l @'34* TRANSCRIPT OF PI-TOCEEDINGS DEPARTI@TENT OF @TALTH PZUChT.@t-0,N AND WELFARE DIVISIOlq OF r-ZE.GIONAL ii@' ICAL PROu'RAYiS AD HOC MM- COIJ41MITTEE PANAL A R.-)ckville, Mciryland MaY 23, 307)-@ ",ages 229 thru HOOVER REPORTING COMPANY, INC. Repoi-tcrs D. C. 546-6666 228A C 0 N T E N T REGION BEGIN MOTION APPROVED 2 IOTIA 231 235 236 3 MEMPHIS 237 251 266 MISSOURI 267 278.' 280 5 NEBRASKA 288 297 297, 6 ITEW MEXICO 299 312 312 7 NORTH CAROLINA 313 321 322 8 NORTH DAKOTA 323 339 341 9 NORTHLANDS 343@ 356 356 10 11 TEXAS 357 401 402 12, OHIO VALLEY 404 421 422 .13 OKLAHO'-4A 423 436 437 14 SOUTH CAROLINTA 440 455 455 15 SOUT14 DAKOTA 4.57 466 475 I(; TENNEESSEE MID/SO. 475 482 485 18 19 20 21 9-2 2.3 2,4 25 HOOVER REPORTING CO, INC. 320 Massachusetts-Avenue, N.[. DEPARTMENT,'OF HEALTH, EDUCATION AND 2 WELFARE 5 6 7 8 AD HOC CONSULTANTS MEETING FOR REVIEW OF 9 RMP.APPLICATIONS 10 12, 13 14 15 16 18 Cofiference Room H Parklawn Building 19 5600'Fishers Lane Rockville, Maryland 20 8:30 A.M. 21 Thursday May 23, 1974 22 2.3 24 25 HOOVER REPORTING CO, INC. 228 5/2 3 am )/em P R 0 C E E D I N b S - - - - - - - - - - - 8.- 40 am 2 MR. CI-IAIIBLISS: I would like to say, first of allo, 3 good morning to the members of this panel. Iindeed commend 4 you again for the diligence and the zeal that you t@ick'led thi3 5 most difficult task we had yesterday. 6 I would like also to welcome to the panel Dr. 7 Scherlis. Good morning, Dr. Scherlis. 8 DR. SCHERLIS: The expression is "the la-:e Dr. Scherlis". 10 MR. CHAMBLISS: And say we are glad to s e you, -11 and we are still.waiting on Mrs. Wyckoff and Dr. Mi ler; 12. but, if the committee so chooses,, I think we can pr ceed. .13 We're halfway through with our task and today i-i-e 14 have fourteen regions yet to be reviewed. The order that I 15 woul d suggest, and certainly this can be changed, would be along the following lines: Iowa, Memphis, Missouri, Nebraska, 17 New Mexico, North Carolina, North Dakota, Northlands,, Ohio 18 Valley, Oklahoma, South Carolina, South Dakota, Tennessee and mid South, and finally Texas, 19 .DR. SLATER: Sir, I have to catch a 5:10 train at 20 the Capital Beltviay, so I have to leave here ab-out 4:15 or 21 maybe a little later,, if it's not raining; and I'm on Texas. 22 I c aft tell you Texas won't take more than five minutes. 23 Jesse Salazar is the primary reviewer, it will take ten 24 minutes. 25 @OOVER REPORTING CO. INC. 20 Massachusetts Averiu3, N.E. 229 em2 MR. CHAMBLISS: It will take ten minutes. 2 DR. SLATER: We should be able to finish. 3 MR. CIIAIIBLIS: I could make the suggestion that 4 we take Texas now. It's too hot in Texas to start wi-.,i Texas. 5 DR. SLATER: We're anxious to talk with each 6 other, because this requires some preliminary review by us 7 to be able to make a sensible presentation.- So if you could 8 do it after lunch, we'd appreciate it. 9 MR. CH2U4BLISS: After lunch? All right, we will @io start out with Texas immediately.afte.r.the-lunch hour. 11 DR. WHITE: Bob, where do we stand in terms of 12 relationship with the other panel? .13 MR* CHAMBLIS: The other panel, as of last night, 14 had completed nine out of 23, and we had completed 14 out of 15 2 8.' 16 DR. WHITE: Some of us'have suggested a target 17 of this afternoon's.joint meeting. Is there some way they 18 can be reinforced in their efforts? 19 MR. VAN WINKLE: We talked with Dr. Pahl just a 20 minutelago and he's over reinforcing that right now. 21 MR. CHAr4BLISS: A suggestion has been made that 22 the first panel that completes its work would go over and 23, join the other and help them speed-up. 24 DR. CARPENTER: I also have to leave about four, and Northlands is therefore a bit of a problem, maybe except 25 IOOVER REPORTING CO, INC. 32 Massachusetts Avenu,, N.E. em3 I if we finish on schedule it won't be. 2 MR. CIIAMBLISS: I think we'll get to N6rthlands 3 about near the lunch hour, just before or just after. 4 DR. CARPENTER: Thank you, sir. 5 MR. CHA14BLIS: Then, shall we begin with Iowa, and 6 welcorie Mrs. Wyckoff. 7 MRS. V7YCXOFF: Sorry to be late; I-couldii't get a 8 cab, 9 10 12. .13 14 17 18 19 20 21 9 -2 2.3 24 25 ioOVER REPORTING CO, INC. 20 Massachusetts AvenL,-, R.E. 231 ern4 1 REGIONAL MEDICAL PROGRAM REVIEW 2 IOWA 3 MR. CHIU4BLISS: In the case cf Iowa, Dr. McP e ran 4 and Mrs. Salazar are the reviewers and Mr. Z-ivlavsky is- the 5 staff support, will provide staff support. 6 DR. McPHEDRAN: . I am recommending that we give 7 Iowa the amount that they are asking for. I think this is a 8 good-Regional Medical Program. 9 And to go through the categories that were suggested 10 on the review sheet, first of all, a little background from 11 me: I site visited Iowa in the past,, it was several years 12 ago, but a lot of the direction of the program that was there 13 at the time is still there, and-I've had occasion to meet 14 with Charles Caldwell on one or two times since then, and he continues to impress,.me as an imaginative coordinator. 15 16 From what is presented'in the application, it sounds as though the Regional Advisory Group, for example, had 17 18 great stength then and continues to be a strength, anticipat- ing the form of the review sheet, 19 To return to thatt the program leadership 1 20 21, classify as at least satisfactory, and the staff-as generally good in the Regional Advisory Group; a good group there. 22 23 The kinds of meetings they have held in t@ past to develop programs and to monitor it as it goes along, seemed ima inative 24, 9 25 and very much to the point. HOOVER REPORTING CO, INC. 320 Massachusetts Avenue, N.C. 23 2 em5 1 Past performance and accomplishments as satisfactory 2 also. Satisfactory in all of the other categories.i 3. I guess that the program staff and the Re ional 4 Advisory Group principally were the factors that make me feel 5 that the over-all assessment of the region i s above average, 6 It is a well-administered staff of gener alists. It's a 7 stated policy,, that is,, that persons on the staff retain 8 some-general competency in various activities that they 9 conduct. 10 There's a good de.al of emphasis on joint lecision 11 making on the staff members. This is gone over in @e 12. current application. I think that they have,, as I say, a good Regional 13 Advisory Group support. 14 The only sour,.note, I guess, for me, was that the 15 16 relationships with Comprehensive Health Planning, which I thought previously were quite good, seemed to be somewhat .17 less than satisfactory, as judged from some letters that I 18 19 think are included in our notebook here, which were not in the original application. 20 But, on the whole, I think that the general program 21- 22 purposes and their past accomplishments simply weren't what 23 they have been asking for. And, according to this master financial sheet, which perhaps I found more helpful than I 24 should, what they are asking for constitutes only 80 percent 25 HOOVER REPORTING CO, INC. ign Mi@tathil-,Ptt@ Avenue- N.C. 233 em6 of what it was thought they could have in targeted available 2 funds. 3 And even if they are expecting to request in July, 4 it would only come to.about 95 percent. .5 I really think with the management and direction of 6 this program it has been good enough in the past that it 7 certainly warrants that kind-of support, without going into 8 further detail. 9 MR. CH2U4BLISS: Thank you,, Dr. McPhedran, lo Mrs. Salazar. 11 MRS. SALAZAR: I subscribe to Dr. McPhedran's 12. views, and this is the impression that I gleaned from the application, 13 14' Hoiieverp there are some concerns which I had an occ asion to discuss with rank briefly about the CIIP involve- 15 ment and some other comments. But the timing seemed to be 16 bad, that they just couldn't get to them. I would like to 17 18 hear from Frank. MR. CHAMBLISS: Mr. zi'vlavskyf would you 19 20 MR .7IVLAVSKY: Iowa,, from the beginning, had a 21@ very close working relationship with CHP. They.have maintained 22 that relationship throughout their program history.' That they have in the application is actually one 23 24 non-official B Agency comment, that there are 15 CIIP agencies in the State, fiv'e of the 15 are actually approved B agencie 25 HOOVER REPORTING CO, INC. qq^ an .... m r 234 em7 The comment you have,here is a comment from one 2 of the non-CHP B agencies. They telephoned them in to 3i Division P14P and requested a three-day delay in their application. This was approved, and they submitted it on 5 the 3rd of May instead of May lst. 6 They just admit it's a breakdown in their machinery 7 for the CIIP to be processed, because they have always taken 8 into account the CIIP comments, have been able to negotiate 9 their differences with CIIP.@ They have submitted five 10 additional letters here, but basically two CHP agencies ave 11 delayed their review. one has favorable comments. one has 12, a recommendation for disapproval. And the last line, I just 13 state that the Iowa CIIP has not yet responded to negative 14' comments or questions due to the short timeframe. We received the , and inserted 15 Pe on the 20th of May .16 these into the books of the reviewers and the coordinator, and we have not had-an official chance to sit down and 18 negotiate on a one-to-one basis with each of the differences. 0 19 of the CHP agencies. And I,usually they have a connent'in 20 there that it's a breakdown in their machinery. The staff is on top of it. 21- 22 I will be watching this closely, and that's really about where it is. 231 MRS. SALAZAR: One of the things that I noted in 24 25 reading the applicati.on is the resiliency of this staff to HOOVER REPORTING Co, INC. A,.@-..- Pi r 235 em8 1 react and turn around and react to all kinds of crises, in 2 a very flexible rqanner. And I think that's very good. 3 MR. CIIAMBLISS: Someone has said that's based on 4 their youth,, because they all are very go-go types, young, aggressive, they move quite fast. I simply throw that in 6 as an observation. 7 DR. McPIIEDRAII: So I. would move that they be funded 8 in the.amount requested, which, to reiterate, is @l,,061,349. 9 MR. CIIA14BLIS: We have a motion on the floor that 10 Iowa be funded, recommended for fund:ing at a leve of 11 $1,061,349. Is that seconded? 12, DR. MILLER: Well, the yellow sheet says 249; 13 but maybe there's a mistake here. 14 DR. WHITE: IIhat is Mr. Cald@vell's background? 15 MR. CIIAI,,MLISS." I believe his background is either in hospital administration or public administration. DR. WHITE: He's about the third coordinator they 17 have had, isn't he? 18 I!) MR. CII2U.D3LISS: To my knowledge he is the second. 20 DR. McPIIEDRAII: Second. DR. WHITE: Willard Prell was first. 21, MR. VA@l WINI"LE: That is 249. 22 23 DR. I.ICPIIEDRAII: Okay. Amend that. 24' MR. CH MIABLISS: Do you amend the motion? Is there a second to the motion? 25 HOOVER REPORTING CO, INC. ')')A N F 2'>j 6 em9 1 MRS. SALAZAR: I second it* 2 MR. PULLEII: It adds up to 349. 3 MR. CIIAI-IBLISS: It has been properly moved and seconded that Iowa be recommended for the level of 5 $1,061,349. 6 It has been seconded, so we now may have discussion. 7 DR. SCIIERLIS: I note that one of the projects is 8 for emergency medical systems. I thought that was specifi- 9 cally exenLpted unless there were continuing projects. Is. 10 this a continuing project? It's for $74,50.0. 11 MR. CHIV.IBLISS: It is a continuing project. 12, DA. McPHEDRAN: Yes, I think it is a continuing 13 projqct. 14 MR. CHM4BLISS: Continuation of a previously 15 funded project. Is there further discussion? 17 If not, the Chair calls the question. 18 Those in favor? [Chorus of "ayes".] 20 MR. CIIIUIBLISS: Those opposed? [No response. 21' 22 MR. CIlAr4BLISS: The "ayes" have it, and the motion passes, 23 24 25 HOOVER REPORTING CO, INC. m r 237 emlO REGIONAL MEDICAL PROGRAM REVIEW 2 MEMPHIS 3 MR. CHAJ,,IBLISS: So we will now turn our attention 4 to the Memphis Regional Medical Program. 5 The reviews there are Dr. Carnenter and Mrs. 6 Wyckoff, with Mrs. Lorraine Kyttle providing staff support. 7 DR. CARPENTER: This is a region that I I ve had an 8 opportunity to visit. As many of you may know, it is an 9 interesting Regional Medical Program involving part of 10 five States and growing out of an existing health planning 11 body in the Memphis area. That body later became a 12. Comprehensive Health Planning agency for the area and that 13 growth of the regional program made a great series of State 14 and local PI.TP's, naturally, and probably it would have been 15 an impossible situation,without that beginning. But it really has worked well, and given the 17 Memphis Regional Program, I think, a particular characteristic 18 of its own. In some ways it seems to me to behave like a very broad planning agency. The nature of the Comprehensive 20 21 Health Planning agency, as much as it behaves like a Regional Health Program. But I don't think it's all bad. 9-2 23 This is a data analysis that attempts to get into 24' health care problems in the region. It is the latest in a 25 series of publications based on .data that was,demographic HOOVER REPORTING CO, INC. .17n M;mtirhtisetts Avenu i. N@E. 2 3 3 emll data that was available and re-analyzed to meet the region's 2 needs. Also surveys of health in various places in the 3 region. 4 As usual, in the world, it's very difficult to 5 determine that the program has been guided in direct ways by 6 this kind of data analysis, but I believe the ability of the' 7 region to generate that kind of data and to-reinforce and 8 talk about the health care needs of Memphis has provided 9 them with a kind of credibility leverage that has been 10 important in the development of the program. 11 The region has a relatively stable staff. The 12, coordinator has been there, Culbertson, for a long time. 13 And they have d stable -- well, they have had some changes 14 in their varying structure because we had legal questions 15 about the ori inal arrangements. They are now settled down 9 16 into a standard RAG arrangement, and that was not 17 terribly adversely affected by the regional catastrophes. 18 They are not terribly explicit in the way they 40 19 write their application. They list, I guess, four goals- and 20 13 objectives; and, as I tried to analyze them, I come up 21 with what I really think are seven ideas. And these are 22 related nicely to the usual medical goals of the Regional 23 Program, and I don't see any problem there. 24 They discuss priorities as though they were separate from their goals and objectives, which is a little discon- 25 IOOVER REPORTING CO, INC. 120 Massachusetts Avenui. N.E. 23 9 eml2 certing, but by the time one o'clock came around I had 2 solved the fact that they were really paraphrases, and one 3 can in fact group their goals and objectives into some range @4 of priorities. 5 The request is for about $700,000 in core support,,, 6 a million six for 28 continuing applications and a million 7 for nine new applications; $300,000 for developmental awards. 8 The projects from the beginning of this region 9 have not had very specific goals. They have been very 10 general: Let's get together, sometimes plan; let's get 11 together for general action kinds of goals. And they've 12. not been evaluated particularly well. 13 I have great difficulty in this application in 14 understanding in some ways what the@), have accomplished. 1 15 On the other hand, they have brought in an enormous 16 number of dollars from other Sources to the region, or at 17 least have contributed to it, and because of this very close 18 working relationship between Comprehensive Health Planning, 19 experimental health care delivery systems, and Regional Medical Programs in the area, it is very difficult to give 20 21 credit for what happens. l@ich is certainly not-a complaint at all, but it does make evaluation very difficult. 22 I believe that the Regional Program in that area 23 had a significant role in brin@ing something like a half 24 9 25 million dollars to the region in other support in each of the HOOVER REPORTING CO, INC. 320 Massachusetts Avenui, N.E. W.iqhinatnn [)C. 20002 2 4 0 eml last three years. 2 They estimate that the have served 200,000 patients' y 3 in the last year, and about 2,000 professionals have been trained. So there are some kinds of program evalu ltion that 4 a 5 are available; but, again# the project evaluation i@ a 6 problem. And one almost gets the feeling that the projects 7 were ancillary to the main issue. 8 Ilhich, again, I think is more an interesting 9 different approach, perhaps; but there are some dif icult 10 I think. 11 There is, for instance, $60,000 invested in a 12. project to improve death certificates. lqhich reall@ turns 13 out to be an experiment by one of the pathologists who does 14 one and a half autopsies a week, and tries to see whether 15 X-rays and gastric analysis would add anything to his 16 ability to perform as a pathologist. 17 That was hard for me to see as a Regional Program. MR. TIIOMPSON: It's interesting, though. 19 DR. CARPENTER: It's very interesting. 20 Of the million dollars, roughly, for the nine new projects, half of it goes for area education centers in ten 21 22 hospitals, and really, this project, lial.f a million dollar project buys an organizer, a librarian, and provides space 23 24 rental to the hospital, provid@s a secretary and some books, 25 journals, and audio-visual material for the area. IOOVER REPORTIttG CO, INC. 120 MassachuseffsAvenui, N.E. Vashington, D.C. 20002 2 4 1 eml4 to be And the outputs of that project are said 2 to list the educational and clinical resources in the area 3 of these ten hospitals, to relate the leadership oflthe 4 clinical and educational resources to determine the need 5 for new educational programs, and to develop an ove -al 6 manpower plan. 7 No;,7, I just believe that that's the work Df the 8 Advisory Conrqittees, not $500, 000 worth of staff. knd I 9 also -- I don't know, at a time when this program i3 going 10 to be phasing out, I wonder what the meaning of a 11 developmental award is. 12. flow, let me stop at that point and see wh my 13 cohort would say. 'MRS. IIYCKOFF: 14 Ilell, I think Memphis has the 15 most beautiful case of euphora about PJIP than any of the I(; P14pls. They have chronic optimism about how this thing 17 is going to go on, and they are just going to conquer all the problems in the world. And it's partly .due to Dr. 18 19 Culbertsonts personality. He carries the thing on his back. 20 pretty well. 21 They also operate as a,very peculiar -animal. They 92 are different from any other RP,IP, because they're like a 23 family. They seem to telephone each other and keep in touch 24 with each other across State lines and across all the terrible amount of paperwork and r ules and regulations that 25 IOOVER REPORTING CO, INC. 20 Massachusetts Avenu-, N,E, Vashington@ D.C. 20002 2 4 2 eml5 exist. They rise above it all and do it in an informal 2 fashion, and they seem to get together after hours and.keep 3 the wheels very well oiled, and do the thinas that ave o 4 be done. 51 It's an incredible.thing, and they cannot believe 6 that they are going to be phased out. They just don't 7 believe it. 8 Instead, as you can see from this report, they 9 make all kinds of alternative plans, so they're goiag to 10 survive no matter what. 11 And I really have a little faith in them.1 I 12. 1 honestly think they may be able to do it. They-havd put it -13 together, they have got this experimental health systems 14 management agency, and of course their Comprehensive Health 15 Planning Groups, and the Y11p, and.they are planning to get ready to jump in any direction when the legislation comes 17 through. They are going to be ready for anything. So I 18 think tjieir development funds will be used to launch l@) whatever needs to be launched at that time. 20 They show more faith in survival, i-i-hen the crunch 21 went on, they went right ahead v7ith their plans, and they 22 are all ready to get their maximum amount of money with new 23 projects and everything wli(mthe funds came through. 24 They have only seven I think it was out of, 25 was it 18? They had only seven,approved and unfunded request HOOVER REPORTING CO, INC. 320 Massachusetts Avenu 3, N.E. 2 43 eml6 at the end, and I think they had 11 that way, succeeded in 2 putting through at the worst possible moment. 3 So I really think that they may be able to a 4 go of this. 5 I would like to hear a little from staff on what 6 they know aboutthe new plans.they have for this newitrustee-. 7 I ship board. If there is anything in there. 8 DR. IIHITE: I wonder if Mrs. Kyttle might also 9 -comment on this phrase "escro-vi accounts". Is that a 10 substitute for keeping money after the thin g is ove ? 11 DR. CARPEIITER: That's a catalysm. 12. MRS. KYTTLE: Well, you asked about the 0 ganiza- -13 tion that is forming, and you are quite right. It's almost 14 incestuous, because N14CC's spawned MIP, and PI.IP's spawned 15 HSM.' P14P responded to the RFP that R&D issued for experimental I(; health systems, wrote the application, pulled the people 17 together, set it under a corporative kind of stance, 18 because that's what the RFP requires, and Voila, there's 1!) Health Systems I-lanagement, Inc., which is right across the 20 hall from RIIP. 21@ DR. McPIIEDRAN: I'm on the ropes, Mrs.- Kyttle. 22 RFPI R&D sent out a request for contract.proposals across 23 the country. That's a request for.contract proposals, for 24 proposals onexperimental health'dblivery systems. Regional 25 14edical Programs in I-lemphis sat down and wrote one, but did IOOVER REPORTING CO, INC. '20 Massachusetts Avenu i, N.E. Vashinpton. D.C. 20002 eml7 24 4 not send it in under their name, because they were not at 2 that tine a proper applicant, They spawned IISM, R14P and the 3 local B, which is one of the most active B's in the State of 4 Tennessee, not just west Tennessee but in the State of 5 Tennessee, had formed an umbrella trusteeship -- and that's 6 not a catalysm; that'Is tlieirs. They call it an umbrella 7 trusteeship. 8 It proposes the merger of the executive committee 9 of each of these agencies, and it is a straight-forward, 10 unabashed move to present the three of them. This is not an 11 area where one is more interested in surving over the other. 12. The three of them want to survive. 13 They did an intemmting thing. They agreed that each 14 of these.three entities, if their full boards ratified it#, 15 and since this paper was prepared all of the boards have i(i ratified it, the full boards. -The body bringing the largest 17 turf to this umbrella trusteeship, and without doubt that's 18 RMP with parts of five Statest would. bring the turf or I!) cognizance of this new group, should the turf want that. 20 And so there is, then, the possibility that there 21 would be an 30-county five-State Ilealth Service-Agency or 22 whatever might come out of the new legislation. 23 They thought that that would be the experiment, 24 and that's the purpose of that -'Organization you asked about. 25 MRS4 VIYCKOFF: They believe in survival. iOOVER REPORTING CO, INC. @20 Massachusetts Avenu,, N.E. Vashington, D.C. 20002 245 eml8 1 MRS. KYTTLE: The three of tJiem, not just PIIP. 2 MR. THOMPSON: It does-offer complication's? 3 however. We're used to, you know, the one-on-one business, .4 whols on, whols off, between CIIP and @MP. 5 Now, they have substituted a menage a trois kind of 6 thing, to complicate it even more. 7 MRS. KY'@"TLE: I don't know if they look at it as 8 a complication in that frame. The possible complication is 9 that Memphis PIIP has assisted, and that is from beginning to 10 where they are now, all other B's in west ennessee all of 11 them. But the one that is operating in southeast entucky 12. is a Memphis PJIP, funded not any longer, but it was MRS. T-7YCKOFF: And Mississippi. .13 14 MRS. 1'.YTTLE: Northern I-lississippi and the boot- heel'of Missouri and eastern Arkansas. The five operating 15 B's are all B's that have been funded and initiated by 16 17 Memphis RMP. 18 Now, if Memphis RMP comes into this umbrella 19 trusteeship with the greatest territory, it will encompass 20 the territory of those B's,, and they kno.,v7 that,, and they 21 realize that that will be the option. If those- 'local B's and indeed the legislation permits that type of arrangement, 22 they thought that that would be the interesting experiment 23 24 to form a new Health Service Agency for that terrain, wit- 25 subcontracts with existing B's, that they have already funded iOOVER REPORTING CO, INC. 320 Massachusetts Avenui, N.E. n 1, )nnn,) 24 6 eml9 e to give Dr. MRS. WYCKOFF: I guess you hav 2 Cannon a little credit for also holding this organization .3 together. 4 MRS. KYTTLE: Yes,, ma'am. 5 DR. SCHERLIS: IloN,7 much of the funding actually 6 would be directed to,,.,7ard the setting up of such a group? 7 How much of it is seed money? 8 MRS. KYTTLE: They seek no funds for that. T e 9 arrangement they have made is that they are rotating for'the 10 first period of operation, the executive director of HMS 11 serves as the chairman of this new board. The staff is 12. provided by IU4P, and the leg work is done by CIIP. 13 And for the next ninety'days, they first started 14 thinking of a year and they realized that that would be too long a time, the next ninety days the coordinator of PJ4P serves as chairman; the staff of IISM has to fund the money 17 to get the staff work done, and the CI-IP organization does the 18 regional communicating. 19 DR. SCIIERLIS: You'told us about that $400,000 in 20 escrow, 21 DR. WHITE: There's actually 800,000.--There are 22 actually two different escrow accounts. 23 MRS. KYTTLE: This application seeks no money for 24 that organization. 25 DR. SCIIERLIS: Yes. But'where does the money come 40OVER REPORTING CO, INC. 320 Massachusetts Avenu i, N.[. A12thinOnn 1) r. ?()nn? 247 em2 0 f rom? 2 Two things: how is it-labeled, and how can a sum 3 of money be available? .4 MRS. KYTTLE: All right, that's the first question 5 you asked about. The $800,000, when you total the two, it's 6 a combination of five and three. Let's speak to the 500 7 first,, and that is the creation of local consortia to 8 develop health manpower needs and relate them to identified 9 health service needs, and relate them to health manpower 10 resources. 11 MR. CHAMBLISS: Is that to which the funds are 12, going to be used? 13 MRS. KYTTLE: rive hu ndred thousand. 14 DR. CARPENTER: That's for ten hospital 15 librarians, ten secretaries, and ten planners, community 16 organizers. 17 MRS. KYTTLE: You asked if that should not be the 18 work of the local advisory committee, because so many of ii) these groups were formed from such advisory committem; but 20 they have no local advisory committees. These are ptedomin- 21 antly in ares where there are not B's, and this-is ovi Memphis starts B's. 22 23 DR. CARPENTER: No, they.have B agencies now 24 except in -- organized in every area, but not 25 MRS. KYTTLE: They are not funded. HOOVER REPORTING CO, INC. 320 Massachusetts Avenu 2, N.E. Waqhinoinn- D-C- 20002 2 4 3 em2l I DR. CARPENTER: Two of them are not funded. But 2 they are two out of ten at most.. 3 No, these are not B agencies, these are 4 MRS. WV.CKOFF: Health Centers. 5 DR. CARPE14TER: These are hospital libraries. 6 MRS. WYCI',OFF: There's the seed money to start 7 things. 8 MRS. KYTTLE: I said they have no local advisory 9 committee in these areas, save Jackson. Ther6.is one in' 10 Jackson, and there's one ongoing there. 11 DR. CARPENTER: But they showed us a map of the B 12. agencies, right, and they cover the whole area except maybe a few outlying counties. .13 MRS. KYTTLE: These are areas that have no health 14 manpower committees working in them. 15 1(; DR. CARPENTER: Oh, okay. No manpower committees. 17 MRS. KYTTLE: And that's how they have spawned, 18 they have first developed some health manpower committees for B's. These are areas wh@e the B's have formed without 19 20 he.alth manpower committees. DR. CARPENTER: That's the point I'm-making. If 21 they had the manpower committees, they wotldn't have to spend 22 a half a million dollars. 23 I-IRS. KYTTLE: Well,'for some reason, and I have 24 25 tried to research it and I don't understand it, the philosophy, iOOVER REPORTING CO, INC. 320 Massachusetts Avenu,, N.E. A12thinotnn 1) P. ?OnO? 2 4 9 em22 I the Memphis-Regional Program thinks local consortia to 2 address health manpower needs should be seated in a 3 hospital. They feel the hospital setting is the setting .4 for an IISEA,, and they have felt that way from the very 5 beginning. And that's where these are, ten sites. 6 MR. CIIATIBLISS: Dr. Scherlis. 7 DR. SCIIERLIS: l@ow welve gotten through the first 8 gear, what happens to the second ten libraries, secretaries, 9 et cetera, for the second year? They are being funded? 10 MRS. KYTTLE: The same thing that will happen for 11 all the others. Some of them will make-application under 12. the new legislation as health service agencies. I mean,, that's going to happen across the country. Most of them 13 14 feel that they are ready to make application. 15 MR. THO!IPSOII:,- Ten libraries are going to be certified as health agencies, as' I understand you? MRS. KYTTLE: One of the first things the local 17 18 area is going to have to do is to create its own manpower committee. The librarian wiri not be -- even she's a part of the system, but she is not the pivot. 20 DR. WIIITE: I'm suffering from an inability to 21 recall Webster's definition of "escrow". But it seems to me 22 it has to do with putting money aside for future use, 23 MRS. KYTTLT: They w"ant to impound their own 24 money. They want to put $500,000 Aside now so that they feel 25 HOOVER REPORT114G CO, INC. 320 Massachusetts Avenu,, N.E. n f, I)nnnl) em23 250 by July they will have gotten these things ready to go to 2 contracts, or in the writing stage now of when, I think one 3 is in Kentucky and the other is in Crittenden County in 4 Arkansas. Rather than coming in in July with thl3 proposal 5 of ten sites all worked up, they want to escrow the money 6 out of the total package now, so that it can begin in July 7 rather than make application to us in July. 8 MR. THOMPSON: So, in other words, they wa t to use 9 the escrow business as a substitute for a specific proposal. 10 MRS. XYTTLE: Yes, and they want to tell you now 11 what they want to put it aside,for. 12. MR. THOMPSON: Has this proposal been matched up 13 through the whole internal review process as a proposal? 14 MRS. KYTTLE: As a concept. 15 DR. CARPENTER. I think there are a series of 16 small proposals. Isn't that the way it got through the RAG 17 as small proposals? But it did in part, in $25,000 hunks 18 it went through RAG. MR. THOMPSON:- $25,000 hunks up to $500,000? 20 That's a nice piece of business. 21 DR. IIIIITE: They have got $800,000 there. 22 MRS. KYTTLE: And it all went through at once. 23 DR. CARPENTER: They didn't hide any of it. e 24 MRS. KYTTLE: It did not bleed through,, it went through as a concept, and $25,000 apiece for ten sites. 25 iOOVER REPORTING CO, INC. @20 Massactiusetts Avenui, N.E. 2 5 1 em2 4 DR. CARPENTER: Can I. at this point, break into 2 the conversation and make a funding recommendation? 3 MR. CIIAIIBLISS: You may, indeed, Dr. Carpenter., -4 DR. CARPENTER: I would, just to get the discussion 5 going, move a certain funding level. Their annualized rate 6 now is a million and a half. Their targeted rate is about 7 two million three, and they request three million four now 8 and predict that they will ask for a million two later, 9 and that will get them at two times target. 10 I think that the region is pretty good, but not 11 in a position to go from a million And a half to four million 12 seven at the time of phase-down. I would suggest a funding .13 level a little above the target level, of $2,,600,,000. 14 MR. CHAIIBLISS: Will you place that in the form of 15 a motion? 1(; DR. CARPENTER: Yes,, I do. 17 MRS. WYCKOFF: I'll second that. 18 MR. CIIAt4BLISS: It has been moved and seconded 19 that the level be established for be recommended for.- Memphis at $2,600,000. 20 Is there discussion? 21, DR. WIIITE: I would like to pursue this further, 22 23 and I an, going to. We've talked about the 5OOtOOO. There's another 300,000 in escrow dollars, which I interpret as this, 24 25 Mrs. Kyttle, as underwriting the survival of these three in HOOVER REPORTING CO, INC. 320 Massachusetts Avenu @, N.[. 25 2 em25 I whatever form they're going to take. 2 It says that, I think. 3 MRS. KYTTLE: It says that high priority out of 4 this developmental will be given to those agencies, 'You know, 51, in the total region. That's the RTIP region that I'm. 6 pursuing, the logical kinds of things that the new legisla- tion proposes. 8 There again that falls within the umbrella purview, 9 but the umbrella -- the organization that is the umbrella is 10 not seeking funds, but it seeks to fortify its philosophy 11 that it's a good umbrella, it hopes that the legislation .12. will speak to a State, you know, whichever one comes out first, 13 and it wants to have agencies funded within it, that it can 14 contract with. 15 That's what the high priority is for those agencies. 16 DR. IIHITE: Now, is that $300,000 the same as the developmental fund? 17 18 MRS. I'\,YTTLE: Some of those are B's. Yes, that's out of that. 19 20 MR. TH014PSON: I think what we see here is probably 21 the bald statement of the problem that you are finding more or less in the same degree in all of these, most of the 22 proposals, and this is an attempt to second-guess what the 23 i 2,4 legislation is going .to be as f'ar as, you know, whether this is regional health authority or State health authority, 25 ,OOVER REPORTING CO, INC. 20 Mamchusetts Avenui, N.E. t'ashin@n- D-C@ 20002 253 em2 6 and it's floating around in all these crazy bills. 2 Now, I think we have a'policy problem here, 3 whether our RI-4P funds should be used to relate an agency,'a 4 proposed agency for nonexistent legislation. And I think 5 that's true here, I think that's true in a subsequent thing 6 that I'll review to you. 7 In other words, when you, from PI.IPS sent the 8 message down: Fellows, get on the ball with your CHP and 9 no kidding this time. We've seen a lot of getting into bed 10 with CIIP, and it's -- in fact it now looks like a plot by 11 the two of them to survive, whatever happens. 12. Now,, I don't know what's going to happen if this '13 legislation setting up this envisioned Regional Health 14 Authority is delayed by two years. You know, all this 15 money that we're pouri@nej @n here to build these various elaborate umbrella agencies, the consortia -- they have about 17 six names for it --.it's going right down the old,tube. 18 MR. VAN WINKLE: I would like to.point out that 19 they have been encouraged to start various programs with'CHP. 20 MR. THO@IPSON: That's what I'd like to know: who 21 has the crystal-ball authority that they can tell me- that 22 the Regional Health Authority is going to be established 23 by the end of P14P's life, and take'over RMP's staff or skills 24 and start in business. Who the hell has got that information. I don't have it, 25 HOOVER REPORTING CO, INC. 320 Massachusetts Avenu i, N.E. 254 em2 7 MRS. KYTTLE: Mr. Thompson, you know it would be 2 beautiful if that were the case,-but no region has,had that 3 word, and they are all trying to take the most logical and 4 flexible stance that they can, trying to provide for the 5 1 possibility of State structure as well as providing'for the 6 local structures, until they see what the legislation is* 7 MR. TflOf4PSON: When you cover all the bets' on a 8 racehorse -it costs a lot of money, and that's what @ese 9 people are doing. They Ire putting two bucks on eve horse lo in the race, hoping that somebody will come in and ey will 11 be on it! As long as it's not their money, that's okay. 12. MR. CHAIIBLISS: This is one of the poli@ questiois 13 that we alluded to earlier on when the committee was convened., 14 and this is one of the issues that will be dealt with as the 15 review goes forward. 16 I would like to acknowledge the presence of Dr. 17 Margolis here, our former Director. And since this is a 18 policy issue, I'm wondering if he would say a few words-on l@) this point. 20 DR. SCHERLIS: I was just going to make one suggestion. I think that Memphis really shows some good 21 judgment with the idea of an escrow account for $800,000 and 22 23 I would think that some of the wisest judgment that this 24 Review Committee could make is to have an escrow account of 25 a hundred, a hundred and twenty to 'forty thousand dollars, HOOVER REPORTING CO, INC. 320 Massachusetts Avenu i, N.E. Wa%hinpton. D.C. 20002 em2 8 that we would have available, and say, let's save that for 2 some decent health planning as of July lst, 1975. 3 @ihile 'I wasn't here yesterday, which is a .4 calendar error that I apologize for, I spent, really, as all 5 of you did, a very difficult time reviewing these, because 6 we're doing it on promise and hope and faith and, frankly, 7 charity. 8 And all the old judgments that we have used have had to go down the drain completely in reviewing these; and 10 I think that if Memphis gets approved for an escrow account, 11 that my next suggestion will be that we vote an escrow 12, account of a hundred or eighty million dollars for July lst, 13 to be used if there will be health planning then. 14 I don't think that putting this into some thirty, 15 forty, fifty little different projects, that we're begged 1(; for and scrounged for by going out and saying, Come on in, 17 we have this last chance to get it. A lot of them read that 18 way. That that is really the equitable way for us to use government funds. 19 20 I have the serious questions that all of you have had, and we're operating within a very difficult framework, 21@ to reach equitable decisions. 22 I am all for escrow accounts, particularly of most 23 24 of that one hundred and twenty or hundred.and forty million 25 dollars. 40OVER REPORTING CO, INC. )20 Massachusetts Avenu,, N.E. Nashington, D.C. 20002 256 em29 I didn't mean to pre-.empt you,, but I wanted that 2 stated somewhere along the line. 3 DR. tiARGOLIS: Well, my most positive word is that 4 I an delighted to see my good friends here again. 5 I am delighted to see that you are tearing at things as usual. 7 I don't understand.your concern, John, in not 8 knowing how to spend money on nonexistent legislation, 9 ioney was appropriated, impounded in 173 to be, After all, r 10 spent in.176; when the authorization would expire by June 11 30th, anyway., 12. So itis a perfectly clearcut situation! 13 I would like to address this question, because I 14 think the points you raise are important, and rather than 15 matters of policy, althpugh.they certainly involve policy, 1(; there are also senses of timing in judgment, which will have 17 to replace, as they often have in this program, some kind 18 of policy base. In all of the discussions on planning, 19 legislation, developed both some kind of unified health 20 planning proposal, there has been more dissatisfaction -- and not very well hidden -- than satisfaction with everybody's 21 22 proposal, as you implied. 23 The administration is not wildly enthusiastic about what it has proposed. The Rogers Committee feels about 24 the same about its own proposals..'Theke is fjreat uneasiness 25 HOOVER REPORTING CO, INC. 320 Massachusetts Avenu @, N.E. em3O 257 about what would occur. Time is running out. And some 2 of the basic problems remain. 3 The problem which everyone has looked at, usually 4 defined so poorly, that it is looked at plainly, is the 5 meaning of planning,, the relationship between planning and 6 implementation; and the relationships between planning and' 7 management. 8 Traditional questions which have been up for 9 consideration time and time again. The difficulty involved 10 in all the pieces of legislation and in the debates which 11 really don't get around to this is that'no one is ready to 12. say what that relationship ought to be. Nobody is willing ..13 to come down hard, although there are indications that a 14 position has been developed.. 15 For example, it is now felt that whatever these I(; health service agencies will bet or whatever name they come 17 out under,, they will be private, nonprofit structures within 18 the State. There will be an uncertain kind of support for I!) State structures. The planni"ng process will be kept from 20 State implementation, however, there will be some small 21 amount of money for implementation, a larger amount of 22 money for implementation based on whose bill you're looking 23 at. 24 What is missing in the process is something which 25 can produce, in the health delivery system, a cooperative HOOVER REPORTING CO, INC. 320 Massachusetts Avenu,, N.E. w.@hinafnn n r. green? 25 8 em3l 1 structure which allows people to operate in the private and 2 in the nonprivate systems in such a way that they are able 3 to do together more effectively those things which they wish 4 to do than they can do them separately. Which is an early 5 description of Regional Medical Programs. 6 It creates a real problem. And in many ways what 7 our reviews are attempting to do is being approached under 8 other names, with different kinds of understanding, and with 9 a variety of methods. 10 But the debate has not been joined. I don't think it will be joined. And when you' re through with this 12. session and we're through with the review session which is 13 coming up after that, there is still going to be great 14 difficulty in making a judgment about what is IUIP going to 15 do in relationship to CIIP, what will the planning function actually be, what will the relationships be between pl anning 17 and implementations and, furthermore, what is going to be 18 the role of the State government in this? Because, in general, the role of State goverment 19 has been downgradedalmost lost sight of 20 there have been 21 serious objections to it from outside and from within. And we're going to be entering the fall season whether using an 22 escrow account or not, with no more certainty about what 23 that relationship is than exis@s at the present time. 24 25 What we have been saying,is a'consequence, and it's HOOVER REPORTING CO, INC. 320 Massachusetts Avenu i, N.E. Washinzton, D.C. 20002 em32 2 5 -0, about the only way out,, maybe not too bad a one, is that the 2 most proved factor beyond a Regional Medical Program, and 3 it's now my job in addressing all these programs, it applies 4 to others as well, certainly the CIIP; but beyond the CIIP, 5 the other kinds of federal programs which are in the 6 States v7hich have sort of opted out of this activity, 7 the most judicious thing for.thera to do is to get together 8 with one another as rapidly and as fully and as enthusiastic- 9 ally as possible, and decide what they're going to do together, 10 regardless of what the legislation is going to look like. 11 And betv@7een the passage or nonpassage, which is a 12. good likelihood,,of the legislation, its approval, its 13 appropriation, its regulations -and its administration, 14 so many'things will occur that if the people who are out 15 there quit trying to decide who is going to be in charge and 16 decide how they are going to run the thing together, they 17 are going to move rapidly ahead. 