i 1 itillilill "'I'll f @n' * 161 * 1, A R r m I-, N I' 0 F If I,' A 1, 'I' 11, Ef)UCA'1'10 N A N D W E L F A R E Health Services and Mental Health Administration Division of Regional Medical Programs National Advisory Council on Regional Medical Programs Minutes of the Meeting February 2-3, 1971 Parklawn Building conference Room G/H I)EPARTMEliT OF HEAI;rli, EDUCATION AND WI-"I,FARL PUBLIC ifEALT[i S@,RVICE National Advisory Council on Regional Medical Programs Minutes of the Twenty-second Meeting February 2-3, 1971 The National Advisory Council on Regional Medical Programs convened for its twenty-second meeting at 8:30 a.m., Tuesday, February 2, 1971, in Conference Room G/H of the Parklawn Buildinp.,,, Rockville, Maryland. Dr. Harold Margulies, Acting Director, Regional Medical Programs Service, presided over the meeting. The Council members present were: Dr. Michael J. Brennan (2/2 only) Dr. William R. liuTit Dr. Bland W. Cannon Dr. Alexander M. McPhedrah Dr. Edwin L. Crosby Dr. Clark li. Millilan Dr. Michael E. DeBakey (2/3 only) Dr. Alton Oclisner Dr. Bruce,W. Everist Mrs. Florence R. Wyckoff Mr. llarold H. Hines, Jr. (2/3 only) Dr. Marc J. Musser (2/2 only) A listing of RMP staff members, and others attending is appended. I. CALL TO ORDER AND OPENING REMARKS The meeting was called to order at 8:45 a.m. on February 2 by Dr. Harold Margulies. 11. INTRODUCTION OF NEW COUNCIL MEMBERS AND EX OFFICIO MRMBER FROM THE VETERANS ADMINISTRATION Dr. Margulies introduced Dr. Herbert B. Pahl, the new Acting Deputy Director for Regional Medical Programs Service. Dr. Pahl will have responsibility for work with the Council. It is hoped that future Council meetings can be held in smaller more convenient quarters with staff services planned to help the members make optimum use of their sessions. Dr. Margulies welcomed Dr. Alton Ochsner as A new Council member, and or. Marc J. Musser, the new Ex Of.ficio member from the Veterans Administration. Another new member, Mr. llarold It. Hines, Jr. was introduced the following day on February 3. I/ Proceedings of meetings are restricted unless cleared by the Office of the Administrator, RSKIRA. The restriction relates to all material stibi@i tted for discussion at the meetings, the supplemental material, and all otile@,@@ official documents, including the, agenda. 21 For the record, it is noted that members absent themselves from the meeting when the Council is discussing application-'S- (a) from their re.spective institutions, or (b) in which a conflict of interest might occur. This. procedure does not, of course, apply to -en bloc actions only when the application is under individual discussion. 2 III. ANNOUNCEMENTS Dr. Margulies made generallannouncements, and called attention to- the statement on, "Conflict of Interest," in the information folder. He reported that Mr. Curtis Treen has resigned from the Coun til and that we are working on the appointment of new Counci,1 members to increase the membership to twenty, not including the Ex Officio member from the Veterans Administration, in accordance with Public Law 91-515. IV. CONFIRMATION OF FUTURE MEETING DATES The Council reaffirmed the following dates for future meetings: May 11-12, 1971 November 9-10, 1971 August 3-4, 1971 February 8-9, 1.972 V. CONSIDERATION OF MINUTES OF THE NOVEMBER 9-10, 1970, MEETING With the addition of Dr. Hunt to the list of Council members present, the Council unanimously recommended Approval of the Minutes of t e November 9-10, 1970, meeting as written. Dr. Brennan, Chairman of a Council subcommittee on automated multi- phasic screening, announced that'the subcommittee had met the day before for six hours and that they are developing a working conference to be held in April 1971. The members of the subcommittee ate: Dr. Michael J. Brennan, Chairman; Dr. Alexander M.:McPhedran, Dr. Clark H. Millikan, and Dr. john E. Ktalewski of the Review Committee. The working conference in April will be held in Detroit -and will report its findings to the Council at the May meeting. VI. LEGISLATION, APPROPRIATIONS - RMPS BUDGET A. Termination of RMP Support for Projects At the November 1970 meeting, Council discussed project renewal and, termination of RMP funding for those that seek such support beyond the dates at which they originally proposed to terminate or become self-sustaining. At this meeting Mr. Roland Peterson, Assistant Director for Planning and Evaluation, presented salient findings from experience in six regions with 90 projects that became operational three or more years ago. In most of these projects, three or more years of RMP support was requested initially. Thirty percent of the group terminated RMP support on schedule. In some regions this happened with 60-70% of the projects. On the other hand, many individual projects expanded their budgets. In some instances projects seemed to disappear from RMP listings, but the activities continued to receive P-MP support through the budgets of core or other project activities. RMP support tended to persist longer for medical school than for community projects. This kind of analysis will continue to be reported. Additional regions will be included as they reach appropriate ages. B. Overview of Adaptation to Requirements of New Legislation The ongoing ptotess of adaptation to the "program review" and triennial cycle must be integrated with adjustment to features added to the legislative base by P.L. 91-515. Regulations and guidelines are being re-examined for this purpose. It is hoped that the formal regulations tan be kept simple and straight-forward. Publication of guidelines should take a form that will facilitate both their development by Council and their application to RMP operations New legislation features of particular interest include: 1. Review of RMP'plans by CHP "b" agencies that have plans in being: RMPS is hopeful of broadening the RMP-CHP working relation- ships beyond the letter of the law, to improve the combined effect of the agencies' planning on health services. 2. DHEW recommendations for changes in the scope of the program: Modification of the disease-categorical targeting of the legislation might be one such proposal that RMPS and Council should examine. Council may wish to express its opinions on any proposals concerning the scope of'RMP or CHP legislation that go;to the Secretary. 3. Annual report on RNP effectiveness: The first report, already repared by RMPS, was essentially a status or baseline report. p Council may wish to tontribute to these reports regularly. The schedule for such reports suggests that Council's input should be resented in the fall of the year. p C4 BudgetAry Outlook Plans for the fiscal year 1972 budget will have a considerable impact on the final apportionment o funds for the remainder of fiscal year 1971. At present the outlook is for level funding of RMP grants at $70 million for each of the two years. 