Al Transcript of Proceedings DEPARTMENT OF HEALTH, EDUCATION, AND WELFARE BHES REVIEW COMMIS Ws) MEETING Rockville, Maryland Friday, 22 September 1972 ACE - FEDERAL REPORTERS, INC. Official Reporters .415 Second Street, N.E. Telephone: Washington, D. C. 20002 (Code 202) 547-6222 NATIONWIDE COVERAGE CR 49 ] Cc paw - 2 10 1 oe . 13 14 15 16 17 18 19 20 21 ( 22 23 @ . Ace — Federal Reporters, Inc. 25 DEPARTMENT OF HEALTH, EDUCATION, AND WELFARE RMPS REVIEW COMMITTEE MEETING Conference Room G-H Parklawn Building Rockville, Maryland Friday, 22 September 1972 eo." TG: . paw 4ce — Federal Reporters, 10 11 12 13 15 16 17 18/] 19 20 21 22 23 24 Inc. 25 14 CONTENTS een ee AREA: Mississippi Missouri New Mexico Northern New England Texas Indiana Memphis PAGE 52 95 139 157 193 210 oe” . 2 ba l 3 10 11 © 12 13 14 15 16 17 18 19 20 2] C 22 23 eo . Ace ~ Federal Reporters, Inc. 25 for the committee and then stop and talk a little bit about the BROCEEDINGS DR. SCHMIDT: I think probably we should begin. We thought that the order of the day would be to begin with Mississippi, which is the last of the demonstration presentation visual aids and the sources of information coming to the committee. Then go on to a report of the Missouri Site Visit and kind of a status report on Missouri. Them move to my state, New Mexico, northern New England, Texas, Indiana and Memphis, in that order, finishing before coffee break this. gorning. So wie will begin then with Mississippi. Dr. Hess. — DR, HESS: Thank yous I would Like to begin just by giving particularly for the hew committee members a little bit of background on Mississippi so that you understand a little bit better what some of the specifics are in our discus- Sion today. | | At the April 1971 Review Committee meeting, when Mississippi “RMP was reviewed, a number of us were very con- cerned because of a program which did not seem to be functioning very effectively in a region which perhaps has some of the greatest needs of any region in the country by almost any health or economic index you want to pick. Mississippi is at the worst end of the spectrum, whether it be per capital income, whether it be physician population ratio, whether it be neo- natal mortality, you name it, Mississippi is at or near the bottom. Y #1 1 10 1] / 12 © 413 14 15 16 17 18 19 20 21 C 22 23 @ 24 Ace ~ Federal Reporters, Inc. 25 We were very much ‘concerned that rather than unduly punishing a region, that this region above all else needed some assistance in order to get itself reorganized to qualify for funding more appropriate to the needs of the people of the region. As a result of that deliberation, an assistance site visit was scheduled in September of 1971. And a number of staff and consultants visited the region. We had two days of frank -- listening to problems and discussion and feedback to the staff, the coordinator, and to select the members of the RAG. And then we returned to wait and see what happened. Some of us who were on that September site visit returned again to see what had occurred. We might just indicate for you some of the -- I haven't had a chance to look at them, some of the recommendation that were made at that September site visit. Concerning the regional advisory group, we recommended very strongly that they review their committee structure and reorganize it more in keeping with the new directions in which RMP was moving. At that time it was largely categorical in its orientation. And we specifically recommended that they deal with questions of planning and evaluation and help the RAG‘ | become more intimately involved in these activities.. The core staff was: not functioning particularly well. One of the problems was they were quartered in a variety of locations around the University of Mississippi Medical Center m 5 #10 «61 f} and this physical separation did lead to some fragmentation ©. 3 2|) and lack of coordination of activities. | 3 And we also recognized that there was some need 4|| for better communication and stronger leadership thrust 51 from the coordinator. We also recommended that they consider 6] setting back their time deadlines for their requesting a re- 7 vision in the time for application in order to allow them more 8|| time to make the adjustments which we recommended. 9 We offered the assistance of the regional office 10}? in Atlanta, RMPS staff in Washington and pointed out they had Iti] a. good deal of work to do. The items that we will report on and discuss today then deal to a large extent with many of the 12 © 13], changes which have occurred since that September site visit, and 14]| Tobert 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 1g|| about two million two hundred thousand people. The region 19], 18 bordered on the east by Alabama, on the south by the 20||Gulf of Mexico and part of Louisiana. On the west by Louis~ 21||iana and on the north by Tennessee. C 22 ' §o the upper counties of Mississippi are somewhat 23|| shared with the Memphis Regional Medical Program in planning @ 24||an coordinating of activities. There are two distinct geographi Ac e - Federal Reporters, Inc. 25 cal areas of the state. The first area is the north and south t # 1 1 10 VW e . 13 14 15 16 17 18 19 20 21 C 22 | 23 @ 24 Ace —Federal Reporters, Inc. 25 Delta which starts in the Tennessee border, goes on down through over to Vicksburg. It takes in the whole area. It takes in all that portion of the Mississippi Plain which lies within the state border and which comprises what usually is referred to simply as the Delta. | ‘This area is one of the two geographical areas, it is by far the smaller taking up about one-fifth of the total land area of Mississippi. It is the only section of the state where agriculture still provides more personal income than manufacturing or government but this is changing due to the influx of small industries, the inability of crop producers to pay a minimum wage and the technological advances in farm machinery. The other area is the Fast Gulf Coastal plain stretching in Mississippi from the Tennessee hills of Appalachia in the north to the Point Hills of the south which terminate along 359 miles of Golf Coastal shoreline. Mississippi is almost uniformly rural in terms of population distribution. The basic urban structure is the small town, often housing one or more light industries but frequently few phy- sicians, nurses or dentists. Poverty was and is a fact of life for too many Mississippians regardless of race. A total of 154,000 families or 50 percent of all families in Mississippi earn less than $3,000 per year and are ranked in a poverty class. The Mississippi RMP 10 iT 12 © 13 14 15 16 17 18 19 20 21 ( 22 23 ® 24 Ace — Federal Reporters, Inc. 25 headquarters is located in Jackson which is also the capital and is also the location of the University Medical Center who serves the grantee for PMP , There were two subregional offices of the RMP located in oxford ana in Gulfport. These offices were just recently established, with supplemental funds awarded to the region for health services, educational activities.. The future plans include a joint staffing of the Oxford office with staff from the Memphis RMP (Slide), there are ten economic development areas in the state. The Mississippi Regional Medical Program recognizes the fact that health care generally follows trade patterns in Mississippi and the ten districts form the basis of any approach to improving health delivery systems as well as the care people receive in the region. These ten areas are also designed to become the comprehensive health planning areas of the state. CHP agencies located in Jackson and there are two CHPB agencies currently funded, one in the southwest and the other in the Three Rivers area. Two more have applied for-funding, Central and Northeast, (slide) and the RMP has been actively involved in the develop- ment. of the agencies and they have a close working relationship with this staff. It should also be noted here that Memphis is also assisting in the formulation or development of some of the agencies in the northern part of the state (slide). This 8 #1 l 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||}médical center in Jackson. During the past yéar the Mississippi 7|| RMP 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. 11q- There are 37 members Of. RAG, with an adequate 12|| balance of consumers and providers. The involvement of RAG © 13|)members this past year is one of the more positive steps 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 1g,it shows the comparison of what has been and what is to be durin 19 the next triennium period. Cledrly it illustrates the change 20} from a categorical program to emphasis’ on multi or non-categoric 2) || activities. ( 22 ' This has increased from an average of 15 percent | 23||Guring the first three operational years to 49 percent which is @ 24||proposed in this current application. It should also be noted Ace deral Reporters, Inc. - os , ara Meporiets 25 that previously a large percent of the program staff budget #} 1 10 1 eo... 13 14 15 16 17 18 19 20 21 C 22 23 @ .: \ce ~ Federal Reporters, Inc. 25 program staff are full time employees of the RMP, with the went into the medical school for supplementing some faculty Salaries. This is no longer the case. All members of the exception of the Assistant Director of Planning and Evaluations who is alsoa private practicing physician. During the (slide) site visit of September 1971 one of the major concerns of the site visit team was the organizational structure of the region both in the program staff and regional advisory qypup. | this overlay illustrates the complexity of the organi- zation prior to September 1971- and very clearly illustrates the categorical make up of the region. There were categorical coordinates, as you see here, that related directly to the coor- dinates of the RMP, and program staff had very little liaison with these people. | ‘The regional advisory group, the categorical committees were composed of non-RAG members. And RAG was no more than a reactionary group. .The categorical committees were actually directing the program. (Slide) | _This is certainly no longer the case and we feel that the restructuring of RAG and program staff has been a major accomplishment for the region.This reorganization was begun during a retreat in early. December of 1971. The program staff are young, dedicated, very cohesive hard-working group. All of the positions are filled with the 10 i @ 12 13 14 15 16 17 18 19 20 2 C 22 23 © 24 Ace — Federal Reporters, Inc. 25 10 exception of the Assistant Coordinator who ‘they are looking for now. And the part-time Assistant Director for Planning Eval- uation I have already mentioned. (Slide) The restructuring of the Regional Advisory Group has resulted in total commitments and involvement of all RAG members. No longer. are’ there commitments of non-RAG members. Each member of RAG is requested to serve on at least one of the task forces. Each task force is responsible for one or more of the goals of the region, and members are involved in reviewing and monitoring the activities and projects that pertain to these goals. And the goals of the region are shown in. each of the task forces, manpower, professional education, health systems design, EMS and public health education. DR. HESS: As you can see from your previous document there were four staff visits to the Mississippi Region during the late part of 1971-1972, as well as numerous telephone contacts and various other forms of assistance. The site visit team for this visit as you can see included Dr. Merrill of the Council, Dr. Nichols, who is a black physician from Susquehanna Valley, Mr. Donald Tranto from Georgia RMP who was a very. valuable asset to the team. Mr. Van Winkle of Harvard, Mr. Ashby, Mr. Nelson, Mr. Ballou and Mr. Grift from the regional office in Atlanta. This application that we are to consider today includes a request 10 VW 13: -outside of the medical center. ‘This has accomplished several 14 15 16 17 18 19 20 21 C 22 23 @ . Ace ~ Federal Reporters, Inc. 25 effectively together. 11 for triennial status; Expansion of program state, and funds for additional regionalization, developmental components, con- tinuation of three previously approved funded projects and funds for 19 new projects. Going over now the review criteria as outlined in the site visit, as already mentioned by Mr. Torbert the roles and objectives of the region have been revised and are mor in keeping with the new directions of RMPS. The coordination between the university medical centers and the Mississippi RMP appears to be extremely good, there always has been good working] relationships there and these continue. ‘The Mississippi RMP has moved into new categories things. First being that the staff are all together now physically, where they are able to communicate and work more And it also has removed any -- some of the questions that existed about undue influence and too’ close liaison with the medical center. We found no problems of real concern in this area. Some of the statistics which reflect hopefully in part the impact of the Mississippi RMP are shown here in the site visit report. Some of them are very dramatic. In 1968, the neo- natal death rate was 28 per hundred thousand live births in Holmes County. This was reduced to 19.8 in 1970, and 7 in mm 12 #1 411971. 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 muvee 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 gi| functioning renal disease program there as near aS we can tell. 9} One of the important accomplishments of this program is to 10|| reduce the cost of dialysis for their patients. lif - They bring families and patients into the medical 12) centers, train them in the use of dialysis and then through © - 433i) 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 15 the dialysis for the patient. 16 Heart clinics have been set up around the state which 17|| have been -~ have resulted in care being given to patients who 18 previously did not have access to this type of care. The 19 existence of the stroke care unit in the medical centers has 20 resulted in the treatment of a large number of patients, the 21 training of a number of physicians and nurses from various barts ( 22 of the state who are now better qualified and equipped to 23 provide higher quality care to patients with this type of problen, @ im Ace —Pederal Reporters, inc. . 95 Pulmonary training programs and inhalation therapy 10 if ©} 12 13 14 15 16 17 18 19 20 21 22 oom 23 Qo . Ace ~ Federal Reporters, Inc. 25 13 has been established in a number of inhalation therapy aids trained who can now provide this type of service in hos- pitals outside of the medical centers located throughout the state. | | The, coronary care unit which initially was funded and operative at the university medical center has trained. 120 nurses in coronary care and they now are functioning in various areas throughout the state to provide a more sophisti- cated and effective type of care for patients with coronary heart disease. Through the efforts of the Mississippi RMP program for training of dental hygienists was initiated and this has had more spin-off, in that there is now discussion of the possibility of initiating a dental program there. But through the use of the training of these additional people, additional dental services are now available. - They have been giving attention to the question of continued support and an example of this is the Hollandale midwife project in which through the fees which are being collected for the services to patients, medicaid and so on, these fees are being put back in to help support the cost of the program. There was some concern about what withdrawal of some of the support to the Medical School faculty might mean in terms of their availability to participate in RMP programs 10 VW a 12 © 43 14 15 16 17 18 19 20 21 C 22 23 24 Ace ~ Federal Reporters, inc. 25 14 and continue education and so forth.’ And the Dean indicated that there was some uncertainty as to how much of the time of the medical school faculty might be -- he might be able to fund and pay for out of other sources in order to continue some of the thrust which they had begun in earlier times. The region is giving attention to the improvement of health care delivery for underserved minorities, this is a major oe of emphasis for the region, and all of these projects that have been conducted in the past have had very important impact and emphasis on the care of underserved minorities. | The needs are tremendous in this area and what has been done is only beginning then to scratch the surface, but the region is certainly very conscious of these needs and appears to be taking appropriate actions. As far as minorities on the staff, currently they have one minority professional and one minority secretary, and this is an area that we gave additional emphasis to, on the site visit, and they expressed their intent to employ additional minority people in unfilled positions or as new positions open up. One of the outstanding programs which has been conducted there is one in which they are seeking to attract black medical students who are going to school outside of the state to come back to Mississippi and practice. As I am sure most of you are aware there is suddenly #1 ] 10 im 12 @ 13 14 15 16 17 18 19 20 21 \ 22 23 24 \ce ~ Federal Reporters, Inc. 25 15 a nationwide competition for qualified black medical stuents, and many of the best students, black students, in Mississippi are being actively recruited by medical schools from all over the country, and are going there to continue their education. Through the black physicians in Mississippi, Mississ- ippi RMP, these students have been, many of these students have been contacted and brought back. and discussions were held in an effort to show them some of the changes that are happening and to develop in them a desire and commitment to retugn to Miss- issippi and practice when their training is completed. I was going to take sometime now -~ now it is going to take sometime to know how effective this effort will be but it certainly seems to be an appropriate one. Along with this is a much greater awareness in the University of Mississippi itself, of the need to admit black students within their | own state and they seem to be making progress in this area. Going on to the coordinator, the ~- Dr. Lamton has been coordinator since January 1971, and we found evidence on this site visit that he indeed is beginning to exert a much stronger leadership role than when we were there in September of 1971. At that time he was relatively new and feeling his way but after the site visit and the report which came back he has not hesitated to take the recommendations seriously and to move on them. 16 #1 1 . 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 kinds 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 pickedup none of that kind of thing. And 7\| there were many indications that the working relationships 8) have improved. His relationship with the RAG seems to be 9|| cordial and effective and we found no evidence of any discord 10]) in that area. Tie. . The program staff has been strengthened, they have 12}} hired a number of additional people who seem to be quite © 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 that 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 19|| axe not sure. But it was evident to us that this is an area 90|| that does need strengthening, and one of our recommendations is 2}|| that this be made a full-time position, and that the new ‘' L 22|| people that they have brought onto the staff be given some - additional training and orientation so that this area of core 23 @ 94|| staff might be further-strengthened. Ace eral Reporters, Inc. | 25 They have a new person in the area of evaluation. #1 1 10 HW gg 12 eo . 14 15 16 17 18 19 20 21 Lo 22 23 24 ice ~ Federal Reporters, Inc. 25 17 From our aiscussions with him he seems to be a competent person, a lot of good ideas and a good approach to evaluation and we are hopeful that the evaluation might improve over the next year or two. Regional advisory groups represent the key health interests in the region. And as indicated by Mr. Tobert's presentations now much more actively involved in planning and decision-making for the region. Attendance at the RAG meetings have been running over 50 percent, they have requirements that if more than three meetins are w#issed then the member is dropped from the RAG. The grantee organization is performing its function effectively as we could tell and we have no questions about that. The major health interests are participating and there are a’ wide variety who are involved and they always seem to be in full support of the objectives, and -- of Mississippi RMP — and what it has accomplished to date. Mr. Tobert indicated the -- how the state is divided into subregional areas for health planning and RMP has been instrumental in helping to facilitate this development and they: are working closely inthe development of these local planning areas. Active discussions are going on concerning organizatio} in nine of the ten areas, and five of these are in the active planning stage at the present time. There is an adequate mechanism for obtaining CHP review and comment. ray #1 a 16 2 10 is 12 eo . 14 15 16 17 18 19 20 21 ( 22 23 24 Ace ~ Federal Reporters, Inc. 25 18 The Mississippi RMP has participated in and/or has available to ita rather large data base documenting the | health fields and resources of Mississippi. However, there has been thus far an apparent lack of the expertise needed to move from available data to program development. This is an area we emphasized to them a number of times and we are hopeful that there. might be some immediate and further movement on this and we have a recent letter from Dr. Landon indicating they have already begun to take steps to address this issue. All the current projects in the current triennial application were developed concurrently with re-thinking of the goals and objectives and restructuring of the RAG and program staff. Consequently the projects have not evolved as a-result of the re-thinking which has gone on during the last few months although several of the projects are compatible with that expressed by the new goals and objectives. ‘Coordination program staff has improved substantially and they have developed a plan for systematic monitoring of individual projects both by written reports and site visits, by project monitoring teams which will include program staff,. ' RAG members and other consultants. Written project progress reports and financial reports are also a standard requirement. We have already mentioned about the new full-time evaluator for whom we have a good deal of hope. He did not have An Opportunity to have much influence on the evaluation aspects HY 10 TI 12 °° 14 15 16 17 18 19 20 21 C 20 23 @ 24 Ace —Federal Reporters, Inc. 25 19 of the projects which are submitted in the triennium, but he does hope to have some influerice on their functioning. And we were assured they would have an active role in reviewing and participating in the development of all new projects so that adequate evaluation is built in from the very beginning. We identified some problems in their documents, differences in evaluated criteria between the stated objectiveg the project development guidelines, the technical review cri- teria, and developmental component priorities, thw RAG rating forms and the program evaluation statement. We felt these all have been developed at different times and with somewhat different people .and we felt, we recommended that they sit down with all of these now and. try to make them consistent and uniform with one another to avoid ‘some potential confusion and improve the baiss for carrying out their evaluation. The region has established priorities. This was accomplished during the retreat. of the Regional Advisory Group in December of 1971 and they are congruent with national goals and objectives. They have begun a School of Allied Health at the University of Mississippi Medical Center, and this is on its way now. The initiation of this school has been attributed to a signific at degree by the RMP, and they: are actively on their way now in recruiting faculty and students and hopefully 20 41 || this will begin to supply a gap in health manpower in the region }. 18 2 Now getting down to the recommendations of the site 3] visit team I am going to save, wait on the financial reconmen- 4|| dations until last. We aid 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 ina 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 time director @ . 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 C£ the training of the staff some RMP 's which they might visit 16) to learn the methods and techniques that would help them. wale _We emphasized the need for developing consistency 18 with the statements having to do with evaluation mentioned 19|| earlier. We felt that their applications, their projects, needed 20 better documentation of need and this went back to the need for 21 strengthening their planning section. ‘ ( 22 We also felt that they needed to improve their technica 23 review input to the RAG, that there were some projects that @ 24|| We looked at, as examples, where we questioned some of the needs Ace —Federal Reporters, Inc. 25] 2s far’ as the equipment and budgetary items and felt that they #1 10 WV 12 13 14 15 16 17 18 19 20 21 22 21 could well benefit from some qualified experts to work with them in reviewing these project requests and determining what was actually necessary and the methods that would be most effective in addressing the methods of the project. We recommended that they should work to obtain both CHP and state funding of on-going health planning data collectiak There was one project in this. group which is directed toward improved data collection, and apparently no one is ina position at the moment to undertake this activity, yet it is a very important and essential activity for all health planning in the state. Ana we agreed that this would be a worthwhile thing for RMP to initiate but it should not be looked upon as a major on-going activity. Another question which came up during the course of the site visit was the staff salary scale which is determined by university salary scales. And we recommended that the salaries should be reviewed with the medical center administration to see if the mechanism can be developed for more adequate program staff compensation. Our concern was that this might be a liability to the program in that they may not be able to retain qualified people and, therefore, continue to build a strong program. I would end my comments at this point. - #2 arl 1 10 iT 12 eo . 14 15 16 17 18 19 20 21 ( 22 23 24 Ace — Federal Reporters, Inc. 25 22 DR. SCHMIDT: I would remind the committee that in front of them are these blackbound books that are computer printouts, and some of the questions yesterday that had to do with funding levels and money going to projects and so on, are very efficiently and effectively answered in the computer printouts, and I personally find them of great value and would recommend them to the committee for funding information. Secondary reviewer is Warren. DR. PERRY: I believe in a characteristic way Joe has done a tremendous job in reviewing the program. My greatest, interest in the program, I have not been in the region, it's been only through application review in the past, has been this tremendous concern and development in manpower potential. Educational programs have really moved in this _state. It is a state that has not had that level of expertise and such to do this. They have been calling in in the allied health area, I know three of my dean type colleagues have been down there in consultation. They have beén moving ahead, as has been said here. A member of our staff in Buffalo has been there in the dental school and dental hygiene program and moving. They're doing a tremendous job as they look at their needs in that state. They recognize the importance of all levels of health care personnel in there, and I think this is a tremendous development here. 23 ar2 1 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 question 4) but this state has made a major turn and is moving ina 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 81} table then? 9 ' DR. HESS: The site visits team had some difficult 10} in arriving at a funding jevel recommendation. I will place ll}} 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 reservations 14|| about this. 15 This came as a sort of compromise, the team 16], xrecommendation~-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 90|| leave and catch our plane. 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 figures On the sheet over here we have @ 24] broken these down. We agreed that with the expansion in Ace — Federal Reporters, Inc. 25|| more subregionalization, some of the additional activities 24 ar3 , 1 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 96,315. 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 recommendatio 10|/| was something about $230,000 below that requested by the 11j)- region for operational projects. 12 So the total ends up with 2,110,138. They had © 13], already received approval for, through supplemental funding, 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’ @ 22|| 10-month year for them. I have some personal reservations 23{| about whether they can effectively use that 1.9 million during @ 24|| that first year. | a _—_— 3 , DR. SCHMIDT: All right. Dr. Hess then moves . ard 10 VW -_ 12 Td 13 14 15 16 17 18 19 21 \ 22 23 @ 24 Ace ~ Federal Reporters, Inc. 25 20 25 with some reservations, then, the team report. Is there a second? Warren, do you second this or not? DR. PERRY: ves, I am going to second it, to get it started here. I -- not having been there, not having a chance to, you know, really be a part of looking at the new projects and such, it is a -- really a, more than a promissory note. It is really an accolade in this funding amount. I would like to ask Bill in relationship to his knowledge of the region of your feel for their ability to handle this increase. | MR. TOBERT: I share with Dr. Hess the 10-month budget at that level. I had no qualms on the second and third year at all. But I think there can be some justification in reducing the first year. | DR. SCHMIDT: Before I call on Dr. James, Mr. Griffith, the regional office representative, is here, and I had asked Ted if he has any comments. | MR. GRIFFITH: No comments at the present time. I go along with the proposed activities so far. DR. SCHMIDT: Obvious and maybe stupid question is if you are worried about the 10-month thing, why not give them ten-twelfths of that amount for the first year? DR. HESS: Personally I think that would be more reasonable. I figured it several different ways, and I think ar5 10 1 | 12 rd 13 14 15 16 17 18 19 20 21 ( 22 23 © 24 \ce —Pederal Reporters, Inc. 25 26 that would be an appropriate way to go about it. DR. SCHMIDT: Well, the chair won't intrude on the workings of the committee. Dr. James? DR. JAMES: As a new member of this committee, I get a gut reaction from the report as given and as stated — 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 without, use its own resources to develop a kind of program that seems to be evolving with the professional help that came about in December of '71, demanding new direction. And I think I would like to emphasize the fact that they have not had the professionalism and expertise prior to December of '71, apparently shows that the efforts of -- of funding apparently have been -- has resulted in the train- ing of personnel which in the long run has affected a net change in direction of what I have heard all day yesterday, that is, in fact, the people have apparently been the recipients of the funding of the efforts of the Mississippi regional program, if this is in fact what is absolutely the case, as seems to be written in this program. ‘ And I, for one, would want to re-emphasize the fact that sometimes when you don't have enough money to go on, you don't have the. expertise and professionalism which in turn helps to cloud an issue and really you do not get the ar6é 10 1 e 12 13 14 15 16 17 18 19 20 21 C 22 23 @ 24 Ace-Pederal Reporters, Inc. 25 27 services to the people, maybe this is what it is all about. And I would strongly suggest that the expertise and professionalism be offered these people on a higher scale so they can use their basics, their abilities to continue their efforts to train more people in Mississippi which net results in services to the people. - The fact that infant mortality, this is an absolute fact, it does sound, you know, almost fictitious, doesn't it? But if this is an absolute figure, can we duplicate that same figure in any other region across the _country? I think if the regional medical program did nothing else but to reduce the infant mortality rate, it has served a very useful purpose. DR. SCHLERIS: I was wondering if I could see that overlay to show how the direction has changed in Mississippi? I confess by saying I always, in driving, have been told by my family of a very poor sense of direction. And in trying to review briefly, I do have some questions to ask about specific projects. I am trying to discern what is really the changt in direction. The multiple is probably where there-is some reason for my questioning this. I am sure heart disease is probably about 13 percent. But if I look at heart disease, cancer and stroke, I would think that the numbers really don't ar7 10 11 12 oe . 