yuyu BRESHELS TO wane AU OF GEOR BOCCET JANUARY 19, 1965 QUESTIONS FOR BLEW. REGARDING PROPORED BILL AUPHORIZING REQGIOUAL MEGICAL COMeLESDS PLsooke 1. What would enactment of this bill accomplish which does not egeur at the present time? what are the now elenents ef organiza tion, treatment, research, er training? How would they relate to existing programs? At the present time, 10 adequate rom sational nese exists whereby the highest quality medical care & rnilaple in university medical centers oan be brought to b me max widely in g community. Conmunity hospitals are eager for assistance from medical scheols, but this usually cannot ba provided by existing arxangementa, Camsmity-wide pliciing, whereby expensive duplication of services aad equipment is avoided, is rudimentary at best. The provisions of the bili would xing abouts ia} Stimnlation of appropricte health planning among wodieal centers, community heapiiels, and other Reaith agencies. {oj Organizational frameworks wherehy necical schools would provide servicas and pexgennel, not. others wise available in community hospitals. (<} Diagnosis and trentsont, now obtainable at only a few loustions, in sore places and supervised by adequately trained doctors not otherwise available to the couwunity hospitals. (€}). an ivproved selection of research patients, who eculd bo gelected from the total number in the omesanity rathey than from the smaller group how available through a university hospital. ~ fe} Training more extensive and varied than that now provided, sinco both a larger number of patients ané 3 moxe varied set of cirounstances — be avaeilaole to the trainea. ® | | 2 3. is the primary purpose of this b111 te improve and aemond treatment, OF Kasearch? if @ combination of the two, what is the proportion of each? Would this proportion upply to wost complexes? She prisary purpose of the Dill ia to make better care more widely available. Yo do this requires that training, re~ search and patient care be carricd out concurrently. The proportion of each varies from time to time end fxyonm loca- tion te location. Medical schools would be acked to assume inoreased responeibility for community health cara. At Ene guse tine, commuaity heepitals would be agked to provice more repourees for traiming and for xceacaseh than they now 19, Within flevibie Limits, the proportions cf training, veneareh and core would be similar in all aamplezes. _ {Gealiy, the proportions of the throc, tach te the others, would be weout that now foumd in any top-quallty university teaching servico. 3, What is the relative priority which the Pegartmant places @ om the various clensats of a Gouplex includings &, centxvsl plaming and administrative machinery for tke complLowas ? b&b. medica ccoters G eategerical reucarch canters a. ecosmmity hempltal Glemonstic and tragtment stations @. other elexants (please specify) what effect would the omiselion of each of these respective elements nave on the operation of this progran? The muypess cf tha bill ie to bring about, by coordination @f existing and to he created components, aa exganisatios ef nictequolity health activities ca a lazger scale than fernorly haa been posoible, To co so requires modical eentera, categorical research centers, and community hospital diagnostie and treatment stations 211 to garticipsta in a 2 oh ammed, centrally = acs ae Le ste ered system. Unch is nccessary? @ omit any would ¢ Sty tag concept, sad operation | o£ the sects would oath sinee ft envisions coordinated and balanced performance of tina parts. BR oe ¥ a 1. Accepting the nead to decrease the lag betuegen now imowiedce and its translation into medical pra wotice, what are ne specific advantages of taciiny actacn on & heart, concer or siroke basis, as opposed to general suggest coz ores txeining and cemenstration applicable to ell major ciscaces? tat are te dige advantages of a categorical appronacn? oe te Nediecina's espectacular advances in the past twanty vears have eccurzed 3 sath mone with the covelopeent’ of erecializa~ tion. Regardless of % ete micht hove beon, the gect is that 66 por cent of cuyrent sat graduates are undertaking apecialty training. Special i only apocialists can peevide the high quality gosgareh and patient D * cave which it ic hevcd to provide more widely in the com wanity., Honmee, vor specialista in cartiovascalar diccams, gabegerical Eacilities are néececsery, amd oo fox othexs Giesases a6 woll. 2. whet waters diseases other the: hoart diceste, cancer end gtrcke doag Che Donartnant plan to inelude? On what basis we, nancial would the Sargean Generel and the tedical Complex Acvisoxry Council select other dicenses as progosed in the bL2L? University affiliated moxtal health and mental retacdetden cookers, nov being devalope? under the Mental | Reteccat lon Paciilities and Command ty Bontet Peaith Centers Cecctemetion Ret of 1963, fit easily inte the organigationz and pimdi.c aanpects Of the modical camplenna. So do various ofher programs, such ag the program-projcct grants in neurological aad eer nSOTY disenses, ang others. When, in the jocorcat of experts in a field, it is determince that advance made moze rapidly than they are kcing applied, 2 Asie OTE Ty te Eyes got fede tet pe oe ase ng is che gage faz npeart Sisease, cancer and Bese. a, attacks unon these new digenses could well be Zeuneches through the oxguiisaticoad structuce of wodical complenes. a fjaatdtubions having undone activities relating to ofhay smajor diseazacn, the Surges ‘General eould designate others categeriae for goeecifle support. Yo cdo so, uncer roguintions, eviconne that a major national service would os peeved would be You omc: graduate medical eon togching Cases, the , ivese eee wy teae ecfest will che prond: cule of oedijcal schools LONCS ae have Yeh ate on, tn Tg riger of dingnestie cute = Sbiwe i “e zd teil store hee Z ta effet %, upon under Greater availabiliuy of excellent vol nm Gor tee ond the of regtarch thodts ahi Fe a ahenapontes rot by fa Bs ‘or wil improve medical education, beat © only eecondacbily. The great edvcationsl anpact oe 3h CS we 2o 0% graduate specialty training and usen the wentin “sing education of coomunity physicians. 