utilization of services available. At least 50 existing projects strategically located along the migrant streams will be up-graded. This increase will also provide approximately 148,000 addi- tional patient visits by migrants and seasonal farmworkers and their families bringing the total of patient visits in 1973 to more than 600,000. The patient visit increase will be accomplished through the support of primary health care projects located in areas of high migrant impact, interrelated with other health services in rural areas. In areas where provider organizations exist, the pro- gram will provide funds which can be used in a third party payment arrangement to assure that the migrants would receive care. In those rural areas where resources and/or services are not accessible to the migrants, the program will direct funds to develop programs that can provide an acceptable benefit package and attract resources to provide services through a variety of arrangements and payment mechanisms. In order to have access to timely and more accurate program information on existing migrant health program activities to enable the program to judge more accurately the extent to which individual projects and the program as a whole are meeting their goals, emphasis will be placed on extending the information system designed and implemented on a limited basis in 1972 to a majority of projects funded in 1973. The projects will also be encouraged to support efforts directed at training migrants for use as paraprofessional staff in ongoing projects and to enhance the training of policy board members in effectively fulfilling their roles. 21? Direct Operations Increase or 1972 1973 Decrease Pos. Amount Pos. Amount Pos. Amount Personnel compensation and benefits........445 $7,021,000 445 $7,664,000 -- +$8643,000 Other expenses........ ~~ 10,960,000 ~~ 11,198,000 -- — +238,000 Total.ceseccecesee445 17,981,000 445 18,862,000 -- +881,000 The direct operations under this activity provide professional and technical assistance to States, communities, providers of health services, medical and health organizations and other Federal units. This activity supports the staff that provides: (1) guidance on health care services essential to promote the utilization of improved methods of health services organization, delivery and financing at the community level in both urban and rural settings; (2) technical assistance and consultation to migrant health projects and other organizations which can contribute to the improvement of health services for the migrants and seasonal farmworkers and their families; and (3) the continuing responsibility of the Community Health Service to serve as the professional health resource of the Social Security Administration in the Medicare program. This latter responsibility provides the mechanism for defining and applying standards of quality for providers of service under Title XVIII of the Social Security Act. These standards are coordinated with those of the Title XIX (Medicaid) program to assure that the programs are consistent and do not adversely influence quality of care or the administration of these two programs. To a large extent, the success of the Federal role in comprehensive heaith services is dependent upon the quality and responsiveness of staff in meeting State and community requests for assistance and for taking the initiative in coordinated actions leading to delivery of health services, The role of staff in the administration of comprehensive health centers goes far beyond just administration of individual grant programs, An extremely important aspect of this role is aimed at providing the positive kind of help required to make our health system more responsive and efficient. The following are examples of staff activities: assisting health centers to develop a strong management capability; developing component program activities; providing assistance in integrating and coordinating health center services with other services in the community; developing and applying techniques to assist the centers in becoming more self-sufficient; and evaluating project activities. Comprehensive Health Services Policy guidance, professional advice and technical assistance are rendered to comprehensive health center projects with emphasis on the development of organized primary care programs for those regions, communities, and population groups which do not have access to adequate primary health care. A substantial proportion of staff and contract effort is devoted to providing expert back-up for HSMHA regional staff activity in improving the management capability and operational aspects of these comprehensive health centers as they become operational. Once such projects are established, extensive staff effort is required to assure an effective operation of health centers. The programs of these centers are so complex they require technical assistance from many different operational levels and on a wide variety of complex issues. 