by a single RMP-CHP staff, by two staffs and a single board, or by one staff and two boards.

2. Under a more complicated and dynamic approach an areawide CHP agency could be given community responsibility for structuring the local health care system, including considerable influence over programs and capital funding decisions. The RMP would provide specialized regional aid, including technical assistance on the development of primary care, training, continuing education, specialized regional services and professional supervision of quality control.

3. Another model would provide for the assumption of geographic responsibility by community hospitals, extending across all levels of care and concerning the efficiency of the total system rather than the efficiency of acute care only.

4. Yet another model might experiment with competitive prepaid group praetices with various options including the ownership of a hospital.

5. Another experiment might focus on relationships along a continuum of care prevention, diagnosis, treatment, and rehabilitation--attempting to distribute responsibility among community institutions for each of these functions and to create the relationships necessary to make it possible for consumers to know how, where, and when they could and should go for various types of treatment and what that treatment will cost.

These health care system experiments will be carefully designed, monitored, and evaluated by HEW and the State. local and private participants. We hope to develop a series of models appropriate to varying geographic areas, to varying demographic conditions and to areas with different patterns of health care needs and resources. We have no single model in mind now, nor do we expect to have a single model in the future. Rather, we expect to develop a series of effective models which could, with modifications, be used in appropriate settings throughout the Nation.

In addition to the Regional Medical Programs and Partnership for Health which I have already discussed, the "Health Services Improvement Act of 1970" extends the authority for Health Services Research and Development. It should be clear from my earlier testimony that research and development activities play an integral part in any effort to improve the delivery of health services. We intend to bring the findings of research and development to bear directly on the design, development and evaluation of health care systems experiments. We also plan to devote some of the future Health Services Research and Development funds and the outstanding expertise of the National Center to the conduct of these experiments.

It is clear to us that we must improve the techniques of applied health services research and that we must establish appropriate experimental methods if we are to establish cause and effect relationships between innovative efforts and apparent health improvements. We must ensure that we know about successful enterprises to reproduce them.

As you know, Mr. Chairman, despite the problems which plague the Nation's health industry, most health services research and development activities of the past have been spotty, fragmented, uncoordinated and limited to isolated geographic or categorical problems. Enactment by the Congress of Section 304 of the Public Health Services Act in 1967, and establishment of the National Center for Health Services Research and Development in 1968, represented the first clearly focused Federal initiatives in this area. We now have the vehicle to support applied health services research and development through the type of sustained, concentrated and adequately funded activities which have characterized, for example, the biomedical research programs of the National Institutes of Health.

We are committed to a bold research and development program to deal with (1) rising costs and inadequate financing methods, (2) unequal distribution and utilization of health services, (3) failures to develop or adopt new technologies for health care and delivery, (4) shortages of professional and paraprofessional personnel, and (5) the need for adequate criteria and methods for evaluating the effectiveness of health services.

With the extension of the authority under Section 304, in the context of the "Health Services Improvement Act of 1970,” the National Center for Health Services Research and Development will continue its critical role in these priority areas with a new impetus to help improve the organization and delivery of heatlh services.

Finally, Mr. Chairman, the proposed bill amends Section 305(a) of the Public Health Service Act to reflect the increasing demand for data on health care

resources, environmental and social health hazards, and family formation, growth and development. It also establishes authority for the initial steps (research, development, and evaluation) in the development of a cooperative health information and statistics system--a continuing joint endeavor by Federal, State and local units, based upon comparable definitions, standards, and methods for the collection and processing of data. The nucleus of a system like this already exists in the area of vital records. While this system has some technical problems it is, nonetheless, an example of a long-standing cooperative Federal-State-local activity which has provided consistently, over the years, valuable data for the development of health programs.

Health statistics currently generated by State and local areas are of uneven quality. While many jurisdictions have recognized this problem, they can not remedy the situation on their own. States and localities which have developed their own data systems may be producing statistics which are not comparable to those of other States or of the Federal government. The States continue to rely on us for some types of data. Yet it would be more reasonable if, in conformance with national standards of uniformity and quality, they could produce detailed data which meet their needs as well as ours. We view the joint system as a critical component of our continuing health partnership with the States and communities.

