. . I I?IVISION OF REGIONAL MEDICAL PROGRAMS - - i FMP AD HOC RE'JIEN COXP'IITTEE 3 b Jj;, !I kqi . . Report by Mr. Rubel .+ 4 j! Report by Dr. Goodman pi+ 5 ;I ~ Comments by members of public: /I ! I ti 1: Rajeshwar Prasad (Nassau-Suffolk RMP) I! Y 23 $9 /I 7 `1 Review of applications for Regional Nedical Programs: Alabama.(Dr.'Vaun) 68 Albany (Mr. Earrows) 72 Arkansas (Dr. Scherlis) Ei-State (f4r. Toomey) Lakes area (f,!r. Barrows!) California (Dr.Heustis) 76 73 85 8O d Central New York (Dr. Eess) 98 Maryland (Dr. Vaun) 193 Colorado/p7yoming (Dr. McPhedran) Mev7 Jersey (Dr. Teschan) Florida (Dr. Miller) 107 109 112 Greater Delaware Valley (Dr. Hess) 116 Hawaii (Dr. Hirschboeck) 119 Washington/Alaska (Mr. Barrows) 121 Illinois (Dr. Scherlis) Indiana (Mr. Thompson) 126 Inter-mountain (Mr. Toomey) 135 * ,. I: j; DEPARTMENT OF HEALTH, EDUCATION AND p?ELFARE I I/ 2 I! - - - 1; !I DIVISION OF' REGIONAL MEDICAL PROGRr.MS REP AD HOC REVIEW COMMITTEE 11 12 13 15 19 20 21 22 / Conference Room G-H Parklawn Building 5600 Fishers Lane Rockville, Maryland 20852 Wednesday ,August 7, 1974. The meeting convened at 8:30 a.m., Dr. Herbert B. Pahl, Acting Director,Division of Regional Medical Programs, presiding. PRESENT: I EUGENE RUBEL, Acting Associate Director, HRP. SARAH J. SILSBEE, Acting Chief, Operations and Development, DRMP. MR. GARDELL, Acting Deputy Director, DRMP. ROBERT TOOMEY, Greenville, South Carolina. DR. WILLIAM THURMAN, New Orleans, Louisiana. DR. ALEXANDER McPHBDRAN, Augusta, Maine. DR. LEONARD SCHERLIS, Baltimore, Maryland. DR. JOHN HIRSCHR~ECK, Milwau?cee, Wisconsin. DR. JOSEPH HESS, Detroit, Michigan. MR. KENNETH BARROWS, Fest Des Moines, Iowa. n 0 e PRESENT (continued): JOHTJ THOMPSON, New Haven, Conn&i 2 cut. DR. WILLIAM VAUN, Loinq Branch, New Jersey. SISY~-"7 ANN JOSEPHINE, Notre Dame, Indiana. DR. , JL TESCHAN, Nashville, Tennessee. MRS. JESSIE SALAZAR, Albuquerque, New Mexico. DR. WINSTON MILLER, Minneapolis, Minnesota. DR. ALBERT HEUSTIS, Thpe Rivers, Michigan. DR. ROBERT CARPENTER, Ann Arbor, Michigan. And Others. 1 PROCEEDINGS - - I - - - - - -- -- -- 3 I 1 2 DOCTOR PAHL: Good morning,. Play we come to order. i 3 And at this time, may I welcome you as members of the Ad Hoc i 4 PW? Review Committee, Pormny in the room, that will be a 5 significant advance this time. 6 I do want to say how much I appreciate having both 7 the review committee members return on such -- after such a 8 9 10 11 short interval, and also such a fine turn-out of our national advisory committee members, council members. We expect to ha7 ! a total of twelve. Can this br turned down a little bit? 12 13 We expect to have a total of twelve of the council members present today, and with other commitments, I believe 14 15 16 there will only be two council members here who will be preser tomorrow, that won't be able to sit in on the proceedings tode Thus, I think we are extremely fortunate in being able to sal- 17 18 19 20 21 vage a very difficult situation and conform with court order requirements and commitments to the Regional Medical Programs, 21 2.3 24 2-i and as well as possibly get into your summer schedules. I want to welcome to this table specifically Sr. Ann. We are pleased to have you back. And I see Dr. McPhedran and I believe the others were here at our previous meeting. j We have as our agenda a relatively short open session', ,fith a few reports from me. I believe some news of great intere to you from Mr. Rubel concerning the legislation. And then, , r . 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 2 t i i 1 4 following some comments from visitors we will go into our i closed session and get on with the day's work which I believe' will be a rather full day. Again, I want to say how much we as a staff appreciat having all of the assistance of the committee members in send? ing in comments and telephoning us about their thoughts SO that this day can be made.as productive as possible. I would like to make a vew comments before asking Mr. Rubel to give his remarks. First of all, as I indicated earlier at our previous meeting omformer acting deputy dir- ector, Mr. Cleveland Chandlis has accepted a year's leave of absence with the National Academy of Sciences to engage in a study of the Veteran's Administration Medical Services and Delivery System. This is a year long activity and he is -expected to return to this agency at the end of that time. Bob official1 started Monday of this week and we expect to see a good bit of him, since he is just down town, but nonetheless we have h to fill that position with the many requirements on my offic and so I am pleased to announce that Mr. Gerald Garde11 will continue to serve as acting deputy director. Having done so while Mr. Chandlis was away for six weeks at a training session at Harvard. So Gerry is joining j our ranks on a semi-permanent basis, depending on our life-time as Pap. e * . e 1 And I am very pleased that he has accepted this ccn- 2 tinuing responsibility. 'l'he court order has been signed and 3 4 5 6 the litigation has come to an end. We now know how much monel- we have finally to distribute and it is about what we indicate5 to you last time. In practical terms we have $28 million dollars of 7 remaining releasafiscal 73 funds for or following tomorrow's 8 council meeting together with whatever unexpended balances 9 10 remain available for support of the regions. So the total that we would have approximates $29 and a half to $30 million dollar: 11 for awards after tomorrow's council meeting. 12 13 14 15 16 17 18 And we will obligate our remaining RN2 funds to the P.XP's prior to August 31, which is our commitment. I would like to take this opportunity since the council members are here and others will be coming a little later to indicate that there was an approval of 88.7 million dollars by the council for RMP's. And we following consulta- tion with the administration decided to award 84.4.million 19 20 which made it possible for us to reserve 28 million for this review cycle. 21 We felt that that would be prudent in view of our 22 23 24 25 *knowledge that there was going to be in the neighborhood of forty some million dollars in requests coming in before you and the council this time. As a matter of fact the applicatiozr before you today to%al 46 million dollars .in requests, so 5 I think that was a wise decision following the last council I meeting. I won't go into all of the specific decisions post council last time because I will take this up tomorrow when YE meet just with the council. I did discuss these decisons uith the committee at it's last meeting. I expect that you are all very interested, however, in knowing something of the status' of legislation which has ; been changing so very rapidly. And Nr. Rubel has consented : to take time out from what is these day's an extremely busy i schedule to tell you what is, I think, some good news, and : possibly give some indication as ;o what you think the time i table might be from now on despite Washington Post headlines / to the contrary. 1 2 3 4 5 6 7 The clean bill is known as HR 16204. There are a couple of copies floating .around town. They are very difficult 2. g 1 to get at the moment, but within the next several days I am 9 sure copies will be available and if you are interested the lo I/ best way, really, is to contact the document room in t:?+iouse, 11 '1 or one of your representatives. 7 MR. RUBEL: Thank you, Iierb. :`is most of you probabl; know by now, the Health and Environmer whatever it is called, subcommittee of the Committee on Interstate and i'oreiq~ Commerce did report out a bill two weeks ago and that bill is on the agenda for the full committee this week. . 12 13 14 15 16 17 18 19 20 21 22 23 The subcommittee spent over a we&k having a so-called policy discussion, sent the staff back to do a draft. A draft was given to the committee. Those are all the e-letives that we are deleting. And the committe then spent almost three 1 weeks on -- I'll try to talk loud and we can do away with this. The committee spent almost three weeks in marking up the bill. I am sure that history is going to talk a lot about something called Omega. This is the draft that they j are working with. Whenever the government printing office actually produces a draft they put a slug on top with some *kind of title, and this was called Omega. We hope that this was going to be the last one. So I 24 1 it was descriptive. And after three weeks this bill is the 25 '1 product. il It is a long bill. I think a hundred eleven pages. i j Ii 1 2 Complicated bill, and Ithink it is fair to say that i,. is a product of the subcommittee. 3 There was very excellent attendance throughout the 4 deliberations. The votes typically had a total of nine or 5 6 7 8 9 10 ten from,.a membership of 11. So that there was very good sit- ting power, if nothing else. And virtually every member of the subcommittee contributed in some way or other. There are certainly very many controversial , items 11 12 both in the bill, and that people proposed that didn't make it. In many respects it is based on the original legislation first proposed by Congressman Rogers, and Roy, and Hastings back in December, and then re-introduced with changes by the ! 13 three of them. 14 15 16 Several months later. HR 12353, and HR 13995. 17 18 19 20 21 22 23 24 25 Certainly the structure that is in this bill is very similar. What we have are Health Systems Agencies at the local level. Private non-profit organizations, at the state, a state agency as well as a state-wide health coordinating council. Those are the structure that they have created or proposed. The coordinating council is composed, two thirds of its membership comes from the health system's agency. And the third appointed by the governor. The state agency is an agency of state government. The composition of the governing board of the health system's agency is one half plus one consumer's and the remain- 8 I 2 4 6 6 7 a 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 3 ing members,providers. So that there is clearly a feeling that everbody has to participate. There is,there I. s a very definite decisior made to preclude our local agency being anything but a privat e non-profit organization. There was an attempt to allow units of local of local governme or a multi-purpose planning organ- ization like COGS, or economic development organizations to b e allowable, and that was not accepted. We had a lotof debate about the functions. I guess the major issue here was to what extent rate review, review of rates to be charged by Health Care institutions should be i 1 a responsibility or should not be a responsibility of this 1 ! ! mechanism. / I After a lot of debate one way or another that .was/ 1 finally excluded completely. That was one big issue, certainly the issue that should concern you the most. The way the bill is structured now, there is a limited resource development fund, able to be used by each of the local health systems agencies. There are limitations on what this money can be usz for. It may not be used to pay for the delivery of services, * or for instruction. There is a limitation on the dollar amot that may be expended for any particular project of $75,000 i any given year, .and there is a limitation on the number of YE that a particular project can be funded: two years. 1 2 3 4 5 6 7 8 9 10 11 12 13 a4 15 16 17 1% 19 23 21 22 23 24 25 At the state level there is a coukinuation very I I much similar to what we%: have today in the Hill-Burton program'. / But certainly that is a vehicle for the development of re- , I sources. There was a proposal made that a fourth unit be 1 created at the state level, non-profit organization whose jobi / and role would be the development of resources. And a mention of implemention of resources developmer at the local level, healthrsystems agencies would have been 1 I deleted. That attempt failed. It was not accepted by the sub- committee. I think the notable changes that were made -- the bil / does provide that if a state wants to participate in this pry 1 gram, it must either enact a certificate of need, or have a ' j certificate of need program, or participate under the program, I under section 1122 of the Social Security Act, that a review I I of capital expenditures. I ! I think there is a very clear commitment on the part ! of the committee that we need controls over capital expendi- [ I tures, in addition to 1122, wherethe penalty is loss of inter:5 8 and appreciation payments under medicare, and medicaid. The 1 t committee decided that a state would have to enact laws on -its own, to prohibit any third party payer from making those \ same payments. And further prohibiting any institution, if it pro- i I ceeded with a capital expenditure that had been denied, from , . 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 I6 17 16 19 2a 21 22 23 24 11 charging any individual for those same capital costs. So that within a relatively short period of time, we will have, , I am prettysure, in place around the country a mechanism where an institution proceedswith a capital expenditure without the approval of this mechanism that is being created here, it will not be able to get re-imbursed after any payment to i / pay for the capital portion, the interest ad depreciation of i that expenditure, although many for services within that inst?- I , tution would continue. ! Would continue to flow. Well, I could sit here for two hours and go over all the details of the bill. Let me ju spend a couple of minutes talking about time-tables. Every- thing that is going on in Washington is dependent upon the action to be taken by the House on Impeachment, and any trial in the Senate. And it is very difficult to know what is going to happen to other activities during the same time period. The critical point here is not so much the House, but the Senate. 1 The Senate held hearings way before the House did on this kind; of legislation, as you probably know. Senator Kennedy intrct i duced S 2994 which is a variation of the original Rogers i bill. The subcommittee, the House subcommittee kind of ' dumped all of its legislation in the laps of the full committee, Whatever it is, the public welfare or something or other, chair6 I j 1 by Senator Williams. They have been holding mark-up sessions 1 2 on manpower legislation and rumor has it that as soon as they I 3 .finish with manpower they will take up planning. When that j I 4 5 6 7 happens, I don't know. / People keep telling me tomorrow, but it was tomorrow I three weeks ago, so I begin to doubt their veracity. People / are expecting more than we can deliver. It is conceivable i I 8 9 10 that it will be next week, though. On .the House side, I thin;< ! the full committee will report out the bill, either by the end I of this week, or at some point next week. I I 11 12 I don't believe there is enough-time to have the bili 13 reported to the House floor prior to the Impeachment debate which is now scheduled to start a week from Monday. So we, lik most of the parts of government are very ,nicely entangled with e 14 15 16 the national debate which is going on. 17 18 19 20 21 Fortunately, there are no immediate problems ahead. There is no immediate need for legialation to be enacted to- morrow. We have, through a variety of circumstances many -- managed to forward fund all of the pieces of this puzzle. I am still reasonably confident that we will have some type of legislation by the end of September. 22 Or sometime in October. Gut I was more than reasona 23 24 25 confident several weeks ago. We are just going to have to see what happens. Herb, if I could, I would like to switch to another 12 : e 1 2 3 4' 5 for Health Policy within HEW. Origl..,:illy they wanted to put 6 7 8 9 10 11 12 13 14 '15 16 17 18 a change in the allotment formula. Welli today the formula is heavily weighted toward rural areas and the weighting is removed, and it would be based on population per capita incoce. And the need for facilities in the state. 