218 The staff assigned to the migrant health program provided consultation on health matters in health care, nursing, health education, hospital administration, nutrition, pharmacy and sanitation. Staff members also provide consultation on statistical reporting, project evaluation, general project administration, consumer participation and community organization. , In conformance with the new and comprehensive series of guidelines concerning the quality of medical care, the participation of consumers, and other aspects of the Migrant Health Program, 64 of the 118 projects reported the establishment of consumer boards. In 1972, the new Family Health Center Program devoted considerable time and effort in the areas of staff recruitment, organization, business management design and implementation of prepayment schemes, and evaluation. Technical and program assistance to potential and funded projects was provided. Continuing emphasis was placed on improving management of the comprehensive health centers through expansion of the site assessment activities and the provision of technical services in the administrative, financial and professional service areas. It is estimated that 12 comprehensive health centers will receive a complete site assessment followed by the development and implementation of corrective action plans to improve the efficiency of the centers and the quality of care furnished. Emphasis is being placed on moving positively toward improving management capacity to secure medicare, medicaid, private insurance, and other forms of reimbursement for services delivered through the centers. In 1973, program emphasis will continue to be directed toward aiding the health centers in achieving a significant degree of financial independence through the garnering of additional third party reimbursements and other State and local support. Technical assistance will be provided to communities to aid them in developing community oriented health care programs. Considerable staff time will be required in connection with the transfer of OEO neighborhood health centers. Nursing Home Improvement Substantial efforts continued to be concentrated on the improvement of the quality of care in nursing homes as a major component of the implementation of the 1971 nursing home initiatives. This has included training health facility surveyors, short-term training of nursing home personnel, the initiation of demonstrations of consumer services programs, and provision of technical assistance to State and local programs. Health facility surveyors or inspectors have the key responsibility for determining whether nursing homes comply with required standards for provision of care. These State inspectors are usually health professionals, well-prepared in their profession, but often lack specific training in the most effective techniques of surveying health facilities, recording and documenting findings, consultation, programming for facility improvements, and the changing requirements and standards of Federal health care programs. A curriculum for university-based training was developed to provide full understanding of health facility components and the health care facility requirements and standards which have been established to protect and maintain the health of patients served by these facilities. The capacity of three university-based programs was increased in 1972 together with the establishment of additional training programs in three new universities, to provide intensive, professionally-directed training for an additional 950 inspectors. 219 Surveyors often need an in-depth knowledge in many specialty areas, other than the one in which they were trained, to make a comprehensive, objective, and accurate evaluation of the compliance of a facility with Federal require- ments under Titles XVIII and XIX and to assist the facility administrator in making needed improvements. In 1972, in-depth specialty courses were conducted at State and local levels for over 2,000 personnel concerned with inspection, in such areas as physical environment, physician services, nursing, medical records and social services. This in-depth training experience has generated more interest in the overall program among the States. New prepackaged in-depth courses will be added during 1973 including social services, dietary services, administrative management and diagnostic services. It is expected that, with increased interest among States and the expanded subject material, the participation for 1973 will approximately double that of the 1972 activity. An expanded and accelerated overall surveyor training effort will provide training for 1,050 inspectors in 1973 which, added to the 950 trained in 1972, will achieve our objective of upgrading the capacity of 2,000 nursing home inspectors employed by the States. During 1972, a nationwide effort was initiated to improve the capabilities of the health personnel serving nursing home patients. Staff efforts are currently underway for working with States and other multi-professional organizations as well as with physician, nurse and other individual disciplines in training efforts aimed at people who have day to day responsibilities for nursing home patients. Special efforts will also be made to develop activities which will bring about a better understanding of mental health problems on the part of nursing home personnel. The short-term training programs for 1973 will give highest priority to rapid and effective achievement of objectives in fulfillment of the President's and the Department's commitments to the improvement of nursing homes in this country. As part of the dynamics of program development, efforts will be directed to closely coordinated activities of State governments, State affiliates of professional societies, and organizations related to the facilities themselves, with the educational systems and institutions which can assist in the actual staging of short-term training programs. These resources will be utilized to develop short-term training models that transmit principles and methods of gerontology and mental health practices to achieve a meaningful impact, as well as effective and viable long-term programs for the improved health, welfare, and mental health of nursing home patients. Fiscal year 1973 funds will support short-term and in-service training to enhance the competence of thousands of professional and ancillary health personnel providing care and service to patients who utilize a nursing home for a part of their requirements for long-term care. This estimate will continue the support for demonstration projects funded in 1972 to assist the States in establishing consumer service or investigative units which will respond in a responsible and constructive way to complaints made by or on behalf of individual patients. The individual who is confined to an institution and dependent upon it is often powerless to make his voice heard. 