A

EOQOOGIB*
Justification

Regional Medical Programs

 

Increase or

 

 

1971 Estimate 1972 Estimate Decrease
Pos. Amount Pos. Amount Pos. Amount
Personnel compensation
and benefits .... 275 $4,436,000 275 $4,756,000 -—- +5 320,000
Other expenses ... -- 77,970,000 -~ 82,515,000 -- +$4,545,000

 

Total ..... . 275 $82,406,000 275 $87,271,000 -- +84, 865,000

 

General Statement
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
physicial 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,
disability, and death in the United States; (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; (5) administers specialized pilot or educational or monitoring
programs in the field of kidney disease and smoking and health, which have
significant importance in improving personal health care and in contributing
toward the accomplishments of Regional Medical Program goals.
Regional Medical Programs:

 

Increase or
1971 Estimate © 1972 Estimate Decrease

(a) Grants.... $70,298,000 $75,000,000 +$4,702,000

 

Grants are awarded to assist in the planning, establishment and operation
of Regional Medical Programs for research, training and demonstrations of
patient care.

It is the objective of the Regional Medical Programs to improve availa-
bility of and access to high quality health care to all Americans through
improvements in the development and more efficient utilization of health
manpower and other resources. Approximately 2,700 institutions including
all medical schools, 1,900 hospitals and a variety of State and voluntary
health organizations are now participating in this effort to improve the
quality of care and the adoption of the latest techniques in the delivery
of health services. ,

The Regional Medical Programs Service seeks to assist the established
Regional Medical Programs to develop a framework of cooperative relationships
for improving the organization and delivery of services to people. This
framework is structured by developing the voluntary cooperation of the
various providers of service, both public and private, in identifying the
patients' needs. When these have been determined, the local groups and
institutions develop projects and programs to meet these needs. The
activities of Regional Medical Programs include the full spectrum of health
care: prevention, primary care, specialized care using the latest scientific
techniques, and rehabilitation. Regional Medical Programs provide funds for
organizing a system of health care locally acceptable and responsive, but
linked to regional resources not available locally.

Program for 1971 and 1972

Fifty-five Regional Medical Programs are now conducting operational
activities.

During the past year, events in the various regions have provided
significant directions for the future. The newly emerging cooperative
arrangements within the regions have demonstrated the role the Regional
Medical Programs can play as a recognizable and locally acceptable force
not only for health planning but for improving the organization and delivery
of health care as well. These changing patterns in the health care system
brought about through operational activities are affording the consumer
immediate and direct benefits.
The movement toward operational status is reflected by the fact that
currently more than 50 percent of funds are now awarded for projects which
demonstrate improved patient care methods, a significant increase from previous
years when planning was the predominant activity. The fields of disease pre-
vention and screening for early detection of disease are receiving increasing
emphasis. The special problems of the poor in both rural and urban populations
are being studied intensively.

The effort of Regional Medical Programs to promote the regionalization of
health resources and enhance the capabilities of providers of care at the com-
munity level involves a numberof different approaches.

One important approach involves all of the regions in developing a base for
regional planning and decision-making through broad representation and partici-
pation of health institutions, organizations and individuals on the planning
committees and the Regional Advisory Group of each Region.

The legislative extension of 1970 emphasized the development of such local
planning capability, especially in relationships with Comprehensive Health
Planning agencies. To promote such cooperation, the new law requires reciprocal
membership on Regional Medical Program and Comprehensive Health Planning advisory
groups. It also provides the Areawide Comprehensive Health Planning Agencies
with the opportunity to review Regional Medical Program grant proposals to ensure
conformance to community-established priorities.

Recognizing that the programs need to complement and support one another as
they work with the health institutions in their area, close cooperation will be
encouraged in the form of joint planning and data collection efforts and common
definition of subregional areas.

Community planning assistance is being promoted in California where, for
example, the California Regional Medical Program recently provided both financial
and staff assistance to the Welfare Planning Council of the Los Angeles Region
for a community report on health problems and priorities in East Los Angeles.
This community approach is a recognition of the fact that health needs originate
in people. This recognition is especially important when looking at a "barrio"
such as East Los Angeles.

Regionalization and new organizational arrangements are major themes of
Regional Medical Programs. Working relationships and linkages among community
hospitals and between such hospitals and medical centers are among the primary
concerns of the program. The linking of less specialized health resources and
facilities such as small community hospitals with more specialized ones is an
important way of overcoming the maldistribution of certain resources, and thereby
increasing their availability and enhancing their accessibility.

The development of regionalized professional and institutional linkages
aids in linking patient care with health research and education within an entire
region to provide a mutually beneficial interaction. It also helps to emphasize
the delivery of primary care at the local or community level, while promoting
specialty care as the province of the medical center and larger community

hospitals.

In North Carolina, community development of comprehensive stroke programs
has been initiated, with a central coordinating unit at the Bowman Gray School
of Medicine. A broad range of activities is being undertaken, including publi-~
cation of guidelines for community stroke programs, educational activities such
as training programs for nurses, annual stroke workshops, stroke consultation
service for physicians through the cooperation of the neurological staffs of the
three medical centers, and a family-patient education unit, designed to help
patients and their families learn to cope with the long-term effects of stroke
disability. :

,

A broad array of manpower activities is being developed to impact on the
health care delivery system. Estimated numbers of health professionals who will
be trained in 1971 as a result of Regional Medical Program activities are as
follows:

 

Doctors 31,628
Nurses. 55,295
Allied/Other Health 39,000

Total 125,923

In addition, over 25,000 emergency health personnel (firemen, ambulance drivers,
policemen, etc.) will receive training. These programs will include both the
teaching of new skills and also the upgrading of existing skills as well as
training new people in the allied and other health areas.

Many Regional Medical Programs have conducted studies to determine the need
for, willingness to accept and feasibility of training categories of manpower to
extend the services of physicians. Most of these are related to the physicians!
assistant concept. Some Regional Medical Programs are designing such projects
and several have funded operational projects in this area.

In Alabama, the Regional Medical Program is sponsoring a program to formulate
and implement training programs for allied health technicians through the coopera-
tive use of funds, manpower, and facilities already in existence at the junior
college and vocational technical training schools level. By linking the resources -
of the University of Alabama, Regional Technical Institute, the Appalachian
Development Commission, and 17 state supported junior colleges, Alabama is taking
a giant step toward solution of its health manpower shortage.

A Guest Residency Program, started two years ago with Regional Medical
Program funds, has helped pave the way for what is a significant innovation in
medical education (WAML) by demonstrating the practicality of its decentraliza-
tion. The new medical education plan, taking its name from the four States
involved (Washington, Alaska, Montana, Idaho), recently received a $1 million
grant from the Commonwealth Fund. Alaska was selected as the first State to
implement the new plan because of the close ties already created by the Wash-
ington/Alaska Regional Medical Program between the University of Washington
Medical School and Alaska academic and medical communities.

Virtually all Regional Medical Programs have projects designed to augment
the knowledge and level of performance of health professionals and parapro-
fessionals. Many of these projects lead to the utilization of personnel in new
ways. Perhaps the greatest Regional Medical Program thrust in this area is the
training of coronary care unit nurses; over 7,000 registered nurses and licensed
practical nurses have been trained to date.

