E(I)U 43 Transcripit of Proceedings DEPARTMENT OF HEALTH, EDUCATION, AND WELFARE W E'riclay,, 2x' Septeri)ber 1972 ACE FEDERAL REPORI'ERS, INC. Official Reporters @415 Second Street, N.E. Telepho!ie: Was.@ington, D. C. 20002 (Code 202) 547-6222 HATIONWIDS COVERAGE c DEPARTMENT OF HEALTIJ, EDUCATIO9, AND WELFARE c paw 2 3 4 RMPS,REVIEW COMMITTEE MEETING 5 6 7 8 9 10 Conference Room G-H 12 Parklawft Building Rockville, Maryland 13 Friday, 22 September 1972 14 15 16 17 18 19 20 21 22 23 24 Ace-Federal Reporters, Inc. 25 2 C 0 N T E N T S - - - - - - - --- 714 9 OLIG: 2 ARTA: PAGE paw 3 Mississippi 3 4 Missouri 52 5 New Mexico 95 6 Northern New England 139 7 Texas 157 8 Indiana 193 9 Memphis 210 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 A,ce-Federal Reporters, Inc. 2 5 3 P R 0. C E )E D I N G S - - - - - - - - - - - DR. SCfU4IDT: I think probably we should begin. 149 2 We thought that the order of the day would be to begin with 3 Mississippi, which is the las t of the demonstration presentations ba 1 4 for the committee and then stop and talk a little bit about the 5 visual aids and the sources of information coming to the 6 committee.' Then go on to a report of the Missouri Site Visit 7 and kind of a status report on Missouri. Them move to my state, 8 New Mexico, northern New England,.Texas, Indiana and Memphis, 9 in that order,!finishing before coffee break this@orning. iol So we will begin then with Mississippi. Dr. Iless.' 11 DR. HESS: Thank you.- I would like to begin just 12 by giving Particularly for the hew committee members a little 13 bit of background on Mississippi so that you understand a. 14 little bit better what some of the specifics are in our discus- 15 sion today. 16 At the April 1971 Review Committee meeting, when 17 Mississiopi'Pj4P was reviewed, a number of us were very con- cerned because of a program which did not seem to be functioning 18 19 very effectively in a region which perhaps has some of the 20 greatest needs of any region in the country by almost any health or economic index you want to'pick. Mississippi is at 2 1 22 the worst end of the spectrum, whether it be per capital income, whether it be physician Dopulatio n ratio, whether it be neo- 23 natal mortality, you name it, Mississippi is at or near the 24 P,ce-Federal ReporteFS, Inc. bottom. 25 We were very much'concerneci that rather than 2 2 unduly punishing a region,.that this region above all else 3 needed some assistance in order to get'itself reorganized to 4 qualify for funding more appropriate to the needs of the people 5 of the region., As a result of that deliberation, an assistance 6 site visit was scheduled in September of 197l.- And a number of 7 staff and consultants visited the region. 8 We had two days of frank -- listening to problems and 9 discussion-and feedback to the staff, the coordinator, and to 10 -select the members of the RAG. And then we returned to wait and 11 see what happened. Some of us who-were on that Seotember site 12 visit returned again to see what had occurred. We might just indicate for you some of the I 13 14 haven't had a chance to look at them, some of the recommendations 15 that were made at that September site visit. Concerning the 16 regional advisory group,, we recommended very strongly that they 17 reviey7 th@ir committee structure and reorganize it more 18 in keeping with the new directions in which RYIP was moving. 19 At that time it was largely categorical in its 20 orientation. And we specifically recommended that they deal i-iith,questions of planning and evaluation and help the -RAG' 21 22 become more intimately involved in these activities. 23 The core staff was@nbt functioning particularly well. 24 One of the,probloms was they were quartered in a variety of Ace- edeal Reporters, Inc. 25 locations around the University of Mississippi Medical Center 5 #1 I and this physical separation did lead to some fragmentation *a 3 2 and lack of coordination of activities. 3 And we'also recognized that there was some need 4for better communication and stronger leadership thrust 5from the coordinator. We also recommended that they consider 6setting back their time deadlines for their requesting a re- 7vision in the time for application in order to allow them more 8time to make the adjustments which we recommended. 9 We offered the assistance of the regional office 10 Iin Atlanta, M4PS staff in Washington and pointed.out they had 11 a good deal of work to do. The items that we will report on 12 and discuss today then deal to a large extent with many of the 13 changes which have occurred @nce that September site visit, and 14 @obert will begin the discussion of that as well as giving 15 you a little more background on the region, Bill Tobert. 16 MR. TOBERT: The Mississippi Regional Medical Program 17 covers the entire State of Mississippi, serves a population of about two million two hundred thousand people. The region 18 19 is bordered on the east by Alabdma, on the south by the 20 Gulf of Mexico and part of Louisiana..On the west by Louis- iana-and on the north by Tennessee. 21 22 So the upper counties.of Mississippi are somewhat 23 shared with the Memphis Regional Medical Program in planning an coordinating of activities. There are two distinct geographi- 24 Ac ral Reporters, Inc. 25 cal areas of the state. The first area is the north and south 6 Delta which starts in the Tennessee border, goes on down through, 4 2 over to Vicksburg. It takes in.tlae whole area. It takes in 3 all that portion of th e Mississippi Plain which lies within 4 the state border and which comprises-what usually is referred 5 to simply as the Delta. 'This arba is one of the two geographical areas, 6 7 it is-by far the smaller taking up about one-fifth of the 81tbtal land area of 14ississippi.. It is the only section of the 9 state where agriculture still provid.es more perso@l income 10I than manufacturing or government but this is changing due to-the 11 influx of small industries, the inability of crop producers to 12 pay a minimum wage and the technological advances in farm 1 3 machinery. 14 The other area is the East Gulf Coastal plain 15 stretching in Mississippi from the Tennessee hills of Appalachia in the north to the Point Ilills of the south which terminate 16 17 along 359 miles of Golf Coastal shoreline. Mississippi is almost 18 uniformly rural in terms of population distribution. The basic urban structure is the small town, often 19 20 housing one or more light industries'but frequently few phy- sicians, nurses or dentists. Povorty-was and i@ a fact of life 21 22 for too many Mississippians regardless of race. A total of 154,000 families or 50 percent of all 23 24 families in Mississippi earn less than $3,000 per year and are Ac al Reporters, Inc. ranked in a poverty class. The Mississippi @IP 25 7 #11 headquarters is located in Jackson which is also the capital 5 2 and is also the location of the University Medical Center who 3 serves the grant@e for PIAP. There were two subregional offices 4 of the RMP located in Oxford and in.Gulfport. These offices 5 were just recently established, with supplemental funds awarded 6 to the region for health services, educational activities.. 7 The future plans include a joint staffing of the 8 Oxford office with staff from the Memphis Pa'4P (Slide), there 9 are ten economic development areas in the state. 10 The Mississippi Pegional Medical Program recognizes 11 the fact that health care generally follows trade patterns 12 in Mississippi and the ten districts form the basis of any approach to improving health delivery systems as well as the 13 14 care peonle receive in the region. 15 These ten areas are also designed to become the comprehensive health planning areas of the state. CHP agencies 1 6 located in Jackson and there are two CHPB agencies currently 17 funded, one in the southwest and the other in the Three Rivers 18 area. Two more have applied for-funding, Central and Northeast, 19 (slide) and the TUIP has been actively-involved in the develop- 20 21 nent-of the agencies and they have a close working relationship 22 with this staff. It should also be noted here that Memphis is also 23 assisting in the formulation or development of some of the 24 Ace - edeal Reporters, Inc. 25 agencies in the northern part of the state (slide). This 8 #1 I overlay shows some of the regionalization of some of the 6 2 activities they have proposed in the application of the review 3 today. 4 Part of this application,.the large majority of the 5 projects and activities were centered around the university 6 medical center in Jacl@son. During the past year the Mississippi 7 PJ.,IP have concentrated their efforts in developing activities 8 which have outreach to all parts of the state. This simply 9 (slide) shows the geographical make up of some of the members 10 of the regional advisory group. 11 There are 37 members of.R.AG, with an adequate 12 balance of consumers and providers. The involvement of RAG 13 members this past year is one of the more positive stens the 14 region has taken and Dr. Hess will comment more on this a little 15 later. 16 (Slide) This chart depicts the distribution of 17 funds for.the region during the three operational years.and 18 it shows the comparison of what has been and what is to be durinj 19 the next triennium period. Clearly it illustrates the change 20 from a categorical program to emphasi s'on multi or non-categorici 21 activities. 22 This has increased from an average of 15 percent' 23 during the first three operational years to 49 percent which is proposed in this current application. It should also be noted 24 Ac ral Reporters, Inc. 25 that previously a largo percent of the program staff budget 9 #1 went into the medical school for supplementing some faculty 7 2 salaries. 3 This is no longer the case. All members of the 4 program staff are full time employees of the RMP, with the 5 exception of the As.4istant Director of Planning and Evaluations 6 who is also a private practicing physician. During the (slide) 7 site visit of September 1971 one of the major concerns of the 8 site visit team was the organitat ional structure of the region 9 both in the piFogram staff and regional advisory @up. 10 This overlay illustrates the complexity.of the organ.i- 11 zation prior.to September 1971-and very clearly illustrates 12 the categorical make up of the region..There were categorical 13 coordinates, as you see here, that related directly to the coor- 14 dinates of the PJIP, and program.staff had very little liaison with these people. 15 16 -The regional advisory group, the categorical committees were composed of non-RAG members. And RAG was no 17 .18 more than a reactionary group.,,.The categorical committees 19 were actually directing the program. (Slide) 20 This is certainly no longer' the case and we feel that the restructuring of RAG and program'staff has been a major 21 22 accomplishment for the region.This reorganization was begun 23 during a retreat in early-Decembe'r of 1971. The program staff are young, dedicated, very cohesive 24 Nce- Federal Reporters, inc- hard-@,lorkina group. All of the positions are filled with the 25 10 Ill exception of the Assistant Coordinator who-they are looking for 8 2 now. And the part-time Assistan-t Director for Planning Eval- 3 uation I have already mentioned. 4 (Slide) The restructuring of the Regional Advisory 5 Group has resulted in total commitments and involvement of 6 all RAG members. No longer are:there commitments of non-RAG 7 members. Each member of RAG is, requested to serve on at least 8 one 'of the task forces. 9 Each task force is responsible for one or more of the 10 goals of the region, and members are involved in reviewing 11 and monitoring the activities and projects that pertain to 12 these goals. And the goals of the region are shown in-each 13 of the task forces, manpower, professional education, health 14 systems design, EMS and public health education. 15 DR. HESS: As you can see from your previous document 16 there were four staff visits to the Mississippi Region during 17 the late part of 1971-1972, as well as numerous telephone 18 contacts and various other forms of assistance. The site visit 19 team for this visit as you can see included Dr. Merrill of the 20 Council, Dr. Nichols, who is a black physician from Susquehanna 21 Valley, Mr. Donald Tranto from Georgia RMP who was a very. 22 valuable asset to the team. 23 Mr. Van Winkle of Harvard, Mr. Ashby, Mr. Nelson, 24 Mr. Ba.llou and Mr. Grift from the regional office in Atlanta. lkce-Fedeial Repoitefs, Inc. This application that we are to consider today includes a reques 25 for triennial status; Expansion of program staff, and funds 9 2 for additional regionaliza'tiori, developmental components, con- 3 tinuation of three previously approved funded projects and 4 funds for 19 new projects. 5 Going over now the review criteria as outlined in 6 the site 'Visit, as Already mentioned by Mr. Torbert the 7 roles-and objectives of the region have been revised and are MOZE 8 in keeping with the new direction s of IVIPS. The coordination 9 between the university medical centers and the Miw-,issippi IUIP 10 appears to be extremely good, there always has been good working 11 relationships there and these continue. The Mississiopi PI.IP has moved into new categories 12 l@ outside of the medical center. This has accomplished several 14 things. First being that the staff are all together now 15 -,ohysically, where they are able to communicate and work more 16 effectively together.. 17 And it also has removed any -- some of the questions .18 that existed about undue influence and too'close liaison with 19 the medical center. 1,7e found no problems of real concern in this 20 area. Some of the statistics which reflect hopefully in part 21 the impact of the Mississippi R14P are shown here in the site 22 visit report. 23 Some of them are very dramatic. In 1968, the neo- 24 natal death rate was 28 per hundred thousand live births in Ace-Fedeial Reporters, Inc. 25 ITolmes County. This was reduced to 19.8 in 1970, and 7 in 1 2 f,l 1971. This reduction is so dramatic you almost question the 10 2 statistics. But the people.there feel that there is no question 3 but what the pediatric nurse assistance and midwife program 4 and so on has had some influence in reducing the neonatal death 5 rate. 6 The regional satellite units have been.set up around 7 the state. They have a very well organized and smoothly 8 functioning renal disease program there as near as we can tell. One of the.imnortant accomplishments of this -program is to 9 10 reduce the cost of dialysis for their patients. 11 They bring families and.patients into the medical 12 centers, train them in the use of dialysis and then through 13 the'use of trailers which have been set up around the families, 14 a@member of the family can come in with a patient and perform the dialysis for the patient. 15 Heart clinics have been s@t up around the state which -16 have been have resulted in care being given to patients who 17 previously did not have access to this type of care. The 18 19 existence of the stroke care untt in.the medical centers has resulted in the treatment of a large'number of patients, the 20 training of a number of physicians and nurses from various f:)arts 21 22 of the state who are now better.qualified and equipped to 23 provide higher quality care to patients with this type of nrobler,i. 24 Ac al Reporters, Inc. 25 Pulmonary training programs and inhalation therapy 1 3 llfl I has been established in a number of inhalation therapy *a 11 2 aids trained who can now provide this type of service in hos- 3 nitals outside of the medical centers located throughout the 4 state. 5 The.coronary care unit which initially was funded 6 and operative at the university medical center has trained. 7 120 nurses in coronary care and they now are functioning in 8 various areas throughout the state to provide a more sophisti- 9 cated and effective type of care for patients with coronary 10 heart disease. 11 Through the efforts of the Mississippi @IP program 12 for training of dental hygienists was initiated and this has 13 had more spin-off-, in that there is now discussion of the 14 possibility of initiating a dental program there. But through 15 the use of the training of these additional people, additional 16 dental services are now available. .They have been giving attention to the question of 17 18 continued support and an example of this is the Hollandale midwife project in which through the fees which are being 19 20 collected for the services to patients, medicaid and so on, 21 these fees are being put back in to help support the cost of 22 the program. There was some concern about what withdrawal of 23 24 some of the support to'the Med.ical School faculty night mean Ace-Federal Reporters, Inc. 25 in terms of their availability to participate in P14P programs 1 4 O'l I and continue education and so forth.'And the Dean indicated 12 2 that there was some uncertainty as to how much of the time 3 of the medical school faculty might be -- he might be able 4 to fund and pay for out of other sources in order to continue 5 some of the thrust which they had begun in earlier times. 6 The region is giving-attention to the improvement 7 of health care delivery for underserved minorities, this is 8 a major area of emphasis for the.region, and all of these 9 projects that have been conducted in the past have had very 10 important impact and emphasis on the care of undersbrved 11 minorities. 12 The needs are tremendous in this area and what has been done is onlv beginning then to scratch the surface, but 13 14 the region is certainly very conscious of these needs and 15 appears to be taking appropriate actions. As far as minorities 16 on the staff, currently they have one minority professional and one minority secretary, and this is an area that we gave 17 18 additional emphasis to, on the site visit, and they expressed their intent to employ additional minority people in unfilled 19 20 positions or as new positions open up. One of the outstanding programs which.has been 21 conducted there is one in which they are seeking to attract 22 23 black medical students who are going-to school outside of th.e 24 state to come back to iiississ ippi and practice. Ace-Federal Reportprs, Inc. As I am sure most'of you are aware there is suddenly 25 15 #1 I a nationwide competition for qualified black medical stuents, A&13 2 and many of the best studehts,.black students, in Mississippi 3 are being actively recruited by medical schools from all over 4 the country, and are going there to continue their education. 5 Through the black physicians in Mississippi, @'llississ- 6ippi PMP, -these students have been, many of these students have 7been contacted and brought back.and discussions were held in an 8effort to show them some of the-changes that are happening and 9to develop in them a desire. and commitment to ret@rn to 14iss- 10 issippi and practice when their training is completed. 11 I was going to take sometime now -- now it is going 12 to take sometime to know how effective this effort will be 13 but it certainly seems to be an appropriate one. Along with this 14 is a much greater awareness in the University of Mississippi 15 itself, of the need to admit black students within their 16 own state and they seem to be making progress in this area. 17 Going on to the coordinator, the -- Dr. Lamton has been coordinator since January 1-971, and we found evidence on 18 -Ehis@site visit that he indeed i-s beginning to exert amuch 19 stronger leadership role than when we' were there in September 20 21 of 1971. 22 At that time he was relatively new and feeling his way 3lbut after the site visit and the report which came back he has 4not hesitated to take the recommendations seriously and to move 0 kce-Fedetat Reporteis, Inc. 25 on them. 16 #1 I There seems also to be a much better working relation- 14 2 ship between he and the staff. And whenwe were there in Septembe 3 of 1971 we were getting all k inds of informal feedback.in the 4 hallway and so on of some of the communications programs 5 and leadership problems which existed. 6 This time we picke,dup none of that kind of tl-iing,. And 7 there were many indications that the working relationships 8 have imoroved. His relationship with the RAG seems to be 9 cordial and effective and we found no evidence of any discord 10 in that area. 11 ".he program staff has been strengthened, they have 12 hired a number of additional peo'le who seem to be quite p 13 capable.. Some of them are young and not too experienced as 14 yet, but appear to have good Potential. one of our concerns, 15 however- was in this area in th'at the Assistant Director 16 for Planning and Evaluation is a practicing physician. 17 He is an internist, hematologist, gynecologist who 18 has a private office and exactly what this half-time means we are not sure. But it was evident to.us that this is an area 19 20 that does need strengthening, and on'e-of our recommendations is that-this be made a full-time position, and that the new 21 people that they have brought onto the staff be given some. 22 additional training and orientation so that this area of core 23 staff might be further-strengthened. 24 Ac- @.@.al Reporters, Inc. 25 They have a new person in the area of evaluation. 17 #1 I From our discussions with him he seems to be a 15 2 competent person, a lot of good ideas and a good approach to 3 evaluation and we are hopeful that the evaluation might improve 4 -over the next year or two. Regional advisory groups represent 5 the key health interests in the region. And as indicated by 6 Mr. Tober-L's presentations now much more actively involved 7 in planning and decision-making for the region. Attendance at 8 the RAG meetings have been running over 50 percent, they have 9 requirements that if more than three meetins are @'ssed then 10 the member is dropped from the RAG. 11 The grantee organization is performin its function 9 12 effectively as we could tell and we have no questions about 13 that. The major health interests are participating and there are 14 a-%vide variety who are involved and they always seem to be in 15 full support of the objectives, and -- of Mississippi P14P' 16 and what it has accomplished to date. 17 Mr. Tobert indicated the -- how the state is divided @18 into subregional areas for health planning'and PIIP has been 19 instrumental in helping to facilitate this development and are working closely inthe 20 they' development of these local 21 planning areas. 22 Active discussions are going on concerning organization 23 in nine of the ten areas, and five of these are in the active 24 planning stage at the present time. There is an adequate kce - Federal Reporters, Inc. 25 mechanism for obtaining CHP'review and comment. 18 The Mississippi RMP has participated in and/or has a 16 2 available to it a rather large data.base documenting the 3 health fields and resources.of Mississippi. However, there 4 has been thus far an apparent lack of the expertise needed 5 to move from available data to program development. This'is an 6 area we emphasized to them a number of times and we are hopeful 7 that there.might be some immediate and,further movement on this 8 and iqe.have a recent letter from Dr. Lan@on indicating they have 9 already begun to take steps to address this issue-. 10 All the current projects in the current triennial 11 ap pli.cation were developed concurrently with re-thinking 12 of the goals and objectives and restructuring of the RAG and 13 program staff. Consequently the projects have not evolv ed as 14 a,result of the re-thinking which has gone on during the last 15 few months although several of the projects are compatible 16 with that expressed, by the.new goals and objectives. 17 -Coordination program staff has improved substantially 18 and they have developed a plan for systematic monitoring of 19 individual projects both by written reports and site visits, 20 by project monitoring teams which will include program staff,. 21 RAG members and other consultants. Written project progress 22 reports and financial reports are also a standard requirement. 23 We have already mentioned about the new full-time 24 2valuator for whom we have a good deal of hope. He did not have 4ce- Federal Reporters, Inc. 25 an opportunity to have much influence on the evaluation aspects 1 9 of the projects which are submitted in the triennium, but he 17 2 does hone to have some influence on their functioning. And 3 we were assured they would have an active role in reviewing 4 and participating in the development'of all new projects so 5 that adequate evaluation is built in from the very beginning. 6 l@le identified some problems in their documents, 7 differences in evaluated criteria between the 8tated objective 8 the nroject development guidelines, the technical review cri- 9 teria, and developmental component priorities, t4o RAG rating 10 forms and the program evaluation statement. 11 TATE felt these all have been developed at different 12 times and'@,,ith somewhat different people.and we felt, we 13 recommended that they sit down with all of these now and.try to 14 make them consistent and uniform with one another to avoid 15 ng ,some potential confusion and improve the baiss for carryi, 16 out their-evaluation. 17 The region has established priorities. This was 18 accomnlished during the retreat-of the Regional Advisory 19 Group in December of 1971 and they are congruent with national 20 goals and objectives. 21 They have begun a School of Allied Health at the 22 Universitv of Mississippi Medical@Center, and this is on its 23 way--now. The initiation of this school has been attributed to 24 a signific at degree by the PJIP, and the@-are actively on AC al Reportefs, Inc. 25 their way now in recruiting faculty and students and hopefully 2 0 141 1 this will begin to supply a gap in health manpower in the regior 18 2 Now getting down-to'the recommendations of the site 3 visit team I am going to save, wait on'the financial recommen- 4 dations until last. We did feel they were ready for triennial 5 status. There was no question that they had addressed all of the 6 areas of concern raised in the September 1971 site visit. 7 And they were in a substantially better position 8 as a region to manage their own affairs and to more effectively 9 address the needs of the people although there are still a 10 number of important areas that they -- where they need further 11 improvement. 12 We recommend that there be a full timeldirector 13 of a planning evaluation staff, and that this section should 14 engage in a good deal of training and we suggested as one part 15 of the training of the staff some @IP's which they might visit 16 to learn the methods and techniques that would help them. 17 We emphasized the need for developing consistency 18 with the statements having to do with evaluation mentioned 19 earlier. lie felt that their applications, their projects, needed better documentation of need and tliis-went back to the need for 20 21 strengthening their planning section4 We also felt that.they needed to improve their technics 22 23 review input to the PAG, that there were some projects that we looked at, as examples, where vie questioned some of the needs 24 AC al Reporters, Inc. 25 as far'as the equipment and budgetary items and felt that they 21 01 I could well benefit from some qualified experts to work with 19 2 them in reviewing these project requests and determining what 3 was- actually necessary and the methods that would be most 4 effective in addressing the methods of the project. 5 V7e recommended that they should work to obtain both 6 CIIP and state funding of on-going health planning data collection 7 There was one project in this.group which is directed toward 8 improved data collection, and apparently no one is in a 9 T)osition at the moment to undertake this activity, yet it is 10 a very important and essential-activity for all health planning 11' in the state. 12 And we agreed that this would be a worthwhile 13 thing for M4P to initiate but it should not be looked upon 14 as a ma3or on-going activity. Another question which came up 15 during the course of the site visit was the staff salary scale 16 which is determined by university salary scales. 17 And we recommended that the salaries should be reviewe. 18 wit]' the medical center administration to see if the mechanism can be developed for more adequate program staff compensation. 19 20 Our concern was that this might be a liability to the program 21 in that they may not be able to retain qualified people and, 22 therefore, continue to build a strong program. I would end my comments at this point. 23 d 24 ;de@l 7items, Inc. 25 22 #2 arl I DR. SCHMIDT: I would remind the-committee that 2 in front of them are these bl.ackbound books that are computer 3 printouts, and some o f the questions yesterday that had to do 4 with funding levels and money going'to projects and so on, 5 are very efficiently and effectively answered in the computer 6 printouts, and I personally find them of great value and would 7 recommend them to the committee for funding information. 8 Secondary reviewer is Warren.' 1 9 DR. PERRY: I believe in. a characteristic way 10 Joe has done a tremendous job in reviewing the program. 11 My greatest.interest in the program, I have not been in the 12 region, :Ctrs been only through application review in the past, 13 has been this tremendous concer n and development in manpower 14 potential. Educational progtams-have really moved in this 15 state. It is a state that has not had that level of expertise 16 and such'to do this.. They have been calling in in the allied 17 health area, I know three of my dean type colleagues have been 18 down there in consultation. They have been moving ahead, as 19 has been said here. 20 A member of our staff in Buffalo has been there 21 in the dental.school and dental hygiene program and moving. 22 They're doing a tremendous job as they look at their' needs 23 in that state. They recognize the importance of all levels 24 of health care personnel in there, and I think this is a Ace-Federal Reporters, Inc. 25 tremendous development herb. 23 aA- I My only concern is.going to be in some of the 2 recommendations on the level of funding here which I would 3 like to turn right back to Joe to make. There is no qIuestion 4 but this state has made a major turn and is moving in a most 5 positive way, 6 DR. SCHMIDT: Bill, was anything left out that, 7 should be -- all right, Joe, can you put a proposal on the 8 table then? 9 DR. HESS: The site visits team had some difficult 10 in arriving at a funding level recommendation. I will place 11 'that before the committee at this,time. There was another 12 wide variety of opinion as to what it should be. I suppose 13 that I ought to express to you some of my personal res ervations 14 about this. 15 This came as a sort of compromise, the team 16 recommendation--is,a compromise. And I happen to personally 17 be on the lower end of the scale concerning the spectrum of 18 opinions of the team for funding recommendations, but neverthe- 19 less the recommendations which'we ended up were in order to 20 leave and catch our plane. f 21 DR. SCHMIDT: The suspense is killing me. 22 DR. HESS: You can see here on your page 11 of 23 the report the total figurE& On the sheet over here we have 24 broken these down. We agreed.that with the expansion in Ace- ederal Repotters, Inc. 25@ more subregionalization, some of the additional activities 24 ar3 I that the program staff planned to get into and so on, that 2 the increase in program staff budget was justified. 3 We felt that they were ready and could effectively 4 use in the first year developmental component of @6,315. The 5 total for operational projects we felt was somewhat high. 6 There were three specific projects there totaling about 7 $200,000 that we had some serious reservations about in terms 8 of their appropriateness when one considers the total health 9 needs of Mississippi, and we reduced their -- our recommendation 10 was something about $230,000 below that requested by the 11 -region for operational projects.. - 12 So the total ends up with 2,110,138. They had 13 already received approval for, through supplemental fu nding, 14 183,634 in kidney, so if you subtract that, it comes down to 15 1,926,504, which is the first year recommendation. 16 The second and third year, you can see on the 17 sheet the kidney money will be included in that, 2.2 and 2.4 18 million the second and third year. 19 So I will place this recommendation on the table 20 in the form of motion, but also say I,have some reservations, 21 particularly considering the fact that the first year is a 10-month year for them. I have some personal reservations' 22 23 about whether they can effectively use that 1.9 million during 24 that first year. Ace - erat Reporteis, Inc. DR. SCIU4IDT': All right. Dr. Hess then moves 25 25 ar4 with some reservations, then, the team report. 'Is there a 2 second? 3 Warren, do you second this or not? 4 DR. PERRY: Yes, I am going to second it, to get 5 it started here. I -- not having been there, not having a 6 chance to, you know, really be a part of looking at the new 7 projects and such, it is a -.- really a, more than a promissory 8 note. It is really an accolade.in this funding amount. 9 I would like to ask Bill in relationship to his 1.0 knowledge of the region of your feel for their ability to 11' handle this increase. 12 MR. TOBERT: I share with Dr. Hess the 10-month budget at that level. I had no qualms on the second and third 13 14 year at all. But I think there can be some justification in 15 reducing the first year. 16 DR. SCHMIDT: Before I call, on Dr. James, Mr. 17 Griffith, the regional office representative, is here, and I had asked Ted if he has any comments. 18 MR. GKIPFITH: No Comments at the present time. 19 I go along with the proposed activities so far. 20 21 DR. SCHMIDT4. Obvious and maybe stupid question is if you are worried about the 10-month thing, why-not give 22 23 them ten-twelfths of that amount for the first year? DR. HESS: Personally I think that would be more 24 Ac ral Reportvs, Inc. 25 reasonable. I figured it'several different ways, and I think 26 ar5 I that would be an appropriate way to go about it. 2 DR. SCHMIDT: Well, the chair won't intrude on 3 the workings of the committee. 4 Dr. James? DR. JAMES: As a new member of this committee, I 5 1 6 get a gut reaction from the report as given and as stated 7 in the site visit report. My gut reaction relates to the fact that we have seen a state that has long been known to be 8 9 without, use its own resources to develop a kind of program io that seems to be evolving with the professional help that came about in December of 171, demanding new direction. 12 And I think I would like to emphasize the fact 13 that they have not had the professionalism and expertise prior 14 to December of 171, apparently shows that the efforts of -- 15 of funding apparently have been.-- has resulted in the train- 16 ing of personnel which in the long run has affected a net 17 change indirection of what I have heard all day yesterday, that is, in fact, the people have apparently been the 18 19 recipients of the funding of the efforts of the Mississippi regional program, if this is in fact what is absolutely the 20 case, as seems to be written in this program. 21 And I, for one, would want.to re-emphasize the 22 fact that sometimes when you don't have enough money to go 23 24 on, you don't have the.expertise and professionalism which kce I Reporters, Inc. in turn helps to cloud'an issue and really you do not get the 25 27 ar6 services to the people, maybe this is 'What it is all about. 2 And I would strongly suggest that the expertise 3 and professional-ism be offered these people on a higher 4 scale so they can use their basics,, their abilities to continue-their efforts to train more people in Mississippi 5 6 which net results in services to the people., 7 The fact that infant mortality, this is an absolute fact, it does sound, you know, almost fictitious, 8 9 doesn't it.? But if this is an absolute figure, can we 10 duplicate that same figure in any other region across the 11 country? 12 I think if the regional medical program did nothing 13 else but to reduce the infant mortality rate, it has served 14 a very useful purpose. 15 DR. SCHLERIS: I was-wondering if I could see that 16 overlay to show how the direction has changed in Mississippi? I confess by saying I always, in driving, have been told by 17 18 my family of a very poor sense of direction. And in trying 19 to review briefly, I do have some questions to ask about specific projects. 20 I am trying to discern what is really the changt 21 22 in direction. The multiple is.probably where there is some 23 reason for my questioning this. I am sure heart disease is probably about 13 percent. But if I look at heart disease, 24 @ce- eal Repoiters, Inc. cancer and stroke, I would think that the numbers really don't 25 ar7 reflect some of the changes here unless these are put into 2 multiple, because as far as some of the new projects coming 3 along the line, those to be supported- some of them appear 4 to be very much what we have been looking at for a long time. 5 The ongoing projects to be supported,$122,000. They put in 6 some projects, I don't know.what you did, electrical hazards, 7 that probably went under multiple, but this is a set of a model electrical hazard safety program, and the hospital 8 9 then to put it through the community. This is about $80,000. 10 This has now been used in most communities as the responsibility 11 of the hospital itself. 12 Radiotherapy.is coming in as a new project for 13 $80,000. 14 Edtcation of radiologists, setting up of peripheral 15 centers, is coming in again at a significant level of support. 16 PulmonaIry therapy as a model project is coming into a 50 to 100-bed hospital to treat pulmonary disease and 17 18 cystic fibrosis, stroke system to be set up for $58,000. My concern, as I look over these projects, is that 1 9 many of them are what we have been used to seeing over the 20 21 past several years, and my concern is that they ate isolattd 22 projects related heavily to hea.rt disease, cancer, stroke. 23 and related diseases, rather than being a part of a new direc- tion. 24 Ace- ederal Reporters, Inc' Some of the' new directions concern me a bit. 25 2 9 ar8 $39,000 for educational program for mentally retarded 2 children is something that I am sure is necessary, but I 3 again think that this is the RMP picking up things that 4 should be done in other ways. Controlled in effect in 5 hospitals, to set up a model unit and then if other hospitals 6 are interested, help them, is $32,000. 7 I have only looked at a few of these, but those 8 that I have looked at would suggest very much a good deal of 9 what@has been going on in the past. Now if the change of 10 direction is in the interest of core, that's one thing, but 11 -I don't see it reflected at all in these projects, and 12 there are myriads of them and just scanning them quickly, I 13 wanted to know how you define the change in direction, admittin] 14 that I have a poor sense of direction. 15 DR. HESS: Well, I had commented on that in passing,, 16 in that their rethinking occurred at the same time the 17 projects-were being developed md consequently, particularly 18 the first year projects do not reflect that, so that it is 19 kind of a phasing problem that'we have seen in many other 20 regions. f 21 And this, the very questions you are raising, are 22 some of the things that bothered me and raise questions in' my 23 own mind as to how much of a favor we are doing the region to 24 get give them enough moftey.t.0 get started and obligated on Ace - ederal Reporters, Inc. 25 some of these projects that I, in my own mind, thought ought 30 ar9 to be low priority. Now some of these we site-visit team we 2 3 felt strongly ought to really be looked at very carefully. 4 We told them so in feedback session, that we just questioned 5 whether these were consistent with the needs and so on of the 6 region, and that they needed to go-back and rethink that whole business and look at those projects again. 7 8 Now, I think they are developing the mechanism 9 and the wherewithal to do that, but.this application does not io reflect that kind of thinkingly you see, and it is a question of how much faith we collectively have in their ability to go 12 back and look again at these projects.. My own feeling is that there should be enough 13 14 restriction on funding that they can be very selective about 15 which ones they choose and which ones they choose to fund -- 16 which ones they choose to fund and which ones they choose not 17 to. And they are going to need some continued help and 18 supervision in order to get things organized and consistently 19 20 moving in the direction that we would like them to be. 21 DR. SCHERLIS: Well, my concern is that once we gave them developmental compone nt, it should be on the basis of 22 23 our knowing that they have indeed demonstrated a change in 24 direction, because in looking at the projects, I have a feeling Ace-Federal Reporters, Inc. of deja vu as far as wha@ we would have a few years ago of 25 31 arlo I seriously challenged as being bits and pieces of projects 2 coming in from all over. 3 I am sure they will do something, but I don't know 4 if they really demonstrate any program, you know; our concern 5 should really be program, we shouldn't be talking projects, 6 and'our chairman,has been most kind in letting us talk projects, because I don't see it as a program, but as bits 7 8 and pieces of unrelated projects'. my immediate reaction is I question whether we 9 io have had a demonstration of their change in direction, but rather what we have been shown is that they recognize there 12 should be, a change in direction, have given us a list of projects, that while they will-do good, I am sur e, doesn't 13 really reflect a level of maturation to demonstrate that they 14 15 are ready to go in the developmental component. Iwould like to have.some other points of view on 16 this. I know this is not the view of the site-visit group. 