19 Two, the budgets that exist in current Hill-Burton 20 law where a certain amount of money is available to state for 21 modernization. A certain amount for construction, and so on. 22 23 Even though this bill would be kind of pour from one bucket to another. 24 We've taken the buckets away and we've got one big 2.5 pail,now. There is one allotment to a state, and there is some subject. MR. BfiRROWS: What happened in the National Council on this thing. FIR. RUBEL: Excuse me, the?-:3 is a National Council it in the Office of the President, and it is definitely in HEW. A council of fifteen,members -- no more than eight of w?:i: are from the same party, and no more than three are Federal officials. With all kinds of expertise on it. DR. HIRSCHBOECK: Is there any remaining Hill-Burton functioning?- , MR. RUBEL: There is pretty much Hill-Burton as ~:e know it today. With, I would say, several major changes. 3e ,. e e e 1 purposes. But they are very minor. 2 Finally, the authorization level in the House bill j S 3 considerably less than what we have under current authorization. 4 5 6 7 , The author. .ration for fiscal 75 is 125 million. 150 million for 76. 1.5 for 77. When the appropriations for fiscal 74 for Hill-Burton was somewhere in the neighborhood of 200 million dollars, 8 9 10 11 12 It is tied in much better than what ws have under current.law with a planning apparatus which will be no longer a separate scheme. It goes out and develops a facility plan. It has all got to be done as one package. 13 14 15 16 Now, the Senate does not appear to be going in that direction, and that is certainly not the direction that the administration has been pushing. I would not -- it seems to me that that is one of the major issues that still needs to be thrashed out some. 17 18 19 20 21 22 23 24 25 The extent to which we continue to rely essential11 on state apparatus or do w, * move to some kind of project grant facility construction. There!.was an amendment proposed by Congressman Nelson that would have converted the program to a project grant program. And the vote was five to five. Therefore, it did not carry, but there was some significant feeling behind it. ; And of,. course, Senator Kennedy proposed very much the same ! kind of mechanism in a separate bill. How that is going to 14 e e . e 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 15 Jerk out, I don't know. DR. MILLER: I understand the new -- has the minimum copulation of 500,000, maximum 3,000,OOO. flow do you view the ransition from our present CBBB agencies to this kin:: of an organizational change. / MR. RUBEL: It's a little bit more complicated than i ~,000,000-500,000. I wish it would be that simple. We can go )ver three million if the area includes an SFISA that has a copulation of three-- an SMSA is a standard metropolitan static :ical area. We have hundreds and hundreds of them around the :ountry. You can tell below 500,000 as well. Under unusual :ircumstances you can go down to 200,000. Andmder highly un- * usual circumstances you can go below that. I have been going [round telling people that I am a year from now probably going :o be the world's greatest expert on the definition of usual ind highly -- I'll be able to quote from verbatim, exactly what i- :: :hey mean, essentially they pun it. What kind of transition from our current B agencies. First of all, let's make it clear that we have a lot of or,ganiza. :ions that are going to be competing and a lot of individuals hat are going to be competing. We have B agencies, we have n many places RMP's, and in other places we have experimental .ealth service systems, and in other places we have Appalachian Legional Commission agencies. 1 7 L A" And then we have a whole variety of others. AC$?XiS 2 that have put themselves togetiher to act as planning agencies, 3 even though'. they have never been sanctioned, or have gotten 4 any money under 314(b). 5 6 And a whole variety of others. The b..sl specifical;: says that the Secretary shall give priority to an application 7 that has been endorsed in effect by either a B agency or an 8 9 10 11 12 Rm? . But what priority means, I don't know quite at this : time. I guess that is something that we are going to have to: work out. 13 We have many, many, many, many B agencies today that have areas that are too sma\l. Virtually everybody agrees to that. When the original 500,000 came out, I said i4 .15 16 that would be into arbitrary, and then the 200,000 came out 17 18 and -- to cite you one example, we have .a B agency just recent1 started a year ago on a Navajo reservation. Well, that is an enormous area. They have something on the order of a population of: 19 20 180,000 in the whole Navajo and Hopie reservation. What are we going to tell them. You can't have a planning mechanism, 21 22 23 24 25 you have to go get the white men involved here. Just political not a very astute way to do things. Everything is moving in the other direction. ::e11, I suppose that is a highly unusual circumstance. There are goi.?g to be very, very significant changes and I would say 1 we will only give very surface treatment to arguments that say 2 well we want to do it. This is the proposition because this j 3 4 is the way we are going to do it today. I don't believe that should be the major criteria. ; 5 6 7 II 9 10 I" t not discuss the area designation process, but there is I in the bill a process laid'out to figure out, to divide the country into health service areas, and the governors of the individual:.: states will have the primary job.there. 11 12 13 And it is going to be up to them to look at these kinds of things pretty critically. We have an opportunity here to set a pattern that will be useful for a lot other thir Hopefully, to avoid some of the mistakes we have made in say, I picking the agency. 14 15 16 Perhaps in picking RMP areas. Perhaps even in desig; I 17 18 19 20 21 22 23 24 25 nating PSRO areas. So it is going to be a nice. A very attic six months. Thus the time period for the area designation process to be carried out. DR. BARROWS: Will administration be centralized as in the case of RMP or will it be de-centralized. Or do you know? HR. RUBEL: Well, the statute does not speak to that. ,There is language proposed in manpower legislation tb -,jould I mandate that there be central administration. I don't conceive that that will happen, here. In all of our planning is under 3 the assumption that it will be de-centralized. 1 I I 17 E i i ' Let me, if there are no further questions on the I 2 legislation, shift to the famous 5 million dollars that was : 3 -the subject of much litigation work over the last several s 4 j/ months. '1 not quite sure where we were the last time we ; met, but an order was entered, I guess about three Weeks ago. r Now, a final order that settled the litigation, and, ~ in effect, well, not in effect. The Secretary was -- I Will j ~ read it to you -- provided however, that the Secretary of / ! IIEV pursuant to the authority contained in Section 9-10 of i I .the public health service act may obligate on or before 90 j days of entry of this order not more than s 5 million dollars 1 of the heretofore obligated portion of the aforesaid fiscal i year 1973 appropriation. Isn't it fantastic the Way lawyers talk? To grantees other than the regional medical programs constituting the planned plaintiff class. Such grants and I contracts under section 9-10 of the Public Health Service Act may be made only for the folloWi.ng activities: one, obligations to augment current efforts in development the state of the i art of health plans with major emphasis on the development . of criteria for expensive facilities and services such as . radiation therapy, and open heart surgery, and thenalong list of specific projects. VJe are pursuing very vigorously the use of this money right now, F?e intend to utilize it all to the extent that we do utilize it all under the contracting 1 authority, and therefore there is no requirement for a Xational 2 Council review under law. 3 I did make a commitment to the council when we last: 4 met to re+:>rt on how we were planning to use this money. And 5 because I can't be here tomorrow, I wanted to take this opgor? 6 7 tunity to do so. / I don't know to what extent we have had copies of ( 8 the document that we have had developed distributed, but if it I 9 hasn't been distributed yet, it will be. 10 MRS.SILSBEE: Yes, it has been. 11 12 13 14 15 16 MR. RUBEL: The court order said to augment the cur-j 8 rent efforts. And there have been very significant current i efforts on our part to try to help the planning process along; What. is it and how do you do a better job of it. The document I 17 18 that you have is really divided into three pieces. 1 The first piece describes things that we have already accomplished. Things that have already been done. The second 19 20 work that is currently under way, and the third part,which begins on page 25, describes our plans for the use of the five million dollars. 21 22 23 24 25 I can only describe for you in very'general terms * specific projects, and I can't really go into the question of dollars to be outfitted to these, because since this is a public meeting , .we have got a lot of contractors out in the world that would be very interested in what our thoughts on II e 0 1 2 3 4 5 6 be open to the public and free for anyone to look at. 7 8 9 10 11 12 13 14 15 16 17 18 19 20 mining whether something is needed or not needed for virtually 21 22 23 24 25 II how many millions of dollars are ping into each of these things. And we are very much determined that this is gcir.g to be a nice, open, competitive process. But following the awarding of contracts, all the materials here will certair.1: We have divided our work into really five pieces, four of which are described here,'and then there is a fifth * catch all, which will only use the minority partof the money, -but we have got a variety of activities that don't quite fit into either of these. ` Any of these four. And this is what the court order Said we should give emphasis to developing planning approaches and -criteria for health services. We already have several major contracts under way. This is an attempt at going even further with the results of both of these efforts. Approximately a year from now we will have contained in one place and it will probably take up this whole room, but in one place kinds of criteria standards to be used for deter- all of these major kinds of services and capital expenditure items that are out in the world. There has been an enormous amount of work done in t.h2 past, but it has never been pulled together. It has never been critically analyzed. It has never been made accessible, and 1 c) L+ 3 4 5 6 7 8 9 10 11 12 13 14 15 16 I7 18 19 20 21 22 23 24 25 if you read this brief description here as v:ell as things previously you get a better understanding of what we are talk- . ing about; from my.point of view there is really nothing more important that we can do. .i The other two pieces relating to that effort are to try and get a better understanding of how institutions should share and how does a planning organization deal with the problems of sharing of services by institutions. Again, a lot of work done, but to what extent it gets to the gut issues that you have to deal with, when you are out in the real world, is debatable. 1 Finally, the third -- how should we deal with tech- nological advances and with the mushrooming of new"things, how do you make decisions today when you don't quite know wha the future is going to bring. And I use as an example here t , constantly the EM1 brain scanner. 1 We have virtually every institution in the country j trying to buy one of these things. There are a lot of people 1 telling us they are obsolete already. The backlog on ordering i them is ten months, or thereabouts. They only cost $350,000 i ! apiece. The profession hasn't quite figured out what kind of quality standards you have to have,. Meanwhile by the time i we 're over we will probably be spending by that time include the cost of these things and the training of the people to it I; . ?? 2 i j/ II 1 /I operate them. I don't how. Many of hundreds of zillions I! iI , 11 2 ;I of doliars. How do you cope with that kind of phenomenon. 4. 4 P" C) 6 7 a 9 10 11 i2 13 I4 15 16 17 18 2f 23 24 2: Another example is the problem of coronary 'J:lr?ass. ;"id all that travail that we have gone through for at least ten years now trying to figure out whether it is useful or not. If it is useful, we probably need to doublt our capacity to perform open heart surgery, If it isn't, we have too many open heart surgery. / 1 units right now. Okay. Now, how do you&al with that in a planning environment. Not a very easy question to answer, but it is simply something that we think needs to be grappled with, The second.major area relates to the data collection and analy- sis. And I won't dwell on it. We are of the opinion that there is a hell of a lot more data around than people know what to do with, and our focus is not sorremuch on the col1ecti.o but how do you use data. And I think that this is something that will be useful to virtually all of our agencies, around j the country. The third -- knowledge about our health care system, How do components interact is the- ,jor thing that we are . trying to pursue here. What are the impacts, for exaz.ple of introduction of the health maintenance organization in the community. What does it mean and what kind of dislocations occur 3 4 5 6 7 8 9 10 11 12 13 17 18 22 24 25 Cake another example. What happens if you put in a neighborho:? wealth center. Sfe make these decisions all the time; somebody says, Aay , we are going to move but we really don't know what it neans for everybody else. And the approach that we want to take here is much, rather than theoretical, trying to look at specifics, look at specific communities, trying to assess what happens when there is a major change. '??hat happened in Sacramento,California, when Xaiser moved in. And try to just describe what has happened ,as a way of beginning to be able to say, okay, this is what happened. NOW, how do you try to deal with it. Things that happen are both positive and negative. There is a plan for something else to happen. In another,community, or in that same community at some later date. In general, we are. trying very hard in all of our work to do as much description as we possibly can. I am o'f the opinion that we have not spent enough time describing: what we have done. We spend a lot of time trying to figure out what kind of impact it has. And the people come along and say what is it that you have done and we can't show them. You can't docu- ment. Ne are so busy doing that we don't spend the time to get it down on paper. Finally, the fourth piece is how do we have people, r 1 how do we get people out there, that can do the job, or prhaps 2 do the job better than perhaps they are doing it today. And I 3 that is broken down into two pieces. 4 The first, what kind of -- essentially what kind of / 5 short term training is useful and desirable. About the health / 6 7 8 9 10 care system, and about the'.specific tools that people need in order to do this job. The 'second, and something that I am ver `Y excited about, something that we are calling now, the Center for Eealth Resources Planning Information. I 11 12 13 II 15 16 We are in the process of setting up an information exchange mechanism that just doesn't exist today. This is the medlars of planning ad development. How many of you sitting around the room have said, okay, we need to work on -- let's say,? a renal disease plan, and you say, okay, what is anybody else done in-'the world. And there is a frantic looking around, and the only 17 18 19 20 21 22 23 24 25 real mechanism that exists today is word of mouth. Within a relatively short period of time. -- we hope some time around Harch -- that it will be trivial for anyone in the field to know exactly -- let's take the EM1 scanner, what kind of work . people have done. / And within a matter of days, or at the most a couple! of weeks to actually have hard copies of what other people have produced. I have observed this is not just confined to plan- 1 ning agencies, but RMP's as well. We have an enormous amount of I e e 1 duplication of effort around the country. People going th,rcs,-:? 