14 15 16 17] 18 19 20 21 C 22 23 © 24 Ace —Federal Reporters, Inc. 25 of the hospital itself. centers, is coming in again at a significant level of support. cystic fibrosis, stroke system to be set up for $58,000. 28 reflect some of the changes here unless these are put into multiple, because as far as some of the new projects coming along the line, those to be supported; some of them appear to be very much what we have been looking at for a long time. The ongoing projects to be supported,$122,000. They put in some projects, I don't know what you did, electrical hazards, that probably went under multiple, but this is a set of a model electrical hazard safety program, and the hospital then to put it through the community. This is about $80,000. This has now been used in most communities as the responsibility} Radiotherapy is coming in as a new project for $80,000. Education of radiologists, setting up of peripheral Pulmonary therapy as a model project is coming into a 50 to 100-bed hospital to treat pulmonary disease and My concern, as I look over these projects, is that many of them are what we have been used to seeing over the past several years, and my concern is that they are isolated projects related heavily to heart disease, cancer, stroke . and related diseases, rather than being a part of a new direc- tion. Some of the new directions concern me a bit. 29 axr8 1 $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 ll]} 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 1g} 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. 21 And this, the very questions you are raising, are. C 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 money to get started and obligated on Ace = Federal Reporters, on some of these projects that I, in my own mind, thought ought ay arg Ace — Federal Reporters, 10 W 12 13 14 15 16 17 18 19 20 21 22 23 24 Inc. 25 30 to be low priority. Now some of these we -- site-visit team -- we felt strongly ought to really be looked at very carefully. We told them so in Poeauaer session, that we just questioned whether these were consistent with the needs and so on of the region, and that they needed to go-back and rethink that whole business and look at those projects again. Now, I think they are developing the mechanism and the wherewithal to do that, but this application does not. reflect that kind of thinking, you see, and it is a question of how much faith we collectively have in their ability to go back and look again at these projects... My own feeling is that there should be enough restriction on funding that they can be very selective about which ones they choose and which ones they choose to fund -- which ones they choose to fund and which ones they choose not to. And they are going to need some continued help and supervision in order to get things organized and consistently moving in the direction that we would like them to be. DR. SCHERLIS: Well, my concern is that once we gave them developmental component, it should be on the basis of our knowing that they have indeed demonstrated a change in direction, because in looking at the projects, I have a feeling of deja vu as far as what we would have a few years ago of arl10 10 11 4 12 © 13 14 15 16 17 18 19 20 21 C 22 23 Ace ~ Federal Reporters, Inc. 25 31 seriously challenged as being bits and pieces of projects coming in from all over. - > I am sure they will do something, but I don't know if they really demonstrate any program, you know; our concern should really be program, we shouldn't be talking projects, and our chairman’ has been most kind in letting us talk projects, because I don't see it as a program, but as bits and pieces of unrelated projects. My immediate reaction is I question whether we have had a demonstration of their change in direction, but rather what we have been shown is that they recognize there should be a change in direction, have given us a list of projects, that while they will do good, I am sure, doesn't really reflect a level of maturation to demonstrate that they are ready to go in the developmental component. I would like to have some other points of view on ‘this. I know this is not the view of the site-visit group. mea-1 CR 7149 #3 10 11 © 12 13 14 15 16 17 18 19 20 21 “—— 22 23 @ . Ace ~ Federal Reporters, Inc. 25 32 DR, LUGINBUHL: I: would like to summarize my views on what I have heard. It seems to me this is an area of desperate need. We would like to give them as much funding as they could well use. Also it seems if they had made real steps toward developing an organization, that we are all concerned that they are still pretty embryotic in their development; they are still focused on projects that aren't very well coordinated, and if we give them too much funding, they are likely to commit themselves very deeply to projects that will not readily be pulled together in a coordinated program. From that basis I wonder if it wouldn't be wise to take a hard look, particularly the first-year budget, with the thought in mind that if indeed they do set | priorities, that they do move. towards a coordinated program; that funding could be increased more rapidly in the second and third quarter. Specifically it is not clear to me from the yellow -sheets as to whether their first-year requests, indeed for a ten-month period or is it for a 12-month period; if it is. for a full-year period, I would think this would reinforce the suggestion that that be reduced to five-sixths of the amount suggested over here which would be about $1,505,000, Can someone tell’me, is that first-year request for ten months or 12 months? - mea~2 10 1 12 13 14 15 16 17 18 19 20 21 22 23 24 Ace — Federal Reporters, Inc. \ 25 33 MR. TOBERT: It is for ten months. DR, LUGINBUHL: That would seem to me to be a rather large increase and I would Like to move an amendment if that is in order. DR. SCHMIDT: The Chair will accept a move to amend. | DR. LUGINBUHL: To reduce the first year to five-sixths of the amount up there. I-will leave the exact calculations to someone else. I did it very quickly; it is about a million and a half dollars, and to omit the developmental component for the first year. DR. SCHMIDT: There is a move to reduce the amount to five-sixths and omit the developmental component for the first year, leaving the second and third years at the recommended level but with obvious interaction between staff and the Review Committee prior to the funding of the second year. Do you accept that total restatement of your - -amendment? DR. LUGINBUHL: Yes. DR. SCHMIDT: All right. Is there a second? . MISS KERR: I would second. DR. THURMAN: Joé is afraid to ask you what you thought. You said you compromised upward for the plane. mea~-3 “0 34 1 What would you really think? td : 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 3 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 ? infections in hospitals, electrical hazards and so on were 10 ones which obviously came up -~ we were very surprised that as 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 is 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 confidence in 22 what was happening, give then 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. Ace — Federal Reporters, Inc. aa . 25 DR. THURMAN: Mr. Tobert, what is your feeling mea-4 10 HW © 212 13 14 15 16 17 18 19 20 21 22 23 @ . \ce — Federal Reporters, Inc. 25 - . 35 about staff reaction to the business of cutting them, this level or lower? We heard a lot yesterday about how if we did not show our faith, hope and charity that we might seriously hurt somebody. MR.-TOBERT: No, I don't think this would affect. the operation at all. DR. THURMAN: What I am really asking is 1.5 or lower. Let's look at both of those, 1.5 and then also | : 7 ~ the lower because I share every concern that Dr. Scherlis. had. - MR. TOBERG: If it is any lower than 1.5 without a developmental proponent, I think it might have some concern on the staff. DR, SCHMIDT: The move to amend was so inconclusive that it isa substitute motion and so really the motion we are talking about right now is the lower amount, John, first. DR. KRALEWSKI: I am in sympathy with cutting the thing back. I have mixed emotion over developmental components, whether we give it to them in programs and help them organizationally to-do this or whether we give it to them as a pat on the back. Organizationally speaking I had been inclined to 36 mea-~5 } 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 220,000 which must be 3 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, going up perhaps around a hundred for ? the second two years, with the cutbacks to bring the total 10 budget down to a million and a half, taken out of the Vy - 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 right, the motion now includes 20 a developmental component of 96,000, which, for the first 21 year then. How about the second and third years? 22 , DR. KRALEWSKI: I suggested 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? | Ace — Federal Reporters, Inc. ; . a, 25 DR. SCHMIDT: All right, 90,000 the first year and mea-6 10 ae e | 13 14 15 16 17 18 19 20 21 \ 22 23 24 Ace ~ Federal Reporters, Inc. 25 3/ a hundred then for years two and three. So that is the motion that is now on the floor. | Further discussion? If not I will call, "Question.' Bill? . | MR. TOBERT: By reducing the developmental component for the second and third year does this in effect reduc’ the total amount you are awarding for those two years? DR. SCHMIDT: Yes, it would be a reduction of 1 110,000 year two, 120,000 in year three, Year one, it would be, without calculating centrigrade and Fahrenheit, are you going to take five-sixths of the amount after the subtraction or before the subtraction? Oh, developmental component isn't subtracted. So it is five-sixths of what? DR. KRALEWSKI: What I was suggesting is a total budget of one and a half. | | DR. SCHMIDT: Including developmental component? DR, KRALEWSKI: Developmental component is 90. DR. SCHMIDT: That clarifies it. | Does the staff understand the recommendation? All right. I will call for the vote then, All in favor please say aye. Opposed no. I hear no dissent. I would like to just take a few minutes now before “moving on to a report on Missouri to ask the committee to express themselves concerning the staff efforts at presenting mea~-7 , . 38 Vi information to you about regions aS part of the review and © 2 triennial applications, that backgrounds the regions a little 3 nore, 4 | You have seen the slides that have gone up. You 5 have heard two presentations by staff as part of the committet 6 review. One of 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 of, it, the 10 detailed nature of it and soon, I called your attention 1 purposely to these books because they do have some of the 12 budget ‘breakdowns that are most handy. @ 13° You have the applications now in their new form. 14 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 they think? Dr. Ellis? 17 : : DR. ELLIS: Mr. Chairman, I would certainly like 18 to express great appreciation for the work of the staff in 19H} 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 L 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 Ace ~ Federal Reporters, inc. 25 I am just very regretful that I wouldn't have it when I mea-8 10 1 } 12 13 14 15 16 17 18 19 20 21 22 23 @ .: \ce ~ Federal Reporters, Inc. 25 present this complicated region today. and I would further make a comment and then a request. medical school and now the medical school has been cut down DR. SCHMIDT: Elizabeth? MISS KERR: I would also commend the staff for thig As I review regions which I intended and plan to visit and also which I review for reporting, I have done the same thing with my own little feeble handwriting on the map that is produced for me on the materials trying to identify locations, centers and so forth. . _ whis is very helpful I found but my request would be, could this kind of material be developed and --. and included in the review materials prior to the review, the site visit even? I think they are that important. DR, SCHMIDT: I think that would be a goal to be achieved. Certainly the mapa of the regions could be done for all regions that were coming up for trienniel review and some of the funding history and particularly things like these pies that show that the whole yellow thing was the to a little piece of pie and I think that these sorts of visuals are great, and could be done in advance. MISS KERR: For example Texas, as large as it is, I had to get some idea of locations of agencies and so forth prior to having a meaningful review from the applica- tion. So this would be very helpful. mea-9 CR 7149 End #3 9 10 1 ~ eo - 13 14 15 16 17 18 19 20 . 21 Co 22 23 @ . Ace ~ Federal Reporters, Inc. 25 DR. SCHMIDT: Let me -- I almost feel a consensus of the group. Let me ask for criticisms; assuming that the committee does favor these, let me ask for criticisms of what has been done either in length of it or detail of it. This doesn't include the Rochester one which was a 30-minute special but I am talking about the five to ten- minute quickies and particularly for other information that you would like to have that might be helpful. Bill?. CR7149 . + #4 -ter-1 . Vi: MR. HILTON: If overused in our initial enthusiasm © 2|| with this kind of a npe approach, it can probably, I think 3 envision a’time it might become monotonous. I think it is 4|| possible to guard against that if we are aware at the outset. 7 I would suggest restricitng the use of the particu- 6 lar’ approaches in the overheads to the background data. We 7 have 50 local RMPs and even though we have been to the place gi| before, individual members may have been there before, it is 9|| a good idea to have that background refresher, geography-kind 10 of display of territory, perhaps consider building up a library i1{| of that kind of data for each region. / 12 I suggest, too, perhaps some variety, like for 6 13 Hawaii, we had -- in addition to the overhead we had the little 14 plastic what do you call it, topographical models. That kind 15 of variety and other approaches to variety would help minimize 16 the boredom of this kind of approach, I would think. 7 . DR. SCHMIDT: I was hoping for some flowers, myself. 18 MR. HILTON: Yes, I would too, like to applaud the 19 ‘staff for the effort and I think it is great. 20 | DR. SCHMIDT: All right, Leonard? 21 DR. SCHLERIS: We had planned some really spectaculanz C 22 events for Hawaii. I can tell you we shared every bit of the 0 Aloha spirit at our presentation. yesterday, that we had in © 2A Hawaii. Only those of you who were there will really appreciate Ace cee eres oe what that alludes to. . ter-2 10 1] e 13 14 15 16 17 18 19 20 21 < 22 43 @ . Ace ~ Federal Reporters, Inc. 25 42 I think these are excellent. I would make one sug- gestion, that is the value of’ putting specific numbers that we are talking about on the wall chart that we have. It is really a great help and I would suggest that this be done previous to the meeting, perhaps, someone on staff could write down for each of the regions, what has been the previous level of support and what is being recommended, because we can all look at the numbers together, and it furnishes a great deal of value. | , a When you use a wall chart, just use a rough draft on the over head, where someone can cross it out and modify it. DR. MARGULIES: For one thing, as you have pointed out, these presentations are all.on prime time, so the question of durations is significant. Certainly, the kind of overlay and in-depth analysis for the beginning of a triennium, I would imagine is a first priority in putting this much effort into it. It emphasizes two things, however, and I would hope that the review committee would help to guide us in one of them, rally, both of them; as much as possible. “There is always the risk in presenting data ina particular way as a preparation for a triennium review that we will begin to influence your thinking by the way in which we put it together. ter-3 10 1] @ 12 43 14 15 16 17 18 19 20 21 \ 22 23 @ . Ace — Federal Reporters, Inc. 25 to It was quite obvious for example, we were making a point in presenting the Rochester regional medical program as’ a case study. You could also see we could have picked other programs for that purpose, We are not going to deliberately do that kind of thing, but in the selection of data and presenty7 ation, there is the risk that -that: will occur. There also is a constant problem which will grow in time in selecting data with the knowledge that no matter what we present, it is rather incomplete. A case in point, I think of Ted Griffith, down at the end of the table representing the HEW REgional Office. It would be fine if we could, in some manner, have a concept of what else is going on in other kinds of health activities within the region. To do that is without really innundating you with materials extremely difficult. But, we are going to have’to do something about how that might be achieved. It would be very helpful if one knew that, what is going on in X areas or is not related toa lot of other things which are underway or are intended from other origins. What I am suggesting is sort of reorganizing the whole Governmental system in presentation. We cannot do that. | The other thing I would like to mention, we have brought up and which Bob Chambliss spoke to you about, yester- day, is the significance, under the circumstances, of the staff 44 ter-4 1{| Anniversary Review Panel, because 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 Al; 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. :) Obviously, you are being burdened with some heavy 9 responsibilities, and you will have to accept owskind of 10 discretion in developing for you what needs to come this way, 1] || and what requires that kind of time. e 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 Review Panel. reviews further. 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 18 summaries, the written word that comes tothe committee that I 19 ‘look at gives me such a good feel for what went on with staff 20 in their deliberations that I can very quickly be satisfied, 21|| OF dissatisfied with what went on by my review of these reports. ( 22 “In the last number of years, I have detected no 23 dissatisfaction on the part of the Committee with this Staff © 24 Anniversary Review Panel process, ‘or the information it gets Mee Federal Reporters, to the committee. | ter-5 10 11 ee... 13 14 15 16 17 (78 19 20 2] i. 22 23 24 Ace —Federal Reporters, Inc. 25 anticipate other people around. That would be most helpful ‘respond in relationship to it. I think the Committee must have the perogative of asking for explanations for actions if they do not understand. But, t don't think there is any need, right now, or any desire on the part of the Committee, to.change that process, or the process of reporting the information to the Committee. That was what I expressed to staff during the past few weeks, and would ask if the Committee members disagrees with that at this point? WazEene an - DR. PERRY: I think, although we do not need,-.you know, no further approval, if..we all agree in the importance of the audio-visual, from one of the comments made yesterday that indeed, the review process might be more open and less involved. This is another important reason to have this quality and kind of material. If there, we can anticipate, you can to have those kinds of things around, so that each person can Also, I think that there can be judicious choice on the part of the staff as Harold has -said. Perhaps, for the triennium. For the important ones. Let us not get in the habit of doing it for everyone, let us do it for those that are really significant and we need for the review. SISTER ANN JOSEPHINE: I would join the other members ter-6 10 1 13 14 1S]. 16 17 18 19 20 21 CO 9 23 @ . Ace —Federal Reporters, Inc. 25 not in the area of needs. That is quantitative rather than ‘think we have not done that as effectively in the past as we 46 of the Committee in complimenting staff on their presentation. And, as I have had an opportunity to function on this committee I begun to realize that the diversity between the regions, qualitative, but the diversity is rather in where individual programs are at the present time, as compared with other programs in an awareness of how to go about meeting the object- ives of the program. And I would think that this type of rgyiew, carried 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 know, in these two programs, that I am responsible for, these efficiencies have been met very effectively and I need to communicate them with those who are working with the other programs. “And in this way we can really begin to share resource that are resources of the regional medical program. And I can do it, now. We have reached a-point'in' time, and it is really sharing facilities. DR. SCHMIDT: Let me end this by asking staff if they have any questions of the Review Committee about the information or whatever? If not -- ter-7 10 11 (g 12 eo . 14 15 16 17 | 18 19 20 21 CO 22 23 24 Ace —Federal Reporters, Inc. 25 comment on, Dick, and, that is that in the interest of express- 47 DR. CHAMBLISS: I might say on behalf of staff that we do appreciate your words of approval for these efforts in the visuals. Especially in the staff of the division of operations and development and DPT, but I think this committee should know who has spearheaded this effort in terms of the visuals. I would like to just say Miss Judy Flasher, over hers at the door, has spearheaded this, and also with equal assist- ance, Mr. Frank Schniowski, who has provided the data for the visuals. Frank is over here and you all know him. “Thank you. | MR, RUSSELL: I would like to say one thing. I think it would be helpful to the staff when on a site-visit, if the site-visitors feel, if a particular visual would be helpful then this would give us direction, we would appreciate it. . | DR. MARGULIES: That picks up what I wanted to ing the kind of diversity which you spoke and Sister Ann, everyone has recognized, if I get the sense of this committee, you will accept the idea that the development of the visual materials and the manner of it is something which might continu to be left to the style, to the interest, to the motivations of the staff people connected with the program. I think that would be better than to say, we have ter-8 10 | iF e ° 13 14 15 16 17} J8 19 20 2] os 22 23 Qo . Ace ~ Federal Reporters, Inc. 25 ‘see? nature with regard to-the region, and with committee handling, one single format which we want to follow. This will give them a greater sense of involvement and I think, they can probably do better that way. | MR. SCHNIOWSKI: Dr. Schmidt, as part of the experi- ment we had one presentation given by staff, another one that was a joint-type, Staff Review Committee and a third one,’ by the Review Committee members. The Review Committee has commented on the audio-vis- uals. I wonder if we could find out if they have any preference in the future as to the type of delivery they would like to MR. HILTON: I would go for that second approach. Specifically, with staff though there would be opportunities as Merle has already suggested, to someway propagandize present- ation to some degree, I think we will guard against it, particularly the staff covering those things that are of a geographical and demographic objective, reporting kind of the other kinds of concerns were here to address. DR. SCHMIDT: I like the quality of interchange with staff being part of the presentation. I see all the heads are going like this. DR. KRALEWSKI: I have always liked to use slides in a presentation. While I agree, I think the background data is well presented by the staff; I think it is useful as an ter-9 10 11 © . 12 13 14 15]. 16 17 18 19 20 2] oo 22 23 @ . Ace — Federal Reporters, Inc. 25 is part of what I am suggesting is part of each of these tion by Staff and site-visitors of the committee, make it a introduction. I think it is useful during the presentation to have the use of slides, also,'though, so really, what we are saying approaches we have previously outlined. | And I think that the site-visit is the time to out- line the kind of, kinds of slides, that you will need for that presentation, because then, you can highlight some of the parts of the program you feel are necessary. a .I think this gets away from the fact then, that the staff may be worrying about their slanting it in a certain direction. DR. SCHMIDT: We will want to bring this to a close, i quickly, then. DR. JAMES: Yes, I have a very, very quick coniment | to make. ~ ‘Again, being new, I certainly enjoyed the audio- visuals yesterday, and I would -concur that the joint presenta- presentation; I also would like to comment that this kind of presentation with the broader presentation of actual figures on the board, helps one to determine where the level of funding would be, because sometimes I see coming about, ceiling figures that may apply to a funding, and I believe this would help to deter the use of ceiling figures. ter-10 . ; Vi. A figure out of the ceiling. © 2 MISS KERR: One other quick request, is if it were 3|| so that we could have these graphs prior to a site-visit, and 4) then if there were such changes as were dramatic enough to show, “s5|| could this suggestion be made by the visiting team to the ‘6 staff member, and the staff member, 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? 10 SISTER ANN JOSEPHINE: Some of the regions are begin- 11 {| ning to develop their own visual material, and it may well 12|| be that some of’ the visual material they have developed could © , 13]| be used for this type of presentation, without a duplication 14 of effort. DR. SCHMIDT: I think Staff will be sensitive to 15 16 that. 17 - MR. TOOMEY : I would like to comment on the fact 18 that seems to me that we are, -- we have been asked to look 19 rather specifically, precisely, and indepth, at the program 20 problems of the organizations that we visit and with which we o are concerned. C 22 “Then, in the course of our discussions, we begin 23 to focus on projects that are part of that. Yet, it is very © 24 incidental. I cannot help but feel that the projects are Ac e~Federal Reporters, Inc.|! extremely important in terms of ananlyzing the congruence of 25 ter-11 1] 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; 9 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 it} 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. e-4/s-5 17 MISS KERR: I am assuming we need not do anything wit 18 that on our evaluation sheet, right? 19 DR. SCHMIDT: That is correct. 20 This is for information. 