Transcript of Proceedings DEPARTMENT OF HEALTH, EDUCATION, AND WELFARE RMPS REVIEW COMMITIUE 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 — 2 7149 1 DEPARTMENT OF HEALTH, EDUCATION, AND WELFARE 2AIG: paw 4 RMPS REVIEW COMMITTEE MEETING 10 11 Conference Room G-H © 12 Parklawn Building Rockville, Maryland ° Friday, 22 September 1972 14 15 16 17 18 19 20 e@ 24 te — Federal Reporters, Inc. 25 } CONTENTS CR 7149 CRAIG: 2 || AREA: PAGE paw _™ ; . ——— e 3\|\Mississippi 3 4||Missourl 52 5||\New Mexico 95 6||\Northern New England 139 7 || Texas 157 8|| Indiana — 193 9||Memphis 210 10 im @ 12 13 14 15 16 17 18 19 @ 22 an hee 24 ‘e ~ Federal Reporters, inc. 25 — CR 7149 #4 2 eo 1 3 so c YH © 12 13 14 15 16 17 18 19 20 24 se ~ Federal Reporters, inc. 25 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 presentations for the committee and then stop and talk a little bit about the 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 morning. So we will begin then with Mississippi. Dr. Hess. DR. HESS: Thank you. I would like to begin just by giving particularly for the new 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 ry the worst end of the spectrum, whether it be pe whether it be physician population ratio, whether it be neo- natal mortality, you name it, Mississippi is at or near the bottom. #1 1 Reba 2 2 so =e > 11 @ 12 13 14 15 16 17 18 19 @ 99 . - hi hen 24 se ~ 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 theth, some of the recommendation that were made at that September site visit. Concerning the regional advisory group, we recommended very strongly that they review théir 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. Ana 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 #1 (J Reba 3 2 @ 3 ‘oO wt Q 1 @ 12 13 14 15 16 17 18 19 20 e - 2] 23 24 1¢ ~ Federal Reporters, Inc. 25 mn and this physical separation did lead to some fragmentation and lack of coordination of activities. And we also recognized that there was some need for better communication and stronger leadership thrust from the coordinator. We also recommended that they consider setting back their time deadlines for their requesting a re- vision in the time for application in order to allow them more time to make the adjustments which we recommended. We offered the assistance of the regional office 'in Atlanta, RMPS staff in Washington and pointed out they had 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 changes which have occurred since that September site visit, and Tobert will begin the discussion of that as well as giving you a little more background on the region, Bill Tobert. MR. TOBERT: The Mississippi Regional Medical Program covers the entire State of Mississippi, serves a population of about two million two hundred thousand people. The region is bordered on the east by Alabama, on the south by the Gulf of Mexico and part of Louisiana. On the west by Louis- lana:'and on the north by Tennessee. So the upner counties of Mississippi are somewhat shared with the Memphis Regional Medical Program in planning an coordinating of activities. There are two distinct geographi cal areas of the state. The first area is the north and south i #1 ] Reba 4 2 sO at co 11 @ 12 13 14 15 16 17 18 19 20 21 @ 22 23 24 :¢ ~ 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 Wississippi 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 East 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 BO percent of all families in Mississippi earn less than $3,000 per year and are ranked in a poverty class. The Mississippi RMP #1] Reba 5 2 10 VW @ 12 13 14 15 16 17 18 19 20 24 e~ 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 RMP, There — two subregional offices of the RMP located in Oxford and 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 Reyional Medical Frogram 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 #1 1 Reba 6 2 sO out oO 1 @ 12 14 @ 15 16 17 18 19 20 @ 29 24 :e ~ Federal Reporters, Inc. 25 overlay shows some of the regionalization of some of the activities they have proposed in the application of the review = ~~ today. Part of this application, the large majority of the projects and activities were centered around the university médical center in Jackson. During the past year the Mississippi RMP have concentrated their efforts in developing activities which have outreach to all parts of the state. This simply (slide) shows the geographical make up of some of the members of the regicnal advisory group. There are 37 members of RAG, with an adequate balance of consumers and providers. The involvement of RAG members this past year is one of the more positive steps the region has taken and Dr. Hess will comment more on this a little later. (Slide) This chart depicts the distribution of funds for the region during the three operational years and it shows the comparison of what has been and what is to be durin the next triennium period. Clearly it illustrates the change from a categorical program to emphasis on multi or non-categoric activities. This has increased from an average of 15 percent during the first three operational years to 49 percent which is proposed in this current application. It should also be noted that previously a large percent of the program staff budget #1 1 Reba 7 2 “ is @ 12 13 14 15 16 17 18 19 @ 22 24 e~ Federal Reporters, Inc. 25 12 1971. This reduction is sc dramatic you almost question the statistics. But the people there feel that there is no question but what the pediatric nurse assistance and midwife program and so on has had some influence in reducing the neonatal death rate. The regional satellite units have been set up around the state. They have a very well organized and smoothly functioning renal disease program there as near as we can tell. One of the important accomplishments of this program is to reduce the cost of dialysis for their patients. | They bring families and patients into the medical centers, train them in the use of dialysis and then through ithe use of trailers which have been set up around the families, a member of the family can come in with a patient and perform the dialysis for the patient. Heart clinics have been set up around the state which have been -- have resulted in care being given to patients who previously did not have access to this type of care. The existence of the stroke care unit in the medical centers has resulted in the treatment of a large number of patients, the training of a number of physicians and nurses from various parts of the state who are now better qualified and equipped to provide higher quality care to patients with this type of problem. Pulmonary training programs and inhalation therapy #1 Reba ll 2 10 H @ 12 13 14 15 16 17 18 19 20 21 @ 22 23 24 7¢ —Federal Reporters, Inc. 25 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 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 #1 1 Reba 12 2 W @ 12 13 14 15 16 17 18 19 @ 22 24 e~ 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 a 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 area 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 ibeen 