; I!! I @, @ @ ii.4 !,i , i @ i , -k" gi,R I'S I N A@L Transcript of Proceedings DEPARTMENT OF HEALTH, EDUCATION, AND WELFARE PUBLIC HEALTH SERVICE HEALTH SERVICES AND @@AL HEALTH AD,41NISTRATION' Executive Session NATIONAL ADVISORY COUNCIL ON REGIONAL MEDICAL PROGRAMS Rockville'i: Maryland @Tuesday 3 ust 1971 @FEDERAL @REPORTERS, orters N@E CR-30 36 GIBSON ng DEPARTI@IE-NT OF HEALTH, EDUCATION, AliD WELFARE 21 Public Health Service 3 Health Services and I-lental Health Administration 4 5 6 7 81 9 10, Executive Session NATIONAL ADVISORY COUNCIL ON REGIONAL i%!EDIC.P-L P.ROGP@2.,!S 12 13 II 141 15 16 Conference Room G-11 1711 Parlzlawn Building Rockville, Maryland Tuesday, August 3, 1971 1911 20 21 22 23 24 Ace-Federal Repofters, Inc. 251 1 2 N G S P R 0 C E E D 'I 2 'DR. l@IARGULIE.'D. 1,7e have some issues to deal with 3 which have some wide implications in terms of the whole P14T.3' 4 mechanism and they justify a little closer attention than we 5 might have in what we call the open session. 61 The executive session is one from which we will have 7 reports if they seem reasonable to report and not otherwise. Ile'll use your judgment about what should be done. 8 Let me get to the first one of primary concern, and 9 10 I'm going to ask Sewell ilillikcn to play a particular lead role in this discussion. This has to do with the Ohio Regional 12 l@ledical Programs. Now, to bring you up to date on that 13 particular subject, there are four programs which operate in 14 the State of Ohio. one of them, the Ohio Regional Valley 15 Program, has most of its activity in the lower valley but it 161 does include Cincinnati and some of the others so it is in 17, addition to its major concern. The other three programs, which are Northwest in 18 @19 Toledo, and Northeast in Cleveland, and North in Colum us, are pretty much confined to the State of Ohio and over a period of 20 21 time all three of the latter programs have been the source of real concern to the Council and to the staff. 22 They are, to put it briefly, quite inadequate, and 23 24 they range from fairly bad to inacceptable, and that's not an Ace-Fedefat Reporters, Inc. exaggeration I'm afraid. The Ohio State Program is sort of 25 I plodding and unimaginative and very much tied in with fairly i traditional interests of the medical school. The Northwest 21 I Program in Toledo has just never been able to achieve anything 31 4 It has had extensive criticism by the Council. It has een put on notice time after time because it is performing so 5 61 badly. It has had problems with the coordinator, with the I regional advisorv group, with the kinds of programs it has 7, developed. It has been mismanged and in general it has 8 accepted in our discussions the fact that it's in bad trouble. 9 The one in Cleveland is a program which became 10 operational a little more than a year ago, as I recall. It had 11 - in its beginnings a very vigorous and fairly dominating 12 coordinator who soon after it became operational 'Left for 13. another activity, and they have in that period of time not been 14 able to locate a coordinator to take over the activities,and 15 they have managed as well as one can under those circumstances, 16 1 But among other problems in the Northeast Ohio one -- that is 17i the one in Cleveland.-- is the re-emergence of some old internal 181 problems in Cleveland between elements of the medical community 191 which continue to paralyze any decision-making process. 20 At the last meeting of the Council we were urged to 21 get together with the people in Ohio and have them reconsider 22 some way in which this could be redesigned into an effective 23 program for the State of Ohio without having three ineffective 24 Ace-Fedefat Repattets, Inc. activities going on. 25 4 He did have a meeting with representatives 'Lro,,n all four programs and that was here in the Parl:lawn Buildin@,, and at 2 that meeting were representatives from the grantee agencies, 3 4 from the regional advisory groups, and the coordinators. There 51 was uncertainty at that time, and I think some uncertainty 6 remains, about the Ohio Valley @.lP aspect of it, but it was 71 quite clear that those people that came from Cincinnati had no 8 interest in moving from, the present arrangement with the Ohio 9 Valley MIP into a new arrangement, regardless of what that 10 might have been, in the State of Ohio. 11 There was