Although Regional Medical Programs does not provide for patient services
directly, it often gets involved in planning for and helping to establish those
health care components which will deliver service. This includes a broad range
Currently demonstrations are being funded for activities such as:

Coronary and other intensive $13,800,000
1 care - 114 coronary care
units and 8 mobile units

 

Ambulatory care ~ 24 neighbor- 3,900,000
-hood health centers, clinics
and out-patient departments

 

Extended and home care 2,200,000
Other - such as emergency and ___1,300, 000

transportation services
Total | $21,200,000

As a result of these demonstrations, communities and hospitals not directly
involved in these projects have been spurred to make much needed improvements.
For example, in 1966 there were only 375-425 coronary care units and 1,100 other
intensive care units in the United States. By 1969 these had increased to 2,101
coronary care units and 2,556 other intensive care units, corresponding to
500 percent and 150 percent increases, respectively.

This range of activity and the types of operational components - being
carried on varies from region to region. In providing a mechanism for planning,
decision-making, and sharing limited health manpower and facilities, the stress
has been on local initiative and control to match local needs, problems, and
available resources.

It is expected that an increasing portion of available funds during 1972
will be directed toward the following general areas:

Activities which lead to more effective and efficient utilization of
health manpower, especially in patient care settings. Training for new
types of health manpower (e.g., physician assistants) will be emphasized,
as will new organizational patterns which make greater use of paramedical
personnel.

Operational activities with increased emphasis on regionalization of
health resources and services, with the focus on strengthening linkages
between those institutions providing specialized care, such as the
medical centers and affiliated hospitals, and primary care, being
provided by smaller community hospitals, neighborhood health centers,
and other community health facilities.

Conjoint and collaborative efforts with Areawide Comprehensive Health
Planning agencies and similar agencies which foster community-based
planning and programs that can begin to materially effect resource allo-
cations/distribution for health at the local level.

Projects which emphasize disease prevention and early detection,
including early and easy access to care.

Activities which encourage and support the development, operation and
success of the emerging Health Maintenance Organizations.
The increase in total funds available for obligation of $4,702,000 would
provide $75,000,000 in 1972. Of this amount, $5,000,000 is earmarked for con-
struction of a regional cancer center in the Northwestern part of the United
States. The balance will be used to meet the continuation costs of grants for
selected programs based on relative merit.

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.
SELECTED DATA

REGIONAL MEDICAL PROGRAMS

. Overview .

Regional Advisory "Groups ne

Planning Committees and Task Forces.

Local and Area Advisory Groups . rr er
RMP Staff... . te eh ee ew ee

CHP - RMP Relationships. a
Hospital Involvement ..... ee ee

Operational Programs by:
- Program Emphasis

- Disease
- Health Care Organization and Delivery .....-. see
Health Professionals Trained .......+.. see ee be

Office of Program Planning and Evaluation
Regional Medical Programs Service
February 15, 1971

SNOOP WA

to ©

 
REGIONS
* “THERE ARE 56

OVERVIEW

4

REGIONAL MEDICAL PROGRAMS

54 are operational

Of these:

2-16-71

5 are in their fourth operational program period
T8 are in their third

21 are in
10 are in

their second
their first

* LARGEST REGION

In population:

In size:

California (20 million)

Washington-Alaska (638,000 square miles)

* SMALLEST REGION

In population:

Northern New England (445,000)

 

 

In size: Metropolitan Washington D.C. (1,500 square miles)
* BOUNDARIES: NUMBER OF REGIONS WHICH
Encompass single states .....- 32
Encompass two or more states... . 4
Are parts of single states. . . 12
Are parts of two or more states. . 8
* POPULATION: NUMBER OF REGIONS WHICH HAVE
Less than 1 million persons 5
1 million to 2 million 11
2 million to 3 million 14
3 million to 4 million 8
4 million to 5 million 7
Over 5 million “11
* HEADQUARTERS : ~
Grantees Coordinating Headquarters
Universities 36 31
State (29) (26)
Private ( 7) ( 5)
Non-profit Agencies. 20 25
State Medical Societies ( 5) ( 4)
Non-profit corporation (15) (21)
INVOLVEMENT

* PERSONNEL: PEOPLE INVOLVED IN THE RMPs TOTAL 16,500:

1550 FTE core staff members

2040 FTE project staff members

2700 on Regional Advisory Groups

10,200 on task forces and local advisory groups.

* HOSPITALS: A TOTAL OF OVER 2,200 OF THE NATION'S 7,000 HOSPITALS
ARE NOW INVOLVED IN RMP PLANNING AND OPERATIONAL ACTIVITIES:

Over 200 short-term, non-federal hospitals represented on
Regional Advisory Groups

Almost 700 STNF represented on other regional and subregional
planning bodies ee
2,000 SINF involved in operational activities.

FUNDING

* $223 MILLION HAD BEEN AWARDED TO THE PROGRAMS THROUGH FY70.
NET GRANT AWARDS IN FY70 TOTALLED 78,202 MILLION
REGIONAL ADVISORY GROUPS

 

* SIZE

1967 1600 total membership
30 average group size

1969 2500 total membership
“45 average group size

1970 2680 total member ship
~ 48 a average group size

10-19 members: 3 RAGs
20-29 members: 11 RAGs
30-59 members: 34 RAGs
60-99 members: . 5 RAGs

100-199 members: 2 RAGs
over 200 members: 1 RAG

Largest: Western New York (329)
Smallest: Missouri. (12)

_* COMPOSITION - total 2680 members

. 728 (27%) practicing physicians
. 387 (14%) medical center officials
347 (13%) hospital administrators
231. ( 9%) voluntary health organization representatives
204 ( 8%) public health officials
.. 255 (10%) other health workers
. 516 (19%) members of the public
12 (---) RMP staff members
PLANNING COMMITTEES AND TASK FORCES

* NUMBER AND SIZE: 500 COMMITTEES IN 56 REGIONS: 5300 TOTAL MEMBERSHIP

* COMPOSITION:

By Profession

Number Percent
TOTAL 5320 100
Physicians . 3273 62
Registered Nurses 486 9
Hospital § Nursing Home Administrators 326 7
Other Health 346 6
Business or Managerial 312 6
Other 577 10
By Affiliation
Number Percent
TOTAL . 5320 100
Medical School 872 16
Affiliated Hospitals 508 10
Other Hospital Interests 879 17
Medical Society - 212 4
Public §& Other Health Agencies. 290 5
Voluntary Health Agencies .355 7
Health Practitioners 1180 22
Public or Consumers 198 4
Other 826 15

- Almost half of these committees are organized according to categorical
diseases; the remaining are in areas such as manpower, training, data
collection, hospital planning, and evaluation.

i
LOCAL AREA AND ADVISORY GROUPS

* PURPOSE: TO STUDY AND PROPOSE ACTIVITIES TO MEET COMMUNITY NEEDS AND
TO STRENGTHEN RELATIONSHIPS AMONG LOCAL INSTITUTIONS AND WITH THE
MEDICAL CENTER.