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 1 Reba 13 2 V1 @ 12 13 14 15 16 17 18 19 20 @ | 22 24 e ~ 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 return to Miss- iesippi 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 put 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 amuch 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. #1 ] Reba 14 2 | @ 12 13 14 15 16 17 18 19 42 24 e ~ Federal Reporters, Inc. 25 16 There seems also to be a much better working relation- ship between he and the staff. And whenwe were there in Septembe of 1971 we were getting all kinds of informal feedback in the hallway and so on of some of the communications programs and leadership problems which existed. This time we pickedup none of that kind of thing. And there were many indications that the working relationships have improved. His relationship with the RAG seems to be cordial and effective and we found no evidence of any discord in that area. The program staff has been strengthened, they have hired a number of additional people who seem to be quite capable.. Some of them are young and not too experienced as yet, but appear to have good potential. One of our concerns, however, was in this area, in that the Assistant Director for Planning and Evaluation is a practicing physician. He is an internist, hematologist, gynecologist who has a private office and exactly what this half-time means we are not sure. But it was evident to us that this is an area that does need strengthening, and one of our recommendations is that this be made a full-time position, and that the new people that they have brought onto the staff be given some additional training and orientation so that this area of core staff might be further strengthened. They have a new person in the area of evaluation. #1 ] Reba 15 2 “sO wa QO 11 @ 12 13 14 15 16 17 18 19 @ 7 . be he 24 1@ ~ Federal Reporters, Inc. 25 17 From our discussions 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 missed 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 oryanizatio} 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. ~ #1 Reba 16 3 @ 11 @ 12 13 14 15 16 17 18 19 20 @ 22 24 e@- Federal Reporters, Inc. 25 18 The Mississippi RMP has participated in and/or has available to it a 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 #1 Reba 17 2 to) oO 1 @ 12 14 15 16 17 18 19 20 ® 29 24 te ~ Federal Reporters, Inc. 25 19 of the projects which are submitted in the triennium, but he does hope to have some influence 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 objectives the project developnent guidelines, the technical review cri- teria, and developmental component priorities, the RAG rating forms and the proyramn 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 niake 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 #1 1 Reba 18 2 11 @ 12 14 @ 15 16 17 18 19 20 21 @ 22 23 24 ze ~ Federal Reporters, Inc. 25 20 this will begin to supply a gap in health manpower in the region Now getting down to the recommendations of the site ~~ visit team I am going to’ save, wait on the financial recommen- dations until last. We did feel they were ready for triennial status. There was no question that they had addressed all of th areas of concern raised in the September 1971 site visit. And they were in a substantially better position as a region to manage their own affairs and to more effectively address the needs of the people although there are still a number of important areas that they ~- where they need further improvement. We recommend that there be a full time director ot a pianning evaluation staff, and that this section should engage in a good deal of training and we suggested as one part of the training of the staff some RMP's which they might visit to learn the methods and techniques that would help them. We emphasized the need for developing consistency with the statements having to do with evaluation mentioned earlier. We felt that their applications, their projects, needed better documentation of need and this went back to the need for strengthening their planning section. We also felt that they needed to improve their technic review input to the RAG, that there were some projects that we looked at, as examples, where we questioned some of the needs as far as the equipment and budgetary items and felt that they lal 21 #1 1|| could well benefit from some qualified experts to work with Reba 19 2|| them in reviewing these project requests and determining what ~_ 3|| was actually necessary and the methods that would be most 4|| effective in addressing the methods of the project. 5 We recommended that they should work to obtain both 6|| CHP and state funding of on-going health planning data collections. 7|| There was one project in this group which is directed toward 8|| improved data collection, and apparently no one is ina 9 position at the moment to undertake this activity, yet it is 10), & very important and essential activity for all health planning 1li}in the state. @ 12 And we agreed that this would be a worthwhile 13 thing for RMP to initiate but it should not be looked upon 14||}as a major on-going activity. Another question which came up 15) during the course of the site visit was the staff salary scale 16||Which is determined by university salary scales. 17 And we recommended that the salaries should be reviewed 1g|with the medicai center administration to see if the mechanism 19||;can be developed for more adequate program staff compensation. 20 |Our concern was that this might be a liability to the program 2) jin that they may not be able to retain qualified people and, ©} . 92 \itherefore, continue to build a strong program. I would ond 23 my comments at this point. end 24 ~ Federal Reporters, Inc. ar ese Beery. we . $2 arl 1 VW @ 12 13 14 15 16 17 18 19 24 e—~ 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 been 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. ar2 so c 11 @ 12 13 14 15 16 17 18 19 20 21 eo : 23 24 e - Federal Reporters, Inc. 25 23 My only concern is going to be in some of the recommendations on the level of funding here which I would like to turn right back to Joe to make. There is no question but this state has made a major turn and is moving in a most positive way. DR. SCHMIDT: Bill, was anything left out that should be -- all right, Joe, can you put a proposal on the table then? DR. HESS: The site visits team had some difficult in arriving at a tunding level recommendation. I will place that before the committee at this time. There was another wide variety of opinion as to what it should be. I suppose that I ought to express to you some of my personal reservations about this. This came as a sort of compromise, the team recommendation-is a compromise. And I happen to personally be on the lower end of the scale concerning the spectrum of opinions of the team for funding recommendations, but neverthe- less the recommendations which we ended up were in order to leave and catch our plane. DR. SCHMIDT: The suspense is killing me. No prec avave secs > You can see here on your page ii of the report the total figures On the sheet over here