2) Lo 92 23 @ 24 Ace ~ Federal Reporters, Inc. 25 — CR 7149 # 4-B follows 4-A 2 kar 1 3 A 10 i 6 «212 13 14 15 16 17 18 19 20 21 \ 22 23 eo . Ace ~ Federal Reporters, Inc. 25 problem in the Missouri RMP, Frankly, it has been a program and “organizational kind of structure problem. _ committee and liaison committee being made up predominantly of Missouri people, it was a very closed kind of corporation, ‘than the University. MR,.TOOMEY: I visited Columbia a month, in company with Dr. Thurman, Dr. Pellegrino, Dr. McPhedran, Donna Howseal, Dr. Farrell, and Judy Silsbee. There has been a kind of major For instance, at the top level there is a problem wit the regional advisory group. It was initially established under Dr. Wilson in three parts. It was a tri-part RAG, a part was an advisory. council, the.wgpecond part wag project review committee, and third part was a liaison committeg which was project oriented. When these three groups met, they in a sense, represented the regional advisory group. However, they met separately as well, and with the advisory council being only 12 people and with the project revig the prior groups and most specifically, of the University of rather than an open advisory group with input from much other When this problem was called to their attention, the} made the decision that the advisory council with 12 people was in fact their RAG. In fact, it does not meet the requirements, the legal requirements of a regional advisory group because it does not have all of the representation, even the legal repre- sentation, Veterans Administration group, and I think some othe i) kar, 2] 10 11 12 13 14 15 16 17 | 18 19 20 21 \ 22 23 @ . Ace ~ Federal Reporters, Inc. 25 -in developing a set of goals and subgoals and priorities. “53 Bill, what was the other? “CHP Agency? In addition to which it had only one minority or consumer involvement. It was one, one lead who was black and who was a Housewife, and she repre- sented the female, the black and the consumer, all by herself. Their focus in the past had beeon on, naturally, the extremely categorical nature of the projects, They had been -- they had been very equipment-hardware oriented, They didn't have adequate goals, subgoals or priorities and within the past year, they. have had a group headed by, I think it is Dr. Mare who has worked, I guess, with great vitality and enthusiasm However, they felt that the objectives that should be established in order to achieve these goals should not be established by their goals committee and it should not be established by RAG, but in order to allow the local regions covered by the Missouri RMP to give to the establishment of thei: projects and their objectives, the local flavor that was necessd: they left the objectives out, They felt very strongly and organizationally they have six or seven subregions and they have a part+time°coordinator in each of these subregions and they felt. that each of the subregions was geographically so different and the’ needs were so varied that for-a central group to establis the objectives for these regions was undesirable. So they did not -- they did nothing other than establish the major goals, the purpose, the major goals and some of the subgoals, o kar 31 eo ., 10 11 © 12 13 14 15 16 17 18 19 20 21 ( 22 23 Qo . Ace ~ Federal Reporters, Inc. 25 -54 Their major goals are the enhancement of the avail- ability and accessibility of health resources, enhancement of quality care and the moderation of costs. And they have under each of these major goals, they have subgoals to the total of 13, Frankly, they have done an excellent job. Their goals and subgoals are great. And if you can accept the fact that -the regional area should be able, through its own input,’to establig: the objectives for that area to determine what its major objecti would be, then it is not an inadequate or it is not an undesirat approach, The program staff was -~ had not had its organizatioy structure changed from the time that it was categorical in nature. And I think I would put it in another framework, They have an organization which is inadequately structured to carry out the goals and subgoals that they have established. They did not have an evaluative mechanism, A committee was established, but it is a little bit hard when you have no objectives to evaluate whether or not what you are doing is being accomplished as it should be, So the evaluation committee really exists in the same kind of a void as the specific objectives exist, We were concerned with the part-time regional coordinators, and really it wasn't until we had an opportunity to meet with these gentlemen, four or five of them being physicians, and retired or semi-retired kind of situation, And q 10 1V @ 12 - 13 14 15 16 17 18 19 20 - 21 C 22 23 @ : Ace - Federal Reporters, Inc. 25 “staff itself, but in addition to which he is director of health when i did meet with them, we found that they were, in my opinion, a very dedicated group of people. The problems that have existed really are the fact that they were part-time and there it did take them a considerable amount of time to travel through the region for which they were responsible to relate to the priors and other people in that region and to begin to draw out of the region the things that the region might do, They felt that they would be better if they had some part-time help themselves in terms of secretarial help or data gathering or kind of people who were -- these with all physiciar and they felt they needed some nonphysician help in the -- in their work, As part of the organizational structure, I think that we looked ver hard at the coordinator, and I don't -- I think I would feel more comfortable when I would say that they, and I quote from a review of their fifth year application, site visit report in '71, "The site visitors find the organizational effectiveness of the coordinator weak. The doctor is not as forceful an administrator as he could be." And in’'72 the remar] is, "Other leadership is still considered weak, Not only does he exhibit through the lack of Organization within the program program for the University extension division and he is directoyx of a HSMHA contract in consumer education, and to compound the weakness which seems quite apparent, he is now devoting only 54 percent of his time to the direction of the Missouri RMP.” kar 51 10 iL e 12 13 14 15 16 17 18 19 20 21 C 22 23 @ . Ace ~ Federal Reporters, Inc. 25 56 Now, the explanation for this is that the consumer project is operated through the University and the University has said this is congruent with the RMP program which is operate |, through the University and therefore, we will put it in RMP and make Dr, Rickley the director. , These, I think, with the organization problems, the structural programs of the organization, the lack of specific objectives even though the goals were considered to be -- in my opinion they have done an excellent job, I think gach of these items was reported directly to their group. I would like to ask Bill if he would like to contribu anything to this, Bill Thurman? DR, THURMAN : I think that I would just add a couple comments, Bob has outlined most. of the concerns, One of the members with us from council indicated, said this was nothing more than a day-long feedback session which is really the feel you got for what we did because it was at times very sticky, uncomfortable and at times they -kept coming back to us with questions like, what is the difference in definition between the advice you send and the recommendations that you send. And we tried to respond to each of these and it was a long,- drawn out type of feedback session, I think that one thing that concerned them the most was whether or not review committee and council's handling of the VAS situation should have been clearer to them than it was, and Dr. Pellegrino's [ory © kar 6 Ace ~ Federal Reporters, 10 11 12 13 15 16 17 18 19 20 21 22 23 24 Inc. 25 ‘changed. 14 recommendation? council decided that, they felt withdrawal of funds in the amoup 57 statement about that, and one of the reasons I have been con- cerned today and yesterday about out patting people on the back who haven't turned the corner is the Pellegrino statement that they have had hit in the head with a 2x4 and still haven't. -So I think this was'a very worthwhile visit. I wonder if we could have one word about council's feelings about not concurring with our recommendation last time around about triennial status for this group and I think the only other point that I would add.to what Bob has said is that the coordinator problem represents a sighificant problem and lead to our ultimate recommendation, MR, TOOMEY: I don't know if the council is familiar with the fact that after the VAS project, which is a computer project, and Dr. Billy Jack's office related to the medical school, council of the advisory committee had recommended it be funded no longer; then a separate contract was signed with HSMHA in order to continue, DR. SCHMIDT: -Bill, what did you mean by your ultimakt DR. THURMAN: Bob is. going to present our recommend-. ation in just a minute, I am sure, MS. HOUSEAL: In response to your council about why = of a hundred thousand and the site visit would be strong enough ‘kar 7 eo. 10 W ( 12 eo. 14 15 16 17 18 19 20 21 C 22 23 ® 24 Ace ~ Federal Reporters, Inc. 25 visit, I gather it is information only, or are there specific core staff, the site visit made no funding recommendations, 58 and they though it would be too harsh to withdraw triennial status, DR. SCHLERIS: What will be the result of this site recommendations? DR. SCHMIDT: I was a little puzzled, obviously, again I am hanging on tender hooks because there was some recommendation made. ; MS), HOUSEAL: The site visit team was~fo go out and carry the message from last time, The recommendation had alread been met or .set by review committee council. at their last .: meetings. The program recommendation, those Mr. Toomey gave regarding settling the RAG issue, making the coordinator full- time, making objectives more specific, evaluation section on ° With regard to the computer contract, there was another site visit held by HSMHA officials this summer and con- tract funds of contract will not be forthcoming from RMPS for this activity, but will be supplied by national centers for research: and development, DR.. THURMAN: I didn't mean to leave the Chairman 4 hanging in mid-air, I think Donna has outlined our recommend-:* ations. A very specific request was made by the site visit team which Bob outlined to have a letter forthcoming from RMPS vk 10 1 12 e 13 14 15 16 17 18 19 20 21 22 E # 4-B 23 @ 24 Ace ~ Federal Reporters, Inc. 25 ‘on the review committee originally and council, descrived it _ to have gotten the message, but when we got there, we realized 59 outlining these spécific forms, My apologies to the Chairman, DR, SCHMIDT: No, Any other comments then before moving on? | DR, SCHLERIS: Does this. go to council with a re- affirmation of our recommendation from before, ox is it just where it was before, because I don't see where this is really more than, you know, it might be well if you did this. Funds have been our means for having some impact, however transiently, on a region, WwW MRS. SILSBEE: I think Dr. Pellegrino, who used to b best as a therapeutic site visit. There were indications, not Ud only beforehand, but at the time of the site visit, that letter wD that had come and advice that had come from the review committe and the council, again, the site visitors looking over the material could not understand how the region could have failed there was a filtering process and they had failed to get the message, : ( So this was-an opportunity to have a face-to-face discussion, to make sure that what the committee and coundil had been saying was understood by the regional medical program, DR, SCHMIDT: All right. We will move on, CR 7149 oe - 2 dor l XXXXXX 6 10 VW @ 12 13 14 15 16 17 18 19 20 21 ( 22 23 Q . Ace ~ Federal Reporters, Inc. 25 DR. SCHMIDT: We will go onto Bi-State before coffee. I guess we are still with Mr. Toomey . MR. TOOMEY: The visit to Bi-State was in regard to an application for triennium status, | A review of the problems that existed with the Bi-State, Bi-State RMP, indicated first of all that the Regional Advisory Group had been-relatively inactive; That there was a Scientific Educational Review Council, and an administrative liaison council made up of representatives from three medical schools, Washington University, St. Louis University, and Southern Illinois University. And the indications were that these two committees which review all of the projects made the basic decision and made their recommeridations then to the Regional Advisory Group. And the record would indicate that the Regional Advisory Group met seldom or perhaps three, perhaps four times a year, and never for more than two hours at a time, and with only approximately one third of the RAG members present. This led into the problem of the grantee organization, which was a joint organization, a so-called consortium, made up of these three universities, who, aS a consortium, handle the grant funds for the Bi-State RMP. 6l dor } 1 . Another problem apparertt ly was the internal. © ; 2\|| organization of the program staff, which was structured 3|| in such a way that all of the nembers of the staff reported 4|| to Dr. Stoneman, the coordinator of the Regional Medical 5|| Program. 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 10|| there was a concern because the rllinois RMP, which was a 11 || growing organization and more aggressive, increasingly | 12 aggressive organization, was concerned because the state © 7 13] Capital of Illinois was being covered by a Bi-State RMP, 14|| rather than the Illinois RMP, as an expression of the -- 15 either of the agressiveness of the rllinois RMP, 16 They had just recently funded a project in 17 Southern Illinois which theoretically was in territory i. 18 covered by Bi-State RMP. 19 Finally there was a concern about the relevance 20 of goals and objectives tothe region's health care needs. 21 The specific issues were -- with which we were ( 97 || concerned were the organizational structure, the role and 23 influence of the consortium, the internal organizational @ 24 problems of the program staff, the dispute over the Southern Aee= — Illinois area with the Illinois RMP, the role of the program dor 3 10 in e@ . 12 13 14 15 16 17 18 19 20 21 C 22 23 @ . Ace — Federal Reporters, Inc. 25 62 committees and the adequacy of proposal development and review process and relevance of goals and objectives to the Region's health care needs. In the establishment of the goals and objectives which came about March 1971, their objectives and priorities were groupd around six major areas. | ‘Their first was manpower; The second, the health care delivery systems, rural and urban; . — “Third, continuing education; Fourth, medical care, primary, secondary and tertiary, ‘and the cardiovascular, cancer, stroke, and other diseases; Fifth, demography and statistics; and, Six, medical information. And their priorities followed this ranking. We were concerned about the categorial orientation of the objectives, recommended that there be deemphasis of the traditional categorical interests. | The objectives tended to reflect highly pre- determined assessment of regional needs. During the categorical period, let me say this: One of the problems that had previously existed before the Bi-State RMP came into being was the inability of the two medical schools in St. Louis to relate to each other in 9! dor 4 10 . © 12 43 14 15 16 17 18 19 20 21 C 22 23 eo . Ace - Federal Reporters, Inc. 25 63 carrying on programs in an effective manner. The RMP during this categorical period brought these two medical’ schools together and their cancer and: | cardiovascular program seemed to be particularly successful. Their other projects that they had accomplished were in the training of coronary nurses, and in a library network which utilized the services of both Washington University and St. Louis University and spread through great, I think, in terms of about a hundred hospitals throughout the region. During the past year.the Bi-State RMP became involved in developing a major medical service emergency project which was funded this past spring. | In the area of continued support, the radiation therapy program has become self-supporting. However, it is being continued and the nurse coronary care unit is continuing. One of the projects that had been established under the old RMP was a -- under the categorical phase of the RMP, was a project, Pruitt Sago; which is a housing section in st. Louis. There they had made an effort to establish a program and project which would provide health care services through the utilization of medical students and training home health aides at that center to provide care to six thousand residents of the Pruitt Sago area. With the exception of thatproject, and beginning dor 5 10 11 oe °* 13 14 15 16 17 18 19 20 21 ( 22 23 @ . Ace ~ Federal Reporters, Inc. 25 64 to look at the problems in East St. Louis,. there had been no indication of minority concetn:.ox minority interest on the part of the Bi-state RMP. They are now concerned with it, not only the urban health care, but the rural health care, and they have ~- part of their consortium is Southern Illinois University, which, in its new medical program has adopted the -- its prime interest, that of developing delivery of health care services to the people in the rural areas in Southern Illinois. And they now have five new projects of the Bi-State RMP directed toward the underserved. | Dr. Stoneman is the coordinator of the Bi-State RMP, and I think we agreed that Dr. Stoneman was a very, very dedicated and very, very fine, dedicated, intelligent person. However, it was our feeling that he was over- stretched in terms of attempting to relate to not only all of the areas in the two states, but he was.on the faculty of the St. Louis University. | He carried, continues to carry on a practice in surgery to a minor degree, several hours a day, two or three hours a day, is what he has stated. And in light of this -- and he also is president elect of the St. Louis Medical Society. Consequently, he is in a position where in light dor 6 10 in 13 ne, 14 15 16 17 18 19 20 21 oom 22 23 Qo . Ace ~ Federal Reporters, Inc. 25 of his desires to relate individually to every person who works on the program staff and.the outside activities, we felt that, as much as anything, that Dr. Stoneman deserved a deputy coordinator, somebody to work with him in the internal organizational matters of the program staff, The program staff, individually, as we met with them, and talked with them and listened to them, seems to be quite an excellent group of people. They had one organizational structural problem which related to the use of part-time associate coordinators - at each of the universities in each of the categories and in Southern Illinois, in their rural health care delivery system. And it was our feeling that these part-time © categorical coordinators should be phased out and that full- time associate coordinators, who would have an interest in. the organization rather than in the category of medical <:-. Gare, should be added to the staff, or should be substituted for the part-time people. As mentioned earlier, the RAG met just three or four times a year, and then for only approximately two hours. Their attendance was minimal, only averaged about a third. As businessmen, which is where it seemed their greatest strength lay, they felt that they were in a position where they should delegate to the universities, to the SERC and the administrative liaison committee the work of developing dor 7 10 VW 12 a © 13 14 15 16 7 18 19 20 21 C 22 @ ° 24 Ace — Federal Reporters, Inc. 25 66 program policies for that particular organization. And they did not feel that it was their responsibility to take as active a part as we felt they should. Consequently, as we looked at both the RAG and the grantee organization, it was our feeling that the influence of the universities should be phased out of that. program and one of our recommendations was that the SERC would be phased out entirely and that the Regional Advisory Group would be made more representative with more consumer interests and minority involvement at the core leveli And as part of our looking at the mechanism by which our projects came through the various committees to the Regional Advisory Group, Dr. Mitchell awnd Maria Flood reviewed, they did an audit trail, if you will, of two of the projects, and I might interrupt and ask Maria Elena if she would like to comment on the trailing of the projects? MS. FLOOD: There was some concern by the site visit team that the university had exerted some tremendous pressures to be assured the projects were named only at the medical school emphais but,‘irideed, as we went through the review process, we didn't find this to be “true and rather found that perhaps the medical schools, the universities, had lacked support in helping them develop mechanisms for proper review, but there were some glaring deficits in the review process we encountered. dor 8 10 1 @ 12 13 14 15 16 17 18 19 20 2] C 22 23 24 Ace ~ Federal Reporters, Inc. 25 67 We were not provided with the cover sheet that the regional Advisory Group meeting, page one of the Regional Advisory Group meetings that ue reviewed, which carried the names and attendance records. We were -- all three meetings, the review started with page two. It could have been an oversight. The review process reflected some deficits in the fact that if the reviewer felt that there were conditions to be met by project proposals, there was no documentation that this information ever got. back to the project proposer or that, indeed, funding was not approved until these conditions were met. | We thought of two studies, one being a medical school oriented,three-pronged nurse-physician assistant type of concept, which was originally rejected and then subsequently resubmitted with a little different approach and was approved on the second review. The other project was a very poorly documented project from a minority impact area, had to do with the educational: facilities for allied health training, and it was ‘one of the problems we encountered in this, that there was no formal development of a format for submission to projects. Our opinion reflected some deficits in the management capabilities of the staff in developing a format for proposers to follow and formal structure for the review dor 9 Ace — Federal Reporters, 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 Inc. 25 68 process. MR. TOOMEY: Thank you. Certainly, the prior groups were involved, including the comprehensive health planning agencies. As a matter of fact, the’ relationship was be- ginning to be so close and RMP was sufficiently interested in continuing this and working closely with the Comprehensive Health Planning Agency that they. recommended to us at the time that we arrived there that, or they didn't recommend, they requested that we give consideration to a funding to strengthen and to allow the Comprehensive Health Planning Agency to continue to become more and more involved in the -- in helping in the assessment of needs and in the planning for the area. They used the Comprehensive Health Planning Agencie to the extent that it is possible to use them now. They see that it is possible for further developments to take effect with the Comprehensive Health Planning Agency and they would like to make them an active ally and provide them with some funds to enhance that whole record. AS a matter of fact, as they assess the needs and resources, they felt that this continued active - cooperation between RMP and CHP should be encouraged. Their ae staff monitors all projects. They control the financing. They monitor the fiscal affairs. mn dor 10 Ace - Federal Reporters, 10 1 12 13 14 15 16 17 18 19 20 21 22 23 24 Inc. 25 program apart than it is to promote its strengths; but they 69 Another problem that, they had was the planning and evaluation was in the hands of one person, a one-person department, and they felt that even though this person was a well-qualified Ph.D, that this perhpas should be split. Bi-State RMP has developed an action plan and from the application and presentation of the visit, appears sound and includes several excellent components. . The RAG has assigned priorities to the objectives and they rank health manpower and health care systems highest. Continued education and catogorical disease strategies were lowest. Their immediate priorities include data base | improvement, primary care strategies and medical information systems. We believe that the REgional Advisory Group needs strengthening and they need to direct, need to direct themselves to do a more adequate job of meeting the needs of the region. Now, much of this sounds, in a sense, it sounds negative and I think, I suppose it is easier to pick the have done an excellent job with the development of their goals and their objectives. They have disseminated these goals, they have a mailing of 8000 organizations, and institutions and individuals. dor ll 10 1 12 13 14 15 16 17 18 19 20 21 C. 22 23 © 24 Ace — Federal Reporters, Inc. 25 70 In addition. to the dissemination of this information they used an interesting mechanism of requesting back from the people to whom they mailed this information requests for projects and programs and specific areas. They felt they coudl establish a program of providing, if you will, it was mentioned yesterday as "mini-proposal," but these are a. little larger than the five thousand dollar proposals, these would be $25,000 proposals, and at the end of the year, they would have, through their evaluative mechamigm, they would be able then to focus in other ones which were most promising and most desirable... The staff, as I mentioned before, was excellent. They have one member of the staff, a Black professional, who is extremely interested in the problems of the innercity and is working with groups in East St. Louis and in the Pruitt Sago, and in the whole Bi-State, area, to develop projects which would be of assistance to the Minority groups, their health service education activities, the non-AHEC, if you will. The AHEC which is non-AHEC, is in the hands of a new person, who is a Ph.D. in education and has begun some programs in this area. Their work in the emergency medical services was excellent. They received, I believe, about a quarter of a . million dollars to carry on this, or to initiate more planning in this and the development of a larger program in this area dor 12 end 5 Ace ~ Federal Reporters, 10 ir 12 3 14 15 17 18 19 20 21 22 23 24 Inc. 25 16 then. Their review of projects has certainly improved, also. 71 CR 7149 6 eak 1 eo | 2 10 1 © 12 13 14 15 16 17 18 19 "20 21 ( 22 23 @ 24 Ace ~ Federal Reporters, Inc. 25 72 In brief, it was our feeling that the organization, while it does exhibit some weaknesses, that with the addition of a coordinator, deputy coordinator -- let me go over it this way. We feel that Dr. Stoneman and his staff have the capability, professional qualifications and interest to build a first rate RMP. The goals; objectives and plans were rele- vant and sound. It has some organizational problems which presently hamper its growth but with a deputy coordinator, the reorganization of RAG and broadening of the involvement of people in the area, we think it has a great potential. We also felt triennial status should not be withheld because of the weaknesses but rather it should be approved on a tentative one-year basis -- if it is triennial status, but with the recommendation that it be reviewed.at the end of the year. The recommendation for the request for funding was for a million four, the first year, a million 463 the second year, ‘a million five the third year. Our recommendation was a $1,150,000 be approved for the first year, $1,230,000 the second year, $1,316,000 the third year. This includes funds for a deputy coordinator and a $50,000 discretionary fund for Dr. Stoneman. Dr. Stoneman's concern as far as the developmental component as opposed to having his desire for developmental component was in order to contend with the problems that existed in 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. | 6 DR. THURMAN: I will have very little to add to >| what Bob has said. I think just because of the fact that the 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 10 || concern when we visited Missouri because of their interrelation-~ 11 ship with Bi-State. I think the question of the coordinator @ 12 probably needs discussion by the whole Review Committee because ~ “43 of the points that Bob has raised. And lI don't think any of us 14 would disagree that if he is to continue in his present 15 action, that a very strong deputy director is needed. Lastly, 16|| My concern, as already reflected by Bob, is the continuing 17 project~ type orientation. 18 It would appear that this tripartite of RAG» 19 basically and their appointment of associate coordinators, 20 af this is not constantly monitored by staff, will perpetuate ° 21 this. type of categorical approach. C 22 MR. TOOMEY: I might ask Maria Elena if she wants 93 to add anything to this? © 24 - MS. FLOOD: Well the only comment I might add is Ace Federal Reporters, that we got the feeling the first day that there was a strong eak 3 10 W eo ° 13 14 15 16 17 18 19 20 21 CO 22 23 eo . Ace ~ Federal Reporters, Inc. 25 staff capability and this was definitely reenforced as the visit progressed. But the management problems are acute, and there has been comment here at this committee that you can't” correct a weak coordinator with a strong deputy but in this case Dr. Stoneman is not really weak. It has just been his insecurit without someone under him to allow the staff to develop the mechanism of interrelationships. They come to him, they answer to him, they report to him. If he were given a strong deputy that could pull together the management trends necessary, I feel strongly personally that this particular staff, under the leadership of Dr. Stoneman, could indeed develop the program and follow the recommendation that we made to begin a trend towards an improved RAG commitment and RAG participation in policy planning and in goals,objectives, and also broaden the scope of the program to really become a program and deemphasize this mini-project advertising that they have used. DR. LUGINBUHL: It is, of course, difficult to judge a program without having visited it and just from hearing discussion and reading the documents. I hope my remarks are not overly critical but I can't help but raise a number of questions from the comments that I have heard and from the review of the material that we have. First of all, it appears to me that there is some problem with this consortium, and I wonder who is minding the store. You have got three different medical schools involved 10 a e: 13 14 15 16 17 18 19 20 21 ( 22 23 eo . Ace — Federal. Reporters, Inc. 25 in this. I asked yesterday specifically who has the authority to replace a coordinator that is inadequate and I was told that it is the grantee. T am not quite clear, who is the grantee in this case, and who has the. authority? Who makes. the decision? You have got two vice-presidents of health affairs at large medical schools, another developing medical school. involved, but who actually makes the decision, who moni- tors this program, that is question number one. Secondly, I can't help but have some question about the coordinator. After a day and a half, I am beginning to think that the terms hard working and dedicated are euphemisms for incompetence and I can't help but think that the suggestion that a deputy coordinator be appointed is simply a way of patching a very worn tire. I may. be wrong in this but I can't help but raise this question. From my point of view, a strong coordinator, a good coordinator is not necessarily a person who is a strong individual or who has a great deal of personal dedication. I think one of the most important qualifications of a coordinator is the ability to delegate, is the ability to organize and motivate staff and when I hear the coordinator has not developed staff, that he does reserve judgments for himself, then that to me raises very serious questions and I think that is.a very serious deficit to try to correct with a deputy. If he hasn't seen this need himself and developed eak 5 10 i } 12 13 14 15 16 17 9 20 21 C. ay) 23 eo . Ace ~ Federal Reporters, Inc. 25 76 the ability to delegate, I think that it is difficult to force this by the appointment of a deputy. Finally, I would lik to raise a question about the budget. I see that the coordinator is listed as 93 percent effort but I read in the narrative that he-is a practicing plastic surgeon. “4 can't help but ask, what is the control that we have over this man's total income? ‘I don't know what the relationship between this program and the consortium is, but if there is simply no limitation on his outside incoffe and the 93 percent figure means very, very little, then I can't help but be worried about the amount of effort he puts into the program and the amount of time he puts into his private practice. In summary, I would like to know who runs the consortium; I would like to hear a little more conversation about the real ability of this individual to run this program. And I would like to have some further insite into the financing. MR. TOOMEY: The consortium has agreed that Washington University will be the grantee agency. And they have an arrangement through which Washington University is the, really, grantee agent, although the three do work together, but it is Washington University. Dr. Guzzi, I believe, was the name of the man from the medical school who is responsible as far as Dr. Stoneman is concerned. You know, as a fellow in management, I think I would agree with you under most ty eak 6 10 i 6 12 13 14 15 16 17 18 9 20 21 C 22 23 ee . Ace — Federal Reporters, Inc. 25 |the universities. He relates well to all of the other 77 circumstances. However, there are some circumstances and this I have seen, that people have varying degress or varying kinds of abilities. Dr. Stoneman's ability is one in which he became a participant in the program as a volunteer member of the faculty when he was a member of the faculty of St. Louis University. He is thoroughly dedicated to its goals, even its present goals. He is, I would say, an extremely capable person, although to a honest with you, he would be better off if he were trained in management rather than in surgery. But he has been trained in surgery and within, if you will excuse me, those limitations, he does a rather fabulous kind of job. He does need somebody who is trained in administration who understands the kinds of things that you are talking about to work with him. He relates well to all of physicians. He relates well to his own staff. They are extremely loyal to him, I think “in every way, by every indication. “He rélates extremely well to the, if you will, the power, the financial and economic power structure in the community. They have a great deal of faith in him. Perhaps too much. | I think this is one of the cases unlike the neighbor that he has in Columbia, Missouri, where I think the administration does not have these abilities. As far as the timé eak 7 10 1] 12 13 14 15 16 17 18 19 20 21 C 22 23 24 Ace — Federal Reporters, Inc. 25 78 is concerned, we did ask him about this and he, his work is done basically at night. and on weekends as far as his home surgery is concerned. I know it is a problemand I don't know any way around it but he says that in order to supplement the income that he receives from the RMP, that he continues a small private practice. He also does continue with his teaching at the St. Louis University. — DR. PAHL: Doctor, I would like to comment on Point 3. You raised the question about what the control is over the total income of coordinators. At the present time, there is no policy within RMPS, HSMHA, or department that I know of that provides any control over total income, other than the usual ones of not being reimbursed twice for presumably the same time expended. However, there is increasing concern being expressed and much more so in recent weeks from both RMP and also the department andwe have been interested in this matter for quite a while ourselves. Not so much the total salary as the matter of part-time direction of RMPS programs and whether programs which are running at $2 million a year can, in fact, be effectively conducted without the full-time direction of the chief executive officer. It is almost impossible for any single program in HSMHA to write a grant management policy about salaries because you are very familiar with all the problems involved with time and effort and we just get into eak 8 10 1 eo ° 13 14 15 16 17 18 19 20 21 ( 22 23 @ 24 Ace ~ Federal Reporters, Inc. 25 79 a tremendously complicated activity. But I should say that there is very serious concern on the part of people within RMPS and at higher levels about the costs of managing a program and the results for the monies being expended, and what consti- tutes good management. And I think there are continuing efforts that are partially underway now. We have some analyses going on now and I think we will be trying to develop some- reasonable kind of statement so that we can improve the management of these programs, without 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 floor. One other one that has been brought up is whether this region really is ready for triennial status given the stated efficiencies in the review process particularly in the area of discretionary funds and whether they have the adequate review and decision mechanism that even meets the minimal standards set by RMPS for the use of discretionary funds. MR. TOOMEY: Let me comment on that a moment, because there was difference of opinion as to its readiness to assume the responsibility for a triennial status. And I guess what we did was to compromise the situation which was to say, triennial status but review at the end of the year. DR. SCHMIDT: Sister, were you going to comment? SISTER ANN JOSEPHINE: Yes, I would just like -- eak 9 1 eo . 