Mr. Chairman, we have given careful thought and study to the proposals contained in the "Health Services Improvement Act of 1970." We made an especially detailed examination of the Regional Medical Programs and the Comprehensive Health Planning Programs. We have had the advice of outside consultant groups, including the initial recommendations of the Task Force on Medicaid and Related Programs. Based on these efforts, we are convinced that our proposals will lead to a more productive use of Federal programs and resources, and to a more fully coordinated and systematic approach to organizing and delivering health care. Our aim, like yours, is to help the American citizen exercise his right to the highest level of care attainable.

My colleagues and I would be pleased, Mr. Chairman, to answer any questions which you and the members of the Subcommittee may have.

Mr. JARMAN. Thank you very much, Dr. Egeberg. The committee will be reading your entire statement and studying it with care.

Now I have one basic question that I might ask at the beginning of the hearing. As in so many authorization bills, I notice in the bills before us, there is provided-specifically in H.R. 15960—a 3-year authorization period and the term "such sums as may be necessary" for grants and contract authority. Could you give the committee any more definite information as to the administration's financial and monetary recommendation?

Dr. EGEBERG. I will refer it to Mr. Lewis.

Mr. LEWIS. Yes; I think, Mr. Chairman, we either already have or will supply to the committee a statement of our financial projections. While they will carry a certain amount of, I think, disclaimer from the Bureau of the Budget, they nevertheless do represent our best estimates and have been cleared by the administration for submission here.

I use the word "disclaimer" in terms of whether or not it actually binds the administration in submitting those specific amounts. But we do have projections which we have already furnished or will furnish to the committee in specific amounts.

Mr. JARMAN. Is there anything further in a general sense that you could submit on that?

Mr. LEWIS. Yes; I have this here. Our total for 1971, using round figures, Mr. Chairman, which would be refined in the statement which we will submit-for 1971, our total estimate is about $393 million for all of the programs covered here, and $490 million for 1972, and for 1973 it is $575 million.

Those amounts are broken down by the various programs, comprehensive health planning, health services research and development, national health statistics program, and regional medical programs. And would you wish those broken down now, sir, or would the statement for the record suffice?

Mr. JARMAN. I think the statement will suffice unless other members want to ask questions on it at this time. Thank you. Mr. Rogers. (The budget estimates referred to follow :)

1 Does not include budget item "Change in selected resources" for any of the programs.

2 Includes increase of $10,000,000 for rubella immunization program.

Includes $30,000,000 transfer of funds and program responsibility from OEO.

* Includes $30,000,000 for OEO projects transferred in fiscal year 1971 plus additional $5,000,000 in fiscal year 1972 and $7,000,000 in fiscal year 1973 for increased costs and growth of projects.

5 Total program direction of CHS.

Program direction for sec. 314 only.

7 Includes chronic disease program.

* Includes added $5,000,000 for experimentation.

* Includes $5,000,000 in fiscal year 1970 and $15,000,000 in fiscal year 1971 carryover from the $20,000,000 held in "Reserve" from fiscal year 1969.

Mr. ROGERS. Thank you very much, Mr. Chairman. Dr. Egeberg and your associates, it is good to have you back before the committee. It seems to me on the proposal you are presenting to the committee it would change the thrust of the legislation that the Congress originally enacted in these two programs. Would you comment on that, please?

Dr. EGEBERG. I don't think it will, sir, for this reason: There will be an opportunity for independent action, independent budgets, within this overall umbrella. The purpose of the cancer, heart, and stroke program was to involve the private sector of medicine in two things primarily in raising the level of medical care and in seeing to it that continuing education and possibly some investigative procedures as to how health care could be better distributed, such as has been done with ambulances in some places, so that they are now saving many of the coronary occlusion cases that would otherwise have died before they got to the hospitals. It was to help medical schools, community hospitals, doctors, and practices to work together toward those two purposes.

