j. A more intense problem exists in the St. Louis, Missouri/Southern Illinois area. Since 1967 Barnes Hospital in particular has been the focal point for ESRD services in Southern Illinois. In fact, the Illinois program was instrumental in helping build the St. Louis program. With the growth of the Illinois program, the Springfield Memorial Hospital Renal Program has continued to expand throughout central and southern Illinois. At the present time, Springfield Memorial Hospital has six satellite units in the following counties in central and southern Illinois: Adams, Sangamon, Macon, Coles, Madison, and Morgan Counties. More importantly, a new referral pattern has developed in Southern Illinois with the newly formed Southern Illinois University Medical School existing in both Carbondale, Jackson County, and Springfield. Since the medical school has been in operation, a Southern Illinois Transplant Program has begun based at Springfield Memorial Hospital. In addition, a new Dialysis Center Program has within the past three months begun at SIU in Carbondale based at Doctor's Hospital with the acquisition of a full time nephrologist. There is a newly developed referral pattern from Carbondale to and from St. Louis and to and from Springfield. In addition, we are finding St. Louis hospitals are referring patients back to Illinois facilities. For example, since June of 1974 there were 27 new ESRD patients from Illinois PSRO Area VIII. Their disposition was as follows: 19 percent went to Springfield, Ill. 03 percent went to Vincennes, Ind. In addition, each of these patients are included in the centralized Illinois Tissue Typing Program based at University of Illinois in Chicago. What has been described above evidences substantial interface and referral patterns existing between St. Louis and Illinois-both to and from. Because of these existing referral patterns, because of the newly developed health delivery system emerging from the Southern Illinois University Medical School, St. Louis SMSA and contiguous counties should be included in a St. Louis/Illinois network. From our conversations with Barnes Hospital, we understand that this will not affect St. Louis referral patterns and would preserve existing St. Louis/ Illinois referrals. This will provide optimal advantage and convenience to patients and providers and preserve a well organized and administered ESRD State Program. To do otherwise would seriously compromise patient flow patterns, as well as disturb efficient administrative structure. The Illinois renal disease program has an annual budget of over $1 million per year to subsidize their existing program. They currently inspect and approve each provider before state funds are made available, similar to our Medicare certification programs for other types of health care providers. They have a Medical Advisory Board for the State program and are now establishing a statewide council of Illinois ESRD providers. Any action by HEW to infringe upon or supercede the existing State of Illinois program for Renal Disease patients will evoke serious negative reaction from State and Federal elected officials. 6. We recommend strongly that new providers be approved by contiguous networks if planned within 50 miles of another network. 7. In the best interest of health planning and delivery, we believe network designations should be reevaluated after the designation of health service areas. 8. The consultants report (Attachment No. 1) which summarizes Region V recommendations is attached. Possible modifications to the consultants report have been suggested (Items 5a through 5j above), but time constraints did not allow for their review by either our ESRD consultants or other Region V agencies. They are submitted herewith for your consideration, subject to modification pending further reviews as noted above. Network issues involving Region V, prepared by ESRD program staff, Rockville, Md., January 1975 Region or regions involved: Regions II, III, V‒‒‒‒‒‒‒ Camden, N.J. and Philadelphia, Pa. are a single Merge eastern Pennsylvania PSRO's 2, 3, 9 Include only southern New Jersey with the above and allow northern New Jersey to exist as a network of its own. It is our opinion that inclusion of all of New Jersey will provide for wider representation of those having an ESRD interest in the Philadelphia/Camden SMDA. If eastern Pennsylvania is included in a New Jersey/eastern Pennsylvania/Delaware network, then western Pennsylvania PSRO's 1, 5, 6, 7, and 8, as well as the Wheeling SMSA and the Wierton/Steubenville SMSA may wish to negotiate with Ohio to form a western Pennsylvania/Ohio network. The West Virginia/Maryland/D.C./Virginia network requires adjustment for the following SMSA's: Regions III and V----- The Wheeling SMSA and the Steubenville Regions III, IV, and V. The Huntington/Ashland SMSA covers 1 Ohio county and 2 Kentucky counties and they should be included in the West Virginia/Maryland/D.C./Virginia network. Regions III and V------- The Parkersburg/Marietta SMSA should be included in the West Virginia/Maryland/D.C./ Virginia network. Regions-IV and V____ Regions IV and V.......... The traditional referral patterns of the Cincin- Regions IV and V_______ The Evansville SMSA includes Henderson Region V.. Regions V and VII_____ Regions V and VII____‒‒ County, Ky. and it should be included in the Within region V the following SMSA's cross The Toledo, Ohio SMSA includes Monroe County, The patient flow from southern Illinois to St. ROBERT VAN HOEK, M.D., JULY 8, 1975. Acting Administrator, Office of the Administrator, Department of Health, Education, and Welfare, Public Health Service, Health Services Administration, Rockville, Md. DEAR DR. VAN HOEK: I was amazed to receive