2 :xactly the same searching and struggling, which is CcIylletel~: 3 Ind totally unnecessary. 4 But there is no organized way to get that inforr?atic:: 5 Xansmitted today from one place to another. Chirpee is also 6 7 8 Jhat we are calling it. It stands for Health and Resources 21x%- ling information, and also listed in the new legislation as something that would become our responsibility. 9 10 DR. SCHERLIS: Will you catalogue other than formerly tublished information? 11 MR. RUBEL: The major emphasis here will not be on 12 13 14 15 16 17 18 19 20 21 22 23 24 25 :ataloging. General kinds of things. It will be on cataloging materials that have been developed by operating institutions. Jith some attempt at screening so we won't put stuff in hera ' . ;hat is awful. We are not, the major focus is not on trying to be 1 great abstracter of the literature, because the literature .s not going to help you most of the time on this stuff. "here Isn't much of a literature. DR. SCHERLIS: Any request? MR. RUBEL: No. The purpose here is to provide a source of .information for people that are out there attenFtir,g :o do this kind of work, to find out what other people have lone to get access to it. Yes, sir. . DR. SCHERLIS: I would hope that part of your funding KXhaniSm would require that YOU have this material subm,itted 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 3.6 17 I 18 20 22 back to you in an appropriate format so that infornation can be made available. One of the difficulties I have found ~:it:? reviewing the comprehensive health plan agency functions or RNP functions ,is that everyone is discovering, all over the country, all over again, and the repetition as far as the development of either education materials, everyone having his own audio-visual laboratory, his own computer.techniques for EKG, interpretation. The list goes ad infinitum. The same is true, if not of P9M alone, but I would think it would be more true of the board of efforts of planning CHBMA planning agencies, NR. RUBEL: Absolutely. DR. SCIIEPLIS: While Chirpee sounds good, the tempta- tion is to sa.< it might be for the birds, unless for a need! to have a format built in this which would demand that you as part of your funding mechanism insist that the reports come back in usable forms, for immediate feedback because I have been'impressed with duplication of wasted facilities at CIIP and at PtiP levels. I am sure they have accomplished a great deal, but now we are starting out new, that this won't be just an atterrpz 'or an effort, that there would be some attempt in this to insist that if money is provided the information be forthcorin: and be available for distribution. XR, RUBEL: Well, absolutely. That is exactly what I 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 l!! 2c 21 2: 2z 24 2: our intent is. DR. PAXL: Thank you, Gene, are there any other I questions? I appreciate, very much, Gene, your spending t?e time today, since we do have the great majority of our council ,1., members here, also since you won't be able to be here to?.crrc:7. So thank you, and stay as long as you can, this morning, and return this afternoon, as we go into our deliberations, if you can. Before asking you to listen to a very brief report the kidney activities, and from Dr. Alvin Goodman concerning this is important because we have in this area, in the present appb some twenty five applications ications. I would like to, both for the record, and,I think for those limited numbers of individuals on our review coz.i:te~ and council who are members of the legal*profession indicate that we certainly have the utmost respect for both the legal profession and I am not directing these comments to anyone in particular. MR. RUBE-L: I'll stand by what I said. DR. PAHL: We've both had a lot of experience this year. I would like to introduce Dr. Alvin Goodman, the Progriir: Director in the Bureau of Quality Assurance in our sister age-s: the tlealth Services Administration. The Program Coordinator, the end stage renal disease program who said that he would be able.to take a few minutes this morning and give you the currer.: I 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 2c 21 21; 22 24 2! 29 ;tatus of this activity because we will be takinq administratit? action on these specific projects as a result of, I guess, the development of the programs. 20 so, I would here take a fe:J minutes and bring us up date. 1 2 3 4 5 6 7 8 9 10 11 1.2 13 14 15 16 17 18 19 20 21 22 23 24 22 23 DR. GOGDMPJJ: Sure. ~11, we have begun the imple- ! mentation of the program, when I spoke, I guess it WaS t0 the! council about eight weeks ago. kJe discussed briefly what the J?. -:ram was to consist of in terms of its regional approach: .I a 2 U-2 present time the regional health administrators have received their packets of instructions and are now sending them, setting about to determine with health planning consult and providers of care their regional networks in the network areas. So we are only going to serve to be another headach to Gene and his people. In developing networks, and network areas, prior to designation of health service areas. We told them not to divide health service areas when they designate thc?$*r areas. But since no one knows what a health service area is the admonishment may not serve any type of a purpose. In - any event, this cooperative network of institutions and hospi tals bringing together all their resources tobear on kidney disease without duplication is&out to be designated during this and next month. And after that is done, that basis is done, the reg 'lations will have appeared by the end of that time, and medic: review boards and so forth will start coming into being. rAnd that, too, has to interface very strongly and tightly with PSRO's. / I *r 3.. 1 2 3 5 6 7 8 9 10 11 12 13 14 15 16 17 , 18 19 20 21 2: 2z 24 21 33 The major problem in term:; of relationship with what may, wh;, must be our antecedent organization rcgi.onal prcgrams. Th... problem that is very recently posed is the the request for funding on kidney projects that have: *c>rne / through and perhaps and perhaps not. We are going to research it, to what degree this is true, whether or not the applicants have taken cognizance of the fact that there is now a new additional legal mechanism` in which to be certified to be a provider or supplier of care that is, the medicare program, and that would be incongruous for one agency of government to grant the where with all to an applicant the ability to provide care, the machines, the dialysis machines, for example, and so forth, or money for personnel, w-herein the applicant organization has not secured approval to be such a provider of care for medicare i I I from the social security agency. Therefore, there is, on.. the one hand, an application / for money for a grant from PNP, but on the other hand, there j is a highly new national program, and the bulk of this care I I falls under social security regulations. And the Bureau of Quality Assurance which I represen. 'has responsibilities for medical aspects of thatprogram, the medical council and social security. This poses a .l certain discipline that would have to be followed by the applicant organization. 1 2 I J 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 i?caning that the rds would be subject to certain caveats that money could no be expended unless the appropriak-z approvals were secured to the lkdicare program, and those instances where a new or extension of services were to be .I supplied, in end-stage renal disease clearly through the , Nedicare program. And the applicant organization must secure that i appropriate approval, otherwise we would wind up on the horns ! of very serious dilemmas. And very serious legal ajudication: 1 problems, if this is not done. / I A perusal of the applications, of 25 plus application would indicate that a large number are requesting either new or extension of dialysis or transplant facilities inciuded I whilemder the Medicare act. Another segment asks ali organ procurement programs, educational programs and actual procure' 7 ment. And the organ procurement also falls under lledicare t reimbursement, as well as effected, fall under our regulations our future permanent regulations. So we have to develop a joint health and social ; ! security attitude as to what we do. I -- about such applicatic and what caveats they may be subject to and the third group 1 of applications fall under computer and data systems. And in time there will be a national Ilcdicare medical data system, * or information system addressing both demographic aspects as well as manpower aspects. 1 2 3 4 5 6 7 8 9 10 11 12 13 I& 15 16 17 18 19 20 21 22 23 24 25 And quality medical c`are aspects. Fnd one I-1,-~:; to ask to what degree that individual application from a particuf.:.: and specific regions requesting funds for such activities : are very duplicative and as well to what extent social securit;? Medicare will pay twice if at all for so much duplication in activity. / When clearly in,PIedicare will support those activitie which are designed on a national basis. And so all of these matters will have to be looked at very closely with our col- leagues in RMP in order to decide exactly what to do. So all I have posed, really, are two problems, the tentative solutions that have to be subject to certain caveats. Decisions are still) pending which should take place in the next few days, . and I suppose that is not unique since we discussed problems before, one is another one in a particular discipline, but anyhow, through it all I do see a kind of silver lining, in that agencies are now cooperating together, looking at these problems very clearly. That while/ ! Gene was talking before, regionalization of that fits. I We areaztually engaged in regionalization of efforts I at the medical care agencies at this moment. And I think all! this type of seeming impediments will come out and wash and * there will be a system a year or so from now that will be working relatively smoothly, thank you. 'DR. PAIIL.: Thank you very rmch, Al. Are there any 1 questions on either the kidney area? I believe that Dr. Shrine:! 2 is not here today. And Dr. Merrill will not be able to make . 3 4 either today's or tomorrow's, is that correct? Tomorrow's council me5 "7. 5 6 I.!cil, thank you very much Al. I appreciate your coming down. 7 8 9 10 11 Before we go into the comments and so forth from the public I would like to take this opportunity to -- since the review committee and the council members to my knowledge have never really met together before, I would like to take this opportunity to introduce to the review committee the 12 13 council members who are here, and who are sitting very quietly and listening. 14 15 16 17 18 Hopefully, then, we'll have their session tomorrow. And since they don't have microphones, perhaps I may do the introductions. And then I would appreciate it, if perhaps, the committee would just introduce itself to the council membe because you will be sitting over the course of the day and I hope you will have some chang e to meet and say hello to each other. 3 19 20 ! I , . 21 So if we may start, on my left. Of the room. I woulr .._ 22 23 24 25 like to introduce Dr. Janeway, Dr. Wammick, Nrs . Ple, one of the big issue5 shoulc; : there be one health service area for t, ..tate of ; Iowa, or should it be divided into pieces? If the decision is state-wide expenditure -- that is going to give you one set of organizations that might be ! competing, and if you divide it, into several pieces that is / I going to give you another set of organizations, so that the decision on area designation indirectly is going to have a I large impact on which organiz'ations as such can compete, now, I of course, individuals can go and work for all sorts of people. , The bill provides that in terms of selection of / ! 1 agencies, it's up to the Secretary to make this selction with ( several constraints. One, he has got to give priority, as I 1 said before toapplications that have been approved' by the j ! B agency, or the FcFIP, or the W? in the area,. / I What priority means has yet to be determined. SeconC. the governor has to approve the selection. That's all the latii / / says. The,bill says. There is no provision for how you go. ! =about putting this together in this bill anymore than there is today, under 314(a) or (b). Or title nine, or the PiQ? legislation. Presumably : it is clear. We can only fund one. :You can't have more than f i 1 2 one agency i., :I area, so you have got to select within the constraints ti:at I mentioned it would be up to federal officiai:.:; 3 to make a decision as to one or the other. 4 DR. SCHERLIS: Let's look at it as if a state has it's 5 6 7 state planning agency, whatever that is called. And it is -- under this, you have potentially, if it's a large state, you have I assume health system agencies. Is that right? 8 9 10 MR. RUBEL: Every state w.ould have one. II 12 13 14 15 16 17 18 DR. SCHERLIS: Well, these local state agencies, Will they be appointed from the federal level, or the state level? MR. RUBEL: By HEN, except that the governor has to approve of the selection of the agency. MR. THOMPSON: It's going to be the damndest boo, ha ha, we've had for quite some time, so there is no reason for anticipating it. Can you imagine a CHB agency designating another ncy to .take it's place without handing shits out? DR. SCHERGIS: I said, the B agency saying we want a B agency. 19 20 21 22 23 24 25 MR. THOMPSON: That's right. And we're not going to prove anything -- MR. RUBEL: Surely. Sister Ann? SR. X?N : When you are talking in terms of identifyinc a program as being productive, do you measure this productivit: in termsof an integrated program, or individual fragments. I mean, individual projects, but a fragmented program? 42 NR. RUDEL: Well, it's very hard to talk about it in 2 I/ the abstract. I would venture to say that sure there is : I/ 'j something being done worth while by the most terrible organiza- iOIl, no matter what it is about. I would look upon it, with I *-fiven money to the organization be throwing it down a rat hole .J 7 8 9 10 13 14 15 16 17 18 that is, you are just going to waste money. How well the plan' is put together. ?!aybe it is fragmented. Or isn't fragmented. I wouldn't put as much smphasis on it at this point. But that is my own private view i Pnd this is something that you will have to decide for yoursel f :?e are not here, you know, under other circumstances I would probably give you a very different response. But recognizing all of the trials and tribulations me have had over the last two years, it's a wonder that we lave got anything out there. And it would be pretty simple for 1s to tick off a hell of a lot of organizations if we xanted : / to. And that is clearly not what the review committee did and lot what the council did. So did that help at all? SR. AN?J: Yes. DR. THURiiON: Sr. Ann is charitable, above all else. Xnd also mild today, very mild. DR. PAHL: Is there any further discussion on the 1 :opic or other points that the committee wishes to address? 14R. THOIIIPSO:4: There is only one question. It wasn't / 1 addressed. And that is how fast the PSRO's are ccming up. 2 Decause many of the proposals we have are to help SOcbbOdy 3 get ready for a PSRO. 4 Now, whether it's defensive or offensively, we don't/ 5 6 know exactly which; From the wording, so I would like to have some comments on you know how fast they are moving. 7 8 DR. PHIL: we don't have a representative, I believe, 9 10 11 12 in the room, fromlPSR0, but I would like to perhaps reply by stating what we have done in an administrative fashion relatil to the IVIP activities which are related to PSRO's. l.?e have me with Dr. Goran, the director of the Bureau of Quality Assuranc under who the PSRO program is beirlg implemented. 