we have broken these down. We agreed that with the expansion in more subregionalization, some of the additional activities ar3 so = Q MH @ 12 13 14 1S 16 17 18 19 20 21 @ 22 23 24 ve — Federal Reporters, Inc. 25 24 that the program staff planned to get into and so on, that the increase in program staff budget was justified. We felt that they were ready and, could effectively use in the first year developmental component of 96,315. The total for operational projects we felt was somewhat high. There were three specific projects there totaling about $200,000 that we had some serious reservations about in terms of their appropriateness when one considers the total health needs of Mississippi, and we reduced their -- our recommendatio was something about $230,000 below that requested by the region for operational projects. So the total ends up with 2,110,138. They had already received approval for, through supplemental funding, 183,634 in kidney, so if you subtract that, it comes down to 1,926,504, which is the first year recommendation. The second and third year, you can see on the sheet the kidney money will be included in that, 2.2 and 2.4 million the second and third year. | So I will place this recommendation on the table in the form of motion, but also say I have some reservations, particularly considering the fact that the first year is a 10-month year for them. I have some personal reservations about whether they can effectively use that 1.9 million during that first year. DR. SCHMIDT: All right. Dr. Hess then moves . ard 14 15 16 17 18 19 20 21 @ 22 23 24 1e ~ Federal Reporters, Inc. 25 25 with some reservations, then, the team report. Is there a second? Warren, do you second this or not? DR. PERRY: Yes, 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 puaget at that ievei. 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 11 ) 12 — 18 14 15 16 17 18 19 @ 22 24 é ~— Federal 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 comitittee. | 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 came about in December of '71, demanding new direction. And I think I would like to emphasize the fact tnat 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 ar6 11 @ 12 13 14 15 16 17 18 19 20 @ 22 24 7¢ ~ Federal 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 fiaqure in any other region across the country? I think if the regional medical program did nothing eise put to reduce the intant 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 change 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 ie @ 12 13 14 15 16 17 18 19 20 21 @ | 22 23 24 10 ~ Federal Reporters, Inc. 25 a5 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 responsibilit of the hospital itself. Radiotherapy is coming in as a new project for $80,660. Education of radiologists, setting up of peripheral centers, is coming in again at a significant level of support. Pulmonary therapy as a model project is coming into a 50 to 100-bed hospital to treat pulmonary disease and cystic fibrosis, stroke system to be set up for $58,000. 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. ar8 sO wel o 11 © 12 13 14 15 16 17 18 9 @ 99 . ae 24 ce — Federal Reporters, Inc. 25 29 $39,000 for educational program for mentally retarded children is something that I am sure is necessary, but I again think that this is the RMP picking up things that should be done in other ways. Controlled in effect in hospitals, to set up a model unit and then if other hospitals are interested, help them, is $32,000. I have only looked at a few of these, but those that I have looked at would suggest very much a good deal of what has been going on in the past. Now if the change of _direction is in the interest of core, that's one thing, put I don't see it reflected at all in these projects, and there are myriads of them and just scanning them quickly, I wanted to know how you define the change in direction, admittin that I have a poor sense of direction. DR. HESS: Well, I had commented on that in passing, in that their rethinking occurred at the same time the projects were being developed md consequently, particularly the first year projects do not reflect that, so that it is kind of a phasing problem that we have seen in many other regions. And this, the very questions you are raising, are some of the things that bothered me and raise questions in my own mind as to how much of a favor we are doing the region to get -- give them enough money to get started and obligated on some of these projects that I, in my own mind, thought ought ar9 10 1 @ 12 13 14 15 16 17 18 19 20 21 ® 22 23 24 @ ~ Federal Reporters, inc. 25 30 to be low priority. Now some of these we -- site-visit team -- we felt strongly ought to teally be looked at very carefully. We told them so in feedback 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 so ont co 11 12 e 14 15 16 17 18 19 20 e 22 24 ce ~ 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-l CR 7149 #3 so nd co 11 12 13 14 15 16 17 18 19 20 24 se — 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 e ~ Federal Reporters, oO mw o> 11 12 13 14 15 16 17 18 19 24 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: Joe is afraid to ask you what you thought. You said you compromised upward for the plane. mea-3 11 © 12 13 14 15 16 17 18 19 20 e . 24 e¢~— Federal Reporters, inc. 25 34 What would you really think? DR. HESS: Well, my feeling was that they could effectively utilize somewhere in the neighborhood of 1.6, 1.7 million. This would cut out about $400,000 worth of projects and if I use my priority system, the ones left in would be ones that are truly helpful and directed to some very urgent problems there. But I share the concern which you expressed. The infections in hospitals, electrical hazards and so on were ones which obviously came up -~ we were very surprised that they got through their review process and this is one of the things that gave me some concern, The nurse or I should say the cancer project is just a one-year; this is the final year or I should say, the stroke care demonstration is a final year for that project so that 122,000 only appears in the first-year budget and I think they are obligated to continue that previously approved -- but taking all these things into account, it is my feeling that they could have quite a bit of money to play with and, not to play with but to use effectively, and still show them that we had confidence in what was happening, give them the support which they need to begin moving more strongly in directions which I am convinced they will move in and not do damage to the program. DR. THURMAN: Mr. Tobert, what is your feeling Mea 11 @ 12 13 14 15 16 17 18 19 20 ® 29 24 e—~ 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 the lower because I share every concern that Dr. Scherlis had. MR. TOBERG: If it is any lower than 1.5 without sLosmental proponent, I think it might have some concern on the staff. DR. SCHMIDT: The move to amend was so inconclusive that it is a 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 mea-5 so _a ° "1 e 12 13 14 15 16 17 18 19 20 21 @ 22 23 24 e ~~ Federal