a variety of attitudes expressed by those 12 who came from Northwest, Northeast and Ohio State, but they were influenced considerably by the sense of determination which 13 we had which suggested to them that they had a number of 14 15 choices but it would all come out to be a consolidated DrograTn of some kind. 16 We gave them some figures about that and pointed out, 17 some of the costs that were involved in multiple Drogr@..s and 18 ,9i reminded them that they really had not done very well. I helped draw their attention to it by giving them six months of funding 20 Iso that they could consider some of the alternatives which 21 22 appeared to concentrate their interest considerably. Now, from that, they drew the conclusion that thev 23 241 should meet together in Ohio; that thev would consider the Ace-Federal Reporters, Inc. potentialities in another kind of an arrangement; and that they 25 5 I have done. Now, one of the fortunate things which was going on 2 3 at the same time is that Sewell Milliken is the Director of the 4 CIIP in the State of Ohio and when this began we didn't know he was going to go on the Council anyway, he didn't know -- and 5 6 so he was a fairly free agent in this and sort of a neutral 7 figure in the activities which were going on, and quite by 8 coincidence, John Cashman, who has until very recently I§een 91 Director of the Community Health Services here in IISPIIIA, has 101 resigned and is going to Ohio in the State Department of Health. So we had some interested, knowledgeable people 121 involved who occupied a very special kind of position. we 13 agreed that when they met'we, the PI-IPS, would stay out of it and that we would be on hand to provide @y kind of information 14 or backup they wanted but the 6ecibion-making process was in 15 16 their hands and we would look forward to what came out of it. Now, unfortunately, at that first meeting which we 17 held here, Sewell ran into airplane difficulties so he got in 18 191 during the afternoon and missed the initial session, but he 20 has been a part of the one that followed and they .had a meeting 21 out there and this led to a second meeting which took place a 22 week ago Sunday, July 28. 23 So what we would like to have you do now, if you will, is bring us up to date on what happened and what sort of issues 24 Ace-Federal Reporters, Inc' we're likely to be facing. 25 iG 'A@ IAILLIKE4'4: In this folder that you have, if you 2@ go down through it you will fin d the minutes of the Ohio FU4P 31 meeting held on July 23, 1971. That's all of the critical' 41 reference that all these other conclusions will lead to. 5 First of all, I'd like to say, probably unnecessarily 6 so, this is a very traumatic thing for the P,,IlPs in Ohio to go 7 through and particularly the RAG. I understand that the RAG in 8 Cleveland has not yet accepted this change in concent, but the Cleveland group is Proceeding in spite of this and I'm sure' 10 they will get along. The critical issue after this meeting, as a result of this meeting of the 28th, focused around who the fiscal 1 2 131 agent would be. Of course, the Ohio State people felt they could play this role and the Ohio State I-ledical School can Dlay 14 this role, and this was not acceptable to any of the other 1 5 16 PllPs for historical reasons. As a result of this, there were two alternatives. Ono 17 was that the Cleveland people -- item number four on this 18 letter, the minutes, is one of the alternatives that was dis- 19 20 cussed in the halls, and this was that the Northeast Ohio 21 Regional Iledical Program is a non-profit corporation and could be moved to Columbus -- change it a little -- and still continue 22 under its previous incorporated-status. This got a lot of 23 -discussion, 24 Ace-Federal Reporters, Inc. The information they received from Dr. Margulies to 25 7 I look at some of the other states and some alternatives of doing 21 this led them to Kentucky, where the University of Kentucky 3Research Foundation has been the fiscal agent, and they studied this and two or three of them met Paul Warren(?) somewhere in 4 Illinois and spent a day with him and discussed this; and as a 5 fresult, the,serious discussion centered around the Ohio State 0 University Research Foundation under similar arrangements that 7 the University of Kentucky Research Foundation has been 8 operating. 