3 7 5 6 10 iB eo = 13 14 1S 16 17 19 20 21 (Co 22 _ 28 © 24 Ace - Federal Reporters, Inc. 25 80 Mr. Toomey, has this program done anything to provide services in Cairo, Illinois? I know this was requested, pr. SCHMIDT: The answer is no. John? DR. KRALEWSKI: Just a couple of questions and comment here that might go along some of the lines you were just outlining but on the budgets it wasn't. clear to me whether we were giving them money to add staff. You were recommending $750,000. They were running 517 or something suckeas that, the way it looks: Could you clarify that for me quickly, what will they be able. to do with the 750? Along with that are you recommending developmental component? MR. TOOMEY: We were recommending full-time people rather than part-time people as associate coordinators to replace the part-time coordinators that were at Southern Illinois and at the other universities. “Rather than having them as linkages to the universities, having them in the area of rural health, urban health and taking a segment of the responsibility for the structure, itself, we were recommending in addition to that only the deputy coordinator. DR. KRALEWSKI: Do you recall how many FTEs that would add? | MR, TOOMEY: Four. | DR. KRALEWSKI: Four? And were you recommending eak 10 10 1] ©} 12 13 14 15 16 e 6 17 18 19 20 21 C 22 23 @ . Ace ~ Federal Reporters, tnc. 25 “program for us. It appears that they implemented some 22 pro- ‘should we- best handle some funds. 81 developmental component? MR. TOOMEY: No, no. I guess it is semantics but it is called discretionary - funds. . MR. KRALEWSKI: One other comment I don't know if I am reading this data, you know, from our book here right or not. But it seems to me that last year in terms of the award that we gave them which essentially was supposed to be used for, you know, for the, to carry on their program, develop some other projects then develop a three-year jects with it at very low level funding and now we are coming back this year and asking to increase that low level funding for all but two of the 22, up to, you know, much more substantia funding. And I raise the question over whether,you know, that indicates any real, you know, ability to really handle the question over what projects should we implement and how #7 arl ] 10 W eo 12 13 14 15 16 17 18 19 20 21 C 22 23 @ : Ace ~ Federal Reporters, Inc. 25 82 MS. HOWSEAL: This region had its budget stated for three months in order to phase into our three-cycle review process, and they operated with the funds to discontinue some of their old process and initiate some of the new ones with this last three months funding, and they did it only with the three months period knowing the projects could be turned off if the reviewers felt they didn't have merit, but it's not any -- they aren't projects started a year ago, they are brand new projects being started the last three months of this presen year, and it is because of our need to bring the region into a different review cycle that that this was done, not because of the -- DR. KRALEWSKI: 22 projects? MS. HOWSEAL: Not only 22. Some of those were held over from the last year. DR. KRALEWSKI: They don't show that unless -- well, I may be reading this wrong. MS. HOWSEAL: The printout probably doesn't show when these projects were initiated. If they were initiated during the last three months, the printout would probably show they started at the beginning of the year, when in reality they would only get funding starting October. | DR. SCHMIDT: Dr. Luginbuhl? DR. LUGINBUHL: I would like to ak a question, point of information. I am looking at the budget in the actual ar2 10 11 e 12 13 14 15 16 17 18 19 20 21 ( 22 23 24 Ace ~ Federal Reporters, Inc. 25 83 grant. I note that the budget in the actual grant lists a number of associate coordinators, but they are categorical. They are not the kind of associate coordinator that you are recommending. | If this award is made under the terms that have been outlined, what assurance do we have that they will hire the kind of associate coordinator that we are recommending as opposed to going ahead with the budget? I am trying to get some feeling for what authority this recommendation has, and I am asking this particularly — because I got the impression that this program had been given some guidance in the previous year about the need for re- structuring the organization, and apparently did not follow it. MR. TOOMEY: I don't know that it had the instruc- tions of the previous year, and I really can't answer honestly the fact that they will do what we say. I would assume if you tell them that this is the basis on which the funding has been made that ‘they will ‘consider it directly enough. I don't think they have much alternative. DR. SCHMIDT: Seems to me at this point to enlarge a little bit on your question, that what has been recommended as one-year funding level was site visit, and so in theory, staff, et cetera, would carry back to the region the strong concerns of the committee and the assurance that ar3 10 1 @ 2 13 4 15 16 17 18 19 20 21 \ 22 23 24 Ace — Federal Reporters, Inc. 25 84 the committee would be looking at what they have done, during the coming year. And the stick that one has is the funding level or the second and third years of the triennium, if you wanted to use a bigger stick, what the committee could do would be to recommend withholding the triennial status and give them one more year, and have them revise: the triennial application and come in in one year with the triennial request. That would be a bigger stick yet. Let me just ask a very simple question that hasn't ; been asked for a year or so around this table, but is this a viable region? MR. -TOOMEY: Yes. That's a simple answer. But you have got interest in the community, you have got interest on the part of the medical profession, you have got a great thrust coming out of southern Illinois, as I see it, in the future. You have, “you really have. A personality of the man. He is a good man running that RMP. You have got capable, qualified staff. ‘You have got an interest in education. You have -- you really have the backing of those three universities. One of our concerns had heen that the university was exercising toc great influence. In actual fact what they were doing was evidencing great interest. Now at the time that it was categorical, I am sure there was great influence coming from the university in terms of their ar4 10 rT e 12 13 14 15 16 17 18 19 20 21 C 22 23 24 Ace ~ Federal Reporters, Inc. 25 85 projects. Right now what you have is great interest on the part of the university in extending its own services and its t own concerns through RMP. So I think there is no question, as I look at the total picture that this is a very viable organization. This was one of the reasons why despite our discussion as to triennial status that we felt with all of these pluses, despite the fact that you can focus on the minuses very easily, in light of all of the intangibles, that this has potentially a great future. DR. SCHMIDT: Do you feel that the turf problem with Illinois is a minor one or moderately serious one or very serious one? MR. TOOMEY: Well, I don't know how to evaluate it. We talked to Dr. Snoke who was out of the governor's office. He is not ready to make the decision himself. DR. SCHMIDT: Dr. Snoke is totally confused by the whole thing. You wouldn't be able to get anything but confu- sion out of Dr. Snoke. | MR. TOOMEY: Certainly the recommendation that the.two groups get together and there is some indication ' that can declare areas of primary concern which would be southern Illinois for the bi-state RMP, and perhaps what we might call a DMZ in the Springfield area in which there would be some concern on the part of both Illinois and bi-state. ar5 10 W e 12 13 14 15 16 17 18 19 20 21 os 22 23 @ . Ace ~ Federal Reporters, inc. 25 86 But, you see, southern Illinois is up in the Springfield area and relates to bi-state as far as its school is concerned so that there are some problems, and this: perhaps would be one of those areas in which there is an acceptable overlap. | | DR. SCHMIDT: Dr. Thurman? DR. THURMAN: I would just agree with Mr. Toomey's analysis. I think in answer to your question, it is a viable region. My second question there, is there a motion on the .£loor? DR. SCHMIDT: Yes, there is a motion on the floor made by the principal reviewer. I am not sure it was seconded. I will ask at this time if the motion which was to-wit, "approval of the triennial status without approval of the developmental component, but with discretionary funds to the tune of 1.15, year one; 1.230, year 2; 1.316, year three" -- is that the motion? MR. TOOMEY: With review at the end of the first year. DR. SCHMIDT: That's correct, with review, with' a site visit? In one year prior to the making of the second year award. Is the motion seconded? It is. ar6 10 lt eo 12 43 14 15 16 17 18 19 20 21 ( 22 23 24 \ce ~ Federal Reporters, Inc. 25 87 Dr. Thurman? DR. THURMAN: I would like to offer a substitute motion going along with the funding, but withholding triennial status with preparation of a triennial application for next year. | | DR. SCHMIDT: All right, is there a second? DR. LUGINBUHL: I will second. DR. SCHMIDT: Substitute motion is seconded. Let me ask someone whether or not this would cause some breakage or to what extent would this be thought detrimental? MR. TOOMEY: I think I'd defer this to somebody who knows the area better than me. MS. HOWSEAL: Well, there are two sides of the story. One is the tougher problem and how this will be settled in the next year. That obviously is a consideration. The second is that this region last year came in with a triennial application and staff said that at that time,. is that correct, that they weren't ready for triennial status at that time, and held them off an additional year? Their program plan seems pretty well in order. But it is the organizational problems that need to be worked on I think it -- DR. SCHMIDT: The question is, breakage, damage and so on. 88 ar7 1 . DR. LUGINBUHL: I have heard discussed several © 2} times in the last day anda 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 6|| xeduction; and, two, :withholding triennial status. I would 7\|| gather that both of these have been employed on a number of 8 occasions in the past. It would be very helpful to me in 9|| voting on this kind of a question to get some indication of 10|| what kinds of damage have actually been observed from these 11) Classes of action in the past. ‘ 12 In other words, has this really resulted in © ° 43i/ Significant injury to some prograns, or is this a concern that 14|| possibly has been weighed too heavily? If that is the case, 15 it would obviously indicate to me that we should use these 16] Measures more freely rather than less freely. 17 I just don't have any feeling for what effects 18 these actions have been on programs and just how real a threat. 19 it is. | 20 | DR. SCHMIDT: I will try to answer that. I think ari that as you hinted at yesterday, the committee during the L 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 @ 24 much breakage, it opted not to stress the region in that Ace~ alana way. Usually other routes for effective action have been 89 ar8 1 taken. Either the chairman of the site-visit committee, © 2\| such as Sister Ann, or the director of the program, or 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 gi| in the past, to answer your question. | 9 The committee, if it's erred, has erred on the side 10 of being conservative,:using these other routes to get the 1] || messages back. And I -- actuaily the committee has talked, , 12|| and staff knows the talk about stopping funding completely © 13 of a region, for example, withdrawing regional status, let 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, 17 which has more or less a cataclysmic year that was achieved 18 really through two site visits ina tow, and we will be talking 19 about that. | 20 | So that I ask the question quite deliberately from oy] mY experience, that sometimes you will run the danger of O ( 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 @ 24 haven't taken that risk deliberately in the past. a as Mrs. Flood? 7 ar9 10 11 e \ 13 15 16 17 18] 19 20 21 ( 22 23 eo . \ce — Federal Reporters, Inc. 25 14 90 MRS. FLOOD: I would like to comment. My point of view as to the potential breakage, I think the member universities of the consortium expressed to the site visitors a concern to fulfill their participation in the guidance of the regional medical program in the new Light of RMP de- emphasizing the medical school-oriénted projects and emphasizing more trends toward a programmatic approach. Seemed to be no qualms on Dr. Posta's part. I think that this is true, Dr. Schmidt's point, that perhaps the, problem of withholding triennium status to this particular region, which I think is viable and has potential, would in a way give these consortium people that feeling to heck with the whole thing, we have tried, but “may be going the wrong way, and now we are getting no backing, and because of the tougher problems, not giving them potential with some secure funding for the future of these years, I would put in a word for the trienniun, DR. SCHMIDT: The issue should be clear for the committee then. The substitute motion would withhold the triennial status, but do everything else that the original motion did so that you will be voting really in effect on the triennial status with the substitute motion. Are you ready for the question? All right, all in favor -- do you understand that if you vote yes, you will be voting to withhold triennial arlo 10 im eo * 13 14 15 16 17 18 19 20 21 ( 22 23 eS . \ce ~ Federal Reporters, Inc. 25 91 status? All in favor of the substitute motion, please say aye. Opposed, no? The motion is defeated. The original motion then is for triennial status, et cetera, et cetera, as I recited it before. Are you ready for that question? DR. SCHLERIS: Like to have a little discussion about the discretionary funds which sound like awglevelopmental component to me. DR. SCHMIDT: I will try to speed this up by comment ing. I think probably the reason they want them is to be able to compete with the Illinois regional medical program that does have these funds it can sprinkle around and stimulate _this in their back yard, and they have got to leable to stimulate this in their back yard in order to be able to develop the sorts of things that will change their direction that we are telling them they have got to do, and we have discussed before that sometimes the regions that deserve the developmental component least need the funds the most in order to have flexibility, et cetera, and I would assume that this is the situation there. Is that accurate? MR. TOOMEY: That's accurate. MR. HILTON: Are we endorsing the concept of discretionary funds for other regions? As -~- seems to me we arll 10 i © 12 13 14 15 16 17 18 19 20 21 L 22 23 @ 24 Ace —Federat Reporters, Inc. 25 92 had zome discussion about the developmental component versus discretionary funds at some earlier region some months back, this came up then, too. | Are we saying that this is a viable option for folks who don't qualify for the developmental component? DR. SCHMIDT: I think that each region. almost has to be looked at individually. Obviously the answer to your question is yes. But we aren't making any general pronounce- ments or anything else. | DR. PAHL: Dr. Margulies indicated to me that ‘he will be presenting this general topic of discretionary funding and developmental components and other names by which these funds go before the forthcoming October council, not trying to make a policy at that time, but to clarify the issues and perhaps come out with a definitive statement, because we do not have a general pronouncement and obviously we are - getting into this area. At the moment you are free to act as you choose on individual case-by-case basis. | IR SCHMIDT: I think we will kind of restrict this to a couple more comments. — Dr. Luginbuhl? DR. LUGINBUHL: Two quick questions. If we are indeed giving the devélopmental component, why don't we call it that? Why do we use some other name? arl2 10 W e : 13 14 15 16 17 18 19 20 21 ( 22 @ 23 24 Ace ~ Federal Reporters, Inc. 25 93 And number two, is the letter that goes to this program, or is the advice that-goes to this program going | to include some expression of concern about having a part- time director with a -- with another outside activity? DR. SCHMIDT: The answer is yes. All right, I am going to call the question, unless there is some -- something new. “Because we are just simply not going to get through our day's work unless we shorten this up. DR. JAMES: The question comes.then to my mind, in this kind of situation, if, in fact, there needs to be some restructuring of organization and which eventually results in restructuring of program, then monies that are already allocated, if in fact they could. not be redirected, I am at a loss to understand why there should be -- why that the RMP should be awarded additional funds for -- whether it is called developmental or discretionary, when in fact it would appear that the base monies that are available need restructuring and when that is done, and used to restructure, organize restructure program, then it, to me, would show that the whole program then can very well use new funds for development, once it gets its base straightened out. DR. SCHMIDT: I think the way I will answer that is to say that the committee just voted not to deny triennial status. That means that in the committee's opinion, the region arl3 Sce ~ Federal Reporters, 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 Inc. 25 94 has the ability to make the necessary decisions to expend the funds they have wisely. One category of which is loose and not earmarked for projects now, but is, quote, discretionary, unquote. | All right, I will put the question. All in favor of the motion, please say aye. And opposed, no. There are "nos," but the "ayes" have it, and the motion is carried. I think that we will at this point take a no more ‘than 15-minute break and start again promptly in 15 minutes. (Recess. ) mea-1 CR 7149 #8 10 11 e : ‘ moe 13 14 15 16 17 18 19 20 214. \ 22 © “ 24 \ce ~ Federal Reporters, Inc. 25 95 DR. SCHMIDT: We are’ going out to the great state of New Mexico which has the largest regional advisory group in the history of the program. During your comments I hope you will discuss why they have a regional advisory group that seems to include the whole population of the State of New Mexico. MR. HILTON: For the record I can't be heard, For the record, okay. 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 items, before we go into specifics to kind of sensitize you to some special problems of the New Mexico area. I should mention that since the submission of the printed documentation on New Mexico we have received much new data, as recently as the day before yesterday a phone call giving us additional information which I will bring up at the appropriate points throughout the report. We were under, during our site visit, some time pressures. The New Mexico Program staff had taken the | Liberty of preparing quite a fairly well stated -- using overheads, other kinds of materials which pretty much blocked in our time. We were forced to subdivide ourselves and fractionate their well-organized plan in order to get a lot of ground covered we wanted to cover, mea-2 Ace —Federal Reporters, 10 W 12 13 14 15 16 17 18 19 20 21 22 23 24 Inc. 25 96 Some points pertinent to the consideration of this region: The state is large ‘geographically with a population of slightly over a million. The geographical expansion of the state creates special problems that the region has attempted to address itself to. The state is multicultural, emphatically so, with the major cultures being Neydcan-Américan, Anglo and Indian ana the feeling generally being that efforts to improve health care have to take chat fact into account and try to work with the facts rather than try to change it and smooth everything out and work with some kind of easy glossy kind of program. The state is poor, I have been told. I haven't been able to verify this. The military installations.are a major source of employment in the state, Continued support therefore for any of the projects being conducted by the program staff has been exceedingly difficult and if you look at some of the projects listed there, RMP has a largely ‘young staff, CHP agencies not awfully prominent in the state. Then RMP in the absence of very forceful representation on the part of these other kinds of health concerns in the state has really become very prominent, That prominence has been greatly helped by the large RAG, that is a relatively new .development there, But we had some concern, still speaking mea-3 10 1 eo... 13 14 15 16 17 18 19 20 21 ( 22 23 eo . \ce — Federal Reporters, Inc. 25 97 generally, that RMP has become the center for sO many things in New Mexico that we may in fact be supporting activities that in other states would be supported by other resources, Going item by item, at a fair clip, too, through our evaluations, our site visit report, I should mention that the primary purpose of the visit was to review their '73-'75 application, triennial application, and to assess their progress since June, 1971 site visit. In conducting that meeting for that purpose, we observed the following things: “That the goals of RMP as stated in materials certainly seem to be in keeping with the RMPs' mission, the increase in availability, improving quality care, moderating the costs of care, et cetera. We had some problem with the goals and objectives in that there seemed to be an absence of measurable short- term objectives in the context of what the program was attempting to do. General priorities have been identified and ‘there is a listed rank-order which aids the program in making decisions about what we found that if resources are reduced, et cetera. Under the area of accomplishments and implementations, program staff has stimulated several “worthwhile activities throughout the state, They do of course now have a pretty substantial EMS activity going on: mea-4 10 in e ” 13 14 15 16 17 18 19 20 21 ( 22 23 eo . \ce ~ Federal Reporters, Inc. 25 . ; 98 Registries, involvement in the hatch area of New Mexico, programs internally to aid staff, things involving processing centers, and a computer budget monitoring system so they can determine on a moment's notice how much they have got to spend in each item, a cultural training laboratory which has already done some things and plans other things that will help with that multicultural nature of the state I referred to earlier. They are developing a statewide systgm for statewide hospitals to centrally purchase items. The hope is they will be able to reduce costs of certain aspects at least Other health agencies within the New Mexico region, as I pointed out earlier, do rely pretty heavily upon the NRMP. They have become the primary agency for data analysis in the state. Physicians do look upon the program for professional and technical assistance, consultation, information, et cetera. Under the area of continued support because of the problem of the general impoverishment of the state, they have not been able to do as well as we would have liked to have seen them do. There have been some accomplishments. We have encouraged other kinds of things be done to get additional help. | Dr. Stone of the medical school in his mea~5 10 i: @ 12 13 14 15 16 17 18 19 20 21 S 22 23 eo . \ce — Federal Reporters, Inc. 25 99 discussion of his grantees, stressed I think very clearly that the medical school: is unable to pick up many of these kinds of efforts that they would like to. He was kind of emphatic about that. On the matter of minority interests, the majority of the state's’ population percentagewise is one minority or another. Representation on the program staff of particularly the Spanish-speaking group was in my opinion quite poor; not my opinion, the team agrees on this, that | representation was quite poor. Very few professionals, very few clerical. Now, it should be pointed out one of the new developments that I referred to earlier that we did receive in our phone call information that the RAG for RMP has met as of September 16 and that at that meeting they declared their intention to initiate an affirmative action plan which would remedy some of our concerns in this area. Even since our meeting with the NMRMP staff there were improvements in that additional persons were hired between the time of our site visit and the time of the September 16 meeting. So there was visible evidence of intention to improve an affirmative plan and it seems to suggest there wil} be greater pickup in this area. I had the opportunity to get into the New Mexico area a few hours earlier than I had expected I would so mea-6 10 1] © 12 13 14 15 16 17 18 19 20 21 ( 22 23 eo . Ace —Federat Reporters, Inc. 25 100 during that period Dr. Gay, the coordinator there, arranged that one of his staff would show me around, I did get a chance to visit a couple of the clinics and some of the local reservations to get a kind of firsthand feel for what the staff's relations were on the community level. The staff, especially in the community health service section of the NRMP staff, is pretty community- minded, generally young, have not been as aggressive, at leas not as yet, as I would have liked to have seen but potential is still there. Talking to a number of staff, even in the setting of the clinics, and talking to the people in the clinics, we were very well received. The manager of one of the clinics I talked to had great hopes for a continuing relationship and a developed relationship. | We did something 7 this particular area in this 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 from the general audience comments, criticisms really, any kind of thing anybody wanted to say about RMP, pro or con, We did that somewhat expecting that we would be blasted,’ . especially from the Spanish-speaking section of the audience but found that on the contrary, while there were things that people had to say and they felt very strongly about them, there was a consensus even among those who were opposed or Tt mea~7 10 1 e ° 13} 14 15 16 17 18 19 20 21 (oy Td , 24 Ace — Federal Reporters, Inc. 25 101 seemed to be opposed to NRMP activities that it was doing better than before and doing ‘well. Concern seemed to center around its not doing enough or what it is doing isn't fast enough to please, The general feeling was even from the opposition that the program is having an impact. Again I relate this to a large degree to the fact of expanded RAG which was expanded by the way to intensify representation from throughout the state, So our recommendation with regard to the minority area is that there should in fact be increased representation, More needs to be done certainly. | Dr. Gay has provided, who is the coordinator, James Gay, has provided pretty strong leadership in the NMRNM. It should be pointed out it is another one of those programs which has undergone some pretty cataclysmic change in the past 12 months or so. In fact, there is evidence of how change was, had been undergone and was still -undergoing. at the very time we were meeting with the NMRNM staff; the changes being some of the literature we have had up to the moment of our going. there to review and discuss was updated in the process of their presenting their visuals. One area for example, prominent instance of this was the complete change in management operations right in the middle of our visit, you might say, moving from a mea-8 10 1 e 13 14 15 16 17 18 19 20 21 ( 22 23 @ 24 ce ~ Federal Reporters, Inc. 25 102 matrix kind of setup in which staff operated on a task force kind. of basis, issue-oriented basis back to a more conventional organizational staff. We kind of got the feeling when this was cast on the screen that it was not only new to us but probably to much of the staff, as an indication of how this is developing. Throughout that, however, Dr. Gay.I think impressed us all with his ready willingness to learn, his enthusiastic willingness to learn, He seemed to be listening ‘and took notes throughout the session of the things that were in fact being said, We began to feel a change both in the site visit and of course with these recent phone calls. We have .seen things happen since the site visit that go well I think generally. | | - Dr. Gay has established excellent relationships with health providers and health-related agencies in New Mexico and I guess that is best testified to by the fact that a great deal of them, if not all of them are on the RAG in addition to considerable consumer vepredentation. With regard to program or core staff, the decision to decategorize the program staff structure, moving away from the traditional emphases appears to have been sound and effective and carried out, though you will mea-9 10 1 6 7 | 13 14 15 16 17 18 19 20 21 oot 22 © 24 \ce ~ Federal Reporters, Inc. 25 gotten at least some of the idea of thrust. 