27 Regions have 335 such groups (4800 persons)

129 of these are located in the Georgia Region

Most include representatives of local hospitals, local health
professionals and other community leaders.

Many do cooperative planning with CHP (b) agencies

Composition is primarily consumer and hospital oriented.

* COMPOSITION

 

By Profession “Number Percent
TOTAL 4843 100
Physicians . 2001 Al
Registered Nurses 445 9
Hospital Administrators 672 14
Other Health 227 5
Business or Managerial 522 11
Other 996 20

By Affiliation Number Percent
TOTAL 4843 100
Medical Schools 75 2
Affiliated Hospitals 452 9
Other Hospital Interests 954 20
Medical Society 401 8
Public § Other Health Agencies 500 10
Voluntary Health Agencies 349 7
Health Practitioners 904 19
Public or Consumer 723 15

All Other ’ 485 10
REGIONAL MEDICAL PROGRAMS STAFF

 

TOTAL: 3590 FULL-TIME EQUIVALENTS

. 1547 on CORE STAFFS
. 2043 staffing OPERATIONAL PROJECTS

 

 

FTE's FTE's

CORE OPERATIONAL ACTIVITIES
TOTAL 1546 2043
Physicians — “220 293
Registered Nurses 53 369
Allied Health . AS 262
Other Professional/Technical 708 703
Secretarial 514 416

CHP - RMP RELATIONSHIPS

* 53 regions have overlapping advisory group membership with state and
areawide agencies:

18 CHP "A" staff members are on Regional Advisory Groups (18 regions)
25 CHP "B" staff members are on Regional Advisory Groups (16 regions)

* 23 regions have common data collection activities with state agencies
‘and 7 areawide agencies

* 16 regions report that their local advisory groups have defined relation-
Ships (staff sharing, joint review, etc.) with CHP areawide agencies.
- HOSPITALS

* TOTAL NUMBER INVOLVED IN REGIONAL MEDICAL PROGRAMS:
Short-term, non-federal
Long-term, non-federal
Federal
*° SHORT-TERM, NON-FEDERAL HOSPITALS INVOLVED:
By bed Size
Under 200 beds
200-399 beds
Over 400 beds
By Affiliation
Medical school affiliated
Non-affiliated
% TOTAL NUMBER INVOLVED IN RMP OPERATIONAL ACTIVITIES:

* TOTAL NUMBER SPONSORING RMP OPERATIONAL ACTIVITIES:

2210

2080
60
70

2080

1310
480
290

1370
710

1600

190

LN LN LN

ie]
WN &
BO oO oO
Newt Nee! Nee
OPERATIONAL PROGRAMS

 

The CURRENT LEVEL OF FUNDING is $95 million, which includes approxi-
mately $39.8 (42%) for core and $55.2 (58%) for projects. Operational
activities reflect the following program emphases: ,

Activity 100%
Continuing Education 22%
Manpower Development and Utilization 31% (General)
Patient Care Demonstrations 31%
Coordination for Health Services 8%
Research and Development 8%

Disease 100%
Heart disease 26%
Cancer . 12%
Stroke 13%
Kidney disease 3%
Related diseases 9%
Multicategorical and/or non-specific 38%

. Organization and Health Care Delivery 100%
Ambulatory care services (e.g., 7%
outpatient depts., neighborhood health
centers
Other out-of-hospital services: (e.g., 7%
home health, extended care, patient
education)

Intensive care (e.g., coronary care units, 23%
stroke units)

Support services (e.g., laboratory 8%
“services, registries, medical records)

Electronic monitoring networks and other 16%
consultation services

Community faculty for subregional | 5%
programs

Integrating services of several hospitals 15%
and other agencies . L
Other . ; 19%
TOTAL

 

 

Physicians
RN's
Allied Health

Multidis-
Cciplinary

 

HEALTH PROFESSIONALS REACHED THROUGH EDUCATION AND TRAINING PROGRAMS

Grand
Totals

193,708
46,352
68,440

# ©56 438

22,478

 

 

 

100%

28
64

 

FY69

52,396

15,719
24,102
6,288
6,287

 

100%.

30

46

12
12

63,973

14,714

 

FY70

19,832
21,750

7,677

 

1003

23

31

34
12

* Includes approximately 20,000 emergency health personnel such
as ambulance drivers, firemen, etc.

 

FY71
6/1/70-2/1/71
76,200 | 100%
15,600 20
23,777. | 31
28,320 38

8,503 11

 

 

February 15, 1971
Distribution of Grants Awarded

by Primary Activity Emphasis and Categorical Disease
(Net to Date and Available Current Period)

Net Operational Grants Awarded to Date

 

 

 

 

Total Net $254.2
Program Direction - Project $ 91.5.
Development, Planning
Operational Projects $162.7
Activity Emphasis - Projects $162.7
Education § Training 88.1
Demonstration of Care 53.1
Research § Development ’ 21.5
Disease . 162.7
Heart 45.9
Cancer 17.1
Stroke 17.4
Related (Diabetes, 16.4
Kidney, Pulmonary)
Multicategorical 65.9

Funds Available Current Program Period
(Level as of 12/31/70)

Total Available

Program Direction - Project

Development, Planning

Overational Projects

 

 

 

$55.2

Activity Emphasis - Projects total $55.2

 

Education §& Training
Demonstration of Care
Research § Development

Disease

Heart
Cancer
Stroke
Related (Diabetes,
Kidney, Pulmonary)
Multicategorical

 

February
OPPE

2
2

4 oO
fs] e

 

HID
wk ute

11, 1971
28
04
52
56
19
50
40
08

31
24
46
26
58
01

43
15
27

02
54
44
51
53

09
32

47
42
34

1967

Awarded
Alabama. .ccecescesscccsvve eee
Albany......- ened cescece 914,627
ArkansasS..... seca seven vens eee
Bi-State..ccrccecosese cee.
California. ...ccccsscesece a
Central N.Y... ccc ceeee ae eee
Colorado-Wyoming....... eee one
ConMecticut..ccccesccesoce:
D.C. Metropolitan.........
Florida....... irs eee
Georgia... cccccccccccene oe eae
Greater Delaware.......... woe
Greater New York......... . 967,010
Hawaii....... be weasesuseas eee
Indiana. ..cccccceccccceses eee
Intermountain....... eeveee 1,790,603
Towa. ..see. eee es eenen esas
KanSaS.wseccccccscccescces 1,076,600
Maine....... sete e cence ence eae
Maryland. ...cccecvsssccens eee
Memphis... ..sccevscssccsees 173,119
Michigan......... eee ccseee eae
Mississippi... csscscccvos eee
MISSOULL. . cece we ee eee eeae 2,887,903
Mountain States......ese0e eae

Nebraska - South Dakota... 350,339
New Jersey... ccsescsccnece oes
New Mexico. ..ccsccsscceces see