455% fh tt Grae wilh be used ars for orofercioaal stakl, ancillary ae eguimiont, wenovation, eociocickion and muytlent caro, “et the otters only for enve alicoulic to exaining, research rs ne aenaeie Ene Weronerlaons Ww saie be ap set foeth is proposed budgets by the app iienye inotitation. Such sudgete sould ba reviowsd, = tive epeciclists, and i theao : By - gecdiontk fwouid be gucgec promulgated Loz tho clinical udlentiste azd ey et to xeguinticn “bay gy s elmiiar rs at research uwiits now ope wera OS ghrough the Nedeie ‘ 2, Agowsliay & complex to be ostablished im tha Washington, D. G. Aven, plence indicate cor i “re ranseooe og, and in what xelative geounts, the allocatl ~ éollave Will be mada? Plenese be apacific. estion eunnes bo anowerced in the absence of a sp pecific LGR hat GooroG Hachingten University wished te make an re eeolLicaticn. toeal advisor Thee Ohh toe Sit wr and the woiversity repre Lue represcntativ 7 URoED, BS ST craverning norcnu of georgetown aah ony gheo whith thc nesplials, t Bxrepar — a cats o tuature of = under whek conditions cac. yoo would agrance to form & med Sand aoe the bill. Enis group, esentata VEGe wold Gleowss with the and gouard Univer nities. and oa aan the banding community indies es Whereoy and nenzent ing titet doe Wonk udad pigtrae Sa ty yy {Me a pre oe a Sen (RL “wlth the sein fox: cee with Geox % cq Sod vey “he il Ney & the compiles. Thora would alse oc noteonold tan Eoom.tnl s counedh ene ok! og efficial pla: nuin g8 ee deter tegzee to wisieh he comelen wind shby yeoisiGe shea iL this hed bean Come, the edvasory group we. asd zag te teasing Se University in preparany & provie: ed, Which Ww ound per Bot Lorth tha otkes gesosGed Cou usa of s a nots watie and in — eae enterotye Cala vould them ae M4 ar ne tte BF acy Fh ah atm ld Roar ats NS ain Ma oe poate, i 78 poybew, me en ys amy g follow, anaes kt poi, athe i, is, te et te E rei ea, 4 (y - a Pl at oe Cove! — ct the sepetem , Espn, ye “et Ahab a ll san, 8 PN ao ix Des. a 2G WA AS 2 seed SCR 5 7 Yrs " ab Baus ft ay, if i Caeree ton University for eee s whew rene oS coe tna A eanie - ath thes 3 saat: antes, mace thom ong comclon migne bey located in e q sect, Phan yet 2 id ” we wig RT ae ye +: & single eity, ors sake Soma gpacline ware ils, x Sie cates, OAL Vite we 7 et at yr _ a oe the sume cunplos might be mice fu ge moce Cli cterent ; , S oie ot ed, de A pricraty but cooperating dnstit Ehonte Lox, including Si SS ah Hes ‘ aby ota gh SP Abe esi : 3. Wey should the vonorren fametion af the on ® er % a 4 Stal « “ ty bon aya % % eonstruction of xesenzen facilities, be financed othex than through existing EH... agthorities ond dollars? Kaltislisity of Tinancing is = @uelicativa. HOrGovers the EL PATrtS, mor ald, of the apects ag EE oy oh de any, | 4 2 IH ata mts ee UE te 9 afficient and unncccnsarily » wutnedientions pomal’ only sie ak fous wd sf aobbeydtdag te ko aoa re ae ie a " ya Ft “e pte eet i Sy by the complex, Besearcch Geant, Een Sree 3LG, CYaewt be uaod fo pay SALALLES for genching, yeh the eooinetian of cn es on fom yg a iste et a he ey cs te teaching. goeccarch and pabscns Gare 18 eagonti: al £o the sxoper functioning of the qocplex. ne cm d fa, oss an pie see es at hye &, Wheat is the selationchip of complexes to esishing and a cyt erin AE agar ann py Spe ante M0 . proposed Federal (progeans supporting aedical education and the ta” ie memetreetion of maddicai schools? See complexes have selotively 4 proposed medical educttion and « 4s pecavped tha comple SoM : aft 4 ty te 7 he ame, tg ty * oe wap " Le iy, ity sig Four Baty geaduate education, fatity thank wor ue nace oe tetuate tonehing» ott an “3 a ‘on og, ie ee ih His, van, ts BE gist ee git Tt ds for tho latter trac cn6 retiiend educetion and conetruce - st om ty ete * tion programs are cesu Moxscevac, th the cooglexes is to cresic eh Gon inietrative oply in sciGents % conctruction as necessary t 2 &} ws hse cies ae we 2s ow wk da ee r “4c PoeNg rag tm: Mak dow elu cicinake would iba ted bye “The 2 Fe Govommeowne? ha Proce che ste? neta? A Stuns vy beton ead eh ig 2 See Chole 3 £ weak snare we yy cogty be phascd son BEM oon Lette t ok me ociengs. wo. gegen se inset Se bet ee sts et be % Fo Foe eng hy o spe Ghinigal cancer % wa sep Semen A A 7h, bocazed im Lo oT PH yees 4g fb be con yal x ei tiden, wis Gee “ # atte oy the ETT gear aE a ty se Se 1S ey tea cee noel ote tog nate, pitt, BH Aner ck wll ania ih = 3 mfg TOP ERY? pha ey Ara cm hat, a My Aah har we "5 at HFS a we tee ne eB £2 QE Gib million. * fay gt et. BG ELAS os: sont $2 2 milit os 5 mititon 2 cogenimity reo pea Nem avhed an fasiorevs st ci} Coe et BaF rd EE I mh ee ee 665 milbiiow, OT ey, Be gm cle L te ety * fore we its om ffe et i ane] Re Reade Ste ska toe F x Ee ee ee ve oh sy any peo e 7 pam pia ee ab ee Wo pee £35 militias & en om Be Fin st ee gone, tbe we amy Sh ase ee werd thin iss, Uhte qe ates Rese ee CSP y aS ae ae awe OS ay go See span 2, 1.4 Fem Sait PF deal + aaa es a He LV - naa 3 Btesetey elt ae asnan trang ihe ita steel nel Bhedete wt "ier Bot aS mh223 empleo. od night ExQEney, £ the seal veins es aye ee ok, Hip Mines Mio ov oe a al pron Lieecmeretes oh ane @ ; ? of ee Ainge 0%, wecucetyte mee Par 4 ‘cS Sade a MOE MELE GA, haw he os x Ft Tiga ree Fy: Bal op gk gt Ee Gea oe uo eerva 5a availa able, i% pale fully " ~ wos, he em cee eT ming TT a SOLS GGUS oe Bee ty, wn, Bae ba. 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WK Bho: "ak + ~ ey ou te ay ft By Poets “7 Mots seg Sue ea woah Pe Tee, ane at Malte SE got Baa? se Sok ape stark Cape inion ws celnags Mae enue BS ES eka ash . 6 : ae taht, “Er regen at ry ay sm § Kaaute De sess as DP daha Nae 2 ny es Lp dine ttl bie he a * 5 ‘A & reo tem cate aM * Ae doors BE afl og imei, A , ; CEE ice naman Sra Ebay BAERS Keke NE na aneatens aeee ie act — @ cuusrrons way should ve give priority attention to Heart, Cancer and stroke? ANSWER: 1, ‘These are the killer diseases.