'I'h3'-s would be accomplished by reserving a large part of the 1971 appropriation to be carried over for obligation in 1972. This presents two -kinds of problems. First, b6tause it requires a major reduction in current commitments to Regional. Medical Programs for both years, the planning and persuasive aspects of the Regional Medical Programs becomes more important, with less emphasis on their capabilities to support projects. Secondly, it presents a very low appropriation base for the 1973 budget, so that maintaining the same 4 $70 million level through that fiscal year will require a significant appropriation increase. The 1973 budget presentation is.essentially A technical problem that mus@ be solved by RMPS within the DHEW structure. The adjustment of RNP awards to the proposed reduction would affect everyone and requires Council's attention. One possible route would be to find the necessary reduction by cutting awards to the' less effective regions, and retaining levels closer to-existing Commitments in tiie more effective regions. This and Alternative policies will be the subjects of intensive study over the next few weeks. D. Progress in Administrative Adjustment to Legislation, the Triennial Cycle and National Emphasis on Programming Couneil's policy statements are being examined for possible review@and ]Zeview criteria have been updated, but are subject to modifi- cation and refinement as necessary. Council's Participation will be sought as plans and drafts become available. When completed, these materials will be g@ven not only to Council and staff,, but also to the Regional Medical Programs as well, as aids to program development. Meanwhile, the Pd4PS is developing a comprehensive review system integrated with a new Management Information System. The objectives of these de- v6lopmOnts ate to effect economies in time, integrate RMP activities with the total HSMHA program surveillance, and improve RMP performance. These developments are intended to potentiate the formation and implementation of our human judgments. 14 The current sta.tus of'the RNPS Management Information System was presented by Mr. Frank Ichniowski, Acting Chief, Office of Systems Management RMPS. During his presentation he highlighted some of the most recent accomplishments of the MIS team and then proceeded to tie in these current activities with the MIS implementation plans. In line with these plans, lie announced a planned reorganization of tlie'Office of Systems Management to better reflect the demands of the Management Information System and to more optimally utilii6 available personnel.. This reorganization provides for separate branch activiti s within-OSM dealing with: MIS Design and Analysis, Programming, and '4 Data Base Control. It was pointed out that At least five major sources will be providing inputs to the MIS. These inputs include the Anniversary Review' Application, the Regional Reporting System, Site Visits, and other reports on contacts, RMPS Staff and the Regional Office. Certa n:othe efforts currently underway by the MIS team were identified, n ly; Development of an MIS liaison team, use of MIS consultant, and Mi@ seminar presentations. it I-. lntc!ii(It@(i Lli,,it Llicse extra curricular acLIVitic-1; Will strengthen and more acciitately guide the plan being developed. Mr. Ichniowski then linked these various ongoing activities to a series of proposed outputs which could reflect the needs and demands of the system users. This output plan categorized outputs as emanating from combinations of four major groupings: Financial Information, Regional Characteristics, Performance Records and Control, and Historical Records. Ultimately, the MIS will provide usage, via remote teletype or video display units, to RMPS, Review Committee, National Advisory Council, HSMHA, the Regional Office and the Regions themselves. The Review Cycle and its Tools. Mr. Ken Baum presented a description of the purposes, phases and tools of the proposed i triennial cycle of review and surveillance. a. Council Discussion On efficiency of operation: Development of such systems always risks over-elaboration of the Management Information System; the manualizihg of procedures, ritualization of site visits and of application reviews can result in evet-indteasing qw demands on staff and advisors' time. ... Danger of over-simplifying a complex multi-disciplinary operation like the management of RMP; observance of rigid pro- cedural specifications may conceal real problems and forestall application of important professional judgments. ... Council-staff responsibilities: Need full understanding of Council's responsibility for program and financial judgments. In some research programs councils have concerned themselves with content, left funding to staff discretion. Some councils control initial funding and commitments others concern them- st!lves with other funding decisions. Staff discretion in approving program changes without Council review also needs definition. ... Regional Medical Program development and progress: Council needs to observe conformance with guides, quality of project designs and operations,, not only to maintain program direction, but also to evaluate its own guidelines and policies. 6 I)cvcl.opments in regions do not always present-themsc-lvc!s on fixed anniversary or triennial dates; sometimes it is highly desirable to review and activate new departures as soon as their virtues becomc-a,pparent. -Cross communication between regions could be impeded at considerable loss in effectiveness if concepts had to await. fixed dates of Council review. Council's job is primarily policy determination, but both cyclical and interim reviews of operating and proposed changes contribute to Council's judgments. Perhaps Council and staff action responsibilities could be enumerated, with staff pre- senting a list of its actions for discussion at each Council meeting.. The position of,the Regional Advisory Group needs very clear specification in documentation of the review process and the assignment of responsibilities. b. Staff Response ... Efficiency of operation: Staff projections for the modes of operation-in the management information and review procedures now envisioned indicate that the new approach will gave time on routine basic processes and'leave more time available for sub stantive tasks. Over-simplification: The general aim of the plan is to emphasize human professional judgments at all points of decision.. ... Council-staff responsibilities: Council's responsibilities for grant decisions are fixed by law- the purpose of this pro_ cedural development is to give Council a choice of ways in which its responsibilities can be carried out efficiently. Staff will prepare a list of Council-staff responsibilities and Council choices for next meeting. ... Regional Medical Program development and progress: Cross- communication between regions occurs naturally through direct region-to-region exchange and through region-staff-region routes. Staff plans to bring Council a report on cross-communication at the next meeting. Council action: Staff was requested to circulate for coh- sideration at the next meeting a description of the proposed review process and the types of judgments that would be reg6rved to the Council. 