Status of
OPERATIONAL GRANTS

1968
Awarded

1,140,015
2,232,864
460,314
418,318
1,416,777

1,127,282

1,789,792

412,841

1,576,304
318,239

aon

749,448
852,241

4,490,607
206,913
214,987

475,798

1969

Awarded

903,105
139,617
579,924
9,602,090
1,237,940

1,146,824
1,548,257

1,427,008
779,085
2,635,789
2,862,484
371,532
903,301

1,572,396
3,113,706
73,979

1,727,063
862,529
2,236,520
890,107
989,229
731, 406
5,227,008
1,997,283

501, 206
1,030,563
1,959,119

February 9, 1971

1970
Awarded

1,148,226
1,534,208
983,127
1,012,307
2,376,152
45,039
1,336,738
1,197,354

1,189,486
1,757,031
68,660
2,500,033
3,093,923
914,701

1,632,990
3,553,599
1,208,683

58,516
453,406
2,124,469
1,301,111
2,725,658
1,754,474
4,996,201
1,959,224

1,162,224
1,412, 366

 

1971
Awarded

32,507
1,094,930

9,256,963

618,002

eee

508,893
68,933
2,167,534

1,047,774

1,191,212
28,444

895,756

1,027,301
125,834
129,985

395,441

1,189,341
03
21
06
63
22
48
23
12

65
25

35
59

18
07
62

38
13
31
37

Northern New England..
Northlands... .ccceecees
North Carolina........
Northwestern Ohio........-
Ohio State......ceeee .
Ohio Valley...........20e

Puerto Rico...... booeee
Rochester..coeees

eevee

South Carolina........
Susquehanna Valley.......

eee

oe

aee

Tennessee Mid. South.....

TOXaS.eeee

ees

Tri-State.....ee.5 eee eceee

Wash. ~ Alaska......ee.
Western N.Y

Western Pennsylvania.....
Wisconsin..

woeoeveereeeoee

eee

Status of

OPERATIONAL GRANTS

February 9, 1971

 

1967 1968 1969 1970 1971
Awarded Awarded Awarded Awarded Awarded
. 955,086 313,788 660,571
eee eae 1,308,058 1,470,765 eee
os 1,799,654 2,168,829 2,275,014 52,166
oe eee eee 1,545,276 26,651
7 964,367 204,175 809,686
oe 855,317 1,269,711 > vee
eee eee 1,121,457 1,408,097 eee
. 598,879 831,888 888,385 14,872
. 238,027 °253,065 1,058,789 :
eee 724,664 1,018,675 939,674 cae
. . 931,507 1,234,457 1,333,301
eee 546,067 719,427 coe
oe 2,088,598 2,712,154 2,668,969 (21,813)
see 1,943,569 coe 2,764,538 1,821,674
see eee 436,122 1,642,162 48,620 ©
Lee 1,086,764 1,090,197 2,035,610 a
. 357,761 1,647,796 1,413,701 226,720
os see eee 2,359,490 eee
eee 643,008 1,209,914 1,841,718 1,200,949
8,160,201" 27,363; 664 65,099, 569 71,553,652 25,952,247
REGIONAL MEDICAL PROGRAMS SERVICE
Applications Approved to Date by the National Advisory Council

on Regional Medical Programs but Not Funded

Alabama . . ee ee ee wee ee + 8 1,576,462
Albany - 6 6 6 ee ee ee ee ew 92,920
Arizona . . 6 es 6 © ere ee et ew 177,501
Arkansas. .-. 2. 2 6 6 © © © © © © © » 61,207,486
Bi-State. . «6 « © © © se ee te wee 141,800"
California. . . «6 6 6 6 © © © ee © 625,359,803
Central New York. . 2. 1 + ee ee ee 280 ,558
Colorado/Wyoming. . 2. 6 2 + ee eee 62,482
Connecticut .« . 2 6 + + © we ew ww 567,094
Florida... ee se eee ee ene 639 ,681
Georgia «6 6 6 ee ee ew we ee 706 ,570
Greater Delaware Valley . «+ + «+ » 668,320
Hawaii. . 6 5 6 1 we ew te ew ee 756,191
Tllinois. «2 6 6 ee ee ew ww ew ee) 61,667,027
Indiana... + «© + © © © @ we we ew ow 684,627
Intermountain « 2. 2. 6 6 © © ee we 703,248
Towa. 2 6 0 ee ew ee ew ee we ew 425,013
Kansas. + + 6 «© © © © © © ee ee 716 ,622
Louisiana « 2 6 6 + 1 6 ee eo eh we 547,532
Maine 2. 6 6 1 ee eo ew ew ee te 751,761
“Maryland. . 1. 6 6 2 ee ee ew ww 562,404
Memphis - 2 + 6 «© ee ee ee ew we 661,405
Metro. New York « . 1 6 2 1 6 ee ow 687 ,547
Metro. D.C. « 6 6 6 2 ew 6 ww ee ee ©) 614949,005
Michigan. - 6 6 ee ee ee ee ee © 1,713,674
Missouri. . « © 2 © © © © © © © © ow 828 ,/19
Mountain States . .« «+ 2 + + ee es 565,748
Mississippi «6 + + e+ es ee ee ee 35,420
North Dakota. . . «6 2 «© © © © eo 145 ,383
Nebraska. + 2 « 20 «© « © eo © wo we 349 ,632
South Dakota. « . « + + «© © © we ew ew 379,000
New Jersey. o © © © © © © © © © 6 8 8 2,165 069
New Mexico. ». . 6 1 6 «© ee we we we we 171,215
North Carolina. . . 1. + + 6 6+ 2 © ow 466,156
Northeastern Ohio . . «+ 2. © « we @ 48,233
Northern New England. .« . « « + 5 © « 58,050
Northlands. . 2... 6 «6 ee + we we . 1,180,657
Northwestern Ohio . . . «2... « «© we 266,768

 
® Page 2 - .
Ohio State . 1. «1. 6 «© « wo
Ohio Valley. . - + + « © «© as
Oklahoma. . oe ees
Oregon « 6 6 + © 2 we ee ee
Puerto Rico. ». « « «+ «© © © «© »
Rochester. .« « « « «© «© «© we « «
South Carolina - . +. « + +» « «
Susquehanna Valley’. . -
Tennessee Mid-South. . 1... -
TexaS. « « © © « « »
Tri-State. .« « « «© © © © «
‘Virginia . ss ee 2 ee es

Washington/Alaska. . «+ + e+ +

Wisconsin. « . 2. « «© «
Western New York . . . 2. « « «+

Western Pennsylvania .- - +--+ <¢ +.

West Virginia. ». . «© «+ + «© 4 +

Total Direct Costs .. .

Estimated Indirect Costs .

Subtotal .

6 Reduction on Awards for Continuation
and Renewal Activities
Total Direct Costs -
Estimated Indirect Costs

Total. . 2. + «© «© «© » « &

|
po

. 2 + $ 284,938
te 854,874
Lee 205,978
. ee 901,738
. ee 903,426
2.) 437,891
Lae 69,281
ee) 223,273
. es 405,290
. « » 830,230
. es 996,530
ee 705,724
652,438
. es 1,156,355
2.» 1,106,242
Lo 43,911

: 483,047

» + «$37,227,949
» +» 8,004,009

- + $45,231,958

- »$ 1,878,149
cee 412,732

$ 2,290,881

» + «$47,522,839

RMPS-GMB
February 12, 1971
1.
2s

.