--71% of deathss ‘Heart Disease 44% , Cancer «1h stroke 11% 2, Maoh that is knows in these fields is not being applied today, 3. ‘The bill does provide authority fox inclusion, at the option of the applicant, of any other disease found by the surgeon General to be of major significance to the health of the Nation, he The experience gained in establishing these complexes will be dnvelushle an we explore wiys and means of organizing our approach to serious problemas of othes types. MQ, Does not the emphasis on the categories of heart disease, cancer, and stroke as individual areas of action under the program run counter to the long term effort? 1. To develop the concept of and means for comprehensive care for the whole patient? "9. To avoid fragmentation of medical education and the teaching 4 process? Aa The importance and magnitude of the health problems in the area of heart disease, cancer and stroke demand special emphasis in arrangements to bring these diseases under control and to assure that the advances of research in these areas wkkk are broadly available. Thus these diseases @. can serve as the initiating point of a program whose eventual culmination will be a general enhancement of health services and the quality of medical care on a broad basis. Thus, although the categorical identification pro= vides an appropriate beginning point, the eventual objective is the kind of comprehensive care which is considered to be the best framework for the delivery of health.services. mere is little danger that this approach will contribute to any fragmentation of the teaching process. Question. What major diseases other than heart disease, cancer and stroke does the Department plan to include? On what basis would the Surgeon General and. the Medical Complex Advisory Council select other diseasea as proposed in the bill? Answer. When, in the judgment, of experts in a field, it is determined that advances are befinmade more rapidly than they are being applied (as is the case for heart disease, cancer and stroke) attacks upon these new diseases could well be launched through the organizational structure of medical complexes. In institutions having unique activities relating to other major fGseases, the surgeon General could designate other categories for specific support. To do so, under regulations, evidence that a major national purpose would be served would be required. @ CUaSTION: vhat other diseases might ba found to be of "major significance to the health of the Nation" so as to be included in the complexes established under this bill. ANSWER: 1, Following the precedent of heart, cancer, and stroke disease we would envisage assisting the astablishment of complexes for diseases involving highly specialized and elaborate treatment (skills, equipment, facilitios and procedures), This might include kthiney disease. 2, It might certainly cover disease entities closely related to | the skills, equipment, etc, necossary for the treatment of heart disease, cancer, and atroke, For examples. Benign tiumors Lung disease Cardio~vasunlar davolvexests othex than stroke QUESTION: Could & mented _retardation comuhex be established. under this bill? ANSWER: There is authority in the bill for inclusion, at the option of the applicant, any disease found by the surgeon General to be of ‘major sigaificance to the health of the Nation." There 13 no doubt that montal retardation fa such a discase, However, under P.L, 88-164 enacted in 1963 there is special authority for the establishment of uiiversity affiliated meatak rovardation facklities and for construction of mental retardation coumunlty facilities, Also, states have moneys uader P.L, a3~156 L/ for planning comprehensive action to combat mental reterdatioa, Ths maternal and child health amendments proposed by the idninistration this year would authorize $2,750,000 amually for 2 yeoara to vats to follow up this planning, i/ eae vaternel and Child Health and Meatal Retardation Flaaaing fmendments of 1903. gpa Sb on at yt Bema pina timate fonts cinta 4 Lt ea wk uotee this BELL? setae Se Saha dale bad an ects ar mye Sew dr aL nes ee fr pie ote fe a is author. uy oes Menweionied g ce Goa Bo os nt ao, i A ie ava oie ECS Genceel to ba of ote Hen che Natlon.™ Ae aia Bel Sa », ~ ho detent Lam ES fave Too Pays ete eye aunt oy tase 190G US 1G GOLDS Cl. MOMSaL Lian such @ disease, However, wader PLL * cd 5 authority fox vouscruction of cond otal health toa natkate ge ot ie OS. 4 ES gf on ease pepe ch is he pike bh in a ‘ed cad whee GP ing ate CORSE Gd eae Bag ty see varie che ae ede eats ee fee ie Ne en 19-183 EET tee ors eae fe spy af. om, ‘ mk pie he aft 42g LS Oe GG HOSS = Legh She. UAE x wechet nce “4 mh UDy afdts ae Ca LS tah heaith Question. What would enactment of this bill accomplish which does not occur at the present time? What are the new elements of organization, treatment, research, or training? Answer. At the present time, no adequate organizational mechanism exists whereby the highest quality medical care available in university medical centers can be brought to bear widely in a community. Community hospitals are eager for assistance from medical schools, but this usually cannot be provided by existing arrangements. Community-wide planning, whereby expensive duplication of services and equipment is avoided, is rudimentary at best. The provisions of the bill would bring about: (a) Stimulation ‘of appropriate health planning among medical centers, community hospitals, and other health agencies. (b) Organizational frameworks whereby medical schools would provide services and personnel not otherwise available in community hospitals. (c) Diagnosis and treatment, now obtainable at only a few locations, in more places and supervised by adequately braiace doctors ‘not otherwise available to the community hospitals. (d) An improved selection of research patients, who could be selected from the