Reporters, Inc. 25 36 say the program would be better of if you would reduce the budget in the area of projects and gave them some developmen- tal money to play with. I think I would be inclined to believe though that ending up with 220,000 which must be one of the larger developmental components ever given toa program would be fair. But I would think that developmental component in terms of perhaps somewhere in the area of that first year's program, going up perhaps around a hundred for the second two years, with the cutbacks to bring the total budget down to a million and a half, taken out of the projects, might be more helpful to a program such as this and give them more running room and give them a chance to turn it around if they are trying to turn it around. DR. LUGINBUHL: Is that an amendment to my substitute motion? If it is, I will accept it as a change. DR. SCHMIDT: I will accept that as an amendment to the substitute motion. The seconder was Elizabeth. MISS KERR: Yes, and I would accept it.: DR. SCHMIDT: All right, the motion now includes a developmental component of 96,000, which, for the first year then. How about the second and third years? DR. KRALEWSK1: I suggested a hundred thousand. isn't much of an increase but suppose we say 90,000 the first year, a hundred the second two? DR. SCHMIDT: All right, 90,000 the first year and mea~-6 so YW °° 13 14 15 16 17 18 19 20 21 e =: 23 24 e — Federal Reporters, Inc. 25 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 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. T 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 sO ned o> VW @ 12 13 {i 14 15 16 17 18 19 20 21 @ 2% pe 23 24 e~- Federal Reporters, Inc. 25 38 information to you about regions as part of the review and triennial applications, that backgrounds the regions a little ~ ~e more, You have seen the slides that have gone up. You have heard two presentations by staff as part of the committe review. One of them was done by John, I believe, as part of his review. He used the visuals that were prepared by staff. And we have talked in the past about the informa- tion that comes to the committee, the amount of it, the detailed nature of it and So on. I called your attention purposely to these books because they do have some of the budget breakdowns that are most handy. You have the applications now in their new form. And you have the reviews of these three regions that were done by staff. So could we have some guidance from the committee on what they think? Dr. Ellis? DR. ELLIS: Mr. Chairman, I would certainly like to express great appreciation for the work of the staff in setting forth these audiovisual presentations. I think they have been very, very helpful. Many times in trying to describe a region it is iust impossihle to do so so that people listen and hear what it is all about when we are talking. But they get our attention; we understand exactly what the region is like and I am just very regretful that I wouldn't have it when Tf Ww mea-8 10 1 @ 12 13 14 15 16 17 18 19 e. ., 24 e ~ Federal Reporters, Inc. 25 medical school and now the medical school has been cut down 39 present this complicated region today. DR. SCHMIDT: Elizabeth? MISS KERR: 1 would also commend the staff for thig and I would further make a comment and then a request. | 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. his 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 maps 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 ce 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 se - Federal Reporters, mt Cc HW 12 13 14 15 16 17 18 19 20 21 22 23 24 Inc. 25 40 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 11 @ 12 13 14 15 16 17 18 19 20 e ., 24 ce — Federal Reporters, Inc. 25 MR. HILTON: If overused in our initial enthusiasm with this kind of a "B" approach, it can probably, I think envision atime it might become monotonous. I think it is possible to guard against that if we are aware at the outset. I would suggest restricitng the use of the particu- lar approaches in the overheads to the background data. We have 50 local RMPs and even though we have been to the place before, individual members may have been there before, it is a good idea to have that background refresher, geography~kind 6f display of territory, perhaps consider building up a library of that kind of data for each region. I suggest, too, perhaps some variety, like for Hawaii, we had -- in addition to the overhead we had the little plastic what do you call it, topographical models. That kind of variety and other approaches to variety would help minimize the boredom of this kind of approach, I would think. DR. SCHMIDT: I was hoping for some flowers, myself. MR. HILTON: Yes, I would too, like to applaud the staff for the effort and I think it is great. | DR. SCHMIDT: All right, Leonard? DR. SCHLERIS: We had planned some really spectaculay events for Hawaii. I can tell you we shared every bit of the Aloha spirit at our presentation yesterday, that we had in Hawaii. Only those of you who were there will really appreciate what that alludes to. ter-2 so oot qo 1 ee. ” 13 14 15 16 17} 18 19 20 @ | 22 24 se ~ Federal Reporters, Inc. 25 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. When you use a wali 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 in a 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 7 OQ 7 @ 12 13 14 15 16 17 18 19 24 ce~ Federal Reporters, Inc. 25 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 a 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 presenty 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 ith, down at the end of the table representing bh think of Ted Grif 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 to a 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 ter-4 i @ 12 13 14 15 16 7 18 19 20 e 22 24 \ce ~ Federal Reporters, Inc. 25 44 Anniversary Review Panel, because if we are to continue with the kind of staff review for those programs, which are not undergoing intensive review, by the review committee, it will give us a greater quality of differentiation for what really requires full-time by the review committee; what needs to be referred to, and what does not present major problems so that it can be kept in some kind of balance. Obviously, you are being burdened with some heavy responsibilities, and you will have to accept our kind of discretion in developing for you what needs to come this way, and what requires that kind of time. DR. SCHMIDT: I would like to comment on the Staff Anniversary Review Panel reviews from my perspective and see if there is the consensus of the committee. If not, we can discuss the Staff Anniversary Review Panel: reviews further. To me, these have been very high-quality efforts by the staff and the reporting of these, the information that is in the staff summaries, the written word that comes to the committee that I look at gives me such a good feel for what went on with staff in their deliberations that I can very quickly be satisfied, or dissatisfied with what went on by my review of these reports. In the last number of vears, T have detected no dissatisfaction on the part of the Committee with this Staff Anniversary Review Panel process, or the information it gets to the committee. ter-5 14 15 16 17 8 19 20 21 @ eZ 23 24 :e -- Federal Reporters, Inc. 25 I think the Committee must have the perogative of asking for explanations for actions if they do not understand. But, I 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? Warren? 