103 notice in the projects themselves that there is still a kind of mix of traditional emphases, plus. some of the newer things that are coming out. Now, traditional programs, or I should say the projects, old projects listed in your printouts have been supplemented by a variety of what they call developmental projects, which we can go into some discussion on a little later on, but these developmental projects then are to be run directly by the project staff. And there more than in the old projects we see a real emphasis on new directions. The community health services section of the NRMP stafé represents the truest form of wnat I would call a thrust, one of the truest forms that I have seen in NRMP. In fact, if you look at the projects, one gets the feeling as mentioned in another program, it said it was being a program, it is a collection of projects, However, in their reorganization and in going back to more traditional organization of staff, they have Community health services represents a compilation of kinds of projects in an area that relates to working with clinics, working in Indian health rehabilitation, working wit! consumers; that thrust also has become what they call their community response system. It is attempting to organize itself ona - Mea-10 10 W @ 12 43 14 15 16 17 18 19 20 . 21 \ 22 23 eo . Ace ~Fedetal Reporters, Inc. 25 ‘be accomplished, by the way, I am not entirely clear, from the ‘the community health services component will be felt through- a year they really get only one side of the state covered in ~. education services which have already devided the state into 104 statewide basis and the exact dimensions of how that shall site visit and not satisfied from the material received subsequently that it is really all worked out yet, but their hope is that through a number of mechanisms available to them out the state and will be the primary source, nerve center, for receiving suggestions for things RMP should do in that region, They have got a number of approaches, number of ways they can go about doing this. They have attempted I think unsuccessfully to use their RAG as a basis for picking up suggestions of projects and their RAG is quite extensive covering the entire state. The problem there is that when they try to hold RAG meetings in Northern New Mexico to cut down the travel they get the Northern New Mexico side of the RAG. If they go to Southern New Mexico, they get the Southern New Mexico side of the RAG so if they hold two meetings in the course of each meeting. So we suggested to them there might be other methods they use; they might go to the community health four quarters, and to use RAGS or local advisory groups, one mea~1l 10 7 cd _ 12 13 14 15 16 17 18 19 20 21 C 22 23 eo . \ce ~ Federal Reporters, Inc. 25 105 for each of the four; that might be another way in which the community health services group might be able to pick up in ar orderly fashion real grass roots kinds of input. There is an interest there in any event in really relating more closely to consumerism as it was pointed out in part their success or failure would depend on bringing in minority staff because as matters stand now there are only three Spanish-speaking staff on the NRMP and this does create difficulties in relating language and culturalywjse the people they are attempting to reach. It is very confusing to look at now on graphs and charts but has additional problems beyond that in that it is a response system first and foremost. Many of the acconp]ishments of the region have really been in response to inquiries from people outside of NRMP who say, "You know,. we need this, that or the other,"and then of course the staff has been geared up to just take that suggestion anda run with it asa response, We did have some criticism that there ought to be more initiation on the part of RMP but we think in that regard that people know about the RMP, certainly not the case of many regions, so they do feel free to come to it despite the fact that it is not itself initiating to the degree we would like to see it. The RAG seems almost too large but as I say, it mea-12 10 1 e@ 12 13 14 15 16 17 18 19 20 21 ( 22 23 @ 24 \ce ~ Federal Reporters, Inc. 25 106 does reflect combining of. a broad’ representation and I think more importantly, reflects a combining of two kinds of life of the program. When Dr. Gay took over, he inherited some of that and felt in his judgment rather than trying to erace what had come before, to integrate it in a newer and bigger scheme. We had less problems with the RAG than the internal organization,numbers of committees, task force kinds of committee structures using RAG and staff personnel to carry out the programs' objectives. Again new information in response to our criticism of the number of committees of which there were some 14 in number, the September 16 meeting had at least, there was some indication in the September 16 meeting that these would be reduced to nine. Consumers are more than adequately represented, by the way., on the present RAG and I think this is certainly necessary in view of the fact of the limited impact of CHP in the area. | One of last year's concerns, in response to the Executive Board, as authorized it increased from eight to 11 members. We also have some concern relating again back to the coordinator that the structures that had been developed did not allow enough coverage of central mea-13 10 11 M149 End #8 14 15 16 17 18 19 20 21 \ 22 23 @ . Ace ~ Federal Reporters, Inc. 25 107 administration; I guess, to put it. another way, if Dr. Gay got sick that the whole thing seemed it would fall apart. He didn't have enough direct help at the top.. They responded to that too. The nine-sixteen meeting did endorse the recommendation that there be two deputies, one for support services and one for operation in the programs that would assist Dr. Gay and in that way further unite or bring together the organization. The grantee agency, you know, of New Mexico has provided excellent administrative support to the RMP. The medical school no longer has ‘as it once did excessive dependency upon RMP,and grantee and RAG relationships are quite good. — Qo” ‘ba l 3 ae \o BO 10 11 @ 12 13 14 15 16 17 18 19 20 21 ( 22 23 @ 24 \ce ~ Federal Reporters, Inc. 25 108 One evidence of the relationship between grantee and staff, we were able to determine what appeared to be in- credulous, but delightful situation where the grantees is apparently providing virutally rent-free facilities for the NRMP as they move into additional space. I say virtually becausgd I don't know if that ever was investigated to everybody's | satisfaction but it looks that it might in fact be the case. _ On the matter of participation, key health interests, institutions and groups are participating in the-program, this accounts again for the size of the RAG. We did hear from the Red Cross representative, the president of the New Mexico Nurses, the CHB representative, the Medical Association, Dean of the Pharmacy School, even testimony from a dissenting student from the medical school locally, on some of the activi- ties, but at least everyone was there and the general feeling was that the problems remained with problems of -the rate ‘of change. We did have two recommendations under the area of local planning, site visitors were made avare of some problems arisen in regard to providing RMP proposal to CHP in advance. and for CHP comment and there was feeling that this should be done so that CHP would have the ‘opportunity to respond well in advance of a proposal going to us. The site vitors recommend that the Chest projects, community health education services projects should in fact 10 i @ 12 : 13 14 15 16 17 18 19 20 21 ( 22 ark) @ 24 Ace — Federal Reporters, Inc. 25 northeastern end of it has its own LAG, Local Advisory Group, ‘informational services office of this outfit is great. 109 create four local advisory groups in the next year to provide ag they are willing to undertake the appropriate responsibilities and resources, their share. We did have concern about the actual representation on such a broad scale of the state and we think if representations focussed locally, as was proposed through the use of the community health education services, that they will have more meaningful participation on the part of each representative. Feeling was that no one in the Norhteastern New Mexico would be motivated to be concerned about Southwestern New Mexico and to look really carefully into that but if the relating to the program that you would get a lot more particip- ation and there would be a focal concern with the local needs there, other matters of assessment of needs and resources you may have seen some of the very nice little brochures, the Publications that they made available, some studies they have done on various aspects of NRMP activities, maybe a set of these booklets, some 14 or 15 in number on the table over there. The program has done a good job of compiling community health profiles but again, It think that is the last program we reviewed, there is a problem in utilizing this information in carrying out the projects and programs. They have done a good research job on this, at least the material looks 10 VW e : 13| 14 15 16 17 18 19 20 21 ( 22 @ 23 24 \ce ~ Federal Reporters, Inc. 25 110 good, it is well written material, easily readable and I have got about 20 pounds of it in the mail in advance of the site The program does need to include assessment of need and resources as criteria for review for determining program staff activities; programs should make better use of the data base for the fund priorities. Under the area of management the site team was impressed with the innovative management pro- cedures and rated this as quite excellent, includgg among those a processing ‘pool, means by which speedier and neater pro-~- duction of information materials could be produced and also their monitoring, computer monitoring system. Budget: Other matters of evaluation, the full-time evaluation director complements the agency and works well with RAGS evaluation committee. Members of the evaluation committee staff and RAG participate in the programs activities where new programs are developed and technical review committee sessions where the proposed programs are technically reviewed. The team endorsed review quarterly progress reports by the evaluations committee and these are required by all project directors. Other matters of program proposals NRMP describes developmental projects as those considered as line items under program staff. This matter of terminology was brought up. We had a sketch in which it was the effort of the coordinator, the Reba 4 2 10 iL @ 12 LB “V4 15 16 17 18 19 20 21 ( 22 93 eo ., Ace ~ Federal Reporters, Inc. 25 111 entire staff to characterize RMP's and to define within that broad characterization exactly where NRMP came to rest. Three models described to us were the traditional RMP, the transitional RMP and the developmental RMP. NRMP classified itself as the last type that had the flexibility within program staff to function quite well in a variety of areas and to really bring about change without depending on branch occies, some really ébject to that. Some aspects of their overall program in fact do look transitional. I already commented on the character of the projects they. wished to support. They ranged from the old categorical through the AHEC right now to their developmental programs, they described what seemed to be pretty relevant kinds of thrusts. They want developmental component funds which will be used to study feasibility of identified program opportunities. The establishment procedures for reviewing new -program proposals will be utilized for developmental component requests. Under dissemination of information a program has efficiently disseminated information to key groups, other healtt related institutions. The team did suggest that the program could more advantageously utilize one of the most important health resources that they apparently’ are not using, the Lovela¢ Foundation for Medical Education and Research located in New Mexico. I think we should be strong on this, we would want Peba 5 2 10 1] oe = 13 iH bee, 14 15 16 17 18 19 20 21 ( 22 93 eo . Ace ~Federal Reporters, Inc. 25 112 it to be collected in the advice letter to this region. Utilization of manpower and facilities, the site team was interested in and enthusiastically supported most of the new directions, the new types of manpower that were described. However, they were somewhat frustrated by the fact that they still are basically intentions and are not well developed programs of activity. This relates somewhat to the response concept, responding but not initiating. Again, in talking with some of the staff in certainly the areas, they have very good ideas there among this young staff. There seemed to be some uncertainty, however, and I had here the opportunity to speak very personally with a numbe of the staff, seemed to be uncertainty as to whether or not these good ideas could in fact be implemented. There was some uneasiness and I am not certain whether the uneasiness is what it was or whether it was when the administration of the local RMP would:-endorse them, perhaps both, I think the site visit in that regard would have been helpful. I think the leadership, we were liberal, encouraging, patted on the back where appropriate and withhold support where appropriate. There are some technical legalities on some of the projects. Several of them in fact appear to be designed to assist established health professions, training programs of one kind or another, specifically dental assistants, medical technicians, inhalation technicians. TT Peba 6 2 10 N @ 12 13 14 15 16 17 18 19 20 21 ( 22 23 @ 24 Ace — Federal Reporters, Inc. 25 113 This is a matter to be looked at very closely. The programs intentions to emphasize new kinds of paramedical manpower are laudatory but plans in this area are not yet well defined perhaps because of the uncertainties that I have | identified. Through a variety of their programs they have in fact contributed significantly to the improvement of health care in the area. There are four New Mexico communities who applied for a national health service core assistance with the help of the NRMP staff and there are several other projects, at the Tierra Maria Community Clinics where there have been some marked good apparently. Short term pay-off, reasonable to expect, the operational activity is proposed will increase the availability and the accessability to service groups and enhance the quality of care in the next two or three years, it was the general judgment of the site visit team. - We did at the time of our site visit on this matter of regionalization encounter some discomfort on this matter of where shall the control lie.’ Dr. Gay had inherited real problems because of the apparent emphasis on decentralization of NMRP resources prior to his assuming that role. In response to that condition which was very limited, created a lot of problems for him, he moved rapidly toward centralizing, putting everything pretty much under the central Albuquerque office control and there appeared to be in the lanauade and the -- the: lancuadce of the anovlication and eo °°! Reba 7 2 10 i @ 2 13 14 15 16 17 18 19 20 21 ( 22 33 eo . \ce ~ Federal Reporters, Inc. 25 114 the thinking of the staff some uncertainty as to this issue of, decentralization versus céntralization of effort. I think as we talked about the need for represent- tation, the plan of using the local Chest LAGS, et cetera, that there began to be a feeling on the part of the staff and part of the coordinator, that there is a middle road between these. two extremes. It remains to be seen whether or not this will in fact come out, in the wash.. But I have a strong fgeling it will because. we approached the topic from several different | directions from the point of view of projects and point of view of local tepresentation, point of view of staff recruitment, even. Not for example be able to recruit people from one community that is -- to which they are indigenous to one end of the state to travel to the other. You are necessarily talking about some kind of decentralization in that area as well. DR. SCHMIDT: Bill, T.will ask if you can try to wrap it up in about five more minutes at the most. MR. HILTON: I think I.can do it in two. The region has provided evidence that they are trying to attract other support. They have not been successful largely because other support really has not been available in many respects but we urged them to try it out on that and they said they would but you really don't know what the direction is going to be. @. | Reba 8 2 10 VW 4 12 @ 13 14 15 16 17 18 19 20 21 ( 22 23 @ =. Ace ~ Federal Reporters, Inc. 25 115 The state apparently is poor and local industry is limited, too, in what it can contribute. All in all this is a general I guess kind of summary of this before we go into matters of budget, it was the site visits' feeling that on the basis of what has happened since Dr. Bay assumed office that this is basically a strong program in need of some guidance and counsel. They are willing to learn. It is not a program which w are going to be having to tape record the same message each year, at least we did not leave with the feeling it was. It is ripe for counsel on some of its directions and goals and so forth. And it is basically a pretty strong program. I think with that I would- normally defer now to our second reviewer who happens to be Sister Ann Josephine. Since she had to leave she did leave me some notes, summarizing any questions or comments she had. _I have not had the chance to look over the notes but I could do that you know, or while we are awaiting questions. . DR. SCHMIDT: If these notes are legible why don't you pass them down to the end of the table and let staff - look at them, and we will ask him to summarize what she hag to Say very briefly, and why don't you go ahead with recommen- dations? MR. HILTON: All right. Site visit team recommended that NMRMP be approved for triennial status for 05, 06 and 07 wD 10 iI eo . 43 14 15 16 17 18 19 20 21 C 22 23 @ . Ace ~ Federal Reporters, Inc. 25 116 years and that developmental component be approved with the condition that a mini-site visit be made within the next year to review the region's progress. On the matter of budget, briefly, the request was in the area of program staff, $1 million 319,000. Site visit recommendation was $830,000 on.that. figure. Developmental component request was for $138,000. Our recommendation was $120,000. Operational projects request was for $223,000, we recommended $350,000 which does in fact include $118,000 for the tumor registry which in the past was reflected in their program staff, moving into their operational projects. DR. SCHMIDT: This is the first year or for all three years? | MR. HILTON: First year and carryover, I think carry- over, -- let's see. Yes, for all three years. | DR. SCHMIDT: Level funding for three years? MR. HILTON: Right. ‘DR. SCHMIDT: Frank, have you had time to glance through Sister Ann's comments? Could you cover anything there that might be in addition to what Mr. Hilton has covered? MR, SCHNIOWSKI: Basically, Sister Ann has six statements here, I will rapidly mention these. one, Sister Ann comments that support from other resources must be developed and this is, further supports the site visits team recommendatio] underneath the criterion number 3, continued support, and second 2 e Peba 10 ° 2 10 ay @ 412 - 13 14 15 16 17 18 19 20 21 ( 22 @ “ 24 Ace — Federal Reporters, Inc. 25 117 comment deals with her concern that maybe the developmental component should be reduced. | | There is no questionmark or there is no exclamation point so I don't know how to interpret this. i am surprised. The third comment deals with the question of whether RMPS should provide consultation and this deals with the statement, if the program is interested and seriously intends to facilitate state HMO-planning, it should bring people with appropriate experience in managerial and financial aspects of HMO planning. We tried to iron this out before the site visit report was written. This is one point that was not clarified and was asked to be included in this. The fourth point. deals with underutilization of information due to lack of knowledge of the resources availability. . Again, Sister asked for guidance by RMP staff to insure adequate use of available data in planning, The fifth deals with evaluation process. And suggests that evaluation process needs to be implemented. Then the final point, final point concerns the tumor registry project which is -- it is a question what plans are there to phase this out between the local Cancer Society. These are the major concerns. DR. SCHMIDT: Is there an answer to that last question? MR, HILTON:We spoke with the tumor registry people. concerning this. We were impressed with the importance of the activity, apparently beyond those who are directly involved with © . Peba 11 10 11 12 13 14 15 16 17 18 19 20 2) 22 23 24 \ce — Federal Reporters, Inc. end # 9 25 that the resources simply were not there. Everyone agreed closely involved with it in attempts to recruit assistance to go out and as one guy said you know spend days, weeks and 118 it. There is also a feeling of its worth. But again apparently they have run into something of a brick wall in terms of attempting to get support for it. The feeling seemed to be it was a good thing to have. -Of course those who were closest to the project felt more strongly about it. We did suggest that more aggressive efforts should be made to seek continued support for the effort. They assured us they would continue to try but there was this feeling of a real frustration, that the effort really wouldn't pay off so why bother.in the first place kind of thing. That in fact efforts in the past despite the amount of work that had been put into this by one of the physicians have been so futile that there did not seem to be any real drive on the part of the people who were supporting the tumor‘registry months at trying to do something that simply was not there. DR. SCHMIDT: We do have a motion on the floor. Is there a second for the motion? | DR. ELLIS: Second. DR. SCHMIDT: All right, it is seconded, so we are ready for discussion. I believe first, well, let's see, John, you have got the microphone. When you are through you can hand it to Dr. Schleris. CR7149 #10-ter-1 10 1 © 12 is 14 154. rr 20 ft 41. ( 22 23 eo . Ace — Federal Reporters, Inc. 25 119 DR. KRALEWSKI: A couple of questions and comment. One, I am in agreement that the state is a poor state and pro- bably has some Limited ability to share in the funding of RMP Programs. On the other hand there is a lot of Federal money going into that state, OEO Programs in the state, HMO, a couple HMO planning grants, I-believe there is a National Center Health Services Demonstration Grant, and I was wondering how much effort is being devoted by the RMP Grows to, ‘you .know, intermix their programs with these programs, and make, you know, these funds useful to some of their activities. Number two, one of the questions in the past was just how much of this budget is going to support that medical school, I wonder if you would comment to that to see if they’ are really breaking away from it, and number three, the comment: on the question of whether they should add staff with HMO capabilities. I am not so sure they should, perhaps, if these “other agencies of HMO Grants, like the Loveless Clinic, et cetera. If they are developing that kind of talent, maybe “RMP should stay out of it. MR. HILTON: Taking your questions backwards, I agree with you, our feeling was, our general feeling was, and we do have a minority report on that by the way, that they probably should, in fact , use the resources that are existent | ter-2 10 11 e - 13 14 15) 16 17 | 18 19 20 21 ( 22 23 6 24 Ace ~ Federal Reporters, Inc. 25 .in fact, may, in years to come. two grants in one area. 120 in their HMO planning. Medical school support, one of the things that was shocking to us or surprising, where we could not see they were getting that much out of it. They were giving away grant. There was involved staff -- staff involvement, more specifically on that. The Dean, at the time we talked to him was on his way to, I believe it was Harvard for a course in fiscal management, and when we questioned him about this, he said, perhaps that is why they have, in fact not benefited or exploited the situation as much as they probably could, and, But on the matter of other Federal help, perhaps, Frank can give us something on that. MR. SCHNIOWSKI: In terms of coordinating with the two HMO Grants in Albuquerque. 'Dr. Gay is on the board of | one of the HMO planning groups and he is actively involved with the other one. I had rather not comment on why there is DR. SCHMIDT: Miss Kerr? MISS KERR: Speaking of other Federal funds available I, too, was concerned when Bill was talking about the educdtiond: programs and as a point of information, the week of October 8th to 13th, there will be 75 hand-picked people, 25 each from the regional medical program, the New Mexico Medical Society and from the Department of Education, and they are bringing in two ter-3 10 11 @ 12 13 14 15 16 17}; 18 19 20 21 ( 22 23 eo ., Ace - Federal Reporters, Inc. 25 121 consultants; one of them is myself, to talk about health care education programs, and what might be available in the State of New Mexico, maybe this is one reason they are: turning to this kind of conference, I hope. | DR. SCHMIDT: Dr. Scherlis? DR. SCHERLIS: Do I read the application correctly, that they are asking for 35 new staff positions, is that correct? -MR. HILTON: You are a’little under. They are, in fact, asking for, let us see, no, they were asking for 25 new ‘positions. DR. SCHERLIS: I added it up and got 35, I guess from the pages 59 up to 62, or three, but they are asking for something within that range? MR. HILTON: Yes. DR. SCHERLIS: Looks Like it is closer to 30. The other question I have is in terms of page 30 of your site-visit report. Do I gather that you all: looked at their individual projects, and suggested a level of funding for each development; oftheir developmental programs? ‘ MR. HILTON: What we specifically did, was to look at their developmental programs. We did this in a couple of sub-group meetings. There was such a lump of some involved there, in that area that we thought we better look and see what ter-4 Ace ~ Federal Reporters, 10 1 12 13 14 15 16 V7 18 19 20 22 23 24 Inc. 25 21 122 it really was going into, so we did invite discussion from those closely involved with the projects to get a clear under- standing in our own minds, rally, what they had in mind; what they were planning to do. Yes? DR. SCHERLIS: I don't mean to suggest that this was not the way to do it, but you assumed they had good judgment and evaluation mechanism, and priority system that they are able to set up their own developmental ee What you have done is X out most of it, then turn around and give them a developmental component and say, "Do with it what you like." I know the hour is late but this is a rather interesting approach. | MR. HILTON: If I can recall again, Frank, r will ask your assistance on this, too. There were clues which preceded our taking this action with regard to the new programs, And, by the way, the team visit was chaired by Dr. Tamiroff,(?) of a hospital in New York who was on vacation, so he was not present at this particular meeting. As I recall, one of our reasons for. taking this particular approach was some indication we got from earlier testimony that some of the program, referring, particularly about the health education for public, there had been some intervention in the program thing, on the part of the ter-5 10 ood e 22 13 14 15 {7 18 19 } “ 24 Ace — Federal Reporters, Inc. 25 123 Assistant or Lieutenant Governor of the state, which had bloated that figure from something closer to $50 thousand to $250 thousand. That may have prompted us to look closely at some of the other new projects. There is no plan for that expansion between what we recommend and what they ask for in health education but that was not entirely a staff decision, either. That was, in a large measure, a result of -- I am not sure, is the Lieutenant Governor a member of the RAG? ~w» Yes. That was largely the result of the represent- ation on the RAG. And, I guess what we found ourselves doing j; then, was sort of going through these projects with the staff to kind of weed out or give them an excuse for weeding out some things that had developed, problems they had inherited with their RAG. | , | DR. SCHERLIS: ‘Point ‘of information -- the AHECs, was that a one-year shot of funds? Was €that planning or what? MR. SCHNIOWSKI: There is four, National Advisory Council recommended approval for four geographically dispersed community health education systems throughout the state. These are four separate projects, twenty, twenty-two thousand dollars apiece. DR. SCHERLIS: Was that just one year? What is going to happen after that year? ter-6 10 1 © 12 43 14 a ( 22 23 © 24 Ace —Federal Reporters, inc. 25 124 MR. SCHNIOWSKT: That is right. DR. SCHMIDT: This is one year planning. DR. SCHERLIS: Was that just planning? DR. SCHMIDT: Planning, yes. Other comments, other issues to raise? | MR. SCHNIOWSKI: . I would like to mention one factor. I am not disagreeing with Mr. Hilton when he stated in concern of the area of minorities but I think it is good to point out that the Program's Regional:Advisory Group contains 44 minority group representatives. This has tremendously increased under Dr. Gay; from previous years. The executive committee has increased | from eight to eleven members. Five of the eleven members are | minority group representatives. At the time of the site-visit, the Program staff had three minority group representatives, | just on the program staff. | After we left and made our recommendations, our suggestions, I might say, to the total site~visit, Dr. Gay has increased this from three to six prograth-staff members. All ftinority members on his RAG are attively involved in all of the committees and the one weekness we did point out was we certainly recommended an increase, we thought he was maybe doing 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. I don't want to -- ter-7 Ace — Federal Reporters, 10 iB 12 13 14 15 16 17 18: 9 23 24 Inc. 25 4 125 DR. SCHERLIS: How large is. RAG? MR. SCHNIOWSKI: ‘One hundred sixteen members. DR. SCHERLIS: That can be representative of a lot of the population. - DR. KRALEWSKI: The whole population. May I make a comment? DR. SCHMIDT: Right. DR. KRALEWSKI: This budget again, if I understand this correctly, we are recommending more money than they are - asking for on operational projects? MR. HILTON: Only because of the tumor --~ j DR. SCHMIDT: There is a switch of funds from up on top to down in there, actually. MR. HILTON: Yes, what we have done is taken out the tumor registry which was listed in their request, their initial request for program staff. The distinction that has to be kept | in mind here, is what they have ‘done, they have got two sets of projects. One, under program staff; and one operational pro- ject which is separated out. ‘And we simply removed from program staff their tumor registry project, and reduced that whole figure substantially in terms of the other projects under that. DR. SCHMIDT: Other questions? Or issues? | DR. LUGINBUHL: I would like to question the tumor ter-8 10 11 eo " 13 15 16 17 18 19 20 21 (| 22 23 Se . Ace ~ Federal Reporters, Inc. 25 14]. 