ORIGINAL Transcript of Proceedings DEPARTMENT OF HEALTH, EDUCATION, AND WELFARE PUBLIC HEALTH SERVICE HEALTH SERVICES AND MENTAL HEALTH ADMINISTRATION © ‘Executive Session : NATIONAL ADVISORY COUNCIL ON REGIONAL MEDICAL PROGRAMS = _ “Rockville, Maryland ee Tuesday 3 August. 1971 ee “ACE - FEDERAL REPORTERS Official Reporters -3036 CrBSON ng W- 10 7 ® 12 : 13 14 15 16 17 18 19 20 ® 21 22 23 24 Ace ~ Federal Reporters, Inc. 25 DEPARTMENT OF HEALTH, EDUCATION, AND WELFARE Public Health Service Health Services and Mental Health Administration Executive Session NATIONAL ADVISORY COUNCIL ON REGIONAL MEDICAL PROGRAMS Conference Room G-H Parklawn Building Rockville, Maryland Tuesday, August 3, 1971 10 11 © 12 13 14 15 16 17 18 19 20 ) 21 22 23 24 Ace ~ Federal Reporters, Inc. 25 PROCEEDINGS ‘DR. MARGULIES: We have some issues to deal with which have some wide implications in terms of the whole RMP mechanism and they justify a little closer attention than we might have in what we call the open session. The executive session is one from which we will have reports if they seem reasonable to report and not otherwise. We'll use your judgment about what should be done. Let me get to the first one of primary concern, and I'm going to ask Sewell Milliken to play a particular lead role in this discussion. This has to do with the Ohio Regional Medical Programs. Now, to bring you up to date on that particular subject, there are four programs which operate in “the State of Ohio. One of them, the Ohio Regional Valley Program, has most of its activity in the lower valley but it does include Cincinnati and some of the others so it is in addition to its major concern. The other three programs, which are Northwest in Toledo, and Northeast in Cleveland, and North in Columbus, are pretty much confined to the State of Ohio and over a period of time all three of the latter programs have been the source of real concern to the Council and to the staff. They are, to put it briefly, quite inadequate, and they range from fairly bad to inacceptable, and that's not an exaggeration I'm afraid. The Ohio State Program is sort of plodding and unimaginative and very much tied in with fairly traditional interests of the medical school. The Northwest 2 @ 3 Program in Toledo has just never been able to achieve anything. 4 It has had extensive criticism by the Council. It has been 5 put on notice time after time because it is performing so , badly. It has had problems with the coordinator, with the o 7 regional advisory group, with the kinds of programs it has : developed. It has been mismanged and in general it has 9 accepted in our discussions the fact that it's in bad trouble. 10 The one in Cleveland is a program which became operational a little more than a year ago, as I recall. It had 11 © 12 in its beginnings a very vigorous and fairly dominating coordinator who soon after it became operational left for 13 14 another activity, and they have in that period of time not been able to locate a coordinator to take over the activities and ° they have managed as well as one can under those circumstances, - But among other problems in the Northeast Ohio one -~ that is the one in Cleveland. -- is the re-emergence of some old internal e problems in Cleveland between elements of the medical community ” which continue to paralyze any decision-making process. ° At the last meeting of the Council we were urged to- @ 2 get together with the people in Ohio and have them reconsider 0 some way in which this could be redesigned into an effective 7 program for the State of Ohio without having three ineffective 24 Ace — Federal Reporters, Inc. activities going on. 25 10 ir @ - 12 13 14 15 16 17 18 19 20 e 21 : 22 23 24 Ace ~ Federal Reporters, Inc. 25 We did have a meeting with representatives from all four programs and that was here in the Parklawn Building, and at that meeting were representatives from the grantee agencies, from the regional advisory groups, and the coordinators. There was uncertainty at that time, and I think some uncertainty remains, about the ohio Valley RMP aspect of it, but it was quite clear that those people that came from Cincinnati had no interest in moving from the present arrangement with the Ohio Valley RMP into a new arrangement, regardless of what that might have been, in the State of Ohio. There was a variety of attitudes expressed by those who came from Northwest, Northeast and Ohio State, but they were influenced considerably by the sense of determination which we had which suggested to them that they had a number of choices but it would all come out to be a consolidated program of some kind. We gave them some figures about that and pointed out. some of the costs that were involved in multiple programs and reminded them that they really had not done very well. I nelpec draw their attention to it by giving them six months of funding so that they could consider some of the alternatives which appeared to concentrate their interest considerably. Now, from that, they drew the conclusion that they should meet together in Ohio; that they would consider the potentialities in another kind of an arrangement; and that they 10 ir eo 12 13 15 16 17 18 19 20 ® 21 | 22 23 24 Ace — Federal Reporters, Inc. 25 14 have done. Now, one of the fortunate things which was going on at the same time is that Sewell Milliken is the birector of the CHP in the State of Ohio and when this began we didn't know he was going to go on the Council -- anyway, he didn't know -- and so he was a fairly free agent in this and sort of a neutral figure in the activities which were going on, and quite by coincidence, John Cashman, who has until very recently Keen Director of the Community Health Services here in HSMHA, has resigned and is going to Ohio in the State Department of Health. So we had some interested, knowledgeable people involved who occupied a very special kind of position. We agreed that when they met we, the RMPS, would stay out of it and that we would be on hand to provide any kind of information or backup they wanted but the decision-making process was in their hands and we would look forward to what came out of it. Now, unfortunately, at that first meeting which we held here, Sewell ran into airplane difficulties so he got in during the afternoon and missed the initial session, but he has been a part of the one that followed and they had a meeting out there and this led to a second meeting which took place a week ago Sunday, July 28. So what we would like to have you do now, if you will, is bring us up to date on what happened and what sort of issues we're likely to be facing. 