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 anticipate other people around. That would be most helpful to have those kinds of things around, so that each person can respond in relationship to it. 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 £0 ter~-6 1|| of the Committee in complimenting staff on their presentation. 2|| And, as I have had an opportunity to function on this committee I begun to realize that the diversity between the regions, 4 not in the area of needs. That is quantitative rather than 5|| qualitative, but the diversity is rather in where individual é|| programs are at the present time, as compared with other 'z|| programs in an awareness of how to go about meeting the object- gi ives of the ere And I would think that this type of review, carried so on as part of the program should be very helpful to staff, ° 11 || because in putting myself into the role of a member of staff, @ 12|| and sitting there and listening to this, I might well say, You 13 know, in these two programs, that I am responsible for, these 14 efficiencies have been met very effectively and I need to 15 communicate them with those who are working with the other 16| Programs. And in this way we can really begin to share resources 17 18 that are resources of the regional medical program. And I 19 think we have not done that as effectively in the past as we 20 can do it, now. We have reached a’ point’ in'time, and it is 2] really sharing facilities. © - oan DR. SCHMIDT: Let me end this by asking staff if . 4a 23 they have any guestions of the Review Committee about the 24 information or whatever? ce — Federal Reporters, Inc. If not -- 25 ter-7 1 @ 12 13 14 15 16 17 18 19 20 21 e 22 23 24 ce — Federal Reporters, Inc. 25 - 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 her@ at the door, has spearheaded this, and also with equal assist- ance, Mr. Frank Schniowski, who has provided the data for the visuais. 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 comment on, Dick, and that is that in the interest of express- 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 na the manner of it is something which might continue 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 1 ter-8 ‘0 1 ©} 12 13 14 15 16 17 J8 19 20 @ 9” - aL 24 ce — Federal Reporters, Inc. 25 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 see? 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 nature with regard to the region, and with committee handling, 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 i ©} 12 13 14 15 16 17 18 19 20 e.g 24 ce - Federal Reporters, Inc. 25 49 introduction. I think it is useful during the presentation to have the use of slides, also,'’though, so really, what we are saying is part of what I am suggesting is part of each of these approaches we have previously outlined. And I think that the site-visit is the timé 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. 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, quickly, then. DR. JAMES: Yes, I have a very, very quick comment to make. Again, being new, I certainly enjoyed the audio- visuals yesterday, and I would concur that the joint presenta- tion by Staff and site-visitors of the committee, make it a 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 iP @ 12 13 14 15 16 17 18 19 20 21 @ 22 23 24 ce ~ Federat Reporters, Inc. 25 A figure ‘out of the ceiling. MISS KERR: One other quick request, is if it were so that we could have these graphs prior to a site-visit, and then if there were such changes as were dramatic enough to show, could this suggestion be made by the visiting team to the staff member, and the staff member, at his discretion, then develop the second audio-visual for comparative purposes? DR. SCHMIDT: We will accept that as a suggestion. Sister Ann? SISTER ANN JOSEPHINE: Some of the regions are begin- ning to develop their own visual material, and it may well be that some of'the visual material they have developed could be used for this type ot presentation, without a duplication t of effort. DR. SCHMIDT: I think Staff will be sensitive to that. MR. TOOMEY: I would like to comment on the fact that seems to me that we are, -- we have been asked to look rather specifically, precisely, and indepth, at the program problems of the organizations that we visit and with which we are concerned. Then, in the course of our discussions, we begin to focus on projects that are part of that. Yet, it is very incidental. I cannot help but feel that the projects are extremely important in terms of ananlyzing the congruence of ter-11 10 1] ©} 12 13 14 15 16 -4/s-5 17 \8 19 20 e... 24 ce ~ Federal Reporters, inc. 25 Ys. the project to the program. And, I am going back to Staff Anniversary Review Panel, because I think those reviews are me great. | I think, perhaps, the most effective presentation on your charts have been the changes from the categorical to the multiples-kind of projects. And, I think if one further facet of Staff Anniversary Review Panel could be, because we are not taking the time to review the projects in any depth; that they probably know them better than anybody else, and if they could spend just a little bit of time on, or at least a comment in relationship to the project, itself, to the pro- gram that we are most specifically concerned with. Do I make myself clear? DR. SCHMIDT: Yes, everybody says, yes,-and it is captured and while you have your microphone on, let us turn then to Missouri and a brief status report from the site-visit. MISS KERR: I am assuming we need not do anything wit that on our evaluation sheet, right? DR. SCHMIDT: That is correct. This is for information. h CR 7149 # 4-B follows 4-A by TER 1 2 kar 1 e ° 4 5 6 7 8 9 10 V1 ) 12 14 15 16 17 18 19 20 21 @ 2 23 24 e+ Federal Reporters, Inc. 25 problem in the Missouri RMP, Frankly, it has been a program and ‘organizational kind of structure problem, 52. MR; .TOOMEY: I visited Columbia a month, in company with Dr. Thurman, Dr. Pellegrino, Dr. McPhedran, Donna Howseal, | \ I 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 _ Wilson in three parts. It was a tri-part RAG. One part was an advisory council, the second 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 witn the advisory council being only 12 people and with the project revi committee and liaison committee being: made up predominantly of the prior groups and most specifically, of the University of Missouri people, it was a very closed kind of corporation, rather than an open advisory group with input from much other than the University. | When this problem was called to their attention, they 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 h PW vy ve kar 2] so ont c> VW @ 12 13 14 15 16 17 18 19 