13 14 .15 16 We have arranged with him to have his office provic the final decision making as to whether an l?JIP request for a PSRO type activity should be funded or should not be funded, and once that decision is made, both the applicant, thz regiol 17 18 19 20 21 22 23 24 25 I ; . !i I/ medical programming, we are informed, and we then release the funds which we have already awarded to the n'4P's but held in escrow until such decision has been made. So, to answer your question, from my information, the PSRO pr?qram, from Parklawn Building, seems to be moving together c;: . . . . ..ly . And that a number of awards both have been and will be made in ths coming months. And insofar as that activity- and our activity go along in some sense in parallel :E f astiion. 1 Ke have administratively qiven the decision making ; 2 authority to the Bureau and to the proqram before funding 3 4 5 6 2ur activities. Now, that is not a completely responsive anst:" 3 your question, and I think we would ha: to qet : somesc .:'jj Ie from BQA to tell us the exact status of :,::eir activity. I honestly can't say unless there is somebody in the 7 8 9 10 11 12 13 14 15 16 17 18 `1E 2C 21 7-a 4' tr 2: 24 2 room who can. Judy? MRS. SILSBEB: NO. I was just going to say Z.2. Thompsor nTe have submitted a number of paqqe 15's in these applications. up to BQA. I understand a memorandum is in process telling us yes, no, or maybe. And then this process will be qin. So we j / lave really,thrown the ball to them. ItR. RUBEL: I can comment in a general way in terms . i of where they are. There were some major contract, 92 odd ; contracts negotiated prior to the end of the fiscal year, for several purposes. We do have several, as I understand it. Conditionally designated PSRO's. The first one was in Utah, with a big Utah, and they! are proceeding to do what the PSRO's are supposed to do. The j great bulk of the contracts would not fit the conditional desiqr tion, but they were for setting up -- and I don't kna;' quite 'the jargon that was used, but essentially planning kind of mechanisms. And that is what the great bulk of activity is around, so far. And I think this fiscal year is going to be largely I! 1 2 .A 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 21 . . 46 a planning year. We'll know probably by the time the year is .over. But maybe it doesn't actually Operatinq ox'~~~mizatiOnS maybe it will be more than that. That is kind of where they are. You are absolutely right. That some of the proposals, certainly in the last batch were offensive, and some were defensive. And we are very much concerned that RMP money not be used to thwart the admission of PSRO's as enacted by the Congress. MR. THO?IPSON: You know, this whole thing reminds me of a very well known parable in the New Testament, which was called the prudent steward. The 'steward was being called up to his king for an accounting and hehew he was in trouble so he went out to the people that he was in charqe of and he said how many barrels of oil do you owe my master, and the qu said 50. So he said all right. Twenty five. And then he went out and he qave away all his masters's qoods. Before he went up to the master. And the master took a look at this and said you indeed were very prudent, and even if the good I word is good, is prudent as evil, perhaps this K*OU~. !IIC a i 1 better world. So it seems we are going around passin?;: i.xt money to; all of these people that is -- a great deal of it., while not I I being poured down a rat hole as you called, is going to support other institutions whose jucture we aren't too damn sure of !t /j 47 1 /I 11 either. 2 `I In other words, here, we are qoing pass CHB a big, I/ , :s 11 chunk over here. Well, CM3 and IVIP may be phased out, you jj - ,! 1:i:ow, the same time. So it is very difficult, you know, ho dec... .Z down which kind of hole you know. I+? are labeling i! 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 il (-1 L 23 24 25 holes now, that's as far as we've gotten. DR. SCI-IERLIS: Is. that parable correct? SR. ANN: That is related to my question, too, you know. Because in terms of productive, you know, some programs may have seen their role as essentially a banker role, and that is related exactly to what you are saying, and you know 1 ! that maybe we are not concerned at this point about that. I I j get that impression. I MR. RUBEL: I share your concern. And I have watch A I have got to focus on the future. i it as well. I have to t focus on the hope that three or four years from now, when I we have a similar group sitting here, we don't keep talking ! , 1 about the same holes. Transitions are difficult and this one has taken ! 1 I I far longer than it should have. I will leave it to the schol a; and historians to do the disection and show us, you know, 1 I what we did right. And what we didn't do right. You know, we have got to get on with the job. , As far as I am concerned, under the very difficult ! conditions that we have with all the Congressional uncertaintic 1 BOW do you move forward? 2 DR. TIIUPzlON: I don't ccmpletely share John's opinior li 3 I 4 of this,thing. Both"the CIIB and the IMP functions arc going to continue, i '-7 are going to continue under new management, 5 and how wall t:is merging of the two is conducted is pretty 6 much a matter up to people like us. "). .'. ' ._ 7 DR. PAHL: Judy. ..' ,'a : **, 8 MRS. SILSBEE: I will say., John, in terms of the PSRC 9 10 review, th,ey started out with a very adament -- the RMP's were getting in their ball park, and as time went on, they studied the situation, they weresort of glad in many instances tohave them there and release the funds.' 13 14 `15 16 17 18 19 e 24 25 DR. PAHL; Is their further discussion? If not I woi like at this time to call for comments. From members of the public who may be here, and I would like to ask that anyone who wishes to make a comment, or submit a statement to the committee to please identify himself and the organization he represents, if other than himself. And to keep the comment not too long, since I belie\ `f I we have a full day. But I do know first, I would like to call on Mr. Prasad, because I know he would like to comment. And if you will please come at this time and introduce yourself and make d your statement. . 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 2E 2 ,i `1 2 IIR. pmSAJ.l: Thai';!< you very much. I am Rajeshwar : ?rasad. I am Executive Director of Ilassau-Suffolk W?P. ?:. . iordand Scherr,whose paper is being distributed to you, xas supposed to '::z here. But being the Chairman of the New Yor:=. State lIedicE;. 3oard his presence was required elsewhere. And he'll be here tomorrow before the national advisor council. And I would brief.ly describe his -- the salient and important aspects of the paper which has been distributed to fou, which he has requested to be incorporated in the minutes., He wished to share VI~?!T you the intended program : shich Nassau-Suffolk RMP has !:' xn up in response to our locali leeds. As I already told you, the paper has been distributed,; and I hope you will have time to go through it, which gives ; 3 clear picture of Nassau's FUIP program. I do recognize the comments mad& by Xr. Rubel and : Dr. Pahl and Dr. Goodman, and I think we have taken into consideration all those comments before, also, . in develcpinc our region's program. First, the peculiarities of the Nassau-Suffolk region: with it's two and a half million inhabitants. We have two counties which are very different. IZassau County is a fair-11 sophisticated county, which needs primary serving traditiozally+r deprived population groups. Supporting services and building a network for health care delivery. 6 On the contrary, Suffolk county is a rural county, 53 i which is, actually, at this point in tim?, in a transitional 2 stage from rural to suburban area. 3 Which has serious manpower facility and service 4 shortages. The program for fiscal year 1975 seems to meet 5 6 the outstanding and particular needs of both the Counties. Secondly the projects which have been submitted and are -- 7 they are built on the accomplishments of the past in the 8 areas of renal disease and medical services. 9 10 11 12 And I emphasize here that we have two projects which are considered projects with the stress on the education aspect. Two medical services projects which emphasis training 13 i-4 15' 16 of ambulance personnel, and nursing personnel. Of the remain. eighteen projects, I would say some fourteen relate to the ambulatory care which is the primary thrust of theprogram for 1975. The thrust is on to meet the area's greatest needs. 17 18 Which have been recognized by FQII? as well as our local CHB. 19 20 21 It is a two pronged approach and that is what has developed il our identification. Of the primary care projects which are ,elated to direct patient care, we have implemented health care pl -8,:'ects which are designed to obviate or n.itigate huma- disfun: an. 3 2 23 24 Dr. Scherr and his follow RAGS members would also like to state publicly that these -- of course on one of them the program has recently ramonstrated the present leadership 1 to have both its bylaws and due process certified which is 2 quite a job. 3 4 Moreover, the granting organization has recently undergone an audit by HEW and I must'stres. hat in the con- 5 6 ference which was held recently, the audi.Ws:s commented the 7 agencies fiscal procedures. Now, the current program strateg and the viable organization of RMP for full consideration of 8 our application before you. 9 Thank you, very mucy. 10 DR. PAHL: Thank you, Mr. Prasad. Are there any questions that you would like to direct to lllr. Prasad? If not, are there other members of the public who have any comments or statements to make. If not, I think we I4 15 16 will adjourn this portion of the meeting, which will terminate I 18 the open session, and because of the full work we have ahead i of us, I would appreciate it if perhaps we could get coffee ; I and doughnuts, and with your permission, bring them back to the table, and perhaps start our day's activities so that we don't delay unduely. And if we could reconvene in fifteen, or no more : than twenty minute:;, as soon as we can get through the line; 1 I think that would : fine. And members of thepublic will not' be admitted to the next session. 24 (Whereupon, a short recess was taken.) I I DR. PAEIL: Could we come to order please? i Y , 1 : f 4 E 6 7 (! 8 10 11 12 13 14 15 16 17 18 '19 20 21 . . 22 23 24 25 This session starts our closed portion of the meeting. The review of applications. Pnd I have really jur;t.one or two things to say, very briefly, and then we will get rigilt into the x ';3ws, with Mrs. Silsbee leading our activities. First, really for the record, I wish to indicate the* general rule of confidentiality of these meetings, and the : discuss&s. Secondly, I would like to again review for you i very briefly our current funding situation so that you would I know the frame work in which we are reviewing these applications And I want to make one or two points which perhaps ! will be helpful in a general way, as we go through the day. / Forty six million dollars are being requested by 53 regions : for this set of applications. We had anticipated having ap- * proximately 43 million dollars in requests, but vith the reintroduction of both the Maryland and the Nassau-Suffolk applications, this 43 and some odd figure millions was increase-: to 46 million. As I mentioned just a while earlier this morning 1 ye had 28 million dollars remaining from the released 73 impounc funds for award, following the council meeting. And xe also have in the neighborhood of one and a half to two rzillions of dollars in unexpended balances, from prior budset periods. Among some of the RMP's. It is our belief, and WP, will be discussing this with the council tomorrow, but since most council me&ers are here, and since it is -- I&e1 it is I 2 appropriate that you know our total picture, we arc going to 1 offset those ;Inexpende(A 1 balances with arrow cxrrcntly available 3 funds which : .S the net i: c-ffect of increasing the funds available 4 5 to us for awards after the council meeting by one and a half to two million dollars. 6 Thus the budget figure is just under 30 million 7 8 li 9 10 11 12 dollars. Is what we have to distribute to the RMP's following the council meeting. I believe we, will be pretty close on target. The award process after August council meeting will complete the obligation by us of our fiscal 73 and 74 funds. All fiscal 74 funds already had been obligated as of 13 14 `15. 16 17 18 19 20 21 22 23 24 25 June 30th` 1974. And the awards that we will be making this month, we trill distribute to the FClP's all funds available to us at this time for support of PJIP's. The only additional source of funds that may be ava: able for us to distribute to RNP's could be a small amount which may remain:, as a result of the five million dollars, wh: ic under the court order has been specifically allocated for other purposes as Mr. Rubel indicated. 1-d for which he is planning to let contracts, hopej go over all the five million dollars, and he has 90 days in which to do this. If at the end of 90 days there is any of that five millions of dollars left unobligated, that reverts to our program for distribution and support of the RNP's. / * So if that, none of that were obligated we would ha1 I 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15' 16 17 18 19 20 21 22 23 24 25 an additional five million to distribute, but in practical terms, I believe all or certainly the great majority of those dollars will be obligated so that we will have at most a very smal! r:mount since we won':. know this until October, I beiieYbV;- Otto! : 20th, is the90 day period from the Court order. What we all plan to do and we have a draft resolution for the council to consider tomorrow, what we plan to do is ; distribute my such residual funds on a formula basis in pro- I i portion to what the decisions have been by the council over [ this year for the different regions. So that each region would share inr;roportion to its I current funding from the several decisions made on the applica- I tion that were reviewed last time and this time. That is a ; little complicated but what I really wish to say is that you have before you 46 million dollars in requests. We have, perha! 