18 Now, sometimes this is interpretative on the part 1!) of PI,4P people, if I'm talking to them, as some of the RMP's 20 are, is that they should quickly move to take over. 21 Now, that v7ouldn't work. CHP takes the same 22 response when they are listening to their own partisans; 23 it's for you to take over. 24 And if they will get just a little smarter,, they 25 will move together; but they are going to have to move with HOOVER REPORTING CO, INC. 320 Massachusetts Avenu,, N.E. Washini,ton, D.C. 20002 26 0 em33 other programs. Maternal and Child Ifealth Service, Community 2 I-lental Ilealth Service, which, for' some reason, along with 3 others, have never been considered a part of the general 4 concept of comprehensive planning. 5 Migrant programs, all of then have each been looked 6 at separately, and all the conversations have been PFP and 7 CHP as if those were the only actors in the game; when, in fact, they are some of the actors, and in many instances rather minor actors. 10 Nov7, I think the additional.thing which isi going 11 to make a difference, about the time we get started,@ith it, 12. is the gro.iqing concern with the regulatory function @within .13 the State which will produce an entirely different enviroh- 14 ment for the total relationship between planning and. 15 implementation. Because,.the regulatory function will throw 16 in a new responsibility which must be a State responsibility,, 17 almost by definition. 18 That regulatory function already applies to 1$) institutional development. It's going to, in all likelihood, 20 involve cost control, becaiiselwe get national health insurance, 21 and there is freer and freer conversation nov7 about a 22 complement to certificate-of-need legislation for construction, 23 and that will be some kind of certificate-of-need for man- 24 power. Noi.i, wien these kinds of things occur, people who 25 IOOVER REPORTING CO, INC. ;20 Massachusetts Avenui, N.[. 'iashington. D.C. 20002 2 6 1 em34 have been vying for responsibility may find themselves vying 2 for getting out of sight,- because it's going to be no 3 child's game. .4 And yet by looking at the total structure, as it 5 will be much faster than many of us have expected, the 6 relationships between the planning, the implementation, the 7 operational and the regulato ry functions can become clearer, 8 and the responsibilities for the various parts will begin 9 to fall into place. 10 But to try to assume full management or full 11 authority for any one of them is injudicious,, it won't work, 12. and I don't think anyone would really want it when they get .13 all through with it. 14 The real struggle, in all sincerity, will be on 15 the part of those who are determined that the regulatory 16 function, particularly control of rates and fees, be placed 17 anywhere but where I am. Nobody is going to want that. 18 And yet it is going to be the part of the system which is 11) going to have the greatest power, and from which most of. 20 the strength is going to flow within the States. I think it will go in the States gradually. 21 The other big debate is whether the National Ifealth Insurance 22 2tl is to be more federal or State directed; but that's a very fundamental issue. 24 Now, I know that's not a policy thing,, but at least 25 HOOVER REPORTING CO, INC. 320 Massachusetts Avenu i, N.E. w.@hi..f.n n r. )nfin,) 262 em35 it's a statement ofsome kind of dynamics which will work 2 well some places and not others. 'The concept of escrow,, I 3 would certainly agree with you, is certainly -- if '(OU re 4 going to consider the setting aside of funds for an,uncertain 5 but realizable goal in the immediate future, that should be 6 a programmatic kind of action across the board, rat@er 7 I than,.limited to any one program, to come up with that kind 8 of an idea 9 And even then, it is a risky kind of thin to do, 10 because you don't know what the situation w ill be w en those 11 funds are released. 12. I don't know if that helps or not. 13 MR. CHPIIBLISS: T,,Iell, thank you, Dr. Margolis. 14 There may be some questions that the panel would like to 15 raise, in addition to --,. Dr. Vaun? 16 DR. VATA4: Getting back to this, not with regard 17 to Dr. Margolis' comments,, the only thina that concerns me 18 about the escrow is that, does this place any of the I!) other P14P's that have seen fit to core back in July,, at a 20 disadvantage? 21 In other words, are these people gambling that all 22 money is going to be doled out on the first round, and,, reall@, 23 whatlpulve been saying is not so there won't be any money 24 left for the second round, so they're putting their little nest-egg in escrow. 25 iDOVER REPORTING CO, INC. @20 Massachusetts Avenu,, N.E. nr,)nnn,) 26 3 /2 64 em3 6 Has that thought occurred to anybody? Is this 2 v7hat they are tr-,,,ing to do? 3 MR. CIIAT-IBLISS: There will be a sum of moneys .4 remaining for the second round. 5 DR. VAUN: So as you envisage it, this would be 6 not placing anybody at a disadvantage? The other PIIP'S. 7 MR. CHA14BLISS: Well, the total-amount is limited, 8 so therefore what is ultimately awarded to Memphis comes out 9 of the entire amount available. 10 DR. MILLER: Isn't it true that previously, 11 except for developmental fund awards, which has not been 12. mentioned in the current directions, no region was allowed to just apply for escrow funds, by lump of escrow money. 14 You got it another way. But,you couldn't apply for escrow funds. And now you do not have an authorization or 17 direction for regions to apply for a development award, 18 either; do you? 19 MR. CIIAIIBLIS3: We cfo not. 20 DR.MILLER: well, isn't it appropriate that this 21 review committee specifically record in the record that we do not recommend funding for that activity or that kind of 22 23 an award, that part? MR. CII7UIBLISS: That would be a problem and we 24 are looking to this committee for its judgment on that. 25 HOOVER REPORTING CO, INC. 320 Massachusetts Avenu @, N.E. Nnthinorfnn 1) r. 9nnO9 em37 265 1 DR. IIILLER: Do you want that in the form of a motioa? 21 MR. CI-IAIIBLISS: A motion is not in order at the 3 present time. There is a motion on the floor, and that 4 motion is-that the level of funding for Memphis be recommends 5i at $2,684,000. 6 MRS. WYCKOFF: Well, v7hy don't we do it? 7 MR. CIIPIIBLISS: You may so indicate that, and the 8 staff eople will take due notice of it. p 9 MRS. WYCKOFF: Should we amend the motion that the 10 escrow funds be taken out of this? DR. T@NIITE: All of the escrow 'funds are on the 12 yellow slieet, they are not on the application. The awards. l@Inat you see on the application@is a developmental award and 14 a project, and I believe we are not supposed to get so deeply 15 into the region's management as to reject a specific 16 project. 17 I guess I have the feeling that if we reduce the 18 requested funds by an appropriate amount, the region will 19 probably behave fairly @,iell..'And I would be satisfied just 20 to reduce the funding amount and then proceed. 21 Does that make sense to anybody. 22 DR. llcPIIEDRAN: Then hov7 about, as a separate pieCE 23 of business that does not have anything to do with this particular consideration of this program, that we could have 24 25 this motion that Dr. Miller suggests. Could we do that? 40OVER REPORTING CO. INC. L?O MassachusettsAvenL,@, N.E. flr 9i!ar,7 em38 266 Just as a general part of the proceedings of this 2 committee. If we could do it that way. 3 MR. VA14 WINKLE: But the staff can also express 4 your concern about these two items. 5 MR. CIlIU4BLISS: Then I call the question, 6 Those in favor please indicate by the usual sign 7 in voting. [Chorus of "ayes".) 9 'MR. CHAIABLISS: Those opposed? 10 [.No response.] MR..CHIU4BLIS: The motion is carried. At two 12. million six, with the concerns of this panel being conveyed 13 to the region in the advice letter and by staff, 14 I must say that the privilege that we've had of 15 having Dr. Margolis, the Deputy Administrator of the i(i Health Resources Administration, come in just at this key 17 moment, when we were discussing a very critical issue having 18 to do with Memphis, was most timely. I would endeavor to ask the staff to set the 20 whole question in some type of framework, and then we would like to have Dr. Margolis comment on those issues be 21 22 conveyed to the staff and to perhaps some of the regions. I think this is very timely, what he has done. 23 24 25 HOOVER REPORTING CO, INC. 320 Massachusetts Avenui, N.E. 26 7 em39 REGIOIIAL MEDICAL PROGPUL REVIEW 2 MISSOURI 3 MR. CHA14BLISS: We shall now then turn our 4 attention to a review of the application from the Missouri 5 Regional Medical Program. The reviewers here will be Dr. 6 McPhedran and Dr. Ililler, and staff support will be provided, 7 by mrs.,Resnik. 8 Thank you, Dr. Margolis. 9 DR. McPHEDIWI: Yesterday Dr. Miller and I got 10 some additional material on the Missouri application, and 11 I cite this now not to beg off, because I have read it, in 12. fact, but it was interesting because it was. a staff visit 13 to Missouri and it was suggested to me that maybe I ought 14 to chan'e my views to some extent, In fact, the value 9 15 of this program and the,.merit of the application, specifically. it; But I must say I think it hasn't changed my views 17 a whole lot, and, while I've got more to say about it than is I did, it really remains about the same. 19 To go through the review sheet: program leadership, 20 I was unable to classify one of the categories, and have checked "satisfactory to poor" because I think that it is 21 variable, without mentioning particular persons. I think 22 that it really is uneven, and I'm basing tJiis on the fact 23 that the leadership seems to me very much the same as I recall 24 it from at least two because I've been there twice 25 IOOVER REPORTING CO, INC. 20 Massachusetts Aveou @, N.E. 26 8 em4O two previous site visits, and a lot of discussion at various 2 National Advisory Council.mectings. 3 I really think that what has happened in Lis. 4 application reflects this leadership to a considerable 5 extent. 6 I have no criticism to make of the program staff, 7 and never did, except that I'tliink it used to be ve large, and the proposal suggests enlargement. I can't _- pnless 9 the marking of that enlargement, it ii 10 currently 30 with a proposed addition of 45 staff. 11 The program staff in the past we used to Friticize, 12, maybe this should have been more a criticism of th elleadershid, 13 for its lack of initiative in helping people in the region 14 to develop parts of the program, develop projects and 15 develop other component parts of the program. 1(; According to the.most'recent visit, that is not a 17 problem now, but it certainly used to be. 18 I am persuaded by the recent visit, I have said l@) that at least it's satisfactory, but I really wonder whether, 20 if it's satisfactory now, it is justified to consider all the additional staff to such an enormously large-staff that 21 22 is proposed. 23 The Regional Advisory Group which, until a couple 24 of years ago, numered only twel've, has been increase4, I thin-,, 25 by two stages to a total of 55 members, and it appears that IOOVER REPORTING CO, INC. @20 Massachusetts Avenu @, N.E. Vashington, D.C. 20002 em4l 2 69 it is satisfactorily supervising the activities of the 2 program. In the fourteen montlas-before this application 3 there were four Regional Advisory Group meetings, I think 4 eight of the Executive Committee, and several of the various 5 technical and standing committees, 6 So the committee structure has continued to functio@ 7 and the Regional Advisory Group also said that there is a 8 fifty percent attendance rate at these several RAG meetings. 9 Past performance and accomplishments, 1 think ate 10 mediocre for the most part. I found it difficult to either 11 say satisfactory or poor or inadequate 12, Considering the amount of money that this program has gotten in the past, it is difficult for me to be more 13 14 generous in my assessment of this. 15 In the past there was a very large investment made in a lot of computer centered activities, and I guess that 17 this still remains with me, although it's all gone from the present application. 18 We thought, those of us who visited it,, that there 19 20 was bad judgment and even, perhaps, appropriate for the State of Missouri 21 mulishness about following the direction and guidance that we attempted to give. 22 The objectives and priorities seemed to be satis- 23 factorily stated. 24 I think that the proposed activities, and I can 25 HOOVER REPORTING CO, INC. 320 Massachusetts Avenu i, N.E. Washington, D.C. 20002 2 70 em42 summarize briefly the categories are satisfactory but not 2 e feasibility, that is, the likelihood that imaginative. Th 3 the activities proposed can be accomplished in the ime that 4 they anticipate the program will continue is, by th i 5 own statement, likely in some and unlikely that the 6 manage in others. 7 For example, they -state that all the EMS activiti s 8 that they-have proposed, and I will come back to thIis, there 9 is a question pertinent to the one Dr. Scherlis raised 10 earlier, whether or not these are new EMS activiti s; but 11 they say that they feel these activities can be up q, raded 12, in the next year. I really ,7onder whether that is Is 0. 13 The cooperation with CHP seems to be quite 14 satisfactory. 15 l@ over-all assessment of the region is that it is only average. 17 I am afraid I have more comments and remarks to 18 make. 19 In this Regional Medical Program there appears to 20 be no serious problem in the relationship of the grantee, which is the University of Missouri, and there-never has beer, 21 and that continues to be,-i gather, a satisfactory relation- 92 ship. 23 MR. TIIOI.IPSON: You'don't shoot Santa Claus., 24 25 DR. McPIIEDRAN: No, not intentially. HOOVER REPORTING CO, INC. 320 Massachusetts Avenu i, N.E. Washington, D.C. 20002 em43 2 7 1 The major thrust that they have stated for then- 2 selves are five: emergency medical systems; health; 3 manpower; education, and under that category especially 4 training people to deal with the problem of high blood 5 1 1 pressure, and training seminars to be conducted for many 6 categories of hospital personnel. Third is listed as integrated health care delivery systems, with especially heavy emphasis, as I see i,:, on 9 -supporting hospitals in developing JCAII type criteria, and 10 also a problem of oriented records for local practi ioners. 11 Ambulatory care systems, particularly con@erned 12@ about availability and of care. 13 The purposes, the major thrusts are as general 14 I'm quoting from the application there; just general, as I'm 15 stating them to be -- systems for-end-State -@- kidney manage- 16 ment. 17 Their fiscal year 175 suggests that their EMS 18 role will be completed, and the local communities will be I!) able to take the developed programs and projects and handle 20 them on their own, although I don't think that my reading of 21@ the application particularly supports that. 22 Then I went through the request for funding, 23 including changes in core staff. I. spent less time, I 24 must say, on the continuing pro ects, but a good deal of 25 time on the new projects, and tried to dig out for my own iODVER REPORTING CO, INC. @20 Massachusetts Avenui, N.[. Vashington, D.C. 20002 7fVi FAfit" em4A 272 I purposes what I thought was a necessary expansion of core 2 staff. And what I questioned might be new EMS projects, and 3 I realize the staff might have gone through this and may want .4 to, perhaps, dispute my judgment. The excisions that I performed enabled me to cut 6 their proposal from $3,010,113 down to $2,295,113. I felt 7 that there was $713,000 that could and in my view should be 8 removed from the proposal; and it happens to coincide with 9 what staff, in the person of t@irs. Resnik# has recommended,- 10 and I guess it also coincides to some extent with the 11 targeted amount. 12, But I think it is worthwhile to suggest what specific things there were. 13 14 There were, for example, requests for what amounted 15 I think, to increases iki core staff. They have six district i(i consultants, and the recent staff site visit suggests that 17 they should be continued. I have no quarrewl with that. 18 But there is a suggested sum of $31,000 by sub region to 19 increase staff support for tl7e distrist liaison to $186,000; 20 and I will quote from the application xqh.at the ultimate justification is. 21 22 It is said that the specific outputs would be a 23 plan and method of implementing the plan to operate under 24 the new legislative athority. If no legislative authority is forthcoming by fiscal year 176,'this year-Is effort will 25 HOOVERREFORTINGCO,INC. 32OMassachusettsAvenui,N.E. Washir,t@n, D.C.20002 273 em45 have been one of which the Missouri Regional Medical Program 2 can well be proud. We will have'brought toge-ther at the 3 working level members of principal federal and State health 4 agencies, to work toward a common cause of improving the Statewide health care system, and I think that I would really 6 have felt that even in a rorm 15 something more specific than 7 that could have been given me as a peroration to convince 8 me that that money ought to have been spent. 9 There are other things in there that I feel are 10 similarly if not worthier of support. I won't bother you with the details, but I do want to mention that I thought that 12. there were about around twelve, as I see it, new projects, 13 no EMS, twelve, roughly, totaling around $245tOOO, that I 14 just don't think are in the guidelines, are they? 15 MRS. RESNIK: We're treating them as sub-components i(i of already existing and ongoing EMS projects, which is 17 essentially what they are. They are dealing with training, 18 but in different locations. And they tell us that they 19 understand that that is within their authority under the. 20 present guidelines. 21@ They are applying to the EMS bureau, but they 22 don't foresee any grants. 23 DR. McPHEDRAN: This looks to me like new EMS, 24 and so that's 245,000, and then going thro'tgli some other 25 projects, I noticed this, but I did it an@iay,, I thought there HOOVER REPORTING CO, INC. 320 Massachusetts Avenu i, N.E. Washington, D.C. 20002 k74 em46 I were several things,, like there's a quality criteria 2 project in a hospital in Jefferson City, and it looks to me 3 as if that really is PSR activity, and I wonder if that 4 similarly should be excluded. And several other things that also seem to me un- suitable. 7 So that, in summary, what I did was I felt that 8 at least $715,000 could come out of it, and I came.out with 9 a recommendation, as I say, of $2,1295,113, which is obviously 10 unreasonably precise, but it is approximately where the 11 targeted sun is. I would have no quarrel if we said the I 12! targeted sum would be satisfactory; and I would like to know 13 what Dr. Miller thought about it. 14 MR. ClIP14BLISS: Dr. Miller. 15 MR. MILLER: .This is an interesting experience we 16 all go through. I pursued a rather different and more 17 devious route of arriving at the same conclusion. 18 I have known the Missouri Regional Medical Program I!) for a long time and many of the staff people on it, an 20 perhaps it is worthwhile to mention a little@ of the background 21 on this. 22 @lhen R14P got started, Missouri was really ready, 23 because Missouri was more regionalized in the medical 24 establishment than most any State in the'union, having their 25 medical school in Columbia, which 'is a small, a relatively HOOVERREFORTI CO,INC. 32OMassachusettsAvenvi,N.E. Washin-Kton, D.C. 20002 em47 275 1 small city, and therefore, having had to farm out clinical 2 medicine for a long time into other communities, which is 3 almost never done in most of the other medical centers in 4 the United States, and which was extremely repugnant to them, 5 as you may all remember. 6 So Missouri was, its time had come, and the mule 7 characteristics recognized this, and they proceeded with 8 vigor. 9 They also had some people in the leadership posi'tio-i 10 who have,considerabl.e skill in recognizing political 11 expediency,, and when it is popular at the national level 12, to spend money onlelectronic computer equipment and remote 13 control things, they were in there for millions and got @em. 14 When it is politically expedient to turn th4m. off, they 15 turn them off like it w4s a water faucet. Tqhich they have now done, because something else is politically exp edient. 17 I have four applications that are mine that are 18 coming up today, all of them are somewhat similar. And 19 Dr. Schleris' comments previously have botlired me, yesterday 20 and today and last night, and even lose.a little sleep over 21 it. 22 Because the principles formally ascribed to 2.3 Regional Medical Programs of quality programs, well evaluated 24 demonstrations that are woth the,money, seem to be all gone, and I suppose it seems a matter of political expedience, but 25 HOOVER REPORTING CO, INC. 320 Massachusetts Avenu,, N.[. Washington, D.C. 20002 em48 2 76 1 it looks like weire stuck anyway. But it is bothersome. 2 And in these four programs that are corung up, they all have 3 applications, they are going gung ho for election, it's -4 politically expedient to get the money and they're out to 5 get it. And by whatever most clever mechanisms they felt 6 could be used to get it, regardless of whether it is cost 7 effective or will be continued really, or what the ultimate 8 goal is. 9 Noxi,, Missouri has done it to a.ratlier great degree. 10 It has it doesn't have an escrow item in here,'a develop- 11 mental fund item, but its method will give it a nice big one. 12. There are separately described staff component 13 projects,, 26 of them in this application, either with a dollar amount, none of which is excessive by itself; but 14 15 together is nice. There are six district liaison systems with a total 16 17 budget of $186,oob. They went all out on EMS without having a general State EMS plan, which is forbidden, so there is are five continuations and el@-ven new EMS projects, for a 19 total of $518,000. 20 21 It would be some little job to keep them coordinated. Maybe they will need those district guys to keep all those 9-2 different outfits working in any kind of a rational coordinatin g 23 way . 24 I could ao on in more details, but I think I will 25 HOOVER REPORTING CO, INC. 320 Massachusetts Avenv@, N.E. Washington. D,C. 20DO2 em49 277 1 say,, first, hoviever, that a little bit in contrast to Dr. 2 McPhedran's view, I feel that the basic questions that we're 3 supposed to answer on this review sheet, most of them 4 relative to other RTIP'S, you'd have to grade Missouri as 5 good to excellent. 6 The program leadership, you may not like them, but, 7 they've done a good job in Missouri. The program staff is 8 equally so. 9 The Regional Advisory Group, they get along with 10 very well. It's a little funny, but it works. Their past performance and accomplishments,, they 12. have been a leader in Missouri without any question. They 13 have lead regionalization in Missouri to a phenomenal 14 degree, and they have more general acceptance than many 15 other regions. Their objectives and priorities I would interpret 17 As political expediency, and they have done it extremely 18 well. 19 The feasibility, of course, is.very low, because we are theoretically supposed to grade these things on whether 20 they can do this in one year, and they obv'lousl@-can't 21 possibly do what they've got in this application. 22 They get along fine withCIIP,, they,support them in 23 f many ways. So they will get -go'od'acceptan6e .by them. 24 The total picture, 26 staff component projects and 25 HOOVER REPORTING CO, INC. 320 Massachusetts Avenu i, N.E. Washington, D.C. 20002 em5G 278 27 continuation projects and 19 new projects. 2 Much of this is overambitious for one-year concept,, 3 and it looks like it cannot be accomplished. -4 MI, conclusion: I recommend funding, however, at 5 the targeted level, which I think it is a way out of the 6 dilemma of coming up with adollar figure. 7 MRS. RE.SIIII,',: They are coming in with a $500 request 8 July 1, they indicate. 9 DR. MILLER: We will address that t-i,7o mo ths from 10 now. 11 MR. CIW93LISS: All right, each of the reviewers 12. has cone up with a different amount here. -13 DR. McPHEDRAIT: Well, T really didn't make that'in 14 the form of a motion. I have no quarrel with 15 f4ILLER:----,Ohl I wbil-ldn't@mind if he 'd DR wante -t6- figure out how you can justify c-'oming out with $2,295,113. 17 I'll go along with it. 18 DR. McPHEDRAII: I will move the target amount, I!) which is $2,364,333. 20 MR. Cl,'Al4BLISS:. Is there a second? 21 DR. MILLER: Iwill second. 22 MR. CIIMIBLISS:. It is moved and seconded that a 23 recommendation for Missouri be the-targeted amount of $2,341,490. 24 DR. IIcPIIED@@: I ]-,now you were probably semi- 25 HOOVER REPORTING CO, INC. 320 Massachusetts Avenu i, N.E. W.ithincrtnn DC-20002 em5l 2 79 facetious, Dr. Miller, in saying that tlle changing in the 2 computer or the electronic program direction which had 3 developed so many electronic aids to care that was turned- 4 off like a water faucet. In fact, that really wasn't so. 5 It was damn hard to turn them off. I mean it really was 6 hard. It took a great deal of effort and persuasion, and 7 determination, and repeated visits, and Bob-Toomey 8 DR. SCHERLIS: It has not been turned off, the 9 output has been changed. 10 DR. MILLER: Excuse me, I should make a comment. I have been through this with several other JU@IP's, some of 12. which I made site visits on also as a coordinator. ..13 I agree with you. The electronic fanaticism in 14 our society is extremely difficult to turn off. lqe had it 15 in T@iany others. Georgia was a good example, when I was down 16 there. 17 But it has been turned off now in almost all is PL,IP S. 19 I-IR. ClIM4BLISS: May I restate the recommended- 20 amount for Missouri as.being @2,364,333.. 21 Is there further discussion? 22 I call the question. 23 Those in favor of the motion, please indicate by 24 the usual sign of voting. 25 [Chorus of "ayes".] HOOVER REPORTING CO, INC. 320 Massachusetts Avenu i, N.E. VVashin on,D,C.20002 2 80 em5 2 MR. CIIA@IBLISS: Those opposed? 2 [No response.) 3 MR. CIIMIBLISS: The motion is carried. 4 DR. SClil@RLIS: I ask one question now that you've 5 voted on it. 6 This relates to the fact you said they had a great 7 many different types of EMS activities, and you questioned 8 coordination. Is that correct? 9 DR. MILLER: Very difficult to do' this with this 10 many separate components. DR. SCIIERLIS: You mean they are making no .12 effort to coordinate it? Is there any umbrella EMS for the 13 region? 14 DR. MILLER: No, no. They would hope to get one. 15 But in the meantime they are going to have all of these 16 various sub-components v7eldh are 'allowable. 17 MR. THO@IPSON: Mr. Chairman, would you transmit our 18 unease about the EMS situation in Missouri to the EMS people? 19 MR. CII@"4BLISS: We 4,iill, indeed. We are much 20 aware of the discussion here, and we will be.in touch with the EMS people, 21 DR. SCHERLIS: I would almost suggest that we give 22 no EIIS funds if they are to be used in disparate programs, 23 24 In the State of Maryland we have had examples of what is. now a large State support of some $2.4 million throu(rh. 25 HOOVER REPORTING CO, INC. 320 Massachusetts Avenui, N.E. Washington, D.C. 20002 (2021546@ em5 3 2 81 the Covernor. In the face of what are already small EMS 2 activities and some not so small', and you will spend endless 3 dollars trying to coordinate what are programs that begin- 4 with noncompatible equipment, noncornpatible standards, 5 noncompatible operations. 6 And I would think that if we perpetuate such 7 support, that we will be causing an excessive amount of funds 8 to have to be spent later on. 9 Some training programs will differ, criteria for 10 State certification will differ because you will be training 11 at a different level. 12, I think part of the insistence tha'L. we should have 13 would indeed be that these be coordinated,, regardless of 14 what the ground rules are. Otherwise, we should not support 15 any EMS activity whatsoever. 30 I feel very strongly about that, having spent a 17 good part of my energies in Maryland, because of the very 18 reasons that we have had different types of funding, I!) different community structures and different involvements. 20 We would be undoing a great deal of what has been done in the 21 past. MR. CIIAMBLISS: The EMS people are moving towards 22 State plans and State systems, Statewide systems, 23 DR. SCHERLIS: But if you give money to that group, 24 they will do their thing. The hist ory of our society is 25 HOOVER REPORTING CO, INC. 320 Massachusetts Avenu i, N.E. Waihington. D.C. 20002 2 82 em5 4 that everyone does his thing if he has the wherewithal to 2 do it,, and I would assume that by making separate structures 3 administratively, with our own means of support,, they will 4 do their own thing. I hope this won't be true of Missouri. 6 MR. VAN WIIIKLE: Vie did that in I-,idney, you know, 7 Len. If that did meet with within the State plan itself, 8 nothing was approved here. 9 DR. SCIIERLIS: But we have this leverage over- 10 these programs,, I gather from some of the feeling that we don't. 12 MR. THODIPSON: You see, the problem is that many 13 of the States do not have State management. 14 MR. CIIAIA-BLISS: A good amount of our previous 15 funding for El-IS has resulted in the,development of State plans. I can assure you of that.. 17 DR. IIILLER: Can I make some comments? I have 18 been connected with this at the local level. Although I 1!) don't pretend to know it all-, I know quite a bit. 20 EMS systems started out with an office of Transportation funding, which is very large and many have 21 them -- there are many of them in the United States. We 22 happen to have a very large onein Minnesota. And they're 23 24 buying ambulances. They are h6aded by ambulance drivers,, 25 by and large; they're buying ambulances and training ambulan(e. HOOVER REPORTING CO, INC. 320 Massachusetts Avenu i, N.E. Washington, D.C. 20002 i-)n,),k @Ar rcra em55 283 attendants, and setting up standards for their performance, 2 and that funding is precluded from doing anything with.the 3 patient except delivering him to the door of the nearest 4 hospital. It cannot go any further. lihen EIIS incentives started with M,!P here a couple 6 of years ago, why, the focus was to try to get comprehensive 7 planning for comprehensive care of emergency caseslland to face the issue about what happened to the patient after they 'got inside the hospital.door. And so many IVIP's un( r oo 10 to do this, And many of us supported planning for c riprehensire 11 emergency system development in the States. 12. Then E.',,IS bill came through, and it seeme.d@like la that this was going to take over, the over-all coordination; 14 but this,, as usual, has not happened. 15 And the leadership there doesn't seem to have the 16 capacity yet for attacking the whole problem. 17 So at the local level the possibilities of local 18 B agencies or regions or districts within the State of 1!) getting funding through the new EMS bill was really quite 20 remote and they came back to RMP in most of the local levels to do this. 21 22 So there are three separate fragmented kind of 23 programs for EMS in this country right now, and they're not coordinated at the national lev'el, and the attempt of RIIP's 24 is to try to get coordination at the local level, which we 25 HOOVER REPORTING CO, INC. 320 Massachusetts Avenu i, N.E. Washington, D.C. 20002 em56 284 have always been challenged to do in the IUT management 2 system. 3 MRS. I-IYCI',OFF: But if you offer them money and .4 say, If you will make a State plan and you have thi,[ money, 5 would this create a climate? 6 DR. MILLER: That's exactly what we did two years 7 ago. Many of us did it two years ago. .8 -1-le paid for the deve lopment of some kind of a State 9 plan. 10 DR. SCIIERLIS: Not necessarily. Iwas c irman 11 of the EMS Committee nationally that reviewed all e 12. pro3ects that came in, and these weren't, except in rare 13 instances, State plans. And I'd say if you look at the whole 14 United States now, there are very few States that have any 1.5 semblance of a State plan. Maybe two or three. 1(; DR. MILLER: Now, there's a good difference between 17' a good State plan and a State plan, so I'm not saying they're 18 good; I'm just saying 1!) DR. SCI-IERLIS: My only concern here is that I hope 20 in whatever letter goes out indicating funding that one 21 proviso of that letter states that each of tliese-areas have 22 set up compatible systems, that there has to be a plan utilizing all their forces. I don't think that this state 23 24 is large enough to have individual areas designated as they 25 have, unless there is some over-all State compatible plan of HOOVER REPORTING CO, INC. 320 Massachusetts Avenui, N.E. Washington, D.C. 20002 285 em5 7 communications and eve rybing else that goes into it. 2 I would think that unless we put that into whatever 3 support letter we send out, this will be something that will 4 have to be dismantled later on and will have to be 5 fragmented. That's the only point of my observation. 6 MR. CIIAIIBLISS: We do appreciate these observations 7 that the panel has made. We have at the table Mr. Mike Posta, who coordinated 9 the EMS activities for the P14.Pls, and he indicates to me that 10 of the 23 site visits that were made by staff over the last year, that the majority of them had, as an effect of the 12! 11 i support, the development of State plans. And we will keep in mind your admonitions for 14 lessening fragmentation and more coordination between the i5 three federal agencies that are supporting EMS activities. I want to assure you that P24P has already been in 17 contact with the Emergency Medi.cal Service Program here, and agreements have been reached as to what we probably might 19 0 fund and what their area of responsibility is. And I assure 20 you those discussions will continue before these funds are 21 awarded. 22 I would call to your attention 231 MRS. RESNIK: May I add one word about the Missouii 24 El@ program and the thrust in this application? 251 It was stimulated, by and large, by the passage of HOOVERREPORTINGCO,INC. 32OMassachusettsAverw@,N.E. Washington, D.C. 20C,02 2 86 em5 8 State Law 57, which set forth standards and requirements for 2 equipment on ambulances at various training levels,: to the 3 extent that these programs involve program with 1 ttle 4 training, and that is the majority of the new acti ities, 5 it is not new in the sense that they are treating new 6 as ect of EL@IS. They are training at various level to p 7 conform, or their existing training to conform to e 8 state requirements as described in the law. 9 And that is why,it looks fragmented, but it is part 10 of eventually a total training system. 11 I raised the question with them about equipment 12, a4d various items of that sort, and there was still! a 13 considerable number of dollars that has to be looked into. 14 But there was a major point in establishing these as separate 15 activities to conform to the State law. I(; MR. CYIPIIDLISS: I think we have already had a vote 17 on Missouri, and the discussions we have been having is an 18 add-on. I would simply suggest to the committee that it 20 mall wish to take a coffee break at this time; and, if so, 21 maybe we could return at 10:30, 10:33 with our -coffee and 22 resume. 23 [Short recess.] 24 MR. CliAt.4J3LISS: May I call the panel to order again please, and indicate to you'that I gather that the 25 HOOVER REPORTING CO, INC. 320 Massachusetts Avenu,, N.E@ Viashington, D.C. 20002 em59 287 other panel is moving quite well -- and so are we -- and 2 suggest that we might take a look at the application from 3 Nebraska Regional lledical Program. 4 Yes, Dr. Thompson? 5 6 7 9 10 12. 14 17 18 19 20 21, 22 23 24 25 HOOVER REPORTING CO, INC. 320 Massachusetts Avenu,, N.E. Washington, D.C. 20002 (202) 546.66&6 em6O 288 REGIOIIAL 14Er)ICAL PROGRAT4 REVIE@L 2 NEBRA SI'@A 3 MR. TIIOMPSOIT: I guess Iam the only one. 4 MR. CHAMBLISS: Yes, you are the reviewer, and 5 the staff support will be provided by Zivlavsky. 6 Will you proceed? 7 MR. THOIIPSON: I will. 8 Nebraska has not been the most flaming W4P among 9 the 53. It's relatively small in amounts of money granted. 10 It never.achieved triennial review. Its status. has always 11 been on an annual basis, although there were indications, 12, I understand from,staff, that they were going to apply for 13 triennial review one month before the famous letter zipped 14 down to tell them to phase out. 15 They have a new man there who has only been there, iti I think, a couple of months, about half time. I expected with 17 his history a far less professional job on that proposal 18 than the one, I find before me. Actually it indicates to me far more strength in 20 the region than has ever existed before.- I don't know exactly what happened to cause it. 21 22 I wish that every report we ever had did what 23 Nebraska did very early in their proposal. There is Exhibit 1, 11 24 qoals/objectives, and they are fairly well spelled out. Both the goals and objectives. 25 HOOVER REPORTING CO, INC. 320 Massachusetts Avenu i, N.E. Washington, D.C, 20002 2 39 em6 1 lihat hay.5pened was that when they got the letter, 2 the original RAG began to fall off and they then reappointed 3 a committee for the phraseout, which consisted of selected 4 people within RAG, and they began the phaseout operations, and then when the breath of life came back into the program 6 they selected from this committee, the phaseout committee, 7 thirteen people from RAG, so they only have thirteen people 8 in their RAG at the present time. 9 Ilowever, when you look at the makeup of this 10 committee it is very widely represented. They have a lot 11 of public representatives, and th ey do have one Indian 12. representative amon the twelve, so there @;zas an attempt 9 13 in this to retain at least A Statewide representative RAG 14 small group. 15 I think what we have to think, to regard this, we i(i have to remember the goals, and the goals are not all that 17 innovative, but they are good solid goals, and I think they 18 are within.their reasonable capacity of Nebraska to carry I!) Out. 20 One of them is kind of unusual, in that their 21 Goal No. 3 has the specific objective to stimulate the development of comprehensive home health care systems. 22 23 In other words, they have really gone all out for home healtlk care systems. 24 Their goals, toughly, in broad terms, there is a 25 HOOVER REPORTING CO, INC. 320 Massachusetts Avenu i, N.E. Washington, D.C. 20002 em62 290 planninc .j goal, there is manpower training goal, there is 2 this goal of home health care systems.- There's the data 3 reporting analyzie kind of goal. And then the last goal is .4 the facilitator, coordinator, gathering people together kind 5 of goals. 6 But in each one of these broad goals there are 7 specific program type objectives. 8 And one must say that there is a very close 9 relationship between these goals and the kinds of programs 10 that we see coming up in the proposal. 11 Now, at the present time, they have been operating 12. at a level of 502,000. I said they are one of the smaller 13 programs, I think they are one of the four smallest programs,. 14 as far as money is concerned. 15 Their target would be some 868,1000. This package l(i here is 962,000 with an indication that they will be coming request 17 in with an additional/of $150,000. 18 So we then have a program that is kind of climbina 19 up beyond their original base level support. The program 20 that probably would have gotten triennial approval, if the 21 funding thing hadn't changed. 22 Now, in general, they -- the most recent change in 23 this program, as it has been with most of the other programs 24 weave seen today, was their relationship with CIIP. They 25 decided to start working with the various CIIP agencies within HOOVER REPORTING CO, INC. 320 Massachusetts Avenu @, N.E. Washington, D.C. 20002 em6 3 29 1 the State, and they have more or less redefined their 2 mission within -- still retain their goals. 3 Therefore, on Nebraska Regional Medical Program, its .4 mission is toward cooperative work with A and B agencies in 5 14ol.)raska State Department of Ilealth, in an attempt to match 6 those health care providers who have a need for service 7 with those resources capable.of responding with services 8 with the ultimate purpose of improving the health care, for 9 all Nebraska citizens. 10 So that this is kind of a redefinition of its own 11 mission, vis-a-vis the CHP agencies. It is not all too 12. clear from the proposal how well this is progressing. 13 Several other projects that we will be talking 14 about actually came from B agencies, and in one B agency 15 right off they said it @,iould be unfair for us to write off ].(i on this, because actually we were involved in gathering the 17 proposal and designing the proposal. 18 There are other sections where there is an absence 19 of a writeoff or a signoff by B agencies or A agencies, and 20 others where the A agencies and B agencies in particular indicate a very positive vievi toward the projects'. 21. So it's kind of spotty. I will try to have the 22 23 staff elaborate on this, because, although it's evident they e are trying to cooperate, how successful they are is a whole 24 nother question. 25 HOOVER REPORTING CO, INC. 320 Massachusetts Avenu i, N.E. Washington, D.C. 20002 em64 292 I Now, when you look at the proposal, and it's orobably 2 the thickest one in this go-around, it seems rather awesome 3 until you realize that it is a fairly simple proposal. 