20 @ 22 24 :e— Federal Reporters, inc. 25 covered by the Missouri RMP to give to the establishment of thej 25 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 wae black and who was 2 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 whoa has worked, I guess, with great vitality and enthusiasm in developing a set of goals and subgoals and priorities. However, they felt that the objectives that should be established in order to achieve these goais shouid not be established by their goals committee and it should not be established by RAG, but in order to allow the local regions 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 establi 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, r ry sh kar 31 so ad © in @ 12 13 14 15 16 17 18 19 20 21 eo | 22 23 24 e~ 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 objectj would be, then it is not an inadequate or it is not an undesirahk The program staff was -- had not had its organizatior 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 Going 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 ve le fal iG 11 @ 12 13 14 15 16 17 18 19 20 21 eo =: 23 24 e ~ Federal Reporters, Inc. 25 55 when we 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 ail physiciag 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 remay is, "Other leadership is still considered weak, Not only does he exhibit through the lack of organization within the program staff itself, but in addition to which he is director of health program for the University extension division and he is directoy 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." s 7 10 nN @ 12 13 14 15 16 17 18 19 20 21 @ 22 23 24 e ~ 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 each 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 te kar 6 e~ Federal Reporters, 10 1 12 own Get 14 15 16 17 18 19 20 21 22 23 24 Inc. 25 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 changed. | | ‘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 ccordinatcr problem represents a significant problem and lead to our ultima recommendation, MR, TOOMEY: I don't know if the councii 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 ultima ‘recommendation? 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 council decided that, they felt withdrawal of funds in the amou of a hundred thousand and the site visit would be strong enough TT = so ° VW @ 12 13 14 15 16 17 18 19 22 24 a~Federal Reporters, Inc. 25 vo and they though it would be too harsh to withdraw triennial status. . —_ DR. SCHLERIS: What will be the result of this site visit, I gather it is information only, or are there specific 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 to go out and carry. the message from last time, The recommendation had alread been met or set by review committee council at their. last 0... 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 core staff, the site visit made no Funding recommendations, 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 hanging in mid-air, I think Donna has outlined our recommend+"" A very specific request was made by the site visit team which Bob outlined to have a letter forthcoming from RMPS Ly 4 15 16 17 18 19 20 2) oe » E# 4-B 23 24], e— Federal Reporters, Inc. 25 oY outlining these specific 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, or 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. MRS . SILSPEF: I think Dr. Péltegrine, who used to b on the review committee originally and council, descrived it best as a therapeutic site visit. There were indications, not only beforehand, but at the time of the site visit, that letter 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 to have gotten the message, but when we got there, we realized 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 council had been saying was understood by the regional medical program, DR. SCHMIDT: All right. We will move on. WW Us (e) CR 7149 | 1 ‘lake 5 2 orl @ ° 4 5 XXXXXX 6 7 8 9 11 eo » 13 (14 15 “16 17 18 ‘19 20 @ | 22 24 @~ Federal Reporters, Inc. 25 60 DR. SCHMIDT: We will go onto Bi-State before coffee. 'T 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. dor ] Se) ot © iW @ 12 13 14 15 16 17 18 19 @ 22 24 7e ~ Federal Reporters, Inc. 25 Another problem apparently was the internal... organization of the program staff, which was structured in such a way that all of the members of the staff reported to Dr. Stoneman, the coordinator of the Regional Medical Program. Additionally, because it was a Bi-State area and covered the area around St. Louis, Missouri, and, in addition, covered the southern part of Illinois, which included the state capital in Illinois, Springfield, where there was a concern because the Ihlinois RMP, which was a growing organization and more aggressive, increasingly aggressive organization, was concerned because the state capitai of Lilinois was being covered by a Bi-State RMP, rather than the Illinois RMP, as an expression of the -- either of the agressiveness of the Illinois RMP. They had just recently funded a project in Southern Illinois which thepretically was in territory {0-1 covered by Bi-State RMP. Finally there was a-concern about the relevance of goals and objectives tothe region's. health care needs. The specific issues were -- with which we were concerned were the organizational structure, the role and influence of the consortium, the internal organizational problems of the program staff, the dispute over the Southern Illinois area with the Illinois RMP, the role of the program dor 3 11 @ | 12 13 14 15 16 17 18 19 20 21 @ 22 23 24 :e ~ Federal Reporters, Inc. 25 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 Giseases; 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 ovis dor 4 10 i. e 12 13 14 15 16 17 18 19 20 21 @ 22 23 24 ‘e ~ 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 1 @ 12 13 14 15 16 17 18 19 20 21 eo 20 23 24 e~ Federal Reporters, Inc. 25 64 to look at the problems in East St. Louis, there had been no indication of minority concernior 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 jor 6 HW ) 12 13 14 15 16 17 18 19 @ 22 24 e~ Federal Reporters, Inc. 25 65 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 ariything, 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 ccordinaters ‘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 7: care, should be added to the staff, or should be substituted for the part-time people. As mentioned earlier, the RAG met just three or 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 oO =a > iT @ 12 13 14 15 16 17 18 19 20 @ 22 24 se + 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 level: And as part of our looking at the mechanism by which our projects came through the various committees to the Regionai Advisory Group, Dr. Mitcheli 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,"’indeed, 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. lor 8 10 nN @ | 12 13 14 15 16 17 18 e 2» 23 24 e — 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 we reviewed, which carried the { I 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 4 medicai 