for the potential of including new construction somewhere in the course of time. Now, a comment in the area of stroke, because this is the area of my particular interest. The American Heart Association has been much interested in stroke and has formed a council on cerebrovascular disease and has been active in promoting teaching and spreading the word in communities. I believe that RMP offers us an opportunity to produce a greater matrix where we are really going to do something about stroke. You are aware of the need for treatment in terms of acute facilities for rehabilitation, reentry of the patient into the community, but we are now beginning to accumulate data which, if we can get the information to the population and to the physicians, will significantly affect stroke prevention. And this is the kind of thing that RMP is designed to do, among other things. One of the most interesting items that is coming on the agenda now is the word "hypertension," or high blood pressure, and we now have definite epidemiological evidence through programs which have been supported and originated by you people that hypertension is as important in stroke as it is in heart disease, certain categories of heart disease in particular, and that via the detection and treatment of hypertension, we may cut significantly down on the incidence of stroke. The Heart Association is designing programs to interrelate to RMP and provide screening and detection mechanisms to find these people. Some 20 percent of hypertensives are not even detected at this point in time. In relationship to the very important subject of hypertension, the regional medical programs offer an excellent matrix for the evaluation of antihypertensive drugs. As programs for screening, detection, and diagnosis of high blood pressure are constructed, funds should be available for evaluation and comparative trials of drug agents; including drugs already known and those which will come out of developmental laboratories. These are simply summaries of some of the comments that are in the formal record. I don't want to belabor these issues, but to me, we are dealing with the national resource, the health of our people, and we couldn't be discussing a more important subject. I congratulate and commend you on all of the things that you have done, and in this particular frame of reference your wisdom in guiding RMP has been unique. (Dr. Millikan's prepared statement follows:) STATEMENT OF DR. CLARK MILLIKAN, CHAIRMAN, COUNCIL ON CEREBROVASCULAR DISEASE, AMERICAN HEART ASSOCIATION I am Dr. Clark Millikan, Chairman of the American Heart Association's Council on Cerebrovascular Disease. Representing the Association I welcome the opportunity of testifying in support of H.R. 15758, the five-year extension of the Regional Medical Program (P. L. 89-239). As one of the organizations instrumental in promoting the original Regional Medical Program in 1965, we are pleased with the significant contribution it has made to the application of new medical knowledge to the diagnosis and treatment of heart disease and stroke. We are particularly pleased that the Regional Medical Program has provided, as intended, an effective vehicle for governmental and non-governmental cooperation in combatting the three diseases taking the greatest toll of life in American society. Maximum responsibility has been on local leadership and regional cooperative arrangements. Heart Associations across the country have been active on almost all Regional Advisory Committees planning programs, gathering data on health manpower requirements and analyzing available health facilities and services. We expect continued participation during the five years of the proposed renewal as the emphasis of the program shifts from the planning to the operational phase. Last week in New York City 400 American Heart Association volunteers and staff from across the nation planned ways in which we can improve our program. One entire discussion group was devoted to the interrelationship of the Regional Medical Program and the American Heart Association. We discussed the ways in which the relationships between Heart Associations in the various states and the governmental agencies in their areas could be reinforced. It was decided at this national meeting that part of our future program would be to encourage our membership to take every available advantage of Regional Medical Programs, so that Heart Associations would be playing their maximum role to the maximum benefit of their communities. The original law provided over a three-year period increasing grants of from $50,000,000 to $200,000,000 for the fiscal year ending June, 1968. We note that H. R. 15758 specifies $65,000,000 for fiscal 1969 and "such sums as may be necessary for the next four fiscal years." We are aware that nearly $35,000,000 of unobligated funds are available in addition to the $65,000,000 provided in this bill for the next fiscal year. However, we would prefer that specific funding for fiscal years 1970 through 1973 had been included in this bill to assure the maximum growth of this successful program. If the $65,000,000 for fiscal 1969 is appropriated and authorized, we understand 30 of the 54 Regional Medical Programs will be receiving their initial operational grants and 14 will be in their second or third year of operational grant activity. It is to be expected that in the following four years operational requirements will increase; yet the legislation under consideration here today leaves the program to the unknown quantity of annual Congressional appropriations after fiscal 1969. We have some reservations as to the wisdom of this approach since long-range planning is essential to the success of this program. One final word as to funds, we stress the minimal necessity of the full $65,000,000 requested in H. R. 15758 for 1969. Among the promising developments in the Regional Medical Program of particular interest to us has been the recent emphasis on extending the development of coronary care units and the necessary trained personnel to hospitals not now having these life-saving