126 registry. Seems to me that a very good test of the work of a program is the ability to find other funding and the fact that this program has not been able to find other funding suggests to me that possibly it is not quite aS valuable as it might appear at first look. And I may be speaking from a general bias, because I have not been impressed with the value of tumor registries, generally, and I have yet to see any very hard data that suggest: that these have had a major impact on even the care of cancer patients, or advancement of our knowledge in this area. So, just as a general principle, I would favor fundink these programs from local resources, and if these are not forthcoming, I think this may be a measure of their true worth DR. SCHMIDT: Well, the question has been answered, so I will limit your answer to what your estimation is that they will seriously attempt to find funding for that on the local. MR. HILTON: If rather emphatic advice is made to them in an advice letter to them, I think that might help to spur them to try again, harder this time. I would not make it strong enough though to make a contingency. DR. PERRY: I have the same question, Sister, and asked about the amount of the developmental component here. This is one of the largest ones that is being earmarked of all the programs. I would like a little fruther justification, you know, that they are really capable. ter-9 10 HW @} 212 13 14 VS]. 16 V7 18 19 20 21 Co 22 23 © 24 Ace ~ Federal Reporters, Inc. 25 the builtin problems apparently in terms of what kind of input ‘cetera, and you know, I would have to, in view of that fact, 127 The questions that have been raised on some of the problems that have been developed, I would like you know, a little further comment on just that one part. MR. HILTON: With regard to that developmental com- ponent, as I recall, in our deliberations, we really did not give that particular matter a great deal of thought. We certainly did not feel they should get as much as they requested on it. The question raised earlier, concerning the develop- ! mental program has been kind of turning round in my head since he raised it, because I.can see the direction he is heading, ‘on that. Yes, we are all in agreement that under Dr. Gay‘s leadership, it all seems to promise real well for the future, but the reason the developmental programs that are 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 would be made to the program despite Dr. Gay's influence, et and in the contention in which it was raised and I would also |: have to look myself, again, at the component as it now stands. ‘I would, at this point then, perhaps, Frank, can recall some things I am forgetting now, with regard to what your deliberations were on the developmental component. MR. SCHNIOWSKI:. I think Dr. Scherlis is concerned ter-10 Ace ~ Federal Reporters, 10 1 12 13 14 15 16 17} 18 19 20 21 22 23 24 Inc. 25 128 with the developmental component. Again, we have to kind of repeat the statement that the region indicated to us, that they were going to control these through program staff, and’ use them as a line, item budget. Our recommendations to treat these as individual project activities, not as a line-item-budget within program staff, reviewed by the RAG, monitored by their systems, and reviewed by CHP. ‘Thus $222 thousand, which we recommend for these activities in essence, is taking this amount of money and ‘moving it down into the operational project area, not keeping it up at the program staff level. | DR. SCHMIDT: I would like to move the group along to making any specific modifications of the recommendation, or whatever. Mrs. Flood? MRS. FLOOD: I don't mean to delay the continuance of our schedule, but I do feel that there is some aspects of « the economic picture of the State of New Mexico, that although it has been covered in some measure, should be expressed at a this time. I think, if you take into consideration, the sparsely populated areas of the state, with the only large urban impact area being in the City of Albuquerque, with the tremen- dous population of minority groups with underdeveloped education ter-1l 10 MH eo = 43 14 15 16 17 18 19 20 21 ( 22 23 © 24 Ace — Federal Reporters, Inc. 25 ‘position to resolve. 129 opportunities, the economy of the state is only dependent, truly, on the military and the many diversified aspects of military input there, Los Alamos, et cetera. That, to put the pressure on discontinuance of pro- grams, even the tumor registry, although I am not in a position to state whether it is a value project at the moment, but to put the burden of pay or maintenance of this type of project on the people of the State of New Mexico, at this time, is just not feasible, it is not a realistic approach. There is not that forthcoming economic base to support programs at home, go I would be reticent to offer any- | thing other than a recommendation to not cut program based on the fact that they have not been able to find other methods of support locally. DR. MARGULIES: I wonder if r might comment, because I think the comment just raised is terribly important in our deliberations. This is the most painful type of consideration we | have to go through. If an activity, over a period of time, is not able to find other means of support, it either suggests that it does not merit other support, or there are no resources: Now, if there are no other pesourees available, that is a kind of deficiency of a systemic kind which we are not in the Whether it is the problem of the economic status of ter-12 10 1] e ° 13 14 15]. e-10/s-11 16 17 “48 19 20 21 ( 22 23 6 24 Ace — Federal Reporters, Inc. 25 130 New Mexico, or as is much more common, the unavailability of third party funds to pay for a service which is generated out of a demonstration activity, et cetera. If RMP funds, or any other program like ours, which is developmental, remain in support of some project or activity because there are no alternatives, rather than because it belongs there. It very rapidly exhausts our resources, and really cannot move. In the case of the tumor registry, it might be even more difficult to justify, because. ghere are | go many doubts about the effectiveness of that as a program, but this is valid even when you are supplying a demonstration activity in a service, and it is especially troublesome, when what you are doing, is really worth doing; but if we begin to supplement Medicaid, or other types of activities with RMP funds, we are lost. CR 7149 Take 11 ©: 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 Ace ~ Federal Reporters, Inc. 25 131 DR. SCHLERIS: I know you are anxious to inove us along but my dilemma is I still haven't reached in my mind how I would react to this and I think that is the position of your review committee, | Looking at some of the projects for which they are requesting support for the 05 year, some one, two, three, 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 next time with these being in the 06 and 07 year, as well as the new ones that have come aboard that they can't phase - out because of lack of support. . My concern is that if everything that is started in New Mexico has to be continued indefinitely because there are no alternative methods for support, we better avoid starting new programs unless we know with assurance that they can be continued or unless we have the feeling ._ that our. beuget will be rising proportionately over the years to take care of this. Also, I reflect the’concern of the site visit group which was impressed with the fact that many projects go on through core, which means they really don't get the | evaluation they should get under other types of surveillance, one way is to move them out of. core, the other is to insist that all core projects have the same type of review. I am in a dilemma as far as the $120,000 for dor 2 10 in @ 12 13 14 15 16 17 18 19 20 21 ( 22 23 ) 24 Ace ~ Federal Reporters, Inc. 25 132 ‘developmental since there are ways of cutting projects out that have been continued now.to the fifty year. , Will you respond to that? MR. HILTON: Well, I think what you have succeeded in doing is pulling me into the dilemma with you a little bit, however, I‘did recall some discussion with Dr. Gay, that he has an intense interest in having available the capability and this again harks back to something said either today or yesterday in one of the other programs. He has an intense interest in having the capability to be flexible in programing,. I think this is where the whole discussion of developmental component came up in the first place. In fact, we discussed at some point his desire to:.be able to rechannel funds in areas in which he felt there was great need. . There may, in fact, and I am uncertain of the details on the other program, there may, in fact, here be a “need for that kind of flexibility in order for NMRMP to become a better program. I have, and again, I think I am speaking for the team, considerable confidence in Dr. Gay's ability to do this in such a way that NMRMP does, in fact, become an asset, whether or not it be done through discretionary funds which he did not question or developmentally, I think that dor 3 \ce ~ Federal Reporters, 10 1 12 13 14 15 16 17 18 19 20 21 22 23 24 Inc. 25 133 flexibility ought to be there. I am confident under his leaderwhip it will be used to the benefit of the program. Would you second, or any. comment with regard to that, Frank? MR. SCHNIOWSKI: Not to beat it to death, but the Tumor Registry Project has drawn outside support from the National Cancer Institute. They rate this as one of the three best registries in the nation, that is their judgment. The project director, Dr. Key, has approached the area of continued support in the wrong manner. He has been advised by one of the -- Dr. Tucker, who talked to him aside, and indicated it would be much more efficient to approach continued support th rough the medical. staffs of the individual hospitals as well as with the hospital administrators which he had been working with in the past. _By the end of '73, they will have only three remaining projects which they originally were’funding. One ‘of these is the tumor registry project. The other, we have recommended the EMS project that has been going on for four years to be locked with the new EMS. activity, which was recently funded from RMPS. | The third progéct is ‘their leukemia Jymphoma project which was started in their third year. DR. SCHMIDT: Bill? dor 4 10 1 ©} 12 13 14 15 16 17 (18 19 20 21 no 22 ©} , 24 \ce ~ Federal Reporters, Inc. 25 134 DR. THURMAN: I just want to add a minority report to what Dr. Margulies has said. A well-run tumor thing is a real asset. Remember during the Civil War we didn't think stethoscopes were any good. DR. MARGULIES: They are now? DR. THURMAN: Depends on the doctor, Harold. DR. SCHMIDT: I presume that resolved everything for us. — i i DR. SCHLERIS: I will listen to him on registries but hardly on stethoscope. DR. SCHMIDT: All right. Does anybody want to do anything in regard to developmental component, then? | I will ask for any amendments and we will test out the developmental component first. Does anyone wish to propose an amendment to the main motion concerning the developmental component? DR. SCHLERIS: I was going to suggest two things. One thing,I think we would do this region a favor if we reduced their total grant because it will make them get rid of some of the projects they have had ongoing for a long period of time. If we want to give the coordinator of the New Mexico program some potential mobility, we wouldn't give it dor 5 10 1 e 12 13 14 15 16 17 18 19 20 21 CO 22 23 @ . Ace ~ Federal Reporters, tnc. 25 - 135 ‘to him if we give him money for projects which EMS might want to phase out. I guess I also suggest reducing the developmental component. I was thinking in terms. of droping that 1.3 down to 1.15, the second year, 1.2, the third year, 1.250, but even that is being generous, but I think developmental component should be significantly cut. DR. SCHMIDT: Would you make -- DR. SCHLERIS: Drop it down to 80 thousand, 80 thousand for each of the three years, developmental component and the first year, the 05‘year; 1.15; second, 1.20;. third, 1.25. DR. SCHMIDT: Do you make that in the form of a substitute motion? DR. SCHLERIS: Yes, sir. DR. SCHMIDT: This includes approval of the. triennial status obviously. Is there a second? | It is seconded. Discussion then will revolve around the substitute motion and we will limit discussion to the impact of this level of funds and their ability to do what they want to do. Are there any comments? MR. HILTON: Is there an assumption here that there is an inordinate number of programs that will be running dor 6 10 1 eo . 13 14 15 16 17}. 18 19 20 21 ( 22 23 @ . Xce ~ Federal Reporters, Inc. 25 136 beyond the 05 years? DR. SCHLERIS: | Both the number and quality of them. They are going into the 05 year now, and if we are going to talk about a triennial status for a region that is attempting to, as you say, get mobility, I don't think you have mobility if you continue these projects and I think this puts on them the onus of deciding what they are going to continue. _ Also, you have looked at their developmental programs, it was apparent you thought many of them were markedly overfunded as far as what they were requesting. I think this gives them the opportunity of sharpening up what they are looking at and I think $120,000 is. an excessive amount, particularly since they are involved now with helping implement the Emergency Services Medical Program, which will absorb a great deal of staff and time because they are funded for two years on that, aren't they? And this is going to absort more than they recognize, as far as being involved, even though they may not be the contractual agency. MR. HILTON: At this point I am inclined to ‘ agree with you on developmental component, which I might move as a motion after we defeat this one. But on the-matter of continued programs, as I understand it, there are only three projects that will be dor 7 10 iT @ 12 13 14 45 16 17 18 19 20 21 ( 22 23 eo . Ace —Federal Reporters, tnc. 25 137 continued beyond the 05 years, one of them being the tumor registry. | MR. SCHNIOWSKI: I don't see any tremendous hangover of dead weight in that regard. DR. SCHLERIS: They are requesting. for the 05 year, the continuation, besides the tumor registry, of five projects. Now what we will be saying is beyond the 05, but we are talking specifically about 06, 06, 07, isn't that right, five projects which add up to something like $170,000 is being requested: into the 05 year, isn't that correct? DR. SCHMIDT: Dr. Ellis, do you have a comment? DR. ELLIS: Yes, I do, Mr. Chairman. I just wanted to point out that this is such a poor area and it seems to me that perhaps the developmental component moght give them the opportunity to work toward _ methods of health delivery that would really mean something in the lives of some of these pepole, and I was thinking about the opportunity to develop nurse midwives and pediatric assistants and assistants for the elderly and work within that frame. But I was thinking that technical assistance, it seems to me, might be helpful in getting them to make the right choices in terms of program without necessarily penalizing them. dor 8 10 1 © 12 13 14 15 16 17 18 19 20 21 ( 22 23 © 24 Ace ~ Federal Reporters, inc. 25 138 DR. SCHERLIS: I just want to make one comment. I am aware of their needs, and I would agree with you. There are certain programs they might move into but I don't see any assurance that we have been given that this is the direction that they will take, as far as the expenditure of their funds and the continuation of projects they have. had, do not seem to be in that direction. This is the other reason for my statement, not a failure to recognize their needs. DR. ELLIS: Would you think that technical ‘assistance might provide this way so we wouldn't have so much lag between the time that these problems appear? Some of these are very long-range problems. DR. SCHERLIS: Right, but we are talking about developmental component and triennial status, it seems beyond a little bit in time as far as telling them they need -a little. bit of technical assistance, this is my concern. DR. SCHMIDT: We are assuming that staff is listening. to this and that, téchnical assistance will be offered and provided and so on. John? DR. KRALEWSKI: I think technical assistance will be useful, I think this budget as being proposed here, however, under the new recommendation will give them room to run and develop that new thrust, and if this is a new order, dor 9 10 iL @ 12 13 14 15 16 17 18 19 20 21 ( 22 23 ee . \ce ~Federal Reporters, Inc. 25 139 I move we curtail debate, is that an order or is that -- DR. SCHMIDT: Yes, it is. I will call the question on the substitute motion unless there is a violent objection from the committee members. All right, then, we will vote on the substitute motion, which is triennial at a level of 80 for developmental component and 1.15, 1.2 and 1.25 for the three years. All in favor please say aye. . (Chorus of ayes.) Opposed, no? The ayes have it 26 the substitution motion carries. And I. believe that the necessary assistance will be arranged for by staff following this discussion. I would like to move on to Northern New England before ue break for lunch. | Some of the committee members sneak some pie or soup or something like this. So the record will show that Northern New England left the room, Bill Luginbuhl. | Dr. Thurman? DR. THURMAN: This will be surprisingly short, ' mainly ‘because the conclusion of our total visit was that) this whole RMP is just like starting a first year. I would point out that we had representation from the Advisory Council and Mrs. Wycoff, Tom Nicholas and - 140 dor 10 @ }]| 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. b 7 - I might give you one quick work of history «=. 7 about this about this group because that is where the real g|| problem has arisen in the past with Northern New England 9 RMP. | ; ; _ 10 | It became operational, had a planning grant in 1] '66, with its first operational year at "69, At that point 12 in time a committee from the University of Vermont Medical @ 13{| School actually ran the program. 7 The man who .is presently coordinator arrived in 15]. the fall of 1969, but throughout all this period of time; 16], their primary emphasis was on developing a data base. 17 : . Some of the questions that arose went high enough 1g} to get to the administrator of HSMHA, for. some type of 19 ‘resolution and that RMP and CHP tried to arrive at a merger type 20 situation, too, so that there would not be an overlap of 21 any: kind. ( 22 This was partly at the request of the governing 23 bodies of the state itself, to further complicate it because © 24 the state was small and because of this experience with RMP “oe ~ Federal ee Oe in the past, had been largely in the data base development dor 11 10 WT @ 12 13 14 15 16 17 18 19 20 21 ( 22 23 eo . \ce ~ Federal Reporters, inc. 25 141 experiment in health service delivery money, they requested one dollar and received $932,000 for supplementary health -- mental health services delivery, so obviously they were not: ready to use it. | | This created even more of a conflict bet ween the RMP and CHP merger. | What happened was that they began to listen more and more to the signals from this committee and others, and RMP actually began to change to a true RMP, roughly in January of this year, 1972, with the appointment of Mr. Danielson as coordinaror, reinstitution of RAG, as we know a RAG, with removal of a lot of situations that had gone on before, I would not leave you with the feeling that there aren't still problems, because of the fact that some of the boards still overlap betw een RMP and CHP, the divorcing of the whole business of the health services delivery syst em contract is still not a complete divorce, even though they changed the name a little bit. | In this change it did make it possible for RMP to get rid of some of the people who have been moved to the other corporations to help continue the data base in related areas but in this reorganization, they have been -- it has been necessary for them to bring about some of their staff. ‘and RMP losing their job. All of this has been accomplished reasonably well dor 12 10 7 e _ i412 13 14 15 16 17 18 19 20 21 ( 22 23 @ 24 sce ~ Federal Reporters, Inc. 25 142 by the people on board, and I think, in essence, represents now, since January of 1972, a nine month, eight month period of time when we were there, of reogranization, along. traditional RMP lines. Dr. Luginbuhl was present for much of the situation because of significant questions in the past, in reference to the RMP to the medical school. I think they have well understood the’ strong staff support and our review committee and council comments about whatwas wrong with their RMP in reference to collection of a data base rather than anything else. At this point in time, I think they have well understood that our feedback session was particularly good. Their request for specific staff assistance, C.C. and others, was very significant and meaningful, I think. And it represented, for me, at least, the opportunity to say very stronbly that this is an RMP that is still back in 1966 and that. is hard to accept, but that “that, the 1966 constitution of this group in 1972, leaves little question in my mind whether they will succeed. The present chairman of the RAG is a little bit still out of step and out of consonance with the new direction of RMP but he is a-very educable individual and they have not developed goals and objectives in the feedback, they actually asked us in a way how much time they had to do dor 13 10 11 | 12 e.. 14 15 16 17 18 19 20 21 ( 22 23 eo . \ce — Federal Reporters, tnc. 25 143 -it and we left them with a figure of 90 to 120 days, which came off the tops of the heads of the site team rather than having any other direction. | I think the whole question of minority interest in Vermont was raised and we were not able to speak to that very well because of the particular structure of Vermont. The only way a minority group could be constituted would be to have somebody who.was born out of the state and then moved neo it, because there are no other minorities in that sense of the word. The poor are not the minority in Vermont. If we are going to get on another New Mexico, it is here. But I think that in- general, in speaking to all of the other segments we normally speak to in review of an application, I could say they presented to us a very good approach of taking the best of what they have had in the ~ past, not related to development of a technic al data base, have coordinated it now with an approach to the future that ‘looks to be well structured and well organized and that we are now in the transition period. This transition period is entirély different from the one that is usually bandied around here about going from categorical to noncategorical, and instead, the transition from data collecting group to a true health care delivery group. Uuor 14 144 il: | , If we are going = ever be able to evaluate any ] 9 RMP, we ought to be able. to evaluate this one because they have 3 got the best data base you have ever seen to see now what 4 is going to happen in the future in all of their areas. 5 I think this will be meaningful, not only to us, P 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 3 end of the site visit report, you will get a feel, and this 9 does not represent all of the things they published. 10 . You get a feel a what the they have done since 1 1966 in collecting information, so we should be able to 12 very: quickly evaluate almost any program that is brought © 3 about in the delivery of health care in this area. 14 I think that as we look at the process of their 15 organization, the coordinators very firmly moving to take 6 total command of the situation with strong assistance from 7 the RAG, he is the one who has been responsible on going 18 face to face with every single ‘person and saying, "You are is ‘not really contributing, why don't you resign," or "We really 20 need you badly, you are the kind of guy who we hope can > help us make the change in the future." ( 7 Although the RAG is very small at the moment, 7 it is open-ended in reference to their by-laws, and I believe © 94 the additions we have brought about will be significant. \ce — Federal Reporters, ne , The RAG chairman clearly is a university man, ©." dor 15 10 1 @ 12 13 14 15 16 17 18 19 20 end 11 21 ( 22 23 eo . Ace — Federal Reporters, Inc. 25 145 but he is a university man who has pioneered community health programs throughout Vermont, which is a reasonably tight structured state. | So I have no en about him carrying too much of the idea of the university. | In speaking to the university and its relationship, one of our fellow committee members has led the charge to get the offices of RMP off the grounds of the university to cut down a tremendously spectacular overhead rate, and he has now succeeded in this and they are moving and they will - now have an off-grounds place, although the university will still be the grantee. We have no concern in any way about the management or effectiveness of funds because they are moving very comfortably in their structure to make sure that all of their so-called advisory committees, which is their mechanism of action, have a very firm.budget. T hey have a definite plan, with each budget there will be a timetable and if that timetable is not met, that the money will no longer be there. #12 10 11 eo | | 43 14 15 16 17 18 19 20 21 ( 22 . 23 @ 24 Ace ~ Federal Reporters, inc. 25 146 Going back to our earlier discussions, money is one of the clubs that we have, and they are using it well in their approach to programs. I think that the program staff is presently being realigned, as I indicated, they are phasing out a total of 11 jobs, actually more than that, but 11 are being phased out, some going to other opportunities and some just being phased out. They have brought on a young physician to work in the area community development. And his enthusiasm and capability mth are significant, and I think on that basis we don't have any real concern that they will begin to derive programs Exom throughout the state that have a strong community base and meet the need for delivery of health care in an entirely different way. | This is his cup of tea. If they can keep him in the program, it will be great. I have some concern that they may lose him because his type of talent is in bad need all over the country today and so he may go. The RAG understands the way to go. | I think that they have -- will make future appointments on the basis of knowing exactly what should be done before they get into it. They have pulled again, as I indicated, not only at RAG, but committee management, they have pulled their best people from the best and have let ‘most of the dead wood go. They have done ‘this very, very well which is a real ar2 10 11 eo . 13 14 15], 16 17 18 19 20 21 ( 22 23 eo . Ace ~ Federal Reporters, Inc. 25 147 tribute to the coordinator in that I think his experience in the program for over two years before he became coordinator made it possible for him to get an honest evaluation of what is going on. I think our only concern is the site team, about his role, was that in the area of continuing education and manpower development, if he has a blind spot, this is it, and we tried to emphasize that pretty much in our site visit. T think staff is well aware of it as a reasonable blind spot. It is emphasized enough in the feedback session > to make everybody else well aware of it, and I believe that will probably answer the most significant problem that exists at the present time in their entirely new development. I believe I would stop now in this discussion becaus there really is nothing else that I can firmly put a hand on at this point in time to say about this program because I ~ think we should look at it as a program that really developed a coordinator, no coordinators’ in January of this year. The RAG is working well, though small, to make itself meaningful. And they really have nothing else to present except a truly significant data basis accomplishment and now with the opportunity to turn around and move on. Rather than recommend, we might listen to what the secondary reviewer has to say first. DR. SCHMIDT: The secondary reviewer is Dr. Lewis. ar3 10 - @ 12 13 14 15 16 17 | 18 19 20 21 ( 22 23 @ . Ace — Federal Reporters, Inc. 25 148 who is not here. So, Spence, do you have any comments on -- let's move on then to your recommendation. DR. THURMAN: Spence, you don't have anything to add, let me add, do you agree with what I have said? No, C.C., I don't know whether you heard about what I said of the possible blind spot of the coordinator being in man- | power coordination and education, and we leaned very heavily on that with the hope that we would do away with his blind spot. MISS CONRATH: Yes, I think one thing the review committee might be interested in.. The Kellogg Foundation has made a grant to the University of Vermont Medical School for the introduction of the problem of oriented medical record in medical practice in Vermont. This offers an opportunity for the northern New England RMP and the medical school through the department of continuing education to join forces in a way in which they have not been able to join forces before. I think this offers a mechanism and advisability as to how the continuing education resources can be addressed in a meaningful way that is a very real promise, I think 7 in terms of case history, maybe of interest to know that - one of the graduate students of the University of Vermont did a master's dissertation on the case history of the northern New England RMP. This person is now on the staff. ar4 10 im 12 j . 