« *

PWN Ee © oO
ee 8+  e@ #8 @

*

e

.

. .

e

seer te me a NST Ee LO
ss © © «© «© 2 © «8 ® « © e -

(1)

REGION

4
labama
ibany

Arkansas

. Arizona

Bi-State
California
Central New York
Colorado/Wyoming
Connecticut
Florida

Georgia

Greater Del. V.
Hawaii

Illinois
Indiana
Intermountain
Towa

Kansas
Louisiana

Maine

Maryland
Memphis

Metro. D.C,
Metro. New York
Michigan

. @:cr
: ssouri

Mountain States
Nassau/Suf folk

Nebraska/S. Dakota

New Jersey

New Mexico
North Carolina
North Dakota

Northeastern Ohio

N. New England
Northlands
Northwest Ohio
Ohio State
Ohio Valley
Oklahoma
Oregon

Puerto Rico
Rochester
South Carolina
Susquehanna V.
Tennessee Mid-S.
Texas
Tri-State

so”

 

(2)

COMMITMENT

$ 870,771

915,910

1,315,752 * |

811,191
709,587
7,068,289
700,091
1,094,572
1,370,565
1,535,568
2,022,571
2,109,357
923,143
1,532,333
1,121,411
2,446,230
651,417
1,404,795
628, 369
893,780
2,077,883
1,086 ,048
1,008,728
2,539,887
1,601, 367
966,160
2,047,610 *
1,611,764
838,061 %
500,250
1,236,255
1,036,719
1,545,105 *
310 ,683
786,187
670,677
1,315,368
781,027
714,075
1,039,195
839,205
761,268%
958,163
508,667
1,089 ,023
545,915
1,985 627
1,316,700
1,882,485
764,826

(3)
REDUCTION

$104,493
109 ,909
106 ,501

97,343

85,150
848,195

84,011
131,348
164,468
184,268
242,709
253,123

110,777

183,880
134,569
293,548
78,170
168,575
75,404
107,254
249, 346
130 ,326
121,047
304,786
192,164
115,939
222,193
193,412
43,567
60,030
148,351
124,406
125,413
37,282
94,342
80,481
157,844
93,723
85 ,689
124,703
100,705
38,382
114,980
61,040
130,683
65,510
238,275.
158,004
225,898
91,779

$ 766,278
’ 806,001
1,209,251

713,848
624,437
6,220,094
616,080
963,224
1,206,097
1,351,300
1,779,862
1,856,234
812,366
1,348,453
986,842
2,152,682
573,247
1,236,220
552,965

786,526

1,828,537
955,722
887,681

2,235,101

1,409 ,203

{850,221

1,825,417

1,418, 352
794,494
440,220

1,087,904
912,313

1,419 ,692
273,401
691,845
590,196

1,157,524
687,304
628,386
914,492
738,500
722,886
843,183

447,627.

958,340
480,405
1,747,352
1,158,696
1,656,587
673,047

(5)
CARRYOVER

235 ,646
480,168

-0-

203,768
-0~
-0-

549 ,344
~0-
-~O-

(6)
TOTAL

$ 766,275
836,001
1,209,251
713,848

860,083 _

6,700,262
645,080
997,998

1,206 ,097

1,351,300

1,779,862

1,856,234
835,762

1,348,453
986 , 842

2,152,682
573,247

1,465,025 .

552,965
797,219
1,828,537
955,722
887,681
2,235,101
1,409,203
850,221
1,825,417
1,418, 352
794,494

440,220 |

1,087,904
1,045,765
1,419,692
293,301
691,845
590,196
1,157,524
687,304
628, 386
939,492
738,500
722,886
843,183

447,627 :
1,162,108 :

480,405

1,747,352 3

{

1,708,0/
1,656, 5
673,0

= OO
sy CD

n
REGION COMMUTMENT: REDUCTION NEW LEVEL CARRYOVER ~ TOTAL

 

 

 

d1. Washington/Alaska $1,617,379 * $181,485 .$1,435,894 -0- $1,435, 8943
32. West Virginia 516,567 61,988 454,579 ~0- 454,579
+3, sstern New York 1,029,459 123,535 905,924 -Q- 905 ,924
34. estern Penna. 944,257 113,311 830,946 -~Q- 830 ,946
5. Wisconsin 1,081,569 129,788 ' 951,781 60,704 1,012,485

Total $69,679,861 $8,104,102 $61,575,759 $2,064,650 $63,640,409

L/ Level for 11 month budget period
1/ Level for 10 month budget period
3/ 6 month extension with funds

‘ Includes additional support over previous commitment. The source of these funds are
from the balance created by the 12% reduction of the initial commitment of program
support for FY 1971. The regions and amounts are as follows:

1. $ 105,000 Washington/Alaska —
2. 428,246 Arkansas
3. 196,000 Missouri
4. 500,000 North Carolina
5. 441,414 Oregon
6. _ 475,000 Nassau/Suffolk
$2,145,660 Total

ditional funds to be awarded in FY 1971 are:

1. $500,000 Nebraska 7/1/71-6/30/72
2. $379,500 South Dakota 7/1/71-6/30/72

he e... periods beginning 7/1/71 for Kansas and South Carolina will be funded from
Y 1972 appropriations.

f..
GMB/RMPS
4/13/71
~~

REGION

Alabama

Albany

Arkansas
Arizona
Bi-State {/
California
Central New York
Colorado/Wyoming
‘Connecticut
‘Florida

Georgia

Greater Del. V.
Hawaii

Illinois
Indiana
Intermountain
Towa LL”

Kansas
Louisiana

Maine

Maryland
Memphis

Metro. D.C.
Metro. New York
Michigan
Mississippi
Missouri
Mountain States
Nassau/Suffolk

Nebraska/S. Dakota’

New Jersey

New Mexico

North Carolina
“North Dakota
Northeastern Ohio

previo

 

 

NEW CHANGE IN PREVIOUS .