10 1 @ 12 13 14 15 16 17 18 419 20 @ 2) 22 23 24 Ace — Federal Reporters, Inc. 25 wh DR. MILLIKEN: In this folder that you have, if you go down through it you will find the minutes of the Ohio RMp meeting held on July 28, 1971. That's all of the critical reference that all these other conclusions will lead to. First of all, I'd like to say, probably unnecessarily so, this is a very traumatic thing for the ‘RMPs in Ohio to go through and particularly the RAG. I understand that the RAG in Cleveland has not yet accepted this change in concert, but | the Cleveland group is proceeding in spite of this and I'm sure’ they will get along. The critical issue after this meeting, as a result of this meeting of the 28th, focused around who the fiscal agent would be. Of course, the Ohio State people felt they could play this role and the Ohio State Medical School can play ‘this role, and this was not acceptable to any of the other RMPs for historical reasons. As a result of this, there were two alternatives. One was that the Cleveland people -- item number four on this letter, the minutes, is one of the alternatives that was dis- cussed in the halls, and this was that the Northeast Ohio Regional Medical Program is a non-profit corporation and could be moved to Columbus -~ change it a little -- and still continue under its previous incorporated status. This got a lot of discussion, | The information they received from Dr. Margulies to 10 i @ 42] 13 14 "45 16 17 18 19 20 @ 21 22 23 24 Ace ~ Federal Reporters, Inc. 25 look at some of the other states and some alternatives of doing this led them to Kentucky, where the University of Kentucky Research Foundation has been the fiscal agent, and they studied this and two or three of them met Paul Warren(?) somewhere in Illinois and spent a day with him and discussed this; and as a result, the serious discussion centered around the Ohio State University Research Foundation under similar arrangements that the University of Kentucky Research Foundation has been operating. It took a lot of talking, but there was finally agreement on the 28th that they would all go this route. Now, the Ohio State people have practically certified -- not under oath, but almost -- that there is no direct relationship between the research foundation and the university, but the others do - 7 —— not quite trust them. DR. DE BAKEY:' The university? DR. MILLIKEN: Yes. However, they are willing to go that route but there is great concern about the fact that Ohio State could end up being the RMP, which the others -- as Dr. Margulies put in his letter to them, he thought that the federal office and this Council would question any arrangement whereby wy any of the existing RMPs took over the others. There was a little disagreement on this meeting on the 28th as to who was the chairman. They asked Dr. Pace to convene the meeting -- he's from Ohio State -~ and he assumed he would 10 ie @ 12 13 14 15 16 17 18 19 20 ) 21 22 23 24 Ace —Federat Reporters, Inc. 25 be chairman. But after he started the meeting he was shown very quickly that they were going to elect their own, and so Dr. Fishbein ended up as chairman for this first meeting. Now, at the next meeting, they have again asked Dr. Pace to convene it. ‘They are meeting tomorrow and take this one more step. I imagine they will rotate the chairmanship of this group. Now, you might go to enclosure number two, which is this long flow chart, and starting, as I guess one is supposed to with such charts, go to the extreme right with their deadline of February 1, their target date for the Washington RMPS reviews and backing up from there, I think this is one of their critical questions, Dr. Margulis, as to whether this February 1 date is correct on that basis for all that has to be done here to meet the timetable. Backing up erom that, this January 15 is rather routine. December 1 is the CHP review and comment which I don't believe presupposes any problem, November the “15th, the proposal review by the interim Ohio Advisory Council will be complete. The October 1 deadline is the real critical a because all of the RMP areas will have to put together their various different concepts of this, and this leads me to a question that has not come up yet by this group, and some of us who have been talking about it in advance feel that it might be well to have some mechanism wherein it would be possible for 10 YW @ 12 43 14 16 17 19 20 @ a 22 23 24 Ace ~ Federal Reporters, tnc. 25 15 18]. some leadership other than that now currently operative in each of the four could rally around. One such activity would be that each of them, if it were acceptable and feasible, could contribute money into a central pot to employ an interim person, oxr.another alternative, as was suggested to me today, is that they might get a loan of a very capable staff person maybe from this office who could be the rallying point around which each of the current organiza-| tions could get an advance and early start towards putting this together organizationally and program-wise so that no one of the existing people now involved has to run the gauntlet and bring in all the past problems. That might happen, but this has not been discussed by anybody in these RMPS. DR. DE BAKEY: Is there enough vested interest cn the part of the various groups to make it so tramatic that you'd almost have to destroy it in order to start over? DR. MILLIKEN: I think just after the meeting of the 28th this was the feeling, but as a result of that meeting and as a result of the communications that's been on-going since, I think they all feel that this is feasible now. DR. MARGULIS: One of the interesting kinds of releases of pressure in this came about during the initial meeting when the people from Cincinnati were disclaiming any interest in moving from where they were, the point being that they had been able to maintain some sense of local integrity 10 iB! @ 12 13 14 15 16 17 18 19 20 @ 21 22 23 24 Ace ~ Federal Reporters, Inc. 25 although they were part of a Kentucky program; and I pointed ou4 the fact that the same thing can happen in Columbus and in Cleveland and in Toledo, that they can be in a single state program and still have a sense of local purpose by subregiona- lizing. Cincinnati was a good example. I think they are beginning to recognize that they aren't giving up everything but actually can retain something. You know, that point that you just raised, Sewell, of the critical issue of deciding on some common goals and priorities, also brings up the other issue which you really haven't dealt with and have to, because in essence what we're doing is combining weaknesses in this program unless we do something extraordinary to bring them together and make ita stronger program; and I think almost of necessity there's going to be some sort of outside infusion necessary at the point where they're deciding exactly what is it they're going to be with this combination. DR. DE BAKEY: The amazing thing to me about this is that they are tremendous resources in the State of Ohio, cer- tainly a talented pool of medical personnel, and why they can't find leadership to energize a program like this into a good, strong program is difficult for me to understand. DR. MARGULIS: Sewell, you're there in the A agency. Do you have some comment? DR. DE BAKEY: I was concerned that it was sort of 10 11 @ 12 13 14 15 16 17 18 19 20 @ 21 22 23 24 Ace - Federal Reporters, Inc. 25 ll too much selfish vested interest. Of course, you have some traditional polarization anywhere you go. You know, there's no place in the country you won't find some polarization, but that hasn't prevented a good, strong RMP program. In fact, some places where it's been strongest ~~~ where they have developed a strong RMP program has been where there's been the stronger traditional polarization. DR. MARGULIS: They kept talking about the vast differences within the State of Ohio and I pointed out to them that they are much greater in other states, that almost every place we work has great differences from one area to another, and some manage and some don't. DR. DE BAKEY: That's right. one of the big differences of the State of Ohio from other places is the talent of medical personnel they've got. . | DR, MERRILL: Is this essentially a “town and gown" thing? Is everybody against the university or are they all against each other? _ ( DR. CANNON: I think there are several things. One of them has been leadership. It's been over a year since they decided the leadership in the Northwest, I believe it was, needed to be changed. Mike, you're the one ~~ as I remember that now, I said “Fire him," and you said, "No, let him work it out." DR. DE BAKEY: That's right. 