29 and a half to 30 million dollars. Isle are not asking you as you know from our non-meeting last time, we are not asking you to reduce each application's requlJ peted amount by a uniform percentage to arrive at this 30 million. We are asking you for the full benefit of your reviews: on the merits of the applications and we would anticipate _^ that there would be varying degrees of funding within that set of applications. So that different percentages would apr>i:: The other point that I would like to address briefly has to do w,ith the requests of these: applications for funds which 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 '19 20 would be used to support specific activities beyond June 3Ot`h 1975. In a number of specific instances, applicants have recjuested budgets which would carry those activities, no+; . . through the June 30,1975 period, but for an additional se::.ind year of funding through June 3Oth, 1976. Now, I would like to make it perfectly clear that all RNP's whether they have . requested specifically second year funding or not have the 1 option locally as we give them the money. After this council, and as we gave them money,after the June council, they have the option to the regional advisor: groups decision making authority to decide which projects will be supported and whether to perhaps fund a more limited ; number of projects for, if they wish, a two year period. . Because this can be done by letting contracts. There is a problem in this which we all are very much aware of, i and that is if the RMP's terminate June 30, 1975, with contrac; outstanding beyond that date, there is a logical question of who will monitor those activities. It is a most appropriate and legitimate question, ar,< if I sat here before and indicated to you and told my staff we are all very much concerned about it, but as is the wi?' with bureaucracy we don't have a definitive answer for you. But logical possibilities are the forthcoming organizations under the new legislations, will absorb such continuing activi- e j: 1 2 3 4 5 6 e * 7 ._ 8 9 10 11 12 13 14 15' 16 17 18 19 beyond a given period of time.. 20 21 22 23 24 25 ties. 56 IIill-Burton has several hundreds of milli:;ns of dollars in continuing obligations out in the fields. so t:2 are not ovc ' concerned about having a few IUIP activities. So either t:li: forthcoming organization will.absorb those res- ponsibilities or the DIIE? regional offices will be called upon to monitor continuing activities. Or Washington headquarters staff under the name of some group or other, will monitor the activities. What I am really saying, therefore, is that as you look at the applica- tions in here, you should be aware that most people have asked for one year funding, through June, 1975. But that if they have asked for funding beyond that period of time, it is legitimate, to ask and legitimate for them to conduct their activities in that sense, unless there is a specific prohibition on your part, to deny the activity that is the recommendation by the council and concurrence by the council to deny that activity in toto or to deny funding you should recognize that by awarding funds knowin! for a second year funding, you are denying funds obviously since their is 02. ,' an approval of 30 million dollars to othe! I?FIP's o So what you give more to one program, obviously must come out in some' undetermined fashion from the remaining tota: RMP'S. r; Lj 6 7 8 9 10 11 12 13 14 15 16 17 18 22 23 24 25 5 7 Now, I want to mention one more thing so that there is no misunderstanding, and it bears on the discussion by Dr. Goodman in the kidney program this morning. This is a very complicated set of activities because it involves the Nedicare reimbursement. And Bureau of Health Insurance, Bureau of Quality Insurance, and Regional Xedical programs. As he indicated to YOU r and as I did also, we are making. administrative arrange- ments with Dr. Goodman's office andMedicare so there again wil be like the PSRO activity no funding of activities which is inconsistent with legislation which is on the books, but over which we have either no control, and certainly no real respon- sibility to administer. And this connection, we will probably in certain cases no permit kidney projects to be supported bey3nd June 30 1975, regardless of what the applicant may request in the appl: tions before you. Because of the problems and schedule of the Bureau of I-Iealth Insurance, Bureau of Quality Assurance, and / Medicare Programs, b they are trying to establish a national etwork and it will be highly inappropriate for RMP's to fund or twc: ;.zars , certain kinds of activities which obviously wi`l: I ye inc stent with what we know to be the government's guide- 1 tines, directions and requirements. l!Jow , we 'will be guided in these decisions by those equirements and by those officials who are in charge of the 1 2 3 4 kidney program. So you do not have to concc:t:! yourself I ! unduly, except to recognize that in the case of kidney, there j may well be an administrative requirement not permitting fundin? beyond n one year, d :tite what the app1."~,2nts have request@ :d o 5 NOW, are the:! anv questions on ~.at I have gone 6 over, or is there anything that I could clarify for you? 7 8 9 10 11 12 If not, I think this represents my full comments and I would like to turn the meeting over to Nrs. Silsbee who will conduct the reviews. Yes, ?lr. Toomey? 13 14 15' 16 MR. TOOEIEY: Perhaps I missed it, but suppose you have a onepar project in which there is a -- which is SLOW in getting started, or in which all of the funds are not used up and the program hasn`t been completed, and perhaps there is another three months. What happens in that overlap of time? Does it phase! 17 18 19 20 out? Does somebody else have to,monitor the last few months? DR. PAHL: Let me say that none of us are really certain what is going to happen. Because it depends on the passage of legislation and the time table in which that occurs 21 22 23 24 In the House bill, which has been submitted,by the full corn- mittee, but not acted upon by the House, there is language I which would permit the extension of CIIPB agencies experimental, health service systems and RMP programs, if necessary to go j 25 through an additional six months beyond June 30, 1975. Li / II l I/ In order to accomodate the t:: :ition problems 2 if the legislation is delayed in passago, I honestly, therefcref 3 I .can 't tell yo': what will happen, but as usual we will know :~hen zt there, nd all I can say is that you are free here to the reco ndations, certainly on the one year period. 6 And I feel certain that there will be an appropriate 7 administrative regulations'developed we find out when and : 8 what legislation is passed, to accomoc;ate that. That is / 9 more than a platitude. I just don't have a decisive answer ; 10 for you. 11 1 DR. IIEUSTIS: Dr. Pahl. Are the instructions sufficier II 12 1 I 1-y clear so that everyone knew th(at they could have applied I"or i i 13 1 a full two years as well as just the one? Let me just paren- : 1 j: 14 thetically add that the majority of the ones that I reviewed ; 15' ask for funds for only one year. 16 11 II Xy reading of the instructions even though I believe 8: 17 I/ I am familiar with what you said, about the possibility that : 1 18 ' the second year did not clearly convey to me that you are reali] 19 asking for two year programs. So on the recommendations which: 20 I made I have just arbitrarily deleted all the funds for the : I second year. And then they could be put back in again. If this e ii 23 11 were overruled by a higher authority. j ! 24 // DR. PAHL: We did no4: encourage, by any means, two year'f unding. At the annual meeting, I am not sure when that 1 2 3 4 5 6 7 a 9 10 11 12 13 14 15' 16 17 18 19 20 21 "9 Lye 23 24 25 now was, March, I blieve. We clearly stated to the assemblage +A--.:'; tv;o year . funding was a possibility, under the conditions which I hava described. But that generally we were talking about having budgets for one year through June 1975, and the reason we had to take that posture is a very realistic one. The administration has made the decision that RMP's may not expend any funds beyond that period, and a number of our R'lP's are free-standing corporations and we get into this set of problems, but there is the possibility we did not. en- courage it, we do not encourage it. But if it seems to you, and to the council in. spe- cific instance that it seems meritorious to provide those additional funds, perhaps we can accomodate it administrathe- ly; Yes I Dr. Miller? DR. NILLER: It seemed to me in that -- there is ano:::< thing that must be going on hsre. And that is where an IWP applies for a project that has a budget of 150 to 300 thousand dollars, on each project, even though there is a ten month situation they must in effect have it in mind that they are going to spend whatever they can in ten mor)ths, and contract for the rest of it. Is that a permissible kind of thing? I was pretty critical. when I reviewed these after that kind of thing. But maybe I was too critical. .: - . .-. ._ 1 2 DR. PHIL: YJc 11. j-t i s permissible. It's hard to know I,lhat's in people's minds and so forth. It is permissible. 3 What we feel will be the self-correcting device is that we 4 have fewer, probably on the average, for a given region than 5 the region requests. 6 7 8 So that is usual when the money's do go back to the region with the award statement there will have to be a decis by the regional advisory group as totwhich projects and for 9 10 11 13 how long. And in that sense we are fortunate, since we have fewer funds than requested dollars. I believe this will be our internal self-correcting mechanism. 13 14 15' 16 Judy, I believed you wished to -- MRS. SILSBEE: 110, DR. P&L: Jessie? '17 18 19 20 2% MRS. SALAZAR: Dr. Pahl; I have been trying to find to talk when this is appropriate. DR. PARL: Could you please use one of the microphon, es so that the reporter can follow? MRS. SALAZAR: I was wondering since we are meeting in joint session today with the National Advisory Council mem that it would be appropriate for us to have a statement from 22 23 24 25 a council member, perhaps you can do this. On a little of the ' background of our two resolutions that we passed in our main ; conference of why they were some of the discussions, and some I of the considerations thizt went into their turning . them dcwnc Gh / jc / I I ! I be Ii j/ i I !I G2 I The auestion'has to do with a council actiirjn DR. PAIIL,: _ /I I 2 ii on the two recommendations made by the committee. The one 11 3 i[ recommendation thatwas drafted by the committee and passed on' !! . 4 /I to the r. ,..e.: kl concerned the cooperation, ifyou will, by CIIPB i .! Ii ' id agencies ti:;:.! planning groups, in relation with working with i 6 IUP's and notifying them of what their actual area wide plans 7 /I are. I! I , 8 So that applications can be reviewed more appropriate1 g by the planning agencies. The reason, I believe, the the count I 10 1ci.l did not deem it necessary to act was first of all, Mr. h 1' 11 Rubel was present at that meeting, to represent, if you will, I 12 I/ both the comprehensive health planning program as it's national/ 13 Idirector, I as far as in his responsibility for the forthcoming / I l4 ilhealth systems agencies organization, ;i !> 15' - i And gave assurance, I believe to the council, that i I 16 !he would, to the extent the time and conditions permitted before 17 'Iwe evolve into something new, I work to effect greater cooperation 18 I both from national headquarters and local groups with RMP's; I 19 and I believe this assurance was of such a nature that the I 20 I council thought it therefore inappropriate to act upon matters 1 , I 21 //which are really not it's responsibility. . 1; I I' !. 22 I Namely the comprehcnsiv- Q health planning program and j 23 "with the assurance of the director of that program here. So I / 24 'satisfied that a statement was not required. The second recom-i 25 mendation which was an action to preserve PNP experience and ! / I 63 relationships and had to do with recommending to IV~lP's that they look to their infra-structure as being appropriate for the transition period. I believe that statement was subject to a number of 5 interpretations. As one viet.?d the different I?J@ situations. That again, with the amount of information that was being 6 7 8 9 10 II. 12 13 14 15 16 17 18 19 20 21 22 23 24 2 generated at that time, and it has almost become a flood of information from headquarters concerning the new legislation. What this implies in the actual constructive activi which are being engaged in now. Which I can mention in a mom to acquaint first hand RJIP organizations CHP organizations and Hill-Burton organizations with the impact of the proposed legislation will have upon these organizations. That again, perhaps it was unwise to adopt a formal statement. I believe the statements were well received. They were discussed, but for those reasons it was not felt necessa to take formal action. With regard to'the last point I men- tioned, namely the constructive steps being taken, I don't be1 1"Ir . Rubel either mentioned or if he did, did not emphasize tha during the latter part of December, and early October, there have been organized already three separate regional meetings to which I have already been invited. Representatives of RMP's CHP's and Hill-Burton progry i and the purpose of these two day meetings, one here in Wash- i I iE nt Y / / !bi .t ington, and one in San Francisco, and one in St. Louis, will i I be for certainly the federal administrators to impart informa. :: tion as part of the agenda. : And secondly, I'm sure, to have those several 4 groups interact :;ong themselves and thirdly to have those E individuals and ,.::ganizations convey feelings, concerns and E needs back to the federal establishment. 'This has already 7 E 8 10 11 12 13 14 15 16 17 18 occured in the sense that the meetings have been arranged and the organizations invited to send participants. So these steps implement, I think, what Mr. Rubel was saying, and are a good faith action on his part. And thus, in a sense it was not necessary for the council to take formal action.' Now, I have tried to summary from memory the set of circumstances which pertained at that time, but if anyone on the council would like to either correc or amplify any of what I said I would certainly be happy. Is that responsive? MRS. SALAZAR: ThankLou. DR. PAHL: Are there any further points before we 19 20 enter? Dr. Carpenter? DR. CARPENTER: I am concerned a little bit about, 21 22 23 24 25 this, still about this possibility of second year funding. 1 In that I think as our discussions go along we may -- it's possible that the committee will becom, 0 more generous as they become more and more aware of the possibilities that exist with that kind of latitude. 1 e 2 3 And so to try '1. zt some constant:! ,boE'I ,en our dGci.sion today and our de,- &.sion it would hely, me to know wheth 4 5 . the members of th- 0 rest of the committee vie?? this as a major consideration in our deliberations. I think principally it comes up to me in relation 6 to the fact that a number of projects suggested seem to me 7 6 to be patently ridiculous within a ten month period. They 9 10 are not nearly so obviously impossible if the region has 22 months in which to complete them. And I am not, you know in the end of all of this 11 12 0 13 14 15 16 we are going to distribute all the money anyti:ay. It's just a question of the nature of the kind of forrzula that we want to end us with. And Z think that varies, depending on whether we are now quite generous with a region Ynat is asking in this application to double its funding. On the basis of a one 17 18 19 20 21 on idi, 23 24 2.5 year application there is no reason on earty to double the funding. That is, if this is in essence a two year applicatic it's not a bad region, then, I can't be, sure they couldn't do something, and I can't be sure they could. * DR.P?AIIL: Dr. PIcPfiedren? DR. PARL: I believe as we go through the applications I this` matter will be taken up. I am really just calling your / 1 ! 1 2 3 3 5 6 7 8 9 10 11 14 15 16 17 18 19 2( 21 2: 22 24 bttention. That you should b': rare as a group that administr; ;ively the regions regardless ~:1: the level of the funding :hey receive this time, and also of COUrSe, from their current: available funds, make their t>.srn decisions as %o whether they ,ish to have fewer programs for a longer period of time, or pend all their money within the one year 'period. And then trust to ,fate as to what will be required rext spring. We can't sit here and make those decisions hecau: hey are local decisions. You should be aware of what the tpplicant is requesting and just your recommendation -- adjust our recommendations in the light of what you think would be est for the total program and for that region specifically. Pnd I can't give further guidance besides pointing but the need to be need to be aware of it. Are their furtherpoints to be raised? Or discussion .o be made on the points that have already been raised? If not, I would like to turn the meeting over to YS. Silsbee, who will lead us through the applications. E-IRS . SILSBEE: I was going to announce that Dr. Cassic ill be late, but I think he may be right on time, since he wa: .ue about 11:OO. But Mr. Barrow does have to leave early so . 'e are going to start out with Alabama. But then we are going o intersperse the applications that Mr. Barrow has been assigr. 