your letter of June 27 stating that the proposed ESRD network designations, as pertaining to Illinois, were submitted to the Secretary unchanged. At the time that I agreed to the meeting on April 22 with Dr. John Marshall in your stead, there was an understanding that if that meeting was not satisfactory, I would pursue a further meeting with you, personally. However, all of the participants from Illinois and regional office of HEW present on April 22 left with the clear impression that revisions would be made in the proposed area designation. For that reason I did not request an additional meeting with you. I now can only come to the conclusion that the meeting on April 22 was, at best, a stalling tactic and, at worst, a deception. I, therefore, now request that a meeting be held with you and Secretary Weinberger and representatives of Illinois as soon as feasible. Yours sincerely, JOYCE C. LASHOF, M.D., Director of Public Health. STATE OF ILLINOIS, DEPARTMENT OF PUBLIC HEALTH, Re: Appendix to subpart U, amendments to part 405 of title 20, CFR: End-Stage Renal Disease Network Areas. Mr. J. B. CARDWELL, Commissioner of Social Security, Department of H.E.W., Social Security Administration, Baltimore, Md. DEAR MR. CARDWELL: The Illinois Department of Public Health disagrees strongly with the designation of network areas 8, 9 and 15 set forth in the proposed amendments cited above and published in the Federal Register, Vol. 40, No. 127 on July 1, 1975. It is our opinion that placing Illinois facilities into this network pattern would needlessly disrupt the high standards and economy of the present program of end-stage renal disease care provided to Illinois patients. It is, further, our opinion that this quality can best be maintained by retaining the present statewide scope of organization of facilities and services. Some of the reasons are as follows: 1. Since 1967 there has been a comprehensive end-stage renal disease care program in Illinois. It has maintained quality of care, availability of care, and economical and efficient development of services as needed throughout the State for all citizens. It also has developed a unique data base with the records of 2300 patients. This program has ben administered through the Illinois Department of Public Health; a statute-mandated advisory committee has worked closely with the Department in developing medical criteria for patient acceptance, guidelines for hospital and facility participation, and specified fee schedules. All cases are subject to medical review and all facilities are site-visited prior to approval. It has been an outstanding example of Medicaid (Illinois Department of Public Aid) and other governmental department cooperation. To replace this proven program with one administered by 3 network councils, or to try to superimpose them on it, would be a regressive step and an unreasonable and costly duplication of effort. 2. Under the Illinois program, effective interrelationships have been developed among facilities in all areas of the state. With the advent of Medicare assistance, a network council has been formed which is capable of performing all the functions specified in the proposed regulations on conditions for coverage. 3. The Legislature of Illinois has appropriated more than one million dollars for each of the past six years to supplement other resources for patients with end-stage renal disease. We consider it very possible that these appropriations could be jeopardized if the administration of the program were divided and subjected to extraneous considerations. 4. The proposed boundaries are not consistent with current patient flow and referral patterns. The enclosed tables show the latest available figures on distribution of facilities used by patients residing in the 66 counties of Illinois named as included in the proposed Network 9. This distribution in southern Illinois has been markedly influenced by the development of facilities in central and southern Illinois. As other examples, both Peoria and Springfield facilities serve some patients residing in proposed Network areas 9 and 15. In connection with patient referral patterns, we are advised that southern Missouri patients are referred to facilities in Tennessee; and western Kansas patients to Colorado. Neither of these patterns appears to have influenced network boundary designations, as it is proposed to keep the States of Missouri and Kansas intact. 5. Despite implications to the contrary in the Federal Register and other documents, the proposed division of Illinois is opposed by an overwhelming majority of knowledgeable persons involved, and is contrary to the recommendations of the Ad Hock Consultants appointed by the Region V HEW office for this purpose. Your attention is most urgently directed to these considerations in the interest of quality of end-stage renal disease patient care; cost economy; efficiency of organization; and the repeatedly expressed wishes and opinions, based on long experience and concern, of those most immediately involved. Yours sincerely, F. DAVID MATHEWS, Ph. D., JOYCE C. LASHOF, M.D., DEPARTMENT OF PUBLIC HEALTH, Secretary of Health, Education, and Welfare, DEAR DR. MATHEWS: The occasion of this letter is the enclosed response (A) from Dr. van Hoek to my plea for consideration of the existing Illinois Renal Network. Our position has been discussed with representatives of HEW at the regional and national level. Despite support at both levels for our views, Dr. van Hoek has been adamant. For some reason he has chosen to focus on the minority of Illinois patients that go to St. Louis as a determinant of the currently drawn network lines to include 66 counties in Illinois along with Kansas and Missouri. The