total number in the community rather than from the smaller group now available through a university hospital. (e) Training more extensive and varied than that now provided, since both a larger number of patients ands a more varied set of circumstances s would be “available to the trainee. — QUusTiows Why is new Federal legislation necessary? ANSWER: The legislative authorities prescatly available are directed toward the support separately of essential basic resources for health facilities, manpower, and knowledge. they do not lend themselves to the specific and gigantic task of integrating research, clinical care, and continuing professional education for a coordinated attack on the three "Killer diseases" (heart, cancer, and atroke). (@ 2 J Q. How much of the proposed program of complexes could | be carried out under present authorities? % } A. The authority provided in S. 596 would allow the creation and support of new mechanisms of relating research, professional education, and high-quality medical care. While all of these activities can be supported to some extent under existing authorities of the Public Health Service, no authority exists to provide for the planning of the complex organizational framework, and the effective linking of research and teaching to diagnosis and treatment of heart disease, cancer, and stroke. Q. What is the proposed use of the construction ‘ authority contained in S. 596 which permits up to 90% matching by the Federal Government? How would this authority relate to the present proposal for extension and expansion of the Health Research “Facilities program and the proposed new authority for nonmatching construction of research facilities for regional and national purposes? A. .. The construction authority contained in S. 596 ould be used to pay up to 90% of the costs of those additive facilities which are essential to the operation of the complex. . We would not anticipate a large amount of new construction under this program, since in most cases the — complex would Link existing institutions and existing facilities. We would expect 4 larger number of applications +o propose some modification of existing facilities. We would not intend to use the construction authority in ” 8. 596 to provide construction funds which could be supplied under other grant mechanisms of the PHS. QUESTION: ANSWER 3 Should a project receive help under this Legislation if it could be helped through normal channels--6,g., Hill-Burton program, forhhospital construction? Our purpose hexe is to provide for the linkages and mechaniems to assure the overall program through support to staff, services and demonstration prograns. those specific items which require additional funds would be referred to existing nochanioms, @ QUESTION: What facilities and equipment could be provided under this ANSWER : legislation that could not be provided under Will-Burton aud Health Research Facilities Legislation? This program ia to establish a networke-the purpose of program is not constsuction alone, Construction would be secondary to the central purpose, providing unique, specialized or otherwise unavailable facilities needed for the purpose of this overall program, tn QUESTIONS AND ANSWERS CONCERNING REGIONAL COMPLEXES FOR HEART DISEASES, CANCER, AND STROKE AS PROPOSED IN S. 596. I Q.. What would be the relationship of the heart disease, cancer, and stroke complexes to the present NIH program “for the support of research and research training in the fields of heart disease, cancer, and stroke and other major diseases? A. The proposed program of medical complexes would not displace present programs of research and research training supported by NIH. The complexes would provide a means for more effectively relating the research and research training activities to clinical training and patient care activities. As the President's Commission on Heart Disease, Cancer, and Stroke made clear, the extensive medical research programs which have resulted from the generous support provided by the Congress to the National Institutes of Health have “helped create numerous centers of medical excellence which can be the foundation stones of the proposed complexes. 3 8 ° Question. In what ways would a regional categorical center (for example, a regional cancer center) differ from a clinical research center now spon sored by the National Cancer Institute? Answer. Although cancer clinical research centers now supported by NCI exhibit a range of characteristics--including many or most of the elements that one would expect to find in a regional cancer center--there are clear differences in concept and purpose. - A regional Cancer Center would involve responsibility for improving the quality and availability of cancer research, training, diagnosis, “and treatment throughout a specified region. A cancer clinical research center as now supported does not have regional respon- sibilities and ig limited in function to clinical research and vf research training only. -- The designation "cancer clinical research centers" refers to a Sd specific limited clinical research component of an existing insti- tution. (Perhaps ten beds with staff and supporting facilities in a cancer research institute, university hospital or similar medical institution.) However, the designation "Regional cancer center" would apply to a broad clinical facility involving an institution as a whole; or a major organizational segment of such an institution. 