COMMITMENT REDUCTION REDUCTION REDUCTION LEVEL NEW LEVEL CARRYOVER TOTAL
$ 870,771 $104,493 $ 74,016 -$ 30,477 $ 796,755 $ 766,278 -0- 766 ,27
915,910 109,909 91,591 -18,318 _ 824,319 806,001 30,000 836 ,0C
1,315,752 * 106,501 75,438 -31,063. . 812,068 1,209,251 -0- 1,209, 25
811,191 97,343 68,951 -28,392 - 742,240 713,848 -0- 713,84
709 ,587 85,150 60,314 24,836 649,273 624,646 235,646 860 ,0€
7,068,289 848,195 600, 804 ~247,391 "6,467,485 6,220,094 480,168 6,700 ,2€
700,091 84,011 59,507 724,504 640,584 616,080 29 ,000 645 ,0§
1,094,572 131,348 93,038 38,310 1,001,534 963,224 34,774 997,95
1,370,565 164,468 116,498 -~47,970 1,254,067 1,206,097 — -O- 1,206 ,0¢
1,535,568 184,268 130,523 ~53,745 1,405,045 1,351,300 -0- 1,351, 3C
2,022,571 242,709 171,918 70,791 1,850,653 1,779,862 -0- 1,779, 8€
2,109,357 253,123 700 ,000 +446 877 1,409,357 1,856,234 -0- 1,856,2:
923,143 110,777 78,467 32,310 844,676 812, 366 23,396 835, 7¢
1,532,333 "183,880 130,248 753,632 1,402,085 1,348,453 ~-0- 1, 348,45
1,121,411 134,569 95,319 ~39,250 1,026,092 986,842 - -0- 986, 8d
2,446,230 293,548 207,929 -85 ,619 2,238,301 2,152,682 -0- 2,152 ,6¢
651,417 78,170 55,370 ~22,800 596,047 573,247 -0- 573,24
1,404,795 168,575 119,407 49,168 1,285,388 1,236,220 228, 805 1,465 ,0%
628,369 75,404 53,411 21,993 574,958 552,965 -0- 552 ,9€
893,780 107,254 75,971 ~31,283 817,809 786,526 10,693 797,2:
2,077,883 249 ,346 500,000 +250 ,654 1,577,883 1,828,537 -0- 1,828,5:
1,086 ,048 130,326 408,605 ~21,721 977,443 955,722 -0- 955,7:
1,008,728 121,047 100,873 -20,174 907,855 887,681 -0- 887, 6%
2,539,887 304,786 500,000 +195 ,214 © 2,039,887 2,235,101 -0- 2,235, 1
1,601,367 192,164 136,116 ~56,048 1,465,251 1,409,203 ~0- 1,409 , 2¢
966,160 115,939 82,123 ~33,816 884,037 850,221 -0- 850,2:
2,047,610 * 222,193 157,386 ~64,807 1,694,224 1,825,417 ~0- 1,825,4,
1,611,764 193,412 136,999 -59 413 1,474,765 1,418,352 -0- 1,418, 3:
838,061 * 43,567 30,860 ~ -12,707 332,201 794,494 -0- 794, 4
500,250 60,030 42,521 ~17,509 457,729 440,220 -0- 440 , 2!
1,236,255 148,351 105,081 -43 270 1,131,174 1,087,904 -0- 1,087,956
“1,036,719 124 ,406 103,672 ~20,734 933,047 912,313 133,452 "1,045 , 7%
1,545,105 * 125,413 ° 88,833 ~ 36,580 | 956,272 1,419,692 -0- 1,419, 6%
310 ,683 37,282 26,408 ~10 ,874 284,275 273,401 19,900 293, 3¢
786 ,187 94,342 78,619 ~15,,723 707,568 691,845 -0- 691,8
om.

XEGION

N. New England
Northlands
Northwest Ohio
Ohio State

Ohio Valley
Oklahoma

Oregon .

‘Puerto Rico
Rochester 2/
South Carolina
Susquehanna Valley

Tennessee Mid-Southt/ 1,985,627

Texas
Tri-State
Virginia d/
Washington/Alaska L/
West Virginia
Western New York
Western Penna.
Wisconsin

Total

 

 

 

 

 

Level’ for 11 month budget period
Level for 10 month budget period
6 month extension with funds ,

‘neludes additional support over previous commitment.

12% reduction of the initial commitment of program support for FY 1971.

1
2
3.
4.
5
6

$ 105,000 Washington/Alaska

428,246 Arkansas
196,000 Missouri

500,000 North Carolina

441,414 Oregon

475,000 Nassau/Suffolk ,

ee nei nema

$2,145,660 Total

GMB/RMPS
4/13/71

x

NEW PREVIOUS: | CHANGE IN = PREVIOUS be =
COMMITMENT . REDUCTION REDUCTION REDUCTION LEVEL NEW LEVEL  CARRYOVER TOTAL
$ 670,677 §$ 80,481 $57,007 -$ 23,474. $ 613,670 $ 590,196 ~0- $ 590,1
1,315,368 157,844 111,806 46,038 1,203,562 1,157,524 -0- 1,157,5
781,027 93,723 78,103 -15,620 702,924 687,304 -0- 68753
714,075 85 ,689 71,408 -14,281 642,667 628,386 -0- 628,3
1,039,195 124,703 88,331 ~36 372 950,864 914,492 25,000 939 ,&
839,205 100,705 71,332 ~29 ,373 767,873 738,500 -0- 738,51
761,268 * 38,382 27,187 -11,195 292,667 722,886 -0- 722,8
958,163 114,980 81,443 -33,537 876,720 843,183 -0- 843,2
508,667 61,040 43,236 -17,804 465,431 447,627 -0- 447,6
- 1,089,023 130,683 92,566 -38,117 996,457 958,340 203,768 1,162,1
545,915 65,510 46,402 -19 ,108 499,513 480,405 -0- 480 , 4
238,275 168,778 -69,497 1,816,349 1,747,352 -0- 1,747,3
1,316,700 158,004 111,919 ~46 ,085 1,204,781 1,158,696 549,344 1,708,0
1,882,485 225,898 160,011 65,887 1,722,474 1,656,587 -0- 1,656,5
764,826 91,779 65,010 -26 769 699,816 673,047 -0- 673,0
1,617,379 ® 181,485 128,552 -52,933 1,383,827 1,435,894 -0- 1,435,6'
516,567 61,988 43,908 -18,080 472,659 - 454,579 -0- 454,5
1,029,459 123,535 87,504 ~36 ,031 941,955 905,924 -0- =) 905,9
944,257 113,311 80, 261 -33,050 863,996 830,946 -0- 830,9
1,081,569 129,788 | 91,933 -37,855 989,636 951,781 60,704 1,012,4
$69,679,861 $8,104,102  §6,963,513 $1,143,589 $60,570,688 $61,575,759 $2,064,650563,640,4

The source of these funds are from the balance created by the
The regions and amounts are as follows:
Regional Medical Programs

Obligations to States for Grants

1972 Estimate

1970 Actual 1972 Estimate

 

 

 

