comparable in organizational structure to the National Institutes of Health. This organizational position is needed in view of the urgency of the health care delivery problems. This elevated structure will give health care delivery research and development the necessary visibility and raise its stature among the public, the health community, and within the government; will permit the new Institute to attract the necessary top management and the talented men and women; and provide the needed strong voice for an increased investment and interest in research and development in health care delivery.

The Institute, in carrying out its research and development efforts, will utilize the multidisciplinary approach. Teams from such academic disciplines as health, medicine, economics engineering, science, accounting, statistics, social sciences, architecture, law, education, and the management sciences, will interact and devote their energies and their attention to an objective inquiry in the public interest and generate action and problem oriented research on the critical and complex problems of health care delivery.

In research and development, one frequently hears the concept "critical mass", a term borrowed from nuclear physics. In research and development this term is used to indicate the minimum size and composition needed to achieve a self-sustaining, creative atmosphere for the undertaking.

The number necessary for this "critical mass" varies with the undertaking. In theoretical basic research, one or two researchers may be adequate. On the other hand, in complex and large research efforts, the "critical mass" may require many more individuals from many disciplines. In these larger and more complex undertakings when the "critical mass" is not achieved, researchers tend to pursue smaller tasks, individually. The Committee believes that the "critical mass" concept is an important one and that the synergism that can occur when a "critical mass" of problem solvers from many academic disciplines interact has not been adequately developed.

Professor William B. Schwartz of the Tufts University School of Medicine last year emphasized the importance of the multidisciplinary approach when he said:

There is a clear implication that the problems will require a multidisciplinary approach-we are not simply dealing with economic problems to be formulated and analyzed by economists or manpower problems to be dealt with by physicians. The problem of delivery or primary medical care, for example, obviously has an enormous number of facets. It involves not simply a question of more and larger medical schools training more physicians but a range of issues including the maldistribution of physicians, inducements to rural and ghetto practice, restriction of physician entry into specialties that are overpopulated, the use of allied medical personnel to replace physicians in the delivery of primary care, the introduction of computer-aided diagnosis and management as a means of upgrading the non-physician's performance and increasing his range of responsibilities, the use of television as a link between doctors and patients, and the introduction of new transportation strategies as a means of making high quality care available to areas of low population density.

In weighing these approaches, consideration must also be given to patient acceptance of new personnel and new technology, to the reliability of computer-aided diagnosis and managment, to the response of the physician to incursions of new health personnel and new technology into his domain, to legal problems related to licensure and malpractice, to the time lags involved in the introduction of new strategy, and to the trade-off between quality and quantity that is implicit in changing the traditional patterns of health care. Only in this way can we allocate resources appropriately and can a desirable mix of manpower and technology be brought to

bear.

The need for improved policy analysis in the nation is critical. Even the Department of Health, Education, and Welfare with its enormous responsibilities has only a small number of individuals at the secretariat level dealing with these matters and their time and attention are too often devoted to "fire fighting" or responding to daily crises. As a result, little if any time remains for exploring longterm issues, no matter how important. The situation in the Congress is similar with the pressures of everyday work and legislation preventing only negligible attention to policy analysis.

Yet, the resolutions of major policy issues will fundamentally shape the future of health care in the United States. Thus there is an urgent need for the development of important analytical capabilities to cope with the larger, more complex, and in the long run, the more important health issues.

Policy analysis will be an important part of the work of the Institute. The Committee intends that there be established within the Institute a Health Policy Analysis division to enable groups of professionals to concentrate on long-term policies in the health field.

The Institute will be headed by a Director, appointed by the President with the advice and consent of the Senate. The Director's salary will be at Executive Level Four, which is similar to and competitive with other Federal Research and Development agencies. The Director is authorized to appoint a Deputy Director and up to four Assistant Directors.

MANDATE

The National Institute is provided with a board legislative mandate. to examine all aspects of the health care system and the ways and means to improve that system, as well as the devising and testing of alternative systems. Its functions will be carried out through both an intramural capability and through an extramural effort at the Regional Health Care Centers and two National Special Emphasis Centers, the Health Care Technology Center and the Health Care Management Center, and through broad authority to: (1) make grants to states, political subdivisions, universities, hospitals, and other public or nonprofit agencies, institutions, or organizations and (2) contract with public or private agencies, institutions, or organizations for the conduct of research and development, experiments, studies, demonstrations, and the training of individuals to plan and conduct such efforts.

Specifically, the Institute is directed to "pursue methods and opportunities to improve and advance the effectiveness, efficiency,

and quality of health care delivery in the states, regions, and communities of the United States, through initiation and support of studies, research, experimentation, development, demonstration of, but not limited to, the following:

(1) The existing health care system, emphasizing means and methods to improve such system and the devising and testing of alternative delivery systems;

(2) Health care systems and subsystems in states, regions, and communities which give special attention to the effective combination and coordination of public and private methods or systems for health care delivery;

(3) Preventive medicine and the techniques and technology, including multiphasic screening and testing, to improve the early diagnosis and treatment of diseases, particularly for preschool children;

(4) Systems and technical components of emergency health care and services (including at least one experimental statewide helicopter transportation emergency care system), which utilize, where possible, the skills of returning military corpsmen;

(5) Systems and components of rural health services;

(6) The development of policy with respect to long-term care, particularly for mentally and physical handicapped individuals and senior citizens, with special emphasis on alternatives to institutionalization, including the use of home health aides;