4 ce Question. Would the research and training functions of the complex (including construction of research facilities) be financed through other sources than the grants for establishment and operation of a medical complex? Answer. Research and research training projects carried out by investi- gators within the complex could be supported under individual research project grants from appropriate PHS or other granting sources. Similarly, support for a categorical clinical research center approved for incor- poration within a complex might be supported directly by a categorical Institute. The pattern in this respect is apt to vary depending upon a variety of institutional funding and cooperative arrangements. e. 1 i Q. What would be the role of the categorical institutes . and the categorical advisory councils? A. The categorical institutes would continue to provide support for research and research training in their respective fields with the advice of their Advisory Councils. It is anticipated that this support would continue to go to the component institutions of the proposed complexes. Individual investigators within these institutions would still apply for research support through present mechanisms and their proposals would be reviewed for scientific merit and for relevance to missions of the institutes. The proposed program of support for medical complexes would not supplant the categorical institutes as the primary providers of research and research training support in the fields of heart disease, cancer, stroke, and other major ' diseases. Q. Would present categorical or general clinical research — centers be absorbed into these complexes? If so, would " they continue to be financed through the categorical institutes or DRFR? , A. NIH would continue to support general categorical or clinical research centers through present mechanisms. It is likely that many applications for grants under the proposed program of medical complexes would be received from institutions which currently receive NIH support for a general categorical or clinical research center. It © would be appropriate for such applications to indicate how present research centers would be related to other parts of the proposed complex. If the present center were included in a complex, support might still be provided through the categorical institute or DRFR; however, the . further development of the complex might include financing ' of the basic core support of the research center through the grant for the complex. Specifically, what institutions vould be eligible for grants? Medical schools? Hospitals? Ucalth depgartacnts? Nbich Hiads of gréints to what kind of isstivwolons? oh ingtivutien AO ay a: Lda y fow @ grant - complexes, AvowUR: A medical school, hospital, hel a c or other nonprarit agency WOUL So to assist then in pleming, esvablis avobably be central funding through the applicaat, justified on basis of who needs of the complex, euestion: Could a local health department initilete a regiomal complex ‘3 project: Answers The Local healt oertment is eligible. It could also provide the lesdcvship intringing together the mesbers of the Aonrisory Council -- dec. 6. ok Cuucationy, HOO. Ca eet ge gs administration, wedical profession, research eclentists, ete _@ QeustiG! at ay What organizst 202 PAY apsly Yor ciag Loy gtetion support? The university Health dapart seat? Would @ propr "Biagnosilo and treatment stubion" ica aunt of a public om nonore: {which could daclude a medics. A profiteucking hospital would tas we host hte z ff AS sony ao “ tae ey eee it: a Ue hae CK tary Ros ke 2 bras tment Lt ? Hospital? * al be dligible? Ate oy Th Ep wos tet ‘ og Moan pha lid wleakie wlio tM ot eng neh oh sh dep : ao QUESTION: ANSWER: My state doesn't have a medical echool, but we have a health department, a good general hospital, and a few nursing homes, 2. Wow ate the folks in my state golag to be benefited by this bill? b, hat cas we do te become part of a “eouplex"? a. Diagnestic and Treatment stations could be in general hospitals, This in turn con be linked to the medical school in an edjoining or uearby state thereby improving the quality b, The medigal profession and the health departzant could teke the initiative in exploriag possible relationonips 3 with complexes in other states. A. 1. What qualitative consideration will be involved in the review and approval of applications for grants for the establishment and operation of regional medical complexes? 2, Will not such centers inevitably mean that these grants will go to the institution and location already capable and well-serviced in respect to research, training, and demonstration capabilities? 3. How will this program help the institutions and areas of the country that do not now have such capabilities? 1. The major qualitative considerations bearing upon the review and approval of applications for grants under this program will be the potential of the proposed program for accomplishing the purposes being sought through the concept of regional medical complexes. Many communi- ties throughout the country have diverse capabilities for improving | the quality of services in these critical areas and for establishing relationships between existing research and teaching institutions. What is needed is the plan and the funds to support the cooperative and coordinate relationships which comprise a regional medical complex. 2. While it is probable that the initial awards will involve institutions and programs based upon existing capabilities, a major objective of the program will be to encourage and assist the development of such capa- bilities on a widely distributed geographical basis. 