220 These demonstrations are designed to show how governmental and voluntary organizations at both State and local levels can function to protect the nursing home patient's personal and property rights and improve the quality of his life while in a care facility. . Activities will continue to support responsibilities in professional and technical assistance to States, communities, providers of health services, medical and health organizations, and other Federal units and to further promote the Federal-State partnership for health. Coordinators will be placed in all ten Regional Offices to work directly with Federal-State programs to assure effectiveness in the development, coordination, and implementation of short-term and in-service educational programs for long-term care personnel and survey improvement activities. In addition to the primary concern for nursing home improvement, emphasis will be made on continuation of activities directed toward correcting deficiencies in facilities which receive Medicare and Medicaid reimbursements. Projects will be supported in five States to correct the most serious provider deficiencies through programs of concerted action, developed through the collabo- ration of State health agencies (planning, licensure, certification, and construc- tion) and related patient care provider organizations. Medical Care Standards and Consultation The Community Health Service supplies, in partnership with the Social Security Administration's Bureau of Health Insurance, the professional health expertise necessary for carrying out the Federal Government's responsibility for establish- ing, implementing, and evaluating Medicare standards and related policies. In 1972, as a result of review and assessment of all Medicare requirements for providers of service and independent laboratories, the updating of regulations for hospitals, extended care facilities, home health agencies, and independent laboratories was completed. This major accomplishment was part of a general effort to clarify, on the basis of five years of Medicare program experience, provider requirements subject to misinterpretation and uneven enforcement and to standardize and improve the overall survey process. Survey report forms and surveyor guidelines for uniform application of the new and revised standards were prepared during 1972 and staffs of all regional offices and State agencies were oriented in the application of the new requirements. During 1973, the revised Medicare provider standards will have had the test of application by the State agencies, and areas in need of further clarification will be identified and appro- priate revisions prepared. To help insure effective application of Medicare quality standards, physicians, nurses, and other health services specialists assigned to regional offices provide continuing assistance and consultation to State Medicare agencies and regional Social Security staff. The resulting upgrading of facilities and services, in which the States are partners, has benefited persons of all ages, has strengthened Sfate licensure statutes and regulations for health facilities, has had a positive effect on voluntary accrediting programs, and will provide the base for assurance of quality care in any national health program the Congress may enact. Program review has become a major continuing process for evaluating the effectiveness of the application of the Medicare provider standards by State agencies. During 1972 and 1973, review teams composed of representatives of the Bureau of Health Insurance and the Community Health Service central and regional offices will conduct extensive reviews in each of the States, providing an in-depth evaluation of each State's Medicare certification operations. Year- é2l round evaluation of State agencies by regional office staff will be enhanced through quarterly visits and sample surveys of providers in each of the States, In 1973, the methodology for conducting program reviews will be modified to be more selective and responsive to the needs of regional offices and the State agencies they serve. Consultation is provided to Social Security Administration on a continuous basis on questions concerning covered services under Medicare, professional ethics, appropriateness of fees, termination of provider status, emergency hospital claims, and the development of policy and procedures not related specifically to standards for providers or independent laboratories, but having an effect on quality or delivery of service. The second administration of an examination for physical therapists not meeting Medicare's formal professional qualifications was conducted during 1972. The 1972 Social Security amendments will require the Secretary to provide a similar route to qualification for other health professionals and subprofessionals and in 1972 staff initiated a number of activities related to this: 1) review of related programs, both governmental and otherwise, which the Medicare program could benefit from; 2) development of intra~government agreements for use of existing examinations; and 3) contracting for an examination which