4 They put their money on two things, an A hex kind o a usine s 5 which they believe should be, like Memphis, to cove afairly 6 smallregion, and if you were concerned over tlae fact that 7 some of these area community healtl-l-education consortia, 8 as they call them here, or hospitals in Memphis, yo will 9 kind some of them are nursing homes in Nebraska, be--ause 10 their primary concern is with that level of traininj. 11 So, of All the projects we're talking about, there's 12, these two main thrusts, the A hex type thrust, @-zith@,a 13 nationalized learning -- I mean.a Statewide learning 14 resource center, and then some one, two, three, four, five, six specific regional agent type outfits. Surprisingly in this proposal, there are eleven 17 different home health proposals, hone care proposals, some of them defined in one way, home health satellite or the 18 111) day-care service for elderly and disabled; and they have 20 these scattered throughout the State, mostly based in nursing home type places. They are trying@to get- nursing 21 homes for whatever few little bits and pieces of visiting 22 nursest associations they can find, and beginning to design 23 24 a global hone health backup pro4ram, for the elderly in 25 various parts of the community. 40OVER REPORTING CO, INC. 320 Massachusetts Avenu i, N.E. Nashington, D.C. 20002 em65 293 And of course this is, as I said, these two tjirusts 2 are in line with their Goals No.'2 and No. 3; and the rest 3 of this rather large list of variety of programs, nurse- 4 physician programs in the cities, shared hospital resources, which are not unusual, they are all small. They run from 6 12 to 33 thousand dollars. It's obvious they're shoving this 7 money into programs that are in existing institutions. 8 There is this problem of their renal program, 9 which is the largest of all these non ---A hex non-home health 10 i related outfits. lqhich I will allow Staff to respond to, because it looks like afairly shaky business, all in all. 12. I'd like to hear from staff. I'm going to use .13 him, if you don't mind, as kind of a secondary reviewer, 14 because my secondary reviewer isn't here, And let him 15 particularly elaborate on the problems of the interface with 16 CIIP's and with the kidney problems, and any other comments 17 he may have on Nebraska. 18 MR. CHAIIBLISS: Mr. Zivlavsky, will you comment, 19 please? 20 MR. ZIVLAVSKY: The Nebraska.application is 21 576 pages. Dr. Iless, three years ago, made a site visit '-)2 out there, followed up ]3y a site visit approximately a year 23 and a half ago. 24 There was a major shakeup out there. They follu,-;ed 25 up on many of the concerns from the first site visit. They HOOVER REPORTING CO, INC. 320 P,!assachusetts AvenL, i, N.E. Wa@h@Ington, D.C. 20002 .29 4 em6 6 increased their program viability and they were just as any 2 upsweep to come in for a triennial anniversary application 3 when our phaseout letter hit them right between the eyes.. 4 Some of the good things that they have been able to 5 do have been their efforts in indirect costs, for example, have been less than five percent of their total costs. 7 Over the past two years they have really been able to do a 8 good job in this relationship. They receive a few stars for 9 that, at least. 10 In the area of minorities, the State has approxi- 11 mately 2.7 percent. They have worked in'the area of sickle 12. cell screening for the entire black community of Lancaster .13 County, which is in the Lincoln area. They have worl,,ed 14 with a mobile cancer bus in terms of screening the Indian 15 population. The program staff has provided assistance to the 17 Panhandle community.action, which involves the migrants and 18 Indians but in western Nebraska. In their phasein they 1.1) have hired an additional min@rity -- I should say they lost 20 one minority person in their program staff. They were able 21 to hire another minority person on their program .staff. 22 I am not sure -- they come in with an application 23 requesting no people. Pres@ly they have 11.5 full-time 24 equivalence. I think they can use a couple of people to help them in the monitoring area. 25 HOOVER REPORTING CO, INC. 320 Massachusetts Avenui, N.E. Wa-hino,tnn. D.C. 20002 em67 295 I don't know. That's up for discussion or grabs, 2 I guess. 3 I like the comment on the negative CIIP comments, 4 - and on page 345 of the application, specifically commenting on Mr. Thompson's CIIPA comment, the reason the CI-IPA agency 6 withheld comment was because they developed the proposal 7 and they were actively involved, and I believe they felt it 8 was a conflict of interest. So they backed off, and this .9 was one-of the reasons that they did not comment. 10 The second negative comment is on project No. 47, 11 and again the CHP agency has commented that this project 12. lacks specificity. 13 The program staff is following up on this particular 14 project, and it involves the Omaha and Winnebago tribes, 15 and basically there's a,rnisunderstanding that the outreach l(i from the community health representative in the community 17 population, the CHR'S. they assume that you have much more 18 time than really is available,- she has a half a day a week l@) for outreach activities, and they didn't really get this 20 clarified before they submitted the proposal to the RAG. 21 The RAG again is following this up with' program 22 staff and I think they can negotiate this difference. 23 The renal project, DPJIPS,.Dr. Mathis, the present 24 coordinator, if he would not seek out-of-State technical 25 consultants,, and he agreed to do this because all the people HOOVER REPORTING CO, INC. 320 Massachusetts Avenu @, N.E. Washington, D.C. 20002 29 6 em6 8 within the State of Nebraska have been involved in their 2 project. 3 Yesterday we received a letter from the associate .4 coordinator for program services, attached to three@comments 5 basically from the technical reviewers. All three ad, negative technical comments,.reducing the budget from 7 approximately $51,920 down to 15 or 20 thousand do.Llars. 8 These comments have not been submitted to@their 9 -regional advisory group, however. The Regional Advisory 10 Group will be meeting this following Friday', reacting to 11 these negative comments. 12, Basically what you have is a questionabl e@ ,stance. .13 We are trying to ask the community for some suggestions 14 or recommendations on what to do with this particular project, 15 I think I have answered, My f MR. TIIOMPSOII: unding recommendation, they ar@ 17 now 502, the target is 868. This comes in at 962. There's 18 a possibility of another 150,000, because there is really no 1!) slush fund or escrow, however, designed in this program. 20 All the money is carefully identified in this, these little 21 small programs. 22 It is Very difficult to cut much of this, but I would make the recommendation they be funded at 9 O 23 which is $50,000 less than the" now have, which reflects thei@ 24 y cost of that kidney program, wliicl-i'I have some doubts about. 25 HOOVER REPORTING CO, INC. 320 Massachusetts Avenui, N.E. Washington, D.C. 20002 em69 297 1 I am not going to tell them that this is against the kidney 2 program,, but they've got to read-. The kidney program has 31 cost 50,000, we're cut 50,000. And they still will be the 4 third smallest program in the country if they get all this. 5 DR. WHITE: 17ell,, in the past @,7c could say thes.e 6 technical experts came out. If you go ahead and insist on each of these, inspite of our advice and their advice, 8 next time around;they can thumb their nose at us this time, 9 because 10 MR. CHAI@IBLISS: Would you speak just alittle 11 louder, please? 12. MR. TIIOPIPSON: I think the technical comments on .13 this I can't see how the RAC:,'can step around them. It was 14 unanimous, and I tliink the RAG will just drop that. 15 So I think we,can put a little hint in the advice 16 letter. 17 I move, then, $912,000 for the Nebraska proposal. 18 MR. TOOIEY: Second 3t. 19 MR. Clik7-IBLISS: The motion has been properly 20 moved and seconded. Is there discussion, please? 21 Question. 22 23 Those in favor? (Chorus of."ayes".] 24 25 MR. CIIAIIBLISS: Those opposed? HOOVER REPORTING CO, INC. -achusetts Avent, @. N.E 320 Mass Wasttinkton, D.C. 20002 em7O 298 [No response.] 2 MR. CII@IBLISS: r.nhe filayesif have it, and the motion 3 carries, at a recoruyiended level for Nebrasl@a of $912,000.. @4 5 6 7 8 9 10 12 14 15 17 18 19 20 21 22 23 24 25 HOOVER REPORTING CO, INC. 320 Massachusetts Avenu i, N.E. Washington, D.C. 20002 29 9 em7l REGIOIIAL IIEDICAL PROCR7UI @VII',@l 2 NEW MEXICO 3 MR. CliAlIBLISS: Shall we then move to New Mexico? 4 The reviewers here are Dr. Miller, and Dr. White, with Mr. Zivlavski as staff support. 6 Will the record so indicate that IIrs. Jesse 7 Salazar is not a part of these proceedings, and has absented 8 herself from the room. 9 'DR. MILLER: The New Mexico application is another 10 of the umbrella type PIIP applications. 11 It is an extremely ambitious one, and has an 12, application for $2.77 million, when the current level of 13 funding is $1,.2. 14 forever it does not plan to come in with another application in July,, so,,this is its total application for the next year. 17 The New Mexico PIIP had has a new coordinator, and who starts, let's see, May lst. Dr. Gaye, who has been, in my opinion, an able coordinator in the past, is resigning 20 as of the 30th of June, but will remain-as a consultant to 21 Dr. Walsh, the new coordinator. 22 Otherwise, the program leadership seems to be good, 2tl and I presume that this arrangement looks like it will still 24 provide a continuity and a fairly stable-program leadership. 25 The program staff seems.to be adequate, and capable HOOVER REPORTING CO, INC. 320 Massachusetts Avenu @, N.E. Withinoinn f) r. 2nnn7 300 em7 2 in general. 2 The original Advisory-Group, I don't quite know 3 what they did -- why they did what it did. I couldn't find .4 it in there, but they recently padded the Regional 1,Advisory 51 Group, increasing its membership to 120 people. 6 And we've seen that in reverse a number of times in the last few years. I don't know what will motivate it doing this. .9 But, of course, it forced the developmen of sub- 10 committees to then run the program, and at least i seems to 11 be reasonably satisfactory. 12. The past performance and accomplishmentsihave some .13 bright spots, and some that maybe aren't quite so bright. 14 But in general they seemto be satisfactory. As I felt 15 their objectives and p@@orities were, also. And the proposal is congruent with the explicit 17 objectives and priorities as given. 18 The feasbility is another one of these where, I!) with the tremendous proposal for a year, it doesn't seem ve@ 20 likely that it can carry out well the projects that it proposes. 21 22 CIIP relationships apparently are quite good. 23 So,, over-all, I felt the program is above average. 24 And I felt that the -- that if P14P was' going to be continued for another three years this re 25 gion, like two or three HOOVER REPORTING CO, INC.I 320 Massachusetts Avenui, N.[. Washington. D.C. 20002 em7 3 30 1 others we'vb had yesterday and today, would be really well- 2 established for going gung 1-io ahead on a three-year program. 3 Most of the projects in this application are really A pro3ects for the staff. There's some confusion in my mind 5 as to what constitutes a staff program in New Mexico and what 6 constitutes an extramural project, since, in most of the 7 projects, why, the WIP is th e, apparently the sponsoring 8 organization, and many of the staff that are going to be 9 working on the project are staff people of the Regional 10 Medical Program. 11 So I interpreted all except two of these projects to actually be essentially staff activities. Which, in this 12. 13 case, would mean,, then,, that almost the whole program in 14 New Mexico is a program, staff management system of staff and 15 projects run by the same people. There are two projects that are extramural, which 17 they list as the lowest priority, in which it received some 18 unfavorable comments. So that which are for a neonatal regional program and -- I for'oget what the other one was'. Genetics. Oh, yes, genetics regional program. 20 21 There's one huge emergency medical service that is 22 an expansion staff project, continuing -.r it's a continuation 23 project, but it's a huge expansion, with a budget of $911,000 Same kind of problem we had before. 24 I don't knoi,,, @@7hat it waq last year. Does the staff 25 HOOVER REPORTING CO, INC. 320 Massachusetts Avenu,, N.E. Washington, D.C. 20002 em74 302 1 knovi? 2 DR. WHITE-. ilelte trying to determine that 3 right now. That kind of information is not in any of our 4 research. 5 I think since the program'is funded to July 172 for 6 $52OfOOO. 7 DR. MILLER: $528,000? Well, it isn't such a huge 8 expansion. 9 DR. WHITE: Well, that was for two years. .10 DR. MILLER: That was a t-vio-year program. 11 DR. WHITE: That was two years? 12. DR. MILLER: That was to7o years of funding? 13 DR. WHITE: Yes. oh. this is one year $911,000- and another one of 14 15 their projects, health education for the public, was expanded to $303,000, and I don't know what the previous level of 17 that was. is MR. VAN WI@ITKLE: Project 25. DR. MILLER: No. 25, health education for tl-ie public. 20 21 MR. ZIVLAVSKI: There is another substantial increase. They had $175,000 in there, and then about 70,000 22 23 for the past six months. And they.put approximately 225,000 in there. e 24 25 DR. MILLER: I have sone'philosophical feelings HOOVER REPORTING CO, INC. 320 Massachusetts Avenu i, N.E. Washinaton, D.C. 20002 em75 303 about health education for the public beamed through every 2 possible communication mechanism for one year for $300,000, 3 as to what are the cost-benefits, and how would you ever 4 know? And if you can't know, what the devil do youldo it for? MR. OIAMBLISS: Dr. TIiller,, I think in ail candor, 7 with the reviewers, it should be noted that we had A staff @8 presentation of that project, health education to -E-ie publi 9 during the last year. We were not overly impressed with 10 what came out of it. 11 I say tl,.at just so the committee may know that that 12. presentation had been made to the staff. .13 DR. MILLER: I think I can complete my statements 14 now with the feeling that this is an over-a@itious largely 15 staff programs in an @IP that is fairly good, and therefore my feeling is that vie ought to hold our funding to the 17 targeted level. 18 MR. CHA14LISS: Dr. White. DR. WIIITE: Well, I noted that Dr. Gaye was 20 retiring. I don't know Dr. Walsh.- I knoyi nothing about New 21 Mexico. This is the first time I've had anything to do with New llexico, other than the site visits as a reviewer. 22 23 Dr. Ilalsh is an unknown quantity, to me at least. 24 The staff seen to have the credentials. 25 My interpretation of the Regional Advisory Group is HOOVER REPORTING CO, INC. 320 Massachusetts Avenu i, N.E. Washington, D.C. 20002 em76 304 that it was ex panded to 120 people in.1971, at whose behest 2 I don't know, but possibly to get the minority group in, 3 or one thing or another. 4 But, in any event, when the phaseout came out, they 5 then began reducing by'- attrition, and beyond that they 6 also began not meeting, to my interpretation, in delegating 7 their authority to an executive committee and I think this 8 is reflected in the fact that the proposals, as I read them, 9 are enormously impossible. 10 If they had trouble spending I think it says 11 in here the number of people they trained in two years in 12. the EL,,IS program for approximately $250,000 a year, they have ..13 no earthly hope of spending 900-some thousand in a year's 14 time and getting their money's worth out of it. 15 I think also that health education to the public Al . is a hopeless proposition by the avenues that they propose. 17 I don't why we can convince people to take aspirin by using 18 mass media, but we can't convince them not to take it. 19 I-IR. TIIOIIPSOII: Viell, you know, Bayer's advertising 20 budget is far beyond anything we put out. 21 DR. WliITE: In any event, beyond that, I would 22 agree with Dr. Ililler. I would consider,this an average, 23 neither bad nor good; and I think it's entitled to its fair 24 share of whatever money is portioned out, and I would agree to the targeted fund minus whatever is reserved for July, 25 HOOVER REFDRTING CO, INC. 320 Mmc@.usetts Avenu @, N.E. n/, qnn^q 30 5 iHD46 1 and let it go at that. 2 MR. C117UIBLISS: Dr. Scherlis. WD fls 3 DR. SCIIERLIS: I looked at the Emergency medical 4 Services, which constitute a great part of their budget, and in reviewing it, I asked some serious questions a'"-out it. It 6 looks at what is the easy side of the Emergency Medical 7 Service, the trainee and the 'Vehicle end of it, but in terms 8 of looking at a system of care, there are some serious 9 questions. 10 Maybe I could just spend a minute or two on this. 11 's Under objectives, it look at training and coinmuni- cations, which really consisted of developing a st atewid-- 13 emergency communications system linking all hospitals and 14 ambulances together, then@-to create a crisis center to inte- 15 grate all communication links. 16 I guess the question I-have is something that maybe 17 they.have not included in this, although they have about 40 18 or 50 pages devoted to it, and I would rather see that than 19 all the individual sources, and that is, are they are talking 20 about characterization of care? 21 I see the reference that this is an important aspect, --)2 but if you are going to have people talking to people, they 23 should talk to them about somethbg aside from the fact: 24 "We're coming in in a hurry; weave got some 25 sick people aboard. HOOVElt REPORTING CO, INC. 320 Masgchusetts AvenL, @, N,E. @liashirigton, D.C.2OW2 3 0 6 WlID47 1 I don't know if they provide in there, and perhaps 2 Staff can comment, whether they have provided medical communi- 3i' cation at one end or whether this is administrative communi- 4 cation. 5 Also, if they are under all of these funds proposed 6 for centers in the state for treating more.specificall'y cer- 7 tain types of catastrophic events, if they are talking about one or twenty burn centers, one or twenty trauma centers, 8 one or twenty cardiovascular centers -- so what is "Training, 9 10 and Communication Evaluation," and I would have to review tnis carefully, but I would think one would like a great 12 deal more in the way of evaluation than what they have included, if they are going to get some answers in terms of 13 what they want to do. 14 15 Continuity -- they are going to ask the Governor 1. for money, which seems to"me the.b'est way to continue all 16 forms of care, at least by going through the appropriate 17 18 motions. But I don't see adequate emphasis in here on what I would think seem to be the real problems despite the fact 19 they are putting in an awful lot of money. 20 They are talking about basically new and. better 21. ambulances, about communications, about training, and I think 22 the other end of-it, in terms of what happens when these 23 people get to a center? I don't/ know if they are talking 24 about bypassing certain areas, or if they are talking about 25 HOOVER REPORTING CO, INC. 320 Massachusetts Avenue, N.[. Washington, D.C. 20002 3 07 WliD48 1 really having hierarchy type of care and really a regional 2 type of emergency system. It does not seem to come out of, 3 at least, the document that we have, and I question whether 4 or not this is really an adequate presentation-or whether 5 you know more about their plans. 6 Maybe this does not.do justice to the plan they 7 have. I don't think that this warrants the price-tag placed 8 on it, at least from the minimal review I have giver it. 9 Perhaps you can comment? 10 MR.-CHAMBLISS: Are there Staff comments i response 11 to Doctor Scherlis's query about New Mexico? 12. MR. ZIVLAVSKI: Why don't I just start from the -13 top and make a few comments? In terms of the RAG and the number of the RAG, when 14 15 Doctor Gaye became Coordi nator, it was his decision to involve more people in the decision-makin'g process. He increased the 16 RAG 220 members, broadly representative and including minori- ties and parts of the state, and the whole thing. 18 19 In this application it seems like a conflict of information, but in the RAG report it-mentions 120 still being 20 there, but actually they have decreased it to 73 members. 21. There is a litUe confusion in interpretation; it 22 depends on which page you look at. The in terms of the 23 of Doctor Miller's comments on whether there is confusion over 24 staff projects, and are they essentially control projects, 25 HOOVER REPORTING CO, INC. 320 Massachusetts Avenue, N.C. n I, )nOn?i 3 0 8 WHD49 1 four or five of these activities were out originally with 2 CO numbers. The last review we had, in a site visit we had 3 down there, we indicated to them that what they needed to do was to place these projects in independent status, provide 4 5 them with a project number and make sure..you give them the 6 -- the information to the Project Directors that these are unlimited activities and they can't crawl back into the wings 7 of the university once the project phases out. 8 Just in the last six months, they have typed these 9 CO type numbers and have been,@able to communicate these to 10 the people. 12 These are free-standing, they are centrally located in the headquarters of the lu4P, physically right in the same 13 14 area. However, they are operating as project directors, 100- percent type of activities; when the project ceases, they 15 are going to have to find new employment, whenever that' 1(; happens. 17 DOCTOR MILLER: But th ey are staff of the RMP; 18 they are listed under the personnel lists for each one of 19 those things as the New Mexico RMP staff. 20 MR. ZIVLAVSKI: There is no duplication.in terms 21 of salaries on the Form 6, which is the core staff salary 9-2 budget, as well as the Project Directors' salaries. There 23 is no duplication of funding; each of the moneys are coming 24 out of different types of activities. 25 HOOVER REPORTING CO, INC. 320 Massachusetts Avenue, N.[. n i, )nnn,) 3 0 9 WHD50 1 You' can look at Project 32, the community health 2 resource development, Project 33,.the health resources 3 registry, and Project 34, regional health resource plan and, 4 development; each of these three projects are leaning toward 5 the future of health resource planning. These are not in escrow, there is not these are 6 7 defined moneys and they tell you exactly what.they hope to do in these areas. 8 Staff did there was a presentation by Project 9 10 No. 25, which is the health education for the public; .'it has substantially increased their re quests. This is a statewide 11 project; the former project director of this is now a Deputy 12 Director of the RMP. 13 14 It presents a problem; maybe the alternate sugges- tion is to have a technical review committee, site visit from out of state consultants to come .in, people that don't have a bias, and maybe we could send this message back and then write an advice letter to the program to have somebody from 18 out of state come in, let theoRMP pay for it with their own 19 funds, then give the report to the Director of the program 20 not to Walsh, not the Deputy Director, who is th6-previous 21- Project Director. 22 Project Number 18, EMS, there is a heavy emphasis they have done a lot of things in here; I don't know how to 24 tackle some of your questions, but you mentioned the fact of 25 HOOVER REPORTING CO, INC. 320 Massachusetts Avenue, N.[. 3lu WlID51 1 categorization; the Deputy Director, Doctor Ilanratty, has 2 been working on a computerized system for it. 31 Their position is that they are not happy with any 4 of the national plans for categorization, AIIA or any-,of these. 5 They would like a modification of each of these plans, and 6 they would like to have a computerized categorization of 7 the hospitals. And they are working on that right now; they 8 started out slightly on their surveys, the form has been pre- 9 pared. I can't tell you what modifications have been made 10 in the categorizations of all the hospitals, but there is an 11 obvious gap, because one or two hospitals in Albuquerque, one 12. in Santa Fe, and then you have the rest of the state, and they haven't completed this. They have the survey form .13 developed. 14 It is a modified form, and what the results will 15 be have not appeared yet. In area medical communications they work closely 18 with the State Department of Communications. Everything they 19 do there is pretty well basedoon a total effort, because there are a lot of scant resources. 20 21 They have done quite a job in terms of-training. No P14P funds have gone into the purchase of vehicles; the @IP 22 Doctor Walsh, by the way, the Present Director of this 23 Program, is also the Director of the EMS project. If he is 24 finally selected as the final Coordinator on July lst, his 25 HOOVER REPORTING CO, INC. 32-OMassachusettsAvenue,N,I. Wnthinainn 1) C. 2nnn2 31.1 WlID52 I Deputy Director, Doctor Hanratty, will -- it looks likely 2 that he will take over as Project'Director. He has been 3 Deputy Director on the project for one year. MR. CHP14BLISS: I wonder if that sufficiently covers 5 the query about the categorization and so on? 6 DOCTOR WHITE: I migh t point out that if you take 7 the targeted fund -- I was a little more charitable in 8 approaching their EMS; I think they do have some compatibility 9 in terms of their training programs, and by'.legislation th6y are oing to be uniform. 10 g Communication as I read it was between am bulances and hospitals, where there are enormous distances to get 12, to. 13 14 DOCTOR SCHERLIS: The average run can be 50 to 100 miles. 15 DOCTOR WHITE,: They need to communicate with the interim stations along the way just in case something happens. 18 DOCTOR SCHERLIS: This is why I asked about-the 1!) categorizations, because I don't know how they are going to 20 react to passing certain ones if they have to, and this.is a key feature to astate that large, with a long hafal-. 21 DOCTOR WHITE: But regardless of the quality --)2 MR. THOMPSON: This is rather ironic. Unless I am 23 mistaken, the first proposal that-ever came in from New 24 Mexico, altogether in the old, old, old, days was on .emergency 25 HOOVER REPORTING CO, INC. ')')n N r 312 WlID53 I medical services. They did a rather large study and they 2 found out that the primary cause of death downthere was not 3 heart, stroke and cancer; it was Indians spread out over the 4 highway in these old cars. 5 We did not give them any money because they did not 6 fit into the categories of heart, stroke and cancer. 7 DOCTOR WHITE: It still do6sfilt solve the problem 8 of the Indians, because they point out in here, there are no 9 areas in which the Indians are terribly keen about participate' 10 ing in. 11 MR. CHAMBLISS: Is there a motion and a recommended 12. level of funding here? DOCTOR MILLER: I move that they be funded at the 13 target level: $1.64 million. 14 15 DOCTOR WHITE: 11 Second. MR. CUMBLISS: It has-been moved and seconded that New Mexico be recommended for funding at a level of $1,644,000. Is there discussion on the motion? 18 All in favor? 19 20 .(Chorus of "Aye") Opposed? The level is recommended at $1,644,754. 21. 22 DOCTOR WHITE: They will get thIe message @out staff ,appraisal of educational efforts-,, won't they? 23 MR. CHAMBLISS: Your Concerns will be passed along, 24 indeed, regarding EMS and,@education-for the public. 25 HOOVER REPORTING CO, INC. 320 Massachusetts Avenue, N.[. REGIONAL ME ,ID-1 DICAL PROGRAM REVIEW 2 NORTII CAROLINA.REGION we go on then to N rth 31 MR. C@IBLISS: Shal 0 4 Carolina? 5 Doctor Miller, Doctor McPhedran, and Staff will be 6 represented by Mrs. Parks. 7 DR. SCHERLIS: We should have Mrs. Salazai-i. come .8 back, shouldnit we? 9 DOCTOR MILLER: This is another large application. 10 North Carolina has a current funding level of $1.67 illion, it puts 11 in an application for $3.26 million, and pl s to sub- mit another application in July for $400,000. 12, 13 Targeted level is $2.78 million, and the composite of the present application with the proposed a.dditions in 14 July-will be 132 percent of the target, or $880,000 over the 15 target amount. The Region is a good Region, in general, has done 18 a lot of things in the past that are quite outstanding. They 19 have a change in the Project Director and Coordinator, which 20 I can not assess. Perhaps the Staff can help us with that. The new Executive Dire ctor, Ben Weaver.,.was Deputy 21 Director for five years, so it is presumed thatlis leadership 92 should probably be adequate. The program staff approach looks all right; the' 24 y plan to increase it quite a lot during this next year, but 25 HOOVER REPORTIN CO, INC. 320 Massachusetts Avenue, N.[. Washinzton, D.C. 20002 31 4 WHD-2 1 they have- a fairlygood nucleus anyway. 2 The Regional Advisory group assessment is all right.1 The past performance, as I mentioned, is go!od; their objectives and priorities are good, and the proposal 4 5 fits in with their objectives and priorities. 6 Their CHP relationships are good. 7 This, in my opinion,'is one of the extremely needy 8 areas in this country, where you can hardly design anything 9 -that would not help, because their needs are so great, and 10 they are really deprived of health care. There are any f health care deprivation in s and ey have 11 areas o ervices, h been working toward these and have made some outstanding 12, achievements, I think, in this area. .13 14 So I think they deserve a recognition of those things. 15 They have, in tgi's application, 45 projects. A lot of them are not very good in principles of feasibility or per- 17 formance, and are not in my opinion justification for the 18 costs. 1!) 20 One continuation, one which bothers me terribly, 21 but I guess it's just one of those things, is a medical. air- operations, which is $50,000, which is a continuation, so I 9-2 suppose they have been doing it, which is solely for the 23 the money is spent solely for the purpose of flying faculty, 24 students and staff around the state in private planes in 25 HOOVER REPORTING CO, INC. 320 Massachusetts Avenue, N.[. Wastlineton. D.C. 20002 3 15 IHD-3 1 support of the area health education center project. 2 Of course, all kinds of.faculty -- as .. well as 3 students and staff -- would like to fly in private airplanes 4 almost anywhere if you give them that luxury. 5 Another one, they have a project in here for the 6 medical foundation they have in the state for a PSRO develop-, 7 ment for $125,000. I think this is inappropriate; PSRO's 8 are going to be funded, and as near as I can tell from that 9 application, it is a pure PSRO project development. 10 Then there.are multiple rural health clinic supports. There are supplementary support to state clinics or state 11 12 rural health clinics, which undoubtedly are.needed, and are supported by the state. But the-amount of this support amounts 13 to $243,000 altogether. 14 And then another.supportive project for supporting 15 the area health education center activities in the state, which is funded outside o@ RMP, to develop a library network for $363,000 in community hospit als throughout the state. 18 19 Although I don't question their statement that community hospitals have no library facilities that amount to anything, 20 and when you want to educate health-care professionals in 21 rural communities, why, one of the things you need is a 22 library, but it seems like an overly ambitious approach with- 23 out any guarantee that it will be-continued. 24 Another of the fundamental things, of course, in a 25 HOOVER REPORTING CO, INC. 320 Massachusetts Avenue, N.E. WHD-4 1 place like North Carolina, which I think is probably true 2 in some of the other similar types of states, there is very 3. little guarantee that these -- any of these activities will 4 be-continued after RMP funding, probably because, ho-,7everf, 5 that their potential for funding things is so poor that tey 6 are quite dependent upon Federal funding programs. 7 In general, I regard this as a superior program, 8 and it is a terrifically needy area, where they -- a composite application which is over-ambitious, and some of it s 9 10 inappropriate, and my recommendation would, again, be a fund- ing at the target level. MR. CHAMBLISS: Doctor McPhedran? 12. DOCTOR MC PHEDRAN: I agree. I really have nothing -13 to add. 14 DOCTOR MILLER: I'll make the motion, then. 15 DOCTOR MC PHED@N: I'll second that. 16 MR. CM-IBLISS: It has been moved and seconded that 18 North Carolina be recommended for funding at the targeted level of $2,775,522. 19 Is there discussion on the motion? 20 DOCTOR MILLER: Their present funding for the. 21 current year is $1,175,000, so they will-get 22 MR-. VAN WINKLE: About $1.1. 23 DOCTOR MILLER: They Vill get $1,100, 000 more 24 money; they probably can't spend that either. 25 HOOVER REPORTING CO, INC. 32OMassachusettsAvenue,N.E. Washinaton, D.C. 20002 IHD-5 1 DOCTOR WHITE: Well, I guess that is what bothers 2 me, in terms of losing out on a million dollars. Even though you said it was a superior Region, yet 4 I look at -- what? 45 new projects, which 5 DOCTOR MILLER: Very needy. How do you really 6 decide on deprived areas? There is no way to solve those 7 problems without pouring money into them. 8 MR. THOMPSON: They are going to come in with another $400,000. 9 10 DOCTOR WHITE: Let's not get people used to some- thing why get the poor people out in the hills used to 12. something they are going to lose next year? ,13 DOCTOR MILLER-.. Reminds me of a site-visit I went 14 on a couple of years ago to West Virginia. Have any of you 15 been to West Virginia? We were questioning d lot of these things, and one of the physicians said: 17 18 "We depend on Federal money for a living; we 19 will do anything -- whatever the Federal money resource requires, because we are totally dependent upon Federal 20 money." 21 DOCTOR SLATER: They are not the only group that 22 says that. MR. CHAMBLISS: Doctor Miller, may I just ask a 2,4 point here, about the PSRO? Did you say that was out and out 25 HOOVER REPORTING CO INC 320 Masuchusetts Avenue, N.[. 'W,s,@hingl,on, D.C. 20002 WHD-6 I PSRO? 2 DOCTOR MILLER: Nearly as I can tell. Does the 3'; Staff have any other interpretation? 4 MRS. PARKS: We thought the.same way. 5 DOCTOR MC PHEDRAN: I agree. 6 DOCTOR MILLER: I think it is totally inappropriate 7 at this time. 8 DOCTOR SCHERLIS: I have some concern, because I 9 think in your description of the various projects, programs anl 10 so on, I was detecting a certain note of lack of enthusiasm, 11 and then I had your conclusions, which reflec ted, in a way., .12 a disparate approach. You know, the need is there, I think we would agree; 13 14 the R@IP has a pretty good track record, and again I would 15 assume that, given an area that is impoverished in many ways, 1. 16 these funds might eventual@y-do some good. I do have a significant concern, though, in terms 17 18 of all that money, in view of what I think were very apt cri:- ticisms of the ability to realty spend this wise,ly, and I 19 would think, particularly in view of the fact that they are 20 21 coming back for at least additional funds at $4OOtOOO, and in view of the fact that we doubt very much that all of this can 22 be -- not just efficiently spent, but let's say inadequately 231 spent, that you might then entertain some reduction from the 24 target figure, understanding that they are going to come back 25 III DOVER REPORTING CO, INC. ?O Massachusetts Avenue, N.C. I'! ask, D.C. 20002 546-6666 .12 WHD7 1 for more, although I know that is not a constraint, but I 2 just have some difficulty, as I view the large array of pro- 3 jects, particularly the one for, say -- well, I guess it 4 would be $362,000 for a statewide network of hospital librar- 5 ies. 6 I wonder if you might not entertain.the possibility 7 of reducing that some, because I don't think they could really effectively utilize this support level. 8 9 DOCTOR MILLER: I judge on that library business they are going to staff those libraries? I could no tell 10 in the application, but they are probably going to set up 11 S! 12, libraries in every one of these hospitals, which ha nothing 13 now. Is that true? 14 15 MRS. PARKS:. Right. They will be tied into the nine area health-education cent,6rs, but I don't think that the 16 17 supportive personnel will solely be funded through the North Carolina RMP. 18 DOCTOR MILLER: Well, it costs a lot of money to 19 set up nine libraries. 20 DOCTOR.IIHITE:- Doesn't it cost a fair amount to 21, keep them going, in termsce personnel? 22 DOCTOR MILLER: It is a terrible problem4 She says 23 they are going to keep them going; will the hospital undertake 24 the responsibility, or the AHEC, or solely someb ody else, for 25 HOOVER REPORTING CO, INC. 320 MassachosettsAvenue, N.C. Wasiiip.gton., D.C. 20002 Mr HD-8 1 the operation.of these libraries after one year, after the 2 RIAP is gone? 3;i DOCTOR WHITE: If nothing else, somebody has to dust 4 the books. 5 MRS. PARKS: I am not really sure. The only infor- 6 mation I have is what is in the Form 15, and it was not clear 7 as to how many would. 8 DOCTOR MILLER: It does not say; there are a lot of unanswered things as you read these. 9 10 DOCTOR WHITE: Did you find contributions from the Appalachian Regional Commission? Matching funds and things 11 12@ of that sort that look as though they might be substantial? DOCTOR MILLER: I don't think they have that in 13 here,d'o.they? 14 MRS. PARKS: No. 15 @IR. THOMPSON: @at I can"t understand; they have 17 been.working specifically with hospital libraries, hospitals 18 and quality control for all these- years. What the hell have.. 19 they been doing? All those snoll hospitals; that was the main thrust of the project -- quality control and libraries. 20 21 DOCTOR VAUN: The objectives of the National Library c' of Medi ine is not to perpetuate the old concept of libraries. 22 It does not cost a lot to build a library that can function 23 through the National Library of Medicine network, and if we 24 ii pour this amount of money into creating a lot of old-fashione 25 HOOVER REPORTING CO, INC. 320 M@chusetts Avenue, N.[. D@C@ 20C,02 321 :@ IliD-9 1 libraries, You might just as well flush it.down thedrain. 2 MR. VAN WINKLE: Staff.had flagged that for that .31 consideration. 4 DOCTOR MILLER: Well, I think cutting the budget, 5 even to the target level, will put the pressure on them for 6 some of this kind of stuff. 7 MR. CHAMBLISS: That is the motion,, to recommend 8 funding at the target level. Is there further discussion? 9 10 DOCTOR SCHERLIS: May I move an amendment to the motion? 11 MR. CHAMBLISS: You may indeed. 12 DOCTOR SCHERLIS: I withdraw my motion. 13 14 MR. CHAMBLISS: Those in favor of the motion, let it be known by the usual sign of voting. 15 (Chorus of "Aye") Those opposed? 17 (No response) 18 May we have a show of hands on that vote, please? 19 (Show of hands.) 20 Three in favor, and the "Nay..'s" have it and the 21 motion is not carried. The Chair will entertain a new motion. 22 DOCTOR SCHERLIS: I would move that the target 23 figure be reduced by $400,000, as the level of funding for 24 the coming fiscal year. 25 HOOVER REPORTING CO, INC. 32O Massachusetts Avenue, N.[. WashinRtor,. D,C, 20002 L-@- A fHDll 1 the vast array of projects, particularly that one, and to 2 think in terms of what will happen to a statewide systems 3 when you have libraries in individual hospitals, and what will 4 occur@-at that time. 5 I think there is a lot of fat in this budget. I 6 don't think this is going to affect their overall program one 7 iota, and I think to fund them at their target level now, 8 when they will be coming back for additional funds, they 9 aren't bound to ask for only $400,000; I'm sure they will be asking f-or a significant sum more I'd like to give them 10 11 that latitude. 12 Now, if you asked me if I reached.a rational feeling, I think that Itried to express myself rationally,.but, I 13 would suggest to you that the input to that was about 95 per@ 14 15 cent gut reaction. Is that a fair-apprai@al? That's what you thought, 16 .didn't you? DOCTOR MC PHEDRAN: That is what I thought. 18 MR. C@IBLISS: Shall I call the question again? 19 Those in favor? 20 (Chorus of "Aye" 21@ Opposed? 22 (No response) 23 The motion is carried" to recommend a level of fund- 24 ing at $2,375,522. 25 HOOVER REPORTING CO, INC. 320 Massachusetts Avenue, N.[. Washington, DC. 20002 rHD10 I DOCTOR WHITE: I'll second that. 2 MR. CHAMBLISS: The motion is now that the recom- 3 mended level be set at $2,375,522. 4 It has been properly moved and seconded. Is there 5 discussion? 6 DOCTOR MC PHEDRAN: I supported the previous motion, 7 and I really feel it is important for me to say that this is another arbitrary choice -- so was the previous one. 8 I don't really know how you decide, and it is obviously arbitrary and I don't know how it can ever be 10 11 intelligently decided. In fact, it can't be without a more detailed review of the projects. 12 So Ithink that I would like to know whether Doctor 13 Scherlis would acknowledge that this is a really arbitrary 14 amount? 15 DOCTOR SCHERLISt/.Let me tell you the rational way inwhich I reached my decision. I sit here and listen to 17 is the reviewer with a great deal of care, because he is going 19 --.has gone through the document more than any of us have, 20 and must really have some expertise. And I get a certain flavor which I file away, I assume, somewhere in-my brain. 21 22 Really, it is a gut,reaction, and then as the dis- cussion goes on and I try to relate what I have heard at 2.3 previous meetings, to a particular state, what I did in this 24 instance was to look at the sum they have asked for, look at 25 HOOVER REPORTING CO, INC. 320 Massachusetts Avenue, N.C. @qashinp,ton, D.C. 20002 (202) 546-6666 WHD12 1 REGIONAL MEDICAL PROGRAM REVIEW 2 NORTH DAKOTA REGION 31 MR. CliAMBLISS: Now we will move to North Dakota. 4 The presenters here will be Doctor Slater and Doctor 5 Scherlis; Miss Resnik will represent the Staff. 6 DOCTOR SCHERLIS: North Dakota, Mr. Chambliss, is 7 the smallest budget RMP in the nation, of $367,746, and are 8 coming back in with a request for $774,057, which is 132 per- 9 cent of the an@ipated target. 