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 14 15 16 17 18 19 20 21 | @ 22 23 24 ‘¢ ~ Federal Reporters, 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 program staff monitors all projects. They control the financing. They monitor the fiscal affairs. Ss dor 10 so ow CD iW @ 12 13 14 15 16 17 18 19 oe ~» 24 se ~ Federal Reporters, Inc. 25 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 program apart than it is to promote its strengths, but they have done an excellent job with the development of their goals and their objectives. They have disseminated these goais, they have a mailing of 8000 organizations, and institutions and individuals. ior ll 10 4 oe. 12 13 14 15 16 17 18 19 20 21 ay) 23 24 e — 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 mechamism, 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 protessionali, 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 1¢ ~ Federal Reporters, 1 12 13 14 15 16 17 18 19 20 21 22 23 24 Inc. 25 then. Their review of projects has certainly ~~ “ ane improved, also. 71 CR 7149 6 = eak L 11 © 12 13 4 15 16 17 18 12 20 21 @ 22 23 24 :— 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 n yy * to sO ra HW @ 12 13 14 15 16 17 18 19 20 24 7e — Federal Reporters, Inc. 25 73 the fact that Illinois RMP had developmental funds and he had none and he wanted to be in a position to handle new projects ~~ as they came up when they came up. DR. SCHMIDT: Thank you. Secondary reviewer, Dr. Thurman. DR. THURMAN: I will have very little to add to what Bob has said. I think just because of the fact that the Missouri site visit came on at the same time the turf question will become a major question and we heard some question of concern when we visited Missouri because of their interrelation-~ ship with Bi-State. I think the question of the coordinator probably needs discussion by the whole Review Committee because of the points that Bob has raised. And I don't think any of us would disagree that if he is to continue in his present action, that a very strong deputy director is needed. Lastly, my concern, as already reflected by Bob, is the continuing project-type orientation. It would appear that this tripartite of RAG {> : basically and their appointment of associate coordinators, if this js not constantly monitored by staff, will perpetuate this. type of categorical approach. MR. TOOMEY: I might ask Maria Elena if she wants to add anything to this? MS. FLOOD: Well the only comment I might add is that we got the feeling the first day that there was a strong i0 1 @ 12 13 14 15 16 17 18 19 20 21 @ 22 23 24 ce ~— Federal Reporters, inc. 25 74 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 eak 4 1 nN @ 12 13 14 15 16 17 18 19 20 21 @ 2 23 24 se -- Federal Reporters, tnc. 25 75 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. “I am not quite clear, who is the . i 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 © 12 i3| 14 15 16 17 18 19 20 21 @ 22 23, 24 :e ~ 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. I 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 income 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 Ww eak 6 “ss Q 11 e 12 13 14 15 16 17 18 19 24 ze —- Federal Reporters, Inc. 25 Oo | '*Hextremely loyal to him, I think in every way, by every the community. They have a great deal of faith in him. Perhaps @ 09 £é 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 be 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. Ne dees needa somebouy wWilc 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 the universities. He relates well to all of the other physicians. He relates well to his own staff. They are indication. “He rélates extremely well to the, if you will, the power, the financial and economic power structure in too much. rr 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 time 10 i 13 14 15 16 7 18 19 20 24 se ~ 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 cf 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 (D sy v 20 iF @ 12 13 14 15 16 17 18 19 20 21 ® 99 | 23 24 ce — 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 g to impese 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 fioor. 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 10 iW © 42) 13 14 15 16 17 18 19 20 | 21 e 22 23 24 ice ~ Federal Reporters, Inc. 25 80 Mr. Toomey, has this program done anything to provide services in Cairo, Illinois? I know this was requested. ~ DR. SCHMIDT: The answer is no. |! 4 d 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 such as 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 recail how many FTEs that would add? MR. TOOMEY:: Four. DR. KRALEWSKI: Four? And were you recommending 81 eak 10 1|| developmental component? 2 MR. TOOMEY: No, no. I guess it is semantics but @ . 3|| it is called discretionary. funds. 4 MR. KRALEWSKI: One other comment I don't know if 5! I am reading this data, you know, from our book here 6 right or not. But it seems to me that last year in terms . 7 of the award that we gave them which essentially was supposed 8|| to be used for, you know, for the, to carry on their 9|| program, develop some other projects then develop a three-year 10] program for us. It appears that they implemented some 22 pro- 11] jects with it at very low level funding and now we are coming @ 12|| back this year and asking to increase that low level funding 13] for all but two of the 22, up to, you know, much more substantia 14] funding. And I raise the question over whether,you know, that 15|| indicates any real, you know, ability to really handle 16] the question over what projects should we implement and how 1 6 _ 17 should we best handle some funds. 18 19 20 21 e : 23 24 ce ~ Federal Reporters, Inc. 25 #7 arl ] om’ SQ 1 @ 12 13 14 15 16 17 18 19 20 24 ce — 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 cnly get funding starting October. DR. SCHMIDT: Dr. Luginbuhl? DR. LUGINBUHL: I would like to wk a question, point of information. I am lcoking at the budget in the actual ar2 so © 11 @ 12 13 14 15 16 17 18 19 @ 22 6 he en 24 :e ~ 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 7 \ 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 ) 12 13 14 15 16 17 18 19 20 21 @ 22 23 24 ce ~ 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 simpie 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 been that the university was exercising too 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 1 © 12 13 14 15 16 17 18 19 S ZZ 24 ‘¢~ 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 — ' 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 he 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 1 © 12 13 14 15 16 17 18 19 20 21 eo 2 23 24 e- 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 areaa 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 sccond question there, is there a motion on the floor? 