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.

[ATTACHMENT A]

STATEMENT OF LESTER BRESLOW, M.D., ON THE CALIFORNIA COMMITTEE ON 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 California 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 facilities 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.

The California Regional Medical Program, therefore, contracted with the Survey Research Center at UCLA to make an analytic region-wide survey of existing training facilities for health service manpower of all sorts. The survey, besides being an inventory of facilities, includes analytic details as to capacities, present enrollments, expansion possibilities, curricula and new programs. It will serve as a basis for second-generation studies and operational proposals in the manpower field.

Physician referral patterns.-The Stanford Research Institute, in cooperation with the California Medical Association, is completing interviews with a random sample of physicians throughout the State on the subject of referral patterns for patients with heart disease, cancer and stroke. Here, too, material never gathered before is being acquired. Questionnaires already completed contain valuable material of two kinds. As a basis for improved delivery of medical service in cases of heart disease, cancer and stroke, referral patterns, both as to physicians and facilities, are being discussed. And, the needs seen by family physicians, and other physicians of first reference, are being recorded and analyzed for the first time in this context.

Registries. A cooperative undertaking involving the System Development Corp. of Santa Monica and the UCLA School of Public Health is doing feasibility testing for possible registries in stroke and heart disease. California has already had rich experience in the development of a tumor registry, covering roughly a third of the hospital beds in the State and providing cancer incidence data of unique significance. The System Development Corp. study is, therefore, moving on to a preliminary examination of registry construction in stroke and heart disease. At the same time, the Director of the California Tumor Registry is cooperating with the California Regional Medical Program in connection with cancer registration and follow-up.

Use of medical scoiety review mechanisms.-On a trial basis, local medical organizations in three California counties are cooperating with the Regional Medical Program to determine the value of local medical review mechanisms-generally associated with claims review in health insurance programs for case identification heart disease, cancer and stroke, review of prevailing community standards and practices in management of such cases, and possible development of postgraduate medical education and other programs. In each case, the county medical group has agreed to cooperate with the appropriate university medical center in the review.

Specialized resources in hospitals.—The sixth and last of the first-generation California planning studies is based on questionnaires sent to all the acute, general hospitals in the State, through the cooperation of the California Hospital Association. The hospitals are reporting whether or not they have various items on a detailed roster of specialized resources or facilities needed for treatment and overall management of patients with heart disease, cancer and stroke. This material, too, has not been gathered before, and is expected to highlight material lacks, oversupplies or maldistributions. At the same time, the study will bring manpower training requirements to a sharper focus as California's Regional Medical Programs enter their operational phase.

All these data gathering studies have been integrated into the 14 operational proposals described earlier. They have also been incorporated into the five operational proposals and the two additional requests for funds especially earmarked by Congress, submitted by the California Committee on Regional Medical Programs during the March, 1968 quarter.

This second set of proposals includes the expansion of existing clinical cancer diagnosis and treatment, social service consultation, radiological physics, nuclear medicine and computer retrieval of pertinent data to 26 hospitals in northern California, a coordinated year-round general practice residency, intensive coronary care training for physicians in small hospitals, and the establishment of a medical library and information service network.

The first of the projects seeking earmarked funds involves a sixth area in California-Orange County, the planning for which has been assigned to the University of California at Irvine proposing a pediatric pulmonary demonstration center. It would be only the fourth of its kind in the Nation. The second project would expand and improve an existing hypertension program of the UC San Francisco Medical Center.

Taken all together, these first operational proposals can be seen as the beginning broad outlines in the development of a region-wide comprehensive blueprint,

whose cohesion and effective potential for vastly improved health care services are emerging, almost on a day-by-day basis, ever more clearly.

Mr. ROGERS. Let me ask this. Is your program getting to the ghetto areas? Could you give us a quick rundown on that?

Dr. BRESLOW. One program that is being considered-I perhaps should not prejudge the issue is the proposal which has been developed by USC and UCLA faculties. It would transfer the medical expertise developed by these two centers, in the field of heart disease, cancer, and stroke, to the Watts-Willowbrook area. It is in this area that the county plans to build a new hospital with the aid of HillBurton support.

The aim of this program is to build around that hospital, bringing in the practicing physicians in the community, a program of postgraduate education, emphasizing heart disease, cancer, and stroke.

We think this will have a remarkable effect in mobilizing the services of that portion of Los Angeles to provide better care.

Mr. ROGERS. Thank you, and I am delighted to see you have given us a statement on the California program, which we will go into in detail. Mr. Kyros?

Mr. KYROS. No questions.

Mr. ROGERS. Dr. Carter?

Mr. CARTER. I am delighted to know you are making all these services available for the Watts area. I wonder what you are doing for the areas around Watts.

Dr. BRESLOW. Our programs extend into the Watts area and also around the Watts area, not only throughout the metropolitan region of Los Angeles, but in the mountainous areas, and so forth. Other projects

Mr. CARTER. I believe in those surrounding areas we are liable to have more heart attacks and strokes. [Laughter.]

Mr. ROGERS. Thank you very much, Dr. Breslow. We appreciate very much your coming here.

I understand that we will try to hear one more witness here. Reverend Works, you and Dr. Price, I understood, were going to have to get away. Could you come forward, then? We will be pleased to hear your testimony.

Mr. Macdonald, your Congressman, wanted to come and introduce you, but the committee knows of your work, and we are delighted to have you here with us, and Dr. Price.

And if you would like, we will make your statements part of the record, without objection and they will appear following your remarks. And if you could then summarize for us the points that you think wolud be important, this would be helpful to the committee. STATEMENTS OF REV. DAVID A. WORKS, EXECUTIVE VICE PRESIDENT, THE NORTH CONWAY INSTITUTE, BOSTON, MASS., AND REV. THOMAS E. PRICE, DIRECTOR OF THE DEPARTMENT OF ALCOHOL PROBLEMS AND DRUG ABUSE, GENERAL BOARD OF CHRISTIAN SOCIAL CONCERNS OF THE METHODIST CHURCH

Dr. WORKS. Thank you, Mr. Chairman. My name is Rev. David Works, of Topsfield, Mass., and North Conway, N.H., an opal clergyman. I am the executive vice