3. An important part of the concept of the program of the President's Commission is effort directed towards enlarging the number of centers of 9 medical excellence and capability throughout the country. Coordinate use of other support programs of the Public Health Service such as the General Research Support Grant, the Health Professions Educational Assistance Act and the research and training grant programs will be utilized to advance and geographically equalize capabilities requisite for the development of effective regional medical complexes. sie Question. If regional medical complexes must be built around recognized centers of research, training and care competence in the three disease areas, how will the program help to bring quality care to persons living in regions. where this competence isn't now found? Answer. It is probably trud that the first regional complexes will be set up where the largest population concentrations and the required insti- tutional competence coincide geographically. But the program is a national one; and its benefits will not be reserved for heavily urbanized or other=- wise favored regions. The Public Health Service, as program administrator, will constantly seek the broadest national access to program benefits. How many regional networks will be required for full national coverage is not clear now; and one can only guess at how long full program implemen- tation will require. (Perhaps ten to twenty years.) But throughout this period--and for most if not for all parts of the country--there should be reasonably steady gains in the quality and accessibility of medical care. The program will promote these gains in several ways. For example, program implementation requires systematic and continuing assessment of institutional competence (both research and care) in relation to local or regional population needs. The resulting profile of national categorical competence becomes a most useful planning document: categorical strong points become possible components for new or extended regional complexes. Potential strong points logically become the focus of joint local and PHS * efforts to raise institutional competence the needed fraction more. Gap areas--if sufficiently serious-~can pin point the need for concerted local and national action, possibly including the establishment of new develop- mental programs. QUESTION: How is the term "region" used in this legislation? ANSWER ¢ We envision that such regions might eventually encompass a@ population of two to 3 million persons, located in a contiguous geographical avea, which might be inter ox intraestate or other gubdivisicn, wo P geet pe iy Pn “5 gre ( . ae doh Pn QUESTION ANSWER : Would you describe the region to be served by such a complex? The applicant must describe the peegraphie region and - population base, Ta any case shis would have to be a geographic area of sufficient size and population to hold resources necessary and assure their effective utilization, Thus, @ region might be part of Greater New York, the entire metropolitan Washington, D. C, area, oF 4 multiecounty portion of Kentucky extending from the university medical pchool, e age Question. Will there be a single medical complex for a specific region, with component institutions responsible for categorical specialization? or will there be separate complexes, at least for each of the three major disease categories? Answer. Each regional medical complex is expected to have (ox to develop) component institutions with the necessary competence in the three major disease areas. Separate networks for each disease category would raise administrative costs; might lead to unnecessary duplication of facilities; would increase competition for trained manpower; and tend to unnecessarily fragment provision of quality care for sick persons. It should be recognized, however, that these regional complexes must @ build on existing categorical competence; and few regions initially will oe be equally well served in the three disease areas. Therefore, it is pos- sible that some networks may at first cover just one disease category. For largest metropolitan areas, with several medical schools and associated hospitals and a number of institutions with required categorical competence, more than one complex may be set up if the need for this is shown. . Question. What are the criteria for evaluating institutions to go into regional complexes? Answer. There are two over-riding criteria for inclusion of institu- tions in medical complexes: (1) recognized competence in one or more of the three major disease areas; and (2) willingness to cooperate in . a regional framework to make high quality care regionally available. . Typically, the regional categorical centers will be drawn from those institutions that are heavily involved in relevant clinical and pre- training, as well as patient care. clinical research and rese2cic Such institutions generally will be found in major university medical centers or associated » with them. On the other hand, the prime ‘location ‘for di agnostic and treatment stations is in conan ty hospitals to - ba the Largest number of patients, and. local physicians have access. ms i As Would the regions to be served by these medical complexes and regional medical centers be, determined solely by the inclinations and desires of the applying institutions or would some specification or plan be worked out nationally for this purpose? At the beginning of the program the original definitions would reflect the initial plans and capabilities of these institutions ready to propose the establishment of medical complexes. As this program develops very positive effort would be made to assure equitable geographic “distribution of medical complexes.” The eventual objective would be . the evolution of. a national network of medical complexes to assure the availability of the benefits of scientific medicine to all population groups and areas of the nation. (®@ Question. To what ext» .< would these me:.2al complexes be locally controlled and locally run? Answer. Regional m .cal complexes woul:. .or the most part encompass non-Federal instit:. .ons, whose particips...n in the complex would be . t supported by gran.. Thus, independent responsibility and local initiative would not be diminished by that relationship. Specific arrangements for local control--including the distribution of responsibility among component institutions--will tend to vary among regions. They will also tend to change through time, as one or another administrative problem develops, or more effective forms of cooperation are found, Initial arrangements for local coordination and control must be spelled out in the grant appli~ cation for the complex. Prerequisites for grant approval probably would include: assurances that a properly constituted local advisory group has" been set up and is functioning, that