10 11 © 12 13 14 15 16 17 18 19 20 @ 2] 22 23 24 Ace ~Federai Reporters, Inc. 25 12 DR. CANNON: And we sent a task force out there and-- DR. DE BAKEY: I remember that very well, Bland, and I have to <-- . DR. CANNON: We never did get rid of him. DR. DE BAKEY: I agree with you we didn't, because I thought they ought to do it themselves, and I still think that was the right thing to do, but obviously it didn't work. DR. MILLIKEN: I think part of the problem that was built into this, some of us tried to do something about this ' two years ago -~ there was unfortunate overlap -- two or three county overlap between each of these programs and when we discussed this two years ago or more with the coordinators ~~ . we have been meeting together ever since the program started -- they all said "Well, this is no problem. A county can have the best of all worlds. They can get some particular thing from one RMP and something else from another." Well, unfortunately, like everything for everybody, there's another side; and the other side was that it's seeded distrust between -- a little bit between “town and gown" and in a couple of areas -- in Lima, Ohio, for example, there was some physicians who graduated from Ohio State and some that graduated from Michigan, and they were pushing their own schools and this built in another controversy. So that some of us shudder to see the review and comment coming down the pike with this county overlap. As somebody told me just before I came in here, in the 13 1} city of Dayton, there are a great many people, physicians 2|| included, who think Dayton isn't in either, but actually it's © 3) in two; but you can't convince them that they belong to either 4|| because there's been no one there. It's created a vacuum 5|| because there's nobody there pushing. ‘Those that are for é|| Cincinnati push it and those in Ohio State push it. 7 DR, MILLIKAN: As you see the emerging design g|| administratively, is it to go the California route with a 9|| separate, simple, relatively small office and then area one, 19{| area two and area three, in all probability? 7 DR, MILLIKEN: Right. @ 12 DR. MILLIKAN: I saw the definitions there. 13 DR. DE BAKEY: The thing that concerns me about that 14|| is that I'm really more worried about how that would effect a 15; real change in strengthening the activities of RMP within the 16 various areas. 17 One of the main reasons that the thing works so well 18 in California I think is because of the leadership they have. 19 They have got very strong leadership there and the people rally 20 around their leader, both in the areas as well as in the central wo . . . J ® 91 administrative office. They have respect for them and it works 22 well. But you can't just take this same group and give them 23 another designation and say it's going to be comparable to oA California. It is now, in a way. Ace - Federal Reporters, Inc. , * ‘ $ en ans DR. MILLIKAN: I didn't mean to imply that. In the 25 a 10 1 @ 12 13 14 15 16 17 18 “19 20 ® 21 22 23 24 Ace — Federal Reporters, Inc. 25 14 first place, you would have a new RAG and the new PAG might consist of the deans of medical schools and people from the Heart Association and Cancer Society. It would be a new RAG overseeing the entire phenomena as in California, if one went that route, and you might engender in that kind of new RAG some sense of responsibility toward the subdivisions. In other ‘words, there is area, one, area two and area three, which is the kind of thing that is going on out there. Now, it is perfectly correct that sooner or later you have got to infuse ' some leadership in each of the subdivisions or you're dead, but. at least there would be the new RAG concept. DR. MARGULIES: JI think it would be a great mistake to move to some sort of bAlkanized concept in which they still have their individual function but work together at some central point. We really have to replace what is there but give them at the same time a sense of purpose within the total RIP. I wonder how much value there might be, when they get to the point of considering the way in which they want to functi together, in getting consultation -~ and I really haven't thought about this -- from some other coordinators who have } —_ — been working on_the statewide basis and who have_some under-"" (ate standing of how this kind of thing functions, no one with any —atae, nearby geographical relationship but some distance away. DR. DE BAKEY: I must say I like the idea Sewell proposed of having someone come in there. I don't know how 10 im © 12 13 14 15 16 17 18 19 . 20 @ 21 22 23 24 Ace ~ Federal Reporters, Inc. 25 15 feasible this is, but it certainly would seem to me it would make it more practical to move them if there was somebody that could come in who would be objective and in a sense nonpartisan in his view and he has no axe to grind and he's not related to any group and they would have to respect him by the very fact | that he obviously would be a person you would send who knows his business to come in there at least on an interim basis and be the regional director and sort of get them started organizationally and constructively and infuse in them some © feeling of trust for the program, I don't know that you're going to be able to do it with the people they have got. DR. SCHREINER: “Did the task force explore that possibility of having it disappear and let it go and take one from Pennsylvania or something? DR. MILLIKEN: That was not realistically explored. They gave it up real quick. DR. EVERIST: Is this the first consolidation that we have had? We have had some separations. | DR. MARGULIS: I think so. DR. EVERIST: We have had no consolidation? DR. MARGULIS: I think so, and we are going to lead to another discussion hereafter of another couple of areas because this is not just an Ohio problem. We have the problem to consider elsewhere. DR. CANNON: It never has been clear to me as to who 10 11 @ 12 13 14 15 16 17 181. 19 20 @ . 