7 VLI,- REMARKS BY DR. VERNON E. WILSON, ADMINISTRATOR, HEALTH SERVICES AND ,IFNTAL ]if-.ALTH ADMINISTRATION A., Appointment of Director: Dr. Harold Margulies has been confirmed as Director, RMPS; only the paper work remains to be completed. B. 'Recommendations of the Willard Task Force: Completion of the task force report is expected soon. Unfortunately a draft could not be developed in time for this session. C. Health Maintenance Organization: The Health Maintenance Organization (HMO) concept is a broad flexible one that has strong HEW support. The term now refers to organizations providing comprehensive health care to enrolled populations and financed by capitation. Prepayment and carefully defined packages of services to represent comprehensive care are important elements in current considerations. HEW is very active in implementing the concept and in stimulating the formation of HMO'S. Late in November the SecretAry appointed the following four task forces to examine important aspects of HEW posture toward the concept: Policy Relationships with non-HEW agencies Financing Technical Assistance The Administrator, HSMHA, heads the technical assistance group. However, heads and members of the groups were selected not to represent their constituent agencies, but to explore concepts of the Department's in- volvement. Ultimate assignments for implementation of HEW policies and responsibilities for HMO's are by no means obvious and certainly are not decided. There is a high probability that HSMHA as the DepArtment's technical agent in health care d-elivery will have an important role in technical assistance for IR40 propagation. CHP agencies undoubtedly will have review and comment responsibilities concerning proposed HMO activation. RMP As a channel for provider expression will be fully involved. It seems clear that HEW will actively -support promotion of HMO attivati6 The Department will offer technical assistance and the planning and coordinating capabilities of its field arms and associated ag6n&ieg. There is no plan to replace existing forms of health care with the HMO. the objective is to open access to health dare as broadly as pbssible@4n4 to offer a choice among health care vehicles to those for whom alternatives are not now available. 8 Funding of HEW activities is as yet unresolved. $2.25 million may be available from NCHSRD 1971 appropriation; some amount might be taken from reserved RMP funds; other amounts may yet be found elsewhere. Technical assistance funding might well become a HSMHA responsibility. Whatever is decided for fiscal year 1971 activities will affect planning for 1972 appropriations for other programs as well as for the IISMHA total. D. Questions and Answers: Q. What are the characteristics of a desirable HMO? A. I* has taken from September to January to arrive at the following list of characteristics: An organized system of contractually related health care facili- ties; an organized multi-disciplinary group of health care pro- fessionals; an enrolled group of clients; a sound insurance p an. No rigid prescriptions have been adopted for Accommodation to the insurance plan or for minimum enrollments. What is the Department's view on coverage of enrollment? A. Broad. If access to health care is to be extended through the HMO device, some groups will require assistance. SSA and SRS are looking at this. A Family Health Insurance Plan might be a vehicle for extending coverage. Q. Looking beyond the problems of initiation and establishment, what will provide long-term support? A. A soundly planned HMO should be supported by the revenues from its operations. Q. Will Federal contributions on behalf of Federal beneficiaries be uniform? A. It seems logical to believe that Federal HMO's will expect uniform or at least minimum packages of individual or family care, but will "regionalize" the prices of the standardized packages. Q.. Could a large employer set up a "house" HMO? A. Some are already studying the idea. It seems likely that three or four will appear soon. Labor organizations also are interested. 9 Q. Is legislation expected? A. Proposals on financing loans and insurance are being considered.. Nothing new is needed for program administration. Q. What rate of progress does the HEW visualize - how many HMO projects might be established in a year? A. Many questions must be investigated in order to organize an HMO, establish the necessary contractual relationships, specify and price service packages, and work out enrollment principles. About fifty groups are known to be interested. Q. What is the outlook for action in the field of quality of medical care? A. Models for operations in this field are needed. SSA, SRS, and HSMHA are studying the possibilities. Agency responsibilities are not yet cleat. The RMP as a provider organization might logically be a vehicle for administration, but lacks credibility because performance has been uneven. This is one of the mult'- program topics on which Council may expect to be asked for advice, in line with last meeting's discussion. VIII. STATUS REPORT ON GUIDELINES, CONTRACTS AND PLANS FOR THE FUTURE A. Heart Disease, Cancer and Stroke Guidelines Dr. Margaret Sloan reported on the status of the heart disease, cancer and stroke guidelines. Preparation of the guidelines has been going forward under three contracts. These have enabled multidisciplinary groups of health professionals representing all'the professional organizations interested in a particular disease area to obtain the consensus of experts. Agreement has been reached on the criteria which would have to be met by medical institutions in the country in regard to personnel, organization, and facilities if they were to be capable of providing the highest quality of care for patients with heart disease, cancer, or stroke. in the original concept, these groups were expected to develop criteria@ for a list or lists of 10-20 outstanding centers in the country as required by Section 907 of PL 89-239. As the work progressed, it was redirected to the present focus on quality care in all types Of medical installations which will be mote broadly useful. The Cancer Guidelines, prepared under a contract with the American College of Surgeons, ate about to be published by the College at their own-expense. The final document will still not be entirely patisfatt6rv to the Council, but should prove useful in setting A goal for development of resources for the treatment of cancer patients. 