17 2 18 19 201 21 22 23 24 Ace-Fedetal Reportvs, Inc. 25 mea-1 32 CR 7149 #3 DR. LUGINBUHL: I would like to summarize my 2 views on what I have heard. It seems to me this is an area 3 of desperate need. We would like to give them as much 4 funding as they could well use. 5 Also it seems if they had made real steps toward 6 developing an organization, that we are all concerned that 7 they are-still pretty embryotic in their development; they 8 are still focused on projects that aren't very well 9 coordinated, and if we give them too much funding, they are 10 likely to commit themselves very deeply to projects that will 11 not readily be pulled together in a coordinated program. 12 From that basis I wonder if it wouldn't be wise 13 to take a hard look, particularly the first-year budget, 14 with the thought in mind that if. indeed they do set 15 priorities, that they do move.towards a coordinated program; 16 that funding could be increased more rapidly in the second 17 and third quarter. 18 SpecificAlly it is not clear to me from the yellow 19 sheets as to whether their first-year requests,indeed for a 20 ten-month period or is it for a 12-month period; if it is. 21 for a full-year period, I would think this would reinforce 22 the suggestion that that be reduced to five-sixths of the 23 amount suggested over here which would be about $1,505 000. 24 Can someone tell'me, is that first-year request Ace -Federal Reporters, Inc. 25 for ten months or 12 months? mea--2 33 MR. TOBERT: It is for ten months. 2 DR. LUGINBUHL: That would seem to me to be a 3 rather large increase and I would like to move an amendment 4 if that is in order. 5 DR. SCHMIDT: The Chair will accept a move to 6 amend. 7 DR. LUGINBUIIL: To reduce the first year to 8 five-sixths of the amount up there, I-will leave the exact 9 calculations to someone else. I did it very quickly; it is 10 about a million and a half dollars,and to omit the 11 developmental component for the first year. 12 DR. SCHMIDT: There is a move to reduce the amount 13 to five-sixths and omit the developmental component for the 14 first year, leaving the second and third years at the 15 recommended level but with obvious interaction between staff 16 and the Review Committee prior to the funding-of the second 17 year. 18 - Do you accept that total restatement of your 19 amendment? 20 DR. LUGINBUHL: Yes. 21 - DR. SCHMIDT: All right. 22 Is there a second? 23 MISS KERR: I would second. 24 DR. THURMAN: Jo6 is afraid to ask you what you Ace - Federal Reporters, Inc. 21 thought. You said-you compromised upward for the plane. mea-3 34 What would you really thinks 2 DR. HESS: Well, my feeling was that they could 3 effectively utilize somewhere in the neighborhood of 1.6, 4 1.7 million. This would cut out about @400,000 worth of 5 projects and if I use my priority system, the ones left in 6 would be ones that are truly helpful and directed to some 7 very urgent problems there. 8 But I share the concern which you expressed. The 9 infections in hospitals, electrical hazards and so on were 10 ones which obv@ously came up'--'we were very surprised that 11 they got through their review process and this is one of the 12 things that gave me some concern. 13 The nurse or I should say the cancer project is 14 just a one-year; this i s the final year or I should say, 15 the stroke care demonstration is a final year for that 16 project so that 122,000 only appears in the first-year 17 budget and I think they are obligated to continue that 18 previously approved -- but taking all these things into 19 account, it is my feeling that they could have quite a bit 20 of money to play with and, not to play with but to use 21 effectively, and still show them that we had-confidenc.e in 22 what was happening, give them the support which they need to 23 begin moving more strongly in directions which I am convinced 24 'they will move in and not do damage to the program. kce- Federal Reporters, Inc. 25 DR. TIIU@'4AN: Mr. Tobert, what is your feeling mea-4 35 about staff reaction to the business of cutting them, this level or lower? 2 3 We heard"a.lot yesterday about how if we did not show our faith, hope and charity that we might seriously 4 5 hurt somebody. MR.-TOBERT: No, I don't think this would affect. 6 7 the. operation at all. 8 DR. THUPd4AN: Wh.at.I am really asking is 1.5 or lower. Let's look at both.of those, 1.5 and then also 9 the lower because I share every concern that Dr. Scherlis 10 had. 12 MR. TOBERG: If it is any lower than 1.5 without a developmental proponent, I-think it might have some 1 3 14 concern on the staff. DR. SCHMIDT: The move to amend was so 15 inconclusive that it is a substitute motion and so really 16 the motion we are talking about right now is the lower 17 amount. 18 John, first. 19 20 DR. KRALEWSKI: I am in sympathy with cutting the 21 thing back. I have mixed emotion.over developmental componen ts, whether we give it to them in programs and 22 help them organizationally to-do this or whether we give it 23 24 to them as a pat on the back. kce - Federa I Repor tvs, Inc. organizationally speaking I had been inclined to 25 mea-5 36 I say the program would be better of'if you would reduce the 2 budget in the area of projects and gave them some developmen- 3 tal money to play with. I think I Would be inclined-to 4 believe though that ending up with 22OtOOO which must be 5 one of the larger developmental components ever given to a 6 program would be fair. But I would think that.developmental 7 component in terms of perhaps somewhere in the area of that 8 first year's program,goiiig up perhaps around A hundred for 9 the second two years, with the cutbacks to bring the total 10 budget down to a million.and a half, taken out of the 11 projects, might be'more helpful to a program such as this 12 and give them more running room and give them a chance to 13 turn it around if they are trying to turn it around. 14 DR. LUGINBUHL: Is that an amendment to my 15 substitute motion? If it is, I will accept it as a change. 16 DR. SCHMIDT: I will accept that as an amendment 17 to the-substitute motion. The seconder was Elizabeth. 18 MISS KERR: Yes, and I would accept it, 19 DR. SCHMIDT: All tight, the motion now includes 20 a developmental component of .96,000,, which, for the first 21 How about the second and third years? year then. 22 DR. KRALEWSKI: I suqqested a hundred thousand 23 isn't much of an increase but suppose we say 90,000 the first 24 year, a hundred the'second two? @ce- ederal Reporters, Inc. 25 DR. SCHMIDT: All right, 90,000 the first year and mea-6 a hundred then for years two and three. So that is the motion 2 that is now on the floor. 3 Further discussion? If not I will call, "Question." 4 Bill? 5 MR. TOBERT: By reducing-the deve lopmental 6 component for the second and third year does this in effect 7 reduce the total amount you_are awarding for those two years? 8 DR. SCHMIDT: Yes, it would be a reduction of 1 9 110,000 year two, 120,000 in year three. Year one, i t would 10 be, without calculating centrigrade and Fahrenheit, are you 11 going to take five-sixths of the amount after the subtraction 12 or before the subtraction? Oh, developmental component 13 isn't subtracted. So it is five-sixths of what? 14 DR. KRALEWSKI'-. What I was suggesting is a total 15 budget of one and a half. 16 DR. SCHMIDT: Including developmental component? 17 DR. KRALEWSKI: Developmental component is 90. 18 DR. SCHMIDT: That clarifies it. 19 Does the staff understand the recommendation? All right. I will call for the vote then. All in 20 21 favor please say aye. opposed no. 22 I hear no dissent. 23 I would like to just take a few minutes now before 24 -moving' on to a report on Missouri to ask the committee to Ace-Federal Reporters, Inc. 25 express themselves concerning the staff efforts at presenting mea-7 38 I information to you about regions as part of the review and 2' triennial applications,' that backgrounds the regions a little 3 more, 4 You have seen the slides that have gone up. You 5 have heard two presentations by staff as part of the committe 6 review@ One o-f them was done by John, I believe, as part of 7 his review. He used the visuals that were prepared by staff. 8 And we have talked in the past about the informa- 9 tion that comes to the committee,. the amount o,& it, the 10 detailed nature of it and so-on. I called your attention 11 purposely to these books because they do have some of the 12 budgetbreakdowns that are most handy. 13 You have the applications now in their new form. i4 And you have the reviews of these three regions that were 15 done by staff. So could we have some guidance from the 16 committee on what the think? Dr. Ellis? y 17 DR. ELLIS: Mr. Chairman, I would certainly like .18 to express great appreciation for the work of the staff in 19 setting forth these audiovisual presentations. I think they 20 have been very, very helpful. 21 Many times in trying to describe a region it is 22 just impossible to do so so that people listen and hear 23 what it is all about when we are talking. But they get our 24 attention; we understand exactly what the region is like and A,ce- ederal Reporters, Inc. 25 I am just very regretful that I wouldn't have it when I mea-8 39 I ted region today. present this complica 2 DR. SCHMIDT: Elizabeth 3 MISS KERR: I would also commend the staff for thi 4 and Iwould further make a comment and then a request. 5 As I review regions which I intended and plan to 6 visit and also which I review for reporting, I have done the 7 same thing with my own little feeble handwriting on the map 8 that is produced for me on the materials trying to identify 9 locations, centers and so forth. 10 This is very helpful I found but my request would 11 be, could.this kind of material be developed and -- and 12 included in the review materials prior.to the review, the 13 site visit even? I think the are that important. y 14 DR. SCHMIDT: I think that would be a goal to be 15 achieved. Certainly the maps of the regions could be done 16 for all regions that were coming up for triennial review and 17 some of the funding history and Particularly things like 18 these pies that show that the whole yellow thing was the 19 medical school and now the medical school has been cut down 20 to a little piece of pie and I think that these sorts of 21 visuals are great, and could be done in advance. 22 MISS KERR: For example Texas, as large as it is, 23 I had to get some idea of locations of agencies and so 24 forth prior to having a meaning ful review from the applica- @ce - Federal Reporters, Inc. 25 tion. So this would be very helpful. mea- 9 4 0 DR. SCHMIDT: Let me I almost feel a consensus 2 of the group. Let me ask for criticisms; assuming that the 3 committee does favor these, let me ask for criticisms of 4 what has been done either in length of it or detail of it. 5 This doesn't include the Rochester one which was 6 a 30-minute special but I am talking about the five to ten- 7 minute quickies and particularly for other information that 8 you would like to have that might be helpful. CR 7149 End #3 9 Bill?, I 0 1 2 13 14 15 16 17 18 19 2 0 2 1 22 23 24 Ace - Federal Reporters, Inc. 25 CR7149 #4 -ter-1 MR. HILTON: If overused in our initial enthusiasm with this kind of a "B" approach, it can probably, I think 2 envision a'time it might become monotonous. I think it is 3 possible to guard against that if we are aware at the outset. 4 5 I would suggest restricitng the use of the particu- lar-approaches in the overheads to the background data. We 6 7 have.50 local RMPs and even though we have been to the place 8 before, individual members may have been there before, it is 9 a good idea to have.that background refresher, geoqkaphy-kind of display of territory, perhaps consider building up a library, 10 of that kind of data for each region. I suggest, too, perhaps some variety, like for 12 13 Hawaii, we had -- in addition to the overhead we had the little plastic what do you call it, topographical models. That kind 14 of variety and other approaches'to variety would help minimize 15 the boredom of this kind of approach, I would think. 1 6 DR. SCHMIDT: I was hoping for some flowers, myself. 17 18 MR.' HILTON:. Yes, I -would too,.like to applaud the 19 -staff for the effort and I think it is great. DR. SCHMIDT: All right, Leonard? 20 DR. SCHLERIS: We had planned some really spectacular 21 events for Hawaii. I can tell you we shared every bit of the 22 23 Aloha spirit at our presentat.ion.yesterday, that we had in 24 Hawaii. Only those of you who were there will really appreciate AC tal Reporters, Inc. what that alludes to. 25 4 2 ter-2 I I think these are excellent. I would make one sug- 2 gestion, that is the value of'puttincr specific numbers that we 3 are talking about on the wall chart that we have. It is really 4 a great help and I would suggest that this be done previous 5 to the meeting, perhaps, someone on staff could write down for each of the regions, what has been the previous level of 7 support and what is being recommended, because we can all look 8 at the numbers together, and it furnishes a great deal of 9 value. 10 When you use a wall chart, just use a rough draft 11 on the over head, where someone can cross it out and modify 12 it. 13 DR. MARGULIES: For'one thing, as you have pointed 14 out, these presentations are al.1-on prime time, so the 15 question of durations is signif icant. Certainly, the kind of 16 overlay and in-depth analysis for the beginnin of a triennium, 9 171 I would imagine is a first priority in putting this much effort into it. 19 It emphasizes two things, however, and I would hope 20 that the review committee would help to guide us in one of 21 them, rally, both of them; as much as possible. 22 There is always the risk in presenting data in a particular way as a preparation 'for a triennium review that we will begin to influence your thinking by the way in which 24 Ace - Federal Reporters, Inc. 25 we put it together. ter-3 I It was quite obvious for example, we were making 2 a'point in presenting the Rochester regional medical program 3 as-a case study. You could also see we could have picked other 4 programs for that purpose. We are not going to deliberately 5 do that kind of thing, but in the selection of data and present- 6 ation, there is the risk that-that-will occur. 7 There also is a constant problem which will grow 8 in time in selecting data with the knowledge that no matter 9 what we present, it is rather incomplete. A case in point, I 1.0 think of Ted Gri.ffith, down at the end of the table representing 11 the HEW REgional Office. 12 It would be fine if-we could, in some manner, have 13 a concept of what else is going on in other kinds of health 14 activities within the region. To do that is without really 15 innundating you with materials extremely difficult. But, we 16 are going to have.-to do something abou:t how that might be 17 achieved. 18 It would be very helpful if.one knew that, what is 19 going on in X areas or is not related to a lot of other things 20 which are underway or are intended from other origins. What I am suggesting is sort of reorganizing the whole Governmental 21 system in presentation. We cannot do that. 22 The other thing I would like to mention, we have 23 24 brought up and which Bob Chambliss spoke to you about,@yester- Ace-Federal Reporters, Inc. 25 day, is the significance, under the circumstances, of the staff 4 4 ter-4 I Anniversary Review Panel, beqause.if we are-to-continue with 2 the kind of staff review'for 'those programs, which are not 3 undergoing intensive review, by the review committee, it will 4 give us a greater quality of differentiation for what really 5 requires full-time by the review committee; what needs to be 6 referred'to, and what does not present major problems so that 7 it can be kept in some kind of balance. 8 Obviously, you are'being burdened with some heavy @9 responsibilities, and you will have to accept o@ kind of 10 discretion in developing for you what needs to come this way, 11 and what reguires that kind of time. 12 DR. SCHMIDT: I would like.to-comment on the Staff 13 Anniversary Review Panel reviews from my perspective and see 14 if there is the consensus of the-committee. If not, we can 15 discuss the Staff Anniversary Revi ew Panel.. reviews f rther. u 16 To me, these have been very high-quality efforts by the staff 17 and the reporting of these, the information that is in the staff summaries, the written word tha t comes to'the committee that I 18 look at gives me such a good feel for what went on with staff 19 in their deliberations that I can very quickly be satisfied, 20 or dissatisfied with what went on by my review of these reports. 22 In the last number of years, I have detected no dissatisfaction on the part of t he Committee with this Staff 23 Anniversary Review Panel process, or the information it gets 24 Ace Federal Reporters, Inc. to the committee. 25 ter-5 I think the Committee must have the perogative of 2 asking for explanations for actions if they do not understand. But, I don't think there is any need, right now, or any desire 4 on the part of the Committee, to,,change-that process, or the 5 process of reporting the information to the Committee. That Was what I expressed to staff during the past 6 7 few weeks, and would ask if the Committee members disagrees 8 with that at this point? 9 WaIrren?, 10 PR. PERRY: I think,. although we do not need,-.You 11 know, no further approval, if..we all agree in the importance 12 of the audio-visual, from one of the comments made yesterday that indeed, the review process,might be more open and'less 13 14, involved. 15 This is another important reason to have this qualit) 16 and kind of material. If.there, we can anticipate, you can 17 anticipate other people around. That would be most helpful to have those kinds of. things a'@ound, so that each person can respond in relationshi@-.to it. 19 Also, I think that there can be judicious choice on 20 21 the part of the staff as Harold has-said. Perhaps, for the ?2 -trie@nn:-LUM. For the important ones. Let us not get in the 23 habit of doing it for everyone, let us do it for those that are 24 really significant and we need for the review. Ace-Federal Reporters, Inc. SISTER ANN-JOSEPHINE: I would join the other members 25 46 ter-6 of the Committee in complimenting staff on their presentation. 2 And, as I have had an opportunity to function on this committee 3 I begun to realize that the diversity between the regions, 4 not in the area of needs. That is quantitative rather than 5 qualitative, but the diversity is rather -in where individual 6 programs are at 'the present time, as compared with other 7 programs in an awareness of how to go.about meeting the object- 8 ives of the program. 9 And I would think that this type of rWiew, carried 10 on as part of the program should be very helpful to staff, because in putting myself into the role of a member of staff, and sitting there and listening to this,.I might well say, You 12 know, in these two programs, that I am responsible for,.these 13 14 efficiencies have been met very effectively and I need to communicate them with those who are working with the other 15 programs.- 16 -And in this way we can really begin to share resourCE! 17 that are resources of.the regional medical program. And I 18 think we have not done that as'effectively in the past as we 19 20 can do it, now. We have reached a-p6itt'in,-Eime, and it is really sharing facilities. 21 DR. SCHMIDT: Let me end this by asking staff if 22 23 they have any questions of the Review Committee about the information or whatever? 24 Ace -Federal Reporters, !pc. If not 25 ter-7 47 DR. CHAMBLISS: I might say on behalf of ttaff that 2 we do appreciate your words of approval for these efforts in 3 the visuals. Especially in the staff'of the division-of 4 operations and development and DPT, but I think this committee 5 should know who has spearheaded this effort in terms of the 6 visuals. 7 I would like to just say Miss Judy Flasher, over her( 8 at the door, has spearheaded this, and also with equal assist- @9 ance,"Mr.-Frank Schniowski, who has provided the data for the 10 visuals. Frank is over here and you all know him. Thank you. 12 MR. RUSSELL: I woul d like to say one thing. I 13 think it would be helpful to the staff when on a.site-visit, 14 if the site-visitors feel, if a particular visual would be 15 helpful then this would give us direction, we would appreciate 16 it. 17 DR. MARGULIE8: That picks up what I wanted to 18 comment on, Dick, and,that is that in the interest of express- 19 ing the kind of diversity which you spoke and Sister Ann, 20 everyone has recognized, if I get the sense of this committee, 21 you,will accept the idea that the development of the visu@l 22 materials and the manner of it.is something which might c6ntinu@ 23 to be left to the style, to the interest, to the motivations of 24 the staff people connected with the program. Ace-Federal Reportvs, Inc. 25 I think that would be better than.to say, we have ter-8 I one single format which we want to follow. This will give.them 2 a greater sense of involvement and I think, they can probably 3 do better that way. 4 MR. SCHNIOWSKI: Dr. Schmidt, as part of the experi- 5 ment we had one presentation given by staff, another one that was a joint-type, Staff Review Committee and a third one,, 7 by the Review Committee members. 8 The Review Committee has commented on the audio-vis- 91 uals. I wonder if we could find out if they have any preference lo: in the future as to the type of delivery they would like to 11 'see'.> 12 MR. HILTON. I would go for that second approach. 13 Specifically, with staff though there would be opportunities 14 as Merle has already suggested, to someway propagandize present@ 15 ation to some degree, I think we will guard against it, 16 particularly the staff covering those things that are of a 17 geographical and demographic objective, reporting kind of 38 nature with regard to-the region, and with committee handling, 19 the other kinds of concerns were here to address. DR. SCHMIDT: I like the quality of interchange 20 21 with-staff being part of the presentation. I see all the @eads 22 are going like this. DR. KRALEWSKI: I have always liked to use slides 23 While I agree, I think the background data 24 in a presentation. Ace-Fedeial Reporters, Inc. 25 is well presented by the staff;.I think it is useful as an 4 9 ter-9 I introduction. 2 I think it is'usef'ul during the presentation to have 3 the use of slides, also,?though, so really, what we are saying 4 is part of what I am suggesting is part of each of these 5 approaches we have previously outlined. 6 And I think that the site-visit is the time to out- 7 line-the kind of, kinds of slides, that you will need for that 8 presentation, because then, you can highlight some of the parts of the program you feel are necessary. 10 I think this gets away from the fact then that the 11 staff may be worrying about their slanting it in a certain 12 direction. 13 DR. SCHMIDT: We will want to bring this to a close, 14 quickly, then. 15 DR. JAMES: Yes, I have' avery, very quick comment 16 to make.- 17 Again, being new, I certainly enjoyed the audio visuals yesterday, and I would.'concur that the joint presenta- 10 tion by Staff and site-visitors' of the committee, make it a 20 presentation; I also would like to comment that this kind of 21 presentation with the broader presentation of actual figures 22 on the board, helps one to determine where the level of funding 23 would be, because sometimes I se e coming about, ceiling figures 24 that may apply to a funding, and I believe this would help to Ace-Federal Reporters, Inc. 25 deter the use of ceiling figures. ter-10 A figuteiout: of the'ceiling. 2 MISS KERR: One other quick request, is if it were 3 so thit we could have-these graphs prior to a site-visit, and 4 then if there were such changes as were dramatic enough to show, 5 could this suggestion be made by the visiting team to the 6 staff member, and the staff memb6r@ at his discretion, then 7 develop the second audio-visual for comparative purposes? 8 DR. SCHMIDT: We will accept that as a suggestion. 9 Sister Ann? SISTER ANN JOSEPHINE: Some of the regions are begin] io ning to develop their own visual material, and it may well be that some of'the visual material they have developed could 12 13 be used for this type of presentation, without a duplication of effort. 14 DR. SCHMIDT: 1 think Staff will be sensitive to 15 16 that. MR. TOOMEY: I would like to comment on the fac i7 t that seems to-me that we are, we have been asked to look 18 19 'ka ther specifically, precisely,. and indepth, at the program problems of the organizations that we visit and with which we 20 21 are concerned. .Then, in the course of our discussions, we begin 22 to focus on projects that are part of that. Yet, it is very 23 24 incidental. I cannot help but feel that the projects are Ac ral Reporters, Inc extremely important in terms of ananlyzing the congruence of 25 ter-11 I the project to the program. And, I'am going back to Staff 2 Anniversary Review Panel, because I think those reviews are 3 great. 4 I think, perhaps, the most effective presentation 5 on your charts have been the changes-from the categorical to -6 the multiples-kind of projects. And, I think if one further 7' facet of Staff Anniversary Review Panel could be, because we 8 are-not taking the time to review the projects in any depth; that they probably know them better than anybody else, and if 10 they could spend just a little bit of time on, or at least 11 a comment in relationship to the project, itself, to the pro- 12 gram that we are most specifically concerned with. .13 Do I make myself clear? 14 DR. SCHMIDT: 'Yes, everybody says, yes,.-and it is 15 captured and-While you have your microphone on, let us turn 16 then to Missouri and a brief status report from the site-visit.i e-4/s-5 17 MISS KERR: I am assuming we need not do anything wi I 18 that on our evaluation sheet, right? 19 DR. SCHMIDT: That is correct. 20 This is for information. 21 J2 23 24 Ace - ederal Reportefs, Inc. 25 CR 7149 5 2 4-B follows 4-A by TER I MR*.TOOMEY: I visited Columbia a month, in company 2 With Dr. Thurman, Dr. Pellegrino, Dr. McPhedran, Donna Howseal, kar 1 3 Dr. Farrell, and Judy Silsbee. There has been a kind of major problem in the Missouri RMP. Frankly, it has been a program ane 5 'organizational kind of structure problem.- 6 For instance, at the top level there is a problem wit'. 7 the regional advisory group. it was initially established 8 under Dr. Wilson in three parts. It was a tri-part RAG. 9 onIe part was an advisbry-council, the@econd part waE 10 project review commit tee, and third part was a liaison committe( 11 Which was p@o]ect oriented. When these three groups met, they in a sensb, represented the regional advisory group. 12 13 However, they met separately as well, and with the 14 advisory council being only 12-people and with the project revi(, 15 committee and liaison committee being made up predominantly of the prior-groups and most.specifically, of the University of 16 17 Missouri people,, it was a very closed kind of corporation, rather than an open advisory g.@.oup with input from much other 18 than the University. 19 When this problem was called to their attention, the,r 20 21 made the decision that the advisory council with 12 people was 22 in fact their RAG. In fact, it does not meet the requirements, 23 the legal requirements of a regional advisory group because it does not have all of the representation, even-the legal repre- 24 Ace -Federal Reporters, Inc. sentation, Veterans Administration group, and I think some othe 25 53 kar,21 Bill, what was the other? 'CHP Agency? In addition to which 2 it had only one minority or consumer involvement.' It was one, 3 one lead who was'black and who was a housewife, and she repre- 4 sented the female, the black and the consumer, all by herself. 5 Their focus in the past had beeon on, naturally, the 6 extremely categorical nature of the projects.' They had been -- 7 they had been very equipment-hardware oriented. They didn't 8 have adequate goals, subgoals or priorities and within the past 9 year, they-have had a group headed by, I think it is Dr. Mare 10 who has worked, I guess, with great vitality and enthusiasm 11 -in developing a set of goals and.subgoals and priorities. 12 However, they felt that the objectives that should 13 be established in order to achieve these goals should not be 14 established by their goals committee and it should not be 15 established by RAGI but in order to allow the local regions 16 covered by the Missouri RMP to give to the establishment of thei- 17 projects.and their objectives, the local flavor that was necessz: they left the objectives out. They felt very strongly and 18 organizationally they have six or seven subregions and they haVE 19 20 a part-time-,,coordinator in each.of these subregions and they 21 felt-that each of the subregions was geographically so different and the'needs were so varied that for-a central group to establi@ 22 23 the objectives for these regions was undesirable. So they did 24 not -- they did nothing other than establish the major goals, Ace - Federal RePDFters, Inc. 25 the purpose, the ma]or goals and some of the subgoals. 54 kar 31 Their major goals are the enhancement of the avail- 2 ability and accessibility of health resources, enhanceme nt of 3 quality care and the moderation of costs., And they have under 4 each of these major goals, they'.have subgoals to the-total of 5 13. Frankly,jthey have done an excellent job. Their goals and 6 subgoals are great. And if you can accept the fact thati-Ehe 7 regional area should be able, through-its own input,to establie' 8 the objectives for that area to determine what its major objecti'- 9 would be, then it is not an inadequate or it is not an undesiral@. 10 approach. 11 The program staff was'-- had not had its organizatio i 12 structure changed from the time that it was categorical in 13 nature. And I think I would put it in another framework. They 14 have an organization which is inadequately structured to carry 15 out the goals and subgoals that they have established. They 16 did not have an evaluative mechanism. 17 A committee was established, but it is a little bit 18 hard when you have no objectives to evaluate whether or not whal 19 you are doing is being accomplished as it should be. So the 20 evaluation committee really exists in the same kind of a void 21 as the specific objectives exist. 22 We were concerned with tlie'part-time regi onal 23 coordinators, and really it wasn't until we had an opportunity 24 to meet with these 4en tlemen, four or five of them being '%Ce -Federal Reporters, Inc. physicians, and retired or semi-retired kind of situation. And 25 55 kar 4 1 when we did meet with them, we found that.they were, in my 2 opinion, a very dedicated group of people. The problems that 3 have existed really are the fact that they were part-time and 4 there it did take them a considerable amount of time to travel 5 through the region for which they were responsible to relate to 6 the priors and other people in-that region and to begin to draw out of the region the things.that the region might do. 7 8 They felt that they would be better if they had some 9 part-time help themselves"in terms of secretarial help or data gathering or kind of people who were -- these with all physician 1.0 - and they felt they needed some nonphysician help in the -- in their work. As part of the organizational structure, I think 12 that we looked ver hard at the coordinator, and I don't -- I 13 think I would feel mo re comfortable when I would say that they, 14 15 and I quote from a review of their fifth year application, site visit report in 171, "The site visitors find the organizational 16 17 effectiveness of the coordinator weak. The doctor is not as forceful an administrator as he could be.11@ And in@172 the rema..] 18 19 is, "Other leadership is.still considered weak. Not only does 20 he exhibit through the lack of organization within the program staff itself, but in addition to which he is director of health 21 22 program for the University extension division and he is director of a HSMHA contract in consumer education, and to compound the 23 weakness which seems quite apparent, he is now devoting only 24 Ace-Federal Reporters, Inc. 54 percent of his time to @he direction of the Missouri P14P.It 25 56 kar 51 Now, the explanation for this is that the consumer 2 project is operated through the University and the University 3 has said this is congruent with the RMP program which is operated 4 through the University and therefore,' we will put it in RMP and 5 'make Dr. Rickley the director. 6 These, I think, with the organization problems, the 7 structural programs of the organization, the lack of specific 8 objectives even though the goals were considered to be -- in my 9 opinion they have done an excellent job. I thin@ach of these 10 items was reported directly to their group. 11 I would like to ask.-Bill if he would like to contribut 12 anything to this,, Bill Thurman? 13 DR. THURIl@l: I think that I would just add a.couple 14 comments. Bob has outlined most.of the concerns. One of the 15 members with us from council indicated, said this was. nothing 16 more than-a day-long feedback session which is really the feel 17 you got for what we did because it was at times very sticky, 18 uncomfortable and at times they,.kept coming back to us with 19 questions like, what is the difference in definition between the advice you send and the recommendations that you send. 20 21 And we tried to respond to each of these and it was a 22 long@,-drawn out type of feedback session. I think that one 23 thing that concerned them the-most was whether or not review committee and councils handling o f the VAS situation should 24 Ace-Federal Reporters, Inc. have been clearer to them than it was, and Dr. Pellegrino's 25 57 kar 6 statement about that, and one of the reasons I have been con- 2 cerned today and yesterday about out patting people on the back 3 who haven't turned the corner is the Pellegrino statement that 4 they have had hit in the head with a2x4 and still haven't 5 changed. 6 So I think this was'a very worthwhile visit. I 7 wonder if we could have one word about councils feelinas about 8 not: concurring with our recommendation last time around about 9 triennial status for this group and I think the only other poin"- 10 that I would add-to what Bob has said is that the coordinator 11 problem represents a significant problem and lead to our ultima-( 12 recommendation. 13 MR. TOOMEY: I don't know if the council is familiar 14 with the fact that after the VAS project, which is a computer 15 project, and Dr. Billy Jack's office related to the medical 16 school, council of the advisory committee had recommended it be 17 funded no longer; then a separate contract was signed with 18 HSMHA in order to continue. 19 DR. SCHMIDT: -Bill, what did you mean by your ultima@, 20 recommendation? 21 DRi THURMAN: Bob is.going to present our recommend-. 22 ation in just a minute, I am sure. 23 MS. IIOUSEAL: In response to your council about why 24 c'ouncil decided that, they felt withdrawal of funds in the amoui Ace -Federal Reporters, Inc. 25 of a hundred thousand and the site visit would be strong enough, 58 kar 7 and they though it would be too harsh to withdraw triennial 2 status. 3 DR. SCHL-ERIS: What will be the result of this site 4 visit, I gather it is information on.ly, or are there specific 5 recommendations? 6 DR. SCHMIDT: I was a little puzzled, obviously, 7 again-I am hanging on tender hooks because there was some 8 recommendation made. 9 MSi. HOUSEAL: The site visit team was@o go out and 10 carry the m@ssage from last time. The recommendation had alrea 11 been met or.set by review committee@council,at their last 12 meetings.' The program recommendation, those Mr. Toomey gave 13 regarding settling the RAG issue, making the coordinator-full- 14 time, making objectives more specific, evaluation section on 15 core staff, the site visit made no funding recommendations. 16 With regard to the computer contract, there was 17 another site visit held by HSMHA officials this summer and con- 18 tract funds.of contract will not be forthcoming from @IPS for 19 this activity, but will be supp lied by national centers for 20 research-and development. 21 DR..THU@IAN: I didn't mean to leave the Chairman 22 hanging in mid-air. I think Donna has outlined our recommend--- 23 ations. 24 A very specific reqpest was made by the site visit kce- ederal Reporters, Inc. 25 team which Bob outlined to have a letter forthcoming from P14PS 59 kar 8 outlining these specific forms. My apologies to the Chairman. 2 DR. SCHMIDT: No. Any other comments then before 3 moving on? 4 DR. SCHLERIS: Does this go to council with a re- 5 affirmation of our recommendation from before, or is it just 6 where it was before, because I don't see where this is really 7 more than,,you know, it might be well if you did this. Funds 8 have been our means for having some impact, however transiently 9 on a regioni 10 MRS. SILSBEE: I think Dr. P61legrino, who used to b@ 11 -on the review committee originally-and council, descrived it 12 best as a therapeutic site visit. There were indications, not 13 only beforehand, but at the time of the site visit, that letter3 14 that had come and advice that had come from the review committe7 15 and the council, again, the site Visitors looking over the 16 material could not understand how the region could have failed 17 to have gotten the message, but when we got there, we realized 18 there was a filterihg.process and they had failed to get the 19 message. 20 So this was an opportunity to have a face-to-face 21 discussion, to make sure that what the!committee and coundil 22 had been saying was understood by the regional medical program. E 4-B 23 DR. SCHMIDT: All right. We will move on. 24 Ac al Repofters, Inc. 25 60 CR 7149 I DR. SCHMIDT: We will go onto Bi-State before 5 2 coffee. dor 1 3 I guess we are still with Mr. Toomey. 4 MR..TOOMEY: The visit to Bi-State was in regard 5 to an application for triennium status. xxxxxx 6 A review of the problems that existed with the 7 Bi-State, Bi-State RMP, indicated first of all that the 8 Regional Advisory Group had been-relatively inactive; 9 That there was a Scientific Educational Review 1.0 Council, and an administrative-liaison council made up of 11 representatives from three medical schools, Washington 12 University, St. Louis University, and Southern Illinois 13 University. 14 And the indications were that these two 15 committees which review all of the projects made the basic 16 decision and made their recommendations' then to the Regional Advisory Group. 17 And the record would indicate that the Regional 18 19 Advisory Group met seldom.or perhaps three, perhaps four times a year, and never for more than two hours at a time, and 20 with-only approximately one third of the RAG members present. 21 This led into the problem of.the grante6 22 23 organization, which was a joint organization, a so-called consortium, made up of these three universities, who, as a 24 Ace-Federal Reporters, Inc. 25 consortium, handle the grant funds for the Bi-State RMP. 61 dor Another problem apparently was the-internal' 2 organization of the program staff, which was structured 3 in-such a way 'that all of the members of the staff reported 4 to Dr. Stoneman, the coordinator of the Regional Medical Program. 5 6 Additionally, because.it was a Bi-State area and 7 covered the area around St. Louis, Missouri, and, in 8 addition, covered the southern part of Illinois, which 9 included the state capital in Illinois, Springfield, where 1.0 there was a concern because the Illinois RMP, which was a II. growing organization and more aggressive increasingly aggressive organization, was concerned because the state 12 capital of Illinois was being covered by a Bi-State RMP, 13 rather than the Illinois RMP, as an expression of the 14 15 either of the agressiveness of the Illinois RMP. They had just rece ntly funded a project it 16 17 Southern Illinois which theoretically was in tetritory'."..@.@'.- covered by Bi-State RMP. 18 Finally there was a concern about the relevance 19 of goals and objectives tothe region's health care needs. 