21 22 23 24 Ace - Federal Reporters, Inc. 25 | because you're going to have to fire some people and that's the | whole thing. The good programs that we have got you can focus 16 has the coordinating responsibility, the grantee? DR. MARGULIS: Yes. DR. CANNON: Then the key to this is the grantee, ~ real quickly on is because of local leadership, the. regional leadership. Now, you have got to fire some people. If you're going to accept this foundation as the grantee you have got to know beforehand that they are willing tad reshuffle and change the personnel because if they're not willing to do that we're going to have the same problem no Matter how we merge them or divide them or anything else, and that's what I think -- if you once get over that hump, I think you've got it made, whether you have four or three or two or one. DR. MARGULIS: That's a good point. DR. CANNON: But we haven't yet -- you Know, we triec to find out who hires and fires the coordinator and it's always 4 been talked about under the table, but no one has ever come out 2 . . ' I and said who is responsible. Can a RAG group? DR. MARGULIS: No. It's the grantee. — ect DR. CANNON: So I can see why they wouldn't want onio State as the grantee, you know. I can see that. I would think it's up to us to decide whether the grantee that's being considered there is an appropriate agency that will make the 10 1 © 12 13 14 15 16 17 18 419 20 ® 21 22 23 24 Ace —- Federal Reporters, inc. 25 affairs? How is it composed? And that's the key to who they 17 decisions that have to be made. ‘DR. MARGULIS: Do you have any idea at this point of how that would be decided? Because you have a corporate body which is the fiscal agent, but then the question after that is how do they make up the body which is going to direct their choose. DR. MILLIKEN: There's a paper in here with the suggested makeup of an interim state RAG. They go in with an interim advisory committee which would then, with some changes, become the final one. Membership would consist of an equal number of representatives from each of the four RMPs, 12 members represent each district office, representatives from each of the four RMPs shall be selected by that region which is part of this whole built-in thing. DR. DE BAKEY: ‘That's a RAG you're talking about now? DR. MILLIKEN: That's right. DR. DE BAKEY: The Ohio Research Foundation? DR. MILLIKAN: Who is that going to be and what kind of a board and so forth? DR. CANNON: Who are "they?"” DR. MILLIKEN: There's a letter here that doesn't answer all those questions, but -- | DR. KOMAROFF: Hasn't it been true, though, that when coordinators have been fired that the RAG really gets together 10 1 © 12 13 14 15 16 17 18 19 20 e | 21 22 23 24 Ace — Federal Reporters, Inc. 25 18 “with the grantee and the grantee -- it's nominal that it's the grantee that does the firing, or the hiring for that matter, but " $t%s really the responsibility, historically, of the RAG? DR. NARGULIS: Well, it has and it hasn't, Tony. It really depends on the working relationship. We'fll get to Susquehanna Valley in a minute and you will see that it's not / necessarily true. That will happen when the RAG is functioning well. In these circumstances, however, it would have to be © without benefit of RAG because almost by the nature of it the RAG would be dissolved, the RAGs, the separate ones. DR. MILLIKEN: The five points in this letter that's with your material sort of spells out their recommended procedure. It's from Stephens, who is the Director of this Research Foundation. They are trying to move from the periphery to the center in a series of steps is what they're trying to do, which assures them all they will continue to have a voice in the changes. This is the big issue and they want. visibility and they even talked about phasing -- doing this in phases, which has some merits, too. But they have gone sort of to the interim board with the expectation that this board will have real clout and will be able to help determine the policies of the fiscal agent. DR. NARGULIS: It would seem to me from what you said that so far as our negotiating position is concerned that the 10 i @ 12 13 14 15 16 17 18 19 20 @ 21 22 23 24 Ace ~ Federal Reporters, Inc. 25 19 interim board and then the fiscal agent are the points on which we can act and the people to whom we can talke and clarify some understandings with. : Northwest Ohio is really basically very passive about it. They are perfectly willing to join any place because they know they're in deep trouble. There's a big difference -- or there was a big difference -- I don't know whether it has sur- vived but I would imagine it has -- between Fred Robbins and Charlie Hudson in Cleveland as to how this would function, with Charlie performing in characteristic manner. He doesn't want any part of it. DR. MILLIKEN: He has sort of stepped out as a result of the meeting on the 28th. He declined to discuss it and this probably would be his posture. DR. MARGULIES: So far as I can tell, if it's agreeable with the Council, the extension of the support for g this, as long as they have gone really quite a long ways, to allow them to come in with a February date is very reasonable. I-€hink that's quite good and shows a definite kind of plan t and we can begin to work with the interim committee and then ener t with the fiscal agent and involve Council and other staff people that seems appropriate. DR. MILLIKAN: I move that the Council go on record as supporting that initial plan. ee DR. KOMAROFF: Second. 1 oR. MARGULIES: Any further discussion? 2 ‘pR. EVERIST: This includes sending a man from staff @ 3|) there? . 4 DR. MARGULIES: Yes, We will begin to work directly : a's 5\| with them on a staff basis now that they have gelled their | | 6] plans. Any further discussion? 7 (No Response) 8 DR. MARGULIES: All in favor say "Aye." 9 ("Ayes") | : 10 DR. MARGULIES: Opposed? 1 (No Response) © 12 DR. MARGULIES: Now, let me move you for a moment -- 13] we are going to have to talk about New York before the afternoor 141 is over, but let's have a reprieve from that for a second and 15|| talk about Susquehanna Valley RMP; not that that makes anything 16|) any easier, but at least you need to be brought up to date on Wit it. 18 DR. ROTH: What's a reprieve about that? 19 DR. MARGULIES: Well, you're quite right. You may 20|| recall that at prior meetings of the Council the level of 9 ' 21! enthusiasm for Susquehanna Valley RMP has been very close to en 22|| that of the Northwest Ohio RHP. It's been a program which has 23|| been in considerable difficulty and there was a very interestin: 94|| discussion about that program the last time because in the Ace —Federal Reporters, Inc. . . . 95|| review of that RMP it was apparent that it really did have some 13 14 15 16 17 18 19 20 @ 21 22 23 24 Ace - Federal Reporters, Inc. 25 21 real assets, that it had potentials for being a good program. It had an’extremely high level of involvement with practicing | physicians. The staff of the RMP, although it was young and inexperienced and derived primarily from non-health fields, had some real vigor and imagination, but there were some major | issues that had interfered with it being a successful program. There was a general impression that the state medical society had totally dominated the RMP and the staff and the working practices, and there was great concern over the fact that they had never had any professional leadership in that - program; that nobody with any health background or any experience in the health field had been in the position of coordinator or in any administrative capacity and that, indeed, the lay director of the program had formerly been on the staff of the Pennsylvania State Medical Society and was sort of loaned to the RMP initially and then remained there permanently. He was not the executive secretary. He had a lesser position with the Pennsylvania State Medical Society. these concerns with the program had been transmitted to Susquehanna Valley on more than one occasion, So it was decided last time that they should be given an opportunity, if it appeared to be appropriate, to have an increase of funding with the understanding that this was based upon a clear declaration of new direction and new effort on their part. It would be tied to that kind of an understanding. 