13 14 15 16 17 18 19 20 21 ( 22 23 © — 24 Ace — Federal Reporters, Inc. 25 149 So if you need a good case history; there is a 100-page dissertation. : DR. SCHMIDT: Recommendations, then? DR. THURMAN : The recommendation of the site team was that triennial status not be granted at this time. This was quite honestly discussed with the entire group, but that it receive two year approval so they understand, or we understand they understand we understand they have turned the corner and are ready to develop a good RMP at this period of time, but with this two year approval at the level of $850,000 each a that we also grant them developmental component or discretionary funds, and our recommendation for the first year there would be 10 percent of the present fund; for the second year, continuing 10 percent of whatever the funding is for the first year. | DR. SCHMIDT: We will have.to label that discretiona and that amount is within the 850,000 obviously. Is there a second to that motion? DR. ELLIS: Seconded. DR. SCHMIDT: It is seconded by Dr. Ellis. Comments DR. JAMES: I would like to have one to explain to me the relationship of the research and development. of health systems incorporated which is the recipient of HSMHA's experimental systems contract. I see where they were awarded $900,000 to develop mS 10 1] eo = 43 14 15 16 17 18 19 20 21 ( 22 23 ® . Ace ~ Federal Reporters, Inc. 25 150 experimental delivery system there: It occurs to me that with the geographic and demographic information we have as far as Vermont is concerned, that there will possibly result some kind of conflict -- well, can't say conflict, but I wonder just how much overlapping of effort in such a small state, that Vermont represents. | It seems to me that there might be some turf interference, and I get the feeling that one is going to take precedent over the other in view of the fact that the popula- tion is small. DR. THURMAN: I might respond to that by saying this is the one dollar they requested for which they received 932,000. And it is very clear in everyone's minds that there will continue to be some degree of difficulty in understanding the role of each of these because of the fact that RMP in 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 that the new program actually represents. The overlapping of boards, who will do what, all of that is still a bad situation. I think this will not be clarified over the next several years because of the fact that RMP actually helped with the development of all of the plans for what is now the experimental system to the tune of “roughly $150,000. Isn't that right, Spence, over the years? Okay, 350,000, missed by 200,000. It is a piddling amount. axr6é 10 1 © 12 1 14 15 16 17 18 19 20 21 ( 22 23 @ . Ace ~ Federal Reporters, Inc. 25 ‘So I think there will continue to be some real problems with the name of this now to call it a Vermont, it now has VHSI ‘burdened, but very concerned about the situation, is Dr. - | 151 this. The medical society is well aware of this,Dr. James, and their concern, the board, they have actually changed to get around some of their problems and their board is made up of providers, politicians, public and the payers. This is part. of the thing they are going through. I think Dr. Danielson as coordinator and the early development of the present RAG, nine tg 12 people, are so burdened by this whole situation that I would not be concerned about RMP being hurt. I am more concerned, not truly that concerned about it, about HSI being an ineffective program because of the emergence of a strong HCP. I think staff will have to continue to look at it and I am sure the northern New England RMP will be coming back 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 right now. Point out that one person who's been not so Luginbuhl because he and others wonder what they are going to do with this 932,000. DR. SCHMIDT: I will comment just briefly. I don't think that blame, with.the word "blame" in quotes, for the situation can be laid at the door of RMP at all. RMP is a victim of essentially HEW muddling and meddling ar7 10 1 : 12 ® 13 14 15 16 17 |. 18 19 20 21 ( 22 23 @ . Ace ~ Federal Reporters, Inc. 25 152 in the state of Vermont, and if somebody's got red ears over this, it is the Secretary of HEW, And this is an incredible blunder by HEW,- and in effect a manipulation of a state plan. | I think that the RMP and people in Vermont are going to have to kind of recover from a reeling blow that was dealt to them by feds coming up there and manipulating the state, and I think the RMP will be in great part, part of the solution of this problem. | My words are quotes from HEW people who have been _ investigating what went on in Vermont and how a request for one dollar got turned into a forced upon the state 1 million by HEW. It is an incredible story. Are there other comments or questions then? DR. ELLIS: We don't understand the $1 request. Could you tell us? DR. THURMAN: They were told that with this tremendous data base in hand, where else could you -~ could really you document what you a doing with experimental health services delivery and other approaches, and so they said don't you want some of our money? ‘ And in essence, the answer back was we are really not ready for it, which is an honest statement, so they said at least put your hand in the pot, and they put their hand in the pot for a dollar, and were showered with greenbacks. ar8 10 1 @ 12 13 14 15 16 17 18, 19 20 2] C 22 23 eo . Ace ~ Federal Reporters, tnc. 25 153 DR. KRALEWSKI: Aside from who would apply for a dollar, I am hesitant to vote, I like your funding recommendations, but I am hesitant to vote that two year kind of thing since generally we deal with a triennium, or say look, here's another year, you can try to work out an applica- tion. Would you comment on this? . Do you think we have to go give them a two-year kind of period? DR. THURMAN: We discussed this at some length and Spence can comment when I finish. | Our feeling was that they really had made a marked change in their approach. They had the people now who under- stood what the story is all about. And therefore that if we would seriously inhibit particularly the development of their community-related program under Dr. Robins and he would not be able to add additional people, he could only talk to them on the basis of one year, and that then triennial status if everything continued to go well. There's been so much problem and so many people like our chairman's referring to, so many HEW investigating groups that have passed through the state that the crown sits on uneasy with so much money. We felt strongly that if we just went for one year with this group that he would have real troubles continuin “£0 develop what he wants. DR. SCHMIDT: This would not, you know, by the two ar9 10 V1 e 13 14 151, 16 17 18 19 20 2) oo 22 23 © 24 Ace — Federal Reporters, inc. 25 - 154 ‘years -- are you saying that under no circumstances next year could they come in with.a triennial? DR. THURMAN: This was discussed at the feedback session, nothing prevented them from coming in for triennial status next year, but we wanted to give them the feél for. two years for continuing development. Spence? MR. COBURN: It is: built into the recommendations -- DR SCHMIDT: It is part of the recommendation. DR. THURMAN: Yes, it is. MR. COBURN: They are not going to be able to write you a triennial application after the site visit. This will be then applied in the second year as you are suggesting here. If we go in with the recommendation that here is a base for a couple years, and although we'd like to have you move as rapidly as possible in formulating a program thrust and ~ developing a three-year program, and sending that program in here for approval, I'd be agreeable to it.’ DR. THURMAN: I think to finish it off, we said there would be a site visit next year. This they understand, and.if they wanted to before that site visit actually prepare a triennial application, fine, but if it looked like they need another year to actually go on as they were, that was one of the reasons for the recommendation of level funding, that they would then know that they had to talk to that group arl0O 10 11 oe |. 413 14 15 16 17} 18 19 20 21 ( 22 23 © 24 Ace — Federal Reporters, Inc. 25 155 or some group again next year about’ an increase in funding. But we felt that the security of this program with its past problems and the actual divorce now of HSI with a whole change from RMPS staff that they may or may not be ready to try triennial application this year in order to meet site visit next August again. DR. HESS: I would like to think that with this recommendation we are coming very close to a leveling off of funding for this particular RMP. So it happens with your recommendation they will be funded at about $2 per capita, which is the highest, as far as I can recall, the highest funded RMP, on a per capita basis of anywhere in the country. True,. they do have scattered population, but no more so than Arizona, New Mexico or the mountain states. Low income, yes, but no more so than Mississippi. I would think there ought to be a point where certain RMPs begin to level off while others are coming up. Particularly when so much other federal money is coming in which is addressing itself to health care systems, so I am just concerned that we don't get into a situation more and more simply because they got in and got something going. ' Seems to me that we have just about reached a plateau. DR. SCHMIDT: Other comments prior to a vote on the motion then? If not, I will call for a vote. 156 arll © 1 | The motion is understood. All in favor, please 2i| say aye. | 3 — Opposed, no? 4 And I hear no dissent. 5 It is 1:15. Cafeteria is out of soup, but there 6 are a few other things left. 7 We will reconvene at 2:00 o'clock sharp. 8 a . (Whereupon, at 1:20 p.m., the hearing was recessed, 9|,| to reconvene at 2:00 p.m., this same date.) el2 10 1 e 13 14 15 16 17 18 19 20 21 ( 22 23 eo . Ace ~ Federal Reporters, Inc. 25 CR 7149 13 eak 1 eo XXXXX 9 10 11 oe °* 13 14 15 16 17 18 19 20 21 ( 22 | Cs @ 24 Ace ~Federal Reporters, Inc. 25 157 AFTERNOON SESSION (2 p.m.) DR. SCHMIDT: It is two o'clock. I have been asked to remind the Review Committee members to be filling out | your rating sheets. All of the regions that are under review should be rated by Review Committee members. So be sure you fill these out. We have three left to do, Texas, Indiana and Memphis. We will begin with Texas and Miss Kerr. ‘MISS KERR: Thank you, Mr. Chairman. I think we want the records to show Mrs. Flood has excused herself. She was an important part of this visit, so. The visit to Texas was made in August of this year. The State of Texas makes up the region and it consists of 254 counties with a population 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 becaus it has accomplished so much and has so much potential that I would like to share it more in detail than I will be able to. The grantee institution is the University of Texas at Austin. It is made up‘of 17 institutions of higher education, three of which have medical schools. Dr. Charles LeMaistre is Chancellor of the system. Physical agent is the same institution. The coordinator is Dr. McCall, central office is in Austin, with projected ten subregional offices. At the momént six exist, at El Paso, Houston, Tyler, Abilene, Laredo and Lubbock. They expect to add to this eak 2 10 7 @ 12 13 14 15 16 17 18 19 20 21 ( 22 23 © 24 Ace — Federal Reporters, Inc. 25 158 list San Antonio; Dallas will then leave two to develop. In Texas there are 21 CHP "B" agencies, 19 of which have councils and have been funded from between $10,000 to $20,000 per agency by state funds. The last site visit was made in July of '71. Dr. George Miller is Chairman of that group. Also on that site visit team was Alfred Pompa. And I say this becaus these two gentlemen were on the visiting team one year later. The region appreciated this continuity. As Chairman of the team! I appreciated this continuity. | In the meantime between the last site visit and the — one in August, there were four interim staff visits to the Texas |jregion, on an introductory visit from Buddy Says here on my right, one relative to health services education activities, one relative to health services activities. Also the members on the team in addition to Dr. George Miller and Dr. Al Pompa were Mrs. Muriel Morgan of the council, and Dr. John Low, director of the South Dakota regional medical program. Regional medical program staff were Mike Posta who is present in the room, Joe dela Puente and Dr. Roberts who is here. And I am hopeful that they will feel free to contribute after I am through with the initial vepore. In addition to this group, we had David: Eubanks from the HEW region 6 as program representative. The purpose of the site visit was to assess program progress, processes and thé proposed triennial application. eak 3 Ace - Federal Reporters, 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 Inc. 25 ; 159 Now, following the last site visit a year ago in August of 1971, there was an advice letter sent out following council meeting which contained five major concerns for this are relative to this area. I will visit those in a moment. However, I would make it clear that we had a team visit the night before at which time the team decided that while we were focusing and basing our observations on all t criteria for review, we would focus primarily on these five area to be sure that we were probing deeply enough to have answers | for this review committee and council when we returned. The five concerns and there is somewhat overlapping,| at the time of a year ago, it was identified that this region needed to establish priorities under its new program direction. The subregional staff members, it was felt, needed more assistan and support from the central office and RAG members in the devel ment of specific program activities. It was felt that there needed to be more and better representation from allied health, one more, additional representation from minority groups, the fifth one, some of the reviewers felt the process seemed to be more of a central office academic review rather than peripheral involvement in input. In developing into these more. deeply, I think they will come out as I progress along through the report, just how we did find these five concerns being based and attende to. From the time of the last site visit until December, it is te t} cy. eak 4 10 ir @ 12 13 14 15 16 17 18 19 20 21 (gn 23 @ 24 Ace - Federal Reporters, Inc. 25 task forces coming back at intervals to compare notes and 160 unbelievable what this region had done with the development of goals,objectives and priorities,. not only the amount of work done but the process in which it was done. | It involved not only the coordinator and staff, but many meetings of the regional medical program, representatives from the subregions, the executive committee, and it was a well-organized process coming out with seven priorities well understated by pertinent goals. There was only one question about thiw’ whole area of goals, objectives and priorities and this was Dr. Low who felt that perhaps the objectives could be stated somewhat more in measurable terms. Didn't seem to be a glaring omission but this was a suggestion for improvement. The -RAG was divided into seven major committees, each one responsible for one of the priorities and they worked individually in finally came up with the seven priorities accepted by the total group. | The objectives by testimony during the site visit are understood by all of those participating and they are suppor: by all those participating. Chief of program development evalu- ations to be employed and more expert consultation will be | sought in strengthening the evaluation committee. They did have a man On staff full-time on evaluation but in the process of further developing the subregions and giving them the kind of ee 10 1 © 12 13 14 15 16 17 18 19 20 2) ( , 22 23 @ 24 Ace ~ Federal Reporters, Inc. 25 activities of local RMP advisory bodies would constitute 161 assistance they felt necessary to come from central office, this agent who is a very capable person was put in a position to coordinate and assist with the activities of the subregion programs and, as a result, it vacated the position of one full-time evaluator but this is in their plans to replace this person very shortly. It is very clear that the subregional offices are no providing more input into the system and. this was verbally supported by every one of the ‘subregional representatives that was there including Mrs. Flood. They. all were very vocal, very supportive and very appreciative of the kinds of assistance that they were getting. The issue of advisability which was done by the council and sent back to the advice letter} the issue of advisability “of developing local advisery groups was discussed and the concensus was that the CHP "B" consumer- fe oriented planning councils are being developed and that potentia duplication of effort. It seems it would also be detrimental to community efforts in Texas because not all potentially effective, ‘ articulate and well informed consumers have been introduced into the system. An effort to train consumers in participation, however, is presently being supported by RMPS. In addition, five contracts for developing an enviroh ment for Chicano health consumer, participation is being supported eak 6 10 1 © 12 43 14 15 16 17 18 19 20 21 \ 22 @ 23 24 Ace — Federal Reporters, Inc. 25 * 4 162 by RMPS in Texas, California, Colorado. These priorities when appropriate have been followed in the funding of operational activities. They are addressed to regional needs and reflect the possibility and instrumentality for continuous development and improvement. .:‘As far as implementation, there is much evidence of continued accomplishments by. RAG committees and staff. For example, support of planning effort toward comprehensive proposal with reference to renal disease has resulted in promising activity. If successfully funded, it will bring to Texas one of the first efforts addressed to compre- hensive care of a particular group by regional basis. Without a doubt, in my experience of project proposals, whether it be RMPS or any other, this proposal for the kidney program was probably as well thought out, planned through a committee, advisory committee, bringing everybody across the state of Texas aboard that could have any input to its implementation and it was exciting really to hear about this. It has been so well done. While many traditional projects have been supported in previous years, these are now being terminated. A new generation of projects as was presented to the visiting team promised to deliver improved accessability. Representatives of various multi-discipline professional organization testified favorably on behalf of RMP. I bring this out primarily because © eak 7 Ace — Federal Reporters, 10 HW 12 13 14 15 16 17 18 19 20 21 22 23 ~ 24 Inc. 25 163 historically this has not been true. The relationships, the acceptance of RMP by the medical association has improved. I would go a step further and say that the executive director of the Texas Medical Association was the one who was there to speak with us. And what is probably a little more reserved in his openness and acceptance of RMPS than I understand about 90 percent of the physicians in that state are so this was encouraging. But the other thing about the change in the predominance of physicians can be told, I think, relative to the adivsory committee. The advisory committee at one time was almost entirely MDs. At this point in time, numbering 51, there are 29 physicians on it. And it was recognized that the region serving an effective role toward the delivery of health services because it, for one thing, it is serving as a bridge between what we call on the site | visit among ourselves in family, town and government. In other words, it is bringing together the practici specialists and general practitioners. © 0 #44 2 ‘a l 10 11 ee . 13 14 15 16 17 18 19 20 21 ( 22 23 eo . Ace — Federal Reporters, Inc. 25 7 164 As far as continued support is concerned, in response to questions by the visitors, the regional representa- tives reviewed the continuing status of the activities fund trhough 1970 to 1972. Of 22 projects supported, only two will continue after the close of the current period. | ‘Eight will be supported by self, or other support that has already been arranged. Seven, will be discontinued. Either because they have been completed or because through evaluation they have proven to be not worthy of cemtinuance. And there is a question about the continuance of three others, Relative to minority interests and you will recall that this was one of the concerns of the last advisory group, and we went armed for bear to find some answers to this, and I would have to say, that as we looked at the advisory committee constituency there was some concern and a little more than concern, that not as. much has been done in this area as wehad hoped would ‘be in the entire interim period. However, there has over the period of the last five years been an increase in minority groups to the number of ll, which seemed not too bad in view of the fact that they only had a quarterly turnover with replacéments. And we can't exvect an unusually rapid increase in this number through -- but there are also some other reasons. I think we all acted like generals for two days in this area and I think Dr. George Miller's hat was the hardest an ey; Reba 2 2 10 N @ 12 13 14 15 16 17 18 19 20 21 ( 22 ark; eS ., Ace - Federal Reporters, Inc. 25 ‘will not commit myself to bringing aboard a black face or 165 the biggest. Having been there before, being the one that made the recommendation for increased involvement of minority groups, he really peppered away at this. We even checked this out’ with Dr. LeMader relative to their civil rights compliance and so forth and so on. They had as I say improved the minority representation on the RAG, not as much as we would have liked but there is a strong commitment to do this. And words can be words, but it is in print. Their procedure for employment of people with a focus on employing those who are of the minority groups. I think at this point I will say that Dr. McCall, as forthright as he is, we could not back him into the corner on this because he was so honest about it and said, "I am looking for these people, I have been looking for these people. I will continue to look for these people and bring them to the board as soon as possible but I Chicano or a white person unless they have the competency and capability that we can build on’ to make them an active con- tributing part of our staff and. RAG."~ The minority groups are extremely well and consumer groups in the subregions. Much of the ‘program is arranged around the inputs from these people. There are a significant mmber of minority personnel on project staffs. I would want to tell you this:Dr. Sid Geroa, who sat there, and he is not a very © #14 1 Peba 3 2 10 1 ) 12 43 14 15 16 17 18 19 20 21 ( 22 ark eo . Ace ~Federal Reporters, Inc. 25 166 vocal person, but he rose to his fee't after much probing in this area, and this was the second day, he rose to his feet and. in a soft kindly way, a Chicano, made it very clear to us that the RAG, the Executive Committee and indeed the grantee institutions as they moved ahead in their pgoram planning and implementation, he felt and it.was like a sermon, he felt that they had the well being of everybody in that state in mind regardless of race, color, creed, age or anything else. And it was beautiful to hear. If he had been more vocal before I don't think it would have been quite so impres- Sive. Relative to process, Dr. NeCall, the coordinator, has undoubtedly provided some of the strongest leadership with able administration in his three year tenure that one could expect. There is a very viable regional advisory group and he has utilized them, diversified talents of its membership, in establishing the plan as presented in the triennial application. Dr. McCall has excellent rapport with members of the RAG and many other health representatives throughout the state. Agencie and associations, individuals, and so forth. As an aside, at this particular time Dr. McCall was being interviewed fora Coroner's position in my own state and as a member of the colleg and faculty there I was aware of this, somewhat involved in this I think he and I treated it with very low profile, inten- tionally. The review committee was aware of this. The possibilit Ui WwW 10 7 e 12 13 14 15 16 17 18 19 20 21 ( 22 93 eo ., \ce — Federal Reporters, Inc. 25 167 of changes, I would say, despite the fact we knew change was possible, we felt that Dr. McCall had developed a staff, had allocated responsibilities or delegated responsibilities and given it the authority to carry out these responsibilities, and if he had, we felt that Mr. Ferguson, his deputy could very well move: in and move ahead with the program they were planning. I hasten to add before you get excited he has decided to stay in Texas. I think Texas is fortunate and I think we would have been fortunate to get him butgve will carry on. Relative to program staff, the staff consists of 19 professionals, all but two of -them serving 100 percent of the ti There has ‘been almost no turnover in the last two years. I think this speaks wéll both for staff and for the coordinator, and six additional professional staff members are requested during the next year and include a director of edu- cational programs, chief of public development and evaluations, nursing education and three subregional representatives. The site visitors believe that these positions as budgeted are justified. The program staff reflects a high quality of broad branch of professional discipline, particularly impressive was the quality of subregional representatives to demonstrated thorough knowledge about their responsibilities with respect to geographical assigned areas. The 51 member RAG group was very active from the time of the last site visit through December and continues to © #14 1 Reba 5 2 10 11 12 a 13 14 15 16 17 18 19 20 21 ( 22 93 @ 24 \ce - Federal Reporters, Inc. 25 168 be but were narticularly active at that time with attendance never going below 70 percent, and with people coming from all over that state of Texas to work on RAG meetings, that attendanc of 70 percent seemed to us to be very good, Geographic distribution of its membership was con- sidered to be satisfactory. However, as with many regional medical programs physicial representation proportionately was high while consumer interests remain relatively low. I alluded to that earlier but I need to go a step further I™“think and indicate again there are still 29 of the 51 who are physicians. This question was raised as to why. And the chairman of the RAG, S. T,. Bradshaw, not Bradshaw, Dr. Eastwood, who is a Ph.D. and director of the medical center at Houston, quite a personality, highly respected by the group who relates well with the RAG group, and in staff and the rapport seemed excellent But anyway Dr. Eastwood explained that with the four Baylor and one other medical school in the state, --- MR. SAYS; University of Houston is the medical school. MS. KERR: Getting underway. If they were to have representation from general practitioners and so forth so on Fhey could see that this could not be cut too much more if they vere to keep the good faith of the physicians that had taken sO long to get it built up and he convinced us that this was r- with the three medical institutions within the system, and with ty ov. peba 6 ° 9 10 1 © 12 43 14 15 16 17 18 19 20 21 CO 22 , 23 24 \ce ~ Federal Reporters, Inc. 25 169 Ana after our visit I think we felt that this too was proper, too. | The executive committee meets more often than the RAG committee and provided ample guidance for the coordinator and staff. Effective in providing leadership in the process ‘and in utilizing regional advisory groups, 51 committees and task forces. These were not left in limbo, they were well organzr- ized and coorindated task forces and committees. Development committee assumed an active role by establishing short term objectives. The Chairman of each program committee is a RAG member and serves.on the executive committee. General program activities for each of the seven priority statements and funding allocations projected for use of growth funds in the second and third year of the proposed triennial event application. All this is to go to say that there has been much planning, thinking, brainstorming, and so forth orior to the submission of their level of request for funding. “tf have talked about the grantee organization. There was some feeling at one time that perhaps there was a little bit too-much control from the grantee organization. We came away from their having probed rather deeply on this too to find that the coordinator, the RAG, feel very free to move ahead with decision making with: absolutely no interference or control from there, from the grantee institution. And they feel very comfortable with the physical @ #14 1 jana 7 2 10 11 13 14 15 16 17 18 19 20 21 \ 22 23 tT 24 \ce ~ Federal Reporters, Inc. 25 170 arrangements, as far as participation is concerned. Many health interest groups are actively participating in the region as evidenced by the number of persons who attended this two day visit. No major group has captured a controlling interest. In preparing the budget request for that of last year there was a complete turn around with respect to funding the major uni versities and institutions. This accomplishment has made more funds aa for the community. But -- as a regalt it has not brought about less cooperation from major health institution The political-economic power of the regions involved in the regional program, the CAP agencies and local ~- not only this but there is CHP representation on the RAG, representation from RMP other PMP. on the CHP Council. CHP and B agencies are involved in the process. I have already talked about the CHP's, and their situation. ‘During the last RMPT the review cycle there was ample evidence that the RMP's minimum review requirements and standards for local review have been carried out in a very satisfactory manner and this continues to exist. As far as the assessments and resources there was ample evidence the region is conscientiously accumulating a great deal of data as evidence . by’ (inaudible) -- the data is utilized in identifying specific and measurable needs of the region. qT Ur @ #14 #1 aba 8B 2 10 if 171 Management, the capability of the region continues to be excellent. Program staff and project activities are well coordinated including monitoring by RAG members and sel~ ected ad hoc members. Progress and financial reports are require On a quarterly and monthly basis respectively. Relative to evaluation as I indicated earlier at the present time there is no full