10 I would like to make a comment that there must be 11 some kind of a leak in this agency, because despite your pro- 12, testations that they don't know what the targeted figures are, North Dakota is so honest that they said: 13 14 "There has resulted a grant application figure 15 that exceeds the target figure." 16 Which doesn t bot er me very much. DOCTOR SLATER: North Dakota also makes a point which I think will rectify that and I am abstracting here: 18 19 @"We have considerable Idifficulty attracting physicians to North Dakota. Our image is ridiculous in 20 view of the,national situation." 21 I think the@ have some problems in this proposal 22 which reflect that self-image. Quite honestly, I am concerned 23 about their priorities, and there is not a thing, I believe, 24 that we can perhaps do about this. 25 HOOVER REPORTING CO, INC. 32OMassachusettsAvenue,N.E. Vlashingion, D.C. 20002 ,@A4% Lie rtre 32 4 n the fa WHD13 1 The. ir-image, in fact, is based o ct that 2 they have about 146 p3?imary care physicians per 100,000 3 population, which is the lowest on the national scene, and 4 their concern is that they need to upgrade their medical care 5 system, primarily going in the direction of producing more 6 manpower and increasing the education of those individuals,. 7 both professional and lay, who are already there in North 8 Dakota. 9 As you know, there has been a major press to develop- 10 -a four-year medical school, and I had the opportunity to 11 visit North Dakota after the original feasibility'study, to determine whether they would become a Region, and recommended to you -- what? In '67, I guess; Doctor Scherlis has been 13 thiare'more recently, so his information is better than mine 14 15 but they now have been accredited for a four-year school, and 1. 16 are searching for ways to @implement thisi 17 Well, to get back to what they have been doing, they have, from what I can make out, a small, reasonably well- 18 organized, active staff, and I will have to rely entirely 19 upon other people's inputs to determine how effec tive they 20 are. 21 I? Their program thrust, as I said, was in education -2 and manpower. 23! Past accomplishments include Emergency Medical 24 1 they have been able to Care System; produce 1,000 Emergency 25 HOOVER REPORTING CO, INC. 32OMassachusettsAvenue,N.E. Washingtor,., D.C- 2Oi3g2 (7p,2) 325 WHD14 1 Medical Technicians, which has produced a number of one per 2 600 population, which is the highest ratio on the national 3 scene. They are proud of that; they feel it makes a very 4 effective dent, at least on attending to accidents aid emer- 5 gency problems. 6 In the second area of activity, the Univerr)ity of 7 North Dakota, working their EXtension Service through the 8 Medical School, and working in conjunction with the Eealth Department, and the.@IP , have really been abLe to get 9 10 engaged in a great deal of data collection and professional education -- continuing education programs. 12, There are four AHEC areas which are active@y involved in the arrangement of local..teaching programs for -13 lay and allied health professional teaching people, and 14 associated with this have been the arrangements for a great 15 deal of travel by nurse educators as well as the bringing in 16 of local physicians to become engaged as teachers in their own 17 special areas of capability, for not only lay but allied 18 19 health professional people. So that by and large, I think they have concentrated 20 a great deal on blanketing the state with a.great variety of 21 types ofcontinuing education and special types of therapy 22 for coronary care, renal, chronic renal disease, problems 23 requiring rehabilitation of the'handicapped and the like. 24 Now, where are they going-, against this kind of a 25 HOOVER REPORTING CO, INC. 320 Massachusetts Avenue, N.[. Washington, D.C. 20002 i z t) WHD-15 background? 2 They have presented a series of activities here 3 which -- in which I would like to-indicate to you w here they: 4 see their priorities, on page 16. 5 Their RAG is made up of 47 people, with nine repre- 6 sentatives from Comprehensive Health Planning. I believe 7 they work very closely with CHP, but I don't have any direct 8 evidence of it from this proposal, except in the sense that the CHP people are involved in reviewing and helping set 9 priorities on the proposals that go through. They are askirg for a series of projects, and I will just run through them and give you the commentary on them. 12. First of all, they are-intereseted in feasibility 13 study to look into the development of,a residency program in 14 internal medicine. This of course is oriented to getting the 15 medical school off the ground. $13,775; this will put togethe: committees, consultants and site visits. The ticularly anxious in looking at .y are par 18 19 Pittsfield, Mass., Rutgers University, Muncie, Indiana, I 20 believe it is, who have been able to develop residency programs at community hospitals. They would like to develop a consor- 21 22 tium of hospitals for the residency programs that emanate from the University of North Dakota. 23 The second project, small -- $9,620 -- a feasibility 24 study to look into the potential for graduate programs of 25 HOOVER REPORTING CO, INC. 320 Massachusetts Avenue, N.[. Wathinoinn n r. 9non? 32 7 11ID16 1 behavioral science related to family practice, and they 2 are looking to the possibility of developing a Master's 3il degree in behavioral technology as a graduate program, and, 4 also set up resources for marital counseling, child-rearing, 5 sex counseling, addiction, dying, and fty will do this 6 through statewide meetings and consultations and this kind 7 of activity trough AHEC. 8 The third type of program is $400,000, abiomedical 9 communications system connecting the four AHEC'S, phase A 10 and B are to go on during this fiscal year, first of all to 11 study the feasibility and costs, and mechanics of this, and secondly to purchase the equipment. 12. After they purchase the equipment, by the end of 13 14 Fiscal Year '75, they will then present a fiscal study to see whether or not it impossible to continue to fund this, 15 and that will go to the legislature, later to be in fact 16 picked up and operated by the University of North Dakota. 17 There is really no mention of the -- apart from 18 microwave connections and a fear general words there is.no 19 mention of the kinds of equipment, how the terminals will 20 operate, what the details are, how the people will fit into 21 this -- now many specific types of programs will be function- 22 ing through the learning centers that will be located in these 2@l i four places. 24 By and large, I don't understand this and am very 2511 HOOVER REPORT116 CO, INC. 320 Mamchuselts Avenue. K.[, WasMngton.. D-C. 2P"-C,2 WHD17 I concerned about this type of expenditure of money. 2 I bring this up now because it is a tremendous i chunk of money to spend when one could put this intolthd pro- 4 duction of personnel who will go out and improve the home care 5 treatment, and so on. 6 Fourth, they want a computer lab. They red y are 7 anxious to be able to program the health data that t@ey are pulling together and improve their computer laboratory capa- 8 )6ility. That is $36,000. 9 Satellite hemadialysis unit they want tiey have 10 one five-bed unit presently, operating at Fargo; ftylwant a three-bed unit put together at the United Hospital in 12. .13 Grand Forks, which would give them two 'in the state. A project review program for North Dakota certifica- 14 15 tion.and need law a.nd the Federal capability expenditures; $25,000. They want to bring in a consulting firm, John, to 1(; tell them what the capability of a certification of need law 17 is. You will have to comment on that for us. 18 They are talking about a human services center, for $41,700. 20 They have developed a medical Pdtk, with two new 21 hospitals going up; I believe it -is in Grand Forks, and they 22 would like to put up a separate facility in which all of the 23 other health and human serviceseagencies are placed, so that 24 everything is laced in one area there, and they can inter- p 25 HOOVER REPORTING CO, INC. 320 Massachusetts Avenue, N.E. Was:4ington, D.C. 20002 329 HD18 1 digitate more effectively. for the coverage of people being 2 serviced by that area. 311 It sounds like a good idea; they put it on the 4 bottom of their priorities list. 5 Number 8 is a data analysis two of these have 6 been withdrawn. The last one is development and tea hing 7 health data collection forms,.to be done by the Department of 8 Health in Bismarck; $25,000. 9 I am very concerned, personally, about the amount 10 of time that is spent up there collecting data and a alyzing 11 it. I don,t quite understand what they are doing with all 12. this data; they were talking about this back in 19671 it seems to me they should have been able to get some kind of 13 14 an operational base on.what can be done in North Dakota, with 15 all these years of RMP activity, so someone from Staff or Doctor Scherlis will have-'to fill us in on that. I would like to suspend further commentary on this at the moment. I can't decide whether or not to suggest that 18 we hold them to the targeted funds, or to wack out the 19 $400,000 entirely, as we just did on that project. 20 @IR. CHMIBLISS: Thank you, Doctor Slat@r. Mr. 21 Doctor Scherlis? 22 DOCTOR SCHERLIS: I don't know if I can b'e'helpful 23 in this. When I was in North Dakota, I guess I share the 24 concerns that other site visitors have had previously; this 25 HOOVER REPORTING CO, INC. 320 Massachusetts Avenue, N.[. Washington, D.C. 20002 33 0 has be WHD19 1 has been a state which, at least in my experience en 2 rather unresponsive to suggestions from out of state. 31 I remember as I was leaving, going to the airport, 4 a finger was thrust at my chest and I was told that: 5 "You people from Washington just don't know 6 what we people out here really need and shoula o.11 7 And I only resented it because I wasn't from Washing ton. 8 Their Executive Director makes this a 25 percent 9 effort as far as his time allotment, and there is no Deputy 10 Director, so that is a blank. And I.think this is indicated in a way by the type of projects that we see, because these do not really indicate any homogenous presentation in terms 12. of addressing what many eople who come to that state feel 13 p the real health needs are. 14 When I was there the thrust was rmre toward 15 Physicians' Assistants and Emergency Medical Technicians, on the bais of what has been there described as faras the ratio 17 of physicians to the population of the state, and it concerns 18 19 me that they are goin g at the computer approach rather than 20 through the people approach. Two of the projects have beenwithdrawn, two which 21 were given very unfavorable ratings by their local CHP agency, 22 so this reduced their overall reque,st by, I think $28,000. 23 DOCTOR,SLATER: Both of those were data collection, 24 again. 25 HOOVER REPORTING CO, INC. 320 Massachusetts Avenue, N.[. WHD20 1 DOCTOR SCHERLIS: Their staff is small; they have 2 a 25 percent Executive Director, an Assistant Director for 3@ Administration -- that's another -.that is a full-t-..me person,, 4 and they have two individuals in Program Evaluation, which is 5 a person and a third, and a full-time person in Heal h 6 Education, who is a nurse involved in health education, so 7 they do suffer from lack of staff, as a great many o; these projects appear to derive from the university. 8 When we were there there were some hopes o@ having 9 10 areas outside of the larger population centers, and et's 11 face it -- North Dakota does not have many large population 12. centers by our criteria, but these do not seem to ha e been implemented, and I think -- and are affected in the present -13 report. 14 As you look at the individual programs, you can 15 fault them. I think in terms of'using RDIP funds for residency programs at a medical school, you know, if you can't get your money anywhere else, RMP can be approached, and yet you could 18 say that in North Dakota, if they can attract physicians that 19 come to their state under any guise, this is a wholly worth- 20 while way of improving health care. 21 I am impressed with the fact that this has a little 9-2 different flavor than it used to have; at least they are 23 interested in more ways, in health care delivery, and the 24 North Dakota project, at least in my experience before, was 25 HOOVER REPORTING CO, INC. 320 Massachusetts Avenue, N.[. .2 Washington, D C. 200C 332 fHDO.21 1 very much from the top and not totally physician and provider 2 oriented. 31 I am concerned, as Doctor Slater was, about that 4 biomedical communications system for $400,000, and also @o 5 the application of computer technology, which was another 6 $36,000, and this was to have health care professionals in 7 the state as they said it:. 8 ... affect an evaluation of the application 9 of computer technology in health care fields. .10 And the way they would do this would be to have the physicians apparently located in different communities to have access 12. to the computers, in order to improve the delivery of health care, and as I read this, I don-'t quite know what they sa' 13 Y. 14 The speak of the selection and implementation of process for computer programs or software will require con- 15 siderable investigation of computer systems now in.operation, and'therefore considerable travel, study and collaboration 18 with other investigators throughout the United States will be necessary." 19 And I guess what they will be looking for are pro- 20 grams that will help physicians improve the level of health 21 care. This is how it comes out, and I would think that, 22 23 Number 1, the funds that they ask for won't be helpful in that regard, and Number 2, a lot of these programs are readily 24 accessible by getting in touch with other areas and utilizing 25 HOOVER REPORTING CO, INC. 320 Massachusetts Avenue, N.E. WHD22 I the mail, and I wonder how much acceptance there will be by 2 North Dakota physicians in this,.and I don't sense from this 31 that the homework has been done. 4 If you talk about a state that asks for th ee and 5 a half million dollars and you cut it down to two a d a halfl 6 million, I don't feel very badly. 7 But when you take a state that is asking for a 8 relative pittance -- it is already the lowest-funded and -then you begin carving out big chunks, you leave it with 9 10 very, very little, if anything, to move on. So one rational approach that I also should have 12 mentioned in my discussion,before is inconsistency, ich is again, one of my chief virtues. -13 So I don't feel constraired..to be consistent in 14 any recommendation that I make, and one thing that this Review 15 Comittee has always impressed me,with is its great ability 1(; 17 to be consistent. This has been, if anything, the most con- sistent feature about it, includ ing the directions that we 18 get on top, about what RMP means this year, at this meeting and this has been true of every meeting I have ever attended, 20 and I think that I won't have to defend ca-sistency any longer 21 in tlat regard. 22 So I would support your general comments; I guess 23 it is a question of coming up with a sum of money to recommend, 24 and perhaps you could have some discussion before we offer 25 HOOVER REPORTING CO, INC. 320 Mamchusetts Avenue, N.[. Via@.hiiigton, D.C. 20002 33 4 that motion, if that is within the purview fHD23 of the reviewer 2 MR. THOMPSON: Has there been any Staff input on 3! this $450,000 thing? 4 MISS RESNIK: Yes, there is one letter in response 5 to a question which I asked a Doctor -- did he need to do 6 all of this at this time? It is tied to the four AH@C's at 7 the four big cities -- Grand Forks, Minor, Bismark a d Fargo. 8 He suggested yes, they probably would not I:ie in 9 with All of the facilities as originally planned. T e letter 10 which I guess I just havenl-t had a chance to duplica e, is 11 from the project Director, Doctor Christ6pherson,-who suggested 12. that he could reduce the equipment by about $80,000,1@and man- -13 power by $24,000, leaving a total of a little over $300,00-0 14 for the project. That still is Very large, and I believe what may 15 16 have happened is that they approached the AHEC's,and @they couldn't get additional funding. They are funded for five 18 years out of the old Manpower grant, and so they are just trying to do something with -this, although tlmy are justifying 19 it on the basis of the educational programs in the medical 20 schools. 21 MR. CHA14BLISS: Doctor Miller? 22 DOCTOR MILLER: I don't think I have a vested 23 interest, so I think it is all right for me to make some com- 24 ments. 25 HOOVER REPORTING CO, INC. 320 Massachusetts Avenue, N.[. VIA@hinctnn Dr 20002 IHD24 I have been a big brother to the North Dakota 2 RI,4P.'s for a long time, and we really need to understand the Dakotas in the center of the country, in a program like this; you know, the Dakota.Territory was a territory and 4 when they finally became a state, which was a long time ago, 5 6 but it was one of the latter.ones, and North and South Dakota are typically pioneer American rugged, independent indivi- 7 dualists, everybody doing his own thing now in his own way, 8 and to heck with his neighbor, and they never could get 9 10 together. 11 They still can't; they are divided between North 12 and South Dakota, as different as though theIy were arch- enemies, though it has modified somewhatlately. 13 North Dakota medically of course is very small; 14 the population is 500,000, MInnesotals is one million. They 15 1. have 50 hospitals in Nort@ -Dakota,.whereas Minnesota has 286. 1(; They have 500 physicians; Minnesota has 5,000. They are arch-conservati.ves, rural America, independent; they 18 have some justifications for it, incidentally. They have 19 very small amounts of medical personnel and hospitals,, by 20 population ratio, but do you know where the longest length of 21, life is in-the United States? Northern North Dakota. 22 They have the fewest number of health care facilities 23 in the United States, by population Northern North Dakota. 24 So maybe there is something about health that is 25 HOOVER REPORTING CO, INC. 320 Massachusetts Avenue, N.[. Washington. D.C. 20002 WHD25 1 more important than medical care. 2 Now, they are beginning.to change, and the change 3- is motivated by the very great need for them to have a com- plete medical school. Nowadays, their two year school, which 5 incidentally was a superb one their graduates cou@d choose 6 almost any othcrmedical school they wanted to go to n the 7 United States and get admitted, because they were very, very 8 well-trained two-year men. 9 But that is not an option now, and they reFlly 10 desperately need to develop their own medical school They have a big AHEC grant, and have these.four units whi6h have 12. the potential of developing a clinical tie-in, multi le small places, with the medical school and still maintain quality 13 in medical education at the clinical level. 14 Now, they need support in every way they can get 15 it in order to carry out -(his rather ambitious plan. They 17 also.pioneered in the training of medic.s, and were one of the first ones, along with Duke but a different approach, 18 19 of trainkg Physicians' Assistants, which has gone very well in North Dakota. 20 So they are moving into a cooperative approach, 21 they are cooperating with each other in their viciously com- 9-2 petitive adjacent towns better than they have before, and I 23 would put in a plug for --- let@s give them a little push. 24 DOCTOR CARPENTER: Is it really true that people in 25 HOOVER REPORTING CO, INC. 320 Massachusetts Avenue, N.[. Washington, D.C. 20002 337 ilHD26 I North Dakota live longer, or does it just seem longer? 2 (Discussion off the record) 3 DOCTOR SCIIERLIS: Anecdotally, North Dakota is the 4 only place I have ever been to where the home that w&-went 5 to, which is o ne of a series of apartments, instead 6 (Further discussion off the record) We do have a number we have arrived at. 7 8 MR. CHAMBLISS: IAll right. We would like to have the recommendation of the presenters. 9 10 DOCTOR SCHERLIS: I would not be prepared to defend 11 it, but that is for a number of $500,000,. which is midway between, actually, what they have asked and what is targeted, 12. 13 and the rationale that we have used, which is not offered as 14 a means of defense, is that they now have a level of $367,000, 15 they requested $774,000, 1. and actually reducing that by what they have indicated they can, which is $104,000, plus eliminat-- ing two projects -- which is not a significant decrease 17 18 it comes to a total of $100,000. 19 I would think at thi-,s particular time, with the medical school coming in, that within the constraints that 20 they have-during the coming year, this would be -- I would 21 assume the values of the programs they are looking at, an 22 certainly they can come back in July for more. 23 The major reduction'i.4 what they have indicated they ,)4 can take. 25 HOOVER REPORTING CO, INC. 320 Massachusetts Avenue, N.[. W@@sh@4,ton, WHD27 1 MISS RESNIK: They are not coming back in July, 2 according to their suggestion. 3 MRS. WYCKOFF: Can they come in now, or is it too 4 late? 5 DOCTOR SCHERLIS: Well, even if they are not coming 6 back, this reduction, $104,000 -- what they have indicated 7 they can make by dropping two projects, again this is not a 8 significant reduction but I think it reflects on some of their well, computer services, that the other additional 9 10 reductions have made, so this is $500,,Qoo, which is over their present level of funding. 11 DOCTOR SLATER: It effectively takes out the bio- 12 medical program. Since the $360,000 was put into microwave 13 sending and receiving equipment, it makes it possible for 14 them, though, still to spend somewhere between $20,000 and 15 $40,00 0 to put in four audio-visual learning packages in the 16 AHEC centers, which could be used locally to improve teaching techniques for various types of personnel. 18 By suggesting this,owe have taken $224,000 out.of the request, so we have effectively killed off the biomedical 20 system. 21 MISS RESNIK: Yes, they still have a start, and now 22 we can go ahead, if it is agreeable,, to suggesting limiting 23 the locations where they are going to try out this Medline" 2,4 microwave. 25 HOOVER REPORTING CO, INC. 320 Massachusetts Avenue, NI. W,k@hinp,ton D-C-20007 WHD28 1 MR. CHAMBLISS: Would the Committee so recommend? 2 Did we have a motion to-that effect, or was that 3 a recommendation? May we have a motion,, please? 4 DOCTOR SLATER: Motion by Doctor Scherlis, seconded 5 by me. 6 MR. CHAMBLISS: It has been moved and seconded 7 that the level of funding for'North Dakota be at the level 8 of $500,000. 9 :Is there discussion? 10 DOCTOR SLATER: I would like Mr. Thompson.to refer briefly to that ques@n before we go on. MR. THOMPSON: There are 24 states that have certi- 12 ficate of need legislation. 13 DOCTOR SLATER: To spend $25,000? 14 DOCTOR VAUN: The importance of certificate of need 15 legislation in a state that is that has only two dialysis units escapes me, but what I wanted to make was the observa- -17 tion that the knife seems to be getting sharper as the day 18 wears on, and I am especially sensitive of this when we have 19 been dealing with other Regions whose requests are in t he 20 millions. 21 We have arbitrarily landed on the target figure, 22 and when we are dealing with a small state'like this, that has 23 a very small -- $80,000 makes a iot of difference, and in lighi. 2,4 of Doctor Miller's comments, I really would like to see us 25 HOOVER REPORTING CO, INC. 32OMassachusettsAvenue,N.E. Washington, D.C. 20002 34 0 IHD29 1 give them at least the target figure. 2 MRS. SALAZAR: Mister Chairman, I endorse that. 311 Is discussion still in order?. 4 MR. CHAMBLISS: Certainly. 5 MRS. SALAZAR: I used to have some administrative 6 responsibility for the state of North Dakota, and of all the 7 Regions I have ever dealt with -- and.I have dealt with quite 8 a few the state of North Dakota has a-long history of being 9 very penurious in their applications. They spend money - 10 wisely and they spend it well, and they are very fiscal, 11 they are very accountable to every dime... I am looking @down the list of the RAG and I see 12. a lot of old familiar names, and,I also see some on the 13 14 staff, and I also note that they are try ng to recruit a Deputy Director, which is one of the things that I recall is 15 16 an old problem, and I am wondering how much we would damage 17 the.program if we reduce it by a relatively small figure? 18 How attractive this would be to somebody they are trying to recruit for leadership, which-is very much needed in this 19 area. 20 DOCTOR SCHERLIS: We would like to withdraw our 21 motion and suggat that it be the,.targeted figure. MR. CHAMBLISS: The amount mentioned in the motion 231 is withdrawn and the target figtre is substituted, and that 24 11 figure is $582,217. 25 11 HO ER REPORTING CO, INC.1 320 Mamchusetts Averue, N.[. Was D.C@ 20'1@12 3 4 1 WHD30 1 DOCTOR SCHERLIS: I would also like to just note 2 for the record -- it is interesting to note, and we should 311 have mentioned this in what I think is a very active motion 4 on appeal -- they never ask money for overhead. Isn It this 5 true? They are the only state in the Union that refuses to 6 ask for overhead of RMP, and.m,aybe this is a way of refunding 7 some of that overhead. 8 MR. CHAIIBLISS: Question? Those in favor of t e motion? 9 (Chorus of "Aye") 10 Those opposed? 11 (No response) 12. The "Aye's" have it; the motion carries. DOCTOR-SLATER-.. Will the Staff advice going back on 14 this indicate the concern over the priorities of communication and so on? IIR. CHAMBLISS: Yog. @R. THOMPSON: And the certificate of need thing.> 18 MR. CI@IBLISS: And'the certificate of need thing. DOCTOR SLATER: This concern is coming from people 20 who have spent time in the-rural areas. 21 MR. CHAMBLISS: Will the Staff note that? 22 I would now like to ask the Committee to make a 23 decision as to how we could proceed during the lunch hour 24 here. We have completed the review of eight regions this HOOVER REPORTING CO, INC. 320 Ntassacht;se,,ts Avenue, t4.1. 2C"@D2 IHD31 morning, we have eight left; we could, if you wish, complete 2 one more and then -- Nor,thlands, and that would free Doctor 3 Carpenter, and then after that immediately start in on Texas, and that would clear Doctor Slater. 4 5 I stand open for.suggestions from the Committee as 6 to how we should proceed. MR. THOMPSON: Let's get going on Northlands. 7 8 9 10 12. 13 14 15 16 18 19 20 21 22 23 24 25 HOOVER REPORTING CO, INC. 320 10,assachusetts Avenue, N.[. 343 IqHD32 1 REGIONAL MEDICAL PROGRAM REVIEW 2 NORTHLANDS REGION 31, MR. CIIAMBLISS: All right, let's move forward to, 4 Northlands, and let the record show that Doctor Miller, the 5 former Coordinator of Northlands, has absented himself from 6 the room. 7 The reviewers here are -- is Doctor.Carpenter. 8 Staff support will be provided by Mr. Jewell, on Northlands. 9 DOCTOR CARPENTER: Well, this is a sort of the 10 same problem. The Coordinator, as is perfectly obvious to 11 everyone here, has left, and I think he left quite a hole. 12. The Region has given up its own priorities, or if -13 it hasn't, at least it doesn't mention them in the applica- tion. 14 15 The stff is --,.it simply lists the Federal words 16 and then says what it might do after that. The staff is tiny.; there are four people, with three 17 professionals. They have in mind enlarging to five, I believe. 18 19 But I see no evaluation of ari7y significance, and again, the 20 projects don't seem to me to,have any specific goals. They are talking about area health education centers 21 but it is not clear that there is local support for these, 22 and it seems more a question of bringing in Mayo-produced 23 software to be displayed to hospitals and staffs who undoubtedly 24 will be busy elsewhere. 25 HOOVER REPORTING CO. INC@ 320 llassachusetts Avenue. N.C. D.C. 20002 34 4 IHD33 I They don't have any activity in primary care, and 2 I was pretty concerned at that point.' That was my first 3 time through, and I -- after I went back through it again, it 4 is a triennial application; this is the third year. 5 Their mechanism, except for the staff, I guess 6 teir mechanism is intact. The RAG was inactive for a while, 7 but it seems to be back again. 8 The man who took over was the Deputy Director for 9 a.number of years, and he puts together a very mechanical application. It is beautiful, you know? All the -- every- 10 11 thing is color7codod, and you can find your way through it 12. very nicely, but I just don't find any substance there. The contracts through CHP and the state agencies 13 will apparently lead to the designation of Emergency Room 14 15 facilities by classification and a better comanuhications system between the various agencies'providing emergency care in the state, and this will be something which I believe the 18 original Coordinator started, and it is going to leave a legacy that I suspect will be useful. The definition of levels of training for various 20 21@ kinds of emergency personnel and performance standards have been elaborated, and-for the continuation and development of 22 this emergency project, they are asking for $140,000 for local 23 plans, and $120,000 for the state coordinating mechanism. 24 Then there is this network of community-based healthi 25 HOOVER REPORTING CO, INC, 320 Massachusetts Avenue, N.[. 1 @@4 @@ n rinnni WHD34 I education centers; they do have local councils, and at least 2 a part-time staff now, in each of-the areas. 3 Continuing education was has'-always been, I guess 4 of importance to them, and they have continued that. 'They @5 are -- they have a series of these AHEC'S; they have a standard description on each of the projects, which is goals 6 7 that I think were set sometime ago, and then.on some of the 8 projects, there is typed in with a different typewriter some additional ideas. 9 10 For instance, some of the they.have a management training program, and some of the AHEC's,, but not all of them, will take advantage of that. 12. 13 One of them is going to get involved in public educa- tion, but no particular information about exactly what that 14 means. 15 Altogether, this program for the community based health-education centers will cost about $636,000-$640,000. 17 Then there are -- they are interested in the PSRO, 18 business, and they are not coirLing at it in a way which I 1.0 would think -- or, I would think they probably should have 20 not started this way; they are interested in quality evalua- 21 tion, and they know that they are laying the groundwork for 22 a PSRO, but I am not sure that they are going to -- I am not 23 sure how you look at it. 24 They are going to set criteria, but they are going 25 HOOVER REPORTING CO, INC. 320 Massachusetts Avenue, N.[. Washinkton. D,C. 20002 WHD35 1 to develop nine pilot programs, too. And all in all, they 2 will invest $190,000 in something.called the "Foundation for Health Care Evaluation," and I hope 4 MR. THOMPSON: It sounds like a PSRO to me. 5 DOCTOR CARPENTER: I hope we can have some descrip- 6 tion of what that organization is. 7 They have managed to pull together some People who 8 don't ordinarily work together in quality care; they got the 9 Medical Society and the hospital group together, and that 10 must have been a challenge, and then they got the Mayo Clinic to go along, too, so there has to be something good going on there. 12 Well, we have a state -- they want to coordinate a 13 state hypertension control program, and that will cost 14 $133,000 for clinics -- for a clinic in one hospital, and 15 1(; then $87,000 for software for public education programs. There is $120,000 to sell the idea of organ procure- ment to both the public and the professionals, and a p art of 18 that program is to find out why heptatitis is a problem in 19 transplantation. 20 There is $69,000 to start the last two CHP's that 21 the state thinks they need. 22 Some of the projects are to vaguely described that 23 the state A agency expressed concern in regard to two of the 24 projects, involving the specificity-of the plans, and I guess, 25 HOOVER REPORTING CO, INC. 320 Massachusetts Avenue, N.[. Washington, D.C. 20002 WHD36 that I am on CHP's side. 2 Can we hear particularly from Staff about the nature 3!@i of that foundation for health care evaluation? 4 -MR. JEWELL:. Doctor Carpenter, I questioned'Mr. 5 Wilkins when he was in here, on this, and it is a fund-holding 6 company. No, not a fund-holding company; I am trying to think 7 of the words he used. 8 I really can't answer your question; I could not get 9 a satisfactory answer at the time he was in there, and I did 10 question him on this. 11 DOCTOR CARPENTER: All right. 12 The number of that project -- well, it,is hard to find the projects because they are u nder,several categories. 13 MR. CHAMBLISS: Is that 107S? 14 DOCTOR CARPENTER: We can find it by the dollar 15 value. 16 MR. CHAMBLISS: 107S and 107? Would that be the 17 activity? 18 19 DOCTOR CARPENTER: Ifiiat is, probably. 20 MR. JEWELL: That is the hospital association. (Discussion off the record) 21 MR. THOMPSON: They say there is $326,676 in 22 quality assurance; how did that number get arrived at by 2.3 Staff? @.4 DOCTOR CARPENTER: Well, it is hard., I'll tell you. 25 HOOVER REPORTitiG CO, tNC. 320 Massachusetts Avenue, N@E. Washinglon, D.C. 20002 WHD37 1 I spent a long time last night trying to do that, but you 2 can add up the various projects in that area. 31 MR. THOMPSON: Well, there is 17S, which i@ 4 $158,000; then there is 107, which is another $73,0011, so evidently Staff, or whoever made up this briefing sheet, .must 5 6 have combined those pro3ects that had something to d with 7 quality assurance, to come up'with the fact that 20 percent 8 of the budget is on quality assurance. MR. JEWELL: That.is from their words, Mr. Thompson. 9 It is on the purple sheet in the front. 10 MR. THOMPSON: I only got the yellow sheet DOCTOR CARPENTER: There is some blurring, too, 12 because there is a hypertension program that was well... -13 there are several of them. One of them is a quality assurance 14 program in hypertension. 15 So some of this quality assurance business, I think, has a little bit of pizzaz to it. There is a guy from the 17 Mayo Clinic who is working pretty hard at it, and he started 18 19 with a single disease and worked out criteria and applied 20 them, and now wants to expand Iit to a couple of others. MR. THOMPSON: Beverly Payne did that a-couple of' 21 years ago in Michigan. You know, and he started out with 22 more than one disease. 23 You know, it is awfulfy difficult; these guys are 24 just rediscovering the wheel. 25 HOOVER REPORTING CO, INC. 320 Massachusetts Avenue, N.[. Was,@ington, D.C. 20002 WHD38 I DOCTOR CARPENTER: It is awfully difficult to match 2 and meet these. lie is matching the relationship between 3 the ability to meet the criteria and the outcome, or trying 4 to in a hypertensbn project. 5 And I think that -- you know, that is a significant area that requires more innovation. 6 Let me you want'a funding level, or do you wan 7 to talk a while? 8 MR. THOMPSON: Go right ahead. 9 What about the kidney thing? Is that going to be 10 legit? 11 DOCTOR CARPENTER: I don't think, very; 'no. 12. MR. THOMPSON: I'd like to pursue legitimate pro- 13 14 jects here; I've got 20 percent, wrapped up in quality assur- ance and I'm not sure that is not a PSRO basis. I have $149,000 or 9 percent of the total budget wrapped up in kidney disease. 17 Then I have the payoff to CHP, which I'll roll 18 by. 19 MR. CHA14BLISS: Let me speak to the CHP issue. 20 MR. THOMPSON: I didn't include the CHP. 21 DOCTOR CARPENTER: The quality assessment, there is 22 about $190,000 going into what might be a PSRO, and if it 23 is not it is so vaguely described it would be impossible for 24 me to support it. 25 HOOVER REPORTING CO, INC. 320 Massachusetts Avenue, N.[. Wa--hinptnn D C- 20002 35 0 WHD39 I The rest of that $326,000 -- you know, I think it 2 is not unreasonable to suggest something will come of that, 3!1 and it certainly will not be a complete PSRO; it will be, 4 you know, an opportunity to try to lead people beyond Beverly 5 Payne's criteria, which I believe is terribly important. 6 The renal project, I don't think, is very good. 7 Are you suggesting though, John, that,we are-not supposed to 8 fund renal projects at all? And I guess the issue then is this is not a catinuation. 9 MR. VAN WINKLE: That is hot a fact. 10 11 The only ting we need to do is'flag the kidney so it can be discussed with Doctor Goodman in the end-stage 12 renal program,. We have to make sure that they are in compli- 13 14 ance, and this sort of thing is not something you fund without 15 checking. DOCTOR CARPENTER: The main thing with that kidney program is that they.are talking about procuring organs, and 17 they don't tell you for what.- 18 I assume they don't plan to bank them indefinitely, 19 but I don't know. 20 MR. VAN WINKLE: Could I speak to that? 21 Doctor Fred Shapiro is the Director of the Renal 22 Program in Minnesota and probably one of the leading nephtol- 23 11 ogists in the country in terms of setting up what we con- 24 sider to be one of the better programs that we have seen. 25 HOOVER REPORTING CO, INC. 320 Massachusets Avenue, N.[. WHD40 HE does have true regionalization; he has been 2 taking care of the Dakotas, too,. as well as Minnesota, and 3, those satellite units you see basically are coming oLt of 4 Shapirols units. 5 DOCTOR CARPENTER: Does he do enough trans:) ants o 6 have an impact on things? 7 MR. VAN WINKLE: Absolutely. MR. THOMPSON: I gues.s my concern is the k@nd of 8 field you have for the project which is not matched #ith at 9 least my idea of the resources that are available in the 10 state. DOCTOR CARPENTER: You mean you think the@ could 12. do more with what they have? -13 MR. THOMPSON: I am talking about -- you know, there 14 are some very good people in that state. 15 DOCTOR CARPENTER:' Well, you know, I can't argue with-you there. M. VAN WINKLE: Mr. Thompson, I don't think there 18 is any".question that after Doctor Miller left, most of the 19 other staff left also, and at one time all we had was Mr. 20 Wilkins, his Deputy, and I believe one other person. Is that 21 correct? And one part-time individual, and I -- Mr. Wilkins '22 is excellent; I am not questioning that whatsoever. It is 23 just so th-in.-' 24 MR. THOMPSON: In the old-days, we used to get some 25 HGOWER REPORTING CO, INC. 320 Massachusetts Avenue, N,E. Washington, D.C. 20002 IIID41 1 real flaming projects out of there. 2 MR. VAN WINKLE: That is right. Their RAG and 3 their Executive Board are excellent. They are very good, @4 but they went into -- as I heard someb ody mention e@rlier 5 irto neutral, and they informed.us at that time that hey were 6 making no moves or any decisions or moving forward i any 1 7 way until they got some answers from us, and we informed 8 them back: "You may have a considerable wait," because we 9 didn't have any at that time. 10 So there was a period of time there was ve y little happening. 12. DOCTOR CARPENTER: Our idea now, at a $1,2 0,000; the target is $2,170,000, the request will, by July, amount .13 14 to $2,500,000, and I would think we might start now at some- where around $1,600 000. 15 DOCTOR WHITE: Can I interject a comment? 16 According to the yellow sheet, at least, all but 18 $226,000 is for on-going activities. They only ask $226,150 19 for new projects. I don't know what percentage of continua- tion projects are being augmented, financially, but if You 20 cut them too drastically you may noteven allow them to con- 21 tinue what has already been started. 22 DOCTOR CARPENTER: Well, it is not too clear. 23 tR. THOMPSON: They mdy be supporting them, but 24 their annualization funds now 25 HOOVER REPORTING CO, INC. 320 Massachusetts Avenue, N.C. Washington, D.C. 20002 7HD42 1 MR. CHTAMBLISS: Did you have a comment on that, Mr. 2 Jewell? 31! MR. JEVTELL: Well, Doctor White, I don't know if 4 it is unusual but it is probably unique. For example,'on EMS 5 they will set a limit of perhaps $25,000, which are funded 6 through the CHP B agencies. You don't -- it isn't grab-bag' 7 here; tey set a fund and if you can comply-- they set a fund 8 for a certain amount, and if you can comply with what they 9 set out as their goals and objectives, then that-set amount 10 is all you get. MR. THOMPSON: I think it is too drastic. 11 DOCTOR CARPENTER: Do you? All right; I had $1,700,0)0 12. .13 I was anywhere., all over the map. If you were to say -- 14 well, give them what -- there is no way that those three guys are going to bring home the bacon and a $1,700,000 worth of 15 16 projects, even if some of them are now under way, I don't think. 17 But I don't know; what do you want to do? Give them 18 half of their new projects, an& what they had before? 1!) DOCTOR WHITE: Does anybody know at what percentage 20 their old projects have been inflated? 21 MR. CHAMBLISS: Do you have any idea? 22 MR. JE@QELL: It is not a great amount. I am sorry, 23 I don't have that figure, but au 'entation of $10,000 would be gm 24 la lot. 25 HOOVER REPORTING CO, INC. 32OtAassachL,settsAvenue,N.E. W3shingl,on, D.C. 20002 HD43 1 DOCTOR CARPENTER: It has to be augmented in a bunch,. 2 doesn't it, because they went from 3i ELL: Well, I meant on t re MR. JEW he individual. The 4 are some of them, Doctor Carpenter, that are larger. 5 DOCTOR CARPENTER: $60.0,000 increase; their reque,=+- 6 is $600,000 larger now than what their annualized amount is, 7 and they are reduced in staff,' and they have $200,00@ worth 8 of new projects, so there must.be a $400,000 increaSE in their continuation $300,000 or $400,000 or someth ng like 9 10 that. MR. CH2UIBLISS: All right. Are You prepar to 11 make a new recommendation, or does your former recom ndation 12. hold? .13 DOCTOR MC PHEDRAN: I have an observation to make 14 that may be beside the point; it is on a matter of detail. 15 16 I think that this matter of developing standards for care of common problems in different hospitals and office prac- 17 tices and so forth, that it is to me an argument of no effect 18 that somebody else has done it in the past,@Beverly Payne or anybody else. 20 21 I really think that people's behavior in the manage- ment of these things will never be changed.until they are doing 22 it themselves on a local level. I think that it is worthwhile 23 to avoid the duplication of efforts in various parts of the 24 state. I don't think it is an inappropr@e expenditure of 25 HOOVER REPORTING CO, INC. Massachusetts Avenue, N.