0 as we go along., Not all at once. I think that isn't a very good way 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 to do it. But his regions are Al.b;:.ny, I,::kes Area, Karyland, New Jersey, and Washington-Alas`=a so those will come out .of the alphabetical order. But let':, :;tart out with Alabama, and the primary revi:3er is Dr. Va:: + DR. SCIIERLIS: 1:'hat kind of a time frame have you concocted for us today? MRS. SILSB-EE: Well, we have 53 applications -- 101 we have 48 applications, and it is now ten minutes till eleven. And we not only have the comments of the people here but we have the commentsof the people who were here in July. Dr. White, and I was going to say Dr. Thurmon, but he is here. Our missing member, so I was trying to do a calculat and I decided it wasn't worth while. But it's about three minutes,, two minutes; now in looking over the comments that you have written it looks as if there has been some coming together: of the reviewers' comments in a good many instances So I think if you feel there is a need for some real discussion don't hesitate to do that. Because, 'by and large, most of them seem to be in some kind of agreement. But becaus the council is here wanting to hear your rationale for the funding recommendations, and staff is, also, interested in tha because we have to provide the feed-back to the Regional Medic Program, and your reviews, and perhaps the primary reviewer could state this and then the reviewer either add or say nothi O! 1 .2 3' 4 5 6 7 8 nchanged from the previous assessment. Can you hear? 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 r, 8 You know, as the case may be. xhat you are recommending and why you are recommend: it in succinct fashion and then I think we can go through them, and then there will be some discussion on scme of these I don't think we should hesitate to do that. Okay. Dr. Vaun? Alabama. DR. VAUN: Alabama. The overall assessment appearec MRS. SILSBEE: Can they hear? DR. PABL: Let me make a general request, because our reporter is trying to get this meeting on tape today to have members use microphones, ` DR. VAUPJ: Could we make a presumption that most people have had our comments and might have read them so that we won't have to spend time reading them?, MRS. SILSBEE: The review committee has had your com- ments . DR. VAUN: Council members have not. HAS . SILSBEE: Council members have not. DR. VAUX: So I guess we are obligated to read them. XRS. SILSBEE: I don't think you have to read them -in total, Dr. Vaun. But in terms of the gist of rxt. DR. PAHL: The highlights, I think, !.;o?i.d be. DR. VAUIJ: That's all I put in any-day. So I have to read them. I.!aybe I'llstart at the end wit3 my recommenda- 1 i other people sitting around the bars b~cnuse they represent : ihe National Advisory Council regions come up for review. Please keep in mind thtzti bot91 council members as well as revie :w committee members should excuse themselves from the room when applications in question are reviewed. So I wou.l,d appreciate it if you could keqj that in mind. Go ahead. -:, QR, VArJN: The general aspects of the Alabama program did not bother me. There was one project; project 134 -- which aspeared very similar to the previous r:%zuest ., on surgical cancer to which we reacted negatively ltist time. ihe ,- I question the priority of such a submission for such a large sum of money devoted to this, and there is some background i as to why this seems to be a high priority in t:&+. b= state of 1 j Alabama, which Perhaps, even though I question the feasibilityi i of implementing some aspects of the the para-naial program i t I in one y%ar* I &se comes this one year :3usiness, again, in my i * i 2 .fj.nal recomnendation 1 di&~'t CCXI~;L~~~~ this. SO pe haps it i is unimportant. The rcquasted fundin level of 8611t.55~ &11,&s I recommend that it be reduced by the amount of the uteral I surgical cancer screening in for 181,000, rounded out to six i 1 hundred eighty thousand dollars `recommended funding. Some 2 3 4 thought was given to the possibility of eliminating these e project funds, might deprive the state of other sources of money for uteral c :vicaL cancer screening. 5 In as rn;; as we do not know the other sources of 6 7 federal funds we cannotassume this. Also, in as much as it was very infeasible that the otherprojects would need all the 8 9 IO funding for the one remaining year. Whether Alabama did or did not implement the uteral cervical cancer screening 11 project with the decreased level of funding would depend on their own priorities, 12 13 14 15 16 17 18 19 20 21 22 23 24 The recommended level of funding, then, is $680,000 MRS. SILSBEE: Mrs. Salazar? NRS . SALAZAR: Judy, 1'11 read this. DR. PAHL: Excuse me, we will have to use the micro- phones. PlRS . SALAZAR: I am sorry. On Dr. Vaun's question about the other -- just one question about the federal funds. The point that Dr. Vaun -- could we, maybe staff it, at this point, have some additional information about it? MRS. SILSBEE:'Mr. Jcwell? . MR. JEWELL: PIrs. Salazar, the only thing I know is that there is a big push on Alabama for cancer now, because the Governor's first wife died of cancer, and they have established -- have broken ground for the Lauraleen Wallace Cancer Foundation, and this is a conglomerate of other federz 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 local and state, and volunteer funds. To 1, :.LLd this institution it is just a traditional building fund, PIUS a big push in the . state for local cancer funds, to establish this. r"iRS. SILSBEE: Did that answer your question? MRS. SALAZAR: Yes. XRS . SILSBEE: Dr. Vaun, is there furtherciiscussion? Mrs. Salazar? MRS. SALAZAR: No. MRS. SILSBEE: Dr. Vaun. You made a recommendation. Do you want to make that a final motion? DR. VAUN: I'll move that the funding level for Alabama be six hundred eighty thousand dollars. MRS. SILSBEE: Is their a second? XRS. SALAZAR: Second. MRS. SILSBEE: The motion has been made and seconded that the Alabama application be approved at the level of eight hundred -- DR. VAUN: Six hundred eighty thousand. MRS. SILSBEE: Six hundred, eighty thousand. Excuse me. Is there further discussion? (Ho response.) . ImS . SILSBEE: Al.1 in favor? VOICES: Aye. PIRS . SILSBEE: No? t (No response.) 1 1 PiRS . SILSl33: The motion is carried. Now we go to 2 Albany. Fir. Barrows? 3 MR. BPJ?.RC%7S : I was like the rest of you concerned 4 5 with thn, inter-regiona, equity. It occurred to me that pro- grams of equal quality should share in the available funds 6- on an equal basis. As a rule of thumb, I took an average 7 prog=m as being entitled.to about sixty five percent of its 8 request. 9 10 Better or worse than average being proportionately moved up and down, whether you agree with that rationale or 11 12 13 not. That is the one I used, to explain my recommendations. Albany looks to me like a top notch program. I think we are all agreed on that. 14 15 16 It has, I would say, only one deficiency by my Stan, dards, keeping it from being excellent, and that is it seems to have involved the practicing hcalkh professionals in a 17 rather minimal degree, at least that is the way I read the 18 data. 19 I think it is one of the unique strengths of the 20 regional medical program, but it is a fine program nonetheles: 21 22 23 I think they ought to get about 80 or 85 percent of their I .request, or $450,000. And I think Dr. Carpenter came up with a more generous analysis. 24 MRS. SSLSBEE: Dr. Carpenter? 25 DR. CARPENTER: Thank you. My unaccustomed generos: 72 li equires some explanation. I gather. I may bo :'i'~ ~ayetd by the .2 act that this is the only application Y read that really did 3 uch for me. 4 And I was :i ..lressed, first of all, that the original 5 6 7 pp- ..::ation in Hay w;. by and large a request for continuation nd my own experience with the region was that in the time they ad to apply, it really was very logical to say the least for 8 he regions to make that kind of a decision. 9 Furthermore, most of the projects that they proposed 10 11 12 13 14 i5 16 eemed to me to be really miraculously well designed for the hort time funding that was available. So I gave them back he money that had been administratdively taken away from them fter cancel's decision and added a good part of this applicati nd came up with a recommendation for $524,000. 17 18 MRS. SILSBEE: Well, one of you could come up with ine figure, and one of you has come up with another. Now, do ou want to negotiate, or allow, or do you want to discuss it 'urther? MR. BARROWS: I would be willing to go up a little bit `o fund this particular program, at almost 100 percent of its equest is going to detract from the funds available for other rqually deserving agencies, programs. MR. MILLER: It is a question of the -- there are two rejects in this group for $130,000 to.$136,000. Do you r-call!, I ,/ .hink*they can use this money effectively in a ten month period? 1 2 3 4 5 6 7 8 9 10 11 12 13 14 i5 16 17 18 19 20 21 22 23 24 25 For these things, primarily care of children of low income 1 families? And data systems for foster -- :IR. IMRROX'S: I would contribute, one of the remarkab=ie strengths of this program is that it has done a fine of / providing cost sharing from other institutions and cc'. ~uity.~ SO with respect to the longivity of the program, and its i;n- j 1 pact I I think they would get high marks on that point. j I MRS. SILSBEE: Is not the primary care for low income children the kind of trial thing, that Bev Myers was trying to do with the other regional medical programs? DR. CARPENTER: Yes, I think that's right. There is a -- RHP contribution to the projsct. Those weren't the projects that bothered me. I think 59 and Gl are weak. i)ut I felt the two you mentioned probably could -- probably were worth the price. MR. BARROWS: To me this long, would you Split the difference? DR. CAPSENTER: Sure. 14~s. SILSBEE: Would you all do the mathematics? Five hundred thousand, Do I hear a motion. MR. BARROWS: 487 would Se more precise. i87. . MRS. SILSBEE: Do you want to make a motion? MR. BARROWS: I'll make that motion. MR. CARPENTER: I'll second that. t MRS. SILSBEE: The motion has been made and seconded hat 87. the Albany application be approved at the amount of Further discussion? (NO response.) MRS . SILSBEE: All in favor? VOICES: Aye. MRS. SILSBEE: Opposed? (No response.) MRS. SILSBEE: The motion is carried. MR. VAUN: May I just make one observation? MRS. SILSBEE: Yes. MR. VAUN: I am a little disturbed on that because zhere is one program here that I think should get more than I.00 percent; the level of the request from Albany is not that great. There are several programs that I think submitted very, very inflated figures, assuming that they are going to get cut. And there are others who really submitted a pure down budget. So I'm not sure because award them 100 percent that we are depriving a good region of something. I think we may taking .a lot more from somebody, but I don't think man> of them deserve.it. Some of them deserve it. . PIR . BARROh& : I am more cynical than you. I think that all of them were inflated. 1 2 3 4 5 6 7 8 9 10 I1 12 13 24 .25 16 17 18 19 20 21 22 23 24 25 76 MRS . SILSBEE: The next aDnlication to be looked at is Arkansas. Ve will skip Arizona for the moment. And the primary reviewer on that is Dr. Scherlis. DR. SCHERLIS: Are we skipping Airzona for any ; I particular reason? MRS. SILSBFX: Because Dr. Teschan isn't here yet. i I I DR. SCFERLIS: This region had been reviewed in ! detail at the time of the May-June review panel and was given an over-all assessment of averageat that time. Mr. Roger Ward had just been appointed in an acting capacity. The Arkansas May 1 application was recommended for approval at a funding level of 1.4 million, with the additional 100 under the arthritis proposal. The July 1 application request was for 816,000 plus In this there were 18 new proposals, Kern felt that the 18 ProjectS:represented an array of proposals which would even challenge any RMP/in the absence of previous.proposals which were approved at the time of the last review committee. There was a significant question as far as those I i projects which were givenlow priorities by the RX? of Arkansas i including a d:sease center for S176,OOOi Also included were * a miscellaneo array of projects including Arkansas rate price project, Some of the projects given even higher priorities appear to represent a collection of average to less than n2 e 0 . 0 I 9 3 4 5 s 7 8 9 10 11 12 13 14 15 16 17 18 `19 20 21 22 pJ 24 25 77 average proposals. In view of the level of funding pre- viously granted, the over-all assets of the ARkansas Regional r4edical program and the number and types of projects now submit. ' , a funding level of S400,OOO is recommended in place c; ,. th., P $810,000 reauested. SO I move a funding level of S400,OOO for the Arkansas Regional Medical Program in the present review cycle. DR. CARPENTER: I am the secondary reviewer, and I think that is a good motion. I second it, MRS . SILSBEE: Do you want to discuss it any further, Dr. Carpenter? DR. CARPENTER: No, not unless someone else questions it. I have written on it. MRS . SILSBCE: O.K. This is the first application that we have reached that has an EMS training project in it. And just as we have fanned out activities from PSRO, the EITS systems and EMS training have been sent over to the Bureau of tiealth Resources Development. We have not yet received an answer from them on any of these. And I think the reason why might be interesting: The EMS training program has been decentralized, and they 'don't know who the applicants are and they don't know what the approvals are. And these will not be avail&e until sometime in September or October. So in order to not hold this up, we 3 6 7 a 3 IO 11 12 0 13 14 15 :is 17 18 19 20 21 2" M 23 0 24 25 will put a caveat in every letter saying keep in touch with / your local regional office and make sure that your activities do not duplicate the other activities. That is about the only way we can do it and keep going. The motion has been made and seconded that the Arkansas application be approved at $400,000. Is there further discussion? (NO response.) MRS. SILSEEE: All in favor? VOICES: Aye. MRS. SILSEEE: Opposed? ', '. (No response.) MRS. SILSEEE: The motion is carried. I n4 e 1 Ipposed? (No response.) MRS. SILSBEE: The motion is carried. 1 2 3 4 5 6 7 8 22 23 MRS. SILSREE: Mow we will go to Greater Delaware Valley, and that is Dr. Hess. DR. FESS: In our ??ay review, we gave the Greater Delaware Valley RMP an above average rating. We noted that there had been good leadership developed there and that in general their goals, objectives and priorities t?ere con- sistent and they seemed to be taking an effective regionwide approach to their responsibilities. Since our May meeting the coordinator, Dr. Poberts, has resigned and has been replaced by Dr. Wolf who formerly hadbzen the PAG chairman. And he certainly has a long background with the Greater Delaware Valley PBP.and should be able to provide capable leadership and continuity. i One of the things that concerned me is the relative preponderance in this submission of medium and low-priority projects. And related to that, the question is whether the region could adequately monitor and manage the large number of new projects proposed in the remaining time. In general these seemed to be of lower quality than theprojects that were submitted in the May application. I suppose that reflects good judgment on their part to save the more uncertain ones to the last. Their request was for a *million, 70 thousand dollars, and my recommendation was $600,000 plus a theraflex budget which relates to Delaware which formerly was in the Greater Delaware Valley and then n42 0 e I . e 5 6 7 8 9 10 23 21 22 23 broke off and naturally does not have a P&P at this present So that would -- 1 forget the precise amount of the theraflex system -- MR. NASH: $84,512. DR. HESS: $84,000. So that would make a total of $684,000, my recommendation. MRS. SILSBEE: Dr. Thurman? DR. THUJWAM: I agree and so move: MRS. SILSBEE: All right. The motion has been made and seconded that the Greater Delaware Valley applica- tion be approved at the level of C684,0@0, of which 884,COO goes to Delaware for theraflex. MR. NASH: That's $84,512. Put the 512 in there.. DR. THURMAN: Thank you, Mr. J?ash. So moved. We will take it. MRS. SILSBEE: $84 thousand what? MR. NASH: 512. MRS. SILSBEE: O.K. The motion has been made and seconded that the Greater Delaware Valley application be approved at $684,512, of which S84,512 is earmarked for - theraflex in Delaware. Is there further discussion? (NO response.) MRS. SILSBEE: All in favor? VOICES: Aye. n43 e e 1 2 3 4 5 6 ? a 9 I.0 11 12 13 14 15 17 18 19 20 21 23 24 2.5 MRS. SILSEFE: Opposed? (No response.) KRS . SILSFEE: The motion is carried. 