9 10 It took a lot of talking, but there was finally 11 agreement on the 28tli that they would all go this route. Now, 121; the Ohio State people have r)ra.cticallv certified -- not under 13 oath, but almost -- that there is no direct relationship between 14 the research foundation and the university, but the others do not quite trust them. 15 16 DRo DE BAKEY:L The university? 17 DR. MILLIKEN: Yes. Howev6r, they are willing to go 18 that route but there is great concern about the fact that Ohio 19 State could end up being the PJAP, which the others -- as Dr. 20 Margulies put in his letter to them, he thought that the federal 21 office and this Council would question a y 22 any of the existing PiNIPs took over the others. There was a little disagreement on this meeting on the 23 24 28th as to who was the chairman. They asked Dr. Pace to convene Ace -Federal Reporters, Inc. the meeting -- he's from Ohio State -- and he assumed he would 25 8 I be chairman. But after he started the meeting he was shown 2 very quickly that they were going to elect their own, and so 3 Dr. Fishbein ended up as chairman for this first meeting. 4 Now, at the next meeting, they have again asked Dr. 5 Pace to convene it. They are meeting tomorrow and take this 6 one more step. I imagine they will rotate the chairmanship o-f this group. 7 Now, you might go to enclosure number two, which is 8 this long flow chart, and starting, as I guess one is supposed 9 to with such charts, go to the extreme ri let with their,deadlinc- 10 9. of February 1, their target date for the Ilashington P14PS review; and backing up from there, I think this is one of their critical 12 13 questions, Dr. lwlargulis, as to whether this February 1 date is 14 correct on that basis for all that has to be done here to meet the timetable. 15 Backing up from that, this January 15 is rather 16 routine. December 1 is the CIIP review and comment which I don't 17 believe presupposes any problem. November the,15th, the 18 proposal review by the interim Ohio Advisory Council will be 19 20 complete. The October 1 deadline is the real critical one because all of the M,IP areas will have to put together their 21 22 various different concepts of this, and this leads me to a 23 question that has not come up yet by this group, and some of us who have been talking about it in advance feel that it might be 241 Ace -Federat Reporters, Inc. well to have some mechanism wherein it would be possible for 25 9 ly opera some leadership other than that now current tive in each 210f the four could rally around. One such activity would be that each of them, if it 3 were acceptable and feasible, could contribute money into a 4 5 central pot to employ an interim nerson, or another alternative, 6 as was suggested to me today, is that they might get a loan of 7 a very capable staff person maybe from this office who could 8 be the rallying point around which each of the current organiza- 9 tions could get an advance and early start towards putting this together organizationally and program-wise so that no one of 10 11 the existing people now involved has to run the gauntlet and I bring in all the past problems. -.,hat might happen, but this 12 has not been discussed by anybody in these P14Ps. 13 DR. DE BAKEY: Is there enough vested interest cn t e 14 part of the various groups to make it so tramatic that you'd 151 1 almost have to destroy it in order to start over? 16 DR. I-.IILLII'%El;: I think just after the meeting of the 17 28th this was the feeling, but as a result of that meeting and 18- as a result of the communications that's been on-going since, I 19 think they all feel that this is feasible now. 20 DR. MARGULIS: One of the interesting kinds of 2.I releases of pressure in this came about during the initial 22 23 meeting when the people from Cincinnati were disclaiming any interest in moving from where they were, the point being that 24 Ace - Federal Reporters, Inc. they had been able to maintain some sense of local integrity 251 lo I although they were part of a Kentucky program; and I pointed out 2 the fact that the same thing can happen in Columbus and in 3: Cleveland and in -oledo, that they can be in a single state 41 program, and still have asense of local purpose by subreg;-ona- 5 lizing. Cincinnati was a good example. I think they are 6 beginning to recognize that they aren't giving up everything 7 but actually can retain something. 