[ Washington, D.C. 20002 WIID 4 4 1 money. r it is within R14P guide- 2 Now, I don't know whethe 31 lines; I haven't really gotten that far in thinking about it. 4 But I really think, from what I have seen since I ha@e moved 5 to Augusta, it makes me feel that the efforts which are being 6 made the staff of this community hospital to develop 7 they are doing GCAH types of preparation for audit parposes, 8 is probably going to be of more value to us than almost any- 9 thing else you may have done, and it really did not aelp them 10 a lot to know that somebody else had made some reco endations 11 in the past. I know it sounds like God and Motherhood" ut I 12. really think it is true; I don't think there is any point in .13 bringing anybody else's recommendation in except as it guides 14 you in making your own. 15 MR. VAN WIIIKLE: I/ tqell,-that is certainly something 16 that,,can be checked-out by Etaff. 17 DOCTOR CARPENTER: I don't think if that is the 18 start-up project that that is a problem. It is this non- 1 9 20 s.pecific -- whatever it is $190,000 for the foundation for 21 health care evaluation, that we just know mothing-about.. I- don't think that is the problem. 22 The other half of that money is for quality assur- 23 ance, and I agree with you. I think it is the best thing 24 they are doing, and ought to be supported. 25 HOOVER REPORTING CO, INC. 320 Massachusetts Avenue, N.[. Washington, D.C. 20002 IHD45 1 So--- would you believe $1,700,000? That is a 2 motion. 3 DOCTOR VAUN: Seconded. 4 MR. CHAMBLISS: It is moved and seconded that the 5 level be set for Northlands at $1,700,000. 6 Is there discussion on the motion? 7 Those in favor.@ 8 (Chorus of "Aye") 9 opposed? 10 (No response) 11 The motion carries. The Committee has done all its work assigned for 12. .13 the morning, and I would say we can have lunch and come back and start with Texas. 14 15 (Whereupon, at 1-12:45 P.M., the Committee recessed 16 for luncheon, to 1:30 P.M.) 17 18 20 21 22 2.3 i 24 25 HOOVERREPORTINGCO,INC. 320 h@assachusetts Aveiue, N-E. Washingon. D.C. 2L@2 TEXAS REGION @357 1 MR. CHIU-IBLISS: May I call the panel to order and 2 indicate that first, I have b een-in contact with the Chairman 3 of the other panel and they are moving along with speed. 4 We ate looking forward to the joint meeting of the 5 two panels so that we can have a view of what they have been 6 doing and they in turn can see where we stand and we are not 7 at the moment certain as to whether this group can meet eithex 8 this afternoon or tomorrow. I am more or less inclined to 9 believe that it may be in the morning. 10 I would then suggest to the reviewers that you 11 may begin to consider amending your plans with that in mind. 12 I do know that doctor let's see, who has to leave today Dr. 14cPhedran. 13 DR. SLATER: I am sorry, I am irreversibly 14 15 committed to leave. 16 MR. CHAIIBLISS: Dr. Slater has already indicated previously. Will you leave today, Mr. Thorqpson? 18 MR. THO@4PSON: Yes, I have an important meeting 19 to make. 20 MR. CHAIIBLISS: Dr. Vaun? 21 DR. VAUN: I have an appointment tomorrow after- 22 noon. 23 MR. CHAI-IBLISS: I think that willnot be aproblem. 24 DR. SCHERLIS: Would it'be advisable that we meet 25 HOOVER REPORTING CO, INC. 320 Massachusetts Avenue, N.[. Washington, D.C. 20002 358 I at 8:00 o'clock instead of 8:30? 2 MR. CHAl,4BLISS: I will get that to the other 3!1 parties. 4 MR. TOOMEY: What is the purpose of the other 5 meeting? 6 MR. CHPIIBLISS: Since we have been split in two 7 groups to coordinate the work of both of them, so that we can 8 have the joint recommendation covering all of the all of 9 the funding levels opposed b the two panels known to and -Y 10 enforced by the entire review committee. DR. McPHEDRAN: Is that something that you need 12. as a pro forma matter? .,13 MR. CHA!,IBLISS: It is a pro forma thing. 14 DR. McPHEDRAN: We can't just give you a blank 15 check? lfi MR. CH7U4BLISS: Since Dr. Indicart has said that 17 this should be a quality review, I think whatever semblance 18 we can maintain of making sure that all of the requirements 19 are met for such, I would hope that as many as can stay over would do so. 20 21 I would call to your attention also the fact that 221we have a new Reporter present. Shall we then begin with a review of the apoli-. 23 cation from Texas and.the reviewers 2411 DR. WHITE: I hope you all will know I am excused. 25 HOOVER REPORTING CO, INC. 320 Massachusetts A-ie,,iue. N.[. 1 MR. CH2UIBLISS: Mrs. Salazar and Dr. Slater and, 2 for the record, we note that Dr.-White has absented himself from the room. 4 Miss Murphy, Miss Mary Murphy, one of our 5 operations people will be the staff person on this region. 6 MRS. SALAZAR: At the outset, I must say at the 7 time of the New Mexico deliberations were 19 minutes, so I 8 am making a push for equal time and a little beyond that, 9 I hope you will bear with me. I am eager not to be 10 discriminatory towards sexes. I thought it would be helpful 11 to go into a little more detail because I found the application 12. extremely hard to understand and perhaps some of you have i3 'had the same difficulty. 14 Texas is rounding out its first year of trienniurrt 15 status, funded at $775,832, which covers 14 project activities, a co-staff of 7 professionals, 5 commercial. 17 This request continued funding for six on going 18 programs and five new areas of health education, health 1$) economics and systems demonstration, health manpower, health 20 care quality, and management of major diseases, amounting to $3,239,000. 21 There is also a staff development component 22 requested in the amount of $287,000. The.present director 2 tl has served his capacity since November 1973. However, he has 24 25 had PD..IP experience since 1970, having served as a deputy HOOVER REPORTING CO, INC. 320 Massachusetts Avenue, N.[. Washington, D.C. 20002 I'JA')% KAr gf@@C I director from June 1971 until August of last year when he 2 became acting director. 311 The remainder of the corps staff has wide 4 experience from 1-1/2 to 4-1/2 years. The total number of 5 staff was reduced from the time of phaseout from 32 to the 6 present 14. And the various disciplines are impressive. 7 But, I do have some concern about the region's 8 ability. to mount the very ambitious program that they now 9 propose without active day to day surveillance and participation 10 by physicians or more immediately related professions. 11 I have other misgivings about the region's ability 12 to deal with the broad State-wide medical programs as they 13 propose in the application with a delegation of authority 14 and responsibility through the project's contract conditions. Especially since these issues are addressed in the oroposed 15 very highly sensible position, access, utilization, organi- zation, manpower and so on. The regional advisor group and the board of 18 trustees of the Texas PJIPL Inc., which is the grantee, appear 20 to have excellent lines of communication. Although it is the same time noted that the executive committee met only onc e 21 in 1973. 22 This committee of RAG which I will hereafter refer 2t3 24 to as RAG has added two minority members, one of rural and one urban base. 25 HOOVER REPORTING CO, INC. 32OMassachusettsAvenue,N.E. 'vVashinRton, D.C. 20002 361 1 It is interesting to note that although the 2 program committees were only reactivated in early April of 31 this year, meetings are already scheduled in June with only 4 three replacements out of the 70 members requiring space. 5 think this is a test to the continuing interest in the State 6 and especially in the RAG-IUIP affairs. 7 The RAG has obviously been very participative 8 in the program development which evolved into this present 9 application. It had a special planning committee in November 10 of 1973 and it met subsequently three times to address internal @ll and external health influences and significant le islative 9 12, thrust. -13 The RAr@ is also moved into the direction of 14 strengthening relationships with the health planning.aqencies 15 and has met with medical,-agencies as well as other Federal and other related associations. Several of the projects seem 17 to emanate from these sources. 18 As a result of the joint Arkansas Council, a 19 proposed rate for high new born death rate is under the 20 Texas @MP for joint funding. This is I think a real break- 21 through for Texas in view of the fact that they seem to be responding better to local needs and demands which cross 2-> traditional State lines. 23 With the CHP involvement in the application, there 24 25 is some very familiar names withI longstanding experience in HOOVER REPORTING CO, INC. 320 Massachusetts Avenue, N.[. Wi,tiiinatnr, Dr. 7nRn7 1 health planning, are rather obviously alert and informed to 2 the new thrust of Texas IU4P. 3 I notice that Sister Marian Strohmever is 4 actively involved. She has been involved in the hellth 5 planning in the lower Rio Grande valley, which is one of the 6 depressed and under-served medical areas of the Stuce. 1 7 However, the time frame for the Dreparation and 8 submission-of this application imnosed very serious 9 -limitations in MY view on community involvement and review. 10 And to me it at least created a vacuum in the appli ation in 11 order to review the CHP report. It appears planned-. It is 12, so planned that it is almost meaningless to me. .13 There were four letters of endorsement with two to follow and there was some expressed reluctance from local 14 groups to comment on Statd-wide programs. They felt they 15 didn't have a bearing, that they'were not capable of that. 16 There is also an element of inconsistency in this vacuum. In February of this year, the second annual meeting- 18 of health planners of 22 councils of government was sponsored 19 20 b-y the Texas P14P. The nurpose of this meeting was to solic3t assistance in information about successful projects funded 21. by the Texas @IP since 1968. Another such meeting is Dlanned 22 for next month. 23 I think that perhans@ it is time to inquire about ?,4 present status and cooperative efforts in view of this, as 25 HOOVER REPORTING CO, INC. 320 Massachusetts Avenue, N.[. Washington, D.C. 20002 363 well as other pending proposals and the RAG reports. That 2 they are under consideration like the Arkansas-Texas joint I 3@l council. 4 AS to feasibility, the contract approach to these 5 proposals seems to have some advantage of concise l@nguage 6 and subject presentation, the goals and objectives are clearl@, 7 defined, easy to read. 8 However, the same economies of languaae do impose 9 specificity and detail. I have no criticism of contracts 10 per se as a mechanism but,I have some problems with e -11 personal non-human approach to fulfilling the provisions of the contracts. -13 There is a quality throughout here of saneness 14 of the language. It is comm6rL-to all the projects and it is 15 difficult to determine the inter phases and the -- the network, 17 in other words, of the relationships of one project to the 18 other. 19 The.language is good and it is lofty and it is 20 worthy and it sounds like they can do it. But once again, the 21 impression that these views that vou are looking at, all of these throw a thin layer of professional systems who are 22 23 unquestionably skilled in such presentation and I have trouble e with the understanding of it. I have trouble with understandi:,Ia 24 25 the programs commitment to addre Iss themselves to these HOOVER REPORTING CO, INC. 320 Massachusetts Avenue, N.[. @V;i,hington- D-C. 20002 -364 I problems. They don't come through in these little .2 descriptions of the request for contracts. That is,mv own 31 bias. 4 There is an intangibility about it that,I find 5 is very difficult to deal with. Let me just quote ne 6 little paragraph. Description of one of the programs. 7 To develop and demonstrate educational pnroaches 8 for barriers to health care. 9 So much of the contracts and the effectiveness 10 of the contracts, I believe depends on the language, that I .11 find it impossible to get an understanding from whatlI read 12. in this application of what Texas is going to do with tl-,ese -13 contracts. I have some concerns about giving contracts to 14 profit organizations and who will nionitok them and 1 will spell those but later. 15 I would not at this time like to make a recommenda- 17 tion until we hear from Dr. Slater about that. MR. CHAIIBLISS: Thank you, Mrs. Salazar. 18 19 Dr. Slater? DR. SLATER: I thought you were going to be going 20 for 19 minutes? 21 I would like to say, Mrs. Salazar and I met just 22 icated on Texas. 23 briefly at lunch, is the first time-we commun 24 'And I will simply reiterate for you what my statement was for her. 25 HOOVER REPORTING CO, INC. 320 Massachusetts Avenue, N.[. 1 was deeply impressed with the objectives as 2 she has quoted them of the Texas,nrogram and felt that as 3 long as looking at health education, quality State-wide 4 disease projects, health manpower concerns, that clearly 5 there is plenty of room to move. 6 And that one cannot fault under any circumstances'- 7 this kind of -- the set of objectives. 8 TAlhat I simply cannot get ahandle on, readina 9 Texas, was what was really coming out of it and Icame 10 prepared to say that I am impressed with the range of 11 activities that are going on and feel that, from what I read, 12. that they apparently do have very good review by an involve- @13 ment of the comprehensive planning group. But I still could 14 not understand it because there is too much, there is too 15 broad a range of activity explained into few words, which I 16 believe you say lack any color whatsoever. 17 I think that perhaps Ilrs. Salazar put a figure 18 on it by saying there doesn't seem to be any medical pro- 19 fessional input into this that gives the sense of the priority within the framework of the humanity aspect of it and I am not 20 saving that that comes through that strongly in the other 21 22 proposals but this is a little too perfect in some ways. 23 What I am saying is that I am impressed with what they are attempting to do and if one takes a look at paae 24, 24 251 the project status report, contract No. 73-1, continuing HOOVER REPORTING CO, INC. 320 hiassachusetts Averue, ii.l. ty 366 1 education for reaistered. nurses providing community health 2 services, is on schedule. 3!i. Comments: Extended 60 days for additional effortli 4 Progress excellent. 5 That is fine. 6 And there is two Dages of this type, or 2-1/2 7 pages of this activity and we simr3ly-have to.accept the fact 8 that evervthinq except the two projects is on target and doin-@ 9 well. 10 on-the basis of that, there is a request for 11 continued activity of, I can't get here, I would say some- 12. thing like, maybe $300,000, $400,000 extension. .13 Now, when one goes beyond that one gets into the 14 matter of what do they plan to do in the future? As Mrs. Salazar pointed out, because they are in 15 16 a tight time frame, they have decided to follow the general guidelines of their thrust, their objectives and sent out 17 proposals for, send out requests for proposals. 18 19 Do you want me toogo on with this? Mrs. Salazar. Yes. 20 21 DR. SLATER: And let me, if I can find my way in 22 again, let me give some sense of what they are doing here. They have an access committee of their RAG, 23 oriented, an access committee concerned about getting into 24 the health T)rogram. It is asking for $286,400 for what is 25 c HOOVER REPORTING CO, IN loassactusetts Avenue, N.[. D,C. 2C,-",')? 367 I called the Texas health education project. Within that 2 there are a whole series of objectives which are fine. 3 Objective 1 is develop and demonstrate a coordinated approach 4 to individual health education in a selected area. @5 Then there are Work Activity A. Apply those 6 guidelines developed in IU4PT Contract k@o. 74-14 through a 7 coordinated approach to individual health education in a 8 specific community, town, county, multi-county region. 9 is available for that. 10 Two, determine health education requirements and 11 develop effective means of meeting those needs. 12 There are four work activity suggestions here 13 sent out, widely distributed throughout the State. They 14 range from Work Activity A, analyze cultural barriers to 15 adequate health care and,,d overcomin ,7yelop methods for g.the I(; 'barriers through education at $48,000; Work Activity B, 17 develop an outline form that can be used in rural poor 18 communities to assess health status and informational needs iq at $40,000. 20 Work Activity C, study the legal barriers to healtl care as perceived by the consumer and provider and recommend 21 educational approaches to overcoming those barriers at 22 $63,400. 2tl 24 And Work Activity D, demonstrate and evaluate the use of upper division nursing and medical students as remote 25 HOOVER REPORTING CO, INC. 320 Massachusetts Avenue, N@l. n r. got),ig area community health educators during non-school periods 2 at $35,000. Objective 3 is improve health care and reduce 4 overall cost through education. 5 Work Activity A, analvze areas of greatest 6 cons umer abuse in the health care system and suggestieducatio@al 7 programs aimed at overcoming same at $55,000. 8 All of those activities add up to something like -$@86,400. 9 10 Then, under the general rule book of the utiliza- -11 tion community, the Texas Health Econorqlcs an Systems 12. Demonstration Project are indicated. That is a figure of 1 -13 $636,340, and I think I would lose you if I read over all, 14 the objectives and work activities. 15 Needless to say 16 MR. THOMPSON: That is a five-year project 17 conservatively speaking. I just reviewed it just for you, 18 Bob. 19 DR. SLATER: Thank you. I didn't even speak to 20 you about it. 21 Health Manpower Committee of the RAG is to a8s3st, coordinate and cooperate with those who wish to perpetuate, 22 23 expand and improve the quality and output of health manpower in Texas for $160,000, and a very laudable group of objectives 24 2 laid out here. I don't think anyone is finding any fault HOOVER REPORTING CO, INC. 320 Massachusetts Avenue, N.[. t'J@@hin,Onn n P. gnnn? it:)9 1 with this. 2 The report on current distribution and trends in 31,' Texas is work activity, none is required at this Itime. 4 They were satisfied at a excuse me, that appears to be 5 in here under what they were going to fund and I have been 6 misled. 7 But they have a series of objectives und r 8 attempting to define better health manpower. Here is a very 9 specific one. 10 Encourage the development of a resnonsiv and 11 timely State-wide health manpower data base for use by health 12. educators, r)olicy-makers and others. -13 llork Activity A,, a six-month study for this 14 purpose, with Governor's office of Information Services, is 15 nearing mid-point. This,.is already under way. (2) Continuing Education Committee is wanting to identify, encourage and assist those health care professionals 18 interested in findling new and'more effective methods for 19 providing continuing education in the region, and they require 20 $308,700 for that. MRS. WYCKOFF: Is that PSRO? 21 DR. SLATER: I don't think so. 22 23 MR. THOMPSON: There is.a quality that is laying the base for that. 24 25 DR. SLATER: Can you identifv that? HOOVER REPORTING CO, INC. 320 Massachusetts Avenue, N.[. n f, ?nr)nl) I MR. THOMPSON: Project No. 111. You mention PSRO 2 specifically in the project, but.although it doesn't make it 3 I!; directlv 4 DR. SLATER: Objective 1 is assist in the. 5 developr..ient of new approaches to upgrading quality health 6 care in response to identified needs of the professional 7 conlnunitv. 8 Ilork Activity A, establish a quality review task 9 group comprised of physicians and other health professionals 10 to provide leadership and decision-making functions for the 11 project. 12. Work Activity B, select a technically qualified, -13 unbiased organization capable of providing research, analysis, 14 evaluation and other work support to the task group. 15 The analysis evaluation, in other words. 16 MR, THOMPSON: I was'on the PSRO task force and 17 I can take this and lay it out and say to the PSRO, here you 18 are, go. 19 DR. SLATER: The final one is just for $6500 20 I don't think I dropped a zero -- I did, $65,000, excuse me, regional disease management program. 21 22 That is oriented to the management of major categorical disease awareness and treatment program in Texas. 23 And the goal is to design and test effective mechanisms for 24 developing and managing State-wide disease programs. IIOOVER REPORTING CO,INC. 320 tilassachusetts Avenue, N.[. 'tyashine- fin. D,l@'. 2OOj2 Now, they have several objectives. 2 To document the methodology in Texas for a 3!i coordinated State-wide response to major disease aw areness 4 and treatment programs. 5 Work Activity A, to evaluate the major disease 6 programs supported by MIPT since 1960, heart, cancer, stroke,- 7 hypertension, renal, to identify successful and unsuccessful 8 features. 9 Now, that is evaluating the major d' lseas 10 supported by PJIP since 1960. That is a lot of work. 11 Deve lop a methodology for a comprehensive, 12. coordinated State-wide approach to major disease. programs. -13 That is to be sublet to somebody or maybe multiple people- 14 for $65,000. There are some other objectives here. 15 Monitor the jnajor disease programs currently being 1(; funded through IU.IPT. objective 3, recommend to the regional advisory 18 group concerning the efficiency of participating, or continuin3 19 to participate, in major disease programs. I am saying that t support this type of activity. 20 21 I think it is very necessary and we have to move increasingly 22 to it in this country. 23 What I don't get a feel.for, either from this 11 brief description as it appears here or of the more extensive 24 25 write-ups that appear in the boo.k and they are not that much HOOVER REPORTING CO, INC. 320 Massachusetts Avenue, N.[. t'Ja@hinofr,n n r. ?Ono? 372 more extensive, they are simply almost the same thing laid 2 out on the dollar street activities, required pages,required by RMP. I can't get a feel how long it takes to do these. 4 l@ether there are groups in Texas to do them and what is 5 the quality of the work that is going to be done. canit 6 seem to get a profes sional sense of this. 7 I am concerned that they are asking for a great 8 deal to be'done in a very short period of time. 9 Now, I gather against this background t.they 10 expect many, many proposals to come in and in fact aving 11 something in the range of 90 or 100 from which they wish to 12 choose about 25, and I am anticipating obviously thait their .13 staff and RAG group are going to screen out those that are 14 technically capable of being done in one year. 15 I come back to the concerns that Mrs. Salazar 16 had, which I believe should be reviewed here and that is the 17 matter of what kind of assurance do we have of the monitoring IL8 that can be done by essentially nonprofessionals, non- I!) physician professional staff and it may be that they need 20 other kinds of professionals on activities that are essentially 21 contracts. 22 The question I have is when one nuts contracts 23 out, are they all to profit-making organizations? 24 Does the contract carry any concern for the 25 conflict of interest between those who are on a profit-making HOOVER REPORTING CO, INC. 320 Massachusetts Avenue, N.[. Washirlzton, D.C. 20-002 f -D 1 basis in providing the kinds that we want in comnared to the 2 usual grant system? 3 I think that I don't want to go any further 4 at this point. 5 Do you have any follow up? 6 MRS. SALAZAR: No, except for this letter. 7 MR. CHA14BLISS: Yes, let me introduce the letter. 8 There has come to the attention of Dr. Pahl 9 what is marked as an urgent'piece of correspondence from. 10 Texas. It arrived during the break and the reviewers have 11 had a chance to read it. 12 I would simply submit that the panel may wish to 13 know of its contents. 14 DR. SLATER: Yes, I think the Texas people were 15 concerned that they had put a proposal into us in which they l(i were really asking us to take on faith the fact that they were ii going, following the program thrust that you have described 18 and had submitted a request for proposals to be submitted to 19 them and that these proposals are now 3ust coming in and that 20 they are planning to have their RAG staff group act finally on those proposals on June 28 or something like that, which 21 is something more than a month after we would have funded 22 23 them to do it. 24 So that we are in fact funding,them in advance of 25 the time that they actually make a decision for the proposals. HOOVER REPORTING CO, INC. 32OMassachusettsAvenue,N.E. IAI@ @t, nr gnnng 374 Miat they are suggesting is.that their proposal 2 as submitted to us, be modified to the extent that they take 3 their 25 top priority proposals and submit them to the R-T..IP 4 staff here who would review them and make a decision on 5 whether or not these satisfy, in essence, the goals of @IP 6 and the thinking of this Committee is the staff cou d 7 interpret that. 8 Is that a fair display of what they say?, 9 MR. POSTA: -Yes, sir. 10 DR. SLATER: They are concerned that 11 DR. SCHERLIS: Could you translate that? 12. MR. POSTA: lqhat their picture is, that y going .13 the contract route they would like to have as long a period 14 as possible, meaning 12 months. 15 If they hadto wait until July 1 to get their 1(; 15's and 16's in more specificity, by the time it got through 17 all counsel, they would have a maximum 10 months to do the 18 activities Droposed and their whole concern is, on the 19 contracts that they had funded in the past, through their 20 evaluation process according to Texas representatives, the ones that have been funded in the least amount of time, have 21 22 not been as successful as those that were given a full year's duration. 23 MR. THOMPSON: Do we have any idea to whom these 24 25 contracts are going to be let? HOOVER REPORTING CO, INC. 320 Massachusetts Avenue, N.C. i,jithine,tnn n f,. gnno? 375 1 MR. CHAMBLISS: Miss Murphy, can you comment on 2 that? 31' MISS MURPHY: I think in the Drimary and 4 secondary review, a summary of contracts funded from 1972 5 through 1974, and just reading down to the people that they 6 were contracted to: 7 Texas Hospital Association these are the past 8 ones and probably some of these same will be included in this 9 round. 10 Texas Hospital Association. 11 Texas Medical Foundation. 12. Chamber of Commerce, Ty er. .13 Coordinating Board, Texas College and University 14 System, Austin. 15 Scott and Ilh,ite Memorial Hospital and Scott, Sherwood and Brindley Foundation-Temple. 16 17 Human Resources Development Foundation-Houstoni 18 Bexar County Medical Foundation-San Antonio. 19 Cameron County Boaord of Health-Harlingen. 20 Texas Hospital Association, Austin. 21 Texas State-Department of Health, Austin. St. Paul Hospital-Dallas. 22 23 Texas t-,Iedical Foundation, Austin. e 24 The University of Texas Health Science Center at San Antonio. 25 HOOVER REPORTING CO, INC. 1 320 Massachusetts Avenue, N.[. 1 Southwest Research,Institute, San Antonio. 2 And I could go on. 3 1 I have another page and a halt. Those are the 4 types of people that they were contracted to. They sent them 5 to a very select group. 6 I have the sheets where they are checked off, 7 how they had selected them and according to thei r expertise. 8 Five hundred. 9 MR. THOMPSON: -I am concerned myself, only faiklv 10 knowledgeable in the,area of health care economics, that 11 this project that they have laid out here is very well done, 12 but the problem is that work, the way it is-laid out,-work 13 activity A has to be completed before work activity B can 14 be begun and C. 15 When I said.it would take five years, I was being slightly facetious. It would take three years. 17 But, I don't know where they are going to find 18 the people down in the hospital association, because I know 19 the people down there who are going to be able to do this. 20 This is a fantastic -- it is a well laid out, fantastic idea. 21@ MISS MURPHY: They are only going to let 30 to 35 2,,' contracts out of this whole group. 23 DR. SLATER: I assume they are going to operate 24 in the future on the basis as they operated in the past. If 25 one takes project status reports and accepts their very brief HOOVER REPORTING CO, INC. 320 Massachusetts ue, N 1. 377 1 indication o-f how they are proceeding, one says they are 2 satisfactory, I just don't have a feeling for this and all 311 we can do is assume on how they are going to operate in the 4 future as they have in the past. 5 MRS. SALAZAR: They seem to be convinced that 6 the contract mechanism is the way they are going., 7 MISS MURPHY: That is the only way they feel they 8 can go. 9 MRS. SALAZAR: They feel that their,experience 10 with the contract is verv good. 11 DR. SLATER: I will accept that.- 12 MR. VAN WINKLE: They have 130 letters of intent 13 out. 14 DR. CARPENTER: Did the regional advisory group 15 approve this? Al 16 MISS MURPHY: Yes. 17 DR. SLATER: I think it is difficult to have done 18 more than this, because of the reporting that will be 19 necessary to get a grasp of the renorts. Either that or. 20 they might have been able to give us an appendix of their 21 status reports which would give us some indication of what 22 was coming out of the projects that are already funded and 23 the implications. MISS MURPHY: This is what the form I referred 2 @4 to do summary of contracts funded. Very small print. 2 HOOVER REPORTING CO, INC. 320 M@amchtise' ts Avenue, N.E. 378 1 MR. CHIV-IBLISS: There have been some concerns 2 on the part of staff expressed about the 16's and the fact 3 that they have not gone into anv detail. 4 We would certainly want the views of the committee 5 on that asnect of the application. 6 MRS. 1,7YCKOFF: Does this mean that they are goina@ 7 to reach out beyond the walls of the great elite establishment 8 in Texas and try to get into the uncovered areas that really 9 been touched? 10 MR. THOMPSON: These are the same old boys. 11 These are the same old boys. 12. DR. SLATER: I would like to take exception to @13 Mr. Thompson. 14 They really are making an effort to look at the 15 mortality rate in the area. MRS. IIYCKOFF: I think the physicians are reallv on the job. MRS. SALAZAR: It is very difficult to say, @Irs.- X@ckoff, from the reading, the@ kind of thing Dr. Slater has 20 indicated, it is very difficult'from the reading. This is why I have problems with the application 21 22 being completed that it will indeed begin to cover these 231 areas. Mary, maybe you can tell us at the time of phase- 24 out, where did Texas go? How far down the road did it go 25 HDOVER REPORTING CO, INC. 3,20 fhasuchusetts A,4eitie. N.rL. 379 I back? 21 Maybe I can get some meaning from it. 3tl MISS MURPHY: They went from 35 Deople and now 4 they have 7 professionals, 8-1/2 5 MRS. SALAZAR: I am not speaking so much of staff. 6 MISS MURPHY: They closed all of the sub-regional 7 offices. No more sub-regional offices. 8 Like these RMP's were sent to El Paso, so many 9 of their old staff th at they had, that they knew were distri- 10 buted throughout the State to try to get a good coverage -- 11 MR. THOMPSON: I don't think-seven ,oeople can 12. monitor these. 13 MISS, MURPHY: Say that you pick a good project 14 director, why would some person have to go out and do it? 15 MRS. SALAZAR: How can you monitor yourself? 16 DR. SLATER: I think'what needs to be clarified 17 is whether or not there is functionally any difference between 18 a contract and the traditional form of grant mechanism that the @.iP follows in the sense (yf professional quality and 19 monitoring and judgments that a re made. 20 21 I think if the committee can satisfy itself, that 22 contracting is just as good functionally. MR. VAN WINKLE: Dr. Miller has had some experience! 2.3 with that methodology. -)4 MR. THOMPSON: Before you go, because you are goin HOOVER REPORTING CO, INC. 320 MassachT,,setts Aveni@e, h.[. D.C- 2P,@, 2 38c) to have a lot more to say about this than I, when we had a project we had a man, an identifiable person who we sometimes 3 were disappointed but we knew his background, we knew what he was good at and bad at and we could judge the contract, I 5 mean the project. The contract, we don't have the man. 6 DR. MILLER: It depends on how you do it. It 7 depends on how you do it and my experience with it was 8 essentially halfway between what you traditionally think of 9 as a ontract and what we traditionally think of s a r)ro c a ject. 10 And by that mechanism, why you know not only the 11 man but you know the institution, you know what you want 12 them to do and you have a lot better control over it than 13 you have over a project. All the way around. MR. THOMPSON: It takes a good monitoring system 14 15 to get that. 16 DR. MILLER: It takes a good system, yes. But 17 it is not an open-bidded contract kind of a thing. You don't 18 just publish.it and give it to the lowest bidder without reg@rel 19 to who it is. You can do 20 DR. SLATER: They are not going to do that here. 21 They are obviously going to look for quality projects or work 22 and then contracts. So would you agree to that in terms of what I 23 understand the system here to be, they are simply using the 2,4 contract method to finance? 25 HOOVER REPORTING CO, INC. 320 Massachusetts Avenue, N.[ - Washiqgtoji, D.C. 20002 1 DR. MILLER: It hasn't any positive attributes. 2 I am thoroughly sold on the contract approach to project. 3 It really puts vou in the driveris seat with regard to 4 management. 5 MRS. SALAZAR: llhy did Texas elect to go this 6 route? 7 MR. CHAMBLISS: That had to do with the change of 8 organizational structure. 9 Will you clear that up Mike? ..Io MR. POSTA: I guess it was December of '72. un 11 to that time the Texas system was the grantee agency which 12. was composed of 17 educational institutions. Then they broke 13 away and formed,a name and a board of directors and of course 14 by that time we had gotten word that Febrtary 173, that we were going out of business'. 15 16 So the regional advisory group got together and said., if we are thinking about feasibility, short-term pay- offs, we had better think in terms of a period of a year. 18 19 Their whole administrative mechanism was to build a device 20 whereby they could call the shots, set up the instructions for the contracts, choose the neople and pay them for the job 21 done and they, qtoting verbally, "have felt that thev have 22 done a better job especially in short runs." 23 1 I They probably would not agree if they had a three- 24 year funding period. But I think their whol.r.,@ remise is based 25 HOOVER REPORTING CO, INC. 120 laassa,.husetts Avenue, N.[. D.(,. 20002 @82 1 on that approach. 2 DR. CARPENTER: Did they use the contract 3 mechanism to get the grants written? 4 MRS. WYCKOFF: You mean the Pj4P? 5 MR. THOMPSON: I think I know who wrote some of 6 these grants. I think that is a facetious question. 7 DR. SLATER: llell-, I think again, given the 8 material that we have in front of us coming from a program 9 that has been site visited and has been a part of the 10 endeavor here for years and for which many peo le have Dersonal p 11 knowledge of the individuals, one has to give the benefit of 12 the doubt. 13 I think there is another major question that 14 comes uD and that is whether or not we feel it is appropriate or some of the monies for the new 15 to consider allocating all,/, i(i projects which have been requested prior to the time that 17 those projects have been chosen. They have requeste t at 18 they do this with the proviso that we, appropriate the staff I() here, the responsibility of reviewing those 25, and 20 representing us and the advisory council, that it is appropriate 21 for them to proceed to carry out. 22 MR. VAN WINKLE: I believe I am correct. Larry, 23 they cannot spend any monev until you have 15's or 16's, is that correct? 24 DR. CARPENTER: What is the 15 and 16? 25 HOOVER REPORTING CO, INC. 320 Massachusetts Avenue, N.E. (3) 1 MR. VAN WINKLE: The budget forms. 2 DR. SLATER: They won't be able to start Until 31 July 10. As soon as you clear the air and the money will be 4 in the bag. Otherwise, they won't get through until the 5 6 Advisory Council meets in August, which is too short and 7 will 8 MR. THOMPSON: Are they talking about this or 9 the next one co-ming.down the pike? MISS IIURPHY: They are sending nothing else in. 10 otherwise the contract will have to be ap ...proved and met in .12 July. DR. SLATER: To get something done. 13 MR. THOMPSON: We are examining this one right 14 now; is that tigh4.-.@ '15 DR. SLATER: @at is-right. We don't know what 1(; the 25 projects are going to be. 17 All we know, are the guidelines being used by 18 19 applicants who already submitted 130 proposals? MR. THOMPSON: If they can do it, why can't every- 20 body else do it and we don't meet in July? 21. DR. SLATER: Well, I think 22 DR. MILLER: Isn't this a slush fund? That is 23 what we turned down yesterday. 24 MR. CHA-MBLISS: We need the judgment of the 25 HOOVER REPORTING CO, INC. 320 Massachusetts Avenue, N.[. Washingtog, D.C. 20002 384 1 reviewers here. 2 I would say there is.a fundamental issue here and ,i that is, I think Dr. Pahl would be very much concerned here 4 and so will the Council, and that is the local decislion-makin 5 Process has not had a chance to.work its will on wh t you 6 are being asked to make a recommendation on today. -1 MRS. 1,7YCKOFF: It is a blanket request. 8 MR. CIIAIIBLISS: I would -- I wanted to, wanted 9 -the discussion to go forward as it has, so that we u 10 thread out of here some advice for counsel and for D Pahl, 12@ MISS MURPHY: Could I ask something? -13 I-IR, CHAIIBLISS: Yes. MISS MURPHY: Each one of these proposals as 14 they'are being worked out before they are submitted to the 15 16 @IP, are to be brought to the attention of the CHP. A comment is going to be made prior to coming to the RM P. 18 MRS. VIYCKOFF: Did they make the comments on the- lU4P that went ott? Or on what comnanies? MISS MURPHY: They have companies on all of this. 20 21 DR. SLATER: I think if the usual history of all 22 the other Projects were being followed by.this one, we woul 23 have 25 more clearly identified, ve@ briefly described 24 @projects which Iwe would look at'and we would say, yes, that I is what they are going to do next vear and they only requested 25 HOOVER REPORTING CO, INC. 320 Massachusetts Avenue, N.[. WashinEton, D,C. 20002 385 1 7 percent of the funds that are targeted for them and it 2 sounds good because they have been producing in the past and 3 so let us go ahead with it. 4 I think that is what we are likely to say as we 5 pick holes in the taraets. 6 MR. THO!@IPSON: We would have some evide ce that 7 CHP 8 MISS MURPHY: You will have it. They will have 9 -reviewed them before they get to the RMP. 10 The proposal is, you know, that is,the direction. 11 MR. THOMPSON: What is to stor) it even i thev 12. get an unfavorable review? 13 DR. SLATER: I think what they have done is wire 14 us and put us on the record and said that the 25 projects that,they send up here would only come on the basis that 15 they went through the usual process and then they put this staff in the position put us in the nosition of defending 17 on the staff to legallv or to put their names on, agreeing 18 that these are avnronriate. 19 MR. THOMPSON: This is going to come up in South 20 Carolina. The same kinds of business, although not so 21 blatant. 22 I just have a vague feeling that I am getting 23 -had. 24 DR. SCHERLIS: The question is, for how much. 25 HOOVER REPORTING CO, INC. 32OMassachusettsAvenue,N.E. Washington, D.C. 20002 1 DR. CARPENTER: There are certain things which I 2 will not put. 3 DR. MILLER: You have been getting had all day. 4 MR. CHA14BLISS: I would assume those comments are 5 off the record? 6 DR. SCIIERLIS: No, sir, I would like those to be 7 on the record. 8 MR. CHIU-IBLISS: All right. 9 DR. SLATER: I think it clearly breaks all 10 precedent, the past, as well as good operations, to approve 11 this kind of thing without some committee review inDuts. 12 Mrs. Salazarts question is whether or not it would 13 be sensible in this case to have a site visit by some of the 14 review committee and the staff to take a look at the situation 15 here in view of the -- in view of the problem. 1(; MR. CHAMBLISS: I would recognize Dr. Scherlis ii fi rst. 18 DR. SCHERLIS: You are obviously looking for 19 some way out. Perhaps we could give a tentative approval, giving their ap 20 proval by July 1. 21 I for one, Although I know that a great deal of what we are doing at this session is really looking at 22 inadequately submitted proposals and making what in time may 23 24 be inadequate decisions, I stilf think we should go through the opportunity that I think we must have and that is exercise. 25 HOOVER REPORTING CO, INC. 320 Massachusetts Avenue, N.[. Washington, D.C. 20002 3@7 ing our right of approval or disapproval and not telling the 2 region, you can do what you want'on, any basis that you choose to and I for one am not that overly impressed that any region, 4 including Texas, once it receives this sum of money will 5 decide that it is going to do anything more, is minimally 6 necessary to have the project operate. 7 Novi, my faith may be less than others because ovex 8 the years that I have been had, including site distances and 9 I would sug est that we have, tentative approval but only 9 10 contingent that we have approval in July to review the 11 contracts. I offer that as a contract. 12. DR. MILLER: This contract is a bit of semantics as a sort of semantics. It is trying to get approval for 14 slush fund projects without approving the project. By calling 15 them contracts. 16 So I support what you do, that we not fund it 17 now but give them the opportunity to come in with their 18 proposals in July for how many ever contracts, projects, 'tted 19 whatever they wish to call them, as long as they are subm-i 20 in the usual way. 21 DR. SLATER: I don't understand what has happened here. I thought you said you would find it provisional unon 22 -9 the receiDt? DR. SCHERLIS: I offered Potential ways of trying 24 to meet this. 2.5 HOOVER REPORTING CO, INC. 320 hiassachu@etts Averue. N.