20 The specific issues were -- with which we were 21 concerned were the organizational structure, the role and 22 23 influence of the consortium, the internal organizational 24 problems of the program staff, the dispute over the Southern Ac al ReporteFS, Inc. 25 Illinois area with the Illinois RMP, the role of the program 62 dor 3 I committees and the adequacy of proposal development and review 2 process and relevance of go als and objectives to the Region's 3 health care needs. 4 In the establishment of-the go&ls and objectives 5 which came about March 1971, their objectives and priorities 6 were groupd around six major areas. ?Their first was manpower; 7 8 The second, the health care delivery systems, 9 rural and urban; 10 Thikd,continuing education; Fourth, medical care, primary, secondary and 11 12 tertiary,-and the cardiovascular, cancer,. stroke, and other diseases; 13 14 Fifth, demography and statistics; and, Six, medical information. 15 16 And their priorities followed this ranking. 17 We were concerned about the categorial orientation he objectives, recommended that there be deemphasis of 18 of t the traditional categorical interests. 19 20 The objectives tended to reflect highly pre- 21 determined assessment of regional needs. 22 During the categorical period, let me say this: 23 one of the problems that had previously existed before the 24 Bi-State RMP came into being was the inability of the two Ace -Federal Reporters, Inc. 25 medical schools in St. Louis to relate to each other in 63 dor 4 carrying on programs in an effective manner.. 2 The RMP during this categorical period brought these two medical'schools together and'their cancer and- 3 4 cardiovascular program seemed to be.particularly successful. 5 Their other projects that they-had accomplished 6 were in the training of coronary-nurses, and in a.library - 7 network which utilized the services of,both Washington 8 University and St. Louis University and spread through great, I think, in-terms of about a hundred hospitals throughout 9 the region. 10 11 During the past year.the Bi-State RMP became 12 involved in developing a major medical service emergency project which was funded this past spring. 13 14 In the area of continued support, the radiation 15 therapy program has become self-supporting. However, it is being continued and the nurse coronary care unit is continuing. 16 One of the projects that had been established 17 under the old RMP was a -- under the categorical phase of the 18 19 RMP, was a project, Pruitt Sago; which is a housing section in 20 St. Louis. There they had .made.an effort to establish a program and project which would provide health care services 21 through the utilization of medical students and training home 22 23 health aides at that center to provide care to six thousand residents of the Pruitt Sago area. 24 Ace -Federal Reporters, Inc. 25 With the .exception of thatproject, and beginning 64 dor 5 I to look at the problems in East St. Louis.-there had been no 2 indication of minority concern,.or minority interest on the 3 part of the Bi-State RMP. They are now concerned with it, 4 not only the urban health care, but the rural health care, and 5 they have -- part of their consortium is Southern Illinois 6 University, which, in its new medical program has adopted 7 the -- its prime interest, that of developing delivery of 8 health care services to the people in the rural areas in 9 Southern Illinois. 10 Andthey now have five new projects of the 11 Bi-State RMP directed toward the underserved. 12 Dr. Stoneman.is the coordinator of the Bi-State 13 RMP, and I think we agreed that Dr. Stoneman was a very, 14 very dedicated and very, Very fine, dedicated, intelligent 15 person. 16 However, it was our feeling that he was over- 17 stretched in terms of attempting to relate to not only all of 18 the areas in the two states, but he was.on the faculty of the 19 St. Louis University. 20 He carried, continues to carry on a practice in 21 surgery to aminor degree, several hours a day,'two or t ree 22 hours a day, is what he has stated. 23 And in light of this and he also is president 24 elect of the St. Louis Medical Society. Ace -Federal Reporters, Inc. 25@ Consequently, he is in a position where in light 65 dor 6 of his desires to relate individually to every person who 2 works on the program staff'a nd-the outside activities, we 3 felt that, as much as anything, that Dr. Stoneman deserved 4 a deputy coordinator, somebody to work with him in the internal 5 organizational matters of the program staff. The Program staff, individually, as we met with 6 7 them, And talked with them and listened to them, seems to be 8 quite an excellent group of people. They had one organizational structural problem 9 which relate@ to the use of part-time associate coordinators. 10 at each of the universities in..each of the categories and in 11 Southern Illinois, in their rural health care delivery system. 12 And it was our feeling that these part-time 13 categorical coordinators should be phased out and that full- 14 time associate coordinators, who would have an interest in. 15 the organization rather than in the category of medical 16 17 care, should be added to the staff, or should be substituted for the part-time people. As mentioned earlier, the RAG met just three or 19 four times a year, and then for.only approximately two hours. 20 21 Their attendanc.e was minimal, only averaged about a third. As businessmen, which is where it seemed their 22 greatest strength lay, they felt that they were in a position 23 24 where they should delegate to the universities, to the SERC A,ce- Federal Reporters, Inc. and the administrative liaison committee the work of developing 25 6 6 dor 7 I program policies for that particular organization. 2 And they did not feel that it was their responsibility to take as active a part as we felt they' 3 4 should. Consequently, as we looked at both the RAG and the grantee organization, it was our feeling that the influence 5 6 of the universities should be phased out of that program and 7 one of our recommendations was that the SERC would be phased 8 out entirely and that the Regional Adviso.ry Group would be 9 made more representative with more consumer interests and minority involvement at the core lbvell 10 And as part of our looking at the mechanism by 11 12 which our projects came through the various committees .to the Regional Advisory Group, Dr. Mitchell awnd Maria Flood 13 reviewed, they did an audit @a:Ul,if you will, of two of the 14 projects, and I might interrupt and ask Maria Elena if she 15 would like to comment on the trailing of the projects? 16 MS. FLOOD: There was some concern by the site 17 18 visit team that the university bad exerted some tremendous pressures to be assured the projects were named only at the 19 medical school emphais but,.-'indeed, as we went through the 20 21 review process, we didn't find this to be '-.true and rather 22 found that perhaps the medical schools', the universities, had lacked support in helping them develop mechanisms for proper 23 review, but there were some glaring deficits in the review 24 Ace-Federal Reporters, Inc. process we encountered. 25 67 dor 8 We were not provided with the cover sheet that 2 the regional Advisory Grou' meeting, page one of the Regional p 3 Advisory Groug meetings that we reviewed, which-carried the 4 names and attendance records. 5 We were -- all three meetings, the review started- with page two. It could have been an oversight. 6 7 The review process reflected some deficits in the 8 fact that if the reviewer felt that there were conditions 9 to be met by project proposals, there was no documentation 10 that this information ever got.ba.ck to the project proposer or that, indeed, funding was not approved until these 11 12 conditions were met. We thought of two studies, one'being a medical 13 14 school oriented,three-pronged nurse-physician assistant type of concept, which was originally rejected and then subsequently 15 16 resubmitted with a little different approach and was approved on the second review. 17 The other project was a very poorly documented 18 19 project from a minority impact area, had to do' with the 20 educational,ifacilities for allied health training, and it was one of the problems we encountered in this, that there was 21 22 no formal development of a format for submission to,projects. Our opinion reflected some deficits in the 23 24 management capabilities of the staff l@n'developing a format Ace-Federal Reporters, Inc. for proposers to follow and formal structure for the review 25 6 8 dor 9 I process. MR. TOOMEY: Thank you. 2 3 Certainly, the prior groups were involved, 4 including the comprehensive health planning agencies. 5 As a matter of fact, the'relationship was be- ginning to be so close and RMP-was sufficiently interested 6 7 in continuing this and working closely,with the Comprehensive 8 Health Planning Agency that they-recommended to us at the 9 time that we arrived there that,'or they didn't recommend, 10 they requested that we give consideration to a funding to 11 strengthen and to allow the Comprehensive Health Planning 12 Agency to continue to become more and more involved in the @13 in helping in the assessment of heeds and in the planning 14 for the area. 15 They-used the Comprehensive Health Planning Agencies 16 to the extent that it is possible to use them now. They see that it is possible for further developments to take effect 17 18 with the Comprehensive.Health Planning Agency and they would 19 like to make them an active ally and provide them with some funds to enhance that whole record. 20 As a matter of fact, as they assess the needs 21 22 and resources, they felt that this continued active 23 cooperation between RMP and CHP should be encouraged. 24 Their program staff monitors all projects. They Ace - Federal Reporters, Inc. control the financing. They monitor the fiscal affairs. 25 69 dor 10 I Another problem that.they had was the planning 2 and evaluation was in the hands. of one person, a one-person 3 department, and they felt that even though this person was 4 a well-qualified Ph.D@ that this perhpas should be split. 5 Bi-State RMP has developed an action plan and from 6 the application and presentation of the visit, appears sound 7 and includes several excellent components. 8 The RAG has assigned priorities to the objectives 9 and they rank health manpower and health care systems highest. 1.0 Continued education and catogoticdl disease strategies were 11 lowest. 12 Their immediate priorities include data base improvement, primary care strategies and medical information 13 14 systems. We believe that the REgional Advisory Group needs 15 strengthening and they need to direct need to direct themselves 16 17 to do a more adequate job of meeting the needs of the 18 region. Now, much of.this sounds, in a sense, it sounds 19 negative and I think, I suppose it is easier to pick the 20 program apart than it is to promote its strengths but they 21 22 have done an excellent job with the development of their goals and their objectives. 23 They have disseminated these goals, they have a 24 Ace-Federal Reporters, Inc. mailing of 8000 organizations, and institutions and individuals. 25 70 dor 11 In addition. to the dissemination of this 2 information they used an interesting mechanism of requesting 3 back from the people to whom they mailed this information 4 requests or projects and programs and specific areas. They 5 felt they coudl establish a program of providing, it you will, 6 it was mentioned'yesterday as "mini-proposal," but these are a.little larger than the five thousand dollar proposals, 7 8 these would be $25,000 proposals and at the end of the year, they would have, through their evaluative mecham they 9 would be able then to focus in other ones which were most 10 11 promising and most desirable. The staff, As I mentioned before, was excellent. 12 They have one member of the staff, a Black professional,.who is 13 extremely interested in the problems of the innercity and is 14 15 -working with groups in East St. Louis and in the Pruitt sago, 16 and in the -Vhole Bi.-State,area, to develop projects which 17 would be of assistance to the minority-groups, their health service education activities, the non-AHEC, if you will. 18 The AHEC which is non-AHEC, is in the hands of 19 a new person, who is a Ph.D. in education and has begun some 201 programs in this area. 21 Their work in the emergency medical services was 22 excellent. They received, I believe, about a quarter of a 23 million dollars to carry on this, or to initiate more planning 24 A,ce-Federat Reportefs, Inc. in this and the development of a larger program in this area 25 71 dor 12 I then. 0 2 Their review'of projects has certainly 3 improved, also. end 5 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 0 Ace-Federal Reporters, Inc. 25 CR 7149 72 6 eak 1 In brief, it was our feeling that the organization, while it does exhibit some weaknesses, that with th e addition 2 3 of a coordinator, deputy coordinator let me go over it 4 this way. We feel that Dr. Stoneman and his staff have the 5 capability, professional qualifications and interest to build 6 a first rate RMP. The goals,, objectives and plans were rele- 7 vant and sound. It has some organizational problems which 8 presently hamper its growth but with a deputy coordinator, 9 the reorganization of RAG and broadening of the involvement of 10 people in the area, we think it has a great potential. We also 11 felt.triennial status should not be-withhe,ld because of the 12 weaknesses but rather it should be approved on a tentative 13 one-year basis -- if it is triennial status, but with the 14 recommendation that it be'reviewed.-at.the.end of the.-year. The recommendation for the request for funding was for a 15 million four, the first year, a million 463 the second year, 16 17 a million-five the third year. 18 Our recommendation.was a $1,150,,OOO be approved 19 for the first year, $1,230,000 the second year, $1,316,000 the third year. 20 This includes funds for a deputy coordinator 21 and a $50,000 discretionary fund for Dr. Stoneman. Dr. 22 @3 Stoneman's concern as far as the developmental componen as opposed to,having his -desire for developmental component 24 4ce- Federal Reporters, Inc. was in order to contend with the problems that existed in 25 73 eak 2 the fact that Illinois RMP had developmental funds and he had 2 none and he wanted to be in a position to handle new projects 3 as they came up when they came up. 4 DR. SCHMIDT: Thank you. Secondary reviewer, 5 Dr. Thurman. DR. THURMAN: I will have very little to add to 6 what Bob has said. I think just because of the fact that the 7 8 Missouri site visit came on at the same time the turf question 9 will become a major question and we heard some question of concern when we visited Missouri because of their interrelation- 10 ship with Bi-State. I think the question of the coordinator 11 probably needs discussion by the whole Review Committee because 12 I of the points that Bob has raised. And I don't think any of us would disagree that if he is to continue in his present 14 15 action, that a very strong deputy director is needed. Lastly, 16 my concern, as already reflected by Bo]5, is the continuing project-type orientation. 17 18 It would appear that this tripartite of'RAG 19 basically and their appointment of associate coordinators, 20 if this is not constantly monitored by staff, will perpetuate this type of categorical approach. 21 22 MR. TOOMEY: I might ask Maria Elena if she wants to add anything to this? 23 0 MS. FLOOD: Well the only comment I might add is 24 Ace.- Federal Reporters, Inc. 25 that we got the feeling the first,day that there was a strong 74 eak 3 I staff capability and this was definitely reenforced as the 2 visit progressed. But the maInagement problems are acute, and 3 there.has been comment here at this committee that you can't' 4 correct a weak coordinator with a strong deputy but in this case 5 Dr. Stoneman is not really weak. It has just been his insecurity 6 without someone under him to allow the staff to develop 7 the mechanism of interrelationships. They come to him, they 8 answer to him, they report to him. If he were given a strong 9 deputy that could pull together the management trends necessary, 10 I feel strongly personally that this particular staff, 11 under the leadership of Dr. Stoneman, could indeed develop the 12 program and follow the recommendation that we made to.begin 13 a trend towards an improved RAG commitment and RAG participation 14 in policy planning and in goals,objectives, and also broaden 15 the scope of the program to really become a program and 16 deemphasize this mini-project advertising that they have used. 17 DR. LUGINBUHL: It is, of course, difficult to 18 judge a program without having visited it and just from 19 hearing discussion and reading the documents. I hope my'remarks 20 are not overly critical but I dan't help but raise a number of 21 questions from the comments that I have heard and from the 22 review of the material that we have. 23 First of all, it appears'to me that there is some 24 problem with this consortium, and I Wonder who is minding the Ace-Federal Reporters, Inc. 25 store. You have got three different medical schools involved 75 k 1 in this. I asked yesterday specifically who has the authority 2 to replace a coordinator that is inadequate and I was told 3 that it is the grantee. I am not quite clear, who is the 4 grantee in this case, and who has the-authority? Who makes 5 the decision? You have got two vice-presidents of health 6 affairs at large ifiedical schools, another developing medical school-involved, but who actually makes the decision, who moni- 7 8 tor8 this program, that is question number one. 9 Secondly, I can't help but have some Uestion about 10 the coordinator. After a day and ahalf, I am beginning to think that the terms hard work 11 ing and dedicated are euphemisms 12 for incompetence and I can't help but think. that the suggestion I13that a deputy coordinator be appointed is simply a way of patching a very worn tire. I may.be wrong in this but 14 I can't help but raise this ques tion. From my point of view, 15 a strong coordinator, a good coordinator is not necessarily a 16 person who is a strong individual or who has a great deal of 17 personal dedication. I think one of the most important 18 19 qualifications of a coordinator is the ability to delegate, 20 is the ability to organize and motivate staff and when I hear the coordinator has not developed staff, that he does reserve 21 judgments for himself, then that to me raises very serious 22 23 questions and I think that is.a very serious deficit to try to correct with a deputy. 24 Ace-Federal Reporters, Inc. if he hasn't seen this need himself and developed 25 eak 5 76 the ability to delegate, I think that it is difficult to 2 force this by the appointment of a deputy. Finally, I would lik=- 3 to raise a question about the budget. 4 I see that the coordinator is listed as 93 percent 5 effort but I read in the narrative that he-is a practicing 6 plastic surgeon. I can't help but ask, what is the control that 7 we have over this man's total 'Income? 'I don't know what the 8 relationship between this program and the consortium is, but if 9 there is simply no limitation on his' outside ihco?re and the 93 10 percent figure means very, very little, then I can't help but 11 be worried about the amount of effort he puts into the program 12 and the amount of time he puts into his private practice. In summary, I would like to know who'runs the 14 consortium; I would like to hear'a little more conversation 15 about the real ability of this individual to run this 16 program. And I would like'to have some further insite into the 17 financing. 18 MR. TOOMEY: The consortium has agreed that 19 Washington University will be the grantee agency. And they have@ 20 an arrangement through which Washington University is the, 21 really, grantee agent, although the three do work together, 22 but it is Washington University. Dr. Guzzi, I believe, was 23 the name of the man from the medical school who is responsible 24 as.far as Dr. Stoneman is concerned.' You know, as a fellow Ace-Fedeial Repofters, Inc. 25 in management, I think I would agree with you under most eak 6 77 I circumstances. 2 However, there are.some circumstances and this I 3have seen, that peopld have varying degress or Varying kinds 4of abilities. Dr. Stoneman's ability is one in which he became 5a participant in the program as a volunteer member of the faculty when he was a member of the faculty of St. Louis 6 University. He is thoroughly dedicated to its goals, even its 7 8present goals. He is, I would-sa.y, an extremely capable person,, although to be honest with you, he would be better off if he 9 were trained in management rather than in surgery. 10 But he has been trained in surgery and within, if 11 12 you will excuse me, those limitations, he.does a rather fabulous kind of job. He does need somebody who is trained 13 in administration who understands the kinds of things that you 14 are talking about to work with him. He relates well to all of 15 the universities. He relates well to all of the other 16 physicians.'. He relates well to his own staff. They are 17 extremely loyal to him, I think-in every way, by every 18 indication. @He relates extremely well to the, if ou will, y 19 the power, the financial and economic power structure in 20 the community. They have a great deal of faith in him. Perhaps 21 too much 22 I think this is one of the cases unlike the 23 neighbor that he has in Columbia, M@ssouti, where I think the 24 Ace-Federal Reporters, Inc. administration does not have these abilities. As far as the tim 25 78 eak 7 I is concerned, we did ask him about this and he, his work 2 is done basically at night-and on weekends as far as his home 3 surgery is concerned. I know it is a 'roblemand I don',t p 4 know any way around it but he says that in order to supplement the income that he receives from the RMP, that he continues 5 6 a small private practice. He also does continue. with his 7 teaching at the St. Louis Oniversity. 8 DR. PAHL: Doctor, I would like to comment on 9 Point 3. You raised the question about what the control is 10 over the total income of coordinators. At the present time, 11 there is no policy within RMPS, H$M.HA, or department that 12 know of that provides any control over total income, other than the usual ones of not being reimbursed twice for presumably 13 14 the same time expended. However, there is increasing concern being expressed 15 and much more so in recent weeks from both RMP and also the 16 17 department- andwe have been interested in this matter for quite awhile ourselves. Not so much the total salary as the matter 18 19 of part-time direction of RMPS programs and whether programs which are running at $2,million a year-can,,in fact, be 20 21 effectively conducted without the full-time direction of the chief executive officer. It is almost impossible for 22 23 any single program in HSMHA to write a grant management policy about salaries because you are very familiar with all 24 Ace-Federal Reporters, Inc. the roblems involved with time and effort and we "ust get into 25 p 3 79 eak 8 1 a tremendously complicated activity. But I shou ld say that 2 there is very serious concern on the part of people within 3 RMPIS.and at higher levels about the costs of managing a program 4 and the results for the monies being expended, and what consti- 5 tutes good management. And I think there are continuing 6 efforts that are partially underway-now. We have some 7 analyses going on now and I think we will be trying to develop 8 some-reasonable kind of statement so that we can improve 9 the management of these programsIwithout at the same time trying to impose.nonworkable definitions of time and effort that' NIH and others have found so impossible to.implement. DR. SCHMIDT: We have two or three issues on the 12 13 floor. One other one that has been brought up is whether this 14 region really is ready for' triennial status given the stated efficiencies in the review process particularly in the area of 15 discretionary funds and whether they h@ve the adequate 16 review and decision mechanism that even meets the minimal 17 18 standards set by RMPS for the use of discretionary funds. MR. TOOMEY: Let me comment on that a moment, 19 because there was difference of opinion as to its readiness 20 to assume the responsibility for a triennial status. And I 21 22 guess what we did was to compromise the situation which was to say, triennial status but review at the end of the year. 23 24 DR. SCHMIDT: Sister, were you,going to comment? Ace-Federal Reporters, Inc. 25 SISTER ANN JOSEPHINE:, Yes, I would just like -- 80 eak 9 I mr. Toomey, has this program done anything to provide services 2 in Cairo, Illinois? I know this was requested. 3 DR. SCHMIDT: The answer is no. 4 John? 5 DR. KRALEWSKI: Just a couple of questions and 6 comment here that might go along some of the lines you were just 7 outlining but on the budgets it wasn't,clear to me whether we 8 were giving them money to add staff. You were recommending 9 $750,000. They were running 517 or -something suc;was that, the 10 way it looks@ Could you,dlar.ify that for me quickly, what will 11 they be able.to do with the 750? Along with that are you 12 recommending developmental component? 13 MR. TOOMEY: We were recommending full-time people 14 rather than part-time people as associate coordinators to 15' replace the part-time coordinators that were at Southern'I'llinoi 16' and at the other universities. I17 'Rather than having them as linkages to the @18 universities, having them in the area of rural health, urban 19 health and taking a segment of the responsibility for the 20 structure, itself, we were recommending in addition to that 21 only,the deputy coordinator. 22 DR. KRALEWSKI: Do you recall how many FTEs that 23 would add? 24 MR. TOOMEY: Four. Ace-Fedetal Reporters, Inc. DR. KRALEWSKI: Four? And were you recommending 25 eak 10 developmental component? 2 MR. TOOMEY: No, no. I. guess it is semantics but 3 it is called discretionary- funds. 4 MR. KRALEWSKI: One other comment I don't know if 5 I am reading this data, you know, from our book here 6 right or not. But it seems to me that last year in terms 7 of the award that we gave them which essentially was supposed 8 to be used for, you know, for the, to carry on their 9 program, develop some other projects then d evelop. a three-year 10 program for us. It appears that they implemented some 22 pro- 11 jects with it at very low level funding and now we are coming 12 back this year and asking to inc rease that low level funding 13 for all but two of the 22, up to, you know, much more substantial 14 funding. And I raise the question over whether,you know, that 15 indicates any real,, you know, ability to really handle 16 the question over what projects should we implement and how e 6 17 should we-best handle some funds. 18 19 20 21 22 23 24 Ace-FedeFal Reportefs, Inc. 25 82 #7 arl I MS. HOWSEAL: This region had its budget stated 2 for three months in order to phase in to our three-cycle review 3 process, and they operated with the funds to discontinue some 4 of their old process and initiate some of the new ones with 5 this last three months funding, and they did it only with the 6 three months period knowing the projects could be turned off 7 if the reviewers felt they didn't have merit, but it's not 8 any--- they aren't projects started a year ago, they are brand 9 new projects being started the last three months of this presen-- 1.0 year, and it is because of our need to bring the region into a 11' different review cycle that that this was done, not because 12 of the 13 DR. KRALEWSKI: 22 projects? 14 MS. HOWSEAL: Not only 22. Some of those were 15 held over from the last year. 16 DR. KRALEWSKI: They don't 'show that unless 17 well, I may be reading this wrong. 18 MS. HOWSEAL: The printout probably doesn't show 19 when these projects were initiated. If they were initiated 20 during the last three months, the printout would probably show 21 they started at the beginning of the year, when in reality they would only get funding starting October. 22 23 DR. SCHMIDT: Dr. Luginbuhl? 24 DR. LUGINBUHL: I would like to wk a question, Ace-Federal Reporters, Inc. 25 point of information. I am looking at the budget in the actual 8 3 ar2 I grant. I note that the budget in the actual grant lists a 2 number of associate coordinators, but they are categorical. 3 They are not the kind of associate coordinator that you are 4 recommending. 5 If this award is made under the terms that have 6 been outlined, what assurance do we have that they will hire the kind of associate coordinator that we are recommending 7 8 as opposed to going ahead with the budget? 9 I am trying to.get some.feeling for @hat authority this recommendation has, and I.am asking this particularly 10 because I got the impression that this program had been given 12 some guidance in the previous year about.the need for re- structuring the organization, and apparently did not follow it. 1 3 MR. TOOMEY: I don't know that it had the instruc- 14 15 tions of the prev.ious year, and I really can't answeIr honestly the fact-that they will do what-we say. 16 I would assume if you tell them that this is the 17 basis on which the funding has'been made that'they will 18 consider it directly enough. I don't think they have much 19 alternative. 20 21 DR. SCHMIDT: Seems to me at this point to 22 enlarge a little bit on your question, that what has been 23 recommended as one-year funding level was site visit, and so 24 in theory, staff, et cetera, would carry back to the region Ace-Federal Reporters, Inc. the strong concerns of the committee and the assurance that 25 8 4 ar3 the committee would be looking at what they have done, during 2 the coming year. And the stick that one has is the 3 funding level or the'second and third years of'the triennium, 4 if you wanted to use a bigger stick, what the committee 5 could do would be to recommend withholding the triennial 6 status and give them one more year, and have them revise the trienn@al application and come in in one year with the 7 8 triennial request. That would be a bigger stick yet. Let me just ask a very simple question that hasn't 9 been asked for a year or so around this table, but is this 10 a viable region? MR.,TOOMEY: Yes. 12 That's a simple answer. But you have got interest 13 in the community, you have got interest on the part of the 14 medical profession, you have got a great thrust coming out of 15 southern Illinois, as I see it,_in the future. You have, 16 17 you really'.have. A personality of the man. He is a good man running that 9MP. You have got-capable, qualified staff. 18 19 -You have got an interestin education. You have -- you really 20 have the backing of those three universities. 21 One of our concerns had been that the university 22 was exercising too great influence. In actual fact what they were doing was evidencing great interest. Now at the 23 24 time that it was categorical, I am sure there was great Ace - Federal Reporters, Inc. influence coming from the university in terms of their 25 85 ar4 I pro3ects. Right now what you have is great interest on the 2 part of the university in.extendin g its own services and its 3 own concerns through RMP. 4 So I think there is no question, as I look at the 5 total picturelthat this is a very viable organization. This 6 was one of the reasons why despite our discussion as to 7 triennial status that we felt with all of these pluses, despite the fact that you can focus on the minuses very 8 9 easily, in light of all of the intangibles, that this has potentially a great future. 10 DR. SCHMIDT: Do you feel that the turf problem 11 12 with Illinois is a minor one or'moderately serious one or very serious one? 13 14 MR. TOOMEY: Well, I don't know how to evaluate it. 15 We talked to Dr. Snoke who was out of the governor's office. 16 He is not ready to make the decision himself. 17 DR. SCHMIDT: Dr. Snoke is totally confused by the whole thing. You wouldn't be able to get anything but confu- 18 sion out of Dr. Snoke. 19 20 MR. TOOMEY: Certainly the-recommendation that the-two groups get together and there is some indication 21 22 that can declare areas of prima.ry concern which would be 23 southern Illinois for the bi-state RMP, and perhaps what we might call a DMZ in the Springfield area in which there would 24 4ce-Federal Repor@s, Inc. be some concern on the' part of both Illinois and bi-state. 25 86 ar5 I But, you see, southern Illinois is up in the 2 Springfield area and relates to bi-state as far as its school 3 is concerned so that there are some problems, and this@perhaps 4 would be one of those areas in which there is an acceptable 5 overlap. DR. SCHMIDT: Dr. Thurman? 6 7 DR. THURMAN: 1 would just agree with Mr. Toomey's 8 analysis. I think in answer to your question, it is a 9 viable region. 10 My second question there, is there a motion on the floor? 11 12 DR. SCHMIDT: Yes, there is a motion on the floor made by the principal reviewer. I am not sure it was seconded. 13 14 I will ask at this time if the motion which was to-wit, "approval of the triennial status without approval of the 15 16 developmental component, but with discr.etionary.funds to the tune of 1.15, year one; 1.230, year 2; 1.316, year three" -- 17 18 is that the motion? MR. TOOMEY: With review at the end of the first 19 20 year. 21 DR6 SCHMIDT: That's correct, with review, with' 22 a site'visit? In one year prior to the making of the second 23 year award. Is the motion seconded? 24 Ace-Federal Reporters, Inc. it is. 25 87 ar6 I Dr. Thurman? 2 DR. THURMAN: I would like.to offer a substitute 3 motion going along with the funding, but withholding triennial 4 status with preparation of a triennial application for next 5 year. 6 DR. SCHMIDT: All right., is there a second? 7 DR. LUGINBUHL: I will second. 8 DR. SCHMIDT: Substitute motion is seconded. 9 Let me ask someone whether or not this would cause 1.0 some breakage or to what extent would this be thought 11, detrimental? 12 MR. TOOMEY: I think I'd defer this to somebody who knows the area better than me. 13 14 MS. HOWSEAL: 'Well, there are two sides of the 15 story. One is the tougher problem and how this will be 16 settled in the next year. That obviously is a consideration. 17 The second is that this region last year came in 18 with a triennial application and staff said that at that time, 19 is that correct, that they weren't ready for' triennial status 20 at that time and held them off an additional year? 21 Their program plan seems pretty well in order. 22 But it is the organizational problems that need to be worked on 23 I think it 24 DR. SCHMIDT: The question ig, breakage, damage Nce -Federal Reporters, Inc. and so on. 25 88 ar7 DR. LUGINBUHL: I have h-eard discussed several 2 times in the last day and'a,half this question of breakage, 3 or.injury to a program by the use of too severe measures 4 to try to bring about remedial action. It appears to me the 5 two measures that are available are,-one, some form of budget reduction; and, two, withholding :triennial status. I would 6 7 gather that both of these have been employed on a number of 8 occasions in the past. It would be ver helpful to me in y 9 voting on this kind of a question to get some indication of 10 what kinds of damage have actually been observed from these classes of action in the past. In other words, has this really resulted in 12 significant injury to some programs, or is this a concern that 13 14 possibly has been weighed too heavily? If that is the case, it would obviously indicate to me that we should use these 15 measures more freely rather than less-freely. 16 17 I just don't have any feeling for what effects 18 these actions have been on prog.rams and just how real a threat. it is. 19 20 OR. SCHMIDT: I will try to answer that. I think that as you hinted At yesterday, the committee during the 21 22 five or six years that I have watched it,. has chosen the 23 route of not stressing region, if there was a question of too .much breakage, it opted not to stress the region in that 24 Ace- ederat Reporters, Inc. way. Usually other routes'kor effective action have been 25 8 9 ar8 taken. Either the chairman of the §ite-visit committee, such as Sister Ann, or the director of the program, or 2 3 somebody went out and got to the people who had to listen 4 who were in a position to do something. 5 Then either the coordinator was removed or the RAG 6 chairman was removed or the.RAG structure was altered. But 7 I don't think that a club has been used with enough force in the past, to answer your question. 8 9 The committee, if it's erred, has erred on the side 10 of being conservative,@using these other routes to get the 11 messages back. And I -- actually the committee has talked, 12 and staff knows the talk about stopping funding,completely of a region, for.example, withdrawing regional status, let 13 14 alone,, you know, something else. 15 And these methods have not been used for really, 16 if you look back the regions, Indiana will be coming up, which has more or less a cataclysmic year that was achieved 17 18 really through two site visits in a row,.and we will be talking 19 about that. So that I ask the question.quite deliberately from 20 21 my experience, that sometimes you will run the danger of 22 the RAG.or some of the critical.people just throwing up their 23 hands and saying the hell with it, and going away. And we haven't taken that risk deliberately in the past. 24 Ace - edeal Reportefs, Inc. Mrs. Flood7 25 90 ar9 I MRS. FLOOD: I would like to comment. My point 2 of view as to the potential breakage, I think the member 3 universities of the consortium expressed to the site visitors 4 a concern to fulfill their participation in the guidance of 5 the regional medical program in the new light of RMP de- 6 emphasizing the medical school,-oriented projects and 7 emphasizing more trends toward a programmatic approach. Seemed to be no qualms on Dr. Po-stals part 911 I think that this is'true, Dr. Schmidt's po.int, IQ that perhaps the.problem of withholding triennium status 11 to this particular region, which I think is viable and has 12 potential, would in a way give these consortium people 13 that feeling to heck with the whole thing, we have tried, but 14 may be going the wrong way, and now we are getting no backing, 15 and because of the tougher problems, not giving,them potential 16 with some secure funding for the future of these years, I 17 would put in a word for the triennium. 18 DR. SCHMIDT: The issue should be clear for the 19 committee then. The substitute motion would withhold the 20 triennial status, but do everything else that the original motion did so that you will be voting really in effect on the 21 22 triennial status with the substitute motion. Are you ready 23 for the question? 24 All right, all in favor do you understand that ce-Federal Reporters, Inc. 25 if you vote yes, you will be voting to withhold triennial 91 arl 0 I status? 2 All in favor of the substitute motion, please say 3 aye. 4 Opposed, no? 5 The motion is defeated. The original motion then 6 is for triennial status, et cetera, et cetera, as I recited it 7 before. Are you ready for that question? 8 DR. SCHLERIS: Like' to have a little discussion 9 about the discretionary funds which sound like evelopmental 101 component to me. 11 DR. SCHMIDT: I will try to speed this up by comment- 12 ing. I @hink probably the reason they want them is to be 13 able to compete with the Illinois regional medical program 14 that does have these funds it can sprinkle around and stimulate 15 this in their back yard, and they have got to beable to 16 stimulate this in their back yard in order to e a e to 17 develop the sorts of things that will change their direction that we are telling them they,have got to'do, and we have 19 discussed before that sometimes the regions that deserve the 20 developmental component least need the funds the most in order 21 to have flexibility, et cetera, and'I would assume that this 22 is the situation there. Is that accurate? 23 MR. TOOMEY: That's accurate. 24 MR. HILTON: Are we endorsing the concept of %ce-FedeF31 Reporters, Inc. 25 discretionary funds for other regions? As -- seems to me we 92 arll I had some discussion about the.developmental component versus 2 discretionary funds at some earlier region some months back, 3 this came up then, too. 4 Are we saying that this is a viable option for 5 folks who don't qualify for the developmental component? 6 DR. SCHMIDT: I think that each region,almost has to be looked at individually. obviously the answer to your 7 8 question is yes. But we aren't making any general pronounce- 9 ments or anything else. DR. PAHL: Dr. Marg ulies indicated to me that 10 'he will be presenting this general-topic of discretionary 11 12 funding and developmental components and other names by which 13 these funds.go before the forthcoming October council, not 14 trying to make a policy at that time, but to clarify the issues and perhaps come out with a def initive statement, because we 15 do not have a general pronouncement and obviously we are 16 17 getting into this area. At the moment you are free to act as you choose 18 19 on individual case-by-case basis. IR SCHMIDT: I think we will kind of restrict this 20 21 to a couple more comments. Dr. Luginbuhl? 