1 MRS. SILSBFX: Now we will do Hawaii. Mr. Russell 2 has been'to Hawaii so many times I am picking up the accent. 3 Dr. Hirschboeck? 4 DR. HIRSCEBOECK: This region "9 improved tre- 5 6 7 8 mendously since the new coordinator has .Laken over. And this was in evidence in the June application or the new application. And this impression persists in the July application. 9 10 11 12 13 14 15 16 17 The projects and programs are all well planned and targeted. The review comments by the CHP agency is excellent. The RAG is very actively involved. And I recoaWz+nd approval for the full amount requested, $486,750. MRS. SILSBEE: Dr. Thurman? DR. THURMAN: Agreed and seconded. MRS. SILSBEE: The motion has been made and seconded that the Hawaii application be approved at $486,750. Is there further discussion? 18 DR. SCHERLIS: Just one question: Is there any ! 19 specific delegation of funds or allocation of funds to the ! i 20 21 trust territories as has been the custom in the past? MRS; SILSBEE':'~~ Mr. Russell? 22 23 24 MR. RUSSELL: Yes, MRS. SILSBEE: Did you hear the question? MR. RUSSELL: Yes, there are funds in as far as 25 the trust territories. 1 I; DR. SCHERLIS: They IJill be reserved specifically i: : :! ;: for them? :: jj r: j MR. RUSSBLL: Right. 4 ij / DR. SCFERLIS: All right. MRS. SILSBEE: That isn't a part of the motion at this point. Do you want to make it part? DR. HIRSCHBOECK: I will include that in the motion. MRS. SILSBEE: Before we have always earmarked funds for the Pacific basin. Is that necessary to do this time? MR. RUSSELL: I don't think it is, but -- MR. 'THOMPSON: YOU are giving them all the money. You don't have to earmark it. MRS. SILSBEE: All right. The motion has been f made and seconded that the Hawaii application be approved at : $486,750. All in favor? VOICES: Aye. MRS. SILSBEE: Opposed? (No response.) MRS. SILSBEE: The motion is carkied. 1. FRS . SILSREE: NOW we will do V1ashington/Alaska. I I!: And that is Mr. Barrows' last one. And let the record show 3 4 5 6 7 % that Mr. Ogden is out of the room. MR. BARROWS: Washington/Alaska is another top- notch program. The July application is for 15 new projects. They are all rather varied; they are all consistent with the past activity of the program and its objectives. They are all for large amounts, too. 9 10 11 12 13 17 18 19 20 21 2% 23 24 2E My recommendation is that t;e fund for around 80 per cent of their requests, which would give them by my standards preferred treatment, or roughly $498,000. MRS . SILSBEE: Mr. Thompson? MR. THOMPSON: I agree with the comments on the program. I was a little more generous, I think, because they went through the trauma of a negative CHP review and then found out it was the wrong CHP agency that was reviewing. MR. BARROWS : I will take your figure. l4R. THOMPSON: So my recommended figure was $530,000 MR. BARROWS: All right. I second it. DR. HEUSTIS: May I raise a matter of information, Madam Chairman, before the motion is made? MRS . SILSBEE: Yes. MR. HEUSTIS: In the opinion of the chair, are we being consistent when we deal with projects we all thought were, excellent in the past in ,applying I?. Barrows' formula? I am thinking we just talked about an excellent program in Hawaii and gave them all they wanted. I And no:q in the opinion of the chair are we beinq fair? I am sorry to put the chair on the spot, but that is the only way I can bring it to the floor. MRS. SILSBEE: Well, the chair feels that it is fair because the Hawaii application, last time they hadn't looked at it in the same light. 'It is because -- DR. HEUSTIS: I don't need any more explanation. MRS. SILSBEE: O.K. MR. BARROWS : I might add that I haven't been applying that up and down the liffe. There have been devia- tions for regions both ways. MRS . SILSBEE: They have been changed by the other reviewer,too. A motion hasn't been made, has it? FR. TBOMPSOK : Yes. A motion has been made that Washington and Alaska be funded at $530,000. DR. SCHERLIS: Seconded. MRS. SILSBEE: The motion has been made that the Washington/Alaska application be fcinded at S530,OOO. A.11 . those in favor? VOICES: Aye. MRS. SILSBEE: Opposed? (No response.) MRS. SILSBEE: The motljlon is carried. 1 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 . '19 20 21 22 23 MRS. SILSBEE: Have P,lr. Ogden come back in. And we can go back to Illinois. DR. SCXFRLIS: Under the specific direction of the chair I will discuss Illinois. At the time of the pay- June review meeting, Illinois uas funded at a level of $2,760,000, with an over-all assessment of average or super- ior. This program has had strong leadership with very : good relationship with the CFP aqencies. The level cf funding provided on the last review was essentially similar to that which had been requested. The present application is for a total of 1 million plus. Review of their various proposals also included the sum of $300,000 for a contract for a metropolitan Chicaqo hospital information system and 10 net? operational prOpOSals for the balance. Some of the projects for which support is requested ajre not up to the level usually received from the Illinois regional medical program. It was noted that approval had not yet been recommended for the S300,OOO contract proposal. There were no priorities listed, and it was a serious ques- * tion as -:to whether the project and how the planning can be accomplished within the one year frame, as suggested. The over-all appraisal of the superior qroup of proposals was that they were at best fair. The funding level 1 i! was therefore recommended which vas reduced to C750,OOO in 2 place of the 1 million plus that had been asked for. 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 .19 20 21 22 23 2.4 25 The statement that, cuote, it is recommended to the RAG the funds be requested and if awarded sequestered for this purpose apply to the S300,OOO. And this seemed to be cacheting the funds until such time as they might have it to spend. It was thought that perhaps a small sum could be used for planning. That is why the sum of 5750,000 was proposed. I therefore offer as a motion that the .Illinois Regional Medical Program he supported at the level of $750,000. MRS . SILSBEE: Now, Dr. Slater was the other reviewer. Dr. Scherlis, have you had an opportunity to look at his comments? DR. SCHERLIS: We discussed this together at the time of the last meeting. It was my understanding that he was'also going to propose the same sum. And he thought that the total should be reduced by about 20 per cent. I reduced it by about 25 per cent. So I would assume o:e are in essential concurrence. . We did discuss this in detail at the time of the last meet- ing. DR. THTJREAN: Seconded. DR. SCHERLIS: Pardon me; at the time of the last n50 ,e . e 1 2 3 4 5 6 7 8 3 10 If 12 13 17 18 19 20 21 22 23 24 25 coffee discussion that we had, whatever thatvas. Y.R . TI1ONPSON: The last nonmeeting. MRS. SILSPJEE: The motion has been made and secondec! that the Illinois application be approved at S750,OOr). Could I ask a question? DR. SCHERLIS: Surely. MRS. SILSBEE: You talked about some contract. Is that part of the motion? DR. SCHERLIS: I would suggest strongly to the region that the sum of $750,000 not be utilized for the. $300,000 contract except on a minimum basis, possibly for planning. This was concurred in. MRS. SILSBEE: That is strong advice to the region. O.K. Is there further discussion? (X0 response.) MRS. SILSBEE: All in favor? VOICES: Aye. MRS. SILSBEE: Opposed? (No response.) MRS. SILSBEE: The motion is carried. 1. 2 llRS. SILSBEE: Now we go to Indiana. That is because it is next in the alphabet. Vr . Thompson? MR. THOMPSON: There is nothing in this request 5 which changes i-3 previous impression that the Indiana Regional Medic ,.. Program has not progressed measurably or 6 matured substantially. And I think the coordinator is 7 leaving or has -- 1 don't .know whether he has left yet or 8 not. 9 10 11 12 The specific proposals may have -- MRS. SILSBEE: Could you use that little thing? MR. THOMPSON: The proposals may have been con- sidered innovative in here. One'of the regional medical ; 13 programs that they do not reflect there in the priorities I 14 15 18 as stated on page 19 towards innovation of medical delivery, medical care delivery. . The relationships with the various comprehensive 17 18 health planning agencies are obviously strained. And even the basic categorical programs they were asked to review got 13 20 21 rtr) dr& 23 24 25 mixed notices. The over-all rating of the programs reflected in this proposal remains below average. A suggested funding level of $215,000. MRS. SILSBFE: And Dr. Slater was the other reviewer He came'up with a slightly different funding level. e MR. THOMPSON: All right. V7hat wasit? 1 2 3 4 5 6 7 8 9 10 12 13 14 15 16 17 18 19 20 21 22 23 24 25 I MRS. SILSBEE: Do you-have it? $255,350. Do you want to make a motion of 215? MR. THOMPSON: Veil , I will spl.it it with him and 1 & ake it $240,000. DR. THURMAN: I am not going to second that. I : am going to discuss. MR. THOMPSON: All right. ! MRS. SILSBEE: It hasn't been seconded so you can't / discuss Ct. MR. TOOMEY: I will second it. DR. THURMAN: O.K. Can we discuss? MRS. SILSBEE: Yes. DR. THURMAN : Why are we giving them any money? MR. THOI4PSON: Are you asking me? I DR. THURMAN: Yes. / I MRS. SILSBEE: Yes. i DR. THURMAN: As I understand it -- and correct me if I am wrong -- we have met the legal constraint and they received money last time around. MRS. SILSBEE: You didn't recommend phasing this one out last time around. DR. THUPJMAN: I know that. But we are not going to burn anybody's fingers if nobody gets the money this time around, because these are supplements to supplements to supplements, actually. . 1 2 9 z :1 0 6 7 8 9 10 1 I 12 13 14 15 16 17 18 19 20 21 22 23 21 25 DR. PAHI,: You may take whatever action you desire on the present application in terms of recommending or not recommending funding. They are not supplements to supple- ments. They are supplements to the has! . grant. .I MI? ZOMPSON: In answer to yc.~r question, I gu-.ss the primary reason that I recommended funding as I did was the fact that at least there was within the project applica- tion -- for the first time, I might add -- at least some concern for something other than a categorical grant. Now, this was for Indiana a fairly major move although- again it was not reflected, you know, in their proposals.. Now, Dr. Slater specifically deleted some grants that were again primarily concerned with specific areas, and came up with somewhat the same kind of review. DR. THURMAN: Again my concern is that Dr. Slater's. comment says, pedestrian, poorly written, lacking in clarity, no conceptual design, reruns, nobody in the State understands what anybody else is doing. And I just -- that is the reason I question it. MR. TFOMPSON: Well, as I say -- DR. REWSTIS: ?!ay I offer a substitute motion? DR. THUPXAN: Pardon? IF Mr. Thompson would accept it, I would offer a substitute motion that we not approve any money for Indiana in this review. DR. HEUSTIS: I would support the amended motion. MRS. SILSERE: Fir, Thompson? VR . TI'O:~IPSO~J : I would not accept that. I think 3 i: we are being a little harsh. And when I say the attempt to change the Indj *la RMP was more than just lip service. They !: 5 6 7 8 17 18 do have in thi. .,eCtiOn an attempt. to involve both RAG and non-RAG representatives in the establishment of priodties for the REP, which is, for them that is a long way down the path. And this is presented on table 1, which makes me think that at least they are trying to drag themselves into the sameplace that most RMP's were in before they were killed. DR. THUFNAN: I call for the question. MRS. SILSEEE: The motion has been made and seconded that the application from Indiana be approved at $24*,*00. All in favor? DR. HEUSTIS: Excuse m.e, Madam Chairman? MRS. SILSBEE: Yes? I DR. HEUSTIS: Was not his amendment supported at . - zero? MRS. SILSBEE: He wouldn't -- MR. THOE?PSON : f would not accept that. * DR. HEIJSTIS: If he gets support for his amendment he doesn't need his acceptance. MS. SILSBEE: Would you want to explain that? DR. SCHERLIS: I would move the chair seek counsel. 1. 2 4 5 6 7 8 9 10 11 12 13 I.4 15 16 17 18 19 20 21 22 23 24 25 DR. THIJRYAN : From whom? Basi tally what I really j I asked, Al, was if Mr. Thompson would accept my amendment. : And he said,.no, hz wouldn't accept it. So I didn't put ; you and II;' ?lf in position of overriding h -- basically :, without h.l.:., permis: ..n. / I I did not offer a substitute motion. , DR. HEUSTIS: Well, may I move to amend his motion?; 1 MRS. SILSBEE: I suppose so. I j DR. HEUSTIS: I would move $100,000. , MRS. SILSBEE: Now * you've got to get somebody to 1 second that. j DR. HEUSTIS: That's right. If somebody supports j , / / it. k I A VOICE: Seconded. MRS. SILSBEE: Does that mean the motion is now ' amended? DR. MILLER: Can we have discussion? / 1 MRS. SILSEEE: Yes, sir. DR. MILLER: The comment that was given to US by / the Staff here,both CHP A and B agency comments were largely negative. I wonder if we could incorporate into the condi- tion also of funding that no projects be funded without resolution of the conflict between the B agencies and the I RMP? 1 DR. TESCHAN: I would like to comment on that. We i i', i :: 4 5 G ? 