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come before this committee anymore. It goes to the Appropriations Committee.

Mr. ROGERS. Mr. Kyros?

Mr. Kyros. Dr. Millikan, I found your testimony most interesting, not only in support of the program, but particularly what you say about money. And, again, as a man who has just come to Congress in the last year or so, it surprises me to see doctors come before this committee and ask for this money and for the continuation of programs.

I used to think that doctors in the American Medical Association took a different view.

I am in full agreement with your position as it is expressed here.
Dr. MILLIKAN. Thank you.
Mr. Rogers. Thank you very much.

It is my understanding that one of our witnesses has a 3 o'clock plane to catch back to California, and if the committee would bear with us, if we could hear his testimony now, it would be helpful.

Dr. Lester Breslow, professor of health administration and chief of the division of health services, School of Public Health, University of California, Los Angeles,

Dr. Breslow, we appreciate your helping the committee, and we will be pleased to receive your testimony. If you would like to file your statement for the record and make appropriate comments, we would be pleased to follow that procedure.



Dr. BRESLOW. Thank you. I am appearing before you as presidentelect of the American Public Health Association. I would lik some remarks based on the written statement which has been sii' nitted for the record.

Mr. Rogers. Your statement will be made a part of the record fu! lowing your remarks.

Dr. BREslow. The effective organization and utilization of the -sources that we now have, and the unique contribution of the orici. cooperative arrangements, are made possible by this program.

The unique contributions are to extend the excellence of the medic..! centers out into the communities, and to accelerate the progress that is being made.

I think it is unfortunate that the American people still do not realize the advances that are being made against heart disease, cancer, and stroke, and the point of this program is to accelerate progress.

When we speak about regional cooperative arrangements, it is important to note that these are developing as a two-way street. The extension of expertise is not only from the medical centers out into the community but also from the point of view of the practicing doctor, from the community hospitals, back to the medical centers. They then begin to appreciate the real problems physicians are up against in the day-to-day handling of medical problems.

This is a truly cooperative arrangement and a two-way street, with motion in both directions.

I would like to say a few words about the progress that is being made in California. From the outset, the California program has

sought to effect cooperation between the hospital associations, the medical associations, the medical schools, and the State health department, Cancer Society, and Heart Association. There has been established a network of good communications, now, through area committees around every medical school and extending into every area of the State. Consequently, effective working bodies around many of the community hospitals and practically in all of the counties in the State are tied in with medical centers.

A couple of advances are being made. We are going to submit, on April 1 and 2, for consideration by our national site review, 14 proposals for operating grants in California. Among these will be a proposal to establish coronary care unit service in the coastal areas of California, a stretch of several hundred miles of small communities. If this program is approved these units will work with the university medical center in San Francisco, in order to extend this whole program out to the periphery of the State.

In the southern part of the State there is a proposal that would bring together the medical faculties of two of our universities there. This proposed program also would bring the medical faculties of these schools in contact with the practicing physicians in the Watts-Willowbrook area, in the center of Los Angeles—a scene of past violence and serious problems. The medical faculties of these schools would work along with the county and hospital administrators of the region who would then develop å postgraduate medical education program with concentration on heart disease, cancer, and stroke.

I mention these two projects merely to emphasize to the committee that this program is going to bring better care to persons not only in the medical centers but also into those parts of the State which have been relatively neglected in the past, such as the ghetto areas in the cities and the rural areas over the great stretches like in California.

Thank you, Mr. Chairman.
(Dr. Breslow's prepared statement follows:)


Mr. Chairman and members of the Committee, I am Lester Breslow, Professor of Health Services Administration in the School of Public Health at UCLA. I have previously been the State Health Officer for the State of California. I have come today to speak in support of H.R. 15758 and particularly that section of the bill which would extend the authority for the Regional Medical Programs.

In my professional career I have long been concerned with the need for a more effective organization of our vast health endeavor, and I view the Regional Medical Programs as having great potential for making a very important contribution to this objective. In recent years this Committee has heard a great deal of discussion about the current difficulties of our health-care system. For this Nation, these problems are not always the lack of health resources but rather the effective organization and utilization of the many resources with which we are blessed, including our resources of talent and knowledge as well as capital, equipment, and personnel.

In passing this legislation three years ago, the Congress expressed a public feeling that the benefits of medical science were not being applied uniformly enough to all segments of our population. This expression was part of a growing recognition within the health field that the present complexity and specialization of health care requires exploration of improved patterns of organization. The legislation carried through with this concern by placing emphasis on the development through the Regional Medical Programs of "regional cooperative arrangements”

among the health personnel and institutions on a regional basis as a necessary prerequisite to accomplish the objectives of reducing the unnecessary toll from these diseases.