22 DR. LUGINBUHL: Two quick questions. If we are 23 indeed giving the developmental component, why don't we 24 Ace -Federal Reporteis, Inc call it that? Why do we use some other name? 25 arl2 93 And number two, is the letter that goes to this 2 program, or is the advice that-goes to this program going 3 to include some expression of concern about having a part- 4 time director with a -- with another outside activity? 5 DR. SCHMIDT: The answer is yes. 6 All right, I am going to call the question, unless 7 there is some -- something new . St simply Because we are 3u 8 not going to get through our day's work unless we shorten this 9 up. 10 DR. J-AMES: The question comes.then to my mind, 11 in this kind of situation, if, in fact, there needs to be 12 some restructuring of organization and which eventually 13 results in restructuring of program, then monies that are 14 already allocated, if in fact they could.not be redirected, 15 I am at a loss to understand why there should be.-- why 16 that the RMP should be awarded additional funds for -- 17 whether it is called developmental or discretionary, when in 18 fact it would appear that the base monies that are available 19 need restructuring and when that is done, and used to 20 restructure, organize..restructure program, then it, to me, 21 would show that the whole program then can very well use new 22 funds for development, once it gets its base straightened out. 23 DR. SCRMIDT: I think the way I will answer that 24 is to say that the committee just voted not to deny triennial Ace-Federal Reporters, Inc. 25 status. That means that in the committee's opinion, the region 94 arl3 I has the ability to make the necessar y decisions to expend the 2 funds they have wisely. One category of which is loose and 3 not earmarked for projects now, but is, quote, discretionary, 4 unquote. 5 All right, I will put the question. All in favor of the motion, please say aye. 6. 7 And opposed, no. 8 There are "nos," but the "ayes" have it, and the 9 motion is carried. 10 I think that we will at this point take a no more 11 than, 15-minute break and start again promptly in 15 minutes. (Recess.) 12 13 14 15 16 17 18 19 20 21 22 23 24 Nce- Federal Reporters, Inc. 25 mea-1 95 CR 7149 #8 DR. SCHMIDT: We are'qoing out to the great state 2 of New Mexico which has the largest regional advisory group 3 in the history of the program. 4 During your comments I hope you will discuss why 5 they have a regional advisory group that seems to include the 6 whole population of the State of New Mexico. 7 MR. HILTON: For'the record I can't be heard. For 8 the record, okay. 9 Just a few preliminary comments and I will make them very brief in view of the pressure of time. My talk deals with specific sources, very general 12 items, before we go into specifics to kind-of sensitize you 13 to some special problems of the New Mexico area. 14 I should mention that since-the submission.of the 15 printed documentation on New Mexico we have received much 16 new data, as recently as the day before yesterday a phone 17 call giving us additional information which I will bring up 18 at the appropriate points throughout the report. 19 We were under, during our site visit, some time 20 pressures. The New Mexico Program staff had taken the 21 liberty of preparing quite a fairly well stated using 22 overheads, other kinds of materials which pretty much blocked 23 in our time. lie were forced to subdivide ourselves and 24 fractionate their well-organized plan in order to get a lot kce-Federal Repottefs, Inc. 25 of ground covered we wanted to cover. mea- 2 9 6 Some points pertinent to the'consideration of this 2 region: The state is large -geographically w.ith a population 3 of slightly over a million. The geographical expansion of 4 the state creates special problems that the region has 5 attempted to address itself to. 6 The state is multiculturallemphatically solwith 7 the major cultures being Mexican-Ambrican, Anglo and Indian 8 and the feeling generally being that efforts to improve 9 health care have to take that fact into account and try to 10 work with the 'facts rather than try to change it and smooth everything out and work with some kind of easy glossy kind of 1 2 program. 1 3 The state is poor, I have been told. I haven't 1 4 been able to verify this. The military installations-are a 15 major source of employment in the state. Continued support 16 therefore for any of the projects being conducted by the 17 program staff has been exceedingly difficult and if you look 18 at some of the projects listed there, RMP has a largely 19 .young staff, CHP agencies not awfully prominent in the state. 20 Then RMP in the absence of very forceful 2 1 representation on the part of'these other kinds of health 22 concerns in the state has really become very prominent. 23 That prominence has been greatly helped by the large RAG,' 0 24 that is a relatively new.development there. Ace -Federal Reporters, Inc. 25 But we had some concern, still speaking mea-3 9 7 generally, that R14P has become the center for so many things 2 in New Mexico that we may in fact be supporting activities 3 that in other states would be supported by other resources'. 4 Going item by item, at a fair clip, too, through 5 our evaluations, our site visit report, I should mention 6 that the primary purpose of the Visit was to review their 7: '73-175 application, triennial application, and to assess 8 their progress since June, 1971 site visit. 9 In conducting that meeting for that purpose, we 10 observed the following things: That the goals of RMP as 11 stated in materials certainly seem to be in keeping with the 12 RMPs' mission, the increase in availability, improving 13 quality care, moderating the costs of care, et cetera. 14 We had some problem with the goals and objectives 15 in that there seemed to be an absence of measurable short- 16 term objectives in the context of what the program was 17 ttempting to do. a 18 General priorities have been identified and 19 there is a listed rank-order which aids the program i n 20 making decisions about what we found that if resources are 21 reduced, et cetera. 22 Under the area of accomplishments and 23 implementations,, program staff has' stimulated several 24 worthwhile activities throughout the state. They do o %ce-Federal Reporters, Inc. 25 course now have a pretty substantial EMS activity going on: 9 8 mea-4 I Registries, involvement in the hatch area of New Mexico',, 2 programs internally to aid staff, things involving processing 3 centers, and a computer budget monitoring system so they 4 can determine on a moment's notice-how much they have got to 5 spend in each item, a cultural training laboratory which has 6 already'done some things and plans other things that will 7 help with that multicultural-nature.of the state I referred 8 to earlier. 9 They are developing'a statewide sys@ for 10 statewide hospitals to centrally purchase items. The hope is 11 they will.be able to reduce costs of certain aspects at least 12 other health agencies within the New Mexico 13 region, as I pointed out earlier, do rely pretty heavily 14 upon the NRMP. They have become the primary agency for 15 data analysis in the state. 16 Physicians do look upon the program for 17 professional and technical assistance, consultation, 18 information, et cetera. 19 Under the area of continued support because of the 20 problem of the general impoverishment of the state, they have 21 not been able to do as well as we'would have liked to have 22 seen them do. There have been some accomplishments. We 23 have encouraged other kinds- of things be done to get 24 additional help. kce-Fedetal Reporters, Inc. 25 Dr. Stone of the medical school in his mea-5 9 9 discussion of his grantees, stressed I think very clearly 2 that the medical school-is unable to pick up many of these 3 kinds of efforts that they would like to. He'was kind of 4 emphatic about that. 5 On the matter of minority interests, the majority 6 of the-statels'population percentagewise is one minority 7 or another. Representation on the program staff of 8 particularly the Spanish-speaking group was in my opinion 9 quite poor; not my opinion, the team agrees on this, that representation was quite poor.. Very few professionals, very 10 few clerical. Now, it should be pointed out one of the new 12 developments that I referred to earlier that we did receive 13 in our phone call information that the RAG for RMP has 14 15 met as of September 16 and that at that meeting they 16 declared their intention. to initiate an affirmative action plan which would remedy some of our concerns in this area. 17 Even since our meeting with the NmRmp staff there were 18 improvements in that additional persons were hired between 19 20 the time of our site visit and the time of the September 16 21 meeting. So there was visible evidence of intention to 22 improve an affirmative plan and it seems to suggest there wil. 23 be greater pickup in this area-. 24 I had the opportunity to get into the New Mexico kce- Federal Reporters, Inc. area a few hours earlier than I had expected I would so 25 mea-6 10 0 during that period Dr. Gay, the coordinator there, arranged 2 that one of his staff would show me around. I did get a 3 chance to visit a couple of the clinics and some of the local 4 reservations to get a kind of firsthand feel for what the 5 staff's relations were on the community level. 6 The staff, especially in the community health 7 service section of the NRMP staff, is pretty community- 8 minded, generally young, have not been as aggressive, at leas: 9 not as yet, as I would have liked to have seen but potential 10 is still there. Talking to a-number of staff, even in the 11 setting of the clinics, and talking to the people in the 12 clinics, we were very well received. 13 The manager of one of the clinics I talked to 14 had great hopes for a continuing relationship and a developed relationship. 15 16 We did something in this particular area in this 17 region.that I don't know how frequently it is done; it has not been done on anything that I have had yet. We invited 18 from the general audience comments, criticisms really, any 19 20 kind of thing anybody wanted.to say about RMP, pro or con. 21 We did that somewhat expecting that we would be blasted'i especially from the Spanish-speaking section of the audience 22 23 but found that on the contrary, while there were things that people had to say and they felt very strongly about them, 24 Ace Federal Reporters, Inc. 25 there was a consensus even among those who were opposed or 101 mea-7 Seemed to be opposed to NPMP adtivities'that it was doing 2 better than before and doing 'well. 3 Concern seemed to center around its not doing 4 enough or what it is doing isn't fast enough to please. The 5 general feeling was even from the opposition that the program .6 is having an impact. 7 Again I relate this to a large degree to the fact 8 of expanded RAG which was expanded by the way to intensify 9 representation from throughout the state. So our 10 recommendation with regard to the minority area is that there should in fact be increased representation. More 12 needs to be done certainly. 13 Dr. Gay has provided, who is the coordinator, 14 James Gay, has provided pretty strong leadership in the 15 NMRNM. It should be pointed out it is another one of those 16 programs which has undergone some pretty cataclysmic change 17 in the past 12 months or so. In fact, there is evidence 18 of how change was, had been.undergon'e and was still 19 undergoing. at the very.time we were meeting with the NMRNM 20 staff; the changes being some of the literature we have had 21 up to the moment of our going there to review and discuss was 22 updated in the process of their presenting their visuals. 23 one area for example, prominent instance of this 24 was the complete change in management operations right in Nce- Federal Reporters, Inc. 25 the middle of our visit, you might say, moving from a mea-8 102 matrix kind of setup in which staff operated on a task force 2 kind.of basis, issue-oriented basis back to a more 3 conventional organizational staff. 4 We kind of got the feeling when this was cast on 5 the screen that it was not only new to us but probably to 6 mucn of the staff, as an indication of how this is 7 developing. 8 Throughout that, however, Dr. Gay,I think 9 impressed us all with his ready willingness to learn, his 10 enthusiastic willingness to learn. He.seemed to be listening 'and took notes throughout the session of the things 12 that were in fact being said. 13 We began to feel a change both in the site visit 14 and of course with these recent phone calls. We have.seen 15 things happen since the site visit that go well I think 16 generally. 17 Dr. Gay has established excellent relationships 18 with health providers and he@lth-related agencies in New 19 Mexico and I guess that is best testified to by the fact 20 that a great deal of them, if not all of them are on the RAG 21 in addition to considerable consumer representation. 22 With regard to program or core staff, the 23 decision to dedategorize the program staff structure, 24 @ce-Federal Reporters, Inc. moving away from the traditional emphases appears to have 25 been sound and effective and carried out, though you will mea-9 103 I notice in the projects themselves that there is still a kind 2 of mix of traditional emphases, plus-some of the newer things 3 that are coming out. 4 Now, traditional programs, or I should say the 5 projects, old projects listed in your printouts have been 6 supplemented by a variety of what they call developmental 7 projects, which we can go into some.discussion on a little 8 later on, but these developmental projects then are to be 9 run directly by the project staff. 10 And there more than in the old projects we. see 11 a real emphasis on new directions. The community health 12 services section of the NRMP staff represents the truest 13 form of what I would call a thrust, one@of-the@truest forms 14 that I have seen in NRMP. In fact, if you look at the 15 projects, one gets the feeling as mentioned in another 16 program, it said it was being a program, it is a collection 17 of projects. However, in their reorganization and in going 18 back to more traditional organization of staff, they have 19 gotten at least some of the i dea of thrust. 20 Community health services represents a compilation 21 of kinds of projects in an area that relates to working with 22 clinics, working in Indian health rehabilitation, workin g witli 23 consumers; that thrust also has become what they call their 24 community response system. %ce-Federal Reportefs, Inc. 25 It is attempting to organize itself on a mea-10 10 4 statewide basis and the exact dimensions of how that shall 2 be accomplished, by the 'way, I am not entirely clear, from thE site visit ahd not satisfied from the material received 3 subsequently that it is really all worked out yet, but their 4 5 hope is that through a number of mechanisms available to them the community health services com onent will be felt through- 6 P 7 out the state and will be the primary source, nerve center, for receiving suggestions for things RMP should do in that 8 region. 9 They have got a number of approaches, number of I JD ways they can go about doing this. They have attempted I 12 think unsuccessfully to use their RAG as a basis for picking up suggestions of projects and their RAG is quite extensive 13 covering the entire state. 14 15 The problem there is that when they try to hold RAG meetings in Northern New Mexico to cut down the travel 16 they get the Northern New Mexico side of the RAG. If they 17 go to Southern New Mexico, they get the Southern New Mexico 18 side of the RAG so if they hold two meetings in the course of 19 20 a year they really get only one side of the state covered in each meeting. 2 1 So we suggested to them there might be-other 22 23 methods they use; they might go to the community health 0 24 education services which have already devided the state into Ace-Federal Reporters, Inc. four quarters, and to use RAGs or local advisory groups, one 25 mea-11 105 I for each of the four; that might be another way in which the 2 community health services group might be able to pick up in ai 3 orderly fashion real grass roots kinds of input. 4 There is an interest there in any event in really 5 relating more closely to consumerism as it was pointed out 6 in part their success or failure would depend on bringing in 7 minority staff because as matters stand now there are only 8 three Spanish-speaking staff-on the NRMP and this does create 9 difficultieis in relating lanquage.and cultural@se the people 10 they are attempting to reach. 11 It is very confusing to look at now on graphs and 12 charts but has additional problems beyond that in that it is 13 a response system first and foremost. 14 Many of the accomplishments of the region have 15 really been in response to inqui ries from people outside of 16 NRMP who say, "You know,. we need this, that or the other,"and 17 then of course the staff has been geared up to just take that suggestion and run with it as. a response. We did have some cIriticism that there ought to be 19 20 more initiation on the part of RMP but we think in that 21 regard that.people know about the-RMP, certainly not the 22 case of many regions, so they do feel free to come to it 23 despite the fact that it is-no@ itself initiating to the 24 degree we would like to see.it. kce - Federal Reporters, Inc. 25 The RAG seems-almost too large but as I say, it mea-12 10 6 does reflect combining of, a broad representation and I think 2 more importantly, reflects a combining of two kinds of life of the program.' 3 4 lihen Dr. Gay took over, he inherited some of that 5 and felt in,his judgment rather than trying to erace what had 6 come before, to integrate it in a newer and'bigger scheme. We had less problems with the RAG than the internal 7 8 organization,numbers of committees, task force kinds of committee structures using RAG and staff personnel to carry 9 10 out the programs' objectives. Again new information.in response to our criticism 11 12 of the number of committees of which there were some 14 in 13 number,the September 16 meeting had at least, there was some indication in the September 16 meeting that these would be 14 reduced to nine. 15 Consumers are more than adequately represented, by 16 17 the way., on the present RAG and I think this is certainly necessary in view of the fact of the limited impact of CHP 18 in the area. 19 20 One of last yearls.concerns, in response to the Executive Board, as authorized it increased from eight t8 i i 21 members. 22 We also have some concern relating again back to 23 the coordinator that'the structures that had been 24 kce-Federat Reporters, Inc. 25 developed did not allow enough coverage of central I mea-13 10 7 administration; I guess,, to 'ut it-another way, if Dr. Gay p got sick that the whole thin g seemed it would fall apart. 2 He didn't have enough direct help at the top.- 3 4 They responded to that too. The nine-s3xteen 5 meeting did endorse the recommendation that there be two 6 deputies, one for support services and one for operation in 7 the programs that would assist Dr. Gay and in that way further unite or bring together the organization. 8 9 The grantee agency, you know, of New Mexico has 10 provided excellent administrative support to the RMP. The medical school no longer has-as it once did excessive 11 dependency upon RMP,and grantee and RAG relationships are *7E 149 12 nd #8 quite good. 13 14 15 16 17 18 19 20 21 22 23 24 Ace-Federal Reporters, inc. 25 10 8 7149 One evidence of the relationship between grantee 4L 9 2 and staff, we were able to' determine what appeared to be in- ,ba 1 3 credulous, but delightful situation where the grantees is 4 apparently providing virutally rent-free facilities for the 5 'LIIUIP as they move into additional space. I say virtually becauSE 6 I don't know if that ever was investigated to ejeryhody's 7 satisfaction but it looks that it might in fact be the case. 8 On the matter of participation, key health interests, 9 institutions and groups are participating in the-program, this 10 accounts again for the size of the RAG. We did hear from the 11 'Red Cross ronresentative, the president of the New Mexico 12 Nurses, the CHB representative, the Medical Association, Dean 13 of the Pharmacv School, even testimony from a dissenting 14 student from the medical school locally, on some of the activi- 15 ties, but at least everyone was there and the general feeling 16 was that the problems remained with problems of-the rate 17 of change-. 18 We did have two recommendations Iunder the area of 19 local planning, site visitors were made aware of some problems 20 arisen in regard to providing P@,IP prop osal to CIIP in advance. 21 and for CIIP comment and there was feeling that this should be 22 done so that CTIP would have the opportunity to respond well 23 in advance of a proposal going to us. 24 The site vito'rs recommend that the Chest projects, kce-Federal Repoiters, Inc. 25 community health education serVipes projects should in fact 10 9 If 9 create four local advisory grou ps in the next year to provide as 2 2 they are willing to undertake the appropriate responsibilities 3 and resources, their share. lle did have concern about'the 4 actual representation on such a broad scale of the state and 5 we think.if representations focussed locally, as v7as proposed 6 through the use of the community health education services-,, 7 that they will have more meaningful participation on the part 8 of each representative. 9 Feeling was that no one in the Norhteastern New 10 4exico would be motivated to be concerned about Southwestern 11 New l@lexico and to look really carefully into that but if the 12 northeastern end of it has its own LAG, Local Advisory Group, 13 relating to the program that you would get a lot more particip- 14 ation and there would be a focal concern with the local needs 15 there, other matters of assessment of needs and resources you 16 may have seen some of the very nice little brochures, the 17 informational services office of this outfit is great. 18 Publications that they made available, some studies 19 they have done on various aspects of NRMP activities, maybe a 20 set of these booklets, some 14 or 15 in number on the table 21 over'there. The orogram has done a good job of compiling 22 community health profiles but again, I think that is'the 23 last program we reviewed, there is a problem in utilizing this 24 information in carrying out the TI ..projects and programs. -iey havc Ace-Fedetat Reporters, Inc. 25 done agood research job on this, at least the material looks 110 if9 I good, it is well written material,, easily readable and I have Rcba 3 2 got about 20 pounds of it in the mail in advance of the site 3 visit. 4 The progrm does need to include assessment of need 5 and resources as criteria for review for determining program 6 staff activities;. programs should make better use of the data 7 base for the fund priorities. -under the area of management the 8 site team was impressed with the innovative management pro- 9 cedures and rated this as quite excellent, inclu@l among those 10 a processing-pool, means by which speedier and neater pro- 11 duction of information materials could be produced and also 12 their moni toring, compute r monitoring sys tem. 13 Budgdt: Other matters of evaluation,t,t-he full-time 14 evaluation director comolements-the agency and works well with 15 PAGS evaluation committee. Members of the evaluation committee 16 staff and'PAG T3artic.ipate in the-programs activities where new 17 programs are developed and technical review committee sessions @18 where the proposed programs are-technically reviewed. 19 The team endorsed review quarterly progress reports 20 by the evaluations committee and these are required by all 21 project directors. Other matters of program proposals NP-,MP 22 describes developmental projects as those considered'as line 23 items under program staff. This matter of te rminolo'gy was brought up. We had 24 %ce- Federal Reporters, Inc.asketch in which it was the effort of the coordinator, the 25 #9 1 entire staff to characterize RMP's and to define within that 'reba 4 2 broad characterization exactly where NM4P came to rest. 3 Three models described to us were the traditional 4 P,@IP, the transitional PJIP and the developmental RMP. NMIP 5 classified itself as the last type that had the flexibility 6 within program staff to function quite well in a,variety of 7 areas and to really bring about chang@ -.-iithout depending on 8 branch occies, some really object to that. Some asnects of 9 their overall program in fact do look transitional. 10 I alreadv commented on the character of the projects 11 -they.wished to sulDport. They ranged from the old categorical 12 through the AIIT.,C right now to their developmental programs, the@ described what seemed to be pretty relevant kinds of thrusts. 14 They want developmental component funds which will be used 15 to study feasibility of identified program opportunities. 16 The establishment procedures for reviewing new 17 program proposals will be utilized for developmental component 18 requests. Under dissemination of information a program has 19 efficiently disseminated information to key groups, other healtl 20 related institutions. The team did suggest that the program 21 could more advantageously utilize one of the most important health resources that they apparently-are not using, the Lbvela(, 22 Foundation for Medical Education and Research located in New 23 24 @--lexico. Ace - Fede ra I Repor te ts, Inc. 25 I think we should be strong on this, we would want 112 9 it to be collected in the advice letter to this region. @-ob,i 5 2 Utilization of manpower and facilities, the site team was 3 interested in and enthusiastically supported most of the new 4 directions, the new types of manpower that were described. 5 Ilowever, they were somewhat frustrated by the 6 fact that they still are basically intentions and are not well 7 developed programs of activity. This.relates somewhat to 8 the response concept, responding but not.initiating. Again, 9 in talking'N,7ith some of the staff in certainly the areas, they 10 have very good ideas there among this young staff. There seemed to be some-iincertainty, however, and 12 I had here the opportunity to speak very personally with a number 13 of the staff, seemed to be uncertainty as to whether or not 14 these good ideas could in fact be implemented. There was some 15 uneasiness and I am not certain whether the uneasiness is what 16 it was or whether it was when the administration of the local 17 PMP would-endorse them, perhaps both, I think the site visit 18 in that regard would have been helpful. 19 I think the leadership, we were liberal, encouraging, 20 patted on the back where appropriate and withhold support where 21 appropriate. There are some technical legalities on some of 22 the projects. Several of them in fact appear to be designed 23 to assist established health professions, training programs of 24 one kind or another,, specifically dental assistants, medical Ace-Federal Reporters, Inc. 25 technicians, inhalation technicians. 113 #9 1 This is a matter to be looked at very closely. The 0 T)eba 6 2 Programs intentions to emphasize new kinds of paramedical 3 manpower are laudatory but plans in this area are not yet well 4 defined perhaps because of the uncertainties that I have 5 identified. Through a variety of their programs they have 6 in fact contributed significantly to the improvement of health 7 care in the area. 8 There are four New Mexico communities who applied 9 for a national health service core assistance with the help 10 of the NPJ-IP staff and there are several other projects, at the 11 'Tierra Maria Community Clinics where there have been some 12 marked good apparently. Short term pay-off, reasonable to 13 expect, the operational activity is proposed will increase 14 the availability and the accessability to service groups and 15 enhance the quality of care in the next two or three years, it 16 was the general judgment of the site visit team. 17 Tie did at the time of our site visit on this matter 18 of regionalization encounter some discomfort on this matter 19 of whore shall the control lie.'Dr. Gay had inherited real 20 Problems because of the apparent emphasis on decentralization 21 of N@IRP resources prior to his assuming that role. In response to that condition which was ve.ry 22 23 limited, created a lot of problems for him, he moved rapidly 24 toward centralizing, p'utting everything prett,,7 much under the Ace-Fedeial Reporters, Inc. 25 central Albuquerque office control and there appeared to be h @1 nne-iiiicyp @nri f-hp -- f-hp I,)nrTiincre of the an-olication and 114 9 I the thinking of the staff some uncertainty as to this issue 'Peba 7 2 of, decentralization versus centralization of effort. 3 1 think as we talked about the need for represent- 4 tation, the plan of using the local Chest LAGS, et cetera, 5 that there began to be a feeling on the part of the staff and 6 part of the coordinator, that there is a middle road'between 7 these.tv;o extremes. 8 It remains to be seen whether or not this will in 9 fact come out.in the wash.. But I have a strong @ling it 10 will because-we approached the topic from several different' 11 directions from the point of view of projects and point of view 19 of local tenresentation, point of view of staff recruitment 1 3even. 14 Not for example be able-to recruit people from one 15 community that is to which they are indigenous to one end 16 pf the state to travel to the other. You are necessarily 17 talking about some kind of decentralization in that area as well. 1 8 DR. SCHMIDT: Bill, I.will ask if you can try to 19 wrap it up in about five more minutes at the most. 20 MR. HILTON: I think I can do it in two. The region 21 has provided evidence that they are trying to attract other 22 support. They have not been successful largely because other 23 support really has not been available in many respects but we 24 urged them to try it out on that and they said they would but kce - Federal Reporters, Inc. 25 you really don't know what the direction is going to be. 115 .a 9 The'state apparently is poor and local industry is 8 2 limited, too, in what it can contribute. All'in all this is 3 a general I guess,kind of summary of this before' we go into 4 matters of budget, it was the site visits' feeling that on the 5 basis of what'has happened since Dr. Bay assumed office that 6 this is basically a strong program in need of-some guidance and 7 counsel. 8 They are willing to learn. It is not a program which i@,,e 9 are going to be having to taDe record the same message each 10 year, at least we did not leave with the feeling it was. It is 11 ripe for counsel on some of its directions and goals and so 12 forth. And it is basically a pretty strong program. I think 13 with that I would normally defer now to our second reviewer 14 who hapnens to be Sister Ann Josephine. Since she had to leave 15 she did leave me some notes, summarizing any questions or 16 comments she had. 17 I have not had the chance to look over the notes but 1 8I could do that you know, or while we are awaitin g questions., 19 DR. SCI-E-4IDT: If these notes Are legible why don't 20 you pass them down to the end of thelt-able and let staff- 21 look at them, and we will ask him to summarize what she hag 22 to say Very briefly, And why don't you go ahead with-recommen- 23 dations? 24 MR. HILTON: All right. Site visit team recommended 4ce-Fedeial Reporters, Inc. 25 that '.TtIP-dtIP be approved for triennial status for 05, 06 and 07 116 f-9 I years and that developmental Component be approved with the b 9 2 condition that a mini-site visit be made within the next year 3 to-review the region's progress. 4 On the.matter of budget, briefly, the request was 5 in the area of program staff, $1 million 319,000. Site visit 6 recommendation was $830,000 on-that.figure. Developmental 7 component request was for $138,000. Our recommendation was 8 $120-,000. operational projects request was for $223,000, we 9 recommended $350,000 which does in fact include $118,000 for 10 the tumor registry which in the -oast was reflected in their 11 program staff, moving into their operational -projects. 12 DR. SCII,%IIDT: This is.the first year or for all three years? 14 MR.'IIILTON: First year and carryover, I think carry- 15 over, let's see. Yes, for all three years. 16 DR. SCHMIDT: Level funding for three years? 17 MR. HILTON: Right. 18 DR. SCHMIDT: Frank, have you had time to glance through Sister Ann's comments? Could you cover anything there 19 20 that might be in addition to what Mr. Hilton has covered? 21 MR. SCHIIIOWSKI,: Basically, Sister Ann has six statements here, I will rapidly mention these. Onb,-Sister 22 23 Ann comments that support from other-resources must be developed and this is, further supports the site visits team recommendation 24 Ace-Federal Reporters, Inc. 25 underneath the criterion number 3, continued support, and second I 11 7 9 1 comment deals with her concern that maybe the developmental 2 t should be reduced. Peba 1. componen 3 There is no questionmark or there is no exclamation 4 point so I don't know how to interpret this. I am surprised. 5 The third comment deals with the question of whether @14PS,should 6 nrovide consultation and this deals'with the statement, if the 7 program is interested and seriously intends to facilitate state 8 11110-planning, it should bring people with appropriate experience 9 in managerial and financial aspects of HI,10 planning. 10 We tried to iron this out before the site visit @@ll report was written. This is one point that was not clarified 12 and was asked to be included in-this. The fourth point-deals 13 with underutilization of information due to lack of knowledge 14 of the resources availability. Again,, Sister asked for guidance 15 by R@IP staff to insure adequate use of available data in plannin(.,-, 16 The fifth deals with evaluation process. And suggests 17 that evaluation process needs to be implemented. Then the 18 final noiht, final point concerns the tumor registry project 19 which is -- it is a question what plans are there to Phase this 20 out between the local Cancer Society. These are the major concerns. 21 DR. SCILklIDT: Is there an answer to that la st qtestion-, 22 23 MR. HILTON:WE spoke with the tumor registry people 24 Concerning this. We were impressed with the importance of the Ace.-Federal Reporters, Inc. activity, apparently beyond'tliose who are directly involved with 25 8 ,49 1 it. There is also a feeling of its worth. But again apparently 11 2 they have run into something of a brick wall in terms of 3 attempting to get support for it. The feeling seemed to be 4 that the resources simplv were not there. Ever@,one agreed 5 it was a good thing to have. Of cou@se those who were closest to the project felt 6 7 more stronglv about it. We did.suggest that more aggressive 8 efforts should be made to seek-cohtinued support for the effort. They assured us they would continue to try but t ere 9 10 was this feeling of a real frustration, that the effort really 11 wouldn't pay off so why bother in the first place kind of 12 thing. That in fact efforts in the past'despite the amount of 13 @7ork that had been put into this by one of the physicians 14 closely involved with it in attempts to recruit assistance 15 have been so futile that there did'not seem to be any real drivcz 16 on the part of the people who were supporting the tumor'registrv 17 to go out and as one guy said you know spend days, weeks and months at trying to do something that simply was not there. DR. SCIUIIDT: We do have a motion on the floor. 19 Is there a second for the motion? 20 21 DR. ELLIS: Second. 22 DR. SCI-EIIDT:' All right, it is seconded, so we are ready for discussion. I believe first, well, let's see, John, 23 24 you have got the microphone. When-you are through you can kce-Fedefal Reporters, Inc 'hand it to Dr. Schleris. 25 end # 9 119 CR7149 #10-ter-1 DR. KRALEWSKI: A couple of questions and comment. 2 One, I am in agreement that the state is a poor state and pro- 3 bably has some Limited ability to share in the funding of RMP 4 Programs. 5 On the other hand there is a lot of Federal money 6 going into that state, OEO Programs in the state, HMO, a 7 couple HMO planning grants, I-believe,there is a National ,8 Center Health Services Demonstra tion Grant, and I was wondering 9 how much effort is being devoted by the RMP Gro@ to,,:you',know, 10 intermix their programs with these programs, and.make, you 11 know, these funds useful to some of their activities. 12 Number two, one of the questions in the past was 13 just how much of this budget is going to support that medical 141 school, I wonder if you would comment to that to see if theyl 15 are really breaking away from it, and number three,,the dommenti 16 on the question of.whether they, should add staff with HMO @7 capabilities. 18 I am not so sure they should, perhaps, if these 19 other agencies of HMO Grants, like the Loveless Clinic, et 30 cetera. If they are developing that kind of talent, maybe-RM-P 31 should stay out of it. 22 MR. HILTON: Taking your questions backwards, I 23 agree with you, our feeling was, our general feeling was, and 24 we do have a minority report on that by the way, that they Ace -Federal Reporters, Inc. 25 probably should, in fact , use the resources that are existent ter-2 120 I in their HMO planning. 2 Medical school support, one of the things that was 3 shocking to us or surprising, where we could not see they were 4 getting that much out of it. They were giving away grant. There was involved staff -- staff involvement, more specifically 5 1 6 on that. The Dean, at the time we talked to'him.was on his 7 way to, I believe it was Harvard for a course in fiscal 8 management, and when we questioned him about this, he said, @9 perhaps that is why they have, in fact not benefited or jo exploited the situation as much as they probably could, and, .in fact, may, in years to come. 12 But on the matter of other Federal help, perhaps,, - Frank can give us something on that. 13 MR. SCHNIOWSKI: In terms of coordinating with the 14 two HMO Grants in Albuquerque.@ 'Dr. Gay is on the board of 15 one of the HMO planning groups and he is actively involved 16 with the other one. I had rather not comment on why there is 17 two grants in one area. 18 DR. SCHMIDT: Miss Kerr? 19 MISS KERR: Speaking. of other Federal funds available 20 21 I, too, was concerned when Bill was talking about the educationd.- programs and as a point of information, the week of,Octobeir 8th 22 23 to 13th, there will be 75 hand-picked people, 25 each from the 0 24 regional medical program, the New Mexico Medical Society and Ace -Federal Reporters, Inc. from the Department of'Education, and they are bringing in two @5 I ter-3 121 I consultants; one of them is myself, to talk about health 2 care education programs, and what might be available in the 3 State of New Mexico, maybe this is one reason they are-turning ,4 to'this kind of conference, I hope. 5 DR. SCHMIDT: Dr. Scherlis? 6 DR. SCHERLIS: Do I read the application correctly, 7 that they are asking for 35 new staff positions, is that '8 correct? @9 MR. HILTON: You are a"little under. They are, in 10 fact, asking for, let us see, no, they were asking for 25 new .positions. 12 DR. SCHERLIS: I added it up and got 35, I guess 1-3 from the pages 59 up to 62, or three, but they are asking for 14 something within that range? 15 MR. HILTON: Yes. DR. SCHERLIS: Looks like it is closer to 30. The 1 16 .other question I have is in terms of page 30 of your site-visiti 17 report. 18 Do I gather that you all looked at their individual 19 20 projects, And suggested a level of funding for each development,! of'their developmental programs? 21 MR. HILTON: What we specifically did, was to look 22 at their developmental programs. We did this in a couple of 23 sub-group meetings. There was such a lump of some involved 24 Ace-Federal Reporters, Inc. 25 there, in that area that we thought we better look and see what ter-4 122 I it really was going into, so we did invite discussion from 2 those closely involved with the projects to get a clear under- 3 standing in our own minds, rally, what they had in mind; what 4 they were planning to do. 5 Yes? 6 DR. SCHERLIS: I don't mean to suggest that this 7 was not the way to do it, but you assumed they had good 8 judgment and evaluation mechanism, and priority system that 9 they are able to set up their own developmental program. 10 What you have done-is,X out most of it, then turn 11 around and give them a develo mental component and say, "Do p 12 with it what you like." 13 I know the hour is late but this is a rather 14 interesting approach. 15 MR. HILTON: If I can recall again, Frank, I will 16 ask your assistance on this, too. The're were clues which 17 preceded our taking this action with regard to the new programs 18 And, by the way, the team visit was chaired by Dr. Tamiroff,(?)l 19 of a hospital in New York who was on vacation, so he was not 20 present at this particular meeting. 