key local agencies, professional groups and institutions have been consulted in setting up the complex, and: that cooperating institutions understand and agree to local arrangements.” ‘ QUESTION: Will avery portion of the United States be covered? “ANSWER: The ultimate objective ie to assure that every person have person have access to the best in medical services, This ; does not mean saturating the country with complexes-- fox we have neither the manpower nor resources to do 60, We view this program es one of developing techniques , stinu- lating broader coverage in all related services and faciiitles-- with the complexes energising Lika demonstrations in a wider comuunity. Guestion; How long will it take to develop a netional network? Answer: Decades (2559) . | @ ‘ GUESTION t ANSWER t Where would responsibility for this program's administration lie within the Public Health Service? In development of our plan for administering this program it fe our intent to utilize competencias found in various componente of the Public Health Service, Assignment to an otganizational unit will be made after the plan has been more fully developed, During the developmental phase the Office of the Surgeon General will assume the responsibility. QUESTION: Could not provision for continuing education in heart disease, cancer end stroke be made under the educational improvement gtants proposed fu the Health Professions Educational Asetetance Amendments of 19657 ANSHER s The Health Professions Educational Assistance Act and the proposed amendments are designed to give primary emphasia to the education of students, This proposel would exphasize the continuing education of tha practicing professional, : Y ms, @ Question. What effect will the proposed categorical approach have on the curricula of medical schools and on undergraduate medical education? Answer. The complexes will have relatively little effect upon undergraduate medical education. Greater availability of excellent teaching cases, the increased volume of research ,and the greater rigor of diagnostic and thera- peutic methods all will improve medical education, but only secondarily. The great educational impact of the complexes will be on graduate specialty training and upon the continuing education of community physicians. Question: Answer: You are proposing to support staff. What proportion of the staff of a regular teaching hospital or medical school are you going to support under this bill. a If they have specialists in cardiology and cancer are you going. to pick up their salaries? Aren't you asking us “c--gomewhere else to give basic support grants to medical - Schools? and improved grants too? os Only those additional professional and technical personnel necessary to operate the components of the "medical complex” would be supported uniler this dill. | oy The major emphasis would be on contimation education for for practicing physicians and other professional personnel. \, \ QUESTION: What will be the impact on manpower--now available or being ANSWER ¢ developed? Will this further dissipate our resources? The complex is a scheme designed to get services to people effectively and efficiently, Thus, although new kinds of medical specialict--teachers will be developed, this will be balanced by personnel economies in improved ways of mobilicing service resources, The complex arrangement will certainly accelerate the coordination end effective use of existing manpowar and improve its quality. Also, the rete of development of manpower will influence rate of development of this program, Q. The program would seem to greatly increase the requirement for medical A. and paramedical personnel. How will these needs be met and where is the manpower coming from? This program will indeed increase the demands for medical and other health personnel. This increase, of course, is reflective of the level of health manpower that this Nation requires to provide high quality and ‘truly effective health services. Present shortages of manpower will obviously affect the pace and magnitude of the initial efforts under this program. However, the plan of the President's Commission calls for specific efforts to enlarge health manpower by continued support and increase in level of training programs, initiation of new training programs at both professional and subprofessional levels, and the ’ expansion and support of health educational institutions and programs. Specific effort to support and enlarge the medical and dental educationd as a part of this program is encompassed in legislation now ‘before the Congress. QUESTION: What will be the relation of the complex to area-wide hospital plenning under the Hill-burton program? ANSWER: § The applicant will be required to show the relationship to local planning activities; further, these are anticipated to be given consideration through the mechanisms of the applicents advisory committee, ’ Question: Ise the prograa, then, another aspect of regional or commmmity planning for health? How would it differ from areawide hospital planning, planning community mental health centers, for e:xa uple which are presently authorized? | Answer: Entphasis on continuing education~-rapidly employing specific . Knowledge in treatment. Not any one of these per se links research, training, and patient care Bill does require relationship with any existing planning activities. QUESTION : ANSWER? Aren't you really telking about developing community plans for service here? Isn't thet the big void to £1117 We seem to be doing a lot of this constracting, research, and training with other support. Communtty plenning for service can subsequently be related, this program is concerned with the quality of health service in commnities<-by bringing to bear tha advances within teaching and research centers to the comunity services, through the community hospital and the practicing professional, Question: Aren't you really talking about planning money and effort heref Don’t you have enough Federal aid