would qualify waivered licensed practical nurses. In 1973, this program will be intensified to initiate action related to all appropriate personnel categories, and will include mechanisms to identify training needs of the examinees, in order that they may upgrade their skills. Staff work will continue from 1972 into 1973 on a number of special activities, such as: (1) anticipated new authority to bar from Medicare parti- cipation any provider or supplier who abuses the program; (2) alternative approaches to the development of standards relating physicians' qualifications to the nature of services provided under the Medicare program; (3) consideration of alternative approaches to the problem of small, substandard rural hospitals; (4) the relationship between the two financing programs and grant-supported projects; (5) an evaluation of the impact of present nursing home standards on patient outcome and cost of care; and (6) anticipated new authority for advance Medicare approval of extended or home health care. In 1973, emphasis will continue on Medicare quality control mechanisms of several kinds. Under a contract co-funded with BHI, we will have completed special training of State staff in clinical laboratory quality control, and the new regulations related to this will be in effect. Another 1972 contract provided for development of a prototype medical school curriculum on medical care appraisal. Seminars and other training in utilization review, as a follow-up on a series of training institutes in 1972, will be made available for providers, intermediaries, and physicians, and State staff will receive intensified training in this area. Direct assistance and advice will continue to be provided to the Medical Services Administration, Social and Rehabilitation Service, on the development and implementation of regulations for skilled nursing homes, intermediate care facilities, utilization review, and medical review under the Title XIX (Medicaid) program. During 1972, Community Health Service regional offices worked closely with the Medical Services Administration in connection with the Nursing Home Improvement Program. 1973 Increases In 1973, an increase of $988,000 is requested. This amount, partially offset by decreases of $38,000 for two less days of pay and $69,000 annualization of DHEW 1972 employment cutback, would provide $120,000 for program increase and $868,000 for mandatory items. The program increase would be used to initiate a 222 reporting system to collect information on the extent of health services obtained by migrants and seasonal farmworkers and their families, The mandatory items would cover annualization of 1972 new positions $443,000, annualization of the uniformed services pay increase, Public Law 92-129, dated September 29, 1971, $25,000, net costs of within grade and longevity increases $179,000 and increases for DHEW Working Capital Fund $95,000, HSMHA Service and Supply Fund $18,000 and FTS charges $108,000, 223 Maternal and Child Health Increase or 1972 1973 Decrease Pos. Amount Pos. Amount Pos. Amount Personnel compensation . and benefits........ 133 $2,633,000 133 $2,658,000 “on +$25,000 Other expenses........ --- 236,081,000 --- 249,890,000 --~ +13,809,000 Total....cccceee 133 238,714,000 133 252,548,000 --- +13,834,000 Introduction The programs authorized under Title V of the Social Security Act are a major national resource for providing basic preventive maternal and child health services and for the location, diagnosis, treatment, and follow-up care of children with crippling or potentially crippling conditions, especially in rural areas and areas which are economically depressed. They respond to the serious deficiencies that exist in the amount and quality of care received by poor children as compared with middle class children which result in an excess of preventable deaths, illnesses and handicapping conditions among the poor. The dual approach to services which the legislation provides--grants to States to strengthen and improve basic services especially in rural areas, and project grants targeted on low-income areas where there is heavy concentration of need-- recognizes today's needs and permits some of the flexibility necessary to respond to them. The research and training programs, concentrating on finding new and improved ways to improve the delivery of services and on filling the manpower gap, round out the comprehensive approach provided by Title V legislation. Section 513(b) provides that not exceeding one half of one percent of funds appropriated under the authority of Title V shall be available for evaluation by the Secretary of programs authorized under this title. In addition to grants and contracts, funds available for evaluation may also be used toe finance consultative and other services related to evaluation purposes. Such consultative services would be performed under contract or through the use of experts and consultants. 