facilities. It is our understanding that the Regional Medical Program has many applications for funds for this purpose. We thoroughly applaud the establishment of these life-saving facilities in every hospital caring for coronary artery problems and hope that in the future even more funds will be available for coronary care units. As the Chairman of the American Heart Association's Council on Cerebrovascular Disease, I can speak with particular knowledge of the constructive purposes the Regional Medical Program has and will continue to serve in mobilizing professional attention and funds for community-wide stroke detection programs and treatment. Teaching units in many medical schools have shied away from involvement with the stroke patient. As part of the planning and operational grants of the Regional Medical Program, new interest in this problem has been stimulated in a constructive way. This promising development must be encouraged in the next five years of the Regional Medical Program and adequate funds supplied for this purpose. Section 103 of the bill extends the Regional Medical Program to areas outside the United States which should be the beneficiary of this program. We endorse the inclusion of Puerto Rico, the Virgin Islands, Guam, American Samoa and the Trust Territories of the Pacific Islands. Value to citizens of the states within the United States should not be hoarded but shared with areas not part of, but historically connected to the United States. Additionally, the American Heart Association endorses the use of grants for two or more Regional Medical Programs, as proposed in Section 910. This provision will permit the economical development of teaching films, videotapes and other educational materials for use by several regions on a national basis. This provision also permits the kind of flexibility the American Heart Association has always envisioned for this program. The inclusion of referals to Regional Medical Program facilities by practicing dentists proposed in Section 107 is of particular importance. Dentists can play an important role in preventing the recurrence of rheumatic fever and bacterial endocarditis if aware of this opportunity. Their inclusion along with physicians in this program is therefore of significance to the alleviation of some forms of cardiovascular disease. In relationship to the very important subject of hypertension, the Regional Medical Programs offer an excellent matrix for the evaluation of anti-hypertensive drugs. As programs for screening, detection and diagnosis of high blood pressure are constructed, funds should be available for evaluation and comparative trials of drug agents; including drugs already known and those which will come out of developmental laboratories. Finally, the American Heart Association endorses the inclusion of federal hospitals (Section 107) in the total operation of the Regional Medical Program. The broadest possible range of community medical facilities enlarges the scope of health services to the public contemplated in the original purpose of the program. Despite one reservation expressed at the beginning of this testimony, the American Heart Association strongly recommends the enactment of H.R. 15758. Mr. ROGERS. Thank you very much, Dr. Millikan. We appreciate your testimony, and I would agree with you that stroke is an area where we need to do great work, and much needs to be done to improve the health of the people in this area. I think it has been overlooked a great deal from the testimony I have heard. Dr. Carter? Mr. CARTER. No questions. Mr. ROGERS. Mr. Skubitz? Mr. SKUBITZ. Doctor, the point I am trying to get across is, I have no objection to a continuing program. But I want the agency to come forth each year, justify what they have done and prove how much additional money is needed. Maybe $65 million is sufficient for 1969, but who is to say how much we need in 1970 or 1971 without the Department coming before us and reviewing the program. Maybe we need $200 million next year, in 1970. And maybe the year following we may need $300 million instead of $100 million. I don't know. What I want is for the Department to come in and justify its request from year to year. If it can't justify them, then I see no need of carrying the program forward. Dr. MILLIKAN. May I ask a question? Are you addressing yourself to just filing the authorizations, or the amount? Mr. SKUBITZ. The amount. Dr. MILLIKAN. I believe these are different things, in essence. It seems to me that the record is now being written on the justification of this program, and that we are seeing significant changes in the interrelationships between the laboratory and teachers, on one hand, and the practicing physician community, on the other hand, which are going to accrue to the benefit of patients all over the Nation. Mr. SKUBITZ. I don't think there is much doubt about that. I am sold on the program. Dr. MILLIKAN. It seems to me that if the question is how much money is to be allocated per year, that is really in the province of the committee, as you deliberate how you establish mechanisms to find out about this. Mr. SKUBITZ. My point is, though, that if we authorize $200 million for 1970 and $300 million for 1971, the Department does not have to 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. STATEMENT OF DR. LESTER BRESLOW, PRESIDENT-ELECT, Dr. BRESLOW. Thank you. I am appearing before you as presidentelect of the American Public Health Association. I would lik make some remarks based on the written statement which has been sitted for the record. Mr. ROGERS. Your statement will be made a part of the record fol lowing your remarks. Dr. BRESLOW. The effective organization and utilization of the 1sources that we now have, and the unique contribution of the origin 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 a 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:) STATEMENT OF DR. LESTER BRESLOW, PROFESSOR OF HEALTH SERVICES ADMINISTRATION, SCHOOL OF PUBLIC HEALTH, UNIVERSITY OF CALIFORNIA AT LOS ANGELES 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" |