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 disagree thoroughly. Unless we have a great deal more specific information about the guality of, the CXP B and A , review process in that State, the negative CIIP comments, I don't believe, have any credence until we know more about 1 it than that. 1 / MRS. SILSBEE: Does Staff have any additional information about the negative CRP comments and the Regional ; / Advisory Groups' response to that? I DR. SCHERLIS: While he is making his was here, I think this is an unnecessary proscription to place upon this State. We have never applied that to any other State, j , at least in a routine matter. And I for one would not be ! swayed either way as far as Indiana is concerned in relation-j ship to the agency 'or agencies because we haven't explored in all the other States when they had given adverse, unfavor-, able comments. , MRS. SILSBEE: Thank you. DR. SCHERLIS: I think it is highly irrelevant. , I MRS. SILSBEE: Mr. Jewell. We can't hear you, / I / Mr. Jewell. MR JEWELL: . Was it on the CHP relationships? . j ' Was that the question? I!?RS. SILSBEE: You didn't hear the discussion? MR. JEWELL: I didn't hear too much of it. MRS. SILSBEE: Dr. Miller was making the point that 3 5 7 e 1 4 5 6 7 8 9 10 11 12 13 I.4 15 16 17 18 19 20 21 En Lo 23 24 25 132 there are a number of negative comments. fird he V;as also suggesting that there be an amendment to the amendment, that : the funding of any of these activities not be provided until j that had been resolved within the region. We would give them money, but the:*7 ?:ould have to resolve it before the, v could put any money into those things that the E agencies had said no to. Dr. Teschan disagreed. we thought perhaps you had some information about how the Regional Advisory Group looked at the B comments and what was done locally. MR. JEWELL: The only thing that I can add, Dr. Miller, is that I was to the wedding of CHP and R!?P within the last six months. And I think they just began to feel their muscles in the SHP -- MR. THOMPSON: Watch that metaphor, now. r-IR. JEPIELL: I think the recommendation, this is going to be done. It is not included in this application, but there will be nothing until these concerns are satisfied. There will be no funding to the local areas where there is a CHP. I have been assured &at. It is not included in 'the application. DR. MILLER: May I make a comment? MRS. SILSBEEI: Dr. Wller. . DR. MILLER: I recognize the reactions of some 1 2 :I 4 5 6 7 8 9 10 11 12 13 14 15 16 17 1% `19 20 21 22 23 24 c& others on the Committee have been expressing. And I share, I think, the fundamental viewpoint that it is not too dis- similar. The resolution of a conflict does not mean that you acquiesce to CEP comments. I means that the Regional Advisory Group pays due consideration to their comments and then acts in an appropriate manner. That was my point, and I doubt that this has occurred here, but I don't know, of course. DR. VAUN: Though I am. not sure what the question is, can I call it? What are we voting on now? ?!RS . SILSBEE: If I understand it, we are voting on $100,000 for the Indiana application. DR. VAUM: Can you axend a motion without the pro- poser acceptingthe amendment? MRS . SILSBEE: Nell, that is what I asked. b?e wi 11 vote on the amendment. DR. VAUN: Then we've qot to vote on the amendment. MRS. SILSBEE: The amendment is S100,OOO. MR. CARROWS: To make this clear, Judy, if we vote down this proposed amendment, then we are back to 2i!r. Thompson. MRS. SILSBEE: 240. Right. O.K. Is everybody clear what you are voting on no'cn. I have some more problems, however, with Inter- 1 mountain. They.have five new planning proposals. This is 1 the categorization that comes from Mr. Kohler, who is the I I I I 1 /j deputy director. There are two, four, six, eight, 10, 12, :! 3, j: 14 rural health proposals. Knd there are five seconda // /< 3 !I i/ tertiary care proposals. j' 4 .ij - These -e:nresent, I fink, somewhere in the neighhor- !i fj // hood of 19 new I. ,ect activities. Mow, this is how Mr. Kohler classifies these proposals in the Yellow sheet in 8 9 10 11 12 jl our booklet. The application requests $480,000 for the I/ support of 19 new project activities. I 'I Six projects address health quality improvement: three,quality assurance: two, availability of health assis- ! jj ' I tance; two, accessibility to health care; three availability I I[ of health care: and three, quality of health care. The j. i l3 11 application includes the CPI-! comments and actions of RAG .! 14 jl and Staff to those comments. jj i! .15 Ij Then I have the problem of, aside from who is 1 16 ii I/ categorizing them and the fact that there is apparently 17 / not consistency in categorizing these proposals as I have l8 Ii read them, I don't think highly of any of them. So that I 19 find myself in the position of feeling that the Intermountain 23 RF4P is a superior organization, has done a superior job in 21 Ij resolving the problems that it has had in the past, has /j 22 '1 moved out beyond Salt Lake City into the other areas of 1. $1 Ii j' 90 /! that section of the country for which they are concerned, .dJ ;! ii 24 j that in,so doing have come up with projects which really (I ' 25 are truly, without going through the details of each one, 1 ! I don't think very highly of the projects. 2 3 3 5 So that I am in a very difficult and very much a quandary on the basis of the program, which is what we basically have been told to concern oursc >s with. I would recommend that the entire $450,(100 that th..~ requested. 6 7 8 9 10 But I think I would do it moreon the basis of the fact that they had requested 4 million dollars previously in June, and we had reduced it to 2.2 million, and on the basis of ; the fact that it is a superior group and it is a very fine organization. 11 And even though these particular projects don't 12 13 14 15 15 appeal to me, I believe that they may be able to develop something within that region. Now, that is, you know, this is my quandary. And Plrs. Salazar, I believe, is the -- MRS. SILSBEE: Mrs. Salazar? MRS. SALAZAR: I share some of IMr. Toomey's con- 17 18 cerns. However, the projects, or not one of them, I think the projects are fatly indicative of the new thrust to 19 20 21 22 23 24 25 other areas of Intermountain. Having looked at Intermountain for a number of years on Staff, I am very delighted to see that some of . ' the programs are now moving out into the hinterland. 1 think probably this is due in part to this intra-council of the regional.medical programs and their participation in RAG and in planning committees and in review committees. / 133 j Some of the residual concerns that I have are I I statements that Intermountain seems to have engraved on all ! their applicationsof minority representation. And they always justify this. I can close my eyes and know exactly what it is going to be. It is going to be -- they say this time, however, that it is being carefully monitored. And I don't under- stand that. By whom is that being carefully monitored? Also, their staff is very dynamic and very able. They have a splendid opportunity, I feel, if they are going to move into these areas of medically deprived areas then they could be involving minorities on staff'as b:ell as on the review committees and evaluation committees and indeed on the projects. I think that probably a statement as to the legal- ity of the health development services -- perhaps we should have a clarification'of that and an updating of our last review. MR. TOOMEY: Dr. Pahl has that. DR. PAHL: I was going to wait. This might be appropriate. . P!RS . SALAZAR: I have a little more. DR. PAHL: All right. Let me hold back, then. MRS. SALAZAR: The proposed rating and review process has been revised, and I was very happy to see that. n65 e 0 1 This was very well streamlined and comprehensive, easy to 2 read. There was one question that I had about these comments 3 and planning review. _ Noticed that they, the CHP groups submitted 5 6 7 a 9 10 11 12 13 14 15 16 17 ia applicatio:, c:nd they were shot down by the Regional Advisory Group. Now, the question that I have is perhaps generic to the entire, all of the Regional Medical Programs. F?ith the exception of one of the applications I reviewed, I saw no provision for the kinds of comments, the negative.comments, Particularly'for CHP groups, to get fed back into the programs and become part of the activation in terms of the monies that we are voting today and that we voted for in May. Maybe Staff can clarify that. If the reports came in and we do not approve, how does that get plowed into the. mainstream of the Regional Advisory Group. MRS. SIISEEE: Jesse, if the covering letter from the Regional Medical Program did not speak to that point, STaff has presumably asked the region how the Regional Advisory Group viewed these comments or if, indeed, they had an opportunity to reflect upon them and what their followup is going to be. In the case of this region, I think, would you ask Miss Murphy if she has additional information about how these negative comments were viewed by the Regional Advisory Group and what they presume to do about it. 14s . . N?RPBY * . PI r . Posta wrote to all of them and ~ send a document recrucsting each comment. And most of the 1 CBP B and A directors sit on the IWG. They are always in at*: .,dance when projects come up. MRS . SILSGCE: Does that answeryour question? MRS . SALAZAR: (Nods head.) / I I DR. PAUL: I would like to comment on the health i I services development corporation. There has been a continuir dialogue between the Regional &!edical Program, the grantee, the University and ourselves since we last met concerning this point. And I can say two things: First of all, the Attorney General of the State of Utah now finds that a corporation under the revised conditions not to have a con- flict of interest with the Univeristy or the Regional Pledical Program. And we, in turn, have met with Dr. John Dickson, the dean of the School of Medicine and Vice President for Medical Affairs, last week. And in a somewhat lengthy and very constructive session. I think I can assure both Committee and Council that there is now nopoblem on conflict *of interest and that this should not play any part in this consideration of this Committee or the Council. It is .an issue which has been resolved satisfac- torily to RN?, to the grantee university and to the Attorney .j I r] 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 "2 i cc 26 24 25 General's office of the State of Utah. IIR . TO01'EY - . I think is one of my points, :.:hich is s!.-*ply that it was:a problem and ha3 been resolved, which has t .in a good deal of action on the part of a good nuTher of I?@OPb which really represents to me an excellent management, excellent group of people.that has been able to take their problems and resolve them. FR. THOMPSON: I have one question. When you reviewed the projects, there were an enormous number of them that were devoted to quality assurance. And Utah is the first one to have a PSRO. Was there any mention made -- ,MR. TOOMEY: Well, that is not how they charact- erize them, John. That is how it was categorized -- and who was responsible for these yellow sheets? MRS. SILSBEE: Staff. MR. TOOMEY: They were categorized by Staff. FIRS . SILSBEE: Miss F!urphy, the categorization that is en your yellow sheet, where did that come,from -- you know, that little blurb? MS. MURPHY: Mr. Kohler's accompanying letter that came with the application. * :IRS. SILSBEE: So this is the RF!P characterization. MR . TOOMEY : Oh, yes? P!S . WRPBY : There was the letter that came in to Vike that they revised. 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 2f 23 24 l-l! Ah DR. DP.I!L: Vary, please use the microphone. Y:e '! can't get it on our record here, and it is important. Mr. Posta? MR . POSTA: I think the question, the whole cues- t.i of quality assurance has given Staff quite a bit of. . problems over the last two reviews., The demarcation you are speaking of could be;I.think, tabulated from your form 15s when they fill in the appropriate information there. In terms of talking with the region on person to person, we asked whether or not they had anything in the application which they considered quality assurance. "I-&e answer was negative. Now, again, I do feel that if there was any project in which the particular application that we in Staff shculd refer to our people here, we would be more than happy to follow through, the same as we have already earmarked, that is, to put in that category. MRS . SILSBEE: Fike , could you clear up-where these various categories that are on this yellow sheet came frcr! ) because we seem to be sort of splitting infinitives? That is what we are trying to get. . MR. POSTA: That came from the cover letter fro> the region, correspondence from the region. MRS. SILSBEE: It wasn't the covering letter, Xe don't find it in the one we have. r"ls * i.l'i!J7PJ'Y : i?lso on the 15s for each 3 j e c t , they put under disease category p 3rd thr 1: is ho+,.7 they cate- : .cjOrizc them. -' r.I.s e JmRPl?Y : !?ach 15 . f3R. POSTA:' That is what 1 was going to say. But I would as far as the feedback to the region like to have those specifically any guestions brought to the attention of Staff so we can feed it back. i4RS . SILSX:IE: Dr. Teschan? ??? ??? ??o?? o ???? ? I tsanted to ask either both .Wr. Toomey and Mrs. Salazar relative to the projects that you felt are a little less satisfying than some of them used to be in the past as to ~7hether the cash f2ow in those is a significant proportion outside of Salt Lake City. That is to say that where the application has been put together by beneficiary sponsors in rural Utah -- HR . TOONEY : Yes. DR. TESCITAN: Well, identify the fine question. MR. TOOMEY : Excuse me. One other thing 1 just rememhe~. And that is that they also were generated by, . I think the specific number were nine members of the Regional Advisory Group to help :flevelop some of these projects. DR. TESCJ?AJ'J: m11, then my question is whether you might consider.: it reasonable that when people who are r i 1 . busy in the region try to get a I?.pIP application in that ij I' 1.s ; sometimes the thing doesn't look quite as polished or as I; $3 : effective or possibly it might have been devebped centrally. 4 zrtainly it is our experience that as soon as we begin tz lvcikring people who really have major needs, their sophis- 3 6 tication in expressing them and managing them was considerabl>r 7 8 9 10 12 12 23 14 15 16 17 18 19 20 21 22 2.3 24 25 less. And we therefore felt you can have that, we really had to make adjustments to that. I don't know if that con- ment is helpful here or whether it applies. But if it dces then it is a very significant point in terms of a funding decision. SR. ApJPl : Mr . Toomey, do you feel that with these projects that are outside of Salt Lake City, as so many of. them are, that as they design them the staff is going to have the capabilities and plans to kind of monitor them and give the support that is necessary, that they can overcome the'problem that has been stated here? MR. TOOFVY: I wish I could tell you yes. I don't know. I just don't, the projects do not excite me as being innovative or meeting great needs. Whether theybe in the . area 0;. -inning or secondary or tertiary care. They've got a d;:nonstration on ecology ward, for instance, which really is nothing but the establishment of a cancer treatment center for children. 5 6 7 8 9 PO 11 12 13 14 15 16 17 10 19 20 21 2% 23 24 25 want to show that; thev c::n treat cancer bEttcr than they have: they have a rural rehabilita tion project which is sending a physical therapist out into the field, to provide physical therapy. I Some of them aren't Cat physical assessment training. They have ruralareas and they are going to train their personnel to do physical assessment, remote monitaring 1 for critical care. There are a number of hospitals with a _ : minimum amount of medical services that can be provided,.so they, perhaps meet the needs. But there is nothing really -- but yet the organiza-i tion is pretty tremendous, and I recommend -- I tell you, I recommend $450,000 which is xhat they requested, because I think that they are a capable organization. I think that they can take the projects and I think that they can do those things that have to be done to make this. Plus the factthat they were cut in half at the last session. DR. NX'IIEDFW?: YOU move that? TiR. TGoi~EY: I move the $450,000. YR. HESS: I ;.:;int to discuss a question with Fir. TOOF.::: Even though they are cut loss time it concerns the fact that they overlap with two other regions are they not still one of the most generously funded regions in the country? MR. TOOMY: I think they are generously funded, yes. 5 P4RS. SAL, 1: One of the things I was pleased to I, 6 7 8 9 10 11 12 13 14 is 16 17 18 20 21 22 23 24 25 ee in the applications covering letter was that they have a zw scheme for monitoring their projects in the field by sign- ng regional advisory group numbers,as advocates of projects. zis to me is new and intermittent, which will tie in staff Aion and staff monitoring, and staff follow up. They are also involved in the review and budget analy think this represents a new dirnmxion for inter mcuntain as sr as their' field activities, are concerned. r~Il-3 . SILSEEE: The motion has been made and seconded kat the Inter-mountain application be approved at $150,000. Is here furtherdiscussion? DR. CARPENTER: I call the questions. MRS. SILSBEE: All in favor. VOICES: Aye. PUS. SILSDEE: Opposed. Let the record shot: that .ree opposed. The motion is carried. . Do you want to bring Mrs. Klein back in, now? It's almost a quarter to one. Would you like to eat? 11R. TOI,UJEY: Yes. . DR. SCHERLIS: P/hat time should we be back? e back 0 -:ne at 1:20 p.m. the Sam3 diay.) re co