224 Grants to States Increase 1972 1973 or Other expenses Amount Amount Decrease Maternal and child health SELVICES... ccc cer eeecves $59,250,000 _ $60,778,000 +$1,528,000 Crippled children's services 62,272,000 64,900,000 +2, 628 ,000 Total ..cccccccvcvcssoee 121,522,000 125,678,000 +4,156,000 The basic purposes of the maternal and child heaith and crippled children's services programs of grants to States are to (1) reduce infant mortality and otherwise promote the health of mothers and children, and (2) locate, diagnose, treat and provide follow-up care for children who are suffering from crippling or handicapping illnesses. In addition to providing grants to States on a formula basis, these programs also fund special projects of regional or national signifi- cance which contribute to improvement of the programs. Specialized program efforts are described in more detail under the appropriate activities. Program Accomplishments Training: In both the maternal and child health and crippled children's programs, States provide for training and use of paid subprofessional staff, with special emphasis given to employing low-income persons. Duties are tailored to the needs of the several programs and include work in casefinding, as nutrition aides, dental aides, home health advisors, and community services aides. As employment of such workers increases, new career opportunities will become avail- able to persons who lack professional training. Training of professional personnel under the maternal and child health and crippled children's special project grants is also continuing. In 1971, more than 660 health-related professional personnel received training through institutions of higher education and State agencies. During 1972 and 1973 the numbers of professionals trained are expected to rise to 700 and 830 respectively. Mentally retarded children: The maternal and child health and crippled children's programs currently support in whole or in part 150 mental retardation clinics in which 57,000 children and their families received diagnostic and counselling services; 20 cytogenetic diagnostic and counselling programs; and 15 special clinics for children with multiple handicaps. The services include diagnosis, evaluation of a child's capacity for growth, the development of a treatment and management plan, interpretation to parents and follow-up care and supervision. A major effort in the prevention of mental retardation continues to be in relation to phenylketonuria (PKU). MCHS continues to work with State health departments in developing the necessary laboratory facilities to detect families with the condition and assisting States to provide special diets and follow-up programs. During 1970 approximately 90 percent of the newborns in the 50 States and District of Columbia were screened. This screening effort by the States, supported through MCHS, turned up approximately one confirmed case for every 16,000 live registered births. Nutrition services: As an integral part of the maternal and child health and crippled children's programs, nutrition services are provided through well-child clinics, pediatric clinics, group care facilities and school health programs. Currently over 500 nutrition personnel are employed by State and local agencies. 225 These personnel play a major role in assisting low-income families to develop a better understanding of normal as well as therapeutic diets. Their activities are contributing to the prevention or elimination of malnutrition in many families. 1. Maternal and child health services States use Federal funds, together with State and local funds, for prenatal and postpartum care in rural areas where mothers may receive clinical services including family planning services and home visits by public health nurses; for well-child clinics where mothers can bring children for examination, immunizations, and competent advice. Such measures have been instrumental in the reduction of maternal and infant mortality. Funds are used to provide medical, dental and nursing services for school health examinations and immunizations. These projects are primarily located in rural areas. Major support for dental services for children through State health departments continues to be from maternal and child health funds. For many basic maternal and child health programs the development and extension of family planning services continue to be a priority in 1972 with special emphasis on the provision of services to pregnant adolescents. Among the more significant services provided through the maternal and child health services program are the following: 1971 1972 1973 Provisional Estimate Estimate Mothers receiving prenatal and postpartum care in maternity CLINICS... ccc cee ecccervcenee 334,000 400,000 400 ,000 Women receiving family planning BOLVICES.. ccc cece evcccescces 752,000 752,000 752,000 Public heaith nursing visits made on behalf of: Mothers... ..2-ccccccecseeoes 566,000 566 ,000 566,000 Children......cccccscceceees 3,290,000 3,290,000 3,290,000 Children attending well child CLANL CE. cece cee ce ese ceceecene 1,500,000 1,500,000 1,500,000 Children receiving screening tests for: VISION... cece ec cee cenrcerece 8,977,000 10,000,000 10,000,000 Hearing.......-eeccceccecere 5,677,000 6,250,000 6,250,000 1973 Program: Funding proposed for 1973, which includes an increase of $1,528,000 over 1972, is expected to continue support of essential services provided through this program and maintain the high level of excellence in quality of such services. eae & 2. Crippled children's services State crippled children's agencies use their funds especially in rural areas, to locate handicapped children, to provide diagnostic services, and then to see that each child gets the medical care, hospitalization, and continuing care by a variety of professional people that he needs. Fewer than half of the children served have orthopedic handicaps. The rest include epilepsy, hearing impairment, cerebral palsy, cystic fibrosis, heart disease, and many congenital defects. Clinics are held periodically by State crippled children's agencies. Some clinics are mobile and travel from place to place; others are held in permanent locations. Any parent may take his child to a crippled children's clinic for diagnosis. Within the last two decades, the number of children using the crippled children's program has more than doubled. In 1950, there were 214,405 children served, while in 1971 the number served was approximately 485,000. More than a third of the children served were new admissions to the crippled children's program. The number of children who received physicians' services in clinics increased (2.1 percent) as did the number who received other physician's services (7.2 percent). The number of children requiring hospital inpatient care decreased (3.8 percent) as did the number of children who received convalescent home care (14.0 percent). Among the specific services provided through this program are the following: 1971 1972 1973 Number of Children Provisional Estimate Estimate Receiving physicians’ services..... 