Grants Grants Grants
Alabama... cc cece ec ec ee eee aeeen $1,148, 266 $ 855,228 $ 855,228
Alaska (See Wash.) cs. ccesenace -—- ten ~---+
AVKANSAS ccc cere rece teen esneeee 983,127 986,663 986,663
ALLZONa. ec eee iee ee eee see eeee 1,079, 200 901,822 901,822
California..... Cee ee ee ane see 1,742,652 7,857,994 7,857,994
Colorado.ccccccceveccccune cee 3,295,962 3,008,703 3,008,703
Mountain States RMP-WICHE... (1,959, 224) (1,791,839) (1,791,839)
Colorado-Wyoming. RMP (1,336,738) (1,216, 864) (1,216, 864)
Connecticut..ccesesseeee rarer 1,197,354 1,523,691 1,523,691
Delaware (See Pa.)w..rsceaseee --~ --- --~
District of Columbia....... . 1,431,784 1,103,044 1,103,044
FLlOrVida. ccc acccsceussesnsecees 1,756,986 . 1,707,130 1,707,130
GOOrgiascecsccccrccrevnevceace 87,270 2,248,543 2,248,543
Hawali..ccceescccusceseuessces 914,701 1,026,281 1,026,281
Idaho (See Colo.) .cciscasecccs —-- -—— ———
TILinodSs cece cc eww cee ene 2,216,969 1,703,533 1,703,533
Indiandscccccccccarevuceecvens 1,632,990 1,246,702 1,246,702
1,144,663 724,197 724,197
58,516 1,561,746 1,561,746
1,141,193 1,155,300 1,155,300
1,144,180 698,574 698,574
453,406 993,516 993,516
Maryland... ccceer eens eceeeene 2,325,944 1,917,127 1,917,127
Massachusetts (Tri-State)..... 1,587,046 2,092,806 2,092,806
Michigan.ccsccescscecves ae 2,737,658 1,780,280 1,780,280
Minnesota (Northlands).......- 1,492,265 1,462,328 1,462,328
MississippL. .. 2... cece ene ences 1,811,387 1,074,105 1,074,105
MISSOULL. cee ccc eee eee eene 5,726,953 2,847, 349 2,847,349
Missouri. RMP (4,714,646) (2,058,482) (2,058, 482)
Bi-State (1,012,307 (788,867) (788, 867)
Montana (See Colo.)..sveccceces --- --- --—
Nebraskascecscacccccsccccseves 1,162,224 556,141 556,141
Nevada (See Colo.)..seeeeeeces --- oo ---
New Hampshire (See Mass.)..... --- -—~ ---
New Jersey, ..cseeee see : 1,362,417 1,374,376 1,374,376
New Mexico.ssseeaee sees . = 1,133,652 1,133,652
New York. cece re ceccccccesncaee 7,379,835 6,371,918 6,371,918
CALDany sec ceeecee esse eeeeeees (1,534, 208) (2,001,548) (1,001,548)
Western N.Y. (1,271,728) (1,144,475) (1,144,475)
Rochester (939,674) (565,499) (565,499)
Central N.Y. (45,039) (778, 310) (778,310)
Greater N.Y. (3,210,923) (2,478,462) (2,478,462)
© Nassau-Suffolk (378, 263) (403,624) (403,624)
North Carolina......see6- see 2,275,014 2,430, 000 2,430,000
North Dakotac.s.sscccsccccavons 361,371 345,394 345,394
“ Regional Medical Programs

   

@ Obligations to States for Grants (Continued)
1970 Actual 1971 Estimate 1972 Estimate
Grants Grants Grants
Ohio. .cccccccnsccaceseces . $2,705,489 $2,494,588 $2,494,588
Ohio State (422,606) (780, 840) (780,840)
N.W. Ohio (1,545,276) (854,053) (854,053)
N.E. Ohio (737,607) (859,695) (859,695)
Oklahoma..... cece cence eneees 1,413,974 932,966 932,966
OLEZON. wacceveves weve we anaes 888,385 355,590 355,590
Pennsylvania..sccsscccncveees 5,561,803 3,369,032 3,369,032
Delaware Valley (2,500,033) (1,712,369) (1,712, 369)
Western Pennsylvania (2,359,490) (1,049,755) (1,049,755)
Susquehanna Valley (702, 280) (606,908) (606,908)
Puerto RiCO.. cece cceccevecs 1,070,577 1,065,215 1,065,215
Rhode Island (See Mass.).. --~ —-— --
South Carolina... .ssssecuceee - 9 1,234,457 1,210,695 1,210,695
South Dakota (See Nebraska). —~-~ — -~-~
PENNESSCO secs ccc ceceneerccece 3,970,080 3,395,065 3,395,065
Tennessee Mid-South (2,668,969) (2,207,472) (2,207,472)
Memphis (1,301,111 (1,187,593 (1,187,593)
TOXAS ccc ace sects cuccccuseee 2,805,538 1,463, 809 1,463,809
Utah (Intermountain)........ 3,562,599 2,719,536 2,719,536
Vermont (N. New England).... 313,788 745,609 745,609
Virginiaccccccccceessceevees 696,633 1,020,331 1,020,331
Washington...ceceecsvcccuees 2,035,610 1,681,350 1,681,350
West Virginia...scccrreseees 447,905 574,281 574,281
WISCONSIN. . creer teeter etsons 1,843,868 1,202,408 1,202,408
Wyoming (See Colorado) .. --- aa ---
$78, 202,039 $74,918,618 $74,918,618
In-center Hospital Hemodialysis - Chronic Hemodialysis

Cost figures range from $15,000 to $50,000 annually per person.

Home Dialysis

For dialysis in the home by the patient or a family member costs average
$15,000 for the first year of dialysis which includes an average 10 weeks
of in-center training, purchase of equipment, and home renovation.

Ensuing years cost in the home range from $5,000 to $7,000 annually.

Limited Care Dialysis
Although complete cost data on dialysis provided in low overhead facilities

is not available, indices. point to an annual cost data range from $7,500

to $15,000 per year per person.

 
‘ KIDNEY DISEASE CONTROL PROGRAM

Cost Trends in Transplantation

It is very difficilt to discuss how advances in transplantation have led
to cost reductions without first defining the components of transplant
cost. The two biggest and most problematical components of transplant
costs are the pre-transplant dialysis (if you want to consider this as

a transplant cost) and the post-transplant complications. The cost of the
actual transplant itself and the immediate post-operative hospital care
for a normal surgical end result is somewhat fixed and standard and is
comparable to other surgical costs. Any improvements in transplant costs,
therefore, will have to come either in the reduction of pre-transplant
dialysis time or in the reduction of post-transplant complications.

Most medical research and advances have also been in these two areas. As
the result ‘of organ procurement projects supported by the Kidney Disease
Control Program and various other organ procurement and sharing projects
through the country, there is the feeling, although very subjective, that
because of organ sharing and procurement programs, a patient's time awaiting
cadaver transplantation has been reduced.’ This, in turn, reduces the
pre-operative dialysis which, therefore, represents a cost savings..

As far as advances directed toward the problem of rejection are concerned,
advances have been made in two basic areas:

1. Tissue typing - Within the last 5 years, considerable refinement
in technique and knowledge of tissue typing has been made. Although
there is a great deal of controversy at the moment, about the efficacy
of tissue typing, most transplanters will agree that tissue typing has
contributed significantly to the recent improvement in transplant
survival data. This is even more evident in the living related donors,
but is also true for cadaveric donors. As tissue typing has become
more refined and transplants are done between more genetically com-
patible donor and recipient, the complications of rejection have
decreased, thus representing a significant cost reduction.

2. Immunosuppression - Immunosuppression directed against the transplan-
tation rejection phenomena has also improved over the past 5 years,
with ALG probably being the most significant addition to the immuno-
suppressive armamentarium. This area, like that of tissue typing, is by
no means adequate as yet, and continued research must be done. However,
better immunosuppressive therapy has resulted in fewer complications
as well as the ability to treat rejection at an earlier stage and has
resulted, ultimately, in less morbidity and less cost.