21 As I recall, one of our reasons for. taking this @2 particular approach was some indication we got from earlier 23 testimony that some of the program,.referring, particularly 24 about the health education for public, there had been some Ace -Federal Reporters, Inc intervention in the program thing, on the part of the 25 ter-5 12 3 Assistant or Lieutenant Governor of the state, which had 2 bloated that figure from something closer to $50 thousand to 3 $250 thousand. 4 That may have prompted us to look closely at some 5 of the other new projects. There is no p@an for that expansion 6 between what we recommend and what they ask for in health 7 education but that was not entirely a.staff decision, either. @8 That was, in a large measure,'a-result of -- I am not sure, is the Lieutenant Governor a member of the RAG? 10 Yes. That was largely the resiilt-of the represen ation on the RAG. And, I guess what we found ourselves doing 12 then, wai sort of going through these.projects with the staff 13 to kind of weed out or give them an excuse for weeding out 14 some things that had developed,. problems they had inherited with their RAG. 15 i6 DR. SCHERLIS: -Point'of information the AHECS, ,i7 was.that a'one"year shot of.funds? 18 Was that planning or what? 19 MR. SCHNIOWSKI: There is four, National Advisory Council recommended approval for four geographically dispersed 1 20 I i community health education systems throughout the state. These 21 22 are four separate projects, twenty, twenty-two thousand dollars apiece. 23 DR. SCHERLIS: Was that just one year? What is goinc 24 Ace-Federal Reporters, Inc. to happen after that year.7 25 124 ter-6 I MR. SCHNIOWSKI: That is right. 2 DR. SCHMIDT: This is one year planning. 3 DR. SCHERLIS: Was that just planning? 4 DR. SCHMIDT: Planning, yes. other comments, 5 other issues,to raise? MR. SCHNIOWSKI: I would like to mention one factor. 6 I am not disagreeing with Mr. Hilton when he stated in concern 7 of the area of minorities but I think it is good to point out 8 m,'s Reqional,-,--AdVisory Gro.up contains 44 minority 9 that the Progra group representatives. 10 This has tremendously.increased under Dr. Gay,- from previous years. The executive committee has increased 12 from eight to eleven members. Five of the eleven members are 13 minority group representatives. At the time of the site-visit, 14 15 the Program staff had three minority group representatives, just on the program staff. 16 After we left and made our recommendations, our i7 suggestions, I might say, to the total site-visit, Dr. Gay has 18 increased this from three to six program-staff members. All 19 minority members on his RAG are actively involved in all of 20 the committees and the one weekhess,we,did point out was wL 21 i 22 certainly recommended an increase, we-thought he was maybe'doing 23 not as good a job as he could, in terms of hiring program staff. And, this is the main-weakness in terms of minority members. 24 Ace-Federal Reporters, Inc I don't want to 25 ter-7 12 5 I DR. SCHERLIS: How large is,RAG? 2 MR. SCHNIOWSKI: One hundred sixteen members. 3 DR. SCHERLIS: That can be representative of a lot of the population. 5 DR. KRALEWSKI: The whole population. May I make 6 a comment? 7 DR. SCHMIDT: Right. 8 DR. KRALEWSKI: This-budget again, if I understand 9 this correctly, we are recommending more money than they are i 10 asking for on operational proj'ects? 11- MR. HILTON: Only because of the tumor 12 DR. SCHMIDT: There is a switch of"fuhds from up 13 on top to down in there, actually- 14 MR. HILTON: Yes, what we have done is taken out thei 15 tumor registry which was listed in their request, their initiali 16 request for program staff. The distinction that has to be kepti in mind here, is what they have'donethey have got two sets 17 18@, of projects. One, under program staff; and one operational pro- 19 20 ject which is separated out. And we simply removed from prograA staff their tumor registry project, and reduced that whole 21 22 figure substantially in terms of the other projects under that. DR. SCHMIDT: Other questions? 23 24 Or issues? Ace-Federal Reporters, Inc. DR. LUGINBUHL: I would like to question the tumor ,25 126 ter-8 I registry. Seems to me that a very good test of the work of a 2 program is the ability to find.other funding and the fact that 3 th'is,program has not been able to find other funding suggests 4 to me that possibly it is not quite as valuable as it might 5 appear at first look. 6 And I may be speaking from a general bias, because 7 I have not been impressed with the value of tumor registries, 8 generally, and I have yet to see any very hard data that suggesq! 9 that these have had a major impact on even the care of cancer 10 patients, or advancement of our knowledge in this area. 11 So, just as a general principle, I would favor fundi@( 12 these programs from local resources, and if these are.not 13 forthcoming, I think this may be a measure of their true worth. 14 DR. SCHMIDT: Well, the question has been answered, 15 so I will limitlyour answer to what your estimation is that they 16 will seriously attempt to find funding for that on the local. 17 MR. HILTON: If rather emphatic advice is made to 18 them in an advice letter to them, I think that might help 19 to spur them to try again, harder this time. I would not 20 make it strong enough though to make a contingency. 21 DR. PERRY: I have the same question, Sister, and 22 asked about the amount of the developmental component here. 23 This is one of the largest ones tha@ is being earmarked of 24 'all the programs. I would like a little fruther justification, Ace-Federal Reporters, In c. 25 you know, that they are really capable. ter-9 127 I The questions that have been raised on some of the 2 problems that have been developed, I would like you know, a 3 little further comment on just that one part. 4 MR. HILTON: With regard-to that developmental com- 5 ponent, as I recall, in our deliberations-, we really did not 6 give that particular matter a great deal of thought. We 7 certainly did not feel they should get as much as they requeste@ 8 on it. 9 The question raised earlier, concerni.W the develop- 10 mental program has been kind of turning round in my head 11 since he raised it, because I.-can@see th e direction he is 12 heading,--on that. Yes, we are all in agreement that under Dr. 13 Gay's leadership, it all seems to promise real well for the 14 future, but the reason. the developmental programs that are 15 listed on page 30 of the site-visit report went went the kind, of sky thing that we gave.them, was because of the -- some of 16 the builtin problems apparently in terms of what kind of input .17 would be made to the program de..spite Dr. Gay's'influence, et 18 19 cetera, and you know, I would have to, in view of that fact, 20 and in the contention in which it was raised and I would also 21 have to look myself, again, at the component as it now stands. 22 I would, at this point then, perhaps, Frank, can 23 recall some things I am forgetting now, with regard to what 24 your deliberations were on the developmental component. Ace-Fedetal Reportets, Inc. MR. SCHNIOWSKI: I think Dr. Scherlis is concerned 25 ter-10 12 8 I with the developmental component. Again, we have to kind of 2 repeat the statement that-the region indicated to us, that they 3 were going to control these through program staff, and'use 4 them as a line, item budget. 5 Our recommendations to treat these as individual 6 pro3ect activities, not as a line-item-budget within program 7 staff, reviewed by the RAG, monitored,by their systems, and 8 reviewed by CHP. 9 'Thus $222 thousand, which we recommend for these 10 activities in essence, is taking this amount of money and 11 -moving it down into the operational project area, not keeping 12 it up at the program staff level. 13 DR. SCHMIDT: I would like to move the group along 14 to making any specific modifications of the recommendation, 15 or whatever. 16 Mrs. Flood? MRS. FLOOD: I don't mean to delay the continuance 17 of our schedule, but I do feel that there is some aspects of 18 the economic picture of the Sta:te of New Mexico, that although 19 it has been covered in some measure, should be expressed at 20 21 this-time. I think, if you take.into consideration, the sparsely 22 23 populated areas of the state,-with the only large urban impact area being in the City of Albuquerque, w3th the tremen- 24 Ace-Federal Reporters, Inc. i dous population of minority groups with underdeveloped educatio 25 ter-11 12 9 I oppor tunities, the economy of the @tate is only'dependent, 2 truly, on the military and the many diversified aspects of 3 military inpu@ there, Los Alamos, et cetera. 4 That, to put the pressure on discontinuance of pro- 5 grams, even the tumor registry, although I am not in a position 6 to state whether it is a value project at the moment, but to I put the burden of pay or maintenance of this type of project 8 on the people of the State of New Mexico, at this time, is just 9 not feasible, it is not a realistic approach. 10 There is not that forthcoming economic base to 11 support programs at home, so I would be reticent to offer any- 12 thing other than a recommendation to not cut program based on 13 the fact that they have not been able to find other methods 14 of support locally. DR. MARGULIES: I wonder if I might comment, because! 15 I think the comment just raised is terribly important in our 16 17 deliberations. This is the most painful type of consideration we 18 19 have to go through. If an activity, over a period of time, is not able to find other means of support, it either suggests 20 21 that it does not merit other support, or there.are no resources., Now, if there are no other resources available, that is a kind 22 23 of deficiency of a systemic kind which we are not in the 24 position to resolve. Ace-Federal Reporters, Inc. Whether it is the problem of the economic status of 25 ter-12 1 30 I New Mexico, or as is much more common, the unavailability of 2 third party funds to pay for a service which is generated out 3 of a demonstration activity, et cetera. 4 If RMP funds, or any other program like ours, which 5 is developmental, remain in support of some project or activity 6 because there are no alternatives, rather than becaus6.it 7 belongs there. It very rapidly exhausts our resources, and 8 really cannot move. In the case of the tumor registry, it 9 might be even more difficult to justify, because@here are 10 so many doubts about the effectiveness of that as a program, 11 but this is valid even when you are supplying a demonstration 12 activity'in a service, and it is especia lly troublesome, when 13 what you are doing, is really worth doing; but if we begin to 14 supplement Medicaid, or other types of activities with RMP 15 funds, we are lost. e-10/s-11 16 17 )8 19 20 21 22 ?3 24 Ace-Federal Reporters, Inc. 25 CR 7149 131 Take 11 I DR. SCHLERIS: I know you are anxious to move us 2 along but my dilemma is I still haven't reached in my mind 3 how I would react to this and I think that is the position 4 of your review committee. 5 Looking at some of the projects for which they are 6 requesting support for the 05 year, some one, two, three,. 7 four, five of them began in the 01 year and if we give them funds now to set up new projects, we are going to be faced 9 next time.with these being in the 06 and 07 year, as well 10 as the new ones that have come aboard that they can't phase 11 out because of lack of support 12 My concern is that if everything that is started in New Mexico has to be continued indefinitely because 13 14 there are no alternative methods for support, we better avoid starting new proqr ams unless we know with assurance 15 that they can be continued or unless we have the feeling 16 17 that our.beuget will be rising proportionately over the 18 -years to take care of this. Also, I reflect the-concern of the site visit 19 20 group which was impressed with.the fact that many projects 21 go on through core, which means they really don't get the evaluation they should get under other types of surveillance, 22 23 one way is to move them out of-core, the other is to insist that all core projects have the same type of review. 24 Ace - Federal Reporters, Inc. 25 I am in a dilemma as far as the $120,000 for 1 32 dor 2 I developmental since there are ways of cutting projects out 2 that have been continued'now-to the fifty year. 3 Will you respond to that? 4 MR. HILTON: Well, I think what you have succeeded 5 in doing is pulling me into the dilemma with you a little 6 bit, however, I'did recall some discussion with Dr. Gay, that he has an intense interest in having available the 7 8 capability and this again harks.back to something said 9 either today or yesterday.in one of the other pro ,grams. He has an intense interest in having the dapabilit 10 y to be flexible in programing.. 11 I think this is where the whole discussion of 12 developmental component came up in the first place. In 13 14 fact, we discussed at some point. his desire to:,be able to 15 rechannel funds in areas in which he felt there was great need. 16 .There may, in fact, and I am uncertain of the 17 @18 details on the other program, .1 @here may, in fact, here be a need for that kind of flexibility in order for NMRMP to become 19 a better program. 20 21 I have, and again, I think I am speaking for the team, cons iderable confidence in Dr. Gay's ability to do 22 23 this in such a way that NMRMP does, in fact, become an 24 asset, whether or not it be dote through discretionary funds O,ce -Federal Reporters, Inc. 25 which he did not question or developmentally, I think that 13 3 dor 3 I flexibility ought'to be there. 2 I am confident under his leaderwhip it will be 3 used to the benefit of the program. 4 Would you second, or any.comment with regard to 5 that,,Frank? MR. SCHNIOWSKI: Not to beat it to death, but the 6 7 Tumor Registry Project has drawn outside support from the 8 National Cancer Institute. They rate this as one of the three best registries in the nation, that is their judgment. 9 The project director, Dr. Key, has approached 10 11 the area of continued support.in the wrong manner. He has been advised by one of the -- Dr. Tucker, who talked to him 12 aside, and indicated it would be much more efficient to 13 approach continued support th rough the medical stafft of 14 the individual hospitals as well As with the hospital 15 administrators which he had been working with in the past. 16 By the end of 173, they will have only three 17 remaining projects which they originally were'funding. One 18 19 of these is the tumor registry-project. The other, we have 20 recommended the EMS project that has been going on for four 21 years to be locked with the new EMS.activity, which was 22 recently funded from RMPS. The third projdct is-their leukemia @ymphoma 23 24 project which was started in their third year. kce- Federal Reporters, Inc. DR. SCHMIDT: Bill? 25 134 dor 4 DR. THURMAN: I just want to add a minority report to what Dr. Margulies has said. 2 3 A well-run tumor thing is a real asset. Remember 4 during the Civil War we didn't think stethoscopes were 5 any good. DR. MARGULIES: They ate now? 6 DR. THURMAN: Depends on the doctor, Harold. 7 8 DR. SCHMIDT: I presume that resolved everything for us. 9 PR. SCHLERIS: I will listen to him on registries 10 but hardly on stethoscope. 11 DR. SCHMIDT: All right. 12 Does anybody want to do anything in.regard 'to 13 14 developmental component, then?. I will ask for any amendments and we will test 15 16 out the development.al component first. 17 Does anyone wish to propose an amendment to the main motion concerning the developmental component? @18 DR. SCHLERIS: I was going to suggest two things. 19 20 One thinq,I think we would do this region a favor 21 if we reduced.their total grant because it will make them get rid of some of the projects they have had ongoing for a 22 long period of time. 23 24 If we want to give the'coordinator of the New kce -Federal Reporters, Inc. Mexico program some potential mobility, we wouldn't give it 25 135 dor 5 .to him if we give'him money for projects which EMS might 2 want to phase out. 3 I guess I also suggest reducing the developmental 4 component. I was thinking in terms-of droping that 1.3 5 down to 1.15,, the second year, 1.2, the third year, 1.250, but 6 even that is being generous, but I think developmental 7 component should be significantly cut. 8 DR. SCHMIDT: Would you make 9 DR. SCHLERIS: Drop it down to 80 th2,usand, 80 10 thousand for each of the three.years, developmental component 11 and the first year, the 05:'.y&.ar' 1.15; second, 1.20; third, 12 1.25. DR. SCHMIDT: Do you make that in the form of 13 14 a substitute motion? DR. SCHLERIS: Yes, sir. 15 16 DR. SCHMIDT: This includes approval of the. 17 triennial status obviously. Is there a second? 18 It is seconded. 19 20 Discussion then will revolve around the substitute 21 motion and we will limit discussion to the impact of this 22 level of funds and their ability to do what they want to do. Are there any comments? 23 24 MR. HILTON: Is there'an assumption here that Ace - Federal Reporters, Inc. 25 there is an inordinate number of programs that will be running 136 dor 6 I beyond the 05 years? 2 DR. SCHLERIS:. Both the number and quality of them. 3 They are going into the 05 year now,-and if we'are going 4 to talk about a triennial status for a region that is 5 attempting to, as you say, get mobility, I don't think you have mobility if you continue these projects and I think 6 7 this puts on them the onus of deciding what they are going to 8 continue. 9 Also, you have looked at their developmental 10 programs, it was apparent you thought many of them were 11 . markedly overfunded as far as what they were requesting. I 12 think this gives them the opportunity of sharpening up what 13 they are looking at and I think $120,000 is an excessive 14 amount, particularly since they are involved now with helping implement the Emergency Services Medical Program, which will 15 16 absorb a great deal of staff and time because they are funded for two years on that, aren't they? 17 And this is going to absort more than they 18 19 recognize, as far as being involved, even though they may not be the contractual agency. 20 MR. HILTON: At this point I am inclined to 21 agree with you on developmental component, which I might 22 move as a motion after we defeat this one. 23 24 But on the.matter of continued programs, as I Nce-Federal Reportefs, Inc. understand it, there ire only three projects that will be 25 3 7 dor 7 I continued beyond the 05 years, one of them being the tumor 2 registry. 3 MR. SCHNIOWSKI: I don't see any tremendous 4 hangover of dead weight in that regard. 5 DR. SCHLERIS: They are requ@@tiiig,:for the 05 1 year, the continuation, besides the tumor registry, of 6 7 five projects. Now what we will be saying is beyond the 8 05, but we are talking specifically about 06, 06, 07, isn't 9 that right, five projects which add up to something like io $170,000 is being requested into the 05 year, isn't that correct? 12 DR. SCHMIDT: Dr. Ellis, do you have a comment? DR. ELLIS: Yes, I do, Mr. Chairman. 13 14 I just wanted to point out that this is such'a 15 poor area and it seems to me that perhaps the developmental 16 component moght give them the opportunity to work toward .17 methods of health delivery that would really mean something in the lives of some of these pepole, and I w-.as thinking 18 about the opportunity to develop nurse midwives and 19 pediatric assistants and assistants for the elderly and work 20 within that frame. 21 But I was thinking that technical assistance, 22 23 it seems to me, might be helpful.in getting them to make 24 the right choices in terms of program without necessarily Ace-Federal Reporters, Inc. penalizing them. 25 1 3 8 dor 8 I DR. SCHERLIS: I just want to make one comment. 2 I am aware of their needs, and I would agree with you. There 3 are certain programs they might move into but I don't see 4 any assurance that we have been given that this is the 5 direction that they will take, as far as the expenditure 6 of their funds and the continuation of projec'ts.they have. had, do not seem to be in that direction. 7 8 This is the other reason for my statement, not a 9 failure to- recognize their needs. 10 DR. ELLIS: Would you think that technical 11 -assistance might provide this way so we wouldn't have so 12 much lag between the time that these problems appear? 13 Some of these are very long-range problems. 14 DR. SCHERLIS: Right, but we are talking about 15 developmental component and triennial status, it seems beyond a little bit in time as far as telling them they need 16 17 a little-bit of technical assistance, this is my concern. 18 DR. SCHMIDT: We ar.e assuming that staff is 19 listenifig@ to this and that, technical assistance will be offered and provided and so on. 20 John? 21 DR. KRALEWSKI: I think technical assistance will 22 be useful, I think this budget as being proposed here, 0 23 however, under the new recommendation will give them room to 24 Ace-Federal Reporters, Inc. 25 run and develop that .new thrustI, and if this is a new order, dor 9 139 I I move we curtail debate, is that an order or is that -- 2 DR. SCHMIDT: -Yes, it is. I will call the 3 question on the-substitute motion unless there is a violent 4 objection from the committee members. All right, then, we will vote on the substitute 5 motion, which is triennial at a level of 80 for developmental 6 7 component and 1.15,, 1.2 and 1.25 for the three years. 8 All in favor please say aye. 9 (Chorus of ayes.) 10 Opposed, no? The ayes have it so the substitution motion 11 carries. 12 13 And I believe that the necessary assistance will 14 be arranged for by staff following this discussion. 15 I would like to move on to Northern New England 16 before we break for lunch. 17 Some of the committee members sneak some pie or 18 soup or something like this. So the record will show that Northern New England left the room, Bill Luginbuhl. 19 Dr. Thurman? 20 DR. THURMAN: This will be surprisingly short, 21 mainly'because the conclusion of our-total visit was that' 22 23 this whole RMP is just like starting a first year. I would point out that we had representation from 24 kce-Federal Repottefs, Inc. 25 the Advisory Council and Mrs. Wycoff, Tom Nicholas and: 14 0 dor 10 I and Roger Warner from operating RMPS, both of whom were 2 valuable to a new RMP in'that sense of the word. 3 Particularly a word of the staff, in that I 4 think that C. C. Conrad and Spencer Crobin, as well as the 5 others with us were quite helpful to this group of people. I mi@ht give you one quick work of history 6 7 about this about this group because that is where the real 8 problem has arisen in the past with Northern New England 9 RMP. 10 It became operational, had a planning grant in 11 '66, with its first operational year at '69. At that point 12 in time a committee from the Univers ty of Vermont Medical School actually ran the program. 13 The man who -,is presently coordinator arrived in 14 the fall of 1969, but throughout all this period of time- 15 their primary emphasis was on developing a data base. 16 Some of the questions that arose went high enough 17 18 to get to the administrator of.HSMHA, for-some type of resolution and that RMP and CHP tried to arrive at a merger type 19 20 situation, too, so that there would not be an overlap of 21 any-kind. This was partly at the request of the governing 22 bodies of the state itself, to further complicate it because 23 the state was small and because of this experience with RMP 24 Nce-Federal Reportefs, Inc. 25 in the past, had been largely in the data base development 14 1 dor 11 I experiment in health service delivdry money, they requested 2 one dollar and received $932,000 for supplementary health -- 3 mental health services delivery, so obviously they were not- 4 ready to use it. 5 This, created even more of-a conflict bet ween the RMP and CHP merger. 6 What happened was that they began to listen more 7 8 an,d-more to the signals from this committee and others, and 9 RMP actually began to change to a true RMP, roughly in 1.0 January of this year, 1972, with-the appointment of Mr. II- Danielson as coordinator, reinstitution of RAG, as we know a RAG, wi th removal of a lot of situations that had gone 12 on before, I would hot leave you with the feeling that there 13 14 aren't still problems, because of the fact that some of the 15 boards still overlap betw een RMP and CHP, the divorcing of 16 the whole business of the health services delivery syst em contract is still not a complete divorce, even though they 17 18 changed the name a little bit. 19 In this change it did make it possible for RMP 20 to get rid of some of the people who have been moved to the other corporations to help continue the data base in related 21 22 areas but in this reorgani.zation, they have been ---it has 23 been necessary for them to bring about some of their staff, 24 and RMP losing their job. Nce- Federal Reporters, Inc. All of this has' been accomplished reasonably well 25 14 2 dor 12 I 'by the people on board, andIthink, in essence, represents 2 now, since January of 19@2,a nine month, eight month period 3 of time when we were there, of reogranization, along,_- 4 traditional RMP lines. 5 Dr. Luginbuhl was present for much of the 6 situation because of significant questions in the past., 7 in reference to the RMP to the medical school. I think 8 they have well understood the'strong staff support and our 9 review committee and council comments about wha@was wrong 10 with their RMP in reference to collection of a data base 11 rather than anything else. 12 At this point in time, I think they have well 13 understood that our feedback session was particularly good. 14 Their request for specific staff assistance, C.C. and 15 others, was very significant and meaningful, I think. 16 And it represented, for me, at least, the 17 opportunity to say very stronbly that this is an RMP that is still back in 1966 and that.is hard to accept, but that 18 19 'that, the 1966 constitution of this group in 1972, leaves 20 little question in my mind whether they will succeed. The present chairman of,the RAG is a little bit 21 still out of step and out of consonance with the new 22 23 direction of RMP but he is a-very educable individual and they have not developed goals and objectives in the feedback, 24 ,ce- Federal Reporters, Inc. they actually asked us in-a way how much time they had to do 25 14 3 dor 13 I it and we left them with a figure of 90 to 120 days, which caME 2 off the tops of the heads of,the site team rather than 3 having any other direction. 4 I think the whole question of minority interest 5 in Vermont was raised and we were not able to speak to that 6 very well because of the particular structure of Vermont. 7 The only way a minority group'could be constituted 8 would be to have somebody who-was born out of the state and 9 then moved into it, because there are no other minorities 10 in that sense of the word. The poor are not the minority in Vermont.. If 11 12 we are going to get on another New Mexico, it is here. 13 But I think that in-general, in speaking to all 14 Of the other segments we normally speak to in review of an 15 application, I could say they presented to us a very good 16 approach-of taking the best of what they have had in the 'past, not related to development of a technic al data base, 17 have coordinated it now with an approach to the future that 18 19 'looks to be well structured and well organized and that we are now in the transition period. 20 21 This transition period is entirely different from the one that is usually bandied around here about going 22 23 from categorical to noncategqrical, and instead, the 24 transition from data collecting group to a true health care kce- Federal Reporters, Inc. 25 delivery group. 14 4 If we are going to ever be able to evaluate any RMP, we ought to be able-to evaluate this one because they have 2 3 got -Che best data base you have ever seen to see now what 4 is going to happen in the future in.all of their areas. I think this will be meaningful, not only to us, 5 6 but'alto.to other branches of HSHMA and HEW, because they do 7 have a truly significant data base and if you look at the end of the site visit report,.you will get a feel, and this 8 does not represent all of the things they published. 9 You get a feel for what the they have done since 10 1966 in collecting information, so we should be able.to Very, quickly evaluate almost any program that is brought 12 about in the delivery of health care in this area. 13 I think that as we look at the process of their 14 organization, the coordinators very firmly moving to take 15 total command of the situation with strong assistance from 16 ..the RAG, he is the one who has been responsible on going 17 face to face with every single-person and.saying, "You are .18 19@ -not really contributing, why don't you resign," or "We really need you badly, you are the kind of guy who we hope can 20 help us make the change in the future." 21 Although the RAG is very small at the moment, 22 it is open-ended in reference to-their by-laws, and I believe 23 24 the additions we have brought about will be significant. @ce- Federal Reporters, Inc. The RAG chairman clearly is a university man, 25 14 5 dor 15 but he is a university man who has pioneered community health 2 programs throughout Vermont, which is a reasonably tight 3 structured state. 4 So I have no concern about him carrying too much 5 of the idea of the university. 6 In speaking to the university and'its relationship, 7 one of our fellow committee members has led the charge to 8 get the offices of RMP off the grounds of the university to 9 cut down a tremendously spectacular overhead rate, and he 10 has now succeeded in this and they are moving and they will 11 now have an off-grounds place, although the university will 12 still be the grantee. 13 We have no concern in any way about the management 14 or effectiveness of funds because they are moving very 15 comfortably in their structure'to make sure that all of their 16 so-called advisory committees, which is their mechanism of 17 action, have a very firm.budget. 18 T hey have a definite plan, with each budget there will be a timetable and if that timetable is not met, 19 that the money will no longer be there. 20 end 11 21 22 23 0 24 Ace-Federal Reporters, Inc. 25 14 6 #12 arl Going back to our earli6r discussions, money is 2 one of the clubs that we have,. and they are using it well in 3 their approach to programs. I think that the program staff 4 is presently being realigned, as I indicated, they are phasing 5 out a total of 11 jobs, actually more than that, but 11 are 6 being phased out, some going to other opportunities and some just being phased out. They have brought on a young physician )8 to work in the area community development. And his 9 enthusiasm and capabilityhdth are significant, and I think 10 on that basis we don't have any real concern that they will 11 begin to derive programs from throughout the state that 12 have A strong community base and meet the need for delivery of 13 health care in an entirely different way. 14 This is his cup of tea. If they can keep him in 15 the program, it will be great. I have some concern that they 16 may lose him because his type of talent is in bad need all 17 over the country today and so he may go. The RAG understands 18 the way to go. 19 I think that they have -- will make future 20 appointments on the basis of knowing exactly what should be 21 done before they got into it. They have pulled again, as 22 I indicated, not only at RAG, but committee management, they 23 have pulled their best people from the best and have let 24 'most of the dead wood go. Ace -Federal Reporters, Inc. 25 They have done'this very, very well which is a real 14 7 ar2 I tribute to the coordinator in that I think his experience 2 in the program for over two years before he became 3 coordinator made it possible for him to get an honest 4 evaluation of what is going on. 5 I think our only concern is the site team, about 6 his role., was that in'the area of continuing education and manpower development, if he has a blind spot, this is it, 7 8 and we tried to emphasize that pretty much in our site visit. 9 I think staff is well aware of it as a reasonable blind spot.. It is emphasized enough in the feedback session 10 11 to make everybody else well aware of it, and I believe that will probably answer the most significant problem that 12 exists at the present time in their entirely new development. 13 14 I believe I would stop now in this discussion becaus 15 there really is nothing else that I can firmly put hand on 16 at this point in time to say about this program because,I think we should look at it as a program that really developed 17 18 a coordinator no coordinators'in January of this year. The RAG is working well, though small, to make 19 itself meaningful. And they really have nothing else to 20 21 present except a truly significantdata basis accomplishment 22 and now with the opportunity to turn around and move on. Rather than recommend, we might listen to what 23 24 the secondary reviewer has to say first. Ace-Federal Reporters, Inc. DR. SCHMIDT: The secondary reviewer is Dr. Lewis. 25 14 8 ar3 I who is not here. So, Spence, do you have any comments on 2 let's move on then to your recommendation. 3 DR. THURMAN: Spence, you'don't have anything to 4 add, let me add, do you agree with what I have said? No, I don't know whether you heard about what I said of 5 C.C.,, 6 the possible blind spot of the coordinator being in man- 7 power coordination and education, and we leaned very 8 heavily on that with the hope that we would do away with his 9 blind spot. 10 MISS CONRATH: Yes, I think one thing the review committee might be interested in.. The Kellogg Foundation 12 has made a grant to the University of Vermont Medical School 13 for the introduction of the problem of oriented medical 14 record in medical practice in Vermont. This offers an 15 opportunity for the northern Now England RMP and the medical 16 school through the department of continuing education to join forces in a way in which they have not been able to join 17 18 forces before. I think this offers a mechanism and advisability 19 20 as to how the continuing education resources can be addressed in a meaningful way that is a very real promise, I think 21 22 in terms of case history, maybe of interest to know that one of the graduate students of the University of Vermont 23 did a master's dissertation on the case history of the 24 Ace-Federal Reportets, Inc' northern New England'RMP. This person is now on the staff. 25 14 9 ar4 I So if you need a good case history; there is a@100-page dissertation. 2 3 DR. SCHMIDT: Recommendations, then-? 4 DR. THURMAN: The recommendation of the site team was that triennial status not be granted at this time. 5 6 This was quite honestly discu.ssed.with the entire group, but that it receive two year approval so they understand, or we 8 understand they understand we understand they have turned the corner and are ready to develop a good RMP at thi s period 9 of time, but with this two year approval at the level of 10 11 $850,000 each year that we also grant them developmental 12 component or discretionary funds, and our recommendation for the first year there would be 10 percent of the present fund; 13 for the second year, continuing 10 percent of whatever the 14 funding is for the first year. 15 16 DR. SCHMIDT: We will have-to label that discretiona- 17 and that amount is within the 850,000 obviously. 18 Is there a second to that motion? DR. ELLIS: Seconded. 19 20 DR. SCHMIDT: It is seconded by Dr. Ellis. Comments? DR. JAMES: I would like to have one to explain to 21 me the relationship of the research and development-of health 22 23 systems incorporated which is the recipient of HSMHA's experimental systems contract. 24 Ace-Federal Reportvs, Inc' I see where the@ were awarded $900,000 to develop 25 150 ar 5 I experimental delivery system there! It occurs'to me that 2 with the geographic and demographic information we have as 3 far as Vermofit is concerned, that there will possibly result 4 some kind of conflict -- well, can't say conflict, but I 5 wonder just how much overlapping of-effort in such a small 6 state, that Vermont represents. It seems to me that there might be some turf 7 8 interference, and I get the feeling that one is going to take 9 precedent over the other in view of the fact that the popula- 10 tion is small. DR. THURMAN: I might respond to that by saying 11 12 this is the one dollar they requested for which they received 932,000. And it is very clear in everyone's minds that there 13 14 will continue to be some-degree of difficulty in understanding 15 the role of each of these because of the fact that RMP in 16 Vermont has had an image of a data system and it is, this divorcing of the data system from RMP as we think of RMP now 17 that the new program actually represents. 18 The overlapping of boards, who will do what, all 19 20 of that is still a bad situation. I think this will not be clarified over the next several years because.of the fact 21 that RMP actually helped with the development of all of the 22 plans for what is now the experimental system to the tune of 23 24 .roughly $150,000. Isn't that right, Spence, over the years? Ace -Federal Reporters, Inc. 25 Okay, 350,000, missed by 200,000. It is a piddling amount. 151 ar6 I So I think there will continue to be some real problems with 2 this. The medical society is well aware of this,Dr. James, 3 and their concern, the board, they have actually changed 4 the name of this now to call it a Vermont, it now has VHSI 5 to get around some of their problems and their board is made 6 up of providers; politicians, public and the payers. This is 7 part,of the thing they are going through. 8 I think Dr. Danielson as coordinator and 9 the early development of the present RAG, nine @ 12 people, 10 are so burdpned by this whole situation that I would not be 11 concerned about RMP being hurt. I am more concerned, not 12 truly that concerned about it, about HS! being an ineffective 13 program because of the emergence of a strong HCP. 14 I think staff will have to continue to look at it 15 and I am sure the northern New England RMP will be coming back 16 to staff-and saying why can't you do something with those other guys in Washington, because that is the way they feel about it 17 18 right now. Point out that one.person whols been not so burdened, but very concerned about the situation, is Dr. 19 20 Luginbuhl because he and others wonder what they are going 21 to do with this @32,000. 22 DR. SCHMIDT: I will comment just briefly. 1 23 don't think that blame, with.the word "blame" in quotes, 24 for the situation can be laid at'the door of PMP at all. Ace-Federal Reporters, Inc RMP is a victim of essentially HEW muddling and meddling 25 152 ar7 in the state of Vermont, and if so@ebody's got red ea3sover this, it is the Secretary of HEW. And this is an incredible 2 3 blunder by HEW,.and in effect a manipulation of a state 4 plan. I thinkthat the RMP and people in Vermont are going 5 1 6 to have to kind of recover.from a reeling blow that was 7 dealt to them by feds coming up there and manipulating the 8 state, and I think the RMP will be in great part,,part of 9 the solution of this problem. My words are quotes from HEW people who have been 10 11 investigating what went on in Vermont and how a request for 12 one dollar got turned into a forced upon the state 1 million by HEW. it is an incredible story. 1 3 14 Are there other comments or questions then? 15 DR. ELLIS: We don't understand the $1 request. Could you tell us? 16 17 DR. THURMAN: They were told that with this 1 8 tremendous data base in hand, where else.could you -- could 19 really you document what you were doing with experimental health services delivery and other approaches, and so they 20 said don't you want some of our money? 21 22 And in essence, the .answer back was we are really 23 not ready for it, which is an honest statement, so they said 24 at least put your hand in the pot, and they put their hand Ace-Fedetal Repofters, Inc' in the pot for a dollar, and were showered with greenbacks. 25 15 3 ar8 DR. KRALEWSKI: Aside from who would apply for a 2 dollar, I am hesitant to vote, I like.your funding 3 recommendations, but I am hesitant to vote that two year kind 4 of thing since generally we deal with a triennium, or say 5 look, here's another year, you can try to work out an applica- 6 tion. Would you comment on this?. Do you think we have to go give them a two-year kind of period? 7 DR. THURMAN: We discussed this at some length 8 9 and Spence can comment when I finish. 10 Our feeling was that they really had made a marked 11 change in their approach. They had the people now who under- stood what the story is all about. And therefore that if we 12 would seriously inhibit particularly the development of their 13 community-related program under Dr. Robins and he would not 14 15 be able to add additional people, he could only talk to them on the basis of one year, and that then triennial status if 16 17 everything continued to go well. 18' There's been so much problem and so many people 19 like our chairman's refe.rring to, so many HEW investigating groups that have passed through the state that the crown 20 21 sits on uneasy with s.o much money. We felt strongly that if we just went for one 22 year with this group that he would have real troubles continuing 23 24 to develop what he wants. Ace-Federal Reporters, Inc. DR.'SCHMIDT: This would not, you know, by the two 25 154 ar9 I -years are you saying that under no circumstances next 2 year could they come in with-a triennial? 