8 You know;, that point that you just raised, Se@qell, of the critical issue of deciding on some common goals and 10 priorities, also brings up the other issue which you really 11 haven't dealt with and have to, because in essence what we're 12 doing is combining weaknesses in this program unless we -lo 131 something extraordinary to bring them together and make it a 14 stronger program; and I think almost of necessity there's going,, 15 to be some sort of outside infusion necessary at the point u%here 16 they're deciding exactly what is it they're going to be with this combination. 17 DR. DE BAYEY: The amazing thing to me about this is 18 19 that they are tremendous resources in the State of Ohio, cer- 1 20 tainly a talented pool of medical personnel, and why they can't 21 find leadership to energize a program like this into Ia good, strong program is difficult for me to understand. 22 23 DR. I-IARGULIS: Sewell-, you're there in the A agency. Do you have some comment? 24 Ace-Federal Reporters, Inc' DR. DE BAKEY: I was concerned that it was sort of 25 I too much selfish vested interest. of course, you have some 2 traditional polarization anywhere you go. You know, there's 3 no place in the country you won't find some polarization, but 41 that hasn't prevented a g- In fact, ood, strong IU,,IP program. 5 some places where it's been strongest --- where they have developed a strong WIP program has been where there's been the 0 7 stronger traditional polarization. 8 DR. I.IARGULIS: They kept talking about the vast 9 differences within the State of Ohio and I pointed out to them 10 that they are much greater in other states,, that almost every 11 place we work has great differences from one area to another, 12 and some manage and some don't.. 13 DR. DE BAYEY: That's right. One of the, big differences of the State of Ohio from other places is the 14 15 talent of medical personnel they've-got. 16 DR. I.IERRILL: Is this essentially a "town and gown" thing? -Is everybody against the university or are they all 17 18 against each other? 19 DR. @illON: I think there are.several things. One of then, has been leadership. it's been over a year since they 20 21 decided the leadership in the Northwest, I believe it was, 22i needed to be changed. 14ike, you're the one -- as I remember 23 that now, I said "Fire him," and you said,, "Tio, let him work it 24 out." Ace - Fedefat Repoiters, Inc. DR. DE BAKEY: That's right. 25 12 1 DR. CA1414ON: And we sent a task force out there and-- 2 DR. DE BAKEY: I remember that very well, Bland, and, 3 1 have to 41 DR. CA'LINON: We never did get rid of him. 5 DR. DE BAYEY: I agree with you we didn't, because I 6 thought they ought to do it themselves, and I still think that 7 was the right thing to do, but obviously it didn't work. 8 DR. MILLII%'EN: I think part of the problem that was 9 built into this, some of us tried to do something about this 10 two years ago -- there was unfortunate overlap -- two or three 11 county overlap between each of these programs and when we 12 discussed this two years ago or more with the coordinators 13 we have been meeting together ever since the program started 14,1 they all said "V.7ell, this is no problem. A county can have the 15 best of all worlds. "@'hey can get some particular thing from one 16 P14P and something else from another." Well, unfortunately, like everything for everybody, there's another side; and the other 17 8 side was that it's seeded distrust between -- a little bit 19 between "toi-in and gown" and in a couple of areas -- in Lima, Ohio, for exariple, there was some physicians who graduated from 20 21 Ohio State and some that graduated from Michigan, and they were pushing their own schools and this built in another controversy. 22 So that some of us shudder to see the review and comment coming 23 down the pike with this county overlap. 24 Ace-Federal Reporters, Inc. As somebody told me just before I came in here, in the 25 1 3 I city of Dayton, there are a great many peoplei'pliysicians 2 included, who t hinl@ Dayton isn't in either, but actually it's 3 in two; but you can't convince them that they belong to either 4 because there's been no one there. It's created a vacuum 5 because there's nobody there pushing-.