The Regional Medical Programs become then an exciting new venture in the development of an improved health system-creating new relationships and capabilities while preserving and building upon the great strengths of our existing institutions, agencies, and personnel.

The history of past efforts at creating a regionalized approach to health services provides ample evidence that the task set for the Regional Medical Programs will be difficult and progress at times will seem slow. There have been previous beginning efforts at regionalized health activities in various parts of the country, some of which were described by this Committee in the report on the original legislation three years ago. Now the pressures of an increasingly complex health enterprise and the rapid advances of medical science and technology have added a considerable urgency to the need for regionalization in the health field if our people are to benefit fully from these advances. The pressures generated by the rapid rise of health-care costs and the increasing urbanization of our society add to this urgency.

The Regional Medical Programs are beginning to show some effectiveness in providing part of the answer to these problems. The activities of the Regional Medical Programs are helping to define the opportunities for improving the excellence of the health services within each region and the contributions that each element of the region's health resources can make to that excellence. The programs are establishing a permanent framework within the regions that becomes a two-way street whereby the expertise in the great medical centers becomes more readily available to the practitioner and institution at the community level, while at the same time the definition of community health needs and the involvement of community resources is made more relevant to the specialized capabilities of the large centers.

I have seen this process at work in California where we face a more complex task than most of the regions because of the great size of the region. This is the largest region with about 20 million people, and the development of the Regional Medical Program is following a somewhat different pattern than other regions, reflecting the commendable flexibility of the legislation in allowing each regional program to develop according to the particular pattern most suitable for that region. The amount of cooperation involving all of the medical schools, the medical profession, the hospitals, the public health agencies, and interested public in California has already made an invaluable contribution to the development of the essential basis for cooperative action. Even before the Califorina Regional Medical Program has received any operational funds, the progress of the program during this planning phase and the establishment of much improved lines of communication among the many elements involved constitute substantial progress. In the interest of time, I would like to submit to the Committee a fuller statement of the accomplishments to date under the California Regional Medical Program. (See attachment A.) I think there is still a long way to go in developing the program in California when the progress is measured against the magnitude of the task. By that same measure, however, we in California are very pleased that the necessary initial steps in the development of the program are now well underway.

I believe that the Regional Medical Programs for heart disease, cancer, and stroke are a very important component of the development of health care on a regional basis in this country. With their emphasis on medical excellence, the involvement of medical centers, the practicing physicians, and the hospitals, the programs are a necessary part of the effort to bring the best in health care to the American people. Regional Medical Programs, however, can only make their full contribution in concert with the many other activities devoted to that goal. The scope of the challenge is too broad to be totally accomplished by any one program, The development of effective interrelationships among the Regional Medical Programs, Comprehensive Health Planning, and the wide variety of other health programs—Federal, State, and local—will be essential. I believe that the development of cooperative relationships among many diverse interests already underway through the Regional Medical Programs is a basis for hope that this cooperation can be extended to a broader level and that the effective interrelationships will be developed in ways appropriate to serve the diversities of the various areas of the country.

As an essential component of this broad effort, the authority for the Regional Medical Programs should be extended and support should be provided for their continued development.

Thank you very much for this opportunity to appear before you today.



REGIONAL MEDICAL PROGRAMS, MARCH 27, 1968 The California Regional Medical Program has been funded for only 15 months and although it would be premature to claim that lives had been saved, nevertheless, it can be said with confidence that the stage has been set for the provision of greatly improved health care services for heart disease, cancer, stroke, and the disorders related to them.

Just this week a study was launched by the California Health Data Corporation to gather information on the origin of every patient admitted during the entire week to every hospital in California. The study, never before undertaken on so large a scale, will show where each patient came from, what his diagnosis was when he was discharged from the hospital, and other information. While these may seem little more than a set of dry statistics, the results should reveal with great accuracy the kinds of medical services needed for Californians and others cared for in the State. Other data gathering studies, which are expected to lead very shortly to operational programs, will be described later.

From the very beginning, planning for the California Regional Medical Program embraced all the major medical and health interests in the State. The California Medical Association, spokesman for the State's 23,000 practicing physicians; the California Hospital Association, representing virtually all of the 600 short-term acute general hospitals in the region; the California State Department of Public Health; the California Heart Associations; the California Division of the American Cancer Society; the deans of all of the eight medical schools in California, and the deans of the two major schools of public health were joined by eight public representatives of the consumer. Together they constitute the legal advisory committee for the region and are known formally as the California Committee on Regional Medical Programs. The Committee has met many times, has gained strength, grown gratifyingly more confident of itself as an entity and has increasingly been able to resolve differences amicably,

As for operational programs, we are looking forward to a two-day site visit in California on April 1 and 2 by a review committee of the National Advisory Council for Regional Medical Programs. They will examine the merits of 14 operational proposals generated by local community interest in five of the State's eight planning areas, and by the California Heart Association. These first operational proposals are heavily weighted toward continuing education, and include some promising innovative experiments.