3 DR. THURMAN: This was discussed at the feedback 4 session, nothing prevented them from coming in for 5 triennial status next year, but we wanted to give them the 6 feel for-two yecArs for continuing development. 7 Spence? 8 MR. COBURN: It is.btiilt into the recommendations DR. SCHMIDT: It is part of the recommendation. 9 DR. THURMAN: Yes, it is. 10 MR. COBURN: They Ake not going to be able to write you a triennial application after the site visit. This will 12 be then applied in the second year as you are suggesting here. 13 If we go in with the recommendation that here is a base 14 for a couple years, and although we'd like to have you move as 15 rapidly as possible in formulating a program thrust and 16 17 developing.a three-year program, and sending that program 18 in here for approval, I'd be agreeable to it.' DR. THURMAN: I think to finish it off, we said 19 20 there would be a site visit next year. This they understand, 21 and-if they wanted to before that site visit actually prepare a triennial application, fine, but if it looked like they 22 23 need another year to actually go on as they were, that was 24 one of the reasons for the recommendation of level funding, Ace-Federal Reporters, Inc. 25 that they would then know.that they had to talk to that group 155 arlo I or some group again next year about'an increase in funding. 2 But we felt that the security of this program with 3 its past problems and the actual divorce now o f HSI with a 4 whole change from RMPS staff that they may or may not be 5 ready to tryltriennial application this year in order to meet 6 site visit next August again. 7 DR. HESS: I would like to think that with this 8 recommendation we are coming very close to a leveling off 9 of funding for this particular RMP. So it happens with your 10 recommendation they will be funded at about $2 per capita, 11 . which is the highest, as far as I.can recall, the highest 12 funded RMP, on a per capita basis of anywhere in the country. True, they do have scattered population, but no 13 14 more so than Arizona, New Mexico or the mountain states. 15 Low income, yes, but no more so than Mississippi. I would think there ought to be a point where 16 17 certain RMPs begin to level off while others are coming up. Particularly when so much other federal money is coming in 18 which is addressing itself to health care systems, so I am 19 just concerned that we don't get into a situation more and 20 21 more simply because they got in and got something going. Seems to me that we have just about reached a plateau. 22 23 DR. SCHMIDT: Other comments prior to a vote on the motion then? 24 Ace-Federal Reporters, Inc. If not, I 'Will call for a vote. 25 156 arll The motion is understood. All in favor, please say aye. 2 3 Opposed, no? 4 And I hear no dissent. 5 It is 1:15. Cafeteria is'out of soup, but there are a few other things left. 6 7 We will reconvene at 2:00,olclock sharp. 8 (Whereupon, at 1:20 p.m., the hearing was recessed, 9 to reconvene at 2:00 p.m., this same date.) el2 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 Ace-Federal Reporters, Inc 25 CR 7149 13 157 eak 1 AFTERNOON SESSION 2 (2 p.m.) 3 DR. SCHMIDT: It is two o"clock. I have been asked 4 to remind the Review Committee members to be filling out your rating sheets. All of the regions that are under review 5 6 should be rated by Review Committee members. So.be sure you 7 fill these out. We have three left to do, Texas, Indiana 8 and Memphis. We will begin with Texas and Miss Kerr. xxxxx 9 MISS KERR:. Thank you, Mr. Chairman. I think we 10 want the records to show Mrs. Plood has excused herself. She was an important part of this visit, so. The visit to Texas 11 was made in August of this year. The State of Texas makes 12 13 up the region and it consists of 254 counties with a population 14 of 11,200,000 people. I feel somewhat pressed for time here and I think this is unfortunate, not'because it is so big but because 15 it has accomplished so much and has so much potential that I 16 would like to share it more in detail than I will be able to. The grantee institution is the University of 18 19 Texas at Austin. It is made up-of 17 institutions of higher - education, three of which have medical-schools. Dr. Charles 20 LeMaistrO is Chancellor of the system. Physical agent is 21 the same' institution. The coordinator is Dr. McCall' central 22 23 office is in Austin, with projected ten subregional offices. 0 24 At the moment six exist, at tl Paso, Houston, Ptce-Federal Reporters, Inc. 25 Tyler, Abilene, Laredo and Lubbock. They expect to add to this eak 2 15 8 I list San Antonio; Dallas will then leave two to develop. In 2 Texas there are 21 CHP "B" agencies, 19 of which have councils 3 and have been funded from between $10,000 to $@0,000 per agency by state funds. The last site visit was made in 4 July of 171. Dr. George Miller is Chairman of that group. Also 5 on that site visit team was Alfred Pompa. And I.Say this becaus 6 7 these two gentlemen were oh the visiti ng team one year later. The region appreciated this continuity. As Chairman of the team 8 I appreciated this continuity. 9 10 In the meantime between the last site visit and the one in August, there were four interim staff.visits to the Texas 11 region, on an introductory visi:t from Buddy Says here oh 12 13 my right, one relative to health services education 14 activities, one relative to health services activities. 15 Also the members on 'the team in addition to Dr. George Miller and Dr. Al Pompa were Mrs. Muriel Morgan of the 16 council, @nd Dr. John Low, director of the South Dakota 17 regional medical program. Regional medical program staff were 18 Mike Posta who is present in the room, Joe dela Puente and 19 Dr. Roberts who is here. And I am hopeful that they will feel 20 free to contribute after I am through with the initial report 21 In addition to this group,. we had David Eubanks 22 from the HEW region 6 as program representative. The purpose 23 of the site visit was to assess program progress, processes 24 Ace-Federal Reporters, Inc. and the proposed triennial application. 25 eak 3 159 Now, following the last site visit a year ago in 2 August of 1971, there was an advice letter sent out following 3 council meeting which contained five major concerns for this are@ 4 relative to this-area. I will visit those in a moment. 5 However, I would make it clear that we had a team 6 visit the night before at which time the team decided 7 that while we were focusing and basing.our observations on all ti 8 criteria for review, we would focus primarily on these five area@= 9 to be sure that we were probing deeply enough to have answers. 10 for this review committee and council when we returned. 11 The five concerns and there is somewhat overlapping, 12 at the time of a year ago, it was identified that this region 13 needed to establish priorities under its new program direction. 14 The subregional staff members, it was felt, needed more assistan: 15 and support from the central office and RAG members in the devel-. 16 ment of specific program activities. it was felt that there 17 needed to be more and better representation from allied health, 18 one- more, additional representation from minority groups, the 19 fifth one, some of the reviewers felt the process seemed to be 2'0 more of a central office academic review rather than peripheral 21 involvement in input. In developing into these more deeply, I think 22 23 they will come out as I progress along through the report, 'just how we did find these five concerns'being based and attendet 24-1 Ace-Federal Reporters, Inc. to. From the time of the last site visit until December, it is 25 eak 4 16 0 I unbelievable what this region had done with the development 2 of goals,objectives and priori ties, riot only the amount of work 3 done but the process in which it was done. 4 It involved not only the coordinator'and staff, but many meetings 5 of the regional medical program, representatives from the 6 subregions, the executive committee, and it was a well-organized 7 process coming out with seven priorities well understated 8 by pertinent goals. 9 There was only'one question about this whole area 10 of goals, objectives and priorities and this was 11 Dr. Low who felt that perhaps the objectives could be stated 12 somewhat more in measurab le terms. Didn't seem to be a glaring 13 omission but this was a suggestion for improvement. The-RAG 14 was divided into seven major committees, each one responsible 15 for one of the priorities and they worked individually in" 16 task forces coming back at@intervals to compare notes and 17 finally came up With the seven priorities accepted by the 18 total group. 19 The objectives by testimony during the site visit 20 are understood by all of those participating and they are supporti 21 by all those participating. Chief of program development evalu- 22 ations to be employed and more expert consultation will be 23 sought in strengthening the evaluation committee. They did have 24 a man on staff full-time on evaluation but in the process of A,ce- Federal Reporters, Inc. 25 further developing the subregions and giving them the kind of 16 1 k 5 I assistance they felt necessary to come from central office, 2 this agent who is a very capable person was put in a position 3 to coordinate and assist with the activities of the subregion 4 programs and, as a result, it vacated the position of one 5 full-time evaluator but this is in their plans to replace this 6 person very shortly. 7 It is very clear that the -subregional offices are no, 8 providing more input into the system and.this was verbally 9 supported by every one-of the:subregional representatives 10 that was there including Mrs. Flood. They all were very vocal, i;l 'very.supportive and very appreciative of the kinds of 12 assistance that they were getting. The issue of advisability 13 which was done by the council and sent back to the advice letter 14 the issue of advisability @of developing local advisory groups 15 was discussed and the concensus was that the CHP "B" consumer- 16 oriented planning councils are being developed and that potentia 17 activities of local RMP advisory bodies would constitute 18 duplication of effort. 19 It seems it would also be detrimettal- to community 20 efforts in Texas because not all potentially effective, 21 articulate and well informed consumers have been introduced 22 into the system. An effort to train consumers in participation, 23 however, is presently being supported by RMPS. 24 In addition, five contracts for developing an enviroji Ace-Fedefal Repofters, Inc. 25 ment for Chicano health consumer,participation is being supported eak 6 16 2 I by RMPS in Texas, California, Colorado. These priorities 2 when appropriate have been followed in the funding 3 of operational activities. They are addressed to regional needs 4 and reflect the possibility and instrumentality for continuous 5 development and improvement. @,As far as@implementation, there 6 is much evidence of continued accomplishments by-RAG committees 7 and staff. 8 For example, support of planning effort toward 9 comprehensive proposal with reference to renal di.sease has 10 resulted in promising activity. If successfully funded, it will 11 bring to Texas one of the first efforts addressed to compre- 12 hensive care of a particular group by regional basis. Without 13 a doubt, in my experience of project proposals, whether it be 14 RMPS or any other, this proposal for the kidney program was probably as well thought out, pl anned through a committee, 15 advisory committee, bringing everybody across the state of Texas 16 "aboard that could have any input to its implementation and it 17 18 was exciting really to hear about this. It has been so well done. 19 While many traditional pro'jects have been supported 20 in previous years, these are now being terminated. A new 21 22 generation of projects as was presented to the visiting team 23 promised to deliver improved accessability. Representatives of various multi-disci'line professional organization testified 24 p Ace -Federal Repo(ters, Inc. favorably oh behalf of RMP. I bring this out primarily because 25 eak 7 16 3 I historically this has not been true.' The relationships, 2 the acceptance of RMP by the medical association has 3 improved. I would go a step further and say that the executive 4 director of the Texas Medical Association was the one who was 5 there to speak with us. And what is 'robably a little more p 6 reserved in his openness and acceptance of RMPS than I 7 understand about 90 percent of the physicians in that state are 8 so this was encouraging. But the other thing about the change 9 in the predominance of physicians can be told, I think, relative 1.0 to the adivsory Committee. The advisory committee at one time 11 was almost entirely MDs. At this point in time, numbering 12 51, there are 29 physicians on it. And it was recognized 13 that the region serving an effective role toward the delivery of 14 health services because it, for one thing, it is serving 15 as a bridge between what we call on the site 16 visit among ourselves in family, town and government. 17 In other words, it is bringing together the practici7 e 13 18 specialists and general practitioners.. 19 20 21 22 ?3 24 Ace-Federal Reporters, Inc. 25 16 4 149 As far as continued.support is concerned, in 14 2 response to questions bv the -Visitors, the regional representa- 3 1 tives reviewed the continuing status of the activities fund 4 trhough 1970 to 1972. Of 22 projects supported, only two will 5 continue after the close of the current period. 6 Eight will be supported by self, or other support 7 that has already been arranged@ Seven,will be discontinued. 8 Either because they have been completed or because through 9 evaluation they have proven to be' not worthy of tinuance. 10 And there is a question about the continuance of 11 three others. Relative to minority interests and you will recall 12 that this -was one of the concerns of the last advisory group,, 13 and we went armed for bear to find some answers to this,.and 14 I would have to say, that as we -looked at the advisory committee 15 constituency there was some concern and a little more than' 16 concern, that not as.much has been done in this area as wehad 17 hoped would be in the entire interim period. 18 However, there has over the period of the last five 19 years been an increase in minority groups to the number of 11, 20 which seemed not too bad in view of the fact that they only 21 had a' quarterly turnover with replacements. And we can't 22 exnect an unusually rapid increase in this number through 23 but there are also some other rea sons. 24 I think we all acted like generals for two days in kce- Federal Reporters, Inc. 25 this area and I think Dr. George Miller's hat was the hardest an'. 16 5 14 1 the biggest. Ilaving been there.before, being the one that made TZeba 2 2 the recommendation for increased involvement of minority 3 grouses, he really peppered away at this. 4 We even checked this out'with Dr. Le@lader relative to 5 their civil rights compliance and so forth and so on. They had 6 as I say improved the minority representation on the RAG, -not 7 as much as we would have liked but there is a strong commitment 8 to do this. 9 And words can be words, but it is in print. Their 10 procedure for employment of people with a focus on employing 11 -those who are of the minority groups. I think at this point 12 I will say that Dr. McCall, as f orthright as he is, we could 13 not back him into-the corner on this because he was so honest 14 about it and-said, "I am looking for these people, I have been 15 looking for these people. I will continue to look for these 16 people and bring them to the board as soon as possible but I 17 @will not commit myself to bringing aboard a black face or 18 Chicano or a white person unless they have the competency and 19 capability that we can build on'to make them an active con- 20 tributing part of our staff and-RAG."' 21 The minority groups are extremely well and consu4er group in the subregions. Much of the'program is arr'ng d 'arounc 22 s a e 23 the innuts from these people. There are a significant rumber of minority personnel 'on project staffs. 'I would want to tell 24 Ace - Federal Reporters, Inc. you t)lis:Dr. Sid,Geroa, who sat there, and he is not a very 25 16 6 #14 1 vocal person, but he rose to his fee't after much'probing 3 2 in this area, and this was the second day, he rose to his feet 3 and-in a soft kindly way, a Chicano, made it very clear to us 4 that the RAG, the Executive Committee and indeed the grantee 5 institutions as they moved ahead in their pgoram planning and 6 implementation, he felt and it.was like a sermon, he felt that 7 they had the well being of everybody in that state in mind 8 regardless of race, color, creed, age or anything else. 9 And it was beautiful to hear. If he had been more 10 vocal before I don't think it would have been quite so impres- 11 sive. T,?,elative to process, Dr. lIcCall, the coordinator, has 12 undoubtedly provided some of the strongest leadership with able 13 administration in his three year tenure that one could expect. 14 There is a very-viable regional advisory group and he has utilized them, diversified talents of its membership, in 15 16 establishing the plan as presented in the triennial application. 17 Dr. lIcCall has excellent rapport with members of the RAG and 18 manv other health representatives throughout the state. Agencie3 and associations, individuals, and so forth. As an aside, at 19 this particul ar time Dr. McCall was being interviewed for a 20 Coroner's position in my own state And as a member of the colleq@ 21 and faculty there I was aware of this, somewhat involved in 22 23 this I think he and I treated it with very low profile, inten- 24 tionally. @ce- Federal Reporters, Inc. 25 The review committee was aware of this. The possibilit 167 f@14 1 Of changes, I would say,, despite the fact we knew change was Tlf-ba 4 2 possible, we felt that Dr. !,IcCall had developed astaff, had 3 allocated responsibilities or delegated responsibilities 4 and given it the authority to carry out these responsibilities, 5 and if he had, we felt that I,lr. Forguson,.his deputy could very 6 well move-in and move ahead with the program they were planning. 7 I hasten to add before you get excited he has 8 decided to stay in Texas. I think Texas is fortunate and I 9 think we would have been fortunate to get him but,44e will carry 10 on. Relative to program staff,-the staff consists of 1'9 11 professionals, all but two of them serving 100 percent of the tin 12 There has'been almost no turnover in the last two years. 13 I think this speaks well both for staff and for the 14 coordinator, and six additional.professional staff members are 15 requested during the next year and include a director of edu- 16 cational programs, chief of public development and evaluations, 17 nursina education and three subregional representatives. 18 The site visitors believe that these positions as 19 budgeted are justified. The program staff reflects a high 20 quality of broad branch of professional discipline, particularly 21 impressive was the quality of subregional representatives 22 to demonstrated thorough knowledge about their responsibilities 23 with respect to geographical assigned areas. 24 The 51 member RAG group was very active from the @ce- Federal Reporters, Inc. 25 time of the last site visit through December and continues to 16 8 #14 be but were Particularly active at,tliat time with attendance 5 2 never going below 70 percent, and with people coming from all 3 over that state of Texas to work on RAG meetings, that attendance of 70 percent seemed to us to be very good. 5 Geographic distribution of its membership was con- 6 sidered to be satisfactory. I-lowever, as with many regional 7 medical programs T)hysicial representation proportionately was 8 high while consumer interests rem ain relatively low. I alluded 9 to that earlier but I need.to go a step further I'Othink and 10 indicate agai-n there are still 29 of the 51 who are physicians. 11 This question was raised as to why. And the chairman 12 of the RAG, S. Bradshaw, not Bradshaw, Dr. Eastwood, who is 13 a Ph.D. and director of the medical center at Houston, quite 14 a personality, highly respected by the group who relates well 15 with the RAG group, and in staff and the rapport seemed excellent. 16 But anyway Dr. Eastwood explained that with the four 17 with the three medical institutions within the system, and with I 8Baylor and one other medical schi6ol in the state, --- 19 MR. SAY8: University of Houston is the medical 20 school. 21 MS. KRPR: Getting underway. If they were to have 22 Representation from general practitioners and so forth so on 23 --hey could see that this could not be cut too much more if they 0 2417ere to keen the good faith of the physicians that had taken %ce-Federat Reportefs, Inc. 25 o long to get it built up and he convinced us that this was 169 ftl4 I And after our visit I thinIC we felt that this too 'Reba 6 2 was proper, too. 3 The executive committee meets more often than the 4 RAG committee and.provided ample guidance for the coordinator 5 and staff. Effective in providing leadership in the process 6 and in utilizing regional advisory groups, 51 committees and task forces. These were not left in limbo, they were well organ,:-, 7 8 izod 'and coor'indated task forces and committees. 9 Development committee assumed an active role by 10 establishing short term objectives,. The Chairman of each 11 program committee is a RAG member and serves.on the executive 12 committee. General program activities for each of the seven 13 priority statements and funding allocations projected for use 14 of growth funds in the second and third year of the proposed 15 triennial event application. All this is to go to say that t ere 16 has been much planning, thinking, brainstorming, and so forth prior to the submission of their level of request for funding. 17 - 1 have talked about the grantee organization. 18 There was some feeling at one time that perhaps there 19 was a little bit too,much control from the grantee organization. 20 We came away from th eir havin probed rather deeply on this 21 9 22 too to find that the coordinator, the PAG, feel very-free to 23 move ahead with decision making with-absolutely no interference 24 or control from there, from the grantee institution. %ce - Federal Reporters, Inc. And they feel very comfortable with the physical 25 170 #14 1 arrangements, as far as participation is concerned. 14any 7 2 health interest groups are' actively.participating in the region 3 as evidenced by the number of persons who attended this two 4day visit. 5 llo major group has captured a controlling interest. 6In orc-paring the 'budget request for that of last year there 7was a.complete turn around with respect to funding the major uni- 8versities and institutions. This accomplishment has made more 9funds available for the community. D.ut -- as a r@lt it has 10 not brought 4bott less cooperation from major health institution 11 The political-economic power of the regions involved in the 12 regional program, the CAP agencies and local -- not only this 13 but there is CHP representation'on the RAG, representation 14 from JTTIP other PI.IP on the CITP Council. CIIP and B agencies 15 are involved in the process. 16 I have already talked about the CHP'S, and their 17 situation. -Durii-ig the last R'14PT the review cycle there was 18 ample evidence that the Rt-IP's minimum review requirements and 19 standards for local review have been carried out in a very 20 satisfactory manner and this continues to exist. 21 As far as the assessments and resources there was 22 ample evidence the region is conscientiously accumulating a 23 great deal of data as evidence-by'(inaudible) -- the data is 24 utilized in identifying specific and measurable needs of the Nce - Federal Reporters, Inc. 25 region. 171 414 1 Management, the capability of the region continues a 8 2 to be excellent. Program staff and project activities are 3 well coordinated including monitoring b RAG members and sel- y 4 ected ad hoc members. Progress and financial reports are require 5 on a quarterly and monthly basis respectively. Relative to 6 evaluation as I indicated earlier at the present time there is 7 no full time evaluations director in the program. 8 I have talked about the termination of funding on 9some projects that come about by evaluation and the limited 10 funding being put on others as a process of evaluation and 11 their.need and expectation to fill this position shortly. As 12 far as program ptonosal the action plan is comprehensive, 13 Priorities have been thoroughly prepared with much review 14 and are clearly congruent with national goals and objectives. I 5Fhe proposed activities relate to stated priorities and ob'ective 3 16 ivbn to the needs of the region. 1,4ethods of reporting accomplish 17 nts and accessing results are proposed but address individual 18 ctivities really more than they.do program achievement but lg)eriod review and updating of priorities are planned. end 14 20 15 fls 21 22; 23 24 Ace-Federal Reporters, Inc. 25 mea-1 CR 7149 #15 172 I As far as dissemination' of knowledge is concerned, 2 most programs have focused on appropriate groups and 3 institutions that will benefit. Knowledge, skills and A. techniques to be disseminated everybody identified to 5 varying degrees among the projects.' 6 There is a notable degree of involvement of 7 health education and medical institutions. Better care to 8 more people is a goal to which-projects are directed. Some 9 solid measurement of result remains to be seen. However, 10 they are also Addressing themselves to moderation of costs 11' of care. 12 Utilization of manpower, the regions utilize 13 community health facilities and it is apparent in the 14 projects that are proposed. 15 Allied health personnel utilization has improved. 16 Although new types of health manpower is a sensitive issue, 17 further attention is being given to this and this statement 18 revolves around the fact that the medical profession in the 19 State of Texas is not yet ready to accept the position of 20 assistance. Maybe this will change but this was why this 21 particular statement was put in there. 22 Improvement of care, access,to health care, is 23 their first priority and projects'are being addressed to.this 24 issue. Ace-Federal Reporters, Inc. 25 Primary care will probably be strengthened since mea-2 173 this is an important element in several of the projects. 2 Less attention is given'to health maintenance and disease 3 prevention in the proposed activities. 4 As far as short-term payqoff the proposal is 5 directed more toward the ability of access to services than 6 simply gathering more information about health problems. 7 The need for feedback is projected. Support of 8 projects not planned beyond three years. Plans for 9 transition to other sources of support are inc@ded in their 10 proposals zo that three years is the limit of funding. As far as regionalization, we have talked about 12 the different regions. It is a major goal of the program. 13 They do share existing resources when possible and now 14 linkages among providers are indicated in the three-year 15 plan. 16 There is ample evidence that the region has and 17 will attract funds from sources other than RMPT. Though not 18 discussed in detail the region account provided the staff 19 with a document which indicates non-RMPT funding, to be 20 new and continuing projects and terminating projects 21 $150,380. it was the feeling of visiting team that Texas 22 23 has much going. That it is well on its way to doing some very 0 24 exciting things based on sound priorities and objectives kce-Federai Reporters, Inc. 25 which have been developed cooperatively with-a great deal of 174 CR 7149 I consideration by all people involved. They have been accepted 15 d. 2 by all people involved and it seems as though they are flq. MEA 3 collectively ready to move out and do'something with these dor 1 4 things. We also felt that the region is under excellent 5 1 6 leadership from the coordinator, who uses well.his central 7 staff of people who do bring to the central staff competencies. 8 We have before us the funding level requests and I 9 think we can all read that the site visitors did recommend 10 that they be approved as requested. 11 Now, I would draw your-attention to the fact 12 that these do include the kidney pro3ect and that there are 13 questions about that. 14 Dr. Roberts pursued that more in depth, but it 15 was the unanimous opinion of the visitors that they be 16 approved at the level requested. 17- It was also the unanimous feeling of the visitors 18 that Texas kept its A rating. 19 DR. SCHMIDT: All right, John. Dr. Kralewski: Just a couple of comments. 20 I didn't visit Texas oh the site visit. As a 21 matter'of fact, I have never visited-Texas RMP, so I really 22 23 don't know the program. I am reacting to the application; I am reacting to 24 Ace-Federal Reporters, Inc. the site visit report.. 25 dor 2 175 I Unfortunately, the reports are striking me a 2 little differently than they apparently struck the group 3 that visited Te'xas, but let me just give you my impre8sion§,-. 4 then we can go from there. 5 First of all, it looks to me as though that RAG 6 is still dominated by producers of services even after the, 7 you know, team previously had been very concerned over it 8 and wanted to make changes. 9 Changes have been minimal, and the addition of 10 women to the Regional Advisory Group, and then putting 11 - minorities on there, to me, is a-cop-out and, secondly, it 12 is a cop-out, I think, to say we don't want to take someone 13 because he is a minority group, we have got to wait until 14 we get that fantastically qualified guy. 15 I have had about three programs tell me that and 16 it is a strict cop-out, because they don't look. There is 17 plenty of good guys out there if they search for them, so 18 I think they are not doing the job in that.regard. 19 Secondly, when I lo6k at the projects, I think 20 this shows up because, of course, in'their screening of the 21 projects, this is the group that sits down and sets the 22 priorities and determine what should,be in and what'should 23 be out. 24 If you look at these projects, a good many of them Ace-Federal Reporters, Inc. 25 are self-serving to the group that is on the Regional ao r .5 176 Advisory Group, self-serving to pr6ducers of se.rvices. I know this is'a conservative state and they 2 3 will have to 'chip away a while before they can do things. I find, on the one project, they are going to help 4 5 someone develop an HMO, and I was looking that over to see who it was going to be, and sure enough, it is the Medical Society. 7 So, now we will have-another foundation developed 8 9 at our expense for the Medical Society more than likely. 1.0 Well, you know, these-are leaving me some real 11, questions. Also, I note in here that it appears that a fair 1 2 amount of projects are carry-over projects, they are not 1 3 14 being phased out. It may be that this again is an indication 15 of some excess money that was given to them in the middle 16 of the year and it just@ doesn't reflect that in this application. 17 18 Well, on the basis,,on that basis, of my feelings, as I read through this and the feeling that I get, you know, 19 20 for what they are doing, I can't really recommend that level of funding, nor an A rating. 2 1 22 On the other hand, as I said,.I have never visited the program. I am acting on the basis of information that 23 24 might be limited. Ace-Fedeial Reporters, Inc. 25 I respect the s'lte team's wishes, obviously they 1 7 7 dor 4 I -spent a lot of time with it, therefore, I am in a bit of 2 a dilemma. 3 DR. SCHMIDT: Let's see. Let me see. Would you 4 second the motion that was made? 5 DR. KRALEWSKI: For that funding le,,rel? I coUldn-t second that, no. 6 7 DR. SCHMIDT: All right, there is.a motion on the 8 floor for approval at the level.'requested. 9 Is there a second to that motion? 10 MR. HILTON: Second, 11 DR. SCHMIDT: All,right, it is seconded. All right. Further discussion? 12 e 15 13 Dr. Luginbuhl? take 16 14 DR. LUGINBUHL: I w as interested to check the population of the area. 15 I'think it is 11 million people, and I don't 16 17 really feel that coming up with per capita figures should be t he way in which we determine allocations. I do think, 18 on the other hand, that we have to give some consideration 19 20 to the size of the area and the numbers of people that are 21 being served. I think that the amount of money proposed works 22 out to something like 22 ce nts per person. 23 24 I know in one of the other programs, we have given Ace - Fedetal Repotteis, Inc ' probabl@. five times as much on a per capita basis. 25 17 8 dor 5 I My question is, if it is'an A rated progr am, why 2 isn't it a bigger program in view of the size of the state, 3 the diversity of income levels, the magnitude 'of the problems, 4 why aren't they able to utilize more funds and meet some of 5 these needs that are there? 6 DR. MARGULIES: I think that is an interesting. 7 kind of a question to raise. It is more a matter of history 8 of program development than it is geography or population. 9 it is a problem that we have wrestled with at 10 various times in RMPS. 11 This particular program was one with a miserable 12 record up until the time of the' last sit e visit, when George Miller was down, sort of astonished at the change about it. 13 14 On the other hand, if you are asking the 15 question, why, if this program is as strong as it is and 16 has that many people it is tot able to identify more 17 activities of value to those people, that is a perfect y 18 valid question. I just don't want to mix the two issues in the 19 discussion. 20 DR. LUGINBUHL: Well, my major question really'de alt 21 with the last issue. I can't help but wonder, in view of. 22 23 the population, why isn't it a larger program, and to lead 24 me to queIstion the wi-sdom of having a single program cover Ace-Federal Reporters, Inc 25 such'a very large geographic area and such a very large 179 dor 6 I population. 2 I am not familiar-with the California program 3 because we have not reviewed it at this time, and I gathered 4 they have dealt with their large population by some sort 5 of great division and I know that New York, which may not be 6 the best-example, of how to run a region, has divided that 7 state into several different regional, medical programs. 8 The question I am really raising, is this too big 9 an area to manage through a single.program? Is there enough emphasis being placed on the sub- 10 11 regions or on dividing ijp the-problem so that it can be addressed? 13 MISS KERR: There was consideration.given to. 14 having three -- Texas make up three regions originally, and it was decided to go with one. 15 16 The other thing is the regions are comparatively 17 new, with their representatives just getting out there and 18 getting involved, and I think.Ithat to use-Mrs. Flood as an 19 example in the El Paso area, where there are many Chicanos, 20 she knows their problems, they relate well and there is a Sister Strohmeyer down in the lower-valley who is equally 21 as -- and I assumed, all of them were, from the way they knew 22 23 their subregions as they discussed them with us, they were 24 identifying problems. kce - Federal Reporters, Inc. 25 I am n.ot sure at this point in time, though I dor 7 180 am sure that they, too, will want more funding eventually, but I am not sure at this point in time but what the 'coordinator 2 3 and the RAG feel that at this particular time @erhaps,that 4 "We better take this much money and do well with it and then go the next step." 5 6 DR. MARGULIES,:' I would like to pick up something 7 John commented on, he used the same words in my mind when he 8 said "cop-out". 9 I react, I guess, with some suppressed violence 10 to this business of, "Oh, yes, we are interested in minorities and women but they must be of the)best kind and 12 of the finest kind of qualifications." Well, I have a couple objections. to that. One 13 14 is that it can easily be used as a facade for inaction. 15 Secondly, if there was absolute equality as 16 equality is usually measured, then there wouldn't be any 17 minority problem in the first place, that is really what 18 we are talking about, and 19 The tlird is I doub-t very much that a program which has to deal-with issues of the-kind that they have in 20 Texas, particularly with the issues of Mexican Americans,, 21 22 migrants, and so forth, can do.so from the kind of experience 23 that they get from people who have never had anything in the 24 world to.do with those problems. Ace-Federal Reporters, Inc. I think it'is a programmatic weakness but what I am 25 181 dor 8 I real ly wondering about is, if you'believe in general in 2 these concepts, at what point does this become an issue of 3 priority in determining what grant levels should be? 4 Now,,we.have identified on several occasions in our 5 review that there are deficiencies but there are signs of 6 progress, and so on. 7 This is one of the criteria. The weight one 8 gives to it, I supposek can be put down in some kind of 9 arithmetic form, but I think there is more to it than that. 1.0 And I think it is only fair to say to you that our 11 own kind of judgment is going to be very strongly influenced 12 by just how much evidence there is of commitment to the issues 6f@,fair play with minorities, with women. This is so 13 14 inseparable from the concept of an effective Regional 15 Medical Program that I find it impossible not to be 16 influenced greatly when we come to the question of grant award. 17 18 Obviously, if there,is a marked disparity. in my 19 view. and that of the review committee, we will yield to the position of the review committee and council, but I do hope 20 that question is be ing given as much consideration as it 21 should. 22 DR. SCHERLIS: I just wanted to take up some more 23 24 questions about the recommendation of the site visit group, Ace-Federal Reporters, Inc. since apparently it, in giving all the funds that were 25 182 dor 9 I -requested, apparently decided all the funds were to be 2 wisely expended. Looking over some individual projects, 3 they are of interest. I question, though, how much impact 4 they will have on health care delivery systems. 5 The health project Number 691 Health Evaluation 6 Acdess and Resources Development, Ector County Medical 7 Foundationt as I read it, it is a computerized effort to 8 aid in diagnosis and seems rather expensive, it is 9 $118,000 for each of the years, 16-ok at some sixthousand 10 people. If I read this correctly, have,a,'@tandardized 11 medical history questionnaire.in English or Spanish,.and if 12 anyone has tried to set up computerized,methods for getting 13 histories to go beyond that, this is a tough area. 14 Perform basic physi cal workup, which consists of urinalysis, blood pressure, vis -aal test and hearing test.7 15 i6 These are the only ones that are listed. .You will then have electronic data processing,, 17 printout, a physician will look at the printout, and decide 18 19 'whether any medical care is necessary. Then from that point, I sort of lost track 20 21 because they say diagnostic and treatment services will be 22 obtained from public volunteer and private sources without 23 charge when possible, and hea,lth,delivery is dependent on 0 24 that vehicle of access, if it is,'it is really a very thorny 4Ce-Federal Reporters, Inc. 25 type of project,to look at. dor 10 1 8 3 Yet, it is one hundred eighteen for each of two years. It is fairly-routine. 2 3 I was wondering if you could tell me what GRO". 4 is, or GRO are, since it is taking place in five places. MISS KERR: Grass roots. 5 6 MR. SAYS: This essentially is seven to twelve. 7 in each group that get together. The, whole idea is a 8 sharing of services. Thus far, about the extent of the 9 actifity has been sharing in service training, but we 10 believe that it will go far beyond that. They are now looking at this. 12 It certainly is an activity that is popular among the consumers as well as the providers. 13 14 DR. SCHERLIS: The other program is an electrical 15 safety servicei one which seems' similar to many of the others, except here they are paying $50,000 for manuals, I guess to 16 be put out. Then to have it self-supporting, I question 17 if at this period of time, knowing what we do about safety 18 19 hazards, since all this is so well documented and available through many agencies and otherwise, I just question if this 20 f 21 should be part of what RMP should support. MR. SAYS: Well, this is a: pickup on an activity 22 23 supported by program staff for about a year. DR. SCHERLIS: But they plan to support that again, 24 Ace-Federal Reporters, Inc. 25 don't they? 184 dor 11 different. MR. SAYS: No, it is a little. 