10 The Heart Disease Guidelines, being prepared by the Inter-Society Commission on Heart Disease Resources under a contract with the American Heart Association, a@e being published in preliminary form as a series o reports in the Journal Circulation. These deal separately with each major form of cardiovascular disease excluding stroke, and cover the areas of prevention, diagnosis, treatment, and rehabilitation. When the last report has appeared it Circulation, they,will all be reviewed again in the light of comments and criticism received, revised as necessary, and printed in monograph form by the C.P.O. Initial response to these reports has been most enthusiastic. RMPS is now working on problems of publicity, distribution, and gaining the attention of physicians, hospital personnel, and health planners to their contents. Implementation will be stimulated by the l@Ps and the affiliates of the AIIA. The Stroke Guidelines are being developed by the Joint Committee for Stroke Facilities under a contract with the American Neurological Association but have not yet reached the publication stage. There was agreement that the Guidelines would be of value only as long as.they are kept up-to-date and, therefore, that a mechanism should be established for periodic updating and.revision. In the case of the Heart Disease Guidelines and in an attempt to preserve continuity in the effort,, it was proposed that a new contract be negotiated with the AHA to continue the ICHD for one more year during which that organization would carry out an evaluation of the acceptance and applicability of the Guidelines. At the end of that period, it was anticipated that the AHA and the American College of Cardiology would jointly assume responsibility for revision and maintaining the currency of the Guidelines. 'A similar arrangement will eventually be considered for the Stroke Guidelines. In the case of the Cancer-Guidelines, which are organized according to the specialty groups involved in diagnosis and treatment, the Council considered the possibility of a different approach which might be mounted to consider all the resources of personnel, organization, and facilities needed to deal with each major type of cancer. The Board of Regents of the American College of Surgeons was considering the establishment of a Task Force which might under- take the development of cancer guidelines dealing more specifically with the major types of cancer. Dr. Brennan proposed that RMPS negotiate a contract to develop a model for the comprehensive, multidisciplinary treatment of cancer patients on a regional basis using a systems analysis approach. The concept proposed involved: 1. Estimating the cancer burden of a selected region for a period of years ahead; 2. Measuring the cancer control resources and capability of the region to provide the quality of control envisioned in the Gtjidc,- lines; 3. Determining the improvements needed to make the region's cancer capabilities equal to its requirements; and 4. Programming steps the providers of health care could take to achieve this goal. Dr. Brennan indicated that Detroit might be an appropriate locality in which to develop the proposed model. Dr. Margulies agreed that RMPS would review the pilot model proposed and report on the plan at its next meeti@. The Council expressed approval of the guideline contracts as a mode of obtaining expert opinion and,consensus of the medical profession in the complicated fields of preventive and clinical medicine. Since the Guidelines were prepared by the profession for the profession, it was felt that they would be far better received than any Federal guide- lines or standards. It was suggested that the Heart Disease Guidelines be considered a model which could be used by HEW for other target disease areas. The Council was warned that such guidelines would not always be accepted without dissent and could provoke controversy. For example, the National Heart and Lung Institute had expressed the opinion that the dietary recommendations in the report on the Prevention of Atherosclerosis, reviewed at the preceding meeting of this Council, were premature. IX. STATUS REPORT ON RMP AND CHP CONTRACTS Mr. Peterson reported on progress made on the contract, HSM 110-RMP-62(l),, "Information Support System (ISS) for Management Control and Evaluation." This contract is to assist the administrators of Regional Medical Programs, in solving problems in management control and program evaluation by providing them with certain types of information which are not Usually available. The system is designed to develop information for Program Coordinators on the character and extent of the interaction of the RMP with the various segments of the medical community, as well as with its, -level of involvement with various types of medical problems. Informatit)n collected through the analysis of documents as grant applications, news- papers, and newsletters will form the basis of individual reports to each Regional Medical Program, and a summary report to the Regional Medical Programs Service. 12 The contract to study, "Comprehensive Health Planning," made with 1 and Technological Innovation, Inc. (OSTI), ,the Organization for Socia and Arthur D. Little, Inc., to assess the character and progress of Comprehensive Health Planning is now getting underway. X. COUNCIL POLICY ON LONG TTRM TRAINING AND TRAINING IN SPECIALTY AREAS' Council continues to receive inquires about specialized long-term training as an RMP activity. Individual inquiries sometimes relate to support of professional pre-doctoral training and sometime to post-doctoral or post-residency training. At the,present meeting, requests urging RMP support of post-resident training in nephrology for physicians and of training for. occupational, physical and speech therapists were received from the Southeastern Coordinators. Council took note of the need for trained personnel in these and other categories and urged the Regional Medical Programs to take steps to identify the needs and stimulate action, such as listing existing vacancies and publicizing them. Council also noted that RMP funds are insufficient to finance a significant contribution to solve this problem. ACTION: Council reaffirmed the position taken at its last two meetings and did not make an exception for the requests presented at