Dr. Marston?

Dr. MARSTON. This is not an easy question to answer at this early stage in the program. We do have operational grants awarded which include more than 100 projects that are underway in the regions.

Perhaps the best way I could answer this might be to take the example of one region and how it has moved in the area of heart disease, cancer and stroke.

I would like to use, from time to time, some of the words of the applicant, because this is a program that is occurring in the region.

The North Carolina regional medical program decided in the late summer of 1967, about a year after it received its planning grant, that it had attained readiness for operational status. Conceptual strategy to achieve the goals of the regional medical program had been developed. A unified, representative leadership of the region, the principal health interests in the region, had been organized for the stimulation of productive, cooperative effort for guidance and coordination of program development, and an organization structured for effective decisionmaking based on needs in the region had been developed and adequately tested.

During 1966 and 1967, North Carolina had had a small project in the area of heart disease. This development was described in the region's progress report as follows: Since cooperative arrangements involving such a wide assortment of people and institutions in one project was a novel departure for us, the experience has been invaluable. We quickly learned that the original project contained seriously inadequate provisions for manpower. Thus, in our operational grant application submitted in October 1967, an expansion of the project was proposed, and as time passes, further modification is anticipated. Conferences with staffs of small community hospitals and observations of patients with acute myocardial infarcts being treated therein convinced us that an effort had to be made to determine the feasibility of an appropriately designed coronary care unit for these small hospitals.

The region's report goes on later to describe the availability of coronary care units, and particularly the ability in these units to do something as far as the rhythm or the electrical disturbances in the heart is concerned, which is not possible without the specialized equipment and trained people in these units.

The growing interest and availability of coronary care units in this region also has generated the need to provide a cardiopulmonary and resuscitation training program to expand on an earlier, limited program of the North Carolina Heart Association.

Additional projects in the heart area, which are in various stages of implementation or planning, include the diagnosis and treatment of hypertension, the use of specially equipped ambulances, pediatric cardiological screening, and so forth.

In the cancer area, the North Carolina program worked with existing groups who have worked in the cancer field before, and they state an increasing number of community hospitals and their staffs are attempting to meet the standard of the American College of Surgeons for the approval of their cancer programs. In this region there are only seven hospital programs that currently are approved, and they would hope to increase this through the regional medical programs.

The North Carolina regional medical program now enjoys, according to a report of progress, an unusually active cooperative arrangement with all of the major groups concerned with planning and implementing cancer activities.

The cancer subcommittee of the regional advisory group provides a mechanism whereby efforts can be better coordinated and tasks more rapidly and effectively accomplished. They are about to initiate a central cancer registry and a central cancer information service. Their goal is to establish a well-coordinated, comprehensive cancer program with full participation of State agencies, academic agencies, community hospitals, and professional and voluntary organizations. This group of cooperating groups also includes a special cancer commission. established by the Governor some years ago, before the advent of the regional medical program.

The North Carolina program reports that much less has been accomplished in the area of stroke than in the other disease categories, but there is an emphasis in this statement that there is an intent to bring the program into balance.

Knowledge sufficient to launch and maintain a meaningful stroke program in both urban and rural North Carolina communities is available, and they have an application before us for development of a community stroke program.

I would like to just mention one other thing, not in a categorical area, about a particular problem that this region has identified through its associate director for hospitals. In the western part of the State there are seven hospitals in as many communities that are facing manpower problems-that are facing the problem of keeping up.

Dr. Amos Johnson, who is a past president of the American Academy of General Practice, told the 1968 Washington conference workshop on regional medical programs that these seven hospitals will be brought together in a coordinated program by the people in the region. These hospitals are prepared to go so far as to apply as a group for a single accreditation under the Joint Commission on Accreditation of Hospitals.

Thus, North Carolina is in the midst of testing the concept of a unique regional hospital organization where no one hospital is able to provide the full range of necessary capabilities.

Mr. KYROS. Thank you.

Dr. LEE There has been in the last 3 years-and we want to make it clear we do not take credit for this with respect to the regional medical programs a significant decline in deaths from high blood pressure. It is about a 20-percent decline over the past 3 years. I think there is no question that as the regional health programs develop activity and the knowledge of early detection of hypertension, and early treatment becomes more available, we will see an acceleration of this very significant decline, which, of course, will affect particularly the stroke problem and, to a lesser extent, the deaths from coronary disease.

Mr. KYROS. Dr Lee, pursuing the question of the effectiveness of the program, let's think for a moment about costs.

As I understand it from your table II, "Regional Medical Programs," a total obligation of funds for the fiscal years 1966 through 1968, you show approximately $85 million, either in planning or operational grant obligations.

Now, as measured against that $85 million, have you made any kind of an analysis or evaluation which shows that, for that kind of money, we have achieved some significant advance through the regional medical program?

Dr. LEE. The program to date primarily has been one of planning and developing the mechanisms which then can be evaluated. For example, we were developing the data base which in many areas is seriously lacking.

After we develop such a data base in the regions, we will carry forward the evaluations for which we are asking specific earmarked

funds.

I think it is really too early to be able to state with any degree of certainty a cost-to-benefit effect.

I think that we should also recognize what I think is going to be one of the most significant contributions of the program. That is the spin off of benefits, well beyond the program itself, not only in terms of people whose care is paid for through medicare or medicaid. For example, as improvement takes place in community hospitals the way Dr. Marston described it, as physicians are able to participate in these programs in community hospitals, the program is bound to have a significant impact on improving quality.

I think the best buy in medical care is good care, high-quality, and this, to me, is going to be one of the most important long-term contributions of the program. And I think this is one of the reasons that we see the kind of enthusiastic support among practicing physicians in many parts of the country who were at first really very suspicious of the program.