[. W'pt,hi,ictn@, D C@ I think we need more suggestion on this. I most strongly do not support the concept of giving them funds at 3 this time for what they have asked for and I am trving to 4 seek a way out. 5 Any suggestion as a wav out 6 DR. SLATER: The question at this point is whethe 7 we will guarantee some sum of money up to what they requested 8 that will be held in escrow here until our requirements are 9 satisfied, which is their submission of whatever the proposal 10 they want as a result of these requests that have go;ne out 11 and the ratification of those proposals by the staffiand now 12. we are adding to that, either a site visit or some members -13 of this committee to get these proposals and talk on the 14 conference, call or come to Washington and do so. 15 Such things that keep our process intact. If we 16 do that by July 10, we will avoid another whole review cycle 17 which they want to avoid in order to be able to do the work. 18 MR. THOMPSON: One of the beautiful rhinos about- 19 a contract, you can specify time. Therefore if it is l@O 20 months or 12 months, they let the contracts. TIhat is the 21 difference? 22 DR. SLATER: Because the only way we can do it 23 is to bring it back for the next review cycle and it will be later part of August, and it will add two months. 24 MRS. TIYCKOFF: They add it to the other end? 25 HOOVER REPORTING CO, INC. 320 faamchusetts Avenue, N.C. n r lnhn- 389 MISS @IURPIIY: No, they can't. 2 MR. THOMPSON: They change the contractl@and 3i MR. CHMIBLISS: T@Te have known for some time that this application presented something of a dilemma. I have 5 just talked with Dr. Pahl on -the T)oint. 6 Dr. Pahl, would you care to make an expression asl 7 it relates to -- the contract activities coming in about the 8 20th of June after this committee 9 MISS MURPHY: No, the 28th. The RAG are goina 10 to meet and aor)rove them and he said they would be ip here @ll by the 10th complete. The 30thlof July. 12, MR. CHIU,.IBLISS: of July, that is worse. 13 DR. PAHL: I really feel -- I don't need the 14 microphone I really feel that we prefer a definite decision 15 not based on staff cadabil@t early July for the following y reasons: Normally I think we would be happy to accommodate 18 that kind of recommendation but we are laboring under some 19 difficulties internally, namely as soon as legislation is passed and none of us know when that is going to be, the 20 21 department is then going to make its decision as to just how many of our staff are going to be departing on the decentrali-I 22 zation basis and I am not sure who is going to be here in 23 July to do the.work, very frankly. 24 I think that it is rather clear issue in the 25 IIOOVER REPORTING CO, INC. 320 Nlassachusetts Avenue, N.I. Iii 390 1 sense that Texas has had and does have as much of a lifetime 2 as any other IB@IP. It happens to be a free-standing organi- 31 zation, it is not the only one that we have. 4 I think that they have chosen to go a certain route and that is,their choice, but the other RMP's have been 6 under the same time limitations and are under the same time 7 limitations and I would suggest that you not'treat them 8 speci,al.than from the other RMP'S. 9 If you can find it appropriate to arrive at a 10 decision on the basis-of the information provided, which 11 leaves you comfortable, we will take that recommendation to 12, Council. But I do not prefer to have it come back to 13 1 14 Committee the staff, because I really don't know our 15 capability to manage thi§,Fesponsibility and it would be really a disservice. The other thing is: I am and you should know 18 this, working with the Office of the Administrator to try to- 19 get an agency policy statement developed which will be sent to granteem pointing out what the Federal responsibility is 20 21. for monitoring activities which go beyond the lifetime of 22 PIIPIS, just trying to look to this eventuality and Dr. Margolis is very sympathetic. 23 Vie have drafted a statement and if this were to 24 occur, for example, then some of the time pressure would be 25 HOOVER REPORTING CO, INC. .I?n M;i-.@rhti@ptts Avenue. N.C.i 391 I off of free-standing organizations. You have to realize 2 that the Government always has programs terminating and 3 continuing activities within those programs. 4 All I am trying to do is to formalize a Federal 5 responsibility at an agency level which would assure Texas 6 and its affiliates, as well as all other grantees, that shoul@t 7 another monitoring device beyond the RMP be necessary, perhaps 8 it could be this agency or the regional offices that could 9 assume that responsibility. 10 If that were the caset then-the fact that an' 11 activity got started later, that would not be so detrimental. i 12. Because that is the thrust of Dr. Ferguson's point of view. 13 In essence, I don't believe that we can accept 14 those kinds of workloads T)rojected into the future with what 15 I know to be our own situation. I feel Texas has a tight 16 to choose its method of handling its funds and grant appli- cation. 18 I do not believe that it is in any other position 19 than any other PI.IP or will be treated differently. To that extent then, we leave you to your own 20 considerations. But perhaps it does give you some guidelines. 21 MR. CHZXIIBLISS: Thank you. 22 Dr. Vaun? 23 DR. VAUN: I think we are playing semantics here. 24 It is unfortunate that Texas picked the word 25 HOOVER REPORTING CO, INC. 320 Massachusetts Avenue, N.[. 3 -02 ficontracts." I think we awarded slush funds in the last day 2 and a half and I don't see any reason why, because they selected the word "contracts," that we should treat them any 4 differently. .5 We talked about slush funds up to $800,000 up t6 6 this point, with very ill definition of what was going to 7 happen to that money, besides it was being tucked away for 8 future legislative proposals. 9 DR. SLATER: May I make a motion to get something .10 on the floor and that is that we, I find it possible to mak e 11 any decision on' how to cut back on what they suggested, so 12. I make the motion that we fund them to the amount that they 13 requested and that 14 MR. THOMPSON: After all this, you are going to 15 do that> DR. MILLER: Go ahead. 17 DR. SLATER: Subject to the contingency that the 18 proposals that they submit are reviewed by a technical 19 by the staff and bv a technical site visit. 20 I think the point'is, I don't think that we can 21 bypass this committee if the committee will have to give the 22 responsibility to some members of the committee and staff to go to Texas and it is just one da to get a grasp on this, 23 'Y 24 to see if we are fulfilling our Federal mandates. t I don't see this as a slush fund for Texas project 25 HOOVER REPORTING CO, INC. 320 Massachusetts Avenue, N.[. I think that the technique used has just been delayed bring- 2 ing projects to look at. 31 MR. VAN WINKLE: Who would the site visitors 4 report back'to, doctor? This group or Council or to whom? DR. SLATER: Back to this group who will be 6 sitting here in July. 7 MR. CHARABLISS: I. think Dr. Pahl has, if I may 8 make the point, has stated that we are uncertain as to the 9 status of our staffing after the first of July and we have 10 no indication as to what our staff availabilities will be 11 to help decide this question. 12 DR. SLATER: You have another round of you 13 have another review cycle to handle. 14 MISS MURPHY: July and August. 15 MR. VAN WINKLE: Another group has laid on us that visit here, right? DR. PAHL: I think there is a different question 18 than what I heard coming up before. 19 We do have a July meeting of this committee, an 20 early August Council meeting. If what you are doing is recommending approval 21 22 subject to your reconsideration in July and then notification 23 of the region and if the Council would buy that, they would 24 thereby in reality have a mid-July approval from you for the full amount. 25 HOOVER REPORTING CO, INC. 320 Massachusetts Avenue, N.[. WashinRton, D.C. 20002 1 DR. SLATER: We met here on July 18, which is one 2 week after they are going to submit it. 3 DR. PAHL: That gives them three weeks. 4 1 understood you to say that staff to d6 it July 5 20. You may recommend approval with -- contingent upon it 6 coming back and confirming it at the July meeting but basically 7 that does not give the money to Texas and they canit go ahead 8 and spend it until July 20 or thereabouts which is three 9 -weeks different than if they take more time to describe it 10 in their July 1 application. 11 I don't know whether that is a good thi or 12, not. 13 DR. SLATER: Is it technically possible for thi-s to be approved by the Council and not have to go back to the 14 15 Advisory council? Could they give this-review committee final right 1(; of approval? 18 MR. THOMPSON: If we make that recommendation. DR. PAHL: We would take that recommendation to the Council. If thev accent it, then we could implement it. 20 DR. CARPENTER: It seems to me that we can. 21 22 accomplish the same thing in a much more Istandard wav. I suppose that if we are right, that these people do have the 23 24 opportunity to develop a good selection of projects, and we want to get them started on that, we can approve an amount 25 HOOVER REPORTING CO, INC. 320 Massachusetts Avenue, N.E. Vlashingion, D.C. 20002 39-@ 1 of money now'. 2 For instance, we viould want to support their 3 11 corns staff right away. We could sunnort something around. 4 $1 million which would get them well past July and if they 5 have the confidence that their program is reasonable, they 6 can assume that when we have a complete description in July 7 we will approve such addition al funds'as will be necessary 8 to carry out the program. 9 I think what we have is a region that is now 10 operating $348,000 worth of Projects, a very small number of 11 projects. 12 They are saying that within a ear they can y 13 productively spend nearly $1.5 million on new projects. 14 I think that I will require additional convincing. So, I think that you get.-them started and they have Dlentv of money to go on, until we have a chance to see their detail- 17 ed proposal. 18 MR. THO.IIPSON: May I ask a question, because I am 19 confused at this Point. This damn telegram that keens zip ing in, we 20 p should have taken it up this morning. 21 22 We are talking about 25 additional projects, is that correct? 23 e DR. SLATER: No. 24 MR. TIIOMPSON: You are talking about these? 25 HOOVER REPORTING CO. INC. 320 to@,amchusetts Averue, N.[. @p nn,,A-, 39b I DR. SLATER: They requested the nrogram staff 2 money and then they have also requested in this package'. 3 money to continue and complete that which is already under 4 way. Something like $348,000 there and then they said we need about $1.5 million for new studies but we haven't got 6 the projects yet. We have the areas and we put out to bid 7 but we don't have the project.yet because we haven't had 8 enough time to get them in. 9 We would like you to live us the right to spend 10 up to $1.5 million which is what the budget boils down to, 11 to support these contracts when we, when our RAG has received 12 them and decided what are the high priority.ones and bv 13 some mechanism this review committee likewise approve them. 14 tqe are simply being asked to approve in advance 15 what they are behind in.,. I don't see it as a slush fund because it has to be reviewed by their RAG and reviewed by 17 us in some way. 18 MR. THOMPSON: Let us just take this crazy, damned economics of the whole delivery system. $656,000 20 DR. SLATER: Those are guidelines for proposals. 21 Those are not the projects. you haven't seen a project 22 description there. You have seen guidelines for proposal. MR. THOMPSON: O.K. Then I understand I buy 23 .Dr. Pahl's proposal that we request Council to permit us at 24 25 ou.r next meeting to review some of these contracts. HOOVER REPORTING CO, INC. 320 Massachusetts Avenue, N.[. LV-hinafnn f) P gonng 397 DR. SLATER: O.K. 2 DR. CARPENTER: They'haven't even chosen sites 3 1 for these projects. 4 You look at the site selection sheet, they are 5 blank. 6 DR. SLATER: Because they have come in. The 7 whole reason to come in now instead of the next route is 8 based on their argument that they have one year leftilike 9 everybody else in the program and they haven't..asked this lo question about any other projects. .11 They said, we really need a whole area if we are .1 12, going to contract and try to do what we are doing. So, we '13 would like to give you a new advance. MR. VAN WINKLE: Dr. Pahl indicated that three 14 15 months from now or four months from now, contracts for a full 12-month period. It is just that the end product will be monitored by somebody else. They can let a contract. 18 DR. SLATER: They can do it up to the last minute as far as the monies are spent. 20 21 MR. THO@IPSON: 14hy can't we separate the thing 22 out? Give them a certain amount of money-, writing WIP's 23 and then request counsel to permit this Committee to review the hard proposal at the next meeting and approve or disapprove 24 them without going through Council. 25 IIOOVER REPORTING CO, INC. 320 Mamchusetts Avenue, N.[. 398 DR. SLATER: That sounds like a good idea. 2 I just had a question strike me like a bolt'of 3i lightning. 4 This is the first time it has happened. 1%7ho.is 5 going to monitor any of these things? 6 All of this work that we are farming out, Dr. 7 Pahl, who is going to be looking at the reports that are 8 coming in? 9 DR. PAHL: That is what I was alluding to. 10 MR. T80MPSON: We brought this up yesterday, about 11 what is the 12, DR. PAHL: In practical terms, it may not be as @13 bad as it always appears to be. 14 For example, the chronic disease control program 15 disappeared, but I remember @IP for about 3-1/2 years matching -16 contracts as a result of the Federal commitments. The whole 17 kidney activity that.we have been doing, is the fold-over 18 and so forth of that activity. 19 I sat with Dr. Mar"golis about -- well, a week.or 20 more aao and again pointed out to him that it would seem nice 21 if we could set this agency kind of policy statement which 22 could be sent to all grantees and we now have drafted one at 23; his request which will be looked at.every carefully and I am not sure what will eventually happen to it. 24 ii But it would be nice if we could tell grantees HOOVER REPORTING CO, INC. ,20 laamch s@-tts D.C. 2C,@;,_? 99 that we recognize the program and that there are continuing 2 operations and that the Federal Government, hopefully this 3i agency or regional offices, will monitor and that w won't 4 all have to get out contracts again. I can't make he commit 5 ment. Ile are trying. That is not a problem.. It will 6 happen. 7 DR. SLATER: We can pass this over to th nex 8 review-cycie. 9 There is only one problem. When they are oneratirg 10 by contracts, they withhold acertain Percentage, I think 11 20 percent of the funds until the contract is completed and 12 then they make the final payment. If they start. late on -13 a one-year contract, then we are past the fiscal year ending 14 and they will have. to pay out the funds for the remainder of 15 the contracts before the.-contract is completed and therebv lose whatever leverage they have on the contract. 17 MR. THO@IPSON: Miv don't we just hold the thing? 18 Why don't we just buy 1!) MRS. 1,7YCKOFF: Put it in escrow. 20 DR. SLATER: I would like to hear from Mrs. 21 Salazar, Mr. Chairman. MRS. SALAZAR: I don't feel that that is a real 22 23 factor in that the Texas EUIP has a board of trustees, so I assume that will have some fiscal responsibility to hold 24 these people accountable; am I correct in that? 25 HOOVER REPORTING CO, INC. 320 Massachusetts Avenue, N.C. n f, )nnn,) 40o 1 MR. POSTA: Yes, but at the uresent time thev 2 plan to terminate it. 3 DR. PAHL: You are in the never, never '-and of 4 grants, Federal legislation, and there is no one in this .5 room who can honestly state what will happen next J ne 30 6 and there are a lot of people concerned and working and nobod' 7 in this agency can tell you and I really say that i all 8 seriousness, because we lived with this whole activ ty, this 9 is the same set of discussions we had internally la t year 10 when the program was going to end, Jerry Gardell, Larry -11 Parker and others have been concerned Iabout it a year ago 1.2 and we are in the same position this year and somehow R-@IP's -13 are here and as a Federal manager, I am trying my best to 14 smooth the,way to,get a transition but I can't get a-cornnit- 15 ment. I would say, make your decision on the merits 17 of the case and don't worry about the tail end payments of contracts. Somehow it will work out. 19 Do what you think is appropriate for spending 20 the money effectively in Texas on the basis of the information 21 you have. And you have to arrive at that decision. But we will worry about the continuation. 22 JR(4)fls 23 24 25 OVER REPORTING CO, INC. 320 Massachusetts Avenue, N.C. tkfnthinotnn DE ,ogers/nii 4ol ape 4 1 DR. MILLER: I submit, -in antagonism, I guess, 2 against the motion, that it isn't going to make that much 3 difference with these activities, whether they start the 20th 4 of July or when does the council meet after? 5 DR. PAHL: 9th of August. Awards would go out 6 effective September 1. 7 DR. MILLER: It isn't. going to ma[re that much 8 difference, and I fail to see a reason why we should make a 9 special procedure for Texas.' Even though, I know they are- 10 accustomed,.to such treatment. DR. SCHERLIS: What was the motion you made an hour 12 ago? MR. CHAMBLISS: Was that a motion? 13 14 DR. CARPENTER: A motion with a second on the floor. 15 DR. SLATER: I will withdraw my motion. MR. CHAMBLISS: The motion is withdrawn and the chair will entertain a new motion. DR. CARPENTER: What I was suggesting is that what - 18 19 I move,, is that we fund Texas whatever the suin of $319 and program existing, plus the continuation project, $348,000,, plus 20 another $350,000 to give them wiggle room. 21, So that is $700 -- $1,100,000. 22 MRS. tTEIKOFF: I second the motion. 23, e MR. CHAMBLISS: It has been moved-and seconded that 24 Texas be funded for this round at the level of $1,100,000. 25 HOOVER REPORTING CO, INC. 320 Massachusetts Avenue, N.[. 402 Are you ready? 2 Is there discussion? 3 1 MRS. SALIZAR: Yes, does your motion, Dr. Carpenter, 4 include the rest of your first condition? 5 DR. CARPENTER: No condition, and I ho'pe they will 6 be back in July 7 DR. SLATER: We have'another cycle to consider. 8 MRS. WEIKOFF: Let them come back in July. 9 MR. CHAMBLISS: With the provision that they will 10 come back in July with a clearer application. 11 DR. CARPENTER: No provision, but just recommend that 12,they tell us all the good opportunities that they have in the 13 July meeting. 14 DR. @fILLER: I will second the motion. 15 MR. CHAMBLISS: It has been moved and seconded. Is there further discussion? 17 DR. MILLER: Could I ask the question from the staff's 18 viewpoint, the fact that they said they were not going to come- back in July does not mean they can't now change and come back in July. 20 21@ MR. CHAMBLISS: They still can come in July, yes. MR. TOOMEY: Question. 22 @IR. CHAMBLISS: All those in favor? 23 (Chorus of ayes.) 24 MR. CIII@IBLISS: Those opposbd? 25 HOOVER REPORTING CO, INC. 32OMassachusettsAvenue,N,E. Viasliington., D,C. 20002 (No response.) 2 CHAMBLISS: There is.no opposition and the 3 motion is passed. 4 DR. SLATER: The next round, all we are gO3-tig 0 0 5 is take a look at the 25 projects if they do it. We. in 6 essence, covered the basic text, of this Texas program, 7 @IR. CHAMBLISS: Let us take a short recess. 8 (Recess) 9 10 12. 13 14 15 19 20 21 22 23 24 HOOVER REPORTING CO, INC. 320 Massachusetts Avenue, N.E. Washington, D.C. 20002 4o4 OHIO VALLEY MR. CHAMBLISS: Shall we resume? 2 our next region for review is Ohio Valley. 31 The presenters for Ohio Valley will be Dr. Vaun 4 and Mr. Thompson, backed up by Mrs. Parks from the staff. 5 There are, in this region, a couple of nuances, 6 having to do with the two regions formerly in Ohio that are 7 no longer in existence. There have been.some special arrange- 8 ments made permitting activities from Ohio to be incorporated 9 into the Ohio Valley application. 10 I wonder before the reviewers make.their- presentation 11 if you would just like to highlight those issues, so that it 12 may be before the ConuDittee as a whole. 13 MR. VAN WINKLE-. What has happened is that the two 14 Ohio's had been phased out, and, as this revival came around 15 we started getting inquir3'-"e@ from there, where can we apply? '16 We don't have an organization, grantee. -17 ArrAngements, were made with the Ohio Valley Regional 18 Medical Program to entertain such proposals, having them act l@) as a grantee agency. 20 I want to call your attention to the fact that I 21 Delieve Dr. Paul made assurances to them that in no way would 22 affect their funding level, Ohio Valley's. 'I mean, it would -iot work to their detriment. 23 MR. THOMPSON: But, nothing in this particular request 24 reflects that change. 25 HOOVER REPORTING CO, INC. 320 Massachusetts Avenue, N.[. 1 MR. VAN WINKLE: I can show you where it is and that 2 is what we want to point out. It would be on page 200, under 3 "Discreet Activity Summary." 4 She indicates the feasibility st udies from this 5 study were conducted on four potential sites in the region. 6 Dayton, Ohio, Southeast or Harlan, Kentucky, South-Central or 7 Somerset, Kentucky, and Southwest, Georgetown, Ohio.. 8 There are two Ohio's in there that are not, fully 9 developed yet. 10 Now, it may even extend on to include Lima, Ohio, 11 and as far north as Toledo. 12, NR. 'TRQM.F$-GN*': I guess I do not know about the .13 previous geography about that craziness in Ohio, which, if 14 remember correctly, we tried to contract before. 15 So. in other words, Miami, where the Ohio University I.(i is, and the new medical school is'going to I:,e, was not 17 Originally in the Ohio Valley. 18 MR. VAN WINKLE: That is correct. MRS. PARKS: Dayton. 20 MR. '.THOMPSON.-., Miami DR. '.VAUN-.:': Where was Cincinnati before?. 21, 22 @a. VAN WINKLE: Ohio Valley. MRS. PARKS: Actually, what happened, or is happening 23 24 as far as the Toledo-Lima areas are concerned, they, of course, 25 'lave expressed interest in some kinds of activity with the Ohio HOOVER REPORTING CO, INC. 320 Massachusetts Avenue, N.[. Washington, D.C. 20002 4o6 I Valley Regional l@ledical Prooram. Part of it was through this 2 particular activity that they are interested in,, simply because .3 lit is a priority in that area. 4 There are three CHP "b" agencies within that area. 5 One.in.Dayton, one in Lima and there is another one in Ohio. 6 But there are three of them. 7 They have expressed an interest in coming together 8 to form a consortium and once this is done they will apply to the Ohio Valley RMP for funds for the development of a sub-. 9 10 regional organization for health., manpower and training. 11 The application has not been developed yet. There will be a meetin- tomorrow in Dayton at the Health Planning Council 12. C) 13 office and it will include representatives of the three CHP "b" 14 agencies within that area, representatives from the academic institutions, health service institutions, Halt agency, .1(; Dr. Milligan will be there, and program staff from Ohio Valley and I think several of the regional advisory council members 18 from the Ohio.area, Dayton, Ohio. And the purpose of the meeting is to discuss this 19 20 arrangement with the Ohio Valley and if they are interested in it, then they will make an application to the region for-fundin(- 21 It will still be subject to the Ohio Valley Regional 22 Advisory Council's approval. 23 They do not envision th"at it will be ready for the 24 Ixt meetin- of the council, which is'July. They figure October 25 HOOVER REPORTING CO, INC. 320 Massachusetts Avenue, N.[, f I which is when the council meets again, will be too late. 2 MP,. VAN WINKLE: You are'talking about the third 3. council. 4 MRS. PARKS: The Ohio Valley council, RAG, they call -5 it, 6 So what they are aiming for is to, with the assistance 7 of the staff from Ohio Valley, help in developing a project and 8 have it ready by August, and it is a possibility that the 9 RAG.will empower the executive committee to act and either- 10 approve, or. whatever. 11 But the RAG, back in 1972 and 1973, developed some 12,specific guidelines for the development of these sohniets., and 13 this is the reason for the meeting tomorrow. 14 They are going to inform this group of what these. 15 Guidelines are, and if they can conform to the guidelines, then their application will be entertained. -17 MRS. WEIKOFF: Is this,the 27(a) through'(h) or just @7(d)? 18 NU . PARKS: The funds budgeted in 27(d) will provide 19 20 funding if the application is approved for the Dayton, Lima 21 and Toledo area. 22 MR. THOMPSON: You said two Ohio programs went down 2.3 the tube? 24 MRS. PARKS: I beg your pardon? 25 MR. THOMPSON: Did you say two Ohio programs went dow HOOVER REPORTING CO, INC.I 320 Massachusetts Avenue, N.[. -4o8 1 the tube? 2 MR. CHAMBLISS: Were phased. 3 I,,IR. VAN WINKLE: Cleveland and Columbus. 4 MR. CHAi4BLISS: Known as Ohio State. 5 MR. THOMPSON: What about Toledo? 6 MR. VAN WINKLE: Toledo was phased out earli3r. 7 MR. THOMPSON: I will be danined, 8 MRS. PARKS: And it only covers certain partB. 9 MR. VAN WINKLE: @This is the only way that we can lo accommodate any requests from the State of Ohi o. MR. CHAMBLISS: Now that you have been informed on 12.future project activities in Ohio., may the presenters @ommence? Thank @ou. .13 DR. VAUN.:: I thought you were going to make.our job 14 15 easier Dy introducing tl@,.Ohio comments, but what you have done ,i(i is make it more difficult. 17 I don't think it has changed one iota, my comments, 18 and one iota on the budget, but it is an enlightening thing. 19 What it is goin(, to do is compensate the leadership 20 for the Ohio Valle program which, in my view, seems complicated y 21 now. That is, it would appear that the leadership of this @NiP 2-;) is somewhat of a coordinator of a troika, and I am not sure 23 how this new partner is going to alter that situation. To wit, e it would appear that the leader of this pro-ram has been an 24 architec 25 t Of sustainin- an isosceles trianole and making sure HOOVER REPORTINI. CO, INC. 320 Massachusetts Avenue, N.[. n f, )nnn,) 1 that all the angles remain the same, and now you introduce 2 another angle and this is going to-foul up the whole niess'. 3 This v@ill come out in the proposals. 4 The reason I say your comments are not going to 5 interest me is because the proposals are not going to be 6 altered one iota by another group, and my criticism will, I think,, remain valid. It would appear that RAG has sustained 8 its effectiveness. 9 I am a little surprised, in looking it over. I 10 shouldn't be surprised from the nature of the projec@t, that 11 there are six of the 40 identified as medical center officials. 12 There are nine also that I would identify as medical there are probably several others who are quasi-medical center 14 officials, so that the program is, although adequately 15 represented, it is heavily,.oriented to the' three medical 1(; i)enters. It would appear that their CHP relationships have 18 Deen okay. .19 Jean was good enough fo fill me in on some staff. 20 chan-es and she may want to comment further, because the 21 numbers on our yellow sheets were incorrect, and I was a'litt e 22 startled by thinking that they were expanding and they are not eally expanding. Their full-time professional staff is going 2,3 24 Crom nine to fourteen,.and these are primarily vacancies and 25 iot new positions. HOOVER REPORTING CO, INC. 320 Massachusetts Avenue, N.[. Washington, D.C. 20002 41o 1 Their full-tiriie others is cooing.to 47, so it would 2 be a total of 21. There are fourteen now. Most of them are 3 unfilled vacancies and not creatinc, new positions. 4 Jean, you also indicated to me that their deputy 5 director position has been filled? 6 MRS. PARKS: Yes, I learned several davs ago that 7 a former member of the program core staff has 'been approached 8 by the Executive Committee to assume duties, effective August 9 1 -as deputy coordinator, Bill Fox. 10 DR. VAU'li--'- I think that will help with@the increase(] 11 amount of money that they are asking for in the funding. 12. With regard to their proposals, my criticism is that 13 the pro'blems in Lexincton, Louisville and Cincinnati, seem 14 amazin-ly alike, both from the point of view of level of fundin@ 15 and typo of problem. To @'i@: I really can't understand how they would have the guts to apply for three colcimetry centers 17 in Louisville, Lexin-ton and Cincinnati, almost to the identical 18 dollar figure. I mean. that is a slap in the face that I just don't 20 understand how they could do that to us, but they did. In any eventI just took the worst of the ones without 21 o,oin- down to indicate that almost all of the other projects 22 23 area third for Louisville, a third for Lexington and a third 24i or Cincinnati. Whether it is ambulatory care, it is a third, 25 third, a third; that is why, I think, the leaders are going, HOOVER REPORTING CO, INC. -2 1, D@Oamchusetts Avenue, N.[. 4,11 to be in a difficult position when.tlie3r introduce the fourth. 2 I am not -- I should not be too critical because, 3 . I apparently., this program has been able to move with this 4 problem, and in ottierareas, this influence has parali ed other areas., 6 I might point out that I arrived at my deduction in 7 a rational way. I think the nature of this proposal reflects their leadership. They are heavil involved in ambulatory y 9 care, they are heavily involved in the ad hoc proposals and, 10 Jean,, unless you would want to add something more at t is point about what I have said before I give a figure, I am 12'ready to pass it on to my fellow re-viewer. 13 @S. PARKS: I agree with what you say about the 14 iierjical- centers bein- funded. They seem to come in threels. 15 But, I don't feel that they have created quite the severe l(i problem as you have discussed, and maybe this is my biased 17 Dpinion. 18 As far as the activities are concerned that they 19 iave developed, I thinlt most of them have been developed, really 20 )ased on study after study after study within the region and 21 .-hey, the activities, were developed from these studies, based 22 'In the needs of particular areas, and.they have sort of moved 2 t3 n the basis of that. DR. ".'VAIW-.I-: Tt 24 is a simple,' technical fact. that 25 rne dolcimetry center could handle all three States put to@ehte HOOVER REPORTING CO, INC. 412 I okay. 2 MRS. PARKS: Well, I wouldn't argue with the 3 DR. VAUN: As I worked through the projects 4 considering the nature of the overall project, I have arrived 5 at a figure that I am happy with production, that comes pretty 6 close to their targets, $514,900. 7 MR. CRAMBLISS: Is that our recommendations y 8 DR. VAUN: That is mine. 9 DR. MILLER: -What is the amount? 10 DR. VAUII: $514,900. 11 DR. MILLER: For what?. DR. VAUN: Off of their request. 12. MRS. PARKS: That is a minus. 13 14 DR. VAUN:. You didn't think it was an add-on? MRS. PARKS: I t:h 'ought it was a recommendation. DR. VAUN: Their request was $2b2,536. @fy identified 16 17 reduction was $514,900, making recommendation $2,507,63'0. 18 MR. CHAMBLISS: Mr. Thompson. 19 DIR. THOMPSON: I agree 100% with my primary reviewer. I will say that although there were many etters 20 from CHP agencies here,, it is obvious that they are playing games 21 because om letter here did not receive a proposal ifi time to 22 review it. They didn't endorse it. 'They said they wouldn't 23 11 turn it down but they would not comment on it. So, it happened' 24 to be that dolcimetry bit, which is tairiy wild. 25 HOOVER REPORTING CO, INC. Ki ri . 413 1 There was also a problem here about one of their 2 home car programs, that the primary purpose of whictiiif I 3 am not mistaken was to stimulate the coverage of home care 4 by Blue Cross programs. This stimulator had been in :he 5 works for four years. 6 It seems to me about time for them to fish r 7 cut bait on whether or not Blue Cross will pick up home care. 8 Now., there happens to be a national policy for Blue 9 CrQss to do that, as much as there can be a national [)Olicy lo for Blue Cross but that looks. like a little bit of a@long 11 time to prove out that something is val id before some8ody else 12, takes over. They have requested continuation. 13 14 DR.. VAUN:. That was one of the largest, too. That fourth year project was a,.$200,000 request. 15 DR. SCHERLIS: I just wanted to ask some questions. The home care, as I add it, it comes to well over, 17 18 well,, it is about $491,0001, is the sume requested for home care, a great deal of which is developmental, at least $200,00j,. I am wondering what plans they have once this amount 1 20 of money is withdrawn as far as what will happen to the need 21 22 that they have stimulated within the conmiunity? It seemed like a rather short time. 23 24 1 have Iother questions. Perhaps I can get some Eeeling on that. 25 HOOVER REPORTING CO, INC. 320 Massachusetts Avenue, N.[. 414 1 DR. VAUN: I think this is what John was tr@l g to 2 raise in his point. 3 Now they have been four years in the process and 4 they are asking $200,000 again. So, the likelihood ill: that 5 much of this is going to remain under-funded at the end of 6 this year. 7 DR@ SCHERLIS: The other two items that trouble me, 8 ambulatory care, again, a.developinental component of @150,000, 9 and developmental for one of their sohmets or'for at least the 10 five additional sohmets. Their suborganizational res onse for 11 health, manpower care and training, I think they have the very interesting, very long and very:varied list of proposals. 12 13 But my concern even more here than elsewhere is what happens when that year ends? They will have built up needs 14 people and no vestige of opportunities, I think, for a great 16 many of these to be supported, particularly, home care. We have all been involved in the home care projects 17 18 for a limited period of timL-. When they die, they die. There- is nothin- to fix them up and they were going down the road with $500)000. 20 IIR. THOMPSON: Except management of the projects 21 that we picked up in the past. 22 DR. WHITE: I am still 6ot sure about this fourth one. 2:3 here is some money that would be earmarked for them. 24 @IRS. PARKS: For what? 25 415 iMR. CHA@IBLISS: For Ohio-. 2 @IRS. PARKS: Toledo, Ohio. The funds requested in 3 !'2 7 (d) . 4 DR. WHITE: That is the developmental complex. 5 l@IRS. PARKS: Yes, it is to provide funds for the 6 development of sohmecs in certain defined georgraphic areas. 7 They included in here some potential sites!, that they 8 plan to start them. The Toledo-Lima-Dayton ones would also be 9 included, but they do not have the application from that 10 particular group of people, as yet. DR. WHITE: This $150,000 is again an escrow account? @fR. CHAMBLISS: It is for future -project activities. 13 DR. VAUN: But., it would appear on the basis of some 14 Commitments by -- that is not totally an escrow. They were led 15 to believe that they would have some access to the Ohio Valley l(i program. 17 I am asking it again. Suppose it is awarded at the 18 level you recommended instead or what they asked? Isn't there' 19 :)ption to say to these other people, sorry, we didn't get all 20 4e asked for, therefore, you are out of luck? ,LNa. CRAMBLISS: We would have to give them specific instructions on that and we wotuld await your judgment on this 22 2.3 oint. DR. IFILLER: i4r. Chairman, there are three projectsI :),4 11 .,am asking the reviewers, there are three projects that are listed 25 ii t 416 1 developmental awards. 2 Are these projects is'this another way of having 3 $500,000 of a developmental fund which they can use as they - choose? 4 one of them is home care develo ental awards, 5 PM $200,000. One of them is sohriiet, $150,000, and one is 6 7 ambulatory care and developmental components, $150,000. $500,000 of developmental funds. Is this all open? 8 DR. VAUN: It is not open and that is how I arrived 9 at some of.my reduction. 10 11 DR. MILLER: You are saying, essentially, that those 12. are things that we disapprove of in engaging in? That $200,000 13 DR. VAUN. care thing as John pointed out, this is the fourth year. Now, how developmental can you 14 be? 15 MR. CHAMBLISS: Is their specific recommendation on that particular part of the application from the committee? @..THOMPSON: I don't think we can tell them that 18 we were concerned about, but if they want to give that, that is if) their prerogative. We need instructions to the re@ion. 20 I think we can say that we were concerned about the 21 odd coincidence of equal requirements for the same kinds of 22 desperate towns, and the second thing we ought to tell them, 23 24 we just really don't know how developiiental'the -fourth year 25 agreement can be.. But that is up to them. HOOVER REPORTING CO, INC. '4')n Mnttnphiizpffz Avpntip. N E 417 1 MR. CIIAMBLISS: Thant< you. We will note your 2 concerns and we will entertain a motion,. DR. VAUN: I move that the request of the Ohio 4 Regional Program be reduced by $514,900, to a figure of 5 $2)305,C)36, with instructions to the region that the specific 6 project that involves development components is that 7 27(b), Jean? 8 MRS. PARKS: Yes. Is that the solimot activity 9 yes. 10 DR. VAUN: @lay not be less'than $100,000,,may not be 11 less than $100,000. 12. \IR. CH@IBLISS Is there a second to the motion? 13 DR. @1ILLER: Second. MR. CHAMBLISS: It is moved and seconded that the 14 15 level be for the Ohio Valley, $2,305,636, with the additional 16 provisions cited by Dr. Vaun, applying to the region. DR. @4HITE: This 27(b), I understand, has not been 17 throu-h a review process. p 18 1.4 -DR. VAUN: No. it has not because this region phasing 20 out of one regional medical program has been given access to 21 this regional medical program, and I guess.they just didn't have @ime to do it. 22 @IRS. PARKS: No. that is' not -- the process of handlin 23 evelopments of activities has been approved by the re-ional 24 dvisory group. They do have some areas identified that they 25 418 1 intend to fund. The Toledo.-Lirna situation, now' that',has not 2 lbeen approved by the RAG, simply because they do not I 3 .ijapplication yet. But, the process of providing funds to 4 certain areas, provided they meet the guidelines, has been 5 approved. 6 DR. WHITE: My point'is, therefore, we cannot say 7 no less than $100,000, unless we appended that, and ttey 8 approve it as being a project, they would otherwise undertake. 9 The regional advisory group has to have the preroga- 10 tive of approving thi@. 11 MS. PARKS: Yes. 12. DR. VAUN: That is why I indicated no less than 13 $100,000. 14 DR. WHITE: If they say it is no good, we don't want 15 to do it 1(; DR. VAUN: How are you going to protect this region 17 which is out in the cold ri-ht now, having been told they 0 18 haven't access to this program? 1!) DR. VAUN: And they would not be penalized because they were doina this out of the goodness of their heart and 20 ID 21 they also handled two arthritis proposals, !and they agreed to monitor evaluate and carry on all grantee activities for those 22 ?articular projects. 23 MR. CHAMBLISS: As add-on S. 24 25 DR. VAUN: There is a way to obviate the criticism. 419 1 That is to guarantee the $100,000. 2 1 think if they do not award up to $100,000@tO'this 3 project, their request will be further reduced by $10 000. 4 DR. IQHITE: This $100,000 can be used for t t or 5 no thing. 6 @aS. PARKS: I am sorry, let me get this cl ar. 7 In- other words, the mone that you are appr ving for y 827(b) can only be used for the Toledo-Linia projects, f it. 9comes in and is approved? 10 DR. VAUN: Right. MRS. PARKS: They cannot use it to start a p activities in some other sites? 2. DR. VAUN: No. 13 14 MR. VAN WINI@LE: Would you award them 2205, whatever it is and in the other,ma@e-an additional award if it comes 15 throuc,h? DR. VAUN: If you tell me that it the best way to 17 18 say it, that way, and I will say it that way -- tell me what the rules are, and I will subscribe. 20 Now, I think you know what I am trying to say. DR. CARPENTER: I guess if I understood, he said let 21 us award them $100,000 less in July than if they come in with 22 this sohmet up north, and we will,give them another. 23 DR. VA UN: Is that what you are saying.? 24 MR. VAN WINI(LE: Your c6ncern seems to be over this 25 -420 solunet9 $100,000, whatever' it is.' 2 Let us say, in the award, that the 22 is for Ohio' 3 !,Valley and the X amount is for the other. 4 MR. CHABIBLISS: Making a total of.$2,305,000, just 5 as you have proposed. 6 DR. VAUN: I will revise my motion to accommodate 7 that statement. 8 DR. SLATER: I wonder if Dr. Vaun would revise h' 3-S 9 position since he is within $10,000 of the target figure, and 10 in view f all the criticism, why are we g iving them more than 0 11 100% of their target ficure? C> -12. DR. VAUN: Because I thin[,, I have arrived at my 13 fi-ure in a far more rational way than they arrived at their's. 14 I have no way of knowing how they arrived at their target 15 figures. 16 DR. @fILLER:. Which is the correct target figure? 17 lqe have two. 18 MR. CHA@IBLISS: The one on the long sheet is the- lq laid-up one and the more correct one. 20 DR. iNaLLER: 35291 -- which is 45,000? 21 MR. VAN WIINKLE: I would like to'point out that the taraet figure is for Ohio Valley. 22 DR. MILLER: Their developmental project includes 2 i3 @i.;hat they are going to give to Ohio Valley. So it is all in 24 @l@here. 421 NR. VAN WINKLE: I am only saying 2 NR. CHAMBLISS: Your point is viell taken, but the 3! -fmotion as presented by Dr. Vaun includes not only Ohio Valley, 4 but the additional $100,000 to take care of Project 27, is thatl correct? 6 MRS. PARI@S: Yes. 7 MR. CHAMBLISS: Now, question from Dr. Scherlis. DR. SCHERLIS: As I recall, we had a great deal bl'. 9 fun@. and games in all of our previous review committees 10 designating the various quadrants, or portals, in which we 11 place various regional medical programs. 12. Could you refresh my memory and tell me where Ohio 13 Valley was? 14 MR. CHAMBLISS: If I recall correctly, Ohio Valley 15 was in the upper quadant. 16 NR. VAN WINKLE: You know, this particular project ii you are speaking of is $150,000. 18 MR. CHAMBLISS: We understand that. It has been reduced to $100,000. That is the point that he is making. 