The greatest single topic of interest among these early operational proposals concerns coronary care units, reflecting a growing consensus throughout the Nation that such units, properly equipped and with highly-skilled doctors and nurses to run them, can bring about a dramatic reduction in deaths due to myocardial infractions and other cardiac emergencies. Four of the 14 proposals deal with the training of physicians and nurses and the equipping of coronary care units. One proposal would offer nurse training in several communities throughout Northwestern California, stretching from the Bay Area to the Oregon border along the Pacific Coast, and would include intensive training for physicians at the San Francisco General Hospital, under the tutelage of University of California cardiologists. Similar proposals would be offered through several hospitals in the highly concentrated Los Angeles basin and include the beefing up of the intensive coronary care unit at the Los Angeles County General Hospital.

A joint proposal by the University of Southern California and the University of California at Los Angeles would join with the Charles R. Drew Medical Society and others to establish a postgraduate medical school in the Watts-Willowbrook ghetto area of Los Angeles. Internship and residency programs would be generated along with inservice and postgraduate training for doctors, nurses and allied health professionals, close relationships with the faculties at USC and UCLA and detailed planning to meet heart disease, cancer and stroke needs in the area.

At Roseville, a community of 20,000 citizens 18 miles northeast of Sacramento, the University of California Davis Medical School has encouraged local physi



cians to establish a "living laboratory' involving the whole community. Continuing education, training for licensed vocational nurses and other paramedical personnel, stroke treatment, handling of central nervous system malignancies, establishment of a tumor board, selected multiphasic screening and community education programs are involved.

The California Heart Association proposes a substantial expansion of its successful student research projects, bringing highly qualified science students into cardiovascular research laboratories.

In Los Angeles, special training in angiography—the visualization of the blood vessel system with the aid of radioactive dyes—would be presented for practicing and qualified radiologists.

Two proposals—one for the Sacramento Valley, the other for the lower San Joaquin-would make use of videotape recording units which would be moved from one hospital to the next, covering several score hospitals. The units would be accompanied by medical television tapes, for instruction of each hospital's staff members, and each local staff could record its own grand rounds, lectures and demonstrations, then, by playing the lesson back, improve its own teaching skills.

The California Heart Association proposes a substantial expansion of its sucpitals in the State, would be expanded to other regions.

The development of simple learning languages in a computer program available for undergraduate, graduate and postgraduate instruction to several regional medical program areas would be encouraged in another proposal.

The Loma Linda University School of Medicine has a highly intriguing pilot project based on a third-generation computer, and proposes to expand its library services to practicing physicians throughout its vast service area. The computer demonstration would test the feasibility of using a remote display, very much like a television set, on which a physician in a community hundreds of miles from the school could, by picking up the telephone, hook into the computer and ask it to analyze the electrocardiograph readings being taken on the patient lying by the physician's side. The computer analysis would be done in real-time, and the answer would return in 2 or 3 minutes. Such a project might provide needed services to small, remotely located hospitals and communities now lacking medical specialists.

These 14 operational proposals are under immediate consideration. Several others, submitted in the March, 1968 quarter, will be briefly detailed in a moment. All have been developed following planning activity which began in January, 1967. The first year's planning activity involved, among other things, the laying down of a data base from which operational proposals are being projected. Construction of the data base has gone through two phases.

In the first phase simple, readily available data were arranged in forms most useful for planning in each of the eight areas of California. Demographic data were acquired from the State Department of Finance. Mortality data were gathered from the State Department of Public Health. Also from the State Health Department, with added information from the California Hospital Association, came material for a complete hospital roster for each of the fornia Regional Medical Program areas. Finally, the first phase of data acquisition entailed analysis of less readily available types of information involving, for example, transportation and the many varieties of morbidity data.

During the second half of the first planning year, six planning studies were undertaken on a region-wide scale. All were approved by a data needs subcommitee on which each of the California Regional Medical Program areas was represented. Each study aimed at relatively deeper penetration into some aspect of the data base needed for planning. At the same time each pointed clearly to the shape of operational proposals in the making.

Patient origin study.This study, rescribed briefly in the opening paragraphs of this statement, will include important material for morbidity analysis, particulary if the survey can be repeated at intervale. At the same time, the survey in is first round is expected to yield information needed for transportation and facil. ities planning in conjunction with the rendering of optimal care for heart disease, cancer and stroke patients.

Training facilities inventory.Many of the ideas for operational projects, which began to take shape in the first planning period, concerned manpower needs and the possibilities of training programs for key health services, in addition to physician services. It was found, though, that little information had been gathered on the simple question of what training facilities now exist.


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