As they have seen it develop, as they have participated, they have become increasingly enthusiastic. We will be developing for this spinoff some techniques for measurement so that we can determine the additional conditions of the program.

Mr. KYROS. Dr. Lee, in this bill as it is proposed, I understand that $65 million is sought for the fiscal year ending June 30, 1969. Dr. LEE. That is correct.

Mr. KYROS. What carryover of funds will we have for this program? Dr. LEE. The carryover is $30 million.

Mr. KYROS. So of the approximately $95 million we are talking about, you have $30 million unobligated as yet.

Dr. LEE. Yes. That is held in reserve, actually, by the Bureau of the Budget.

Mr. KYROS. My next question is a general one about your program. Has the American Medical Association now endorsed this program as it is being carried out?

Dr. MARSTON. I think the best answer to that is a paper that Dr. Dwight Wilbur gave at a conference workshop-which has been published in the current issue of JAMA. It is very supportive of the program.

Mr. KYROS. What does this program do for a general practitioner, say, in a rural area like in my own State of Maine?

Dr. LEE. I might add one thing. If the AMA has endorsed it, these are actions that would have to be taken by the house of delegates. They would have to vote on a resolution saying they endorse it, and I am not sure that action has been taken.

Mr. KYROS. But the President has put in a statement that he supports it.

Can you tell us specifically how a general practitioner in a rural area gets involved in a program? Say there is a regional program in the area in which he practices, but he is in a small town that doesn't have a hospital.

Dr. MARSTON. A number of examples come to mind. There was a problem-again in North Carolina, to take up where I left offof a community that was about to be without a physician, and the people in the community turned to the regional medical program for

assistance.

The regional program was able to examine what the problems were in attracting physicians to that community and growing out of that, there has developed a rather major study for that region in the problems of the rural area.

The principal example, I think, is an easy one: The tradition of the Birmingham Associates which, as you will recall from testimony leading to passage of this legislation, was held up as a model of how various health institutions and resources can have a relationship through an organization such as the associates. The activities of the Birmingham Associates are being expanded and carried further by the regional medical programs.

There are a variety of other things being done to assist the physician in rural areas where no hospital exists. There are opportunities for physicians from one part of Washington State to come into and actually spend time in larger hospitals. This includes an exchange so that someone arranges to take over their practice for a period of time. There are the usual continuing education programs, but I think with a different emphasis with the emphasis on doing those things that meet the needs of the physician rather than offering a course that is preselected for him.

The difference has been that the physician is involved in decisions and in planning in terms of his needs rather than coming in at a later stage.

There are also other facilities or services in a number of the regions that are planned and will be implemented for the physician.

Dr. LEE. I would just add another comment on that, and this relates to a personal experience I had visiting Vinel Haven Island, where there is one physician in general practice. He has been able to attract occasionally third- and fourth-year medical students to come and spend part of the summer with him, and this has been a tremendous stimulus to him. It has provided him the best possible opportunity to keep up. It has also been a unique educational experience for the students, because people have lived there for many, many generations, and certain disease patterns there are somewhat unique. He has developed relationships with, for example, diabetic experts at Harvard, who have been interested in diabetes in this particular population group.

He has been able to keep up far more effectively than the average practitioner, and one of the things that is being explored in the program is the participation of third- and fourth-year medical students in these community hospital teaching programs.

The development of teaching programs in community hospitals, the extension of teaching programs, will attract young physicians to areas

that would otherwise not have been attractive to them. They have been used to active teaching programs in the university centers, and they have tended not to want to go too far from these.

But I think the opportunity to keep up professionally, to interact with other people and with students on a continuing basis, will be an added benefit.

Maine is a very good example of the needs of the country to attract physicians to areas other than these urban areas where most of them have settled, or the suburban areas.

I think that the regional medical programs are making and can continue to make a significant contribution to this.

Mr. KYROS. I have one last question, Mr. Chairman. That is this: You have seen the program in operation for a couple of years now. What can you say about the fact that this is Federal money, that there is a possibility, always, when using Federal funds, that the Federal Government gets some kind of control over the medicine and medical practice. You know, we hear this all the time, and we are concerned about it, and I wouldn't want to see Federal control over medicine.

How can you say, sir, as administrator of this program, that Federal control is not an encroachment on medical practice through this program?

Dr. MARSTON. I think this committee took a very important step when it gave essentially veto power to the regional advisory groups. This means that we cannot establish on the national level any regional operational activity that has not had prior approval of the appropriate Regional Advisory Group. And this is perhaps the strongest point.

The other point is that, again, the Surgeon General is limited by the fact that every application must be recommended for approval by the non-Federal, National Advisory Council on regional medical programs. I think basically these are the two sharpest assurances that the control will remain at the regional level.

A third assurance is that the programs are working with the control remaining at the regional level. This is recognized, I think, at the Federal level as well as throughout the country.

Mr. KYROS. You have had no feedback of any problems concerning complaints of Federal control like we have had in programs, such as OEO and others?

Dr. LEE. I think there was a great deal of speculation that this would be the case. The fact that it has not been the case, the fact that there has been increasing participation by practicing physicians in the planning of the programs and as the operational programs develop, the extent of participation, the fact that there are 800 hospitals with their staffs participating are indications that this, in the planning and early operation stage, really has grassroots support.

I would add one other thing to what Dr. Marston said. I think the actions of this committee and the periodic oversight of the program by the Congress is another assurance to physicians, with the law as it is written, that there will not be Federal control.

Certainly, the way in which the program has been administered has been just in the opposite direction, to stimulate to the maximum extent possible, local initiative. Those who participate have to solve their local differences, which have been considerable in some of the regions.