The report of the President's Commission on Heart Disease, Cancer, and Stroke, issued in December 1964, focused attention on societal needs and led directly to introduction of the legislation authorizing Regional Medical Programs. Many of the Commission's recommendations were significantly altered by the Congress in the legislative process but The Act was clearly passed to meet needs and problems identified and given national recognition in the Commission's report and in the Congressional hearings preceding passage in The Act. Some of these needs and problems were expressed as follows:

A program is needed to focus the Nation's health resources for research, teaching and patient care on heart disease, cancer, stroke and related diseases, because together they cause 70 percent of the deaths in the United States.

A significant number of Americans with these diseases die or are disabled because the benefits of present knowledge in the medical sciences are not uniformly available throughout the country. There is not enough trained manpower to meet the health needs of the American people within the present system for the delivery of health services.

Pressures threatening the Nation's health resources are building because demands for health services are rapidly increasing at a time when increasing costs are posing obstacles for many who require these preventive, diagnostic, therapeutic and rehabilitative services.

A creative partnership must be forged among the Nation's medical scientists, practicing physicians, and all of the Nation's other health resources so that new knowledge can be translated more rapidly into better patient care. This partnership should make it possible for every community's practicing physicians to share in the diagnostic, therapeutic and consultative resources of major medical institutions. They should similarly be provided the opportunity to participate in the academic environment of research, teaching and patient care which stimulates and supports medical practice of the highest quality.

Institutions with high quality research programs in heart disease, cancer, stroke, and related diseases are too few, given the magnitude of the problems, and are not uniformly distributed throughout the country.

There is a need to educate the public regarding health affairs. Education in many cases will permit people to extend their own lives by changing personal habits to prevent heart disease, cancer, stroke and related diseases. Such education will enable individuals to recognize the need for diagnostic, therapeutic or rehabilitative services, and to know where to find these services, and it will motivate them to seek such services when needed.

During the Congressional hearings on this bill, representatives of major groups and institutions with an interest in the American health system were heard, particularly spokesmen for practicing physicians and community hospitals of the Nation. The Act which emerged turned away from the idea of a detailed Federal blueprint for action. Specifically, the network of "regional centers" recommended earlier by the President's Commission was replaced by a concept of “regional cooperative arrangements" among existing health resources. The Act establishes a system of grants to enable representatives of health resources to exercise initiative to identify and meet local needs within the area of the categorical diseases through a broadly defined process. Recognition of geographical and societal diversities within the United States was the main reason for this approach, and spokesmen for the Nation's health resources who testified during the hearings strengthened the case for local initiative. Thus the degree to which the various Regional Medical Programs meet the objectives of The Act will provide a measure of how well local health resources can take the initiative and work together to improve patient care for heart disease, cancer, stroke and related diseases at the local level.

The Act is intended to provide the means for conveying to the medical institutions and professions of the Nation the latest advances in medical science for diagnosis, treatment, and rehabilitation of patients afflicted with heart disease, cancer, stroke, or related diseases—and to prevent these diseases. The grants authorized by The Act are to encourage and assist in the establishment of regional cooperative arrangements among medical schools, research institu tions, hospitals, and other medical institutions and agencies to achieve these ends by research, education, and demonstrations of patient care. Through these means, the programs authorized by The Act are also intended to improve generally the health manpower and facilities of the Nation.

In the two years since the President signed The Act, broadly representative groups have organized themselves to conduct Regional Medical Programs in more than 50 Regions which they themselves have defined. These Regions encompass the Nation's population. They have been formed by the organizing groups using functional as well as geographic criteria. These Regions include combinations of entire states (e.g. the Washington-Alaska Region), portions of several states (e.g. the Intermountain Region includes Utah and sections of Colorado, Idaho, Montana, Nevada and Wyoming), single states (e.g. Georgia), and portions of states around a metropolitan center (e.g. the Rochester Region which includes the city and 11 surrounding counties). Within these Regional Programs, a wide variety of organization structures have been developed, including executive and planning committees, categorical disease task forces, and community and other types of sub-regional advisory committees. Regions first may receive planning grants from the Division of Regional Medical Programs, and then may be awarded operational grants to fund activities planned with initial and subsequent planning

grants. These operational programs are the direct means for Regional Medical Programs to accomplish their objectives. Planning moves a Region toward operational activity and is a continuing means for assuring the relevancy and appropriateness of operational activity. It is the effects of the operational activities, however, which will produce results by which Regional Medical Programs will be judged.

On November 9, 1967, the President sent the Congress the Report on Regional Medical Programs prepared by the Surgeon General of the Public Health Service, and submitted to the President through the Secretary of Health, Education, and Welfare, in compliance with The Act. The Report details the progress of Regional Medical Programs and recommends continuation of the Programs beyond the June 30, 1968, limit set forth in The Act. The President's letter transmitting the Report to the Congress was at once encouraging and exhortative when it said, in part: "Because the law and the idea behind it are and the problem is so vast, the program is just emerging from the planning state. But this report gives encouraging evidence of progress and it promises great advances in speeding research knowledge to the patient's bedside." Thus in the final seven words of the President's message, the objective of Regional Medical Programs is clearly emphasized.