The other program was and still is the broad, comprehensive planning which ties in with States, which ties in, in some instances, with welfare and in some instances with the health department of the State to see that in the broad organization there is not too much duplication, that there is a pattern of planning toward a common end; and these two will be worked separately; but, already there has been a fairly large amount of working together, cooperation between comprehensive health care planning and the regional medical programs.

I need not give you an example, but one comes to mind. In Maine, the RMP people also run the other, and in a number of States they have gotten together on projects for delivery of health service to the poor, and there has been a feeling-out of how they should relate. This gives them an opportunity to relate but not to become one, and I can assure you personally I feel very strongly about the regional medical programs.

I was chairman of the California group for a long time, and I feel this gives them a better opportunity to carry out their mission than if they sort of continue just independently.

Mr. ROGERS. Well, this is my concern. If we put them under one title, I am not sure we are quite ready for this, I mean combining them, because it seems to me to lay the foundation for a combination which I don't think we are quite ready for.

When we passed the regional medical program, the thrust of this was to come down from our research centers to bring the knowledge down and get it out quickly to community hospitals and to the profession so it could be disseminated quickly, continuing education, whereas area wide planning was just the opposite. It was to start from the grassroots as to what they needed, what this community needed, how many facilities they should have, and to start the initiative from the local level, going up.

Now to put them both together, it seems to me to pervert what the Congress was trying to do at the time-to bring the greatest knowledge from all of the millions we spend, at the National Institutes of Health and so forth, to get it down quickly but to get delivery and to where action needs to be taken locally to generate it from the people who should know best who are in the community.

If we begin to tie this together, I am not sure but one or the other brings about a perversion of what we are trying to do. This is my

concern.

Dr. EGEBERG. Well, it would be mine, too, sir, except that we are not bringing them together in that sense. They will have independent action, they will have added correlation of memberships on their committee, of RMP on other committee and vice versa.

Mr. ROGERS. I think we can, in the regular legislation, say: They shall have interchange of representatives on their boards or councils. I agree with this, and I think it is well to have this coordinated, but I am not sure that the regional medical program should dominate area wide planning or vice versa, because of the situation of the two different thrusts of those programs.

Dr. EGEBERG. I don't think either one should or will dominate the other, and this gives an opportunity for a focus in an overall committee to do a great deal about shaping the future of the delivery of health care.

You can take a look at the budget that is projected, and it is a better budget than would have existed if RMP had been alone. One of my concerns has been to really preserve RMP.

Mr. ROGERS. Yes. I hope this is so, but judging by the request of the administration for money--and I know you say that these funds, although they don't bind the administration, the present thinking in HEW is in this direction, at least in a part of HEW, and I am not sure it really has the whole departmental approval.

Mr. LEWIS. Yes.

Mr. ROGERS. The Secretary is going to stand behind the figures? Dr. EGEBERG. It does not have final budget approval but has been discussed far enough so that we think so.

Mr. ROGERS. What I ask: Is Secretary Finch going to stand behind this?

Mr. LEWIS. I would assume he would. It has had departmental clearance these data.

Mr. ROGERS. How do you get departmental clearance? Who gave it? This concerns me.

Mr. LEWIS. Well, I could not assure you that Secretary Finch had personally reviewed each figure.

Mr. ROGERS. This is what I wonder, because this is a problem which I want to question you on quickly, because I keep seeing this problem, that we have statements and we talk about health crises, but somehow something is not communicated to the Secretary.

This is the point I am talking about-the budget request, and I understand budgetary limitations, because we have to deal with them all the time in these programs we authorize, and we authorized above. what has been requested by the budget or appropriated, naturally, and this seems to be a pattern, but I am concerned about the communications now and I keep reading reports in the paper, so many lately here, that I wonder if we are getting the message of health crises to Secretary Finch.

For instance-and I don't want to embarrass you, and if you don't want to answer, it is all right, Mr. Secretary-but how many times have you seen Secretary Finch and had a real working conference with him?