@ Those that are for 6 Cincinnati push it and those in Ohio State push it. 7 DR. MILLIM"4: As you see the emerging design 8 administratively, is it to go the California route with a 9 separate, simple, relatively small office and then area one, 10 area two and area three, in all probability?. 11 DR. ZIILLIKEN: Right. 12 DR. MILLIK70,1: I saw the definitions there. DR. DE BAKEY: The thing that concerns me about that 131 14 is that I'm really more worried about how that would effect a 15 real change in strengthening the activities of PIIP within the 16 various areas. One of the main reasons that the thing works so well 17 18 -in California I think is because of the leadership they have. 19 They have got very strong leadership there and the people rally around their leader, both in the.areas as well as in the central 20 administrative office. They have respect for them and it works 21 well. But you can't just take this same group and aive them 22 another designation and say it's going to be comparable to 23 24 California. It is now, in a way. Ace-Federat Reporters, Inc. DR. @,IILLIKAN: I didn't mean to imply that. In the 25 14 1 first lace, you would have a new RAG and the new PAG might p 2 consist of the deans of medical schools and people from the 3 lIeart Association and Cancer Society. It would be a new RAG 4 overseeing the entire phenomena as in California, if one went that route, and you might engender in that kind of new PAG some 5 sense of responsibility toward the subdivisions. In other 0 words, there is area, one, area two and area three, which is 7 the kind of thing that is going on out there. Now, it is 8 perfectly correct that sooner or later. you have got to infuse 10 some leadership in each of the subdivisions or you're dead, but at least there would be the new RAG concept. DR. MARGULIES I think it would be a great mistake 12 13 to move to some sort of b#lkanized concept in,,which they still 14 have their individual function but work together at some centra point. We really have to replace what is there but ive then a@ 15 16 the same time a sense of purpose within the total RIIP. I wonder how much value there might be, when they ge4,- 17 18 to the,point of considering the way in which they want to func@..' itogether, in getting consultation -- and I really haven't 19' thought about this -- from some other coordinators who have 20 and who have some under--' 21 22 standing of how this kind.of thing functions., no one with any 23 nearby geographical rel I-iiit-- --,Om distance away. DR. DE BAYEY: I mus t say I like the idea Sewell 24 Ace-Federal Reporters, Inc,. proposed of having someone come in there. I don't know how 25 15 feasible this is, but it certainly would seem to me it would 2 make it more practical to move them if there was somebody that 3 could come in who would be objective and in a sense nonpartisan in his view and he has no axe to grind and he's not related to 4 5 any group and they would have to respect him by the very fact 6 that he obviously would be a person you would send who knows 7 his business to come in there at least on an interim basis and be the regional director and sort of get them started 81 organizationally and constructively and infuse in them some 9 feeling of trust for the program. I don't know that you're 10 going to be able to do it with the people they have got. DR. SCHREINER: .,Did the task force explore that 12 13 possibility of having it disappear and let it go and take one 14 from Pennsylvania or something? DR, MILLIKEN: That was not realistically explored. 15 16 They gave it up real quick. DR, EVERIST: Is this the first consolidation that 17 18 we have had? We have had some separations. DR. IIARGULIS: I think so, 19 DR. EVERIST: Ile have had no consolidation? 20 DR. MARGULIS: I think so, and we are going to lead 21 to another discussion hereafter of another couple of areas 22 23 because this is not just an Ohio problem. We have the problem to consider elsewhere. 24 Ace-Federal Repo(teis, Inc. DR. CANNON: It never has been clear to me as to who 25 I has the coordinating responsibility, the grantee? 2 DR. IIARGULIS: Yes. DR. CANNO14: Then the key to this is the grantee, 31 4 because you're going to have to fire some people and that's ti-@e 5 %.;hole thing. The good programs that we have got you can focus 6 real quickly on is because of local leadership, the.regional 7 leadership. Now, you have,got to fire some people. 