attached tables (B) illustrate clearly the predominantly intrastate nature of Illinois referrals. At a recent meeting in St. Louis it was explained by Mrs. Kyttle of the BQA that the reason for including most of Illinois in the network was the referral pattern from southern Illinois to Springfield. We see this as a reason for maintaining southern Illinois in an Illinois network-not in the currently proposed network. It is our feverent hope that you will give renewed attention to the Department's present network designation because it ignores all factual arguments presented, HEW policy guidelines, and brings the principles advanced by the department into question. I will deal with each of these assertions: 1. Factual arguments have been presented in detail previously. The most cogent statement was the result of analysis by your department's consultants and staff. Dr. Ellis' recommendations in his February 4 letter (C) state the case completely. We are concerned that the proposed network will interrupt patient referral patterns for there was the implication that SSA payment may not be made for those who cross network lines in the draft regulations (D page 4, paragraph 2). While the published regulations eliminate this wording, we want to be certain that they do not allow for this kind of restriction. Management of the program will become more difficult in the proposed network since the established network in Illinois covers services not provided under the SSA program. We have developed standards over a period of eight years which have been acceptable to SSA in the designation of providers for reimbursement. We have organized a smooth flowing referral and formalized system of regional professional relationships. For example, our Renal Disease Advisory Committee was established by statute in 1968. Our system now joins together professionals throughout the State who share patients, information, research interest and generally assist one another to provide the best possible management. The University of Illinois Hospital in Chicago is the primary state-wide resource for our tissue typing services. Patients are referred there from throughout the State almost as an emergency measure when a kidney for transplant happens to become available. We respectfully urge your review of these and other facts as given in Dr. Ellis' memorandum and previous documentation in your files. 2. HEW policy guidelines have been ignored in our opinion. The caution appearing in the statement of April, 1974, (E) under 1-Background is indicated. In this action, with respect to ESRD networks, I submit that the onus intended has not been avoided but rather reinforced the fear of domination by a federal bureaucracy. 3. This brings me to the final point-the principles guiding departmental policies. I believe it is the stated view of the department that federal domination of social welfare planning should be prevented where possible that while leadership is expected of the executive branch, strong state and local involvement is necessary to a practical, effective human resource effort. The network designation contradicts the department's stance. We, in State government, share this view especially with respect to local government, and particularly in dealing with health providers. It is our policy to reassure those who view all government regulations with suspicion that we are acting in the public interest. This applies to legislators, health providers, and the general public. We support federal standards as well as our own, and generally attempt to be supportive of quality and cost control. We are proud of the credibility established here with nephrologists and others in this program. However, department action seriously weakens our standing and our efforts to exert innovative leadership. Our nephrologists, for example, are incredulous of your intentions in the ESRD program and may come to doubt ours. In our view this decision casts serious doubt on our ability to mount a joint effort to implement health planning and national health insurance legislation. I hope you will agree with me that the department's position is inconsistent in relation to the network design it proposes in the regulations and that you will reconsider our request for modification. Yours sincerely, JOYCE C. LASHOF, M.D., MEMORIAL MEDICAL CENTER, DEPARTMENT OF MEDICINE, DIVISION OF NEPHROLOGY, Springfield, Ill., August 21, 1975. Re: Appendix to subpart U, amendments to part 405 of title 20, CFR: Endstage Renal Disease Network Areas. Mr. J. B. CARD WELL, Commissioner of Social Security, Department of H.E.W., Social Security Administration, Baltimore, Md. DEAR MR. CARDWELL: I wish to express my vehement opposition to the establishment of Endstage Renal Disease Network 9 as detailed in Conditions of Coverage of Suppliers of Endstage Renal Disease Services, published in volume 40, number 127 of the Federal Register on Tuesday, July 1, 1975. I agree with and heartily endorse the letters written to you on August 7, 1975 by Dr. E. T. Sorenson (Illinois Society of Nephrology) and on August 12, 1975 by Dr. Joyce C. Lashof (Illinois Department of Public Health), copies of which are appended. Similar statements in opposition to the proposed regulations are being formulated by the National Kidney Foundation Subcommittee on Endstage Renal Disease and a group convened under the auspices of the Missouri Regional Medical Program consisting of the majority of providers in Missouri, Kansas and Southern Illinois. The facts of the situation are well known to everyone and the appropriate arguments and data to support them have been put forth. I do not believe it would serve to repeat the statements in the previous letters that I have already endorsed. |