this meeting. XI. COUNCIL POLICY ON PUBLIC SERVICE PROGRAMS (BROADCASTS) OF RMPs Council was asked to consider enunciation of a policy governing content of broadcast or other public service utterances of Regional Medical Programs. One incident was reported to illustrate the need for a stated policy. Council noted that a Regional Medical Program through an unguarded issuance can embroil itself in counter productive controversy. It was noted, alsoi that such incidents have been few in number, and local@in effect. There is some danger of exaggerating the significance of such events by making a formal pronouncement of whati in general, is a matter of common sense. ACTION: The Acting Director, RNPS, was asked to discuss the specific circumstances with the coordinator of the region in which it occurred. XII. HYPERTENSION RESOLUTION A representative of the National Heart and Lung Institute presented resolutions of the Councils of that Institute and the National Institute of Neurological Diseases and Stroke with a resolution of the Joint Council Sub-Committee on Cerebrovascular Disease. Redom- mended by all three was a program of community projects for appli- cation of drugs to control of hypertension. VA studies utilizing 13 experimental placebo groups have shown such dramatic effects with both severe and moderate hypertensives that medical ethics dictated discontinuance of the placebo control groups. The NHLI has prepared request for proposals for clinical trials in the general population. All three of the advisory bodies mentioned above have commended this need and effort to the attention of the Regional Medical Programs, in hope that they will find ways to initiate and assist in such trialsi ACTION: Council requested RMPS to alert all Regional Medical Programs to these opportunities and to distribute the NI[LI requests for pro- posals as well as reports of the VA experience to all regions. XIII. REPORT OF THE AD HOC REVIEW CO@4ITTEE ON KIDNEY DISEASE At the request of Dr. Harold Margulies, this Ad Hoc Committee was convened on January 27-28, 1971, .to review the applications submitted to RMPS related to renal disease projects. It was the unanimous opinion of the committee that there is a need to define the mechanism of evaluation of these projects. It is clear that there is a significant gap between the existence of proven life-saving techniques in kidney disease control and their application on a broad scale. In reviewing the submitted proposals on renal disease, it became obvious that there was inadequate screening at the local level. This is a result of the lack of an established advisory group in renal disease in most areas and the difficulty in finding local expertise not involved with the submitted projects. This Committee recognizes the need for the development of kidney disease projects at the local level, based upon the unique needs of a given region. However, based upon our present review experience, we would recommend that these projects undergo more intensive oeer revi@w and applicants b& encouraged to submit the proposal to a panel of reviewers in the field. These reviewers could be from within or outside of the region. Local Regional Medical Programs intending to submit proposals could receive aid in the preparation and technica I review of their project from the Kidney Disease Control Program. It would, there fore, be possible for a region to submit a realistic proposal which best suits its particular area and has undergone extensive review. In view of the fact that the total amount of funds and manpower which will be Available for kidney disease projects will not fulfill the total national needs for these projects, we believe that the existence 14 of a categorical review body at the Federal level may have distinct advantages. A Kidney Disease Review Committee would be capable of examining all projects in this area and determining a priority assignment based upon a proper national distribution of facilities with emphasis on sharing of facilities and the promotion of inter- regional cooperation. In collaboration with the Kidney Disease Control Program, the Committee would therefore be capable of providing an overall perspective which would be geared to avoiding wasteful duplication of effort And expense in this area and stimulating activity where needs exist. Ultimately, we are confident that advances in the state of the art and in the development of new funding mechanisms will evolve to the point where there will be no advantage to the consideration of kidney disease projects separately. A non-categorical approach to evaluation of these projects will be more appropriate at that time. Pot the present, however, we feel that the establishment of a categorical peer review group, which is capable of comparing the numerous kidney disease projects submitted by the various Regional Medical Programs, would be an effective way of ensuring the development of kidney disease activities that embody local needs as well as a broader national or inter-regional overview.' XIV. RECOMMENDATIONS FOR ACTION - REVIEW OF APPLICATIONS 1/ ALABAMA REGIONAL MEDICAL PROGRAM - RM 00028 2/71 Total direct cost levels for continuation. New, renewal, And develop- mental activities for the next three years are as follows: 01 - $1,765,557 04 $1,654,245 05 - $1,373,606 Request for developmental funding is approved as requested. Council did not believe another site visit was needed to appraise the capacity of the Region to utilize this type of funding. This Council action differs from Review Committee in that approval for developmental component and additional funds for this purpose are recommended. This Council action also reflects consideration of the policy issues raised by the Continuin Education and training 9 Branch regarding Proje6t #37 - Taking the Lid Off the LPN and Project #4R - Health Manpower in Junior Colleges. Council believes the Region's priorities should be the determining factor concerning these education activities since present policy does not preclude their funding. 