20 MR. VAN WINKLE: I thought he said not less than that 21 DR. VAUN: You are satisfying rae.if you leave it the way it is. 22 23 IvaS. WEIYOFF: Not less' than $100,000. DR. VAUN: The award to this re-ion.. My reconunendati n 24 25 is $2,305,000, with additional $100,000 for 27(d), if the RAG i4nnUrRRi:PnRTINrrn lNr. 422 1 of the Ohio Valley approves it. 2 MR. CHA@IBLISS: I think that is of sufficient clarity, 31 Doctor to be understood. 4 If they don't request that amount, then the principle 5 of reversion tat-,es place. 6 DR. SCHERLIS: Call for the question. 7 NR. CHAMBLISS: All riaht, the.question. 'Those in 8 favor of the motion? 9 (Chorus of ayes.) MR. CHAI.-IBLISS: Those opposed? 10 11 (No response.) 12. D@IR. CHAMBLISS: The motion is carried. 13 Let'us now turn our attention to the application from Oklahoma. 14 15 17 18 19 20 21 -24 25 HOOVER REPORTING CO, ItiC. 423 OKLAHOIIA 2 MR. CHAMBLISS: Oklahoma will be reviewed by. 3. Dr. Scherlis and Mr. Toomey with Miss Resnick as staff repre- 4 sentative. 5 DR. SCHERLIS: For those of you who are iDerhaps not 6 familiar with Oklahoma, perhaps I can give a brief history. 7 Oklahoma had been very heavily oriented toward 8 professional education, and for sometime the feeling was that 9 this.v)as not only its main th@ust, but almost its only thrust, 10 This posed some problei-a.. 11 It has,always been very much procedure-oriented and 12 this is apparent when you meet with both of the regional 13 medical program advisory groups and when you review the 14 programs that they had over the years. They have had a change 15 as far as leadership is concerned. Their present director is Albert M. Donnell and in 17 his letter of April 30th, with his grant request, I think he 18 indicates some-points that I would like to refer to because I$) it at least gives some orientation to the rest of their appli- 20 --ation. 21 As he points out, the budget request which he s'uiDmits 22 Ls based upon how the money can best be invested wisely and 2tl I)roductively in achieving the maximum cost effectiveness for I- !thort-run and also aids in the long run. 24 25 I think, and it is an important statement, because, OOVER REPORTING CO, INC. 20 Massachusetts Avenue, N.C. n r, -)nnn,) 1 as you review their request, a great deal is based on cost 2 ef fec tiveness. 3 When they put together their application, they did 4 it in A way that I think will merit some discussion. .,They saic' 5 their program development began with a consideration of the 6 past and present DRMP mission, including guidelines and 7 priorities with anticipation as to the most probable cause 8 of action Con@ress would take in formulatin- remedial legisia- 9 tion. ORMP structure was then closely examined, including.its 10 RAO organiation, past and present program activities, the 11 staff structure and personnet.capacities, and the roles 12. relationships and functions between the grantee institution 13 OUHSC and ORIIP. 14 The program then evolved and was further structured 15 to demonstrate the willingness and ability at the State level 16 for health planning, devei'opment,,implementation and regulation to co-exist and function effectively, although under different or-anizational entities. 18 0 They submit this as bein- their new game plan. l@t they have done is to put to-ether a series of projects and 20 21 plans which relate to, I think, a great deal of emphasis on 22 provider base and also. on consortiunis of hospitals to reduce 23 costs as far as the various services which they give. There are a few points which I want to make in this ,)4 ilregatd. They state they developed a program, the Ot@lahor4ia 25 HOOVER REPORTING CO, INC. 3'LIO Massachusetts Averue. N.[. ill,@ b;,rig+on, D.C. 2CiYJ2 425 1 iledical Program did not I want to emphasize, did not announc@ 2 an open invitation to bidders to regional support funds for 3 development of fiscal year '75 program.. Since the regional 4 health development area program, which they referred to 5 officially as RHDAP, and has been adopted as the'base program 6 for 1974. 7 The program content was related to the question where 8 to expand,, which development induced them to existing RHDAP 9 staffs and what supports are utilized in makinc, the cost and 10 quality effective. 11 What they have moved into, as best I can determine it .12.a structure called Re-ional Health Development Area Program, 0 13 and., therefore, have developed several such areas throughout the ,4 State, and have built their futur.e.programs on this, basing art of this on the fact that they are not quite sure which p direction RIIDAP or CHP will @o, so'they are loo[ring to an overall area type of programorganization. 17 18 They say that the major program thrust will include their continuation of remote coronary systems. 20 This has been areas where they have been quite success- ful in attracting a well-trained ca0i,(?-Iog'i@-t to assist nei-hbor- 21 0 Ln- hospitals. I might add that he is one of my fellows and 22 ,-.hat is a very effective program from what I have heard from him 23 s well as other people in the area. 24 They have emphasized I,,idney-centers, as part of the 25 HOOVER REPORTING CO, INC. 320 Massachusetts Avenue, N.[. wnqhill.otn,n 426 1 programs that they wish to continue. They have been involved 2 tlirouch their reaional health development groups, non-profit C> 31,icorporations known as @ledical Profit Systems,.Incorporated. 4 These are ways of sharing joint purchasing of druas, I .V 5 solutions, various other services. 6 This has proved to be, according to their cost 7 effectiveness analysis, helpful as far as reducing hospital 8 costs,, and becomes apparent as you go through their program, 9 that a great deal of their emphasis continues to be on io hospitals or providers working together as far as more 11 effective cost mechanism. 12. In reviewing some of the things that we would ,13 like to do and their staff, I think it is important to 14 emphasize a few things. One, their e),-ecutive director Dr. Donnell has been 15 16 their for a year and four months. 'They have associate director, 17 director of telecommunications, program director, program assessment manpower development, placement service, emphasis,- 18 y ac,ain on education and, I guess, that which speaks most to 19 1>0 what you can do through provider orientation. They do have 211 significant vacancies on their staff that I calculated out as bein- approximately $56,000 a year and some of these are at 22 ignificant levels. 2LI In terms of what they w'ould like to do with their !,4 ,Fl.aone they have asked for several re,-ional health development y HOOVER REPORTIW,3 GO, INC. 320 ?Aassa,,hLsetts A@ z --@e. %.E. W@Ai@@@ nr I programs, that, as I total it, come to something l-'[-e $500,000 2 for the total number of five or six which they have requeIsted 3 'and perhaps to give you a flavor of what these would like to do!,, 4 I can read from one of them, and many of them are pul@--together 5 just exactly the same way. 6 This concerns one of their medical product service 7 groups which is under regional,liealth development program. 8 This was-created for the purpose of achieving the following 9 long-range goals: 10 Promote area-wide participation of hospitals, other 11 health care providers and consumers, in exemplary programs for 12, effective cost containment. 13 Improve the availability, accessibility and quality 14 Of health services throughout the area through a more sophisl-i- 15 cated health care system in concert with State and area-wide 16 health planning efforts. Attract and better utilize health manpower in rural 18 communities. Promote expansion of shared services voluntary 20 hospital organization concept. 21 They are the -eneral ones. 22 Cost containment services will be pursued through the 23 following activities: -roup purchasing to initially include 24 drugs, I-V's and selected hospital-supplies- shared services i 25 to include micro'Li@ing and printing; shared personnel,, HOOVER REPORTING CO, INC. 320 Massachusetts Avenue, N.E - Wi@hin@tnn D C. 20002 42b 1 commencing with dietary and medical record consultants. 2 They put them into each one of these areas. A 3 whole wide range of programs which, if effective, would 4 obviously accomplish a great deal. They point to a complement 5 to their pharmaceutical, drug costs, 50%, I-V equipment by 6 40%,and so on. In each one of these areas where they have 7 planned or existing systems, they point out that they have 8 been able to reduce costs or will reduce costs. 9 They have stated specifically in their general 10 description that they are provider-oriented and certainly this ii has been one of their main thrusts, has been in that area. is 12.Other projects include program staff which $317,000, EMS 13 @raining, $100,000 so they are asking for a total of 14 approx@iately $1,380,000. This exceeds their estimated 140% tar et, $1,000,000, by a total of $350 000. They have, as I 15 9 16 pointed out, successfully developed some remote coronary 17 programs. Their emphasis is obviously now on their regional 18 health development area programs, which, if these work, can be- very effective. 19 20 Much of the effort appears to be in really reducing 21 costs by mutual purchases, the hospitals, and the others, as I have indicated, appear to be essentially.continuation of the 2-@ 23 projects. I will withhold any motion until there is further 2,4 1 Jiscussion,, and we have had staff comments on that. 25 HOOVER REPORTING CO, INC. 320 Massachusetts Avenue, N.E. 429 1 MR. CHAMBLISS: All right, than[.-, you. 2 Mr. Toomey? 3 MR. TOO@Y: I think it is interesting that the thrus@ 4 of the Oklahoma program has moved from their early cooperative 5 programs in the clinical field and evolved as cooperative 6 efforts in the management and the hospital operation. 7 I suppose the three major -- three or four of the 8 major efforts in the hospital field today have to do with 9 shared services, mergers, contract management and this ki nd io ofoperatio,n. The people in the hospital business look -- they ii look at this kind of evolution as being something really 12, tremendously desirable because it talc-es many of the problems 13 and many of the isolation factors related to small hospitals 14 operating as autonomous individual institutions that are 15 essentially uneconomic,bec,ause with small hospitals havin- 16 to purchase things that they purchase and hire the kinds of 11 People that they hire, in a small hospital and expensive -- 18 for example, a dieticians or social worker in a small hospital- 1!) may not have enough outlet for her capabilities or her capa- 20 'Dilities in that one institution alone. Whereas., the sharing of 21 people, the sharing of resources, whether they be financial 22 resources or personnel resources or equipment resources, has 2.3 to be, as far as I am concerned, it has to be the move of the 24 future in order to create some kind of an institutional health ,are system. 25 HOOVER REPORTING CO, INC. 320 Massachusetts Avenue, N.I. Now, I really only differ with them in the use of 2 some words. For instance, to call-it a health delivery system, 3@ I think it is probably wrong. I do agree, certainly, that it il@ 4 .an institutional kind of melting of services and sharing of 5 services. 6 I look upon it really as a thrust in two areas. One 7is economics and the other is the enhancement of the manpower 8or the professional personnel who are basically in short 9supply and-certainly if theycan be shared it is desirable. 10 SO, I can't help but be very much in favor of this 11 kind of move in terms of the service s. it enhances the services 12.rendered to the people; it enhances the problems, the cost of 13 containments. It has a very strong economic thrust in terms of 14 value to the community and value to the institutions and value 15 to the patients who use these institutions. 16 I think that it is an extremely desirable kind of 17 thing and I think that it is certainly interesting, that it 18 springs from the initial sharing going on in the heart disease, :ancer and stroke and they moved over into the institutional .:, ields, and I suppose part of the reason I don't know whether 20 J)onnell, however, you pronounce it, is a physician, if you call 21 Lim a doctor 22 MR. VAN WINKLE: He is a hospital administrator. 23 24 M. TOOIEY: Well, I remember that-, he was Donnell,@il.H.A. 25 HOOVER REPORTING CO, INC. 32OMassachusettsAvenue,N.E. WaRhington. D-C. 20002 1 which is a @las-ter's decree in hospital administration, so I 211 think it is, perhaps, just as logical . for this guy as a 3 hospital administrator to move his R i" in that direction as it 4 is for a physician Ri%M directed to move his RAG in the 5 direction of clinical services. 6 In either way, I think there are values to be gotten@ 7 and Oklahoma, as a rural State, as far-as I am concerned., with the 8 this kind of thin is a very large degree, I would say, at 9 9 present time, you could look upon them as almost a model. io What could be done from the institutional. point of view with 11 other institutions. 12 So, the,only other question that the only .13 question, really,@tt-iat I had was.the -- it is a small staff, bu- 14 if you put it on a percentagewise basis, it is about a 70% 15 increase in the staff that they are asking- This is one place, Mrs. Resnick, where I think we l@vc 16 17 to lean on you to find out if that increase in staff, with the 18 fact that their programs are under way, and they are just expandino, them, rather than bu@ding in a lot of new ones,. 19 C> whether that is justified. 20 21 I'FISS RESNICK: I think- they need some strengthening of staff. But I felt at first it was a little too much at this 22 time. 23 The regional health development programs are well 24 lon@ as far as the models are concerned, because Enid and HOOVER REPORTING CO, INC. 320 @tassachusetts Aveiue, N.[. 1 Bartlesville have been successful. Enid and Bartlesville 2 were initiated just as a pilot last spring Keith '74 iaonies, an 3 1 they do want to expand and probably will follow the 4 Bartlesville approach. They are getting very good reactions 5 from the communities. 6 You are right, they feel this is an excellent 7 mechanism for the rural area outreach and that is what it 8 will prove.- 9 As for this new.st.aff, I can't speak to it axactly- I haven't been in the area and talked to Mr4 -Donnell. I think 10 he needs some strengthening, but I am not sure that h -needs 11 C> that many people. Seven new positions are proposed . Four 12. .13 professionals and three clerical,administrative and that sort of thing. 14 MR. THOi'4PSON: Have you had any more definite relationships with CHP? When you-get these programs, then 16 CHP usually starts screaming. 17 18 NISS RESNICK: There are four funded eastern area 1!) CHP "b" regions which were extremely laudatory of the program. 20 One of the projects if you will notice, is to assist in western Oklahoma. Actually, it is two programs in' 21 western Oklahoma will eventually go on their own, but right now 22 it is a very weak area and they have had a rocky history with 23 the CHP a-ency and even the "a" agency. 24 I,lr, DonneL4:1 think,was with the a agency and he is 25 HOOVER REPORTING CO, INC. 320 Massachusetts Avenue, N.C. DC 20OD2 433 well aware and sensitive to this development in connection with 2 the CHP "b. 3 He feels that it is helping to strengthen the 4 relationship. 5 Now,, if that answers the question 6 DR. SCHERLIS: I have tried not to put too much 7 a qualitative feeling when I presented it. I come away quite 8 co6l to this. 9 I think a good many of these projects should have .10 been done by the Oklahoma Hospital Association without having 11 any semblance of involvement whatsoever, of any consumer @12 groups or other regional cooperative ventures. 13 I d"Ld-.nbt know that he was a hospital administrator. 14 If I had, perhaps I would have so identified him in the 15 presentation and it would'.1-iave been covered fully by that. 16 1 say it only because .I'don't think this reflects 17 a regional cooperative venture. I thin[,, it reflects the swing 18 away from what they used to have. When they formerly were 11) heavily oriented towards education, who was it, Dr. Dale Dromes, 20 and I was very concerned because it was totally professional 21 education and we spoke then rather prosaically of this or that 22 medical prograri., having turned the corner,.and Oklahoma seemed at that time never to find t e correct corner or a correc 23 corner to turn. 24 25 Now., they have turned and are still heavily provider HOOVER REPORTING CO, INC. 320 Massachusetts Avenue, N.[. W;t,dilnoinn D C 20002 1 oriented, but now it is a different group which is providing 2that and that is the hospital-based need and they are spinning 3 loff cooperations which are looking at what I.thin't-, are very 4im ortant aspects of mutual purchase of equipment, sharin- of p 5facilities and I see that the thrust that they .point to 6under proposals, are one thing. When they get progress, they 7can point to the facts that they are now reducing the cost o-P 8I-V equipment and now have joint microfilriiing,and so on, but 9these are -the progress notes. 10 Under their whole area health programs, much broader 11 thrusts are envisioned. But, I think they are doing first 12 things first. Everyone does his own thin-, and I thin[-, he 'is 13 doing his own thing very effectively. 14 I would like you to react to that. 15 MR. TOOMEY: I react two ways. One is, you could conceivably say either the medical'societies or the various ,7 medical schools, and all of the States have been involved in the contribution or dissemination of medical information to the 18 outlying rural areas before RMP came in with its medical thrust. 20 You say the hospital association should have done it. Well, the hospital association is a collection of individual 21, 22 Institutions just as the -- just as the medical society is a 23 collection of individual physicians, and I think that each one ias its own thing to protect. 24 25 I think that they are trade'associations, either way, HOOVER REPORTING CO, INC. 320 Massactiusetts Avenue, N.[. Washinptori. D.C. 20002 435 I and to say that in the profession of institution management 2 the hospital association should inflict its desires for great 31 development of an' integrated health delivery system utilizing I 4 all physicians is any different from saying that the hospital 5 association should indicate all hospitals, so that you have 6 hospital systems. 7 You can argue one way and I think it is just as 8 inappropriate, really, for me to say about that, about the 9 medical association, just as it is for you to say it about the 10 hospital association. 11 I think it is a major breakthrough in institutional 12 management, which is for the benefit of large numbers of 13 individuals. Granted it really is to the benefit economically 14 and in terms of quality of care. It provides these things hat were not provided befor 15 t 'p.. It is in a different context of clinical -- but it 17 does provide an excellent, an increase in enhancement of the 18 2aliber of care within those institutions, and I think that., I- 19 think you are going to be interested in what medicine does, 20 i@hat nursing and dieticians and x-ray technicians and what the 21 other people do. Because each has a bearing. 22 So, I think that, we are both talking from different 2.3 points of view, but from my point of'view, this is great. 24 DR. SCHERLIS: I don't mean this to be a debate. it 25 is obvious we didn't get together at lunch. HOOVER REPORTING CO, INC. 320 Massachusetts Avenue, N,E. 1 l@. CHA14BLISS: A brief comment by Viiss Resnick. 2 MISS RESNICK: The origin-of these area development 3. corporations was a manpower development device to begin with. 4- It is not emphasized quite as much in this presentation as it was the last time and that is still a component of their 6 operation. It is not just sharing costs and containments. It 7 is manpower seminars, workshops', development of -- they will 8 have a conference that is b eing spread out throughout these 9 hospitals, so it is a little more than meets the eye. 10 I don't think it is exclusively a hospital management 11 MR. VAN WINKLE: You wouldn 't believe the community 12 involvement in this program. Never saw such enthusiasm. 13 MRS. WEII@OFF-. This is just a piece of the whole 14 tt-ii ng. 15 14R. CHA@IBLISS: -I wonder if the representatives are ready to make a motion? DR. SCHERLIS: Recognizing that hospitals are 18 important, I would move that we fund them to the level of their tarc,et which is $1,033,000. This reduces what they asked by 20 $150,000, which I do without coneciencereally. M. CHA@IBLISS: If you will look at your spread 21 sheets, you will see the more current target figure-is 22 $1,062,337. Would that be covered in your recommendation? 23 24 DR. SCHERLIS.: I would"move -- yes. MR. CL@MLISS: Is there a'second? 25 HOOVER REPORTING CO, INC. 320 Massachusetts Avenue, N.[. r )nnn,) 437 MR. TOOIE@Y: I will second it, and then just as an 2 aside tell you that you gave $62-000 more than I was goina, to ask. 4 @IR. CHAMBLISS: All right, it has been movec and 5 seconded. 6 Is there further discussion?. 7 Dr. White? 8 DR. tiHITE: Is there some concern on the yellow page 9 about the duplication? EPS activities? 10 DR. SCHERLIS: We have been assured this is ot a ii factor. 12. 1,4ISS RESKICK: It is just a continuation of what 13 they have been doing. Very little additional money, training, 14 3nd, apparent ly, it is acceptable. CHAMBLISS: C 15 all the-question. MRS. I-IEII@OFF: Question. MR. C@IBLISS: Those in favor of the motion? 17 18 (Chorus of ayes.) MR. CHA@FBLISS: Those opposed? (No response.) 20 14R. CIiAl@fBLISS: The ayes have it. 21 I would simply wish, if I may indulge in the preroca- 22 23 tLves of the chair, maL-,e the observation that not only is the 24 coordinator of O'L@laho i-na an administrator, I understand that 25 his RAG chairman is a hospital administrator, one of your HOOVER REPORTING CO. INC. 438 reviewers, @ir. Toomey, is a hospital administrator. 2 Your staff assistant is a hospital administrator and 3 i so is your chairman. 4 And, I would say it is about time that hospital 5 administrators became more involved. We have sought to oet 6 their participation over the years, and it now comes it a 7 rather late date. 8 DR. SCHERLIS: Nothing succeeds like success. 9 DR. CARPENTER: Could I ask one questi on7 10 Is Mr. @ysor involved in the regional program in 11 Oklahoma? You didn't see the name in the application 12. IIR. TO@IEY: No, I didn't notice. 13 la. C@13LISS: I would like to note one thing for 14 the record if I may that at this late date in our review 15 process, that all of the reviewers,are still in the room. 16 I would like the record to show that. And, it shows 17 certainly the commitment that our viewers have had to this 18 process. 19 We do, indeed, appreciate the support that you are 20 givin- us in this review and I will say that I hate to spoil. 21. what Ihave said. Off the record. 22 (Discussion off the record.) M. CHAIIBLISS: Now, we,are back on the record. 23 24 Our last region -- our next.region for review is 25 South Carolina. After South Carolina., we will have only one HOOVER REPORTING CO INC. '4')(i Au ", N r 439 1 additional re--ion to coi-,ie before this panel 2 DR. 14ILLER: You have two., 3 MR. CHAIIBLISS: Thanlr, you for correcting me, we 4 have two after this. 5 7 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 HOOVER REPORTING CO, INC. 44o SOUTH CAROLINA RE@GION 2 MR. CliAMBLISS: Let the record show that Mr. Toomey has left the room for this review. 4 The reviewers here are Mr. Thompson and Dr. Vaun, 5 supported by Mrs. Kyttle, who represents the staff. 6 MR. TflOMPSON: South Carolina contains many of 7 the problems that we have been discussion here today, such as: slush funds. 9 Previous approval of contracts have not been 10 completed and so let me just start out with a positive point. There is on page 'Qb of the application, a thing 12 entitled a.chronology to boggle the mind. That reviews the 13 history of the poor South Carolina project from 1972 back up 14 to 1974, and it is true, it was @ chronology to boggle the mind 15 The program wasin the first year, I think, its triennium review program when the axe fell. Its RAG has 17 maintained itself, although I have many problems with the RAG. 18 I went through it and I find out that the RAG, there 19 is a total of 58 people, 24 of whom are physicians, ten of 20 whom are educators., four of whom are nurses, four of whom are 21 hospital administrators, ten of whom are other professionals. 22 one dentist and there are four civilians on their RAG. 23 Now, whom they represent. Eight represent the State 24 educational system' seven the voluntary health agencies, three 25 -F t-k@m !n -ea n-r-i -,).a f-@ N4 nc! 1 ii c- c 1 441 I official health agencies, four of them public State agencies 2 two in health plannin- 3 Down on the bottom, after you go throu-h s@ven from 4 hospitals and medical centers and, finally, six public 5 representatives which makes one kind of wonder what kind of 6 direction this pro-ram has @one into. 7 The proposals, then, are very clear and logLca y 8 presented. I will try to sum up what this is. 9 The objectives are in six Roman nlmberals. The regionalizati6n of service, health manp wer 10 development improvement, strengthening of quality ass ance 12, efforts, special categorical interests, primary h-ealt care .13 and advanced resources planning. 14 These reflect both inputs from the national and some inputs from the localsqene. Each operational project 15 is hooked directly, or indirectly, to one of these Roman numerals of overall priority areas. 18 However, do not be misl-,ed@ by the logic of this 1!) presentation. Because when one looks at the budget proposal 20 which, by the way, this is now,funded at $1.,250,000, their 21 target is @2444. Their request for this is $3,000,000 even and they have put us on notice that they are going to come 22 sliding in with another $500,000 which is a pretty big growth 2t3 I ?,4 for a program that has been operatin g at a rate of 1250. When one examines their request, one finds that 25 HOOVER REPORTitiG CO, INC. 442 Roman, numerals, six Roman numerals, and the staff accounts for 2 67% of the total requests. 3 Npw, in their defense., they have indicated several 4 future projects that are in the pipeline of each one of the 5 Roman numerals and they are not. They did not like Texas 6 saying, "Give us some money and we will put some of these thin-s 7 into effect." 8 on the other hand, they have asked an inordinate 9 amount of money for the support of these Roman numerals, which 10 are not connected at this time to specific programs. When one looks at the specific programs, even thouch C2 12.they only require only consist of 33% of the total budget, 13 they are.consistent with the main goals and they are consistent.' 14 ;iith wLiat little I know of health problems in South Carolina. 15 In other words tL-i@-te is -a nurse @iifbry project' L@or example. There is a great deal of attention to quality 17 -ontrol. 18 As you probably know, prenatal quality is a real ii) )robleni in South Carolina and the prenatal death rate is very 20 high, and they have paid attention to it. 21 I have some problems that some of the other quality 22 control or mecical evaluation systems. They are institutionally 2t3 based. Those hospitals that have@been doing their -'ob should 24 have paid attention to Quality Control lon,- before this word 25 HOOVER REPORTING CO, INC. 443 became stylish to PSRO or to any other kind of way. But, I 2 can't argue with this specific project. 31 '' ,Now, as far as the CHP relationships, something very 4 interesting has happened. Evidentally, the CHP agency and 5 the P@IP agency got together and.said, "What are we going to 6 do with this unknown legislation that might be comina sliding 7 down the pit-,e. 8 So., they decided to get together.to talk about an 9 advanced health@resource planning group. They are supposed 10 to have the "b" agency, the 'a agency and PLIP and $164,000. 11 was allocated to this advanced health resources group. 12 Evidentally, they were going along when one "'D" 13 agency, I think it was the "b" agency of Gharleston, zipped 14 in on this proposal. Since it seems peculiar that one a-ency 15 would scream, and the other didn'E scream, I tried to find out from the staff if there was a funded MO down there. That somehc@@i that "b" agency was the fault of the DRMP because Dr. Margolis 18 signed that grant and although they were no longer with RMP, 19 it might have helped-. We are very much in a problem then 20 that they are requesting to approve what is roughly $1,092,000, 21 in these six Roman numerals, which really represent a lot of 22 specific projects that have not been advanced. 23 Now I understand they have told the staff that if we 2,4 -ive them this money, they will not come back in the next round. 25 In other words., they would take the money that we woul unnurvoronDTINern iNr 444 give, for example, to quality assurance, and give it away,to some of the projects that they have in the pipeline of quality 3 assurance., 4 I am very reluctant to do this, although Ican see 5 the rationale of it, because I think we would, in essence,be 6 ivin- them one hell of a big slush fund. 9 7 It isn't that I don't trust them, but we haven't had 8 anybody else recently tried that big a structure, Let me close 9 then, 10 It is a well-written project. Probably the best 11 written project I have ever seen from South Carolina. The .12! priorities are carefully spelled out. The projects do relate 13 to priorities. They are making a real attempt to get together 14 with CHP and solve this. The health authority problem. 15 But I can't see civing them all this money for proj'ec:s 16 that are still unapproved. 17 I will close. 18 MR. CHAIIBLISS: Thanko you, Mr. Thompson. 19 Dr..Vaun?: 20 DR. VAUN: I don't think there is much doubt that the 21 eadersl-iip orogram has come through on this, very well. I'think 22 ohn has identified the makeup of RAG.. I am not sure that it Texas made any difference in the thrust of the pro,,ram, at least 23 as I surveyed the pro4ects. They don't meet too o'ten, but 24 Poarentl . they seem to cret the job done. The staff, in my 25 y 1145 1 opinion, looks good@ and I think it couches the realization 2 with CHP, in eneral terms. It is difficult, at this point, 3 jto forecast whether the divergence are good, whether they 4 are checks and balances or forceps that may prove to be 5 counterproductive. That may say a lot of it may not say 6 too much. 7 I must admit that I was more conformable with this 8 propos,al.before Texas and I mean that very sincerely. 9 I thin[-, I could have been very comfortable coming up with 10 some kind of recommendation before I saw wi-iat,we did specifical-Y ii with regard tokxas, and'that is even more so here because two- 12 third of the request is in this never-never land of advanced health resources plannin,-. $164,000. Primarily, health care 13 14 to b cts 0 e defined in contra that is 194. The other was 1'4. 15 Special categorical inter6's@, $404,000, etcetera. 16 1 think John has identified this. There is no - need for me to belabor it at this point. I think perhaps 17 18 Mrs. Kyttle could help us. MR. CHAMBLISS: Miss Kyttle, would you proceed? 1!) 20 MISS ICYTTLE: Going back to RAG, RAG has evolved 21@ and is still evolvin- into what it is now. It was a 72-mem'Der 22 c)ody with '0'3 physicians on it, not too long ago, and they 2t3 listened to get that RAG in a better balance and as memberships 24 @irote it, the balance is coming, it is not there yet, but it 25 is coiiiin-. HOOVER REPORTING CO, (NC. Ro,,ers/ml 446 1 But) South Carolina is and has been for some time 2Idivided into ten very precise medical districts, They are 311 planning districts. They are economic districts, and.they are 4Nqell-settled'districts for many matters.in the States. 5 14hen regional:medical programs began, it had a very 6 touryh time gettinc, off in South Carolina, until it assured each 7 district that a physician from each district would sit on 8 ,but iqhat they thoucht would then be the governing.body,l which 9 turned out tc, 'L)e,-the re@ional advisory group and they have 10 notmdved away from that promise. 11 So, whatever evolves from the RAG, you are goin- to 12, have ten representatives one each from its medical district. 13 They call them civilians down there, too. 14 1,T,. THOMPSON: I know, I took it ri-iit off your 15 checklist. end tape 6 16 .ontine on taoe 7 17 18 19 20 21 22 231 24 25 i4nnUFR RrpnRTING CO- INC. .447 JR-7 I MISS KYTTLE: The actual submission, that is not 1 dm 2 quite right in that they have not promised us that they will .3 not come in. But we put the regions on a bit of a spot. 4 Before they heard words from this review cycle, 5 we asked them to look what the next cycle would like and 6 South Carolina dodged and said, depending on what comes out 7 of this cycle, we will do this,or this or this. 8 We had their proposal and it sort of boggled our 9 minds and we hit the middle, the $500,000 is a middle 10 contingency and for the purposes of producing this right, but 11 not correct list here,'We hit $5,000 out of all of the 12 contingencies that South Carolina proposed right back to 13 US. 14 If they get full funding they do not plan to come 15 in. If they don't get fiiIA.funding, and it is this or,this 16 or this and that is the kind of contingency this July 1 is. With respect to the kinds of institutions that 18 they are dealing with, South Carolina had, about two years 19 ago when its hospitals got into accreditation and certifica- 20 tion trouble and that has fostered some of this activity in 21. some of the categories that you mentioned. CHP, the comments 22 on the vellow sheet do not relate only to CIIP. In South Carolina there@are at least five forces 23 24 that have been active in their own rights:and very active in watching everyone else. It is Appalachia, well-funded and 25 HOOVER REPORTING CO, INC. @nn ?d ri 448 dm 2 1 strongly provincial. CHpf 1.)oth'A and B, external and internal 2. problems. P-TIP, the State Health DeT)artment in which the 3 "A" is seeded and the Governor has created a Health Welfare 4 and Environment Council which is beginning to move State 5 money around from .everyone into everyone else and into the 6 Governorts Office. 7 And South Carolina is politically, healthwise, 8 in quite a turmoil right now. 9 I don't know whether it is that they are farther .10 along in.some States and they are getting to the range like 11 that other States will get to or whether it is the approach, I just don't know and that is why I say I don't know whether 12. 13 they will be good checks and balances or counter productive. 14 There is a lame duck Governor. 15 This Council that he.has created has made two attempts, neither Of which was successful, to get legislative life. It is just a dotted line out of the Governor's office and everyone wonders when the Governor goes, will the Coundil- 18 19 go. It is a political arena right now healthwise in South Carolina, to have pulled as much constituency together as 20 21 South Carolina did, is remarkable. MR. VAN WINKLE: Doesn't Westmoreland sit on that 22 Council? 23 MISS KYTTLE: No, not on the Council, he is runnin@ 24 for Governor. 25 ,,^^@irnnrnn*Tikii-nn imp 449 drn3 1 MR. THOMPSON: ily official recommendation was 2 that $2.2 million which is just under $1 million more than 3 they have.now, but is some $800,000 less than thev requested 4 and most of that money, I would suggest could be turned into @5 the second review when some of these programs in the general 6 areas were more specific. I am not making this as a motion. 7 I am just saving this is what I came out with. 8 I would not be adverse to recommending the 9 $2.4 million-, but I don't think that we can give them in all io due respect, all this money, these slush funds that they are 11 requesting. 12@' MR. CHATIBLISS: All right. .13 MISS KYTTLE: I alerted you that the pages of the application d6.show the people with whom thev will be 14 doing business with, the sites'with whom thev will be doing 15 business with and the money that will be involved. 17 Unlikd Texas, these have been received, identified, 18 negotiated, some of the budgets have already been negotiated. down. 19 20 There have been preliminary studies by CHP. CHP promises and that is part of the hang up there, their staff 21 has to get through things that require the time, some even 22 said we won't even need 30 days'-- some of the submitters 2t3 I are B's and they can get by late June their internal process 24 finished on these specific applications. They could have 25 dm 4 1 put a 15 in for everyone of them. They could have --ut a 16 2 in.for everyone of them but they.are not through their final 31 review process and South Carolina is very precise about their 4 review process with respect to their regional advisory' 5 group. 6 They would not put the 15 in this ap .placation be- 7 cause it hadn't gone through the second round through RAG. 8 It has,been through the first. 9 MR. THOMPSON: My problem is if it ain't in.the 10 book, I can't grab it. 11 MR. CHZLNIBLISS: Are there further points of 12. discussion? Dr. Miller? 13 (8) 14 DR. MILLER: Dr. McPhedran and I, after yeat er- 15 day's discussion and much discussion about slush funds, 16 discussed about whether we should put a motion in that would establish the principle of the review committee not to approve 18 anv slush fund components of applications and we discussed it a little bit and decided maybe it wasn't going to come up and maybe there wasn't much point in putting up a motion that 20 wasn't going to come up again and I just commented to him, I 21 has been inappropriate. It would have been a good 22 guess it 23 idea to have the motion put in, because it seems to keep coming back, doesn't it? 24 25 MR. THOMPSON: In their-defense, everybody is HOOVER REPORTING CO, INC. 320 Massachusetts Avenue, N.C. Washington. D.C. 20002 Li5l dm 5 laying $2 on the horse race and covering all 2 MR. CIIAt4BLISS: Is there further discussion? 3 Dr, .1,7hite? 4 DR. WHITE: Miss Kyttlon-, you are implying that 5 if this money was restricted at this time, in these numerical 6 categories, that they would by July have these things in 7 form which we could see, is that correct? 8 MISS KYTTLE: Yes, they were trying to obviate 9 the necessity to come into the July cycle and come in 10 September. 11 DR. WHITE: Thev were trving to save us a trip? 12 MISS KYTTLE: They were trying to save themselves -13 two months, too. 14 They have made inroads with MUSC on contracts, 15 affiliation agreements are tough for a year. Not too many I(; of us have sat around and said that. That is one of the beauties of a contract. In 18 addition to it, contracts as Cr.-Miller said, give you 19 opportunities to do things that when South Carolina discovers 20 the control of the contract, they like it, they have used 21 them sparingly through MUSC, because they.had to educate their grantee. Having done that, they propose the contract method 22 2tl with these. 24 These are and in that, it is merely a physical 25 mechanism and I think the group got hung up on the differences 41- 2 between agreements and a nroject and a contract and they are dm 6 2 all the same thing. Thev wanted to let them as of U.L-,r. L. 3 Also in their application they said the would 4 hope for July 1 beginning dates on the use and theylwill be 5 ready to go by then, they tell us, because they will have 6 had the opportunity to capture several things. They will hav 7 their full sta a@ full ff complement to monitor them for th 8 year in South Carolina and they do that precisely too. 9 They will have the opportunity to . come rough 10 the.review group here with the staff at its highest cornnlement 11 here in DPNIP because they see the erosion coming to staff 12. that Dr. Pahl mentioned, later, and they see the bodv that is 13 meeting here today that they are not so sure that there will 14 be the continuity'of it in Julv. 15 MR. TIIOMPSON:,/ -TA7hat is the incidence of hyper- 16 tension in children, does anybody know what the incidence 17 of hypertension is in children? 18 Dr. Scherlis, do you know? 19 DR. SCIIERLIS: No, I would assume vou would be 20 dealing with blacks as opposed to whites. -You would have a. 21 much higher incidence but I don't know what the incidence 22 would be. 23 MR. TIIOMPSON: They,have a specific orogram for hypertension in kids. 24 MR. CH@IBLISS: I can comment briefly on that. 25 HOOVER REPORTING CO, INC. 453 dm 7 That is the incidence of hypertension in black chil,:--,@@ does 2 not seem to increase until the stress mechanism gets to work- 3 ing and that is towards adolescence and above. 4 DR. 14cPIIEDRAN: I think it is quite significant 5 in black adolescent children. I don't know how high it is. 6 MISS KYTTLE: Part of the interest of that 7 activity is to nab beginnings of renal disease. As using 8 hypertension in children, female children considerably. 9 DR. WHITE: What is a special categorical interest? 10- Have you 'an idea what thev mean by that? 11 MR,. THOMPSON: The priority areas. 12, DR. WRITE: No, special categorical interests 13 for 14 MR. THOMPSON: That is IV. 15 DR. WHITE: lkpow what it is called. MISS KYTTLE: Because the others deal with heart, ii stroke 18 MR. THOMPSON: Hypertension, is their big one because they have a high black population. MR. CH&NIBLISS: Yes, but they don't develop the 20 21, mechanisms to take care of the hypertension once it is 22 discovered. 23 DR. SCIIERLIS: Just !screening. 2,4 MR. CHA,14BLISS: The mechanismis not there, I think in all candor, that should be said. 25 HOOVER REPORTING CO, INC. 454 dm 1 MR. TFIO,IIPSON: Diabetes is another one taat is 2 specifically mentioned in this, emphysema, arthritis, heart 3 disease, cancer, they cover the whole categorical @ing that 4 they had in hypertension, that in the pipeline there are 5 some peculiar ones, esophogean cancer. 6 MR. CHAMBLISS: I would like to get a sense of 7 the.committee's feeling,on this application and call. for a 8 motion if I may. 9 MR. T11014PSON: My second reviewer has a comment. 10 DR. VAUN: Jesse, in the Texas write up,l how much did you see where these contracts were going to and here? MRS. SALAZAR: None. 12, 13 DR. VAUN: My mentioning Texas, I think was un- 14 fair., Miss Kyttle, think-you did mention the who and 16 where? MISS KYTTLE: And the budget and that is import- 18 ant. 11) MR. CHP-1,4BLISS: The basic thing, would this con-mittee in its judgment wish to approve these before these 20 issues are in fact settled there? 