for all these things if you could only join them together by planning? — Answer No, we don't have all the pleces--we are avare of gaps, of varying degrees, in many areas. This program provides for planning plus the organizational linkages ani elements or the networke that are inter-institutional, etc., and that link the professional practitioners to the research and the educetional system. , QUisTIONs How 43 a 90% Federal share justified in thig contrasted to other PHS grant prograns? ANSWER: The higher Federal share is justified by the urgenoy of the neod to launch a concerted attack on these 3 "Killer diseases," and the necessity of rapid developnent of aystens for provision of high quality patient care so that research knowledge can be applied as rapidly as possible to People, progran ag question; What share of the funds would be used for construction? Answer; A minor portion even in the earliest phase of the progran. Minimal if any »- once the complex has become established. é @® Question. What will the grant monies be used for, €.8-, Professional staff, ancillary staff, equipment, renovation, new construction, patient care? In what proportion? Who will decide? Answer. Grant funds will be used for professional staff, ancillary staff, equipment, renovation, construction and patient care, but the latter only for care allocable to training, research or demonstration. The proportions would be as set forth in proposed budgets by the applicant institutions. Such budgets would be reviewed, both by medical scientists’ and by administra- tive specialists, and would be subject to regulations similar to those promulgated for the clinical research units now operated through the NIH. © CUESTIONe How do you contemplate using $50 million in this first year? ANWERe We envision the establishuent of fur such complexes in the first year of operation, ranging in cost from (10-15 million each, Roughly, we believe this may be distributed as followas 12,5 million per complex, generally as follows: $2.5 million « for the administrative network and commmication Lines of the medical. ceater, $5.0 million « for basic support of specific activities in heart disease, cancer and stroke, 45.0 million = to establish 20 diagnostic and treatment stations 1n local and commnity health facilities, ($250,000 por station) 912. 5 million a ee QUESTION s ANSWER ¢ How would the complexes help the practicing physician whe is not otherwise associated with a medical school, teaching hospital, or other sponsoring institution? Three ways are envistoned: (1) he has accesa, through hie local sffilfations, to the programs of continuing education . caxtied out by the complex, and (2) he had recourse to gonsultation end aseistance, (3) he may refer hie patient to the center, eo Q. The bill provides for the payment by the patient or a reaponsible third party, for the services rendered under this program except when such services are incident to research teaching or demonstration. 1. Who will be the recipient of and what will be the disposition of such collected fees?, ; | | | 2. Should they not be used to offset, reduce or ‘otherwise reimburse the Federal expenditure? What arrangements will be made for this? _ Ae Fees received by institutions comprising a medical complex for services rendered under this program will be received by the normal collection framework of such institutions and will be used to reduce or reimburse for the Federal expenditures made in support of the program of the @ - medical complex. Accounting arrangements will be worked out which will provide for appropriate allocation of costs under. this program between the | Federally supported activities and those constituting a normal operating : _ costs of the participating institutions. and these pattems will ‘be used ee to allocate income received for services. rendered, to: provide. for proper wt a : £ , : oe reimbursement for Federal expenditures. @ question: Will the costs of transporting patients to regional centers | be paid for under this program? | Anever; | In specific situation where essential to the purposes of the program, Yes «» 4.0, for research, training, or demonstration Purposes. e Question; How would a “demonstration” patient be differentiated from one who was an omlinary patient? Answer: A "demonstration" potient is a variation on a teaching patient, also a variation of a research subject. Who would be hospitalized under agreements clearly identifying hia status. Block grant to medical complex, Regular patient care coats are to tet borne by other mechaniems -< voluntary insurance, ete. Questions You eay you are not going to pay patient care costs except Anawer: those incident to training, research, ox demonstration | activities. How do you judge whether a patient te being used for training purposest If hospitilized only for teaching purposes == yes. Extra costs above normal, if hospital satay were extended for 6@ Tew days to facilitate teaching. * wo 6 1 Question: Answer: You bave stated patient care will be provided only for demonstration, training, or research. Won't this mean flooding elements of the complex with persone seeking quality service? Part of the applicant's submitted program will include procedures to be established to mest this problem.. Much as 4t our National Clinical Center, eligibility will be timé-phased for elther research, training or demonstrations. It will not de a continuing or constant operation. Each complex will determine its ow refertal syoten. ‘The key to this referral system is the practioing physictan. QUESTION: Are you going to serve more patiente (if so--how? and how many?) - of just raise the quality of care of patients now being served? ANSWER: Both, This progran will be providing something that fe not attainable now except in soma ateat, The patients who have these diseases will have access to better and more intensive care, More service will be avatleble to thea with their | physicians having available to thes better gxasourcee and consultation, atte