1/ All amounts a-re direct costs only and unless otherwise specified refer to a 12-month period. The designation 01, 02, etc. relates to the first', second, etc., budget periods for the sub@ect application, not necessarily the budget periods that will npfiinlity hp'.Qtinhii-Tn@nt-pii-' 15 ARKANSAS@Rl,'CIONAL MEDICAL PROGRAM - RM 00052 2/11 (Supplement) Additional funding is recommended at a minimum of $111,925, $113,734, $122,884 with the maximum to-be determined by staff after receiving technical site visit team's recommendations regarding funding for Project #37 - Comprehensive Pro@ram for Kidney Disease Control. CALIFORNIA REGIONAL MEDICAL PROGRAM - RM 00019 2/71 & 11/70 (Supplement) Approval of developmental component funding for California REP. Approval of increasing level of funding for current 03@year by $407,768 of which $200,000 is for developmental funding. Approval.of future funding for California RMP for both core, projects and developmental funding at following levels: 04 - $8 363,994 05 - $8,363,994 06 - $8,363,994 Subject to following conditions: 1) overall RMPS funding restrictions; and 2) satisfactory pr ogram priorities to be included in May 1971 application. D61egation to California RAG decisions regarding allocation.for all projects included in both November 1970 and February 1971 ap lications p t for Project #65 Comprehensive Renal Detection, Diagnosis excep and Treatm6nt Program (Area VIII) and #74, Blood Banking (Area V). This action-differg from Review Committee recommendations in the number of years of funding recommended. Council concurred with site visit team that this Region needed guidance from Council regarding overall level of funding to be anticipated before sub- mitting application for thre6-year funding of operational projects in May 1971. COLORADO/WYOMING REGIONAL MEDICAL PROGFPI4 RM 00040 2/71 (Supplement) No additional funding is recommended. Developmental. funding is disapproved. Region may rebudget available funds into Project #22 and Project #24 if the RAG determines that they: a) respond to a recognized need for local regionalization and improvement; and b) demonstrate integration into the Region's health care system in a way that will permit dis- engagement of RMP funding within a short time. Because of Council policy regarding use of RMP funds for basic education, Project #23 is ineligible. This Council action incorporates recommendations of the Review Cormnittee and staff interpretation of policy regarding Project #23. 16 ('ONNI-'CTICUT REGIONAI, MFI)LCAL Pit0rRAM RM 00008 2/71 (Stipplemc-nti 4 Additional funding at a reduced amount of $70,496 is recommended for the current 03 year. This Council action is the same as recommended by the Review Committee. FLORIDA REGIONAL MEDICAL PROGRAM - RM 00024 2/71 Additional funding at a reduced level of $200,000 - 03 year4 $160,000 04 year; $145,000 - 05 year is recommended. Action on Project #38, The Florida Statewide System of Patients With End SLaZ6 Kidney Disease, was deferred to provide time for advice, revision and resubmission as recommended by the Ad Hoc Panel on Renal Disease. This Council action concurs with the combined recommendations of the Review Committee, and Ad Hoc Panel on Renal Disease and staff with regard to renewal of Project #15. GREATER DEIAWARE VALLEY REGIONAL MEDICAL PROGRAM - RM 00026 2/71 No additional funding is recommended for activities presented in this application. Region has option to rebudget available funds into new Project #27 Director of Medical Education as well as for previously approved Projects #6, #8, #10, #14, and #15. RMPS funding is precluded for the training of lay personnel proposed in Project #28, First Care Cardiopulmonary Resuscitation Traini@ Program (December 1969 Countil). Projects #25, Regigtal Dialysis Training Project - Crozer-Chest6r Medical Center and #26 - Demonstration and Evaluation of a Dialysis Training Program - ThomAs-Jefferson University ate disapproved. Council agrees with Review Committee and Ad Hoc Panel on Renal Disease that two dialysis training projects in same area raise serious questions about cooperative planning and review procedures in the Region. This Council action differs from Review Committee recommendations in respect to funding recommended. 17 HAWAII REGIONAL MEDICAL PROGRAM - RM 00001 2/71 (Supplement) Addi.tional funds are recommended for three years: 03 - $366,300 04 - $285,182 05 - $285,119 Request for one year developmental funding is approved. Because of Council policy, Project #23, Mobile Cor Care, is not recommended for support. This Council action concurs with Review Committee recommendations. INDIANA PEGIONAL MEDICAL PROGRAM - RM 00043 2/71 (Supplement) Additional funding of $150,000 for one'year is recommended for this Region. Request for developmental funding is disapproved. This Council action coincides with Review Committee recommendations. ILLINOIS REGIONAL MEDICAL PROGRAM - RM 00061 2/71 Increase in support for one year only to a total level of $2 million is recommended for the Illinois IIMP. Dev6lopmental funding request is disap roved at this time. p This Council action coincides with Review Committee recommendations. INTERMOUNTAIN REGIONAL MEDICAL PROGRAM - RM 00015 2/71 Additional funding of $225,000 recommended for this Region for one year. Request for developmental funding is approved as requested. Region may rebudget funds into any projects included in this application or for continued cooperative planning for Project #29, Physician's Assistants Training,. (11/70 application). However, Council would like to advise Region that decision to continue funding of Project #16R Endocrine ram - would raise doubts..about Regional priorities. This Council action coincides with Review Committee recommendations. 18 LOUISIANA REGIONAL MEDICAL PROGRAM RM 00033 2171 Additional funding of $400,000 for one year is recommended. Request for developmental funding is disapproved. Region may rebudget available funds into supplemental, core, planning and feasibility studies or projects included in this application. Project #9, The Metropolitan Organ Bank, is approved with advice to Region about the budget and the educational program plans, as noted by the Ad Hoc Panel on Renal Disease. This Council action coincides with recommendations of the Review Committee and incorporates the advice of the Ad Hoc Panel on Renal Disease. @tARYLAND REGIONAL MEDICAL PROGRAM - RM 00044 2/71 No additional funding is recommended for activities proposed in this application. The request for developmental funding is disapproved. Project #33, A Comprehensive Regional Approach to Educatiot and Therapy for Chronic Renal Failur6, is disapproved as recommended by the Ad Hoc Panel on Renal Disease. Advice to Region should convey Countil's specific desire that in- formation about program concerns should not be interpreted as criticism of the new coordinator, rather as hope that he can mobilize MRNP resources for coordinated action. This Council action coincides with recommendations of both Review Committee and Ad Hoc Panel on Renal Disease. METROPOLITAN WASHINGTON REGIONAL MEDICAL PROGRAM - RM 00031 2/71 Total direct cost funding for three-year levels are recommended for continuation, new or renewal activities as follows: 04 - $1 658,351; 05 - $1,359,906;,06 - $1,116,353. Request for developmental funding is disapproved. Additional funding for continuation of Project #12, Mobile Coronary Care Unit, is not recommended but Region may rebudg or 0 'ded completing two full years of activity, as originally proposed, pr vi evaluation is completed. 