21@ MR. TIIOZ.IPSON: That is why the recommendation 22 MR. CHX,,IBLISS: Would you put that in the form of 23 Index a motion> " Recor(im- 24 Bndation" MR. TIIOJ.IPSON: $2.2 rfiillion. 25 -455 dm9 MR. CIIA.'-IBLISS: The recommendation for a level 21@ of funding for South Carolina is $2.2 million. 3ii DR. SCHERLIS: I second that. 4 MR. CIIN,@IBLISS: It'has been seconded by Dr. 5 Scherlis. 6 Is there discussion? 7 Dr. Vaun? 8 DR. VAUN: John, I don't understand yo ur sub- 9 mission. This is the award for South Carolina, period. 10 MR. CHPC@1,BLISS: They can still come in. 11 MR. THOMPSON: There is $500,000 coming in. 12. MISS KYTTLE: There will be more than the $500,000. 13 MR. CH2V-.IBLISS: There will be funds available 14 at that time. 15 MR. THOMPSON:-The $2.2 million is arrived at by 16 taking out some but not all of these non-program areas. 17 MR. CH2UIBLISS: Would you like that instruction to go to the region -- all right, we have a motion, we have a' 18 second, we have discussion. 19 Shall Icall the question? 20 Those in favor? 21 (Chorus of "ayes.") 22 MR. CHXIBLISS: Those opposed? (No response.) 24 MR. CH@-IBLISS: The ayes have it and the level is 25 1.@56 dm 10 I set at $2.2 million. 2 I would call upon the Committee again to, ask 3 how we should spend our time for the balance of the after-' 4 noon? I am given to understand that the other panel will 5 coRplete its work today. They will met at 8:00 o'clock, they 6 will be available for a joint meeting with this Committee at 7 9:00 o'clock and I would like to know if you-would like a 8 break for a moment or would you like to continue? 9 DR. McPHEDRAN: 9:00 a.m.? 10 DR. SCHERLIS: Do we have any reason to meet 11 from 8:00 o'clock to 9:00 o'clock if we complete these two 12, regions? ','That would we do if we meet at 8:00 o'clock? 13 MR. CHA-@IBLISS: We would have no basis unless 14 the Committee wished to look over what it has done and we 15 would have a listing of,all the actions that we have taken 16 and a showing of the current levels annualized, the taraot 17 amount, the request and the actions coming out of this group. 18 I-le can look at our work product as a whole. J!) DR. MILLER: Let us finish un. 20 21 22 231 24 25 HOOVER REPORTINC- CO, INC. ti ri dm 11 SOUTII DAKOTA 2 MR. CTIA-14BLISS: All right, I would then ask,vou 3 to turn your attention to South Dakota. 4 The reviewer there is Mrs. Salazar, staff supporti 5 by Miss Resnick. 6 Mrs. Salazar? (9) 7 MRS. SALAZAR: In the interest of movin along, 8 I will.try-to shorten this. I promise not to do as 9 I did on Texas. 10 MR. CHMIBLISS: A little louder, please. 11 MRS. SALAZAR: The application is requesting 12. 6 continuing activities and the RAG has 11 of th em, ith 5 13 new ones. @14 Perhaps it would be better if I start in the back 15 of the summary that I see as a summary of this application. 1(; That the RAG and the staff are obviously addressing the ii peculiar needs of this State,.very large rural area with 18 limited man and woman manpower and resources in various remote locations. 20 They propose a consortium of educational insti- tutions and health institutions to very innovative and 21, 22 creative approach to South Dakotals health needs. Regionalization of the core of the center concen@. 23 24 is what they are proposing, is @iell supported and the region is making every effort to bring supported activities to the i 25 HOOVER REPORTING CO, INC. 320 Massachusetts Avenue, N.[, nr )nnng 458 dm 12 point of self-sufficiency. 2 As most of you remember., South Dakota -TUIP pulled 311 aviay from Nebraska-South Dakota which was the original 4 planning grant as far back as 1969. The first program for 5 South Dakota as a.separate entity was extended through August 6 of 1972. It gained operational experience immediately and 7 submitted its first triennium application effort last year 8 but because of pending phase out, it was never reviewed; 9 is that corr6ct? 10 MR. CHAMBLISS: That is correct. 11 MRS. SALAZAR: It was extended again in March of' 12 1973 through January of 1974 and approved through June of 13 this year. 14 I am telling you this because South Dakota seems 15 to have an awful lot of tt ,Arting and stoppina and yet there is a great deal of continuity through the whole application, which is amazing. At the time of the staff implementation crisis 18 19 this year, a couDle months ago, the region was found to be 20 viable and energetic and it was certified, I believe it is excellent in its review criteria and procedures. It naturally 21 22 has a great emohasis on rural out reach with a focus on man and woman power development through'the process of regional- 23 e ization. 24 There is an integrated nrocess with CHP planning 25 HOOVER REPORTING CO, INC. 459 dm 13 which is very remarkable, in th'at the CHP board is the RAG, 2 the one and the same body. Manpower training, the distribution and utiliza- 4 tion of manpower are primarily important to the region and 5 these elements are found throughout all of the projects. 6 I find this proposal a very exciting and well 7 organized Western Plains, no nonsense language. It sets 8 forth what it wants to do verv matter of factly into two 9 general categories of projects. 10 One, thos.e that are designed to achieve their 11 objectives within the 1975 framework of funding and; 12. Two, those with interim RMP support, and I-think 13 that is very significant that they specifically say this 14 interim report can be given impetus beyond 175 to attain 15 their specific goals or tcvachieve permanent status either I(; independently or under other funding sources. 17 The staff appears ready to move into new avenues 18 of health.resource planning. There is already good chemistry' 19 that exists between the other health agencies. Coordination 20 of efforts and cooperation with other agencies is very 21 apparent in the application. A quick review of the projects did emphasize the 22 23 South Dakota commitment to improving health services that are not now adequately covered. Yet at the same time the apdli- 24 cation is realistic, it is very local, it is very regional and 25 HOOVER REPORTING CO, INC. 460 dm 14 1 in response to the Geographic handicaps and that ver y rugaed 2 climate.that exists out there. 31 The in tandem onera4@-ion of the CHP aqency is 4 quite visible in a State of 600,000. of course the social 5 and Dolitical and business interrelationships is more apT)aren-0 6 than in under-nonulated areas. -1 The regional medical proaram there is bl d i,7 th 8 a capable and dedicated staff and it has verv enthus' tic 9 and energetic support and I believe ongoing continuing 10 supDort through the University of South Dako4--a. 11 The application states that this will be augmented 12, by two Additional nrogram staff nersons who have plannina 13 and evaluation expertise. It v7as a little unclear to me why 14 the a ication, in the application, whv the Indian 3 nvolve- .Ppl 15 ment in the corps staff, Aen so.many of their programs are based, have Indian populations, very large Indian populations 17 in the State and out-reach. There is no more active involve- 18 ment of Indians on the staff. Especially in view of manv 19 significant Indian problems in South Dakota4 20 MISS RESNICK: Staffing with Indian personnel 21 well, they are using their Indian outreach through their 22 RAG. There are four members representing the Indian reservation population and they are taking the service out to the reserva-I 23 tion in those corps components, working very closely with the ?4 Indian area office in Aberdeen. 'It is Vermilion and I think 25 461 dm 15 1 their resources would be extremely limited. That is where 2 the program is based. 3@i That is the onlv explanation I can give for it. I 4 I think they take it out to the reservations rather than try 5 to bring an Indian professional in where they have so few. 6 MRS. SALAZAR: they have some very talented Indiar 7 people in that State and that is why I was wonderin 'why 8 they-weren't involved more at the coriDs level.-' IIISS,RESNICK:-' I think it.comes through only at 10 the RAG and they take it out to the reservation area from 11 what I can judae. 12 MRS. IIYCKOFF: The staff out there., there is other 13 area staff. 14 MISS RESNICK:,,!rhere is eight components from the 15 staff and three or four deal with Indian reservations, .16 preceptorship, allied health, a summer training program and ii they are very close to the Indian program. 18 MRS. TqYCKOFr: I think Mrs. Salazar's question is, who is getting the jobs? 19 20 MISS RESNICK: Iknow she asked if there is an Indian person, professionals on the staff in Vermilion.@ The 21 answer is "No," but the only explanation I can give that there 22 23 are few resources around Vermilion and thev carry on their 24 activities right on the spot in the Indian reservation areas. MRS. SALAZAR: They are used, in my estimate, for 462 dm 16 instance, are using some Indians as consultants to come in 2 when there are deliberations that involve projects and 3 I planning for Indians. It is very important to have an Indian trhere to 5 find out if he wants to be planned for. 6 MISS RES14ICK: There are four Indians on the 7 RAG and it is through them that they are having the direct 8 contact., as-I understand it, with the Indian reservation 9 problems. 10 MRS. IVYCKOFF:.- The,,., do the planning. 11 MISS RESNICK: One or two have made certain II 12. proposals but thev have come from the Indian reservation or 13 hospital orogran,. I thought you meant staff. There was there is 14 no Indian staff. 15 MRS. SALAZAR: Yes 17 MISS RESNICK; They are very much involved. The 18 Indian health facilities and programs are very much involved- I!) in the Chair's activities and they have asked for help from 20 the Oahe and the Lewis and Clark,wherever they happen to be 21 close. 2-@ MRS. SALAZAR: I don't mean to imply that the program leadership is not energetic and well motivated. 23 e I-ii.ss RESNICK: I think thev are actively engaged 24 with them. 25 HOOVER REPORTING CO, INC. .63 1 MRS. SALAZAR dm 17 The RAG is also verv strong and 211 active and has organized into several, what is obviously verv! 3! productive committees. 4 The Chairman, interestingly enough is an author, 5 rancher, farmer. He is well informed of State Drobi ms and 6 involved in many community and educational health ef forts, which is probablv one of the reasons in the health education 8 community concept. He is an active facilitator and I gather 9 gets great respect throughout the entire Stdte:. 10 At the same time he is very adequately saccessfull@, 11 '-reoresenting all of their interests, of the CHP, as ell as 12. the MLP. 13 MR. THOMPSON: Is he on the CHP board as well? 14 MRS. SALAZAR: Yes, it is the same board. Forty- 15 one members. 16 MR. THOMPSON: Fifty-one percent on the board? 17 MRS. SALAZAR: I think it is interesting to note 18 that the executive committee of the RAG met six times in the. 1.1) last 12 months with almost 100-nercent participation in spite of that rugged winter out there, weather and the climate 20 21 too. 22 They seem to be very proud of the fact that their members also serve without remuneration. 23 F MISS RESNICK: They have project consultants who 24 serve without reimbursement. 25 HOOVER REPORTING CO, INC. 464 dm 18 Manv of them in this Particular Program4 2 MRS. SALAZAR: Just to wind up, the highest- 3 priority'rating of the RAG was assigned to the emergency 4 medical services. That program the,y have is very small and 5 they are only asking for th(@, training efforts, about $50,000 6 for that. 7 I presume that this means that there will be 8 another. application in emergency medical services ar,ter thev 9 try this one out. MISS RESNICK: They are plannin to and Ithev are 10 9 11 also going to come in here again in July 1. 12, The thrust is manpower development again. 13 MRS. SALAZAR: That is the next one. The two 14 health committee based centers. I believe basied-on the r)ast experience of South Dakota, that the goals and program Are achievable and the current momentum of the program indicates that thev have a 17 fairly good chance I believe, a fairlv good chance of settina 18 01 - out what they set out to do. Laudable, I think the CHP joint efforts are corlmendable. 20 21 I think that their efforts toward trying to bring Indian populations more actively into the program also are 22 23 very commendable efforts and I recommend -- may I make a 24 recommendation, Mr. Chairman? MR. CHAMBLISS: You'may indeed, Mrs. Salazar. 25 IMP 4b@ dm 19 MRS. SALAZAR: That we approve this application 2 as requested. DR. SCHERLIS: That would exceed their target by i 4 $531,000 by $198,000. 5 MRS. SALAZAR: Yes. 6 DR. MILLER: Being a neighbor and havinc had 7 much to do with the Texas, I thought it might be worthwhile 8 to say -a little what 1 know about the South Dakota program. 9 and its relationships. 10 As it started-out with South Dakota and Nebraska .11 together, incidentally, the reason Northland was mentioned I I 12. was before I ever came on board our big medical-centers in -13 Minnesota figured that we would have the Dakotas in Montana 14 and a good deal of the upper Midwest and so I have had a lot 15 to do with them it is,-a different story. But they have, they couldn't join with North 17 Dakota because thev never get along so they joined with 18 Nebraska, but they couldn't get along with Nebraska either 19 because Nebraska tried to dominate them. So thev are impeding 20 movements which could have gotten started in South Dakota. 21 But then Dr. Haves, who was the South Dakota associated' 22 coordinator of the South Dakota-Nebraska program moved, left 23 the PI.IP to become Commissioner of Health in the State and I. although I don't know, I suppose he is "- is he? 24 14ISS RESNICK: Yes, very actively involved. 25 HOOVER REPORTING CO, INC. 320 Massachusetts Avenue, N.[. -466 dm 20 DR. MILLER: He is completely attuned to this 2 whole movement. And Mr. Brecken is an outstanding leader, 3 staff leader and so forth, so that actually this re ion would 4 if it had gotten going sooner, would have had the p tential 5 to Achieve much further than it has now and we wouldn't have 6 this limited target estimate which is based on this very 7 late start.- 8 -NIBLISS: All right. MR. CH@ 9 MISS RESNICK: The target estimate is $571,000. 10 I am sorry the y ellow sheet was not updated. (10) 11 MR. CHA.MBLISS: We have a recommended fund of .12 $571,000. The requested level of $724,417. .13 I don't have a motion vet to that effect. 14 MRS. SALAZAR,; I said it was requested. 15 MRS. T,7YCKOFF: $729,714? MR. CHA!-IBLISS: Would vou restate your motion 17 since there is some question about which figure vou had in 18 mind? 19 The targeted figure? 20 MRS. SALAZAR: $729,714 as requested. That is 21 my motion. DR. VAUN: I will second it. 22 23 MR. CHA-MBLISS: It has been moved and seconded 24 that the level for South Dakota be 'Set at the requested amount, of $729,@liz. 25 467 dm 21 1 Is there a discussion on the motion? 2 DR. SCHEI@IS: Yes. At the risk of antagonizing 311 people who like m-,?--elf are hungr,,,, there are two sv-----@ 4 programs that I have question about. 5 One is the PSRO activitv of $100 000. 6 I was wondering if that is what we really want to 7 support? 8 The next question relates to the medical genetics 9 program which is a total of $46,000. 10 As I-read their nrogram, which 'isa verylambitious 11 one, in States many times that size, I was wondering whether 12, that is one of the prime needs for the State of South Dakota. IIISS RESNICK: They reduce the number of possible 13 14 trainees and this is tied to the medical school, a po int which I think Mrs. Salaza@failed to make. A four-year 15 16 medical school recently approved by the State legislature and -17 now going up for approval'bv the National Association. We met this professor and doctor in genetics, she, 18 19 has had support from a number of sources including a little bit from @NIP last year to get started on this genetics 20 21 program. She is looking for other funds and at the moment 22 nothing is coming through.. They think the States will support 23 it within a year. 24 It is for this reason that they would like very much to have this continued and not lose what she has already 25 unnuca orpnRTINC cn iNr I I 4'o- 8 dm 22 accomplished and she is getting.a lot of sunnort from the 2 medical Profession. 3 MR. CHX,4BLI8S: Ilhat is the purvose of the 4 project per se? 5 MISS RESNICK: It is a primary care, re lly, 6 activity with a referral, a resource for referral of patients 7 to professionals and to specialists. 8 MR. CHAJIBLISS: That are they looking for? 9 MISS RESNICK: They are starting with 10 MR. CII@'%IBLISS: All the chromosomes where you 11 screen for genetics are abnormal? 3.2. DR. SCHERLIS: I think it is one of the programs .13 in looking at many States, I would put as not high on a 14 priority listing particularly as one looks at the needs of 15 South Dakota. I am not addressing myself to the needs of Dr., Virginia Johnson who is in charge of genetics at that school. 18 I am trying to look at it from the point of view of what are 19 some higher Driorities in any of the projects that they submitted. 20 21 This is one reason that I wouldn't be able to support the motion because I would not particularly attach 22 23 significant priority to that. X4hat was their rating of that? 24 MISS RESNICK: The ftAO rated that among the ton 25 469 dm 23 three. And'it had a lot of visibility. 2 DR. SCHERLIS: I don'.t,know what they are going 3 ti to do with this when they get it. 4 MRS. IIYCKOFF: We hire all their products from 5 California. We will hire them all in California. 6 You needn't worry about whether they need them in, 7 South Dakota. Ile need them in California so-there is a place 8 for them. 9 MR. THOMPSON: I would remind you that California 10 is putting in for $8,017,000 and let them have their own 11 -genetics. 12 MR. CH;V.IBLISS: There has always been some policy .13 questions about RMP support in this whole area of aenetics, 14 including sickle cell and the like. 15 I probed a bit just to get a chance to say that. We have, as a matter of policy, suggested that projects dealina with genetics and sickle cell should go to the NIH 18 for support. 19 We will probably, althouah the committee has. acted on some other genetic applications, there have been 20 one or two in some of the packages, we will probably look at 21@ 22 those before they, before they are recommended for funds. 23 DR. SCHERLIS: Comment on the PSRO. 24 MISS RESNICK: It is identified as PSRO by our old options.. It is actually a continuing education activity 25 HOOVER REPORTING CO, INC. 320 Massachusetts Avenue, N.C. 470 dm24 which thev started last spring at a very low level and it 2 is to develop guidelines, I guess,,and examine criteria which will be essentially'a base for the PSRO organization 4 which the State eventually hopes to organize. 5 MR. CHA,?,IBLISS: The other policy issue, that is 6 there are funds from other sources other than R14P. That is 7 for strict PSRO. 8 MISS RESNICK: it is not a 9 DR. SCIIERLIS: I will differ with you-for one 10 reason. As I read their description of that project, it 11 goes along the lines of saying the Federal Government will 12, be funding sometime in the near future. 13 Vile are going to be geared un to ask for the 14 funds when they come out.,/ 15 MR. CHAI-%IBLISS: Yes, pure and simple. DR. SCIIE'RLIS: Ur) to the present time -- 16 MISS RESNICK: It is going to be a medical 17 research foundation eventually and I think this is to enable 18 19 it to get off the ground. 20 But I don't get the impression we have to restudy it. 21 DR. SCIIERLIS: A minimum of 25 percent of oractic- 9-? e I ina .11-ID's to soonsor for this T)rogram as it goes throuah. 21 1 - - - MRS. SALAZAR: I get,the feeling that since the 24 grant of the project is directed by the medical association, dm2 5 1 it seems to me that it is kind of a selling job. 2 MR. THOMPSON: Let them sell themselves @or, 3 1 PSPO. 4 MR. CHA.NIBLISS: We do 4ave prohibitions a nst 5 directlv funding operational activities in a PSRO. would 6 hone the committee would take that into consideratio 7 DR..SCIIERLIS: Mav I suggest $100,000 ofF the suggested level. That we don't have to specifv that it be 8 9 reduced as a matter of policy. 10 MRS. SALAZAR: I feel that there is a kind of 11 schizophrenia here because we have done some similar PSRO 12 activities in regions that we have kind of glossed over. MR. THOMPSON: Not today. 1 3 14 DR. VAUN: Apart from the PSRO, I don't hear anythina in there that tellis me there is going to be an 15 1(; operational PSRO. This is develonmental PSRO. 17 There has been a lot more than 40,000 that has 18 slipped through on PSRO. As far as genetics, it would apnear to me if there is no genetic facilitv within the State of 19 South Dakotai then I don't think establishing one in a medical 20 21 school, and the only medical school, is something that we ought to turn down. With,an Indian population like that, 22 there is probably some genetic counseling that should be 23 going on and if there is no.other g@netic counseling in the 24 State, and my guess is there is hot, I would be awfully 25 472 dm 26 hesitant to turn this down. 2 Tlaybe some advice should go to the department 3 i heads that they should try to conceal this money in some 4 other way in other departments other than to try to@itrain 5 20 technologists. 6 I think the money is worthwhile. 7 DR. SCHERLIS: I.am going to make a comment which 8 may be_pertinent or not Pertinent. I really think e get the States that are asking for small sums of monev.-, out tendencv 9 10 is to really use what is.a double standard in evaluation and 11 when a State like South Dakota or North Dakota or Oklahoma . I 1 12. come in and requests are made, our t(--ndencv is to say the- are 13 only 4skinq for small sums anyway. Let us ask for additional 14 sums. I would think@hat other criteria, that we would 15 question individual projects that they are doing, working, if this is the best way for the State to go in its overall 17 program and strongly urge that some individuals ao there to 18 19 the site visit to see what they are doing. 20 I have never approved the idea.of funds from TIP 21. going to medical schools unless there were strong needs 22 expressed by other segments, for these services, and I think to use funds for that ourpose, I would put it at a subsidiary 2t3 level. 24 25 I think to take a p@ogram which is now at a level HOOVER REPORTING CO, INC. 473 dm 27 of, let's see, $428,000 and to talk in terms of their 2 handling $300,000 more, is proportionately a large differ- 3 ence. 4 Novi, I would like South Dakota to be ab] e to 5 utilize funds of a much larger nature. But I would have 6 hoped more Droductively than this. Even if we reduce it 7 by $100,000, they are still getting over $100,000 over the 8 targeted figure. 9 I don't know if this is the wisest use that we 10 can recommend for it. 11 MISS RESNICK: Their base is also a planIning base. 12. Unlike the other orograms they were the onlv plannin g program., 13 that is olanning status; and they just became operational. 14 It was a fact of life in the calendar. 15 So that base is'a little bit unrealistic but 16 they seem to indicate that they could use the additional 17 amounts. 18 DR. SCHERLIS: I would rather thev put it in to 19 developmental or planning than into projects which they will have very little to do i-iith. 20 21 DR. WHITE: I would like to voice a difference of oninion. 22 Since we are second-quessing what is best for 23 South Dakota here in Washington, D.C. -- I am not through 24 5 we have heard from both primary reviewer and someone who is 2 474 dm 28 1 familiar with the.,rngion, that-this is a quality program 2 and would have been farther along if not for certain political. 3! problems. 4 We have in the nast two days reviewed other 5 programs,granted them what they have requested. Sometimes 6 it has been less or more than the target. 7 I can look at consultants for hc;spital-medical 8 training units. Again, I don't know if that is appropriate, 9 but I am not going to second-guess them. They know better 10 than I do what serves their purpose. 11 DR. MILLER: Just one comment. The comment that 12 has been made about action with regard to these, I drew the 13 analogy to affirmative action and I think we do have a double 14 standard. We want to support the have-not's. It is an affirmative action program.. Reverse Drejudice, if you like. 15 DR. VAUN: Question. MR. CHNIBLISS: Those in favor of the motion of 18 funding South Dakota at the requested level of $.729,417, 19 please let it be known by the usual sign of voting. (Chorus of "ayes.") 20 MR. CH2VIBLISS: Those opposed.> 21 (No.) 22 23 MR. CHMIBLISS: There is, one in opposition, Mr. Thompson 24 It is approved. 25 HOOVER REPORTING CO, INC. hi r 475 dm 29 TENNESSEE MID -SOUTH 2 MR. CHA-PIBLISS: The last one for review is 3 Tennessee Mid-South. The reviewers are Mrs. @7yckoff and 4 Dr. Miller with Mrs. Kyttle supporting staff. 5 MRS. IIYCKOFF: This is a request for $2,282,972 6 which is 72 percent of the target of which $370,000 is for 7 program staff and $1,094,000 is for 18 continuing activities 8 and $81.8,000 is for 21 new activities. 9 The present staff consists of 12 total, and proposed staff is increased to 18 with 2 added professional and 4 for support staff. 12,. The former staff was approximately 36. Their 13 present annualized rate is $1.5 million now. 14 The Tennessee Mid-South @IP coordinator is Dr. 15 Richard Cannon, who has behn on duty as such since last- September, 100 percent of the time; but has been in the RMP since 1968. 18 Ile came on board when Dr. Teschan left. 19 Perhaps we ought to have a little background on 20 what happened there. Dr. Teschan had a difference of opinion 21 with the grantee and technically 1 guess was fired by the grantee. He is a Vanderbilt Medical School man who has tenure 22 and is still there in Vanderbilt,. 23 The new man, Dr. Richard Cannon, the coordinator, 24 is also a Vanderbilt man with tenure. The big problem that 25 UAAUVO DrOnRTINr fA IN(' 476 arose w dm 30 as the communication of this P-1@4P by Vanderbilt. It 2 was very -- the board, the RAG was regarded by Vanderbilt 3 as its creature and they @,7ei7en't about to let go until there 1 4 was some pretty strong urging from T@;IP that this had to be 5 more of a tripar4l-ite-type program with the RAG independent 6 of Vanderbilt and with the coordinator independent. 7 So there was a big paroxysm and I think the R@IP 8 went down there and gave the parties a Dutch uncle, talk and 9 the act, the results were described in the report when the 10 recent -- this report says on September 9, 1973 in a 11 magnificent maneuver of Parliamentary procedure, the RAG 12. dissolved itself, reorganized a new RAG and adopted new bv- 13 laws,,all in the same meeting. 14 They formed a smaller RAG of 36 members with 15 broader representation limited to one three-year term and 16 elected an executive committee with broader representation. 17 And the grantee responsibilities were closely defined. 18 This was the real Droblem with trying to get all ce. of these people and organizations in the right Dla 20 The new chairman is a University of Tennessee 21 man, Dr. Cannon, and they have on it the president of the university at the South, he is the vice chairman, of the 22 University of the South at Sewanee. I was not able to identif@ 23 much more than three consumers or four consumers that really, 24 25 if you can call them consumers on that board, all the rest HOOVERREPORTINGCO,INC. 477 DM31 1 providers, so in a sense it has not been a very great chanae 2 in the character of the board. 3 Their past performance has been good in-a sense, 4 they have carried out their five priorities, access, regionall- 5 zation of health services and the sharing of scarce resources 6 high quality of health care at reasonable cost; community-basdd 7 health manpower consortium concept; and the promotion of more 8 effective utilization of health care resources. These are. 9 the principal goals. In the past two years they funded 68 separate 11 activities totaling $2,246,165 as follows: 12 Primary health care and emergency medical 13 service, 15 projects, $443,629,.using for example nurse 14 clinician and nurse Practitioner primarily in rural and urban 15 disadvantaged areas. 1(; They have launched seven emergency medical 17 service projects. $173,241 on that. 18 They spent $447,753 in new projects such as the nurse mid-wife teleconference program. 20 They have spent $414,392 on secondary care. 21- Seventeen projects in hypertension, Icidney disease with @22 special emphasis on dialvsis and organ-donor procurement. They have had five projects of $560,264 in 23 24 strengthening of quality assurance efforts. They have done regionalization, five projects, 25 478 dm32 1 $206,886. 2 For example high risk new borns to the medical li 14 centers for coTnp rehensive care. 4 They summarize all this by saying .they have taken 5 care of 634,681 iDeople -- 634,681 neoDle received emergency 6 service or aDnroved access to Drinary care and 626,178 Deonle- 7 received secondary or tertiary care. And 758 newlv trained 8 health personnel. 9 They take all of the credit for the R-.IP, which 10 I guess is legitimate in telling the story which they did. 11 The budget now in the application, 49,nercent is budgeted for continuation activities and 37 percent for new 12. 13 projects and 14 percent for staf 14 They give well, I don't know, it is getting kind of late, I don't knots/ how much you want of this. There 15 are eight new Drojects, six of these relate to rural appli- cation health districts. 17 18 One concerns a disadvantaged area. There are eight new oro3ects in secondary care and regionalization. 19 They focus on cancer, hypertension, renal dialysis, venereal 20 disease, pneumoconiosis surveillance and rehabilitation. 21 There is excellent distribution of projects throughout their 23 region. Now, we have of-the seven continuing projects, 24 two have received State-wide attention. These projects, one 25 unnurRRFPnRTINGCn-INC. I 479 dm 33 at the University of Tennessee memorial Research Center and 2 Hospital, Knoxville; the other at Childrenis Hosnit if 3 il Vanderbilt medical Center, Nashville, are concerned@with a 4 coordinated regional high-risk, new born service. The 5 service provides transportation in specially equipped 6 vehicles, of high-risk new bornis to respective medi,6al 7 centers for intensive secondary care. These'two pro'ects, .A 8 when combined with a similar project funded by Memnh s PIIP, 9 provide the State with a'netN%,ork of high ri8k,;nev7 brn lo secondary care. There is other Projects that they emphasize is 12, very important in the monitoring of hiah risk obstetrical -13 Patients at Vanderbilt Universitv Hospital v7hich is being 14 expanded from 5 to 10 hospitals in the recTion. Then they have 5 projects concerning the develon- 15 ment of health manpower. 17 One relates to the maintenance man in the small community hospital and Provides in-service training in basic 19 biomedical engineering and safety procedures. 20 Another under the.direction of the Tennessee 21 Hospital Association coordinates health manpower needs in the 22 region with production by education and includes the State 23 Commissioner of Higher Education's Office in the program's direction. 24 An innovative Program submitted by Aquinas Junior 25 HOOVER REPORTING CO, INC. .120 IAi-cArhiisp@tts Avenue. N.[.i 480 dm 34 1 College, Nashville, attacks the problem of hospital trained 2 allied health personnel, for example radiology technologists, 3 respiratory therapists, dental hygienists who desire to move 4 uD the career ladder by taking additional educational courses 5 and receiving the associate degree. 6 This is a planned work-study program which can 7 be extended over a Period of several vears. 8 I would try to.condense this. 9 In July they are coming in for a total let 10 me see, $658,127 in additi-on. There will be $189,746@'in 11 primary care, $130,774 in secondary care; $88,463 in manpower 12.. development and $249,144 in quality of care and cost contain- 13 ment. 14 So that will bring them over the 105 I think it 15 is percent limit. I have been throuqh this enormous number of small 17 projects and I must say, having made a site visit there, I really was very thrilled to see the development of some of 18 19 these projects that started out as just a little urge on the 20 part of a small ar.ouD of little students or some little effort to get something going,, esneciallv out in the Apnalachihn 21 Region where the needs are so great and the terrain is so 22 difficult. 23 24 I think they have done a job in cooperation with 25 the Appalachian Regional Commission and with that incredible 481 4- dm 35 health organization that they have up there, tha. is reallv 2 remarkable and I do give them credit and I would like to give 3 the students of Vanderbilt credit for keeping the nressure 4 on and getting these things done, really remarkable things. 5 The faculty has cooperated, sometimes reluctantly but has 6 cooperated to make these things become a reality. 7 There were only two projects that I raised a 8 question about. One was a project in kidney health education 9 in which they wanted to make a film for home dialvsis. They 10 wanted $125,000 for this and it seemed to me that there are 11 plenty of films on home dialysis that have been made. I know 12. we have made some in California and I think there have been 13 quite,a few films that have been made on this and I wonder 14 if this was a legitimate expenditure and there was $24,000 15 for a program on life ad'@@@ment to cancer which seemed to I(; me that they could refer to the national cancer situation, 17 which those two would make a total of.$149,000. 18 Those are the ones that I thought perhaps ought 19 to be either deducted or I would like to hear some more 20 discussion on these before making a final recommendation. 21 MR. Cl@@IBLISS: All right. 22 Dr. Miller. 23 DR. MILLER: I have verv little to add. I agree almost entirely with what she has said. 24 25 This is a very needy region, there have been HOOVER REPORTING CO, INC. @@. I------ id c 482 dm36 1 problems. I think a lot of their projects look like passive 2 funding enrichment for organizations to do things that are 1 3 or should be doing anyway, but nevertheless the needs are 4 great and I share her views. 5 DR. 14cPHEDRAN: Are the two projects th t you 6 question, do vou think that they are W-,IP guidelines MRS. liYCKOF 7 F: The kidney educational iml I 8 -think someone ought to take a look at that and see if it is 9 legitimate 4.- pe of film. y 10 MR. THOMPSON: Ther.e is no reason, unless thev 11 want to put it to country music or something. 12. MRS. L@IYCKOFF- Life adjustment cancer, I just- 13 think that perhaps 14 MR. VAN WINKLE: There are certainly grant ranage-i 15 ment regulations that they have to comply with in making a 1(; film. If they meet them there is nothing to preclude then 17 from makina the film. 18 But they do have to meet certain regulations. 19 MR. CIIXIBLISS: There is an O!..IB clearance that 20 they have to 21 MR. THOMPSON: Tell them to buy one or rent one. MRS. '@7YCKOFF:' Yes. I would like to recommend 22 2tl that their budaet be set at $2,133,000, a cut of $150,000. 24 $2,133,972, which is '?150,000 below'the amount that they 25 requested and it is even belong the 73 percent of their target. I 483 oriing back. dm37 I DR. SCHERLIS: They will be c 2 MISS KYTTLE: They requested $2,283,000. 3 MRS. WYCKOFF: This is $2 million 4 MR. CH)VIIIBLISS: There is a motion on the floor. 5 DR. MILLER: I will second it. 6 MR. CH)V,,IBLISS: Is there a discussion? 7 Dr. White? 8 DR. WHITE: I have been laboring on the question 9 of ignorance. Before Dr. Scherlis says I know it, I thought i 10 there was some formula in determining this taraet. 11 MR. THOMPSON: There is. It is 140 percent 12, divided, assigned out by the average dailv budaet for the 13 past 15 vears. 14 DR. WHITE: Why would theirs be $3 million? That 15 is 200 percent. 16 MR. THOMPSON: But thev went back and p cked un. 17 DR. SCHERLIS: Tell us about that bookkeeping, is will vou? 19 MRS. WYCKOFF: That is an odd thing. It is $3 million. 20 21. MISS KYTTLE: I don't understand their target level. I didn't set it or commute it. 22 !.IRS. WYCKOFF: I used what was on the yellow 231- e i sheet. 24 MR. TH014PSON: They took the oresent mix of 25 HOOVERREPORTINGCO.INC. Al..-@@. u r 484 dm38 I monies and got how much of the total part they are g@ting 2 now and then assigned that as a percent. 3 MR.:CHMIBLIS: There must be an error there. 4 There must be an error there. 5 DR. MILLER: It must be $2,718,000. 6 MR. CHIU-IBLISS: This is a computer error as 7 @opposed to being a 8 MRS. TIYCKOFF: Human error. 9 MR. VAN WINKLE: If you look at 10 DR. SCIIERLIS: It should be about $2.5 million. 11 DR. MILLER: Yes. 12,' MR. CIlAiMBLISS: Giving us 40 percent of what the annualized level should be. 13 14 MISS KYTTLE: I think the annualized level is 15 wrong. When the 6.9 was distributed, Tennessee Mid South didn't come in for any of it because it did not mee-t the 17 logical base on which the 6.9 formula was developed. 18 Well, when the money stayed out there in escrow for so long and was not permitted to be used for the reason it was Drorated, the lonaer it stayed out there, the less 20 21 rationale there was to,the base and so it was redistributed and Tennessee ',,-lid South came in for almost $200,000 in the 29 last days of its grant year that"I don't think is reflected 23 24 in its current annualized level of funding. MR. CIIAMBLISS: I would suggest 25 485 dm 39 1 DR. SCIIERLIS:, I always feel that you are so 2 clear and that I should understand you, but somewhere along 3 the lineiI know you are right, but 4 MR. CHP-T,4BLISS: Let me suggest to the committee 5 if you have discomfo.rt herei we can clear this issu6 uD 6 overnight and present this to you in the morning. 7 There is a motion on the floor that has@@been 8 properlv moved and seconded. 9 I am at a loss to in light of this., low we 10 should dispose of it. 11 DR. VAUN: That fiqure is related to thei request 12, and not the target date. So why don't we go ahead and vote. 13 Then if there is a gross error 14 MR. CHA-MBLISS: If the committee is comfortable with that, we will certainly rest)ect vour wishes then. 15 Shall I call for the question? DR. SCHERLIS: Question. 17 18 MR. CHP2@IBLISS: Those in favor? 1!) (Chorus of "ayes.") MR. CHI@IBLISS: Those op osed? 20 p 21 (No response.) MR. CHMIBLISS:- The level has been recommended 22 for the Tennessee Mid-South Regi"onal Program at $2,133,952. 2:3 24 DR. l@IOIGIIT: I would like to pursue this a little further if I may, Mr. Chairman. 25 486 DM 40 1 It is important to me because when I was not able 2 to make a judgment in any other way I figured it was no 3 worse or better than ten others that we looked at. Thinking 4 that somehow or another there seems to be some.disparities 5 on whether our decision-making was based on error in the 6 last two days. 7 MRS. WYCKOFF: It is a very disturbing thought. 8 DR. MILLER: Their targeted funds is more than 9 they asked for. We never gave anybody more than they asked for. DR'. WHITE: Their target funds may have been in 12, error. 13 MR. THOMPSON: Whenever we did that, the way 14 MR. CHP-MBLISS: Is there further concern on the 15 part of the panel? DR. MILLER: What time do we meet in the morning? 17 MR. CH@IBLISS: Let me close out by saying one or 18 two things here. 1!) First, you have handled your charge in a very commendable war,-. 20 21 I think the committee should know that Miss Kyttle 22 who has transferred from IIMP to the Health Services Administra-- 23 tion Division of Review, viill no,longer be with P24P. As a matter of fact, she has already transferred and I would like 24 to take note of the great work that she has done over the 25 HOOVER REPORTING CO, INC. 487 I vears as a member of the RMP staff. dm4l 2' DR. SCIIERLIS: I.would do nothing other than to 3 second that, 4 MR. CHA14BLISS: I would like the committee also \5 to note the fact that Mrs. Edith Leventhal, who has been over 6 the years one of the strong workers behind the scenes, has 7 given me support here today and yesterday and has provided RMP with a good amount Of staff support over the years.. 9 I would like you simply to note her participation 10 I would like to sall), that Iknow I express on 11 the part of Dr. Paul and the Health Resources Administration and the Bureau of Health Resources Development for the sunnort 12, 13 of and participation of this panel, and I would say that vou 14 have been very patient in tackling this job. Finally, I think you would like to know that the other panel is still in the process of completing its 17 DR. PAHL: They just started their last one a 18 minute ago. This panel won. MR. CIIMIBLISS: It has been agreed that we would 19 20 meet at 9:30 in the morning in the joint session in this 21 room. DR. PAHL: The arthritis meeting is meeting at 22 8:00 o'clock. 2tl 24 DR. t.IcPHEDRM@: How long do you expect that meetinc 25 is going to take? 488 dm 42 1 MR. CIIX,-IBLISS: l,qould you have an estimate on 2 that, Dr. Pahl? 3 DR. PAHL: I would guess it would perhaps onlv 4 be for an hour and a half because the purpose of the meeting 5 is more basically the two groups and chairmen to see that 6 similar topics have been handled equitably and to trv to 7 grouo the applications into a,master sort of three-leveled 8 tier, jtst these seem to be above average and these are good 9 solid ones and these are perhaps weaker,, but nonetheless- 10 satisfactory, but not'trv to do anything within the grou, ps 11 but this will be of help as we go to Council after this 12, lengthy period of absence and make. sure that similar problems 13 have been handled equitably between the two panels. 14 I would see perhaps mid morning, get together at 15 9:00 o'clock, it seems to me that vou ought to accomplish that in that period. I(; 17 The word that I received from the other panel 18 would be 9:30 as opposed to 9:00 o'clock. 1!) DR. PAHL: I-Ihy don't we trv to head for a taraet I I 20 period of around 11:00, if 9:30 is the time for the other group? 21 MR. Cll2U4BLISS: Do you feel that this panel should 22 23 meet for any further review activity in the morning?' DR. PAHL: Have you clustered your own aoplication@. 24 into three grouDs? 25 HOOVER REPORTING CO, INC. 320 Massachusetts Avenu i, N.E.