485,000 500 ,000 500 ,000 Receiving hospital inpatient care.. 82,000 82,000 82,000 With multiple handicaps............ 90,000 90,000 90,000 With congenital heart disease...... 33,000 33,000 33,000 1973 Program: The additional $2,628,000 proposed for 1973 will help States meet the rising costs of providing care for crippled children. Increased costs in the crippled children's program are due not only to the average annual increase in medical care costs but also to the fact that the more effective treatment methods are now more complicated technically and more costly. _ - ty _— eel Project Grants Increase or 1972 1973 Decrease Other expenses No. Amount No. Amount No. Amount Maternity and infant care: Comprehensive centers 56 $42,675,000 56 $46,332,000 -- +83,657,000 Intensive care of infantsS..........6. 8 753,000 8 900 ,000 -- +147 ,000 Children and youth..... 59 47,400,000 59 52,842,000 -- +5,442,000 Dental health of Children.....c.eeeeee 17 1,180,000 17 1,256,000 -= +76,000 Total..ccceccceee 140 92,008,000 140 101,330,000 -- +9,322,000 These programs provide comprehensive medical care to poor and near-poor mothers and children who might otherwise not receive such services. Efforts are particularly focused on those who live in urban slums. The comprehensive maternity and infant care (M&I), and children and youth (C&Y) projects together with related neighborhood health centers are making it possible for community health organizations to develop new and imaginative methods of reaching out to the people in slum areas, decentralizing services into neighbor- hoods, reducing crowding in tax-supported hospitals by paying for care in voluntary hospitals, and establishing well-organized systems of providing compre- hensive health programs for casefinding, prevention, health supervision, and treatment. These programs, for the most part, are being carried out in areas where there are few physicians in private practice and where existing clinics are grossly overcrowded. In these areas they are creating new resources and changing existing methods of delivering health services in order to be responsive to the needs of the people. Of the 115 comprehensive M&I and C&Y projects now in operation almost one-third are involved in cooperative efforts with other Federal programs. Two-thirds are located in city slum areas. Over 1,600 community aides are employed through these projects. In 1973 and future years, emphasis will be on coordination of existing maternal and child health programs with other Federal-State-local sponsored service and financing mechanisms. The M&I and C&Y projects are Health Maintenance Organization prototypes incorporating several of the basic characteristics of Health Maintenance Organizations. They are a form of group practice, but broader than the usual group practice model in that they include the services of nutri- tionists, social workers, public health nurses, and aides. Prevention is a major emphasis and patients are enrolled in a system of continuing health supervision rather than one which responds only to episodic illnesses. The services are prepaid through tax funds and the staff is salaried. The additional resources available for FY 1973 will help to expand and broaden the existing centers and to facilitate their collaboration with other health providers and financing systems. 228 l, Maternity and infant care Comprehensive maternity and infant care projects: spring of 1964, now has 56 projects in operation in lar and in rural areas, These projects are located in 35 States, the Dictriet of columbia and Puerto Rico. While more than 60 percent of the maternity and infant of 100,000 inhabitants or more, projects are also located in rural and urban-rural populations in such States Florida, Arkansas, Idaho and others. All the projects serve This program, begun in the ge and middle-sized cities 1971 1972 1973 Provisional Estimate Estimate Admissions for services: Mothers..............0....,.,.. 141,000 144,000 152,000 Cumulative since Start of Program. ................,,.., 877,000 1,021,000 1,173,000 Infants...............0....,,.. 47,000 49,000 53,000 -omen receiving family planning Services.................,,. see 134,000 134,000 134,000 Approximately 60 percent of all women admitted for maternity care in the srojects during fiscal year 1971 (the most recent year for which complete data is tvailable) were black » and the rest were of other origin, he central-city, metropolitan as well as the predominance of blacks in the medically rban population, -2cation of the projects --digent segment of the u Thirty-nine percent of all women admitted for maternity care in fiscal year -771 had become Pregnant out-of-wedlock, This figure varied The large reported ne populations and from emphasis on the Bart of projects in reaching this particular hig! seighborhood canvassin n-risk group either through 8 or through referral agreements with schools and other e-=munity agencies. Significant contributions t ttality rate have been made t t:< comprehensive maternity t<