2 The core staff'activity, they demonstrated the 3 feasibility of this in six hospitals and the Texas Hospital 4 Association, which is very progressive, very cooperative with the RMP, as well as other prior,organizations, has seen 5 6 fit to take this activity, asking.for support for one year only, after which it@:.will be continued through fees. 7 8 It goes far beyond putting a manual for hospitals, 9 but offering them assistance, actually going in and taking 10 a look at the way they go about checking out their equipment, and so forth, and possibly, even in some of the smaller 12 hospitals, sharing electrical engineers, where the single hospital may not now be able to do so. 13 14 DR. SCHERLIS:- Well, the lutline doesn't go that 15 far. 16 MR. SAYS: If you look at the full-blown application, it does. 17 18 DR. SCHERLIS: I guess you had the raw project. I question if this is the way to do it, since there are other 19 20 ways of approaching it. This was the question that I had. DR. SCHM IDT: Mr. Toomey? 21 MR4 TOOMEY: I couldn't find any mention of an 22 23 HMO proposal, but I would like to comment that if there is s.uch a proposal, and if it does concern itself with a 24 Ace-Federal Reporters, Inc. 25 medical care foundation, then I would recommend that it be 1 85 dor 12 I supported. 2 I am concerned about the medical care foundations 3 that are established'on A as a defense mechanism against more 4 and different and, if you will, innovative kinds of pro- 5 visions of medical care, and to use the foundation for 6 medical care as-a mechanism to defeat something which is new 7 and different,turns me off, but to fund a project which has 8 as its base and concept great.numh_ers o peop e or 9 representatives of hospitals, public health agencies, CHP 10 agencies, RMP people, physicians, medical schools, and so on, it would be very refreshing and as & matter of fact, it 12 might just possibly come up with something which would be very worthwhile in terms of-an HMO foundation for medical 13 care kind of proposal and would be different. 14 15 I would like to see'it. MISS KERR: I am not sure but what there is some 16 misunderstanding about this because the HMO activity has 17 been as a result of RMP involved staff assistance, but it 18 19 is being funded by HSMHA, county medical society, but the 20 region itself is not involvedlin any funding of the HMO. DR. KRALEWSKI: My comment to HMO was along the 21 22 lines that this is the way they devoted some of their discretionary funds, I believe,.and core staff effort, and 23 24 it may be appropriate. It only occurred to me that I suppose %ce-Fedeial Reporters, Inc. there was a lot of different areas that could have used that 25 186 r 13 1 kind of help, and as I was reading through it, where they 2 talked about the fact they were giving help to groups to 3 reogranize the health system, lo and behold, it 4 happened to work out that way, and it may be good. 5 I'don't wish to speak against it, but I think that, 6 you know, this is a big region, they have got a lot of people 7 they are trying to subregionalize, and I hope that that will 8 help a bit. 9 ..The site team obviously thought that they have 10 some strength and will be able to grow and so I guess, really, though, that my reflection:: on this is that I feel 12 it,.would really be giving them'a bit too much of a pat on 13 the back to go one hundred percent of what they have asked, both in light of the accomplishments that they have achieved 14 and in terms of what has been made on these projects. 15 16 Therefore, I guess what I would really like to do is offer a substitute motion, of funding at levels of 1.9, -17 18 2.1, and 2.3, with developmental funds in the range of 80 first year, one hundred and one hundred for the second and 19 third year. 20 21 I think this will give them an increase in funds,, and -as-.,has been pointed out, this is.a large population 22 group and probable that budget is not out of line. 23 24 Y et, I think it will indicate to them that we Ace-Fedefal Reportefs, Inc. 25 still have some questions about exactly what is going on and 18 7 dor 14 I where that money is going. DR. SCHERLIS: 'I second that. 2 3 DR. SCHMIDT: All right, there is a'second, then, 4 to the substitute motion. end 16 Their level last ye ar? 5 take 17 6 DR. KRALEWSKI: 1.58. 7' DR. SCHMIDT: 1.58, so this would be up to 1.9. 8 MR. SAYS: Doctor, I know there is a motion, but 9 I think there are some things perhaps you are not aware of, 10 Dr. Kralewski, in this whole situation. Dr. McCall is an extremely capable coordinator 11 12 and he understands that to pull off a.successful program takes the commitment of the people to whom it is to be 13 14 delivered, and also those who%are involved in the process. 15 If you look at the application very closely,, it took him from July, when the 1 ast site visit was made, up 16 17 until December of 1971, through a very.long hassle with his RAG and his development committee. The priorities were 18 19 developed once and rejected by the RAG. They went back to the drawing board. 20 They had only two months to bring in some kind of 21 22 pro3ects for this application, hence, the reason for his 23 growth funding in the second and third year. I happen to know that sinc e this application got 24 - PAce- Federal Reporters, Inc. into the hopper, in Januar@, they could use easily a half a 25 188 dor 15 million dollars more now. For an example, in Houston, they are now 2 3 operating, or talking with a group, this program has almost 4 developed, it would take $150,000. -It involves two barrios, 5 where they would like to employ six half-time:'.-health advocates 6 in each barrio,'under the supervision of Chicanos. This 7 dove-tails in with a program by Baylor, the Department of 8 Community Medicine, which is als'o involved in a hospital 9 district that has the direction@of.seven clinics@ rom that 10 city that deal with very poor neighborhoods, an excellent 11 opportunity perhaps to examine access or evaluate access 12 and quality performance on a patient population of 60,000. This is just, you know, a couple of 13 prograr6s. that 14 have been examined and are in the hopper at this time. This application started almost a year ago. 15 16 D@. KRALEWSKI:. Well, I appreciate that additional informatio n and I feel that if you are correct that this 17 gentleman is a really good manager, that he would be able to take a million nine and probably reorganize some of the 19 20 things that he is doing and probably, as a matter of fact, 21 go through these projects and come out of there with, you 22 know, ten or twelve or fifteen percent savings, at least, and then devot e that to these very worthwhile activities 23 24 that you are mentioning, and I suppose he does have also lkce - FedeFal RepoFteis, Inc. 25 the opportunity, to come back with an application a bit later 189 dor 16 for some additional activities as they develop.' 2 MR. SAYS: One year hence. DR'. LUGINBUHL: I am certainly very much influenced 3 4 by your evaluation of the leadership of the program, but I 5 think the information about the timing problem is quite 6 significant. What I would wonder about is this: Would it be 7 8 possible within our ability to make some cutback in terms 9 of the project part of the money, but give that money to the. 1.0 program in a way that they could-use it flexibly over the II- coming year. 12 If he is a really good man, he has come up with 13 good new things, now that he has gotten priorities 14 straightened around, I would like to give him the flexibility 15 because it already is a fairly limited sum of money for the population and problems. 16 17 I don't see the imaginative approach to the large, unserved segments of that population in this application, 18 19 and maybe if we could pr.eserve the dollars but give some more flexibility to the director, he could begih@.,to address those 20 21 programs. Finally, I am somewhat concerned about the RAG and 22 23 the fact that it does appear to be heavily influenced by professionals. 24 I%ce- Federal Reporters, Inc. 25 I am wondering,' as I have listened to these dor 17 19 0 I discussions, about the size of these groups. This one, I 2 think, is 50 or so people, and Iwonder how well they are 3 really able to meet and set some of these priorities and 4 particularly how do some of the underserved get their priorities 5 into the application, if the group is dominated by priors. 6 DR. @CHMIDT: Well, I think one of the points that 7 John.was making was that if this is a wise manager, he can 8 get discretionary funds out of the money he has just by 9 simply not spending it for some of.the things that in the 10 application.he said he was going to spend it for. You are 11 saying can we force him by earmarking discretionary funds and 12 the answer to that is, he can be advised or it can be 13 recommended but we haven't been in the habit of so ear- 14 marking funds. 15 DR. LUGINBUHL: My concern is a little bit 16 different. If I am correct in my understanding of the process, 17 @18 whereby some of these projects.get into an application, I 19 think what happens at times is'that people propose these 20 pro3ects and they are nominally within line with the goals 21 and objectives and the group making-the decision at the local 22 level finds it very, very hard to say no, especially when therE 23 is not some other proposal at that point in time competing 0 24 for those dollars. Ace-Federal Reporters, Inc. 25 Frankly, I suspect at times the problem of 19 1 dor 18 I setting priorities is getting passed on up to us. 2 If you have the money or the potential for getting 3 money and you are not forced to set priorities, frequently the 4 easiest thing to do is just not set them. 5 What I am suggesting is that by cutting back on 6 the project money, you are going to force them.to set some 7 priorities and you are going to let them reallocate those 8 dollars or force them to reallocate those dollars by 9 increasing the discretionary funds and I would think that for 10 at least some coordinators, this would be a very welcome 11 -opportunity to set priorities and-to, in fact, strengthen 12 their hand in dealing with their regional advisory group 13 and dealing with some of the priorities that are making 14 demands for project support. 15 DR. HESS: Just a question to further clarify 16 this. 17 It is my understanding that an RMP may shift 18 developmental components into projects but the reverse is not true unless it is authorized, is that correct? 19 DR. SCHMIDT: That is correct. 20 DR. HESS: So the implication of your statement! 21 is, would be to approve the developmental component-at the 22 23 requested level and take the cut in the project section of the budget in order to achieve your goal; if that is what we 24 Ace-Federal Reporters, Inc. 25 are after, I think that ought to be specified. 192 dor 19 I DR. SCHMIDT: All right, is this acceptable to 2 the mover as a piece of legislative history that will be 3 directive then? In other words, developmental component is given 5 at the 10 percent level, the maximum allowable, but the cut, 6 the reduction down to 1.9 comes out of the project funds. 7 That-we can do. 8 DR. KRALEWSKI: Acceptable. 9 DR. SCHMIDT: All right.to the secondW, is 10 that acceptable? 11 DR. SCHERLIS: Yes. 12 MISS KERR: I would like clarification as to'what 13 the motion of the moment is now? 14 DR. SCHMIDT: It is.for approval of the triennial 15 period at the levels, 1.9, 2.1, and 2.3 total funding levels. 16 The original substitute motion was for developmental 17 component of 80, but this has now been changed to a 18 developmental component that would be the-maximum allowable 19 under the policy, or ten percent of the award, really, 20 which would give them, what did they ask for? 21 MISS KERR: They--,asked for first year $160,000, 22 second, two hundred thousand, and the third, two tw6nty-five thousand. 23 DR. SCHMIDT: Well, that would still be permissible 24 %ce-Fedeial Reporters, Inc. then because it could go up to 10 percent of the award. So 25 dor 20 19 3 I that gives them some amounts of flexible funds. 2 All right. 3 Other comments or questions then? 4 If not, I will call for a vote on the substitute 5 motion which,we just reviewed. 6 All in favor, please say "aye". 7 Opposed'.Ino? 8 Dissent is recorded. 9 Thank you very much. 10 I think that is the first time we have ever 11 completed adiscussion of T exas.in 55 minutes, 65 minutes.- 12 We can conclude a discussion of Indiana in 30 13 minutes. xxxxxx 14 DR. PERRY,@.'- The word catalyst has been used 15 so I will just say there has been a most dramatic transition 16 here in Indiana in the past year. 17 A site visit has not been held in Indiana, although 18 an August site visit was set up, it was canceled by RMPS for the following valid reasons: 19 Dr. Stonehill, the coordinator of Indiana resigned 20 21 effective April 30, 1972. The triennial application that Iwas submitted was submitted without really the assistance of a 22 23 coordinator, was reviewed by the staff here at RMPS, did not clearly present a three-year plan, thus the site visit was 24 Ace -Federal Reporters, Inc. cancelled. 25 19 4 dor 21 1 RMPS recommended the submission of a one-year 2 anniversary application which would lead to a much stronger 3 triennial req uest next year and this'has been done. 4 Dr. Schmidt, the second reviewer and I have been 5 on two separate site visits at Indiana. Dr. Brennan and I 6 in 1970, representing the council and the review committee, 7 were there, We were not welcomed back for the next site 8 visit. 9 Dr. Schmidt was in Indiana in 1971 and I am not sure 10 ;of,-@ his reaction about being welcomed back for a site visit 11 this time, but the purpose of the-site visit and which was 12 communicated at the site visit periods, I believe have led.," 13 to the most important decisions for change in this region. 14 If there is anyone thing that I would say was 15 probably the greatest strength'of all is this attitude of 16 desire to change that is recorded in this, not only in the application, but by other means. 17 18 I am delighted that Bill is here at the table with us because members of the-staff, since we have not been 19 there during this period of thime, there are members of the 20 21 staff that have been in the Indiana region and it i§ some of their reflections and their reactions and certainly-the 22 23 recommendations of RMPS that will be a part of my recommenda- tions here today. 24 Nce-Federat Reporters, Inc. 25 To evaluate Indiana, let's look at some of the 19 5 dor 2 2 I strengths and then some of the weaknesses for, indeed, even 2 with the problems and dramatic changes'.-that have taken 3 place,.there are strengths that can be indicated here.. 4 With Dr. Stonehill's departure, which was 5 requested two months earlier than his date of resignation by 6 the RAG, I think this tells a little about the.story there. 7 I am putting this as a strength and it must be 8 taken as a plus, as far back as the time of the, of this 1970 9 site visit, in which I participated, there was a great deal of 10 antagonism expressed between many Indiana Medical Associations, 11 and by various groups, representatives of the Medical School 1 2 at Indiana,@haVe stated.--.toBill.-@ to others.that they have been misinformed on the status of IRMP. 13 14 And that the tight ship that had been identified 15 and I guess these are words that both Al and.our group used, that 16 this man was running what was evidently heading for very 17 rocky shoals. 18 With his departure, Dr.Behring, Associate Dean of the Medical School, has been appointed the interim or acting 19 coordinator and a search committee has been set up for his 20 2 1replacement. I recall Dr. Behring, he has served with-this 22 23 group and with the RAG for a considerable period of time, perhaps an indication,-h6wever, that this RAG was not that 24 Ace - Federal Reporters, Inc. active'and not that inv.olved. 2 5 19 6 dor 2 3 Already the relationship', and I would put this as a strength, already the relati onship of the Medical Society 2 3 and other health-agencies have indicated a marked improvement 4 in the few months recorded since the resignation of the coordinator. 5 6 Dr. Behring reports, as the interim.ooordinato.r,, 7 thatthere are improved relationships wit hthe Indian Hospital Association, many of the health associations that have been 8 9 identified.in relationship to this program, that they are, 10 indeed, sharing with them their request for help in putting 11 this region into better shape. The RAG, with many of the problems,.,Ii-will@list under 12 weaknesses. 13 14 I feel, however, the complete review that is taking place with the RAG today-is absolutely essential. It 15 16, is still in the process of major revision. Although the lar .ger number are from Indiana University, and there have been 17 comments on this from the beginning, Indiana4@ in that setting 18 19 and in that state, certainly Indiana University deserves and should be in a major relationship to this RMP. 20 21 But in addition to this group, we find here other institutions, other groups, their relationship with CHP, 22 23 w ich I will speak to further her e, other organizations throughout Indiana are.being represented in some of the 24 Ace-Federal Reporters Inc. 25 planning that is going'on. 19 7 dor 24 There is no question abo-ut the still-great need for consumer input. Representatives of some of the other 2 health professions, the health professions are 'physicians 3 and nurses only. Dr. Behring, however, again has expressed 4 5 his eagerness to the members of the RMPS here. He plans to 6' answer the criticism that IRMP.has received and that, indeed, 7 the Medical School will assume a different kind of relationship on the RAG and in relationship to the total program. 8 end 17 9 1-0 11 12 13 14 15 16 17 18 19 20 21 22 23 24 Ace-Fedetat Reporteis, Inc. 25 19 8 CP 7149 18 Perhaps the most exciting strenc ,rth to mention is Tlcba 1 2 the regionalization that although begun several years ago 3 has culminated in the nast few months with some very strong 4 effects. Nine area action grouos have been formed and the 5 formulation of active relationships with five existing CIIP agen- 6 cies has been car'ried out. 7 The formulation of two othdr,CHP's are being planned 8 with I P@,'--. I Wnow in a working assisting relationship with them. 1 9 On just a nersonal level I had the opportunity of@,peaking 10 it my home town which is Richmond, which does not.liave any 11 I guess'T)roblem here in terms of into-rests in the project. 12 I was speaking to the Medical SociOty of Wayne County 13 and it invited Liberty County to' this meeting. They did not 14 know my relationship to @MP in any way and in the business 15 agenda of that meeting it was pretty exciting to hear them 16 putting toqeth er, having received a request for Indianapolis 17 for the first time to get involved, to select the people to work 18 with them. 19 To be a part of action' groups. There was certainly 20 to me as I look back and as I read this application, an indi- 21 cation of the little small town out there of 40,1000 that had 22 been asked for the first time to participate in this-project 23 and this nroaram and really their'excitiement that Indian- 24 anolis was looking out to them for them thev felt for the Nce- Federal Reporters, Inc. 25 first time. 19 9 018 So this regionalization p .lan is a most important 2 2 r)lus. Development of effective comprehensive data base 3 which is one of the major concerns of the 1970 site visit which deplored the lack of any really major statistical basis .for 4 nlanning T)riorities and needs, this has been accomplished al- 5 though there are barts of it that need to be looked at out in 6 these scoarate marts of the areas that are being put together. 7 8 The state-wide basis has been accomplished and listed in this. I am sure Dr. Brennan will be happy to s@ that since 9 this is one of his major pushes at the 1970 visit. 10 23 now major data sources have been obtained. 12 These have-been obtained through contra.ct.sources and such there in the state. And certainly there is a working set.to 13 ,-fork with here in looking at the.regional characterization. 14 Their set of objectives, broad objectives that have been put 15 ; together certainly has to be better defined than they are at 16 the nresent time. 17 But they have this bas@4s for the firs@ time to look 18 at it and really to work with it'. The strengthening of the 19 20 program staff has been looked at as one of the major commitments and needs of this program. And already there is a reassignment 21 29 Df responsibilities of some of the people on the program staff. 23 This is a relatively.sma'll staff those of you that are looking at any of the material and whether one considers 24 A,ce -Federal Reporters, Inc. --hat the amount of money at an annualized level for the program 25 20 0 #18 1 staff is around $379,000, this.has been a small staff that reba 3 2 the former coordinator wanted in relationship to running 3 the program. 4 In the projects area, particularly those of a categori- 5 cal continuing educational nature, it is exciting to find 6 that there has been a transfer of many of the larger funded 7 projects to local funds. The coronary pare project that they 8 have-carried for years, their stroke project, these have been 9 taken over'by the other levels and other kinds of. funding. 10 ,lore about this also in the recommendations. As 11 I said you know and I will go back-to that as another major 12 strenth attitudinal desire now to change, it is very strong and. 13 I happen to feel that they do have the capacity to bring this 14 about. 15 What are the @,7eaknesse s? The major weaknesses, 16 Proaram staff, there must be additions to this. There are only 17 -two vacancies, in the list of what has been requested. This 18 must be done in certain areas particularly, planning, evaluation, essentially. They have an educational Dsychologist there, and 19 20 he needs additional staff help.-He needs a model, he needs 21 some help on how really to relate their projects an eva uate them toward program goals. 22 Mr. Smith who I had the privilege of knowing through 23 this project and have had a working relationship in many other 24 Ace-Federal Reporters, Inc. ways who was responsible for allied health and nursing has been 25 20 1 I so succesful in that area and he really got quite a bit going a 4 2 there, he is so successful he has been moved'into another job 3 there and he is going to be head of all the active planning 4 in the regional parts of the program. 5 May 'I say that leaves quite an opening, however, for allied health and nursing there, and they do need staffing. 6 7 ulo in that area, particularly since they have begun to turn 8 the people on there in that area in relationship to this. As 9 a weakness again, from personal background, they have no one 10 yet from there major division of allied medical professions v7hicli is in the medical school at Indiana.wliich is recognized as one 11 of the most broadly developed T)rograms because there is only 12 13 one medical center in that state, has responsibility for all the 14 community college programs throughout the state. 15 Still thev have no voice in any way although some T)rojects in the RAG or in any of the relationships there to the 16 program I do not know for this is an excellent program. They 17 have peonle of national stature in that setting, some of them 18 serving with me on two AMA committees in relationship to allied 19 20 health. A weakness, the revitalization of this RAG, a spefli ng 21 out of responsibilities, certainly a leadership role,-planning 22 23 role, rather than just a reactor role to what has been bubbling un or coming in is essential. Must be a major reassessment of 0 24 Ace -Federal Reporters, Inc. the regions review process. If one looks.and one has pointed'thi 25 202 018 I out in the last two reviews there @-,,d site' P,eba 5 2 visits. 3 Many members of the of the program 4 have made all of the major decision-., have a 5 very poor history of turning anyth'..@@ indications 6 are that this review process ..t and already 7 in the N-7orks, some of the T)lanninc; c must be done. 8 minority representation in the t@'. .,.ee are no 9 minority professionals yet on t],@ 10 Two professionals are their 11 projects and three minority peop"t., It is an 12 inadequate representation still ovement over 13 two years ago. They still have i). However, 1.1 had and 14 in the oroject orientation, the 15 I remember quite well, visits wi physicians 16 who was heading up.one of the jects, neigh- 17 borhood health projects in India7@.. ave some 18 good projects going in this are-a. 19 Of approximately 15 piErij,@ in this -program only three old ones are.r,-,@',, @inuation. 20 21 Of these the neighborhood health c., a tracti tionet3 22 are two of these. There are eel are ready'to ao. These are, some of from the 23 1 categorical. 24 Ace-Federal Reporters, Inc. Thev have some health relationship 25 20 3 to their newer goals. I will.quickly make a recommendation 6 2 to get this on the table then 'I certainly want Bill and 3 particularly Al., who has been on site visit and Bill who has 4 been there recently to respond to this, but let's get the 5 recommendation out in relationship to this. They are currently 6 funded in this region at $1 million 121,000. They have re- 7 quested a million five hundred-thousan!l in round numbers. 8 The staff having looked at this total plan have re-.. 9 commended an increase of only around $80,000 to Trillion 10 200,000. And-the breakdown for this. As I said, they are in 11 -- their major needs as I see their projects in this core 12 staff so f am recommending or approving actually the recommen- 13 dation made by the RPT-1 review staff here of approximateIly 14 $500FOOO of this amount for staff.. 15 This will give them increases in salarv. This will 16 provide for the new director. This will add some to their 17 evaluation staff. It will give them an opportunity to really staff up there where they are really going,to need it in 19 staff that has been held certainly to the bare bones. In 20 relationship to one of their other major needs, and that is 21 to continue with the projects as they relate to the regi6nali- 22 zation and into these areas, they have requested $500,000 23 for this. 24 In contractual services. The recommendation of Oice-Federal Reporters, Inc. 25 the review staff here was that this be cut to approximately 20 4 #18 1 $300FOOO. With this they should indeed be able to go on further a 7 2 with their feasibility studies, their expansion of subregional 3 T)lanning, and staffing in relationship'to the regional-program. 4 They have made a request for approximately $600,000 5 for continuation projects and for new projects.The recommendatit 6 is breaking this down to $200,000 each, $200,000 for contin- 7 uation and $200,000 for new projects. Adding this $500,$300 8 two $200 ones, we come up with a total of $1 million 200,000. 9 1,7hat this does give this program, an opportunity to do with 10 even this small increase of $80,000, which is recommended, 11 is to -- they have turned the corner and made the decision 12 to change. 13 They have 6 long way to go to make this the kind 14 of nrogram that we really can believe is ready for a triennial 15 review and I believe with discussion with Bill that any recorm- 16 endation that we make with the changes and things that they 17 need to do, rather than insist or even ask for a trieenial 18 review next year, that they be held at this level for two 19 years, during this period of transition. 20 They have turned the corner,-they have got a lot 21 of plans going, things thev have to do during this period of time.' Getting a new director although I am sure they ate 22 23 going to be moving right Ahead with this, with the Associate Dean of the Medical School that is working with them but I 24 Ace-Fedeial Reportefs, Inc. 25 think thev need a period of time and we are not increasing the amount in the recommendation more than this $80,000. 20 5 149 That is my recommendation I put on the board. 2 DP,. SCI-TT4IDT: Okay..I am the secondary reviewer @a 1 3 and'I will trv to just bring out the issues as I see them. 4 At the time of the site visit last year there was just a god 5 awful program. They got P's straight across the board and it is 6 a nrogram that if substantive changes had not occurred one would 7 be considering whether to just stop all funding and just 8 declare the thing defunct and tell them to start over gain. 9 Problems with ineffective coordinator who had 10 a small staff they ran tightly'and the staff really was not 11' doing the riaht sort of things. They had the worst kind of 12 possible relationship with the medical school. The medical 13 school completely dominated it. The majority of people on the 14 executive committee than ran the program were from the medical 15 school. 16 The principal person involved', George Lucameyer, 17 Assodiate Dean of the School, did not and does not understand 18 regional medical programs. For reasons easy to understand 19 the medical school is scared to death of the Indiana Medical 20 Society because their legislative support comes from the Indiana 21 '-Iedidal Society. Indiana Medical Society did not like the 22 coordinator or regional medical program. 23 The medical school dictated exactly what P.MP could 24 a.nd could not do. The coordinator's primary allegiance was to ti,c Ace - Federal Reporters, Inc. 25 medical school. I 20 6 ITe said if T)ush came to shove his medical school 2 2 appointment was far more'important than anvthiiig having to 3 do with P-MP. The Exedutive Committee was not functioning well, 4 there was no data, no objectives, no.priorities, there was 5 no nrograms, there was no plan, there was some projects. There 6 was no subregional effort. And it was just terrible. 7 The site visit two years ago told them this, they 8got real mad, said it was an unfair site visit and they just 9stayed mad for a whole year. And I walked into the biggest 10 trap I have ever seen set bv a region that was pulling site 11 visitors up against everybody and the coordinator took a day to realize that we had been set up. 12 And we left essentially escorted to the state line 13 by the highway Datrol. And I doubled back to one ray of hope 14 who was a bright and new lady of' the regional advisory group 15 and we just did suggest that the program leadership needed 16 to be changed, the medical school put off at arm's length. 17 We had to get the people in the school who did not 18 19 know what Pd4P was about out of the picture. And so on. One 20 member of my institution is for'liaison purposes a member of 21 the Indiana regional advisory group..Done Casely. And lie would 22 come back from Indiana RAG meetings just cackling with glee 23 and hand me the minutes of the. meeting which took apart one 24 by one the site visitors and challenged the integrity and so kce- Federal Reporters, Inc. 25 on and so on. 207 419 1 But largely through Haver and some other people, a 3 2 and through the supportive. staff I would like to point out 3 to the review committee the importance'of staff support and 4 consistency of staff support in taking to the regions the 5 recommendations of the review committee and sticking by them 6 and really accurately reflecting and confirming.and supporting 7 review committee in this. 8 They came in to see Harold, they probably came in to 9 see Henrv Kissinqer, I don't know who all they came in to see 10 but they got the same message each time and there was a revo- 11 lution. The coordinator resigned and RAG decided he did not 12 resign quick enough and threi-i him out. 13 Baring,.I think it is a cop out. Medical school 14 is suddenly saying we did not know. Well, you know it was IM'OOSSI 15 'ble that they couldn't have known what was going on 16 because they were the program. They just were not paying 17 attention, And I really think that they did know but they are 18 having a change of heart and they are withdrawing. The program is doing somethings that I think really 19 20 are terribly important and if we are going to have a program 21 there, merit the supoort of the RI,4PS -- they do have a data basis. 'They have new leadership there inorganizing the staff, 22 23 recruiting a new staff. They have,a different relationship to the school. 24 Ace-Federal Reporters, Inc. 25 They have a very strong and excellent RAG chairman who seems 2 0 8 #19 1 to have taken over. They have the new goals, priorities, (,-@a 4 and plans. There is an excellent exercise in subregionali- 2 3 zation. They have phased out projects'and they are phasing 4 out projects. 5 They are restructuring their committee structure 6 and they have for the first-time a really pretty.good relation- 7 ship with the Indiana State liedical Society. Their area, groups 8 are very important, the@ are finally recognizing the fact 9 that their.CIIPB agencies are around and they are beginning to 16 internhase with fantastic amounts of dollars that poured into 11 -Indianapolis, millions into OEO and M4P just said man, we have 12 to stay away from that power an6 that influence and all those 13 dollars and so on, because the medical school said we have got 14 to keep a low profile. 15 They are beginning to-interphase with the things 16 that are going on in the real world about them. I think that 17 I will support the idea of funding them at 1.2. I think they 18 need this money to do the things that they are doing. I don't know if they are falling into the trap of continuing the 19 20 old activities. The ones they are continuing seem to be in the rTght 21 direction. I think there must be absolutely strong word from 22 23 here that what they are to do with these funds is to build their staff, to continue the subregionaliz.ation efforts and 24 Ace - Federal Reporters, Inc. 25 put money into that, to use their data base to get specific 209 f- 1 9 I rogran plan, to get a specifi(:4 @-in conjunction 'Pcba 5 2 @-i'lth the agencies and subreq'Lc,- ihere to evolve 3 they are going. 4 That is the third tl-i--': :."iiue the involvement 5 with Indianapolis OEO and all ltiplicity of 6 programs that are active in tli.. which range 7 from a very rural thing in tl-.@- (on up. Finally to 8 keep-that damn medical school headquarters 9 and let them be the fiscal ag(-.@ @@.s terribly op- .i -.eek the recommen- 10 res@ive school out of the T)ic',-- 11' dation then, feeling that if tl'. .,od coordinator, 12 I think Baring will bring thi.@-,. and'he has gotten 13 the word. 14 If they will get a c@@. will continue 15 what he is doing. whether th-@- .:ith a triennial neXt year or not I am not surc, @@.ould be good to 16 give them the business of you year's support,, 17 18 you can have another year's sii-,-; ,-a triennial if you need it. 19 We will look at you visit in a year 20 re doing and 21 or staff site visit in.a year i., a phase. 22 offer staff support while they Discussion? 23 0 24 DR. SCITLERIS: Would @@--..ostion seconded kce- Federal Reporters, Inc. bv a member of the committee @-@@--he chairman? 25 210 @ig DP. SCTIIIIDT: Let's see. Yes, somebody get me off 2 t he hook. 3 DR. SCHLERIS: I second the motion. 4 DR. SCIIMIDT: All right, thank you. John? 5 DR. KPALEWSKI: We are moving this then for two. 6 years instead of the one. 7 DR. SCIRIIDT: That is right,.at the level funding. 8 And.i4ith, you know, if they can dome in with a whiz bang 9 triennial next year, great, but if they can't, let them have 1.0 the feeling theyqot a little -Eime'. 11 DR. K-RALEWSJ'\I: Thank ybu4' 12 DR. SCILr4IDT: Other comments or questions? -It is 13 an example of a region that was turned around. Florida was 14 another one I can think of and so on. I think the main things 15 that have turned it around were the site visitors, who had the 16 strong support of staff who said yes, they are right you know, 17 quit looking for an out. 18 All right, I will call the question then. All in 19 favor please say ave. Opposed, no? 20 Last but not least then it is Memphis. And the 21 primary reviewer is Dr..Ellis. DR. ELLIS: Thank you, Mr. Chairman. I have'been told 22 23 that I did not have to many minutes to do this by some of my. 24 friends and I am going to try to be brief so that they won't Nce- Federal Reporters, Inc. 25 e unhappy with me this time. 211 fl9 I Memphis is a very interesting region and I would a 7 2 just like to mention before we go into the discussion of the 3 visits something of the background and demographic information 4 because this is a very large region and it is culturally diver- 5 sified. 6 The region actuallv consists of parts of five 7 states, and it is made up really of what is traditionally 8 a trade area. Also the area that is based on hospital care 9 that is given to people in this 75 county area. 21 of the 10 counties are in Tennessee, West Tennessee. 16 in Arkansas. II. 27 in P-lississipni. 6 in Missouri and five in Kentucky. And yot 12 know that in this it is extremely difficult. There is a population of two and a half million, 1 3 14 that is the 1970. It is interesting also that there is an 15 essentially rural area, except for 4emphis which has abo ut 16 800,000 people, 600,000 people, and then the next largest 17 city in this whole area after that is Jackson, Tennessee, with 18 50,000 people. 19 In terms of the racial composition there are 31 percent roughly a third black,. A few Orientals and the rest 20 a also inter 21 re white. Many of these are poor. It is esting to note that in the Kentucky section there are quite-a few 22 old oeople, the largest number of people over 65 in Kentucky. 23 With reference to the racial matter while I am here 24 Ace-Federal Reporters, Inc. 25 I will say that' this 31 percent does not reflect the situation 212 19 in some of the counties. In Tunica County, Mississippi, there 0 'Peba 8 2 are 73 nercent of the population is black. While in the 3 Ozark area you will have about the same kind of thing with 4 reference to white people. And nine of the 27 counties in the 5 Mississippi subregion having populations of more than fifty 6 percent are black'. 7 The infant mortality.rate, I will mention this because 8 it is very significant and will have a lot to do perhaps with 9 the long range programs which can bring about institutional 10 change. And.while we have liere.an infant mortality rate this 11 is 28.9, comnared for -- to this region and this is compared 12 to the national average in 1970 which is'21.7, it is lower than 13 that now. 14 The thing we want to point out, that in Mississippi, 15 in the subregions in two counties the infant mortality rate 16 was more than twice the national average. When you see an 17 Infant mortality rate of 28 and you recognize that there are 18 counties with more than half, I.mean twice-as much the national 19 average, you really know you have a very, very serious problem 20 and oftentimes this is overlooked. 2 1 Now Memphis region did not-have a site visit. This 22 time. The last, well, I might just tell you in passing that 23 this region became operational. in'1967, I mean started its 24 planning in 196G and 1967, became 'Operation in 1969, and in kce-Federat Repoiters, Inc. 25 1971 had site visit in response to the triennial application. 213 4fl9 1 1 will just go briefly through what the site Tleba 9 2visitors had to say. The main -- I will point out the main 3orol3lems. And the main problems that they found in the'site 4visit and that was really known before the site visit was made, 5was that the RAG, the Advisory Group of a health council, and 6that this advisory group consisted of about 156 people, and most 7of these people were in the priors class. And this was a 8purely untenable thing to have the -- this committee and 9council combined in this way so that the coordinator of the I 0n really was not in a position to carry out the program 11 in the way that was in keeping with-the expectations of the 12 regional medical program. 13 Also the administrator, the coordinator of the 14 program, was thought by everybody to be greatly overextended. 15 And he, Dr. Culverson, was the only medical person in the 16 program. And he did not have a good manager under him to carry 17 out the administration of it, the administrative aspects of 18 the program. 19 So it was felt that bdcausb of the conditions 20 existing in the regional advisory group and because of the 21 lack'of proper supportive staff, that the -- a developmental 22 grant could not be given. Now there was -- with some'definite 23 strengths noted at that time. 24 These concerned the fact that the University of Ace-Federal Reporters, Inc. 25 Tennessee had given the program the authority. While the 214 #191 regional medical nrogram grew under-the guardianship of the a 10 2 university, it really changed, after the visit in 1969, and 3 made it possible for the PAG to develop on its 'own. 4 The excellent thing about the program seen in 1971 5 was the fact that five CHP, five agen-cies and probably five 6 or six B agencies worked very closQly with the R14P program. It 7' was described as being a really excellent, because PIIP provided 8 staff to help the B agencies with their work, and also worked 9 with them in planning and all kinds of outreach activities in 10 the community. The staff really developed well. And in the community 12 they were described as excellent brokers for the PD4P program and also they were not just trying to sell programs but t'nr-,y 13 14 were reallv architects, too, after they got over the operational 15 phase in the program. I said that the coordinator over extended 16 himself but the people the sit e visitors felt that the 17 program had potential for being'one of the best programs. 