10 VW ©} 12 13 14 15 16 17 18 19 20! @ 21 22 23 24 Ace -Federal Reporters, Inc. 25 22 So we had them come in and on that occasion we had representatives from the Hershey Medical School, from the Pennsylvania Medical Society, from the Regional Advisory Group, from the Board of Trustees of the Pennsylvania Society, as well as the Executive Secretary of it, and the coordinator. In the process of that discussion, there was a copmlete rejection of th4 constant criticism that the medical society had run the affairs of the RMP and they said this is simply not true, and the coordinator denied that it was true, and so what we had was one report vying against another, and that didn't help matters very much. However, during the discussion, they asked me directly if it was my judgment that the coordinator who was sitting there should be replaced by someone who had a medical backgrounc and my response was "Yes" and he resigned; so he is no longer the coordinator and they have an interim arrangement and they have a search committee now to locate a coordinator who has medical competence and a medical background to go into the program, We also had a discussion of the problems there which related to the medical school and you may recall that there was the feeling that the relationships between the RNP and the i medical school were tenuous at best. Well, I tried to press the dean a little bit to see what he thought the relationship shoulc be and I asked him, "Well, what do you think RMP could mean to 23 1] your medical school?" And to capsulate it, his answer was, 2\| "well, they could use some new angiocardiographic equipment ," rd) 3/, and this was the general pattern of his response. 4 . Well, I tried some other tacks, you know. He was- 5 concerned over the fact that they had started with the idea of 6|| making this a family practice kind of medical school but he 7\|| kept bragging about myocardial metabolic studies, and he said g|| that the family practice unit was being swamped by people in 9|, this area who saw it as a good place to get medical care, which 10|| made it very difficult to use it for teaching purposes if it 11 || was going to provide that much service. I said, “Well, do you @ 12) think it might be a reasonable thing if the RMP played a role EN V3 in working with the local family practitioners to try to replan 14|) the distribution of health services so that you: peripheralize 15} the activities of the medical school and created some balance?" 16|| And he said, "No, that would be improper for the RMP because 17|| that would be interfering with the way individual practitioners: 18 functions and they were a very conservative group," which is what I always hear when somebody doesn't want to do something -- 19 20 "We have a very conservative medical society," they say. @ 21 So I got the feeling out of that that the relationship 2 with the medical school are just not likely to prosper under any 93 circumstances. It doesn't seem to be designed for that kind of o4 linkage. So what we have up to the present time, unless this Ace — Federal Reporters, Inc. 25 is being misread, is an agreement on the part of the medical Ace —Federal Reporters, 10 i 12 13 14 15 16 17 18 19 20 21 22 23 24 Inc. 25 24 society that they will seek out another kind of an individual to act as the coordinator. The chairman of the Regional Advisory Group under- stood the RMP concepts and was very helpful. I think he's the chairman-elect. He's a physician. But we are still left in an uncomfortable position because the relationship between the agency and the RMP remains what it was initially. The lack of a medical school. which is really going to be tied. in with the RMP remains a problem, and we have only gone partway toward the resolution of this issue. DR. DE BAKEY: it seems to me, there again, it's the lack of leadership. I can understand the lack of imagination on the part of the dean. You almost have to have that trait to be a dean, so that's not unusual. But there is, it seems to me -- if you have leadership on the part of the Regional Medica: Program coordinator, then he could get around this kind of lacx of imagination on the part of the dean and actually bring in faculty members, many of whom I know would be very anxious to take advantage of the opportunity of the regional concept there. and that would provide them with really a rich outlet from thei: standpoint in raining, and at the same time add considerably to the strength of the Regional Nedical Program in the communit: and particularly with the doctors in the community. So, again, it seems to me you come right back to the same business, and that is the lack of leadership and someone 10 uN © 12 13 14 15 16 7 18 19 20 @ 21 | 22 23 24 Ace — Federal Reporters, Inc. 25 very difficult to be comfortable with people in organizations 25 fired up with the concept who will not allow the dead hand of the dean to interfere with what he can do, and this is what's happened, ~ DR. ROTH: I was simply going to say that as long as this is an executive session and all in the family, that it's that are undergoing convulsive disorders themselves. This is about the situation with Hershey Medical School, and I think it's a mistake to expect to correlate into an RMP program a young medical school which is having severe financial problems. They have had their own plans from the Milton Hershey Foundation totally upset, which turned out not to be enough millions, so they have had to give the school over to Pennsylvania State University. They set out to be a new humanist-type of medical education and very promptly got themselves embroiled in an unsolved argument with all the general practitioners in the area of Hershey, Pennsylvania and so on by a very undiplomatic suggestion of the dean that these general practitioners could bring their patients into the hospitals and be members of the staff under two conditions: the medical school collected all the fees, charged 20 percent for administration, and exacted an additional 25 percent voluntary contribution to an academic enrichment fund. So the practitioners find their fees dis- counted 45 percent from the moment they start. Then, on top of this,. their first graduating class 10 11 © 12 13 14 15 16 17 18]. 