8 If you're going to accept this foundation as the 91 grantee you,have got to know beforehand that they are willing tc 10 reshuffle and change the personnel because if they're not 11 willing to do that we're going to have the same problem no I matter how we merge the-i or divide them or anything else, and 121 13i that's what I think -- if you once get over that hump, I think 14 you've got it made, whether you have four or three or t%,;c., or one. 15 DR. IIARGULIS: That s a good point. 16 DR. CA1114014: But we haven't yet -- you know, we tried 17 to find out who hires and fires the coordinator and it's alT@avs 18 19 been talked about under the table, but no one has ever come out and said who is responsible. 'Can a RA(72 grouo? 201 211 DR. klARGULIS: No. It's DR. CANIZON: So I can see why thev woul t 0.@@ i o 22 23 State.as the grantee, you know. I can see that. I would think it's up to us to decide whether the grantee that's being 24 Ace -Federal Reporters, Inc. considered there is an appropriate agency that will make t:!,e 2 5 17 1 decisions that have to be made. 2 'DR. IIARGULIS: Do you have any idea at this point of 3 how that would be decided? Because you have a corporate body 4 which is the fiscal agent, but then the question after that is 5 how do they make up the body which is going to direct their 6-affairs? How is it composed? And that's the key to who they 7choose. 81 DR. I-IILLIKEII-. There's a paper in here with the 9suggested makeup of an interim state RAG. They.go in with an 101 interim advisory committee which would then, with some changes, become the final one. I-lembership would consist of an equal number of representatives from each of the four RAPS, 12 members 12i 13 represent each district office, representatives from each of the '14 four R:,IPs shall be selected by that region which is part of this 15 whole built-in thing. DR. DE BI@KEY: That's a RAG youtre talking about now? 16 17 DR. IIILLI.KETI: That's right. DR. DE BAKEY: The Ohio Research Foundation? 18 191 DR6 MILLIKAN: Ilho is that going to be and what kind 201 of a board and'so forth? DR. CA14NON: Who are "they?". 21 - DR. MILLII'%EN: There's a letter here that doesn't 22 answer all those questions, but--- 23 24 DR. KOI.IAROFF: Hasn't it been true, though, that when Ace-FederalReporters,lnc. coordinators have been fired that the RAG really gets together 251 I with the grantee and the grantee -- it's nominal that it-.Is the 2 grantee that does the firing,or the hiring for that matter, but 3' it's really the responsibilityhistorically, of the RA-@? 41 DR. IIARGULIS: TIell, it has 'and it hasn' t, Tony. It 5 really depends on the working relationship. We'll got to Susquehanna Valley in a minute and you will see that it's not 0 7 necessarily true. That will happen when the RAG is functioning 8 well. 9 In these circumstances, however, it would have to be 10 without benefit of @AG because almost by the nature of it the RAG would be dissolved, the RAGS, the separate ones. 12i DR. L@IILLIKEN: The five points in this letter that's 131 with your material sort of spells out their recommended 14 procedure. It's from Stephens, who is the Director of @,-iis Research Foundation. They are trying to iove from the 15 periphery to the center in a series of steps is what they're 16 17 trying to do, which assures them all they will continue to have a voice in the changes. This is the big issue and they want 18 visibility and they even talked about phasing -- doing this in 19 phases, which has some merits, too. But they have gone sort of 20 - to the interim board with the expectation that this board will 21 have real clout and will be able to help determine the policies 22 of the fiscal agent. 23 24 DR. I.IARGULIS: It would seem to me from what you said Ace-Federal Reporters, Inc' that so far as our negotiating position is concerned that the 25 19 I interim board and then the fiscal agent are the points on which 21 we can act and the people to whom we can talke and clarify some 3 understandings with. 4 Northwest Ohio is really basically very passive about 5 it. They are perfectly willing,to join any place because they 6 know they're in deep trouble. There's a big difference -- or 7 there was a big difference -- I don't knot%,, whether it has sur- 8 vived but I would imagine it has -- between Fred Robbins and 9 Charlie Hudson in Cleveland as to how this would function, with 10 Charlie performing in characteristic manner. He doesn't want 11 any part of it4 12 DR. I.IILLII