18 And while they did not fund, I mean suggest a develop- 19 mental component, they did grant triennial status as a result of the visit. flow with the suggestion that there be a complete- 20 overhauling of the @G and the administrative structure and that 21 22 some effort be made to correct certain things. end - 23 24 Ace-Federal Reporters, Inc. 25 215 #20 arl I Now I have said before that this is a very 2 difficult region to describe'with so many people who are 3 very poor. Black and white. But one of the things that was 4 pointed out was that there were -- there was only one black 5 person, female, on the staff. And also there was very little 6 input, opportunity for input from the people being served. 7 Now I will go right on quickly to say that for a 8 year after this visit, after this 1971 visit -- and there's 9 nobody from the advisory committee-who made tha @ isit, we 10 did have members of the council who were on that.visit, these 11 recommendations were made, and I would think, I said I didn't 12 make it,'but I would think from reading-the records that Dr. 13 Culverson made everyeffort to begin to do something toward 14 correcting the things that have@been pointed out. 15 The -- there was a site visit made in the s @ er 16 by staff-to take a look at what the situation was at the 17 present time. And I would like to say that Mts.Kyttle 18 knows this situation very well.and can add to it after I 19 have just said a few words. 20 It seems now that the RAG has been reconstituted. 21 I didn't tell you that that 156 member group has executive 22 committee of about 45 members. And it was just absolutely 23 impossible to get anything done'that they didn't themselves 24 want because they met every month, while the @G met only Ace-Fedefal Reportefs, Inc. 25 once a year, I guess. Twice. Once or twice a year. 2 16 ar2 I Now the situation has changed quite a bit. The 2 RAG consists of 36 members. They are well chosen from the 3 geographic areas'. They are old and young, reflect the' racial 4 composition, and women. I think that there are nine blacks 5 and six women oh this new RAG. And it is a freestanding 6 group, not encumbered by the old pattern. Dr.-Culverson has 7 moved immediately to see that guidelines have been developed, 8 bylaws, that is, and also that three committees, policy -- 9 the planning committee, and the policy and review committee, 10 and also reference committees. 11 Now, these reference committees are made up 12 primarily of the people who had to do with categorical programs. 13 There has been also a change in focus. The program activity 14 actually is looking at the underserved. In the subregional 15 areas where, like in the crowde d areas of Memphis and in the 16 rural areas there is an attempt to extend servi.ces to the 17 people through cardiac clinics. 18 Also there is a very important high risk infant 19 component which is regional. Ithink this is funded jointly 20 with the other agencies, too, isn't it7 Yes, it has just f 21 started. Also family planting services. It is hard in this brief time to tell you ever thing 22 y 23 that's been done here. I think it is extremely significant 24 that the regional program has.applied staff to other agencies Ace -Federal Reporters, Inc. 25 in order for them to get very much needed services in the 217 ar3 family planning area and also to do something about getting 2 ambulatory services to these-greatly deprived areas that they 3 are working to develop Lee County cooperative clinic in 4 Arkansas and so on. 5 'I said before that the University of Tennessee has been-supportive, has helped in making decisions, but has 6 .7 not forced its own views. And I think that the management 8 aspects of the program have not 'been reviewed yet. Right? MRS. KYTTLE: That's correct. 9 PR. ELLIS: But it is expected they will be. I 10 mention this because the visitors in 1971 talked about the 12 kinds of-positions which should be filled and talked specifically to the point of not having the staff expenditures 1 3 be -- grow any larger until some of the operational aspects 14 could be shored up. 15 I'believe there was a recommendation that, by the 16 17 staff, though, that because of the fact that the coordinator is greatly overextended, that he be given an-assistant administrate .18 to look at the management affairs particularly. 19 We have said there is no problem with assessing 20 21 resources and.so on. Now the evaluation component is not strong because of the fact that, well, they can't work too 22 well because one of the weaknesses that still exists in the 23 programs, there is not a clear statement,of the objectives, 24 Ace-Federal Reporters, Inc. goals and priorities. They have stated some broad goals, 25 218 ar4 I very broad, to make health care more accessible and to make it 2 more available, and to compare the health costs, lower the 3 health costs where possible in doing these two things. 4 But there are no clearly-stated objectives as to 5 how broad goals can be accomplished; consequently it is hard 6 to'evaluate the-program because most everything can fit into what has been stated as objectives. 7 I think the staff,.khowing the whole story, and 8 unfortunately I have never beeninto this section at all, I 9 just know what people have told me about certain things, I 10 feel that the direction in which this program is moving is very, very excellent indeed. And the staff feels that the changes 12 that had to be made as recommended by the site visitors in 13 1971 have been made in the main. 14 15 Mrs. Kyttle is here, and I would like her to add a few things because she has visited the area twice, 16 rather recently, and has talked with the coordinator and the 17 other people. @18 DR. SCHMIDT: Okay,.would you make any comment 19 20 that you would? 21 MRS. KYTTLE: Dr. Hess has to leave at fourish, so perhaps he would like to make his comments now. 22 23 DR. SCHMIDT: Okay, Joe? DR. HESS: One certainly is at a disadvantage in 24 Ace -Federal Reporters, Inc. 25 trying to evaluate the region from what appears on paper alone. 219 ar5 I And I must say when I first started going through this and 2 looking carefully at what was there, the first question that 3 came to my mind'is how with all these problems with the 4 RAG and what-not did this region ever achieve triennial status. 5 And, but, however, in talking with Mrs. Kyttle, I gather that 6 what is actually going on down there is probably much better 7 than what was reflected in the paper and so that one has to 8 somewhat separate the activities that are being carried 9 out from the -- what you might call in a general way the 10 organizational structures of the region. 11 But I would like to point out a few things that 12 are of some concern to me in looking at this total picture and. 13 trying to render a judgment concerning the funding request. 14 One particular feature of this region we need to 15 keep in mind is that it overlaps with three or four other MIPs in terms of geographical area and population, so that 16 17 there is the potential for. funding coming into certain areas 18 from more than one source. The problems of coordination have been worked out 19 fairly well and a couple of these others remain to be 20 resolved. 21 22 It is alluded to in.the presentation, the RAG has 23 recently been redefined from the original 150 some odd person group to 36 person group and the bylaws have been approved now. 24 Ace-Federal Reporters, Inc. 25 But a lot of the further reorganization in terms of factories, 220 ar6 I so on, remains to be done, and so that at this point it is 2 unknown to us exactly how that is going to shape up. 3 The new bylaws do spell out certain subcommittees, 4 but there is a broad category of -- appointive committees 5 which we have no information on what is going to happen there. 6 So that the new RAG is one question mark. 7 Another question that came to mind was the size 8 of the staff and the way the staff is organized. In the 9 submitted.budget for this upcoming year, there is a place 10 for 59 core staff situations, 54 of them full time, and 11 there are 13 vacancies shown on the staff budget list. 12 I haven't taken the time to go through and enumerate other 13 core staffs, but this certainly seems to be close to a 14 record for number of staff people in relationship to the size 15 of the program and fundi ng and'so forth. So that is another 16 question. 17 And in looking at what one can tell from the 18 internal organization of staff, the data.that is in the 19 application, I have some question about the tightness and adequacy of internal organization of.-staff. As mentioned, 20 there a3n goals and some related objectives, but the prior'l'ti es 21 are statements which, as one looks at them, may or may not be 22 23 related to goals, exactly how they fit into their system of logic is not clear to-me from the application. 24 Ace-Federal Reporters, Inc In summary, Iperhaps would have to say that I 25 2 2 1 ar7 am taking on faith what I have learned from Mrs. Kyttle's comments to me informally', that they are doin.g many good 2 3 things. Somd of these are enumerated in their progress report. 4 But I do have some qiestions about it, what is happening in 5 terms of the program management system, including the RAG and core staff. 6 The new projects which are proposed, there are two 7 8 of these which stand out in my mind as most consistent with 9 some of the things stated in their goals and objectives. One is project 36,.extension of services, neighbor- 10 hood health centers,and the other, 42 12 13 14 15 16 17 18 19 20 21 22 23 24 Ace-Federal Reporters, Inc. 25 CR 7149 22 2 21 eak 1 I DR. SCHMIDT: Let's continue on and get a data 2 base, ask Mrs. Kyttle if there is anything she wants to say. 3 MRS. KYTTLE: The Committee work 4 DR. SCHMIDT: Could you put the mike right in front 5 of you. 6 MRS. KYTTLE: The Committee work and task force 7 structure is not doomed. It was done.so recently that it could 8 not get into this document. The, staffing pattern is a proposed 9 staffing pattern. It does-not list.vacancies. @se vacancies 10 are new positions and that is what we intend to have. There is 11 only one vacancy in existing positions and that is the vacancy 12 that Dr. McCall left quite a while ago.an.d it has never been filled and it separately needs to be filled but to say that 13 there are 56 positions in this regional medical program is not 14 quite right. There are 44. One is vacant. 15 Ihave attended the three meetings of the new RAG. 16 It has kept-me down there a lot but I thought if this is the new 17 18 blood here, then that is where.,the action will be. It wasn't ig a redefinition of the regional advisory group. It was creating 20 a new one and it did break off from its parent, which was the 14-county CHP-"B" to the Memphis-Shelby area MMCC, just about 21 22 everything. It was also regional medical programs. -And It was not easy to get away from-thdt parent and still have good 23 parental ties. And Drs. Culbertso n and Cannon have done it, and 24 Ace-Federal Reporters, Inc. 25 in my view done,it.very well. 22 3 eak 2 I Dr. Johnson at UT was helpful in getting it done. 2 The old regional advisory grou p was representative of only those 3 14 counties, and that is what raised the legality of the regiona 4 advisory group and that was the single factor that disqualified 5 them for developmental component funding when they were placed 6 on triennial status. 7 The big funding issue or one of the big funding issu@ 8I believe, is the middle contract under core. And when staff 9met to try to identify issues, that-was one that @me up I 10 immediately., Essentially Memphis is pursuing two things, its 11 own concept pf area health education centers which it calls 12 model learning centers which it thinks.shbuld'be in the hospital 13 and then development of the involvement from that rather-than 14 developing the consortium and including the hospital. 15 They competed unsuccessfully for health services 16 money last June. Then the,second large component of it is, 17 Memphis submitted AEMS application for supplemental funding, .18 received one year planning funds to sharpen a data base which if 19 Memphis has anything it has a sharp data base. 20 Coming from MMCC, it has received as the collector 21 of the data since 1966, so Memphis is writing back saying b y 22 January 1, which is their next year, we will have sharpened our 23 data base and they are reapplying for the operational dollars thE, 24 applied for before for emergency medical services and that Ace-Federal Reporters, Inc. 25 ties into something I said before. Their task forces have been 22 4 eak 3 established 'and one of them is a task force for emergency medica services. And at a metting of the regi onal advisory council las-- 2 week, I heard Dr.-Cole who is the new RAG Chairman and Dr. 3 Culbertson feeling this group out on beginning to think now abou- 4 5 priorities on funding levels that might not approach the .1 3.2 that they asked for. 6 And where -- beginning to think now about where the 7 emphasis would be. And I heard this regional advisory council 8 say that if we have to make choices under that million dollar 9 contract category,;.then the choice will be emergency medical 10 services. 11 12 The whole state of Tennessee, Dr. Tur.bshen and 13 Dr. Culbertson have worked together quite sometime on the state of Tennessee's program. Dr. Culbertson has all buy revived 14 15 the Mississippi Emergency Medical Plan that was almost in disarray. No work yet is underway with the Arkansas Department 16 of Transportation, hos ital association, traditional linkages. 17 p But the State of Tennessee and State of Mississippi -- a scale 18 - of 1 to 5 are about 3 on emergency medical services and they are 19 so deep into it that I don't know, it would be difficult to turn' 20 back, 21 DR. SCHLERIS: A few questions. A few questions 22 first,then perhaps a comment. If I read this correctly, their 23 RAG met Once last year, is that correct? 24 Ace - Federal Reporters, Inc. MRS. KYTTLE: That is traditional with the old MMCC 25 225 eak 4 I which was their RAG at the time this'application,was prepared. 2 That is the old RAG. 3 DR! SCHLERIS: Right and emergency health services 4 met accordingly at the time of the application, zero? 5 MRS. KYTTLE: That is the-emerg6ncy medical group 6 out of the old RAG. That is MMCC. You are right. 7' DR. SCHMIDT: Wait a minute. 8 DR. SCHLERIS: I am trying to get an indication 9 of activity. 10 DR. SCHMIDT: Right but the RAG now, recently has II- met how many times, the new RAG. 12 MRS. KYTTLE: The new council is three months old 13 and it has met three times. 14 DR. SCHMIDT: -Right, okay, so that 15 DR. SCHLERIS: Well, this is important because 16 I think in terms of developmental component and reaching deci- 17 sions according to priority, accotding'to what would be supporte,. 18 it is of interest to see what their past record is for the past.- year and not just for the past three months. 19 20 DR. KYTTLE: Dr. Schleris, it is not the same group. DR. SCHMIDT: Do you see they have constituted reall, 21 for the first time a regional advisory group three months ago. 22 DR. SCHLERIS: Well, you.see my dilemma. I know 23 this. I try to count the number too of RAG, and the old group, 24 Ace-Federal Reporters, Inc. 25 and it is their application we are looking at. And what you area 226 eak 5 I doing is supplying us with additional and very important new 2 data. I appreciate it but at the s.ame-time, it is difficult 3 to get an objective judgment on this. In other words, the new 4 group which is how many now, 36, but the program here was put 5 together by the old group, isn't that'right and the report we 6 are looking at in the application is from the old group, is 7 that correct? 8 MRS. KYTTLE: Dr. Schleris, you can appreciate that 9 a regional advisory group of 151 members that had R&D's 10 experimental contract, CHP and,RMP, didn't give a lot of time 11 and this was quite a bit of the Memphis regional medical 12 programs application but it nevertheless had to go through 13 a regional advisory group that had EMS committee that never met. 14 DR. SCHLERIS:' I am not trying to put a qualitative 15 judgment on it. I am just trying to get an understanding from 16 this document. Looking at some of the'specific proposals, 17 1 will ask out of curiousity about the proposal to improve 18 death statistics by teaching, individuals, examinations, post- 19 mortem, where they don't have legal rights to do autopsy and so 20 on. I wonder if you have any more information on what appears 21 to be a-very intrigu ing and difficult proposal, how that cleared 22 RAG and what priority. Did you see that.. It is'project 23 number 33. 24 MRS. KYTTLE: No, I am afraid -- I can tell you that Ace-Federal Reporters, Inc. it must have cleared RAG with a priority that was at least 25 eak 6 227 I in the first five because it was one that Memphis chose 2 to drag up from an approved but unfunded when they were extended 3 and had money to'activate, they activated that one but the tech- 4 nical aspects of it I don't know. 5 DR. SCHLERIS: I don't know what communication 6 you got as far as emergency medical services @as,concerned. 7 They haveapplied for let's see, $1,100,000, were given 8 $80,000 for the planning. It goes to more than just 9 data base,.I assure you. I don't know the details but, perhaps 10 Dr. Rose does. This was one of the requests for larger amount 11 of funding. It was felt that they -for many reasons weren't at 12 that stage. It wasn't just getting numbers of cases. There was, 13 a lot of homework that had to be done. Can You comment on 14 that, Dr. Rose? 15 DR. ROSE: Yes, in fact a large part of the concern 16 of the reviewers related to how this Memphis or .suburban, 17 if you will, EMS-type activity was going to relate to what else 18 was going on in Arkansas.and Mississippi and in the rest of that particular state. In speaking with Loraine subsequently on 19 several occasions about that, I.tend to believe that they really 20 did have considerable more information than was included in the 21 application which, of course, the reviewers had to act on.' 22 DR. SCHMIDT: Okay then. John? 23 DR. KRALEWSKI: I am not sure we have a motion on 24 Ace-Federal Reporters, Inc. 25 the board here or not. 22 8 eak 7 I DR. SCHMIDT: No, we are going to return to Dr. 2 Ellis for proposal. 3 DR. KRALEWSKI: Okay, I will hold up then. 4 DR. ELLIS: The application which is before us 5requested roughly 3.267 for this year'five. The staff 6reviewing this made the recommendation that the amount to be 7granted be 2.25, and that this would inlcude $162,700 for a 8developmental component. Also, in talking about the supplements 9request that we have been talking about, staff suggested that 1.0 $237,000 be granted to support'selected new activities, includin] 11 the expansion of component number 36. That is greatly strength- 12 ening the neighborhood centers and giving them something in orde- 13 to really build the program and extend it. And then $225,000 14 to pursue selected activities under the contract request, this 15 being primarily to be used for EMS. I would move that this, 16 these recommendations be accepted. DR. SCHMIDT: Is the re a second? 17 DR. HILTON: Second. 18 DR. SCHMIDT: All right. That is a second so 19 the motion can be discussed. 20 John and then Joe. 21 22 DR. KRALEWSKI: I am inclined.to believe that in viei7 Iof the organizational, some of the organizational concerns 23 24 that have been expressed here even though they are changing, Ace-Federal Reporters, Inc. there is a new direction and I know you have new information 25 229 eak 8 I you really believe this organization is.go.ing to really do it. 2 But we are giving them substantial.developmental component 3 plus a fair amount of contract money and that is placing 4 a fair amount of.bucks in their organization without many 5 restrictions on it and that makes me 'a little bit nervous. 61 DR. HESS: I would-like-to make a substitute 7 motion. 8 DR. SCHMIDT: All right, before I accept that, I 9 will let Dr. Ellis respond. DR. ELLIS: It is my understanding that the 10 monies which they have now are very tightly budgeted and that 11 12 there would be very little room for growth and expansion in 13 these new directions. And so it seems that a developmental 14 component of some magnitude might be very desirable in this 15 instance. In order to give the new director, I mean he 16 is not a new director ut is almost like a new director becalm 17 he does not have all of those 156 people and all of the problems 18 with no committees or anything to work with him. That has been eliminated and I think he does need a chance to show how he 19 e2l can expand th e program. 20 21 22 23 24 Ace-Federal Reporters, Inc. 25 CR 7149 230 22 kar 11 MRS. KYTTLE: Dr. Kralewski, the original structure 2 complication arose not so'much because it wasn't working, Memphi! 3 made it work. And it very quietly went about a very good 4 program. It was the legality that raised the issue about the 5 CHPBL MNICC, with a mandate to serve 14 counties being the decis:( 6 making body that'was serving 75. 7 I would not want you to think that it was a compli- 8 cated, unworkable structure. It.'was a complicated, of doubtful 9 legality, structure. 10 DR. SCHLERIS: It only met once that year, didn't it' 11 MRS. KYTTLE: The full body traditionally met twice, 12 that year'it met once. The real decision making was in the 13 board of trustees,, 45 members, 'still"serving 14.counties. 14 DR. SCHMIDT: Let's see, do you have a comment -- 15 in order here we have someone who wants to make a substitute 16 motion. If y ou have a comment on what is being discussed now, 17 please speak. 18 DR. ELLIS: I do. I. wouldn't think'a program, regari. 19 less of legality, that only serves 14 communities when it is 20 supposed to serve 75, is really functioning and functioning 21 properly. And neither will I think-that the guidelines, which 22 they were using in terms of developing the new programs, were 23 appropriate to get services to the underserved, which is part 24 of the thing we are talking about'. @ce-Federal Reporters, Inc. 25 But I do think that this legality thing, was a point 2 31 kar 21 and I wanted to ask the question,.did the-regional council rule 2 this out of order legally? 1 know,it was requested that he 3 giv'e.a ruling. 4 MRS. KYTTLE: We thought we might work with the regicr 5 in obviating that necessity and they got a new council and so 6 we didn't have to seek an opinion.' 7 MISS KERR: I would like to make a comment, but I 8 would be willing to wait until after the substitute motion and 9 action is taken on that. 1.0 DR. SCHMIDT: Joe, the'floor is yours. 11 DR. HESS: Perhaps somebody might just make some notES 12 of this other paper there. I would like to suggest for program 13 staff, eight hundred thousand. For contract, two hundred thousen 14 and I am assuming here that some planning has gone on and that 15 as ar as this emergency medical service is concerned, I gather 16 that that owuld be their priority use. 17 It is somehow, some proven need in the community. 18 That developmental component of.a hundred thousand included, an@ 19 projects of nine hundred.thousand. To provide money to accomplis 20 Project No. 36, which I gather is a key project in their strategy 21 and through re-examining some of. their currently funded projects, 22 that they should be able to find money to-fund the other projects 23 or two in their new list, which is compatible with the new so directions in which they say they are going. 24 P,ce- Federal Reporters, Inc. That adds up to a round figure of two million dollar 25 2 32 kar 31 DR. SCHMIDT: Is there a second for the substitute 2 motion? 3 MRS. F'LOOD: Second. 4 DR. SCHMIDT: All right, Mrs. Flood's second. We 5 are now discussing a two million dollar funding level. 6 Miss Kerr? 7 MISS KERR: ilhile it is late, it is not so late and 8 I am not so tired, but I feel I have to speak my piece. In view 9 of decisions made earlier by comparison and in view of ingrodien 10 of a viable potentially exciting program, I cannot, in all con- 11 s,ciousness, support either one'of-these recommendations at this 12 point. 13 DR. SCHMIDT: You say either one? 14 MISS KERR: No. 15 DR. SCHMIDT: Lorraine? 16 MRS. KYTTLE: Miss Kerr this is an anniversary withi- 17 a triennium and it comes to committee without any site visit 18 report that would give you the flavor of some of the exciting 19 things that this region is doin4. 20 But it is a quietly efficient region. It has some 21 very-exciting things ongoing and even though it is late, I don't 22 know if you would have the time.to hear about them. Can I just 23 tell you about one? Memphis has'two multi-pliase screening projects ongoing 24 Ace -Federal Reporters, Inc. 25 and they just didn't happen. one is a mobile, white northeaster 2 3 3 kar 41 Mississippi, two and a half years. ago. 2 MISS KERR: Was this thrust of RMPS? 3 MRS. KYTTLE: Two and a half years ago it was startec 4 It is just widening up. The companion one with an intercity 5 Memphis, predominantly black stationary multi-basic screening. 6 In anticipation of this year, they'will have completed the 7 targeted screening. The multi-phasing screening activities acrcE 8 the 'country have gotten together-and they met here in Washingto 9 to develop a protocol to evaluate what we have done and nine 1.0 were selected, axid both-6f Memphis' were. 11 Memphis' multi-p4asic screening have screened more 12 people than all the others combined. They are going to be a 13 pivot for a contract to evaluate what we have done. And they 14 -have just gone about it very quietly. 15 Inter-mountain is in there, Ohio vallies is in there 16 and so is Memphis'. And I just if you would like to listen 17 to some of the things that they have done like that, there is 18 more excitement there, but this is not.that kind of application. 19 It is not a triennial. It doesn't have a site visit report and 20 I think it is at a disadvantage here. 21 DR. SCHMIDT.: Mrs. Flood? 22 MRS. FLOOD: Well, again, recognizing the'disadvantage 23 of trying to evaluate on paper, looking at the print-outs for 24 the components sort of descriptor devisions that are provided Ace-Fedefal Reporters, Inc. 25 in the print-out for the staff and of regional functions done 2 34 kar 5 1 under the previous contractual fundings we have talked in the 2 history of the region of the tremendous impact of the 21 and 3 under, of the minority groups, yet if you study the print-outs, 4 which is not a very good way to evaluate, but there is no emphae 5 utilized from the central core staff activities to address 6 these high priority needs of these,particular types of populatic 7 and as Dr. Schleris pointed out,'our point of reference has to 8 be.the track record and, again,.I will realize staff is at a 9 disadvantage trying to present to us this changing flow. But 1.0 I am not sure that we are adequate in giving them the requested 11 funding and perhaps even at the level that Dr. liess has proposed 12 DR. SCHMIDT: John? 13 DR. KRALEWSKI: Would you refresh my memory again on 14 the contracts, what do they hope to accomplish with that? 15 MRS. KYTTLE,. On page 19 of the document, I have 16 written out the five categories of the'million dollar contract. 17 And the three large portions 'of it, one half of it is for 18 emergency medical services and.we have seen their application 19 on that. 20 And, here is emphasis, Mrs. Flood. Through the work of the staff, which surveyed emergency rooms, its'needs, their 21 uses, the population that they serve, the State of Tennessee-in 22 developing a statewide emergency plan zeroed in on the regional 23 medical program as the lead role for the' emergency, stemming 24 Ace-Federal Reporters, Inc. 25 directly from the staff work. 235 kar 6 1 DR. KRALEWSKI: Well, have they applied for emergenc) 2 health service grant? 3 MRS. KYTTLE: Right. 4 DR. KRALEWSKI: And they-have been partially funded? 5 MRS. KYTTLE: Right. 6 DR. KRALEWSKI: Why.is that showing up as five hundr(i 7 thousand dollar contract? 8 MRS. KYTTLE: There'is no mechanism for them to 9 reapply for the operational dollars.. 10 DR. KRALEWSKI: Have they completed their planning? 11 MRS. KYTTLE: The region felt they had completed 12 their planning before we told them to plan. Very strongly. 13 DR. SCHLERIS: Is there anything to prevent their 14 coming to RMP for emergency medical service plan in the future 15 as part of their RMP program? 16 MRS. KYTTLE: That is-'what they are doing. 17 -DR. SCHLERIS: But they are asking for a contract .18 here to do it locally, isn't that right? 19 MRS. KYTTLE: Yes. 20 DR. SCHLERIS: Without there being any documentation 21 of what it is they are actually planning to do. At least a 22 part of their document is concerned. 23 MRS. KYTTLE: They.lo6k activate the same plan they presented to us back in June. 24 kce-Federal Reporters, Inc. DR. SCHLERIS: I want to make one point clear; that 25 236 kar 7 1 is, there is a great deal of differe nce between putting somethit 2 in writing and then verbal reports. This disturbs me a great 3 deal. I know you are familiar with the area, but qoin' through 9 4 volume one and two, I don't come out with a great deal of in- 5 formation about what it is that they are going to do with these 6 funds and the Memphis application as it came in for emergency 7 medical service didn't reflect all the planning that you indica-: 8 took place, and this is troublesome even to be told that well, 9 they had already done all the planning.@.:They thought every bit 10 had been done. 11 It wasn't reflective of-what they said. I do have 12 considerable concern about the level of funding. I question 13 whether emergency is the way to go as the first step. 14 MRS. KYTTLE: It is a part of civil steps. That is 15 RMP's role. @IP's role in this state consortium is the emergen@ 16 room. 17 DR. SCHLERIS: As I see it, if we apkove-,.thesefunds, 18 we are saying we think that contract is-a great idea. I for 19 one --'if-you want me to have faith, believe me, on a Friday 20 afternoon after two days, my faith increases more and more and 21 more and I will become a believer if you like, but it takes an 22 awful lot of conversation even:this late in the day-. 23 MRS. KYTTLE: No, we didn't think it was worth five s why.@he staff recommended 225,000 for 24 hundred thousand, that i Ace-Federal Reporters, Inc. 25 all contract work and they are going to have to make their 2 37 kar 8 1 choice. And they have told.'us thei'r choice is still EMS. 2 DR. SCHMIDT: Okay. Where we are is With the 3 substitute motion at the two million dollar level. 22 4 5 6 7 8 9 1.0 11' 12 13 14 15 16 17 18 19 20 21 22 23 24 Ace-Federal Repoiteis, Inc. 25 2 38 #23 arl I Are there other points to be brought up? If not, 2 then I will call the question. 3 On the $2 million level with the breakdown of 4 900, 100, 200 and 800, as you see on the board 5 DR. JAMES: I would like to make a comment, I 6 believe.- I think I am still hung up on and will be as 7 long-as I possibly will remain on this committee, in regard 8 to geographical locations of R'MP s, especially as they are 9 related to populations. Like Mississippi. Lik ew Mexico. 10 Like Memphis. 11 And I think that we have heard that there'-- in 12 the Mempfiis area that there has been a restructuring of their 13 administrative structure, which is too young yeti I think, to 14 have a real impact in terms of.what really are we going to do, 15 because we just haven't had time, but I believe from the' 16 statistics and information we have received in terms of, 17 again, going back to the neonatal infant mortality which is .18 an indicator of the lack of health services in the area, and 19 I don't think that that needs any further elaboration, I 20 would feel that these are the areas that need the strongest 21 support of staff continuing technical advice to the RMP, 22 to stay on top of the RMP to be surethat it is creating the kin3 23 of program that will benefit-the people. And this is what I 24 hear are services. Ace-Fedefal Reportefs, Inc. 25 I am aware of some problems Memphis had tot too 2 39 ar2 I long ago in another area. I don't want to get anything 2 confused, but I realize that-this is an opportunity for RMP 3 to begin to shore up some of those ends that were not 4 covered in some other areas that have to do with the same kind 5 of circumstances. I realize that I don't have as much information as 6 even,maybe some of the rest of you have, because you are famili 7 with some of the programs that were going on prior. But just 8 in terms of the situation.and the effort that is being put 9 forth and the direction, we may be at a disadvantage when we 10 heard Memphis yesterday mornixi to start out with, we may be 11 9 a little-bit more, would have been a little bit more under- 12 standing of the problem that exists there. 13 But I think that I can only say that if we can go 14 with Vermont and a 400,000 population, with the excess amounts 15 of money,that have been poured into that community and that 16 state, then we can go with Memphis and help them to improve 17 their services. @18 DR. SCHMIDT: There-are some issues raised there, 19 Leonard. Do you want to comment? 20 21 DR. SCHLERIS: Be outrageous to try to answer that, but @erhaps I can try only in one way. This is not-meant at 22 all as a rebuttal because Ishare your concerns. Our problem, 23 24 though, is I think a little different than looking at an area Ace-Fedefat Reporteis, Inc that has needs. I think it is a question also of looking 25 2 40 ar3 at whether the funds requested really go at those needs and whether they would be handled eMctively. 3 I think RMPS would fall flat on its face many 4 more times than it already has if it were to say that because an area has desperate needs that therefore we should be 5 1 6 uncritical in our judgment.as far as these needs are concerned. 7 My reason for referring to the fact that it is late in the 8 day is that I think the group is getting more lenient late 9 in the day and,not harder late in the day. 10 My concern about these funds relate to looking at the pro jects as submitted and some of these are frankly experimental. The one,about more accurate death certificate, 12 certification, I question manyespects of it. I would like to 1 3 14 know more about it. It is essentially a research project. I am surprised it has cleared RAG. 15 The problem with mul tip@asing screening is of 16 17 interest., too, because of certain RMPS statements on this 18 sort. Included in this is a project on home care, which again many of these have been supported around the country, there 19 are certain statistics on this. 20 One can go through the various projects and 21 come away with a feeling that RAG has not set its priorities. 22 23 I am a little unhappy about the response of the emergency medical services and how they are going about this, and it 24 Ace Federal Reporters, Inc. 'had the full information, but again 25 would'be better.if we 24 1 ar4 I on faith the contract of 200,0.00 or part of it, even though 2 there is need and heaven knows there is need all around the 3 country for EMS, $200,000, I don't know how they are going to 4 use it. We,are being told we should depend on the group, 5 6 but if you go about their decision-making capability reviews to what we have been told, RAG met once, the county-, three 7 8 times, the EMS met zero, so I don't know what went into that 9 formulation. so it isn't a question of feeling Memphis doesn't have need. It is a question o f my inhibition in terms of 10 whether or not they are going about meeting these needs in the most effective way they can. I am just trying to equate it 12 13 on that basis and I think $2 million as advised here is for 14 what we have seen, I think, a very generous way of meeting it because they still have the developmental components. 15 16 I, fot.one, will support the $2 million. I may 17 'have come up with a lower sum. If this.fails, I might still 18 offer that as a suggestion. DR. SCHMIDT: I think unless there is something new 19 to put before the group, we should call the question. 20 John? 21 DR. KRALEWSKI: I would like to offer an amendment 22 23 to this alternate proposal here and that is that we strike the contract money, w& keep that project money at the 900,000 24 A ce - Federal Reporters, Inc' that's being suggested, and we give them a full developmental 25 24 2 a-L -i I component to the limit of what that-would run wild be about 2 there, essentially what they are asking, 162, maybe a little 3 more than that as it would work out in the final budget, but 4 then out of the contract they can rethink their whole plan 5 of slipping into an emergency program here that might not have been outlined and still have some money under 6 7 developmental for some discretionary kinds of activities. 8 DR. SCHMIDT: Well, if I am with you, you'd give 9 them the 800, program staff, and the 900 for projects, and 10 that is 1 million 7. 10 percent of that is 170, and that would come down then to l..87 millions That is an amendment 12 to the substitutd.,motion to the main motion. 13 Is there a second? 14 DR. SCHLERIS: I will second it4 15 DR. SCHMIDT: All right, it is seconded, so now 16 we are down to discussion of the amendment to the substitute 17 motion.. Anything hot germane to that is out of order. 18 MRS. KYTTLE: I think.some of.the flavor of the amendment came from comments by Dr. Schleris and we have got 19 to do something about these printouts that led you to think 20 21 that this home health care is less than winding up. It was something that was started two and a.half years ago. The- 22 multiphasic screening projects were started two and a half year@ 23 ago, and if you are going to look at these printouts and not 24 Ace-Federal Reporters, Inc. equatb proper time with them to realize that that is the part 25 ar6 24 3 I of this program,that that is.the.part of this program that is 2 phasing out, then they are misleading. 3 I have heard this group several times today get 4 hung up on that. That's the phasing out program. The high risk infant. The expansion of the home health center. 5 6 The satellite clinics. That is the new part of this program that-is building up and the part that disturbed you is the 7 part that was started two and'a. half years ago. 8 9 DR. SCHMIDT: The current level ther @ s at 1.627. 10 What is being recommended now is 1.87, which is not too much of an increase. I think we wi 11 test the sentiment then by vote onthe amendment to the substitute which is 1.87, with a 12 13 170,000 developmental and no contract. All in favor of this,. please say aye. 14 And opposed no. 15 All right, the."noes@' have it, and the amendment 16 is defeated. We are back to the 2 million level, and I will 17 call the question on that. .18 All in favor, please say aye. 19 20 Opposed, no. I will have to ask for a-show of hands. Please 21 raise our hand. 22 y I have four ayes.. 23 24 Noes? Ace-Federal Reporters, Inc. Four. 25 2 4 4 ar7 I The chairman will vote to break the tie. And vote 2 aye. So that the substituted motion has it. 3 Before we adjourn, I would'like to ask the one 4 question. At the request of staff, we did prepare DR. JAMES: Excuse me, sir, I didn't quite under- 5 6 stand that. You said the substitute motion pas.ses? You 7 voted aye for which motion? 8 DR. SCHMIDT: The substitute motion. DR. SCHLERIS: $2 million. 9 10 DR. SCHMIDT: 2 million level, which is 800, 200., 100, 900. 12 DR. JAMES: Thank you. 13 DR.,-SCHMIDT: Is there a question about procedure? 14 DR. JAMES: No. MRS. KYTTLE: I am @orry, which one? The 2 million? 15 16 Okay. 17 DR. SCHMIDT: It is approved at a 2 million level. DR. JAMES: Yes. Okay. 18 DR. SCH14IDT: Staff-has-requested that I request 19 2o the committee recommendations remaining, if there are any comments about this chapter four that I asked you to look'at 21 22 last night. It has to do with.the functions of review 23 committee and council and so on. This will go to council. For their essential, essentially their approval. I am asking 24 Ace-Federal Reporters, Inc. if there are any substantive queries or comments on that at 25 24 5 ar8 'this time? 2 MR. HILTON: 1 would say only that I would have 3 appreciated having that document of that upon joining the 4 committee. I have since that time just about figured it out, 5 but it was an awful loss in productivity while I figured it. 6 So I am very glad to see that this will be available to the future members who join the committee. 7 8 DR. SCHMIDT: I will.strongly urge that a letter 9 be sent to review committee members asking for s@ecific 10 comments prior to this going to council. I will express my personal appreciation to a most -- somebody turn off-their 11 mike. -- To a most hardworking and understanding committee, 12 particularly for understanding and tolerance exhibited to @.@l 3 14 the cha irman. Thank you. Be sure to pull out your rating sheet and have that 15 available for staff pickup. Thank you. 16 .(Whereupon, at 4:40 p.m., the hearing was 17 adjourned.) e23 19 20 2 1 22 23 24 Ace-Fedefal Repofters, Inc. 25