(7) Methods to meet the Nation's medical manpower requirements, including new types of manpower and their utilization and the extent to which tasks performed by physicians and other health professionals may be safely delegated to other appropriately trained individuals in both new and existent health occupations;

(8) Continuing education and the exploration of programs and methods to help health professionals to stay abreast of current developments and to maintain professional excellence;

(9) Health manpower credentialing, licensing, and certification;

(10) The medical malpractice problem, particularly as it relates to quality care, the practice of 'defensive medicine' and added costs to the public;

(11) Programs for educating health manpower and the accreditation of such education programs;

(12) Application of all forms of technology, including computers and other electronic devices, in health care delivery;

(13) The efficiency, management, and utilization of new and existing health care facilities including studies of admission practices and examination of cost-finding techniques;

(14) The development of tools and methods to improve planning, management, and decisionmaking in the health care system; (15) The development of information by which quality, efficiency, and the cost of health care may be measured;

(16) The development of uniform accounting practices, financial reporting, and uniform health records;

(17) The development and testing of incentive payment mechanisms that reward efficiency in health care delivery without compromising the quality of care;

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(18) The needs of individuals, families, and groups for health care and related services, emphasizing the various life styles, including environmental, recreational, and nutritional factors that bear on an individual's health; identification of those factors affecting acceptance and utilization of health care and related services; and the development of educational materials and methods communicating to the public the importance of personal decisions and actions on health;

(19) The economics of health care and related services, and the impact of the total system of health care delivery and related services upon the standards of living and the general stability of the national economy;

(20) Proposals for the financing of health care, including the potential cost and benefits, and their impact on the health care system;

(21) Concepts and data essential to formation of a factual basis for national health policies; and

(22) The effects on health care delivery of the organization, functions, and interrelationships of Federal, State, and local governmental agencies and programs concerned with planning, organization, and financing of health care delivery.

TRAINING AND TECHNICAL ASSISTANCE

The Committee is aware that our ability to expand research and development in the health field will require additional skilled, and talented personnel. The Committee is further aware that the number of economists, health professionals, engineers, lawyers, and other experts, qualified by training and experience to work in the health policy field is limited. The Committee believes, however, that the flexibility granted to the Institute and its Centers will assist it to recruit qualified individuals.

Similarly, the training authority of the Institute and Centers is also broad and will help to create the additional manpower needed. They are directed to develop methods and support for the training of individuals to plan and conduct research, development, demonstration and evaluation of health care delivery.

The Committee believes that the recruitment and training of top caliber personnel must be an important priority of the Institute, for the ultimate success of the enterprise will depend on the men and women who direct and work in the Institute and the Centers.

The Institute is also directed to provide technical assistance and to develop methods for the transfer of new knowledge, components and assistance to the health community and to collaborate and exchange information with other countries for the advancement of health care in the United States and cooperating nations.

EVALUATION ROLE

The Committee envisions a major evaluation role for the Institute and the Committee's bill specifically directs the Institute to evaluate the quality, the effectiveness, and the efficiency of all Federal health programs.

The Committee believes that Federal health programs have not been adequately evaluated in the past and that the Institute will materially

enhance the Federal Government's evaluation capacity in the health field.

For such evaluation, the Secretary of Health, Education, and Welfare is authorized to transfer evaluation funds appropriated pursuant to Section 513 of the Public Health Service Act as he deems necessary. SUPPLEMENTAL INCENTIVE GRANTS TO ENCOURAGE EXPERIMENTATION

Sec. 1214 authorizes the Director of the Institute to make supplemental incentive grants to individuals, institutions, and health facilities to encourage experimentation. Under this authority, the Director may supplement regular Federal health grant-in-aid programs in order to encourage experimental projects which would not otherwise be undertaken without such assistance and which have been designated as "essential" by the National Advisory Council. There are two limitations on this authority. First, the Federal portion of the funding of the project may not exceed 80 percent and, secondly, not more than 10 percent of the funds appropriated to the Institute may be used for such grants.

ACTIVE ADVISORY COUNCIL

The Institute will have a twenty-one member National Advisory Council on Health Care Delivery. Fifteen of the members will be selected by the President from: (1) persons who are leaders in the field of medical science, or in the organization, delivery, or financing of health care; (2) leaders in the management sciences; and (3) representatives of the consumers of health care. The Committee believes that at least one member of the Council should be a practicing physician. At least seven of the appointed members must be representatives of consumers.

The Secretary of Health, Education, and Welfare, the Chief Medical Officer of the Veterans Administration, a medical officer designated by the Secretary of Defense, the Director of the National Institutes of Health, the Administrator of the Health Services and Mental Health Administration, and the Director of the National Institute of Health Care Delivery will serve as ex officio members of the Board. The Committee intends, however, that all members of the Council participate fully in the Council activities-discussions, voting, etc.-and that there will be no distinction made in such activities between appointed and other members.

The President will designate the Chairman of the Council. The Council will meet at the call of the Chairman, but not less than four times yearly. The Committee intends that the Council should be an active one and specific responsibilities are outlined in the legislation. The Council will be responsible for: (1) reviewing the programs, policies, and priorities of the Institute and Centers; (2) examining and coordinating health care delivery efforts within the Department of Health, Education, and Welfare and other federal agencies so as to avoid duplication; (3) assuring that significant research and development findings are communicated within the research community and to the public; and (4) evaluating the impact that the Institute's research and development efforts are having on the health care system. As further indication of the Committee's views regarding the Coun