Another very recent technical advancement, which has represented significant
cost saving in a limited number of transplant centers, is the pulsatile pro-
fusion apparatus developed by Dr. Belzer. In the centers most experienced

in using this apparatus, one is able to remove the donor kidneys, and evaluate
them anatomically and physiologically,before embarking on the tissue typing,
thus cutting down significantly on tissue typing expenses. However, this
saving is significant only in a limited number of centers that have had a
ereat deal of experience with this apparatus. As more centers use it and
gain, more experience with it, one is hopeful that this will represent wide-
spread savings. ,

Another very significant factor affecting reduction of transplant costs is
experience and number of transplants done by the center. Dr. Kountz's
testimony at last year's Senate hearings stated that of the 200 transplants
that were performed at their center, the first 50 cost about $20,000, the
next 100, between $10,000 and $15,000, and the last 50, between $5,000 and
$10,000.

Unfortunately, progress in transplantation has been somewhat slow and
steady, and there have been no major or drastic breakthroughs as yet. I
have rendered transplantation just an ordinary surgical procedure.
Therefore, costs still tend to be very high and somewhat difficult to assess.
KIDNEY DISEASE CONTROL PROGRAM
Cost Trends in Hemodialysis

The-Kidney Disease Control Program let 12 six-year home ‘hemodialysis training
program contracts in 1967. The purposes of these contracts are to test

the feasibility of home dialysis as an effective and efficient method

of treatment of end-stage kidney disease, to provide the Kidney Disease
Control Program with pertinent cost and medical data, and to develop financial
sources other than Federal to support such a training program.

The cost data collected from these contracts has shown that the costs of
home dialysis are considerably lower than center dialysis and the trends
of these home costs indicate they will continue to drop. Contributing
factors to these lower costs have been such things as:

1. lowering costs of equipment and supplies;

2. bulk buying and storage of supplies by the training center for the
home patient;

3. development of techniques for resue of certain supplies, i.e., blood
tubing, artificial kidney (coil, capillary, and Kiil);

4, lower personnel costs through the effective use of paramedical personnel
for patient training and supervision; and :

5. effective utilization of already over~crowded hospital beds: if a
hospital operates on a 6 day, 2 shift schedule, 4 center dialysis
patients will continually occupy one bed; however, if that same bed is
used to train a patient for home dialysis using the average training
time of 6 to 8 weeks, six to eight patients will occupy that bed every

year.

A certain number of patients cannot be trained for home hemodialysis for a
variety of reasons, some of which include intellectual inability to grasp the
procedure, psychological problems in accepting the responsibility, and not
having a reliable partner to assist in the procedure at home.

Thus, in order to develop a relatively economical way to treat these patients,
the concept of "limited care" dialysis came into being. The Kidney Disease
Control Program began funding three limited care facilities in June 1970.

The purpose of these units is to provide dialysis in a low overhead facility
staffed with limited medical personnel and operated essentially by para-
medical personnel. Complete cost data on the operation of this kind of

unit is not available at this time but all indexes point to average costs
per dialysis of between $50 to $100 as compared to the average of $200 to
$300 per dialysis costs in a hospital setting.
 

POE Se CRY sy COIR A OS
KEDARY DFSEASE

This dialyzer is cemposed of seme 10 to 13,006 deacetylated celiulose acetate
hollow fibers, plasticized and imbeddad in a silicone rubber bese at either
end. The fibers are but 215 microns in diamater providing an effective
dialyzing surface of approximately | meter equare. They are about 8 inches
long and require only about 115 co 135 mls of priming fluid (depending upon
the geometry of the header used}, The performance of this dialyzer, in
general, is as effective as a coil type élalyzer with regard to dialysance
and ultrafiltration. its cost, ease of use, and its reuseability make

it move efficient than most of the avgilable equinment, However, all is
not as rosy 4s appears, The one major drawback to this plece of equipment
is in its thrombogenic tendencies, a fact that makes its general appli-
cability impractical at the present time. In regard to performance, the
dialysance, as measured by the creatinine, ured and phosphate clearances,
demonstrate that this unit functions as effectively as the Coil and
considerably more so than the Kiil., In addition, Dr. Gotch was not able

to demonstrate any tangible differences in the well being of the patients
dialyzed with any of these dialyzers. Ultrafiltration was quite easily
effected by varying the negative pressures produced by a Venturi.

Kegative pressures could be easily generated from @ «250 to a <-500 miLlLi-
meters of mercury with a mere 25= to 30-pound waterhead pressure. Two
potential problems arise in this area:

   

1. Attaining a 30=pound head of pressure from the water tap, and

2. Adjustments that would necessarily be made to adapt the dialyzer to
these new pressures,

Apparently, both can be handled quite easily mechanically, However, the
latter of these points appears to be more troublesome because of the
reluctance of some of the manufacturing companies to make modifications
on their machines (usually, this involves not much more than a change in
dial settings and readout dials).

In regard to its efficiency of use, this unit combines the best points

of the Kiil and the Coil dialyzers, The unit at present costs about
$18.95. Mass’ production began in January and over 1,200 were sold,
February sales figures will run over 2,000 and there is presently an
adequate inventory on hand for purchase, I[t comes presterilized, requiring
only a brief period of time to set it up, yet it can easily be cleaned

and resterilized with Formalin solution, to be used again (a process which
only takes about 15 minutes). The HFAK can be used without a blood pump
and can be used with either a fistula or an external cannula.

‘
The major problem associated with this dialyzer Ls ite thrombogenic tenden-
cies, which appear to be net only related to the unlt itself, but alse to
the individual patient. Such facters as fiber distortion, a problem which
probably will not be completely eradicated beceuse of the difficulty in the
manufacturing process itself, and the shape of the header, an area where
blood pools before it goes through the hellew fibers, are the two major
mechanical preblems at the prasent time, Often, one will see significant
stagnation of flow in the header resulting in hemoconcentration because of
fluid dynamic changes occurring when moving from @ lerge bore tube to a
very ewall bore tube, Indeed, both of these facters will tend toward
spontaneous thrombosis. In eddition,; there appears to be cansiderable
patient variance in regard to spontaneous clotting within the dialyzer
itself. Dx, Gotch has already undertaken some basic coagulation studies:
in small groups of patients, and these seem to suggest that there are
certain characteristics found im patients who do not readily clot their
units, These factors are threefold:

1. They seem to have prolonged bleeding time;
2, They appear to have a decreased prothrombin consumption time; and

3. They appear to have abnormal platelet clumping with collagen
stimulation.

One therapeutic maneuver that immediately suggests itself is to place
patients on long-term anticoagulation with Coumadin. However, this only
slightly prolonged the life of the dialyzer in those patients with a
tendency to clot but, unfortunately, with a significant increase in
morbidity, This finding hints that the clotting may be primarily
related to factors other than those related to coagulation. Indeed,

Dr. Gotch presently suspects that the clotting is secondary to platelet-
fibrin clumping, which subeequently occludes the hollow fibers and
secondarily results in clot formation. At present, he was working on
more detailed coagulation experiments in an attempt to further elucidate
the problem.

The Cordis Dow Corporation is presently in the process of developing a
more efficient capillary that will effectively reduce clot formation,
It will be introduced by Dr. Gotch at the ASAIO this summer and
subsequently be put on the market, It will sell for the same price as
the present kidney,