19 METROPOLITAN RMP CONT. All kidney disease projects tire disapproved. Project #16 - Mobile Dialysis Center, Project #47 A Regional Nephrology Program, and Project #31 Capitol Hemodialysis Trainipa are disapproved as recommended by the site visit team and the Ad Hoc Panel on Renal Disease. Region should be advised of Council's interest in further review only of a comprehensive proposal for renal disease, rather than project-by-project proposals. Region may rebudget funds into projects included in this application if RAG determines that they are of high priority and within RMPS policy. Project #17, National Career Council, Project #23. Inhalation Ther@ Training, and Project #43, Cervical Cancer Detection raise policy issues. One year funding only is recommended for Project #2R. This Council action differs from Review Committee recommendations only in level of funding recommended for each of three years, coincides with recommendations of Ad Hoc Panel on Renal Disease and incorporates advice from the December:7-8, 1970 site visit teim. MICHIGAN REGIONAL MEDICAL PROGRAM - RM 00053 2/71 (Supplement) Additional three-year funding at a reduced level is recommended for two new projects as follows: 01 - $368,07 3 02 - $366,098 03 - $388,274 This Council action coincides with Review Committee recommendations. NEW JERSEY REGIONAL MEDICAL PROGRAM - RM 00042 2/71 Total direct cost levels for continuation, new and renewal activities recommended for the next three years as follows: 01 - $2,989,501\-\ 02 - $1,454,750 03 - $1,276,466 The second and third year levels do not reflect core support which was not requested At this time. Request for developmental funding is approved as requested. Request for one additional year of support for Project #3Ri R6gi6nal Training Center for Cardiac Nursing, is approved. This Council action coincides with Review Committee and incorporates advice and recommendations from December 1970 site visit team. 20 - NEW MEXICO REGIONAL MEDICAL PROGRAM - RM 00034 2/71 (Supplement) Additional funding is recommen ded as requested for Project #16, Hear t, Sound, and Murmur Screening Program for New Mexico School Children, as follows: 03 - $45,188 04 $55,558 05 - $57,069 This Council action coincides with Review Committee recommendations. NEW YORK METROPOLITAN REGIONAL MEDICAL PROGRAM -.RM 00058 2/71 (Supplement) Additional funding of $200,000 for developmental component Is recommended for one year. No additional funding is recommended for new Projects #25, #26, #27, and #28; however, Region has option to rebudget available funds into these activities, provided RAG determines they are of high priority for present goals and objectives of Region. This Council action coincides with Review Committee recommendations. NORTH DAKOTA REGIONAL MEDICAL PROGRAM - RM 00060 2/71 Additional funding of $30,000 is recommended for one year. Request for developmental funding is disapproved. Region may rebudget available funds for increased core or approved projects in line with its own priority. This Council action coincides with Review Committee recommendations and incorporates advice from the December 1970 site visit team. NORTHLANDS REGIONAL MEDICAL PROGRAM - RM 00021 2/11 Approval of level of funding for three years for all activities, including continuation, new activities and developmental funding As follows: 03 - $1,9545,400 04 - $1,511,600 05 $1,378,700 Approval of developmental funding as requested for three years. Regipn may rebudget available funds into any of activities proposed in this application, if RAG determines they are of high priority for Regional objectives and in line with RMPS polici68i Attention to RMP. polity is particularly pertinent in regard to Project #20, Diabetes Education Center, and #21 Congenital Heart Disease Registry. Region should be advised of Council's questions regarding priorities for Project #22, #23, #13, and #12 and the limited time recommended for Project'#14, as noted by the Review Committee. 21 NORTHLANDS RMP CONT. This-Council action coincides with Review Committee recommendations and incorporates advice from the site visit team. OREGON REGIONAL MI?DICAL PROGRAM - RM 00012 2/71 A total direct cost level of $1,064 291 for the 15-month 04 year is recommended for this region. Region may rebud et available 04 year funds into core, continuation 9 projects, renewal projects and new projects in line with its priorities and objectives. Approval for'the renewal projects.is for one year only with the exception of Project #4R, Comprehensive Stroke Care with Regional Education, which is approved for the 05 and 06 years as requeste 05 - $54.,444 06 - $56,617 Council takes exception to its general policy regarding phase-out of RNP projects because of Project 4R's outstanding demonstration qualities. Thig Council action differs from Review Committee recommendations in the level of funding recommended for the 04 year. Project #21 was withdrawn by the Region and Council concurred with staff's recommendation that $91,580 additional funding was needed to support on-going projects.@ SOUTII DAKOTA REGIONAL MEDICAL PROGRAM - RM 00067 2/71 Approval of South Dakota Regional Medical Program as a separate Region. Three-year funding for core and one year continued funding for coronary care activities in three South Dakota hospitals is recommended as follows;- 01 - $379,500 02 - $313,000 03 - $3769000 This Council action coincides with Review Committee recommendations. SUSQUEHANNA VALLEY REGIONAL MEDICAL PROGRAM - RM 00059 2/71 (SPECIAL ACTION) Approval of two years' additional funding for Project #6R, nar Care Nurses' Training Program, G6isinger Medical Center and one year funding for Project #25, Altoona Coronary Care Training, in followin amounts: 01 - $88,425 02 - $31,551 22 SUSQUEHANNA VALI,EY RMP CONT. Deferral of remainder of application for new funding, pending a site visit to study the program progress, plans for priorities for the future. This Council action differs from Review Committee recommendations. Council considered as a special action the Region's third proposal for CCU Training at the Altoona Hospital and recommended funding for one year. TLXAS RL,'GIONAL MEDICAL PROGRAM - RM 00007 2/7i _(@PP E@LTIA S@@IAL AC-T @114 Additional funds are recommended As follows: 03 - $26,900 04 - $26,500 Region may rebudget available funds into any of the other activities included in the supplemental application in line with Regi6h's priorities. Council wishes to advise the Texas RAG that any RMP funding for both Project #53, Choriocarcinoma and Related TkppA@lastic Diseases and #50, Control of Hypertension and Chronic Renal Di@ a@se, should be transitional only to permit project directors time to locate other sources of funding. Council recognizes that long-range support is necessary to accomplish the aims of Project #5031 but does not believe @IP should be the source. The previous restriction on expenditure of funds for Pro'ect #14R, Stroke Demonstration Program for ive Patient C re, should be lifted. This Council action incorporates recommendations from both Review Committee and the Ad floc Panel on Renal Disease. VIRGINIA RLIGIONAL MEDICAL PROGRAM - RM 00049 2/71 (Sup@enen@t) No additional funding is recommended for the Virginia Regional Medical Program. The request for developmental funding is disapproved. Council will reconsider request for additional fundinp, for Project #10, Multiohasic Screening Program, in May when special Council subcommittee reports its recommendations. Action on Project #12 Procurement of Cadaver Kidneva for Tta hs6lahtati66, i6-deferred, pending Region's response to advice from Ad tioc Pane Renal Disease. 23 VIRGINIA RMP CONT. Region should be advised of Council policy regarding support of new mobile units in relation to Project #11. This Council action incorporates recommendations from Review Committee and Ad Hoc Panel on Renal Disease. WASHINGTON-ALASKA REGIONAL MEDICAL PROGRAM - RM 00038 2/71.1 & 2 71.2 Additional funds are recommended as follows: 04 - $289,778 05 - $-268,129 06 - $30 700 Developmental funding is approved as requested. Additional funding is recommended for Project #9R Alaska Medical Library, and #38R - Medical Computer Service, as requested. Additional funding is recommended for the Regional Kidney Program, as noted by the Ad.Hoc Panel on Renal Disease. Region should be advised, however, that despite the Panel's concerns about specifics of the Regional Education Program, Region may incorporate continuing education on renal disease into overall continuing education program when appro- priate. This Council action coincides with recommendations of Review Committee and the Ad Hoc Panel on Renal Disease. WESTERN NEW YORK REGIONAL MEDICAL PROGRAM - RM 00013 2/71 Additional funding is recommended for Western New York as follows. 04 - $359,424 05 - $374,827 06 - $113,265 The request for developmental. funding is disapproved. Region has option to rebudgot funds into projects, included in this application, but should be advised on Council's concerns about lack of priorities for the overall program. Funding for Project #21, Choriocarcinoma and Related Trophoblastic Disease, should be considered as transitional and short-term only to provide time to develop other sources of funding. C6uncil cites Project #lR, Tel6phone Lecture Network, for special consideration in funding. This Council action coincides with Review Committee recommendations. 24 WEST VIRGINIA REGIONAL MEDICAL PROGRAM - RM 00045 2/71 Additional funds are recommended as follows: 02 $260 000 03 - $260,000 04 $260,000 Region may rebudget available funds into any activities included in this application if RAG determines they are of high priority and in line with RMPS policy. Attention is called specifically to Council policy on registries related to Project #12, Cancer Education and Service. Region should be advis6d,bf Council's special interest in Project #8. Medical Self-Audit. This Cobncil action coincides with Review Committee recommendations. WISCONSIN REGIONAL MEDICAL PROGRA!4 - RM 00037 2/71 (Supplement) Action on this request for developmental funding is deferred pending Council consideration of Region's triennial application in August 1971. Council suggests that Region incorporate plans for developmental funding in Triennial application. This Council action coincides with Review Committee recommendations. XV. ADJOURNMENT The meeting was.adjourned at 12:30 p.m. on February 3i 1971. I hereby certify that, to the best of MY knowledge, the foregoing minutes and attachments are accurate and complete. Harold Margulies, Director Regional Medical Programs Service April 26, 1971 ATTENDANCE AT THE NATIONAL ADVISORY COUNCIL MEETING FEBRUARY 2-3, 1971 RMPS REPRESENTATIVES IN RMPS STAFF REGIONAL OFFICES Mr. Ken Baum Mt. William A. McKenna Region I Dr. Edward T. Blomquist Mr. T. H. Griffith: -Region IV Mr. Cleveland Chambliss Mr Maurice C. Ryan Region V Mr. Spencer Colburn Mr: C. Ray Maddox Region VII Miss Cecilia Conrath Mr. Daniel P. Webster Region VIII Mr. Ronald S. Currie Region IX Mr Tom Croft Mr, Herbert Dunning Mr. Hugh S. Campbell Region X Mr. Gerald T. Gardell Mr., Terrance T. Genz OTHERS ATTENDING Mr. Samuel 0. Gilmer, Jr. Mrs. Eva Handal Dr. Vernon 9. Wilson, Administrator, USM Mr. Charles Hilsenroth Dr. Margaret H. Edwards, NCI NIH Miss Dona Houseal Mrs. Frances H. Howard, NLM, NIH Mr. Frank Ichniowski Dr. William Zukel, NHLI, NIH Dr. Philip A. Klieger Dr. Alan Kaplan Dr. Marshall J. Keyes Mr. John M. Korn, Jr. Dr. Harold Margulies Mr. Frank Nash Dr. Herbert B. Pahl Mr. Ronald L. Peterson Mr. Eugene S. Piatek mri Michael J. Posts Miss Leah Resnick Mr. Abraham Ringel @Mr. Dale Robertson Mr. Morton Robins Mrs. Jacki Rosenthal Mt. Richard L. Russell Mrs. Pat Schoeni Mr. R. Shaw Mrs. Sarah J. Silsbee Mr. Thomas H. Simonds Dr. Margaret H. Sloan Mr. James A. Smith Mr. Dan Spain Mr. Lee E. Van Winkle Mr. David Lovenvirth, RMPS Consultant NATIONAL ADVISORY COUNCIL ON REGIONAL MEDICAL PROGRAMS BRENNAN, Michael J., M.D. (72) McPHEDRAN, Alexander M., M.D. (73) President, Michigan Cancer Foundation Emory University Clinic 4811 John R Street 1365 Clifton Road, N. E. Detroit,, Michigan 48201 Atlanta, Georgia '30322 CANNON, Bland W., M.D. (73) MILLIKAN', Clark H., M.D. (72) 910 Madison Avenue Consultant in Neurology Memphis, Tennessee ,38103 Mayo Clinic Rochester, Minnesota 55902 CROSBY, Edwin L., M.D. (71) Executive President OCHSNERO Alton, M.D. (73) Ameridan Hospital Association Ochsner Clinic Chicago, Illinois 60611 1514 Jefferson Highway New Orleans, Louisana 70121 DEBAK.EY, Michael E., M.D. (72) President and Chief Executive Officer ROTH, Russell B., M.D. (73) Baylor College of Medicine 240 West 416t Street Houston, Texas 77025 Erie, Pennsylvania 16508 @VERIST, Bruce W., M.D. (71) WYCKOFF, Mks. Florence R. (72) Chief of Pediatrics 243 Corralito6 Road Green Clinic Watsonville, California 95076 Ruston, Louisiana 71270 HINES, Mr. Harold H., Jr. (74) EX OFFICIO MEMBER Senior Vite President Marsh & McLennan, Inc,. MUSSER, Mart J.,, M.D. 231 South LaSalle Street Chief Medical Officer Chicagot Illinois 60604 Veterans Administration Washingtoni D. C. 20420 HUNT, William R., M.D. (71) commissioner County of Allegheny 101 Courthouse Pittsburgh, Pennsylvania 15219 CHAIRMAN Vernon E. Wilson, M.D. Administrator Health Services and Mental Health Administration 5600 Fishers Lane Rockville, Maryland 20852