19 20 ® 21 | 22 23 24 Ace —Federai Reporters, Inc. 25 ‘ school. They are just now appointing heads of important ' departments. So they can't contribute much. 26 was 24 students dedicated to family practice and only one of them signs up for a family practice post-graduate education. The other 23 are going on into orthodox residency programs. That's the medical school's problem and they area fledgling Now, on the medical society side, you had an employee a third-range lay employee, who wasn't doing a very good job for the medical society and it looked like a real good place to put him, where they needed a coordinator on a program, and he hasn't been any more successful in this. The best thing that | has happened is to have him voluntarily resign, because you have got a soft-hearted director there that didn't have the guts to fire hin. I think we are now at the fringes of a new day, but if they can get a strong director of the program -- I agree that they have all the resources and they ought to let the medical school tag along and be as much help to them as they can to keep them involved, but not expect the medical school to ‘run the thing. tL think the additional funding will help because it shows that we're not turning our back on them. They have the potentialities. The medical society would like to run a successful show and I would hope that they will give better cooperation than they did in appointing Dick McKenzie. - 10 in @ | 12 13 14 15 16 17 18 19 20 @ 2] 22 23 24 Ace ~ Federal Reporters, Inc. 25 27 DR. HUNT: Are you talking about the pennsylvania Medical Society or the county society? DR. MARGULIES: The Pennsylvania Medical society. DR. HUNT: I would recommend that you get the Pennsylvania Medical Society out of this and put the Dauphin Medical Society into this. On the one hand you're dealing with administrative officers who have a statewide obligation and also an elective board of trustees that have a statewide obli- gation and are not knowledgeable or primarily concerned with the Susquehanna Valley, but I think that possibly another sponsoring group, like the Dauphin Country Medical Society and the surrounding groups possibly -- and I second what Russell has said about the medical school. You talk about leadership -- I think that that's where the leadership has to change, too. DR. ROTH: I wouldn't go along with that. I wouldn't change that. DR. HUNT: You can't start a medical school with these kinds of statements out in the community. DR. SCHREINER: I was up there just recently and in Hershey there is no physician problem. All of the people did exactly what he asked them to do. They are all working there, with one exception that left town. DR. HUNT: The other thing I think that influences this, Harold, is that this is an area that is probably the most evenly affluent community in all the country. It really is. ' 10 iW @ 12 13 14 15 16 17 18 19 20 @ 21 22 23 24 Ace - Federal Reporters, Inc. 25 28 There's practically no indigent population in this area. DR. CANNON: I was on the site visit team survey for Susquehanna Valley and I'd like to give you some of the impressions which cut across what you have said and some of | what Russ said. Number one, I don't think that they have a real big problem outside of the one of having the proper coordinator. They have got a good young staff. The staff at Susquehanna I thought was one of the best staffs, and Dick McKenzie put it completely together but what he didn't have, he couldn't sit eyeball to eyeball with the physicians. You see they looked down on him. The dean looked down on him. In fact, the dean was so disinterested during our meeting there that he didn't. say a word, even when we tried to get him to enter into the discussion he failed to do so. I see nothing wrong with the Pennsylvania Medical Society being the grantee. It's not the elected board of trustees. They have a separate committee, a sort of foundation, that is supposed to run the RMP affairs, but they perhaps haven't used good judgment in failing to replace the coordinato! which was put there by the state executive. So I really don't think you have any problem in Susquehanna Valley other than getting a good, strong coordinator with a medical background that can talk straight to doctors on an equal basis. fT think the school would be asking RMP for help then. nN 10 11: @ 12 13 14 15 16 17 18 19 20 . ° 22 23 24 Ace ~Federa! Reporters, Inc. 25 29 DR. MARCGULIES: Fine. The one thing that I thought that I would like to do in discussing their selection of a new coordinator is to make sure that they do consult fully with the Regional Advisory Group. There is no requirement that they do so but I think that this would he a balancing device considering the fact that there is so much accusation in that area and I continue to get telephone calls claiming that the medical society is trying to run things the way they always have. I had the same impression you did, Bland, when they came down here to talk about it. I think they recognized the need to do things differently. I think the medical society really wants to have a good RMP. It's no joy for them to take on this one particular activity as a statewide medical society, but I think they do recognize their responsibilities and want to get the job done. So if they can select a good coordinator, I would be > inclined to say that they have done the best thing to move into. a position -- | DR. CANNON: © They have a man there that's on a part- time basis.--I think he's a cardiologist -- during the meeting of today days I would have picked as being an excellent coordinator, and I told them in front of the group and McKenzie that he's the one that ought to be coordinator, so it's in the minutes. They know the story. I have been receiving phone calls too. 39 1 DR. MARGULIES: I think both of these that we have 2 discussed represent some progress reports and I think they sort @ 3, of set the stage for what we have to talk about in a moment. i 4 would also like to mention to you since we last met that there 5 have been some other coordinator changes. Fitz has resigned b from New Mexico and he's been replaced by Jim Gay, whom you 7 know I'm sure, Bland, a neurosurgeon. We won't hold that 8 against him. We'll assume he can do well anyway. | 9 DR. CANNON: He's an organizational man. 10 DR. ROTH: Can he survive the fact that he was a i classmate of mine? @ | 2 | DR. MARGULIES: I haven't tested him on that one, 13 either. : 14 DR. DE BAKEY: Is Fitz staying out there? 