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THE NATURE AND POTENTIAL OF REGIONAL MEDICAL PROGRAMS

GOAL-IMPROVED PATIENT CARE

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The Goal is described in the Surgeon General's Report as ... clear and unequivocal. The focus is on the patient. The object is to influence the present arrangements for health services in a manner that will permit the best in modern medical care for heart disease, cancer, stroke, and related diseases to be available to all."

MEANS THE PROCESS OF REGIONALIZATION

Note: Regionalization can connote more than a regional cooperative arrangement, but for the purpose of this publication, the two terms will be used interchangeably. The Act uses "regional cooperative arrangement," but "regionalization" has become a more convenient synonym.

A regional cooperative arrangement among the full array of available health resources is a necessary step in bringing the benefits of scientific advances in medicine to people wherever they live in a Region they themselves have defined. It enables patients to benefit from the inevitable specialization and division of labor which accompany the expansion of medical knowledge because it provides a system of working relationships among health personnel and the institutions and organizations in which they work. This requires

a commitment of individual and institutional spirit and resources which must be worked out by each Regional Medical Program. It is facilitated by voluntary agreements to serve, systematically, the needs of the public as regards the categorical diseases on a regional rather than some more narrow basis.

Regionalization, or a regional cooperative arrangement, within the context of Regional Medical Programs has several other important facets:

● It is both functional and geographic in character. Functionally, regionalization is the mechanism for linking patient care with health research and education within the entire region to provide a mutually beneficial interaction. This interaction should occur within the operational activities as well as in the total program. The geographic boundaries of a region serve to define the population for which each Regional Program will be concerned and responsible. This concern and responsibility should be matched by responsiveness, which is effected by providing the population with a significant voice in the Regional Program's decisionmaking process.

● It provides a means for sharing limited health manpower and facilities to maximize the quality and quantity of care and service available to the Region's population, and to do this as economically as possible. In some instances, this may require interregional cooperation between two or among several Regional Programs.

Finally, it also constitutes a mechanism for coordinating its categorical program with other health programs in the Region so that their combined effect may be increased and so that they contribute to the creation and maintenance of a system of comprehensive health care within the entire Region.

Because the advance of knowledge changes the nature of medical care, regionalization can best be viewed as a continuous process rather than a plan which it totally developed and then implemented. This process of regionalization, or cooperative arrangements, consists of at least the following elements: involvement, identification of needs and opportunities, assessment of resources, definition of objectives, setting of priorities, implementation, and evaluation. While these seven elements in the process will be described and discussed separately, in practice they are interrelated, continuous and often occur simultaneously.

Involvement-The involvement and commitment of individuals, organizations and institutions which will engage in the activity of a Regional Medical Program, as well as those which will be affected by this activity, underlie a Regional Program. By involving in the steps of study and decision all those in a region who are essential to implementation and ultimate success, better solutions may be found, the opportunity for wider acceptance of decisions is improved, and implementation of decisions is achieved more rapidly. Other

attempts to organize health resources on a regional basis have experienced difficulty or have been diverted from their objectives because there was not this voluntary involvement and commitment by the necessary individuals, institutions and organizations. The Act is quite specific to assure this necessary involvement in Regional Medical Programs: it defines, for example, the minimum composition of Regional Advisory Groups.

The Act states these Regional Advisory Groups must include "practicing physicians, medical center officials, hospital administrators, representatives from appropriate medical societies, voluntary health agencies, and representatives of other organizations, institutions and agencies concerned with activities of the kind to be carried on under the program and members of the public familiar with the need for the services provided under the program." To ensure a maximum opportunity for success, the composition of the Regional Advisory Group also should be reflective of the total spectrum of health interests and resources of the entire Region. And it should be broadly representative of the geographic areas and all of the socioeconomic groups which will be served by the Regional Program. The Regional Advisory Group does not have direct administrative responsibility for the Regional Program, but the clear intent of the Congress was that the Advisory Group would ensure that the Regional Medical Program is planned and developed with the continuing advice and assistance of a group which is broadly representative of the health interests of the Region. The Advisory Group must approve all proposals for operational activities within the Regional Program, and it prepares an annual statement giving its evaluation of the effectiveness of the regional cooperative arrangements established under the Regional Medical Program.

Identification of Needs and Opportunities—A Regional Medical Program identifies the needs as regards heart disease, cancer, stroke and related diseases within the entire Region. These needs are stated in terms which offer opportunities for solution.

This process of identification of needs and opportunities for solution requires a continuing analysis of the problems in delivering the best medical care for the target diseases on a regional basis, and it goes beyond a generalized statement to definitions which can be translated into operational activity. Particular opportunities may be defined by: ideas and approaches generated within the Region, extension of activities already present within the Region, and approaches and activities developed elsewhere which might be applied within the Region.

Among various identified needs there also are often relationships which, when perceived, offer even greater opportunities for solutions. In examining the problem of coronary care units throughout its Region, for example, a Regional Program may recognize that the more effective approach would be to consider the total problem of the treatment of myocardial infarction patients within the Region. This broadened approach on a regional basis enables the Regional