time evaluations director in the program. I have talked about the termination of funding on Some projects that come about by evaluation and the limited funding being put on others as a process of evaluation and their need and expectation to fill this position shortly. As far as program proposal the action plan is comprehensive, 12 @ 13 14 15 16 17 18 19 end # 14 909 # 15 fils 21 23 eo . Ace — Federal Reporters, Inc. 25 priorities have been thoroughly prepared with much review and are clearly congruent with national goals and objectives. The proposed activities relate to stated priorities and objective: given to the needs of the region. Methods of reporting accomplish} ments and accessing results are proposed but address individual activities really more than they. do program achievement but beriod review and updating of priorities are planned. mea-1l CR 7149 #15 10 HW eo * 13 14 15 16 17 18 19 20 21 \ 22 23 eo . Ace ~ Federal Reporters, Inc. 25 172 As far as dissemination of knowledge is concerned, ‘most programs have focused on appropriate groups and institutions that will benefit. Knowledge, skills and techniques to be disseminated everybody identified to varying degrees among the projects. There is a notable degree of involvement of health education and medical institutions. Better care to more people is a goal to which projects are directed. Some solid measurement of result remains to be seen. However, they are also addressing themselves to moderation of costs of care. | Utilization of manpower, the regions utilize community health facilities and it is apparent in the projects that are proposed. Allied health personnel utilization has improved. Although new types of health manpower is a sensitive issue, further attention is being given to this and this statement revolves around the fact that the medical profession in the State of Texas is not yet ready to accept the position of assistance. Maybe this will change but this was why this particular statement was put in there. Improvement of care, access to health care, is their first priority and projects are being addressed to this ' issue. Primary care will probably be strengthened since mea-2 10 im eo. 13 14 15 16, 17 18 19 20 21 22 23 eo . \ce ~ Federal Reporters, inc. 25 - 173 this is an important element in several of the projects. Less attention is given to health maintenance and disease prevention in the proposed activities. As far as short-term payQoff the proposal is directed more toward the ability of access to services than simply gathering more information about health problems. The need for feedback is projected. Support of projects not planned beyond three years. Plans for transition to other sources of support are inclyded in their proposals =o that three years. is the limit of funding. _As far as regionalization, we have talked about the different regions. It is a major goal of the program. They do share existing resources when possible and new linkages among providers are indicated in the three-year plan. | There is ample evidence that the region has and will attract funds from sources other than RMPT, Though not discussed in detail the region account provided the staff with a document which indicates non-RMPT funding, to be new and continuing projects and terminating projects $150,380. It was the feeling of visiting team that Texas has much going. That it is well on its way to doing some very exciting things based on sound priorities and objectives which have been developed cooperatively with a great deal of CR 7149 contd. fig, MEA dor 1 10 1 12 13 14 15 16 17 ||: 18 19 20 21 22 23 24 Ace —Federa! Reporters, Inc. 25 174 consideration by all people involved. They have been accepted by all people involved and it seems as though they are collectively ready to move out and do something with these things. . We also felt that the region is under excellent leadership from the coordinator, who uses well his central staff of people who do bring to the central staff competencies. We have before us the funding level requests and I think we can all read that the site visitors did recommend that they be approved as requested. “Now, I would draw your attention to the fact that these do include the kidney project and that there are questions about that. | Dr. Roberts pursued that more in depth, but it was the unanimous opinion of the visitors that they be approved at the level requested. It was also the unanimous feeling of the visitors that Texas kept its A rating. DR. SCHMIDT: All right, John. Dr. Kralewski: Just a couple of comments. I didn't visit Texas on the site visit. Asa ° matter of fact, I have never visited Texas RMP, so I really don't know the program. I am reacting to the application; I am reacting to the site visit report. dor 2 10 7 @ 12 13 14 15 16 17 | 18 19 20 21 ( 22 23 eo . Ace — Federal Reporters, Inc. 25 175 Unfortunately, the reports are striking me a little differently than they apparently struck the group that visited Texas, but let me just give you my impressions,-- then we can go from there. | First of all, it looks to me as though that RAG is still dominated by producers of services even after the, you know, team previously had been very concerned over it and wanted to make changes. Changes have been minimal, and the addition of women to the Regional Advisory Group, and then putting ‘-minorities on there, to me, is a cop-out and, secondly, it is a cop-out, I think, to say we don't want to take someone because he is a minority group, we have got to wait until we get that fantastically qualified guy. I have had about three programs tell me that and it is a strict cop-out, because they don't look. There is plenty of good guys out there if they search for them, so I think they are not doing the job in that. regard. Secondly, when I look at the projects, I think this shows up because, of course, in their screening of the projects, this is the group that sits down and sets the priorities and determine what shouldbe in and what’ should be out. If you look at these projects, a good many of them are self-serving to the group that is on the Regional aor s 10 iW @ 12 43 14 15 16 17 18 19 20 21 ( 22 23 tO 24 Ace — Federal Reporters, Inc. 25 176 Advisory Group, self-serving to producers of services. I know this is a conservative state and they will have to chip away a while before they can do things. I find, on the one project, they are going to help 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. So, now we will have another foundation developed at our expense for the Medical Society more than likely. Well, you know, these are leaving me some real questions. | Also, I note in here that it appears that a fair amount of projects are carry-over projects, they are not being phased out. It may be that this again is an indication of some excess money that was given to them in the middle of the year and it just: doesn't reflect that in this application. Well, on the basis, on that basis, of my feelings, as I read through this and the feeling that I get, you know, for what they are doing, I can't really recommend that level of funding, nor an A rating. On the other hand, as I said, I have never visited the program. I am acting on the basis of information that might be limited. I respect the site team's wishes, obviously they dor 4 10 VW 4 | 12 @. | 13 take 16 14 15 17 18 19 20 21 ( 22 23 td 24 Ace — Federal Reporters, Inc. 25 16 177 ‘spent a lot of time with it, therefore, I am in a bit of a dilemma. " DR. SCHMIDT: Let's see. Let me see. Would you second the motion that was made? DR. KRALEWSKI: For that funding level? I couldn't second that, no. DR. SCHMIDT: All right, there is a motion on the floor for approval at the level requested. Is there a second to that motion? MR. HILTON: Second. DR. SCHMIDT: All right, it is seconded. All right. Further discussion? Dr. Luginbuhl? DR. LUGINBUHL: I was interested to check the population of the area. I’ think it is 11 million people, and I don't. really feel that coming up with per capita figures should be t he way in which we determine allocations. I do think, ‘on the other hand, that we have to give some consideration to the size of the area and the numbers of people that are being served. I think that the amount of money proposed works out to something like 22 cents per person. I know in one of the other programs, we have given probably five times as much on a per capita basis. dor 5 10 1 @ 12 13 14 15 16 17]: 18 19 20 21 ( 29 23 o . Ace ~ Federal Reporters, Inc. 25 178 My question is, if it is an A rated program, why isn't it a bigger program in view of the size of the state, the diversity of income levels, the magnitude of the problems, why aren't they able to utilize more funds and meet some of these needs that are there? DR. MARGULIES: I think that is an interesting kind of a question to raise. It is more a matter of history of program development than it is geography or population. It is a problem that we have wrestled with at various times in RMPS. This particular program was one with a miserable record i until the time of the last sit e visit, when George Miller was down, sort of astonished at the change about it. On the other hand, if you are asking the question, why, if this program is as strong as it is and has that many people it is not able to identify more activities of value to those people, that is a perfectly valid question. I just don't want to mix the two issues in the discussion. DR. LUGINBUHL: Well, my Major question really ‘dealt with the last issue. I can't help but wonder, in view of. the population, why isn't it a larger program, and to lead me to question the wisdom of having a single program cover such a very large geographic area and such a very large dor 6 10 1 © «i212 13 14 15 16 17 18 19 20 21 22 23 eo . \ce — Federal Reporters, Inc. 25 179 ‘population. I am not familiar with the California program because we have not reviewed it at this time, and I gathered they have dealt with their large population by some sort of great division and I know that New York, which may not be the best: example. of how to run a region, has divided that state into several different regional medical programs. The question I am really raising, is this too big an area to manage through a single program? a ts there enough emphasis being placed on the sub- | regions or on dividing up the. problem 30 that it can be addressed? MISS KERR: There was consideration given to. having three -- Texas make up three regions originally, and it was decided to go with one. The other thing is the regions are comparatively “new, with their representatives just getting out there and getting involved, and I think that to use Mrs. Flood as an ‘example in the El Paso area, where there are many Chicanos, she knows their problems, they relate well and there is a Sister Strohmeyer down in the lower valley who is equally as -- and I assumed, all of them were, from the way they knew their subregions as they discussed them with us, they were identifying problems. I am not sure at this point in time, though I dor 7 10 11 eo . 13 14 15 16 17 ]- 18 19 20 21 ~~ 22 23 © 24 Ace ~ Federal Reporters, inc. 25 . 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 and the RAG feel that at this particular time perhaps that "We better take this much money and do well with it and then go the next step." DR. MARGULIES: I would like to pick up something John commented on, he used the same words in my mind when he said "cop-out". I react, I guess, with some suppressed violence to this business of, "Oh, yes, we are interested in _minorities and women but they must be of the»best kind and of the finest kind of gualifications." Well, I have a couple objections to that. “One is that it can easily be used as a facade for inaction. Secondly, if there was absolute equality as equality is usually measured, then there wouldn't be any minority problem in the first place, that is really what we are talking about, and | The third is I doubt very much that a program which has to deal with issues of the. kind that they have in Texas, particularly with the issues of Mexican Americans," migrants, and so forth, can do so from the kind of experience that they get from people who have never had anything in the world to do with those problems. I think it is a programmatic weakness but what I am dor 8 10 W @ 12 13 14 15 16 17 18 19 20 21 ( 22 23 @ 24 Ace - Federal Reporters, Inc. 25 181 real ly wondering about is, if you ‘believe in general in these concepts, at what point does this become an issue of priority in determining what grant levels should be? Now, we have identified on several occasions in our review that there are deficiencies but there are signs of progress, and so on. This is one of the criteria. The weight one gives to it, I supposek can be put down in some kind of arithmetic form, but I think there is more to it than that. And I think it is only fair to say to you that our own kind of judgment is going to be very strongly influenced by just how much evidence there is of commitment to the issues of: fair play with minorities, with women. This is so inseparable from the concept of an effective Regional Medical Program that I find it impossible not to be influenced greatly when we come to the question of grant award. Obviously, if there is a marked disparity. in my view. and that of the review committee, we will yield to the position of the review committee and council, but I do hope - that question is being given as much consideration as it should. DR. SCHERLIS: I just wanted to take up some more ‘questions about the recommendation of the site visit group, since apparently it, in giving all the funds that were dor 9 10 11 12 e. 4 15 16 18 19 20 21 22 23 @ . Ace — Federal Reporters, inc. 25 17 7 ; 182 requested, apparently decided all the funds were to be wisely expended. Looking over some individual projects, they ‘are of interest. I question, though, how much impact they will have on health care delivery systems. The health project Number 69, Health Evaluation Access and Resources Development, Ector County Medical . Foundation, as I read it, it is a computerized effort to aid in diagnosis and seems rather expensive, it is $118,000 for each of the years, 106k at some six thousand people. If 1 read this correctly, have: a. standardized medical history questionnaire. in English or Spanish, and if anyone has tried to set up computerized methods for getting histories to go beyond that, this is a tough area. Perform basic physical workup, which consists of urinalysis, blood pressure, visual test and hearing test. These are the only ones that are listed. You will then have electronic data processing, printout, a physician will look at the printout, and decide ‘whether any medical care is necessary. Then from that point, I sort of lost track because they say diagnostic and treatment services will be obtained from public volunteer and private sources without charge when possible, and health delivery is dependent on that vehicle of access, if it is, it is really a very thorny type of project to look at. dor 10 10 - e 12 4B 14 15 16 17 18 “19 20 21 ( 22 23 eo . Ace ~ Federal Reporters, tnc. 25 183 Yet, it is one hundred eighteen for each of two years. It is fairly routine. I was wondering if you could tell me what GRO. is, or GRO are, since it is taking place in five places. MISS KERR: Grass roots. MR. SAYS: This essentially is seven-to twelve. in each group that get together. The whole idea is a sharing of services. Thus far, about the extent of the actifity has been sharing in service training, but we believe that it will go far beyond that. They are now looking -at this. It certainly is an activity that is popular among the consumers as well as the providers. DR. SCHERLIS: The other program is an electrical safety service, one which seems similar to many of the others, except here they are paying $50,000 for manuals, I guess to . be put out. Then to have it self-supporting, I question if at this period of time, knowing what we do about safety hazards, since all this is so well documented and available through many agencies and otherwise, I just question if this should be part of what RMP should support. MR. SAYS: Well, this is a pickup on an activity supported by program staff for about a year. _ DR. SCHERLIS: But they plan to support that again, don't they? dor ll 10 It @ 12 13 14 15 16 17 18 19 20 21 f 22 23 © 24 Ace — Federal Reporters, Inc. 25 184 MR. SAYS: No, it is a little different. The core staff activity, they demonstrated the feasibility of this in six hospitals and the Texas Hospital. Association, which is very progressive, very cooperative with the RMP, as well as other prior organizations, has seen fit to take this activity, asking for support for one year only, after which it--will be continued through fees. It goes far beyond putting a manual for hospitals, but offering them assistance, actually going in and taking a look at the way they go about checking out their equipment, and so forth, and possibly, even in some of the smaller hospitals, sharing electrical engineers, where the single hospital may not now be able to do so. DR. SCHERLIS: Well, the lutline doesn't go that MR. SAYS: If you look at the full-blown application, it does. DR. SCHERLIS: I guess you had the raw project. I question if this is the way to do it, since there are other ways of approaching it. This was the question that I had. DR. SCHMIDT: Mr. Toomey? MR. TOOMEY: I couldn't find any mention -of an HMO proposal, but I would like to comment that if there is_ ‘such a proposal, and if it does concern itself with a medical care foundation, then I would recommend that it be dor 12 10 1 e OW 13 4 15 16 17 18 19 20 21 ( 22 23 @ . \ce — Federal Reporters, Inc. 25 185 ‘supported. I am concerned about the medical care foundations that are established ‘on A as a defense mechanism against more and different and, if you will, innovative kinds of pro- visions of medical care, and to use the foundation for medical care as:‘a mechanism to defeat something which is new and different.turns me off, but to fund a project which has as its base and concept great numbers of people or representatives of hospitals, public health agencies, CHP agencies, RMP people, physicians, medical schools, and so on, it: would be very refreshing and as a matter of fact, it might just possibly come up with something which would be very worthwhile in terms of. an HMO foundation for medical care kind of proposal and would be different. I would like to see it. MISS KERR: I am not sure but what there is some - misunderstanding about this because the HMO activity has been as a result of RMP involved staff assistance, but it -is being funded by HSMHA, county medical society, but the region itself is not involved in any funding of the HMO. DR. KRALEWSKI: My comment to HMO was along the lines that this is the way they devoted some of their discretionary funds, I believe,. and core staff effort, and it may be appropriate. It only occurred to me that I suppose there was a lot of different areas that could have used that 10 1 @ 12 13 14 15 16 17 18 19 20 21 ( 22 23 @ . Ace — Federal Reporters, inc. 25 186 kind of help, and as I was reading through it, where they talked about the fact they were giving help to groups to reogranize the health system, lo and behold, it happened to work out that way; and it may be good. I don't wish to speak against it, but I think that, you know, this is a big region, they have got a lot of people they are trying to subregionalize, and I hope that that will help a bit. | _ The site team obviously thought that they have some strength and will be able to grow and so I guess, _ really, though, that my reflection: on this is that I feel it.would really be giving them’a bit too much of a pat on the back to go one hundred percent of what they have asked, both in light of the accomplishments that they have achieved and in térms of what has been made on these projects. Therefore, I guess what I would really like to do is offer a substitute motion, of funding at levels of 1.9, 2.1, and 2.3, with developmental funds in the range of 80 first year, one hundred and one hundred for the second and third year. I think this will give them an increase in funds, and asuhas been pointed out, this is.a large population | group and probable that budget is not out of line. Y et, I think it will indicate to them that we still have some questions about exactly what is going on and dor 14 eo . 2 end 16 5 take 17 b 10 I eo |. 43 14 45 16 17 18 19 20 21 ( 22 23 @ . Ace ~ Federal Reporters, Inc. 25 187 where that money is going. DR. SCHERLIS: I. second that. DR. SCHMIDT: All right, there is a second, then, to the substitute motion. | Their level last year? DR. KRALEWSKI: 1.58. DR. SCHMIDT: 1.58, so this would be up to 1.9. MR. SAYS: Doctor, I know there is a motion, but I think there are some things perhaps you are not aware of, Dr. Kralewski, in this whole situation. Dr. McCall is an extremely capable coordinator and he understands that to pull off a successful program takes the commitment of the people to whom it is to be delivered, and also those who: are involved in the process. If you look at the application very closely, it took him from July, when the last site visit was made, up until December of 1971, through a very. long hassle with his RAG and his development committee. The priorities were developed once and rejected by the RAG. They went back to the drawing board. They had only two months to bring in some kind of projects for this application, hence, the reason for his growth funding in the second and third year. I happen to know that since this application got into the hopper, in January, they could use easily a half a dor 15 10 7 © 12 13 14 15 16 17 18 19 20 21 Co 22 23 ®@ . Ace ~ Federal Reporters, inc. 25 188 ‘million dollars more now. For an example, in Houston, they are now . operating, or talking with a group, this program has almost developed, it would take $150,000. .-It involves two barrios, where they would like to employ six half-time ‘health advocates in each barrio, ‘under the supervision of Chicanos. This dove-tails in with a program by Baylor, the Department of Community Medicine, which is also involved in a hospital district that has the direction of seven clinics from that city that deal with very poor neighborhoods, an excellent opportunity perhaps to examine access or evaluate access and quality performance on a patient population of 60,000. This is just, you know, a couple of programs that have been examined and are in the hopper at this time. This application started almost a year ago. DR. KRALEWSKI: Well, I appreciate that additional information and I feel that if you are correct that this gentleman is a really good manager, that he would be able ‘to take a million nine and probably reorganize some of the things that he is doing and probably, as a matter of fact, go through these projects and come out of there with, you know, ten or twelve or fifteen percent savings, at least, and then devot e that to these very worthwhile activities that you are mentioning, and I suppose he does have also the opportunity to come back with an application a bit later dor 16 10 it @ 12 13 14 15 16 17 18 19 20 21 ( 22 23 @ . Ace ~ Federal Reporters, Inc. 25 189 for some additional activities as they develop. MR. SAYS: One year hence. DR. LUGINBUHL: I am certainly very much influenced by your evaluation of the leadership of the program, but I think the information about the timing problem is quite Significant. What I would wonder about is this: Would it be possible within our ability to make some cutback in terms of the project part of the money, but give that money to the | program in a way that they could-use it flexibly over the coming year. | | If he is a really good man,.he has come up with good new things, now that he has gotten priorities straightened around, I would like to give him the flexibility because it already is a fairly limited sum of money for the population and problems. I don't see the imaginative approach to the large, unserved segments of that population in this application, and maybe if we could preserve the dollars but give some more flexibility to the director, he could begin:'to address those programs. Finally, I am somewhat concerned about the RAG and the fact that it does appear to be heavily influenced by ‘professionals. I am wondering, as I have listened to these dor 17 10 1 @ Ww 13 14 15 16 17 18 19 20 21 ( 22 23 eo . Ace ~ Federal Reporters, Inc. 25 discussions, about the size of these groups. This one, I particularly how do some of the underserved get their prioritie: ‘think what happens at times is that people propose these 190 think, is 50 or so people, and I wonder how well they are really able to meet and set some of these priorities and into the application, if the group is dominated by priors. DR. SCHMIDT: Well, I think one of the points that John. was making was that if this is a wise manager, he can get discretionary funds out of the money he has just by simply not spending it for some of the things thgt in the application. he said he was going to spend it for. You are ™ saying can we force him by earmarking discretionary funds and the answér to that is, he can be advised or it can be recommended but we haven't been in the habit of so ear-. marking funds. DR. LUGINBUHL: My concern is a little bit different. If I am correct in my understanding of the process, whereby some of these projects get into an application, I projects and they are nominally within line with the goals and objectives and the group making the decision at the local level finds it very, very hard to say no, especially when therg is not some other proposal at that point in time competing for those dollars. Frankly, I suspect at times the problem of dor 18 10 if @ 12 43 14 15 16 17 18 19 20 21 ( 22 23 eo . Ace ~Federal Reporters, Inc. 25 191 setting priorities is getting passed on up to us. If you have the money or the potential for getting money and you are not forced to set priorities, frequently the easiest thing to do is just not set them. | What I am suggesting is that by cutting back on the project money, you are going to force them to set some priorities and you are going to let them reallocate those dollars or force them to reallocate those dollars by increasing the discretionary funds and I would think that for at least some coordinators, this would be a very welcome Opportunity to set priorities and to, in fact, strengthen their hand in dealing with their regional advisory group and dealing with some of the priorities that are making demands for project support. DR. HESS: Just a question to further clarify this. It is my understanding that an RMP may shift developmental components into projects but the reverse is not true unless it is authorized, is that correct? DR. SCHMIDT: That is correct. DR. HESS: So the implication of your statement’ is, would be to approve the developmental component at the requested level and take the cut in the project section of the budget in order to achieve your goal; if that is what we are after, I think that ought to be specified. dor 19 10 HN @ 12 | 13 14 15 16 17 18 19 20 21 C 22 23 @ 24 \ce - Federal Reporters, Inc. 25 192 DR. SCHMIDT: All right, is this acceptable to the mover as a piece of legislative history that will be directive then? In other words, developmental component is given at the 10 percent level, the maximum allowable, but the cut, the reduction down to 1.9 comes out of the project funds. That we can do. DR. KRALEWSKI: Acceptable. DR. SCHMIDT: All right to the secondg-, is that acceptable? DR. SCHERLIS: Yes. MISS KERR: I would like clarification as to what the motion of the moment is now? DR. SCHMIDT: It is for approval of the triennial period at the levels, 1.9, 2.1, and 2.3 total funding levels. The original substitute motion was for developmental “component of 80, but this has now been changed to a developmental component that would be the maximum allowable ‘under the policy, or ten percent of the award, really, which would give them, what did they ask for? MISS KERR: They’asked for first year $160,000, second, two hundred thousand, and the third, two twenty-five thousand. DR. SCHMIDT: Well, that would still be permissible then because it could go up to 10 percent of the award. So dor 20 10 HW oe . 13 XXXXXX 14 15 16 17 18 19 20 21 ( 22 23 @ 24 Ace ~ Federal Reporters, Inc. 25 193 that gives them some amounts of flexible funds. All right. Other comments or questions then? If not, I will call for a vote on the substitute motion which we just reviewed. | All in favor, please say "aye". Opposed’ no? Dissent is recorded. . Thank you very much. I think that is the first time we have ever . completed a discussion of T exas in 55 minutes, 65 minutes. We can conclude a discussion of Indiana in 30 minutes. DR. PERRY?: the word catalyst has been used so I will just say there has béen a most dramatic transition here in Indiana in the past year. A site visit has not been held in Indiana, although an August site visit was set up, it was canceled by RMPS for the following valid reasons: Dr. Stonehill, the coordinator of Indiana resigned effective April 30, 1972. The triennial application that ‘was submitted was submitted without really the assistance of a coordinator, was reviewed by the staff here at RMPS, did not clearly present a three-year plan, thus the site visit was cancelled. dor 21 10 i eo... ( 13 14 15 16 17]. 18 19 20 21 (- 22 23 @ 24 \ce ~ Federal Reporters, Inc. 25 194 RMPS recommended the submission of a one-year anniversary application which would lead to a much stronger triennial req vest next year and this’ has been done. Dr. Schmidt, the second reviewer and I have been on two separate site visits at Indiana. Dr. Brennan and I in 1970, representing the council and the review committee, were there, We were not welcomed back for the next site visit. . Dr. Schmidt was in Indiana in 1971 and I am not sure -of- his reaction about being welcomed back for a site visit _this time, but the purpose of the site visit and which was communicated at the site visit periods, I believe have led” to the most important decisions for change in this region. If there is anyone thing that I would say was probably the greatest strength of all is this attitude of desire €6 change that is recorded in this, not only in the application, but by other means. I am delighted that Bill is here at the table with us because members of the-staff, since we have not been there during this period of thime, there are members of the staff that have been in the Indiana region and it is some of their reflections and their reactions and certainly the recommendations of RMPS that will be a part of my recommenda- tions here today. To evaluate Indiana, let's look at some of the dor 22 10 VW @ 12 13 14 15 16 17 18 19 20 21 o 22 23 @ . Ace ~ Federal Reporters, Inc. 25 195 strengths and then some of the weaknesses for, indeed, even with the problems and dramatic changes’:that have taken place, there are strengths that can be indicated here. With Dr. Stonehill's departure, which was requested two months earlier than his date of resignation by the RAG, I think this tells a little about the story there. I am putting this as a strength and it must be taken as a plus, as far back as the time of the, of this 1970 site visit, in which I participated, there was a great deal of antagonism expressed between many Indiana Medical Associations, -and by various groups, representatives of the Medical School at Indiana,Shave. stated.to Bill