15 DR. SCHREINER: No.) 16 DR. KOMAROFF: He's thinking of spending a year with 7 the Commonwealth. | | 18 . DR. MARGULIES: ‘That's my understanding. There's a 19 new coordinator in Nebraska. Morgan has resigned and has Seen 20 replaced. Al ileustis has retired and they are in search of | 21 a new coordinator at Michigan. This was retirement because it ® 92 was a time in his life when he wanted to retire. There was no 23 particular issue involved in that one. 24 Are there others that you recall at the moment? Ace Federal Reporters, Ie. MR. PETERSON: I think the Greater Delaware Valley 10 1 © 12 13 14 15 16 17 18] 19 20 @ 21 “22 23 24 Ace ~ Federal Reporters, Inc. 25 31 one has been known for some time. DR. MARGULIS: We talked about that. There is a replacement in the coordinator in the Greater Delaware Valley on an interim basis. They haven't selected a new one. Now, let me just bring up -- and I don't think we can get very far with this discussion this afternoon -- some of the problems which you will see, and this is in anticipation of the review of the New York programs because it was impossibid| for us to further escape the issues which are involved in those programs and it was a rather extraordinary exercise during the review committee which was more hysterical than historical so far as I was concerned; that they went to the program in Rochester and Albany and the one in Syracuse and independently each of these review committees recommended that somebody be found as an assistant coordinator to bolster up the existing coordinator so he can somehow function in an effective fashion, and it seems to me apparent as I sat listening to them that what they really were talking about is fire these guys and get some- b ody who's good. Well, that appears to be a more complicated device in the flow of events than it needs to be because that really ‘is the problem in each of these cases. The rather extraordinary situation in New York in which you once set up on a regional basis would appear to be very sensible arrangements around the medical schools, and some of them with most remarkable resources 10 1 @ 12 13 14 15 16 17 18 19 20 ® 21, 22 23 24 Ace — Federal Reporters, Inc. state New York and with a variety of circumstances and apparentl 25 like Rochester, which should be an ideal place for regionailiza- tion of medical care ~~ and with the exception of RMP tends to be that kind of an area -- and I think it has never happened there any more than it has in Albany or in Syracuse. The review committee was very reluctant -- in fact, they refused to make any comment for your benefit on what needs to be done about New York, but they were deeply troubled by the fact that you had one good PNP in Buffalo and the rest quite inadequate. In the rest of New York you're dealing with cown- , no natural mechanism, no political mechanism, no social mechanism in the State of New York to bring these groups together the way one might have been able to do as we did in Ohio. At least there was enough commonality to begin to talk to them about it. Now, the only kind of encouragement I have had was an opportunity I took to speak with Dr. Mou, who is Vice Chancellor of Medical Affairs at SUNY, State University of New York system, and I raised with him the possibility of creating a kind of coordinating environment in the State of New York through their educational process which has an amazing strength. You Know, the SUNY system has something like 350,000 students in it and at the present time is, by far, the largest source of health manpower, excepting physicians, for the State. The poor guy had to go to a meeting with 32 deans of 10 7 @ 12 13 14 15] 16 17 18 19 20 @ 21 22 23 24 Ace ~ Federal Reporters, inc. 25 33 nursing schools, and a fellow who can do that and come through is capable of some some very remarkable things. They have set up in the SUNY system a kind of advisory steering committee which has on it such people as Ed Pelligrino and the new dean of Downstate, who, interestingly enough, is Plimpton, who has resigned his position at Amherst to go down there to get back in the medical education end of things. | I have suggested that we would be very willing to talk with that group about the health care systems and the educational potentialities in the State of New York. We might be able to get a total view of, what needs to be done by that kind of a route, but SUNY is involved with only some of the medical schools which have RMPs and is not involved with others. The CHP agency is not well-designed in the State of New York for that purpose and we don't have any pivotal point upon which to bring these together. So I think we will have to seek some other kind of political method to move into the area and if any of you have Some wise thoughts on it they would be most welcome, because it's going to have great difficulty in surviving. I don't think anybody seriously believes that we can solve the problems of metropolitan New York versus the rest of New York with or without RMP, so I'm not proposing that. But you will find, as you get to the review of these programs, that it's a tough one 10 14 16 17 18 19 20 @ 21 22 24 Ace —Federal Reporters, Inc. 25 nN @ 12 13 15 23 34 and it isn't simply a matter of leadership in that case but a matter of separatism and the lack of territorial interest. DR. DE BAKEY: But, Harold, there has to be’ some kind of certain ingredients ina place like Rochester. Now, they have great strength in their medical school. They have great strength in their surrounding community. The practitioners in that area are certainly a good group, and you can't help but feel that there must be some factor or some ingredient that is i missing in not being able to develop the concept of a good RMP program in that area. DR. EVERIST: Well, they have been project oriented the whole time and their projects have been pedestrian, and that's one of the major reasons they haven't done anything. DR. DE BAKEY: But, you know, I can understand that , they have been project oriented and I agree with you that many lof their projects are certainly lacking in any innovative aspects, but it seems to me like it's more than that. I get the | distinct impression in discussions we have had previously about them and the reviews we have had previously of their projects and so on that it's kind of being used -- not really being developed for the purposes of the goals and objectives of the RMP, but rather being used for sort of isolated purposes within the area, that somehow the concept has been missed and it's been used by both the practitioners and the university group by simple projects which in a sense isolate the activity 104) ' suspect that there is a way of getting at this problem which is i © 12 13 14 15 16 17 18 19 20 @ 21 22 23 24 Ace ~ Federal Reporters, Inc. 25 ‘to a lack of leadership in giving them the concept and a lack of the RAG group in understanding the concept. ‘avery nice guy, and it always comes out the same way. "He's such a nice fellow and he's served us so well in past years that ‘ what can you do about it?" 35 for that sort of isolated purpose. Again, I can't help but feel that it must be related DR. MARGULIS: Well, I think you're right. In each case we have the interesting phenomenon of a coordinator who's I guess all I'm saying at this point is that I not the same as the Ohio one but which I'd like to have you bear in mind tonorrow as we go through the review process because it's a common kind of an issue. DR. EVERIST: It looks as if that one is a natural for the California type of solution. DR. MARGULIES: It could be. Now, one other thing that I want to mention that we have brought up in the past having to do with this whole territorial problem. You may remember that the State of Nevada was keenly interested in being separate as a Regional Medical Program. I think that the intensity of interest in going in that direction has been ameliorated somewhat, but the issue has not disappeared. One of the things which I believe they recognized in 10 1] © 12 13 14 15 16 17 18 19 20 @ 21 | 22 23 24 Ace — Federal Reporters, Inc. 25 ’ 36 the process of trying to become separate is that the funding circumstances didn't suggest that there was any great advantage ’ to them in thus doing so, so that is less of a problem. The State of Delaware is something totally different and the State of Delaware is determined that it will be a Regional iledical Program separate from Greater Delaware Valley, which does not leave us unencumbered with other kinds of problems, and they have pushed very hard through the governor for the creation of a new arrangement with a separate RMP with “some strong concepts about comprehensive health planning being 4 ' developed to a higher level and with a new kind of state government which has a Department of Human Resources and which really does know what it's about. They argue that there is no way in the world in which the State of Delaware can get the attention from the city of Philadelphia and that's rather hard to argue against. They have a combination of health manpower people, facilities people, welfare groups and so forth, who are working well together, and have a clear idea when they come to us of what they are after. What is now under discussion, and we are going to be having some meetings with them very soon, is the possibility of doing something which the Secretary and the Administrator of HSMHA are interested in, and that is using a small state like that as a place in which one can test the possibilities of 10 YW © 12 43 14 15 16 17 18 19 20 @ 21 22 23 24 Ace — Federal Reporters, Inc. 25 37 combining state and federal health activities in some sort of quasi-governmental structure which would include an input from the Regional Medical Programs to make some sense out of their health care system in what is really an area not very large territorially and not very large in population. Most of its major territory area resources are outside of the area, like in Philadelphia or in Baltimore or even in New York. So the discussion is moving in that direction. It's. becoming a bigger kind of an issue than just RMP and is really becoming an expression of interest in HEW in finding other more sensible ways of dealing with state governments and with their health activities. | This still leaves us, however, no matter how it comes 4 out, with the problems of the relationships between Delaware and Philadelphia and the Greater Delaware Valley and all that that implies, not the least of which is the very keen interest of Chairman Flood, and I think that has to be borne in mind. In fact, I bear it in mind regularly. | | So I think that we haven't resolved that one either, but the push is there. The governor is concerned and he's not backing away from it. He knows what he's after and I think that we are likely to see some kind of very specific proposal come in from there. What we did tell them is that there is no reason why they and the State of Delaware cannot initiate on t heir own an effort to create a separate RMP, set up the 10 "1 © 412 . 13 14 15 16 17 18}. 19 20 e 2] 22 | 23 24 Ace ~ Federal Reporters, Inc. 25 38 organizational structure and bring it to the Council for its consideration, and they plan to do this. DR. CANNON: Have you heard anything from New Jersey? DR. MARGULIES: No. We have left them out of con- sideration for the moment also.. DR. EVERIST: I think that would be a great idea, for RMP to pick up and take a leadership role in the business of this experimental plan with a state the size of Delaware. DR. MARGULIES: I think it has very good possibilities If you look at the State of Delaware, it's also a rather ideal place for an area health education center in Wilmington. It's got all the potentialities. whey have got a strong Veterans Administration hospital activity there and it was one of the places selected in the Carnegie Commission Report -- and certainly not the place for a medical school, with all the medical schools right across the border in Philadelphia -- but they have a sense of integrity as a state which they want to stick with. Now, it's fairly late, so I'm not going to go beyond this point, excepting to suggest to you that a lot of the dis- cussion we have been having in the last few minutes has been raising issues of regional distribution and raising questions of state boundaries, and we have from time to time been asked to reconsider -~ and I'm sure it's going to happen in the future, and the future may not be too distant -- the whole issue 10 11 13 14 16 17 18 “19 20 © 21 22 23 24 Ace — Federal Reporters, Inc. 25 39 of what sort of division of regions we're talking about in the RP. I will share with, you in the very near future a paper which we prepared, primarily with Pete's input, on the issues which would be involved in ‘considering state boundaries for RMPs rather than the original concept. I can see Bland | flinching already, but, nevertheless, if you look at all the issues on the way they're presently distributed and ask yourself well, where does RMP work well and where does it work poorly and. are the original issues the same as they are now and what is happening to the political system in terms of state boundaries; how will it be affected by new concepts of federal/state relationships and so forth; it's something which is not going tq disappear. It's going'to get closer and closer to some kind of resolution and we are not ready for it now but we have to think about it. You know, Bland, we only have really two areas which represent the kind of problem that Memphis is, and that's Memphis and St. Louis. When you start looking over the other parts of the country, they are virtually all state boundaries or several programs within a state or multiples of states. We can make exceptions, but I think that there's a lot of pressure to move in that direction. DR. CANNON: You're not going to -- well, we don't want to _ into that argument now, but when you start shaking up the natural trend of referral patterns and geographic units “. 10 ~ @ 12 13 14 15 ~4 16 4 7 4 18 |. % 19 20 @ 21 22 23 24 Ace — Federal Reporters, Inc." 25 wy ‘there any way you can find out -- I understood the Senate/House 40 that have been set up in this country either by natural rivers or highways or whatever, the culture of an area to make it fit into the political boundaries of states, I think you're going td get this program into trouble, Harold. DR. MARGULIES: I always like to hear a guy from the South speak against states' rights. DR. CANNON: I know, but I can see it will ruin the regional program. ” DR. MARGULIES: I think this is a very good point upon which to adjourn the meeting today. I would like to adjourn on a happier note because I just received a letter today which is the kind I like to see occasionally. This is addressed to Paul Ward from Carl Smith, who is the Acting Director of CHP in California. | (Reading letter) DR. DE BAKEY: Harold, only one other thing. Is Conference Committee was meeting today. DR. MARGULIES: On the appropriations? DR. DE BAKEY: Yes. I think we can find out about it. DR. MARGULIES DR. DE BAKEY: It would be nice to know because of all the talk we have heard here. You know, one thing you've got to keep in mind is that unless we get the money it doesn't do any good. 10 P| @ 12 | 13 14 45 16 17 18 19 20 @ 21 22 23 24 Ace —Federa! Reporters, inc. 25 4:25 p.m.) DR. MARGULIES: Yes, I know about that, Thank you. (Whereupon, the Executive Session adjourned at 41