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 14 15 16 17 18 19 20 21 @ | 22 23 24 1¢ — 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 tc 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. ar7 i. e 12 i3 14 15 16 17 18 19 20 21 @ 22 23 24 :e ~ Federal Reporters, Inc. 25 88 DR. LUGINBUHL: I have heard discussed several times in the last day and a half this question of breakage, ~~ or injury to a program by the use of too severe measures L 1 to try to bring about remedial action. It appears to me the two measures that are available are, one, some form of budget reduction; and, two, «withholding triennial status. I would gather that both of these have been employed on a number of occasions in the past. It would be very helpful to me in voting on this kind of a question to get some indication of what kinds of damage have actually been observed from these classes of action in the past. In other words, has this really resulted in significant injury to some programs, or is this a concern that possibly has been weighed too heavily? If that is the case, it would obviously indicate to me that we should use these measures more freely rather than less freely. I just don't have any feeling for what effects these actions have been on programs and just how real a threat it is. | DR. SCHMIDT: I will try to answer that. I think that as you hinted at yesterday, the committee during the five or six years that I have watched it, has chosen the route of not stressing region, if there was a question of too much breakage, it opted not to stress the region in that way. Usually other routes for effective action have been ar8 11 @ ‘12 13 14 15 16 17 18 19 20 2] e » 23 24 ¢ — Federal Reporters, fnc. 25 89 taken. Either the chairman of the site-visit committee, such as Sister Ann, or the director of the program, or somebody went out and got to the people who had to listen who were in a position to do something. Then either the coordinator was removed or the RAG chairman was removed or the RAG structure was altered. But I don't think that a club has been used with enough force in the past, to answer your question. The committee, if it's erred, has erred on the side of being conservative, using these other routes to get the messages back. And I -- actually the committee has talked, and staff knows the talk about stopping funding completely of a region, for example, withdrawing regional status, let alone, you know, something else. And these methods have not been used for really, if you look back the regions, Indiana will be coming up, which has more or less a cataclysmic year that was achieved really through two site visits in a row, and we will be talking about that. | So that I ask the question quite deliberately from my experience, that sometimes you will run the danger of the RAG or some of the critical people just throwing up their hands and saying the hell with it, and going away. And we haven't taken that risk deliberately in the past. Mrs. Flood? arg “oO net <> 1 ) 12 14 15 16 17 18 19 @ 22 24 se — Federal Reporters, Inc. 25 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-oriented projects and emphasizing more trends toward a programmatic approach. Seemed to be no qualms on Dr. Posta's part. think that this is true, Dr. Schmidt's point, Ht 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 triennium. 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 arl10 YW © 12 13 14 15 16 17 18 19 20 24 e ~ 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 a developmental 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 lkable 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 a @ 12 14 15 16 17 18 19 ® 22 24 ce - Federal Reporters, Inc. 25 92 had some 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 developmental component, why don't we call it that? Why do we use some other name? arl2 10 11 12 14 15 16 17 18 19 20 21 @ 22 23 24 te — 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 resuits 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 10 1 12 :@ 14 15 16 17 18 19 20 2) @ 22 23 24 e ~ Federal Reporters, inc. 25 13} 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 e ~ Federal Reporters, 11 12 13 14 15 16 17 18 19 20 24 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 so onl @ 1 @ 12 13 14 15 16 17 18 19 20 2] oe » 23 24 e — Federal Reporters, 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 Mexican-American, Anglo and Indian and the feeling generally being that efforts to improve health care have to take that 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 so aw © 1 @ 12 13 14 15 16 17 18 19 20 e » 24 e — 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 ‘~o ° 11 @ 12 13 14 15 16 17 18 19 20 21 @ 2? a 23 24 ‘@~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 ona 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 system for Statewide hospitals to centrally purchase items. 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 Oo i @ 12 13 14 15 16 17 18 19 20 21 @ 22 a 23 24 e~ Federal Reporters, Inc. 25 the time of our site visit and the time of the September 16 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 mite noor. 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 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 so =a Q 1 @ 12 13 14 15 16 17 18 19 @ 9 22 24 ‘e~Federal 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 ig still there. Balking 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 anda developed relationship. We did something in 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 mea-7 i. @ 12 13 14 15 16 17 18 19 20 e 8 » 24 e ~ Federal Reporters, tnc. 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 op 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 froma . mea-& 10 1 © 12 13 14 15 16 17 18 19 20 @ 74 424 24 2~— 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 representation. 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 ©} 12 13 14 15 16 17 18 19 @ an £a 24 e ~ Federal Reporters, Inc. 25 103 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 staff represents the truest form of what 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 gotten at least some of the idea of thrust. Community health services represents a compilation of kinds of projects in an area that relates to working with consumers; that thrust also has become what they call their community response system. It is attempting to organize itself ona Ami. ‘a Mea-10 10 11 @ 12 14 15 16 17 . 18 19 20 21 oe » 23 24 2~ Federal Reporters, Inc. 25 a year they really get only one side of the state covered in 104 statewide basis and the exact dimensions of how that shall be accomplished,. by the way, tam not entirely clear, from the 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 the community health services component will be felt through- 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 education services which have already devided the state into four quarters, and to use RAGs or local advisory groups, one mea-11 wet Cc. i @ 12 13 14 15 16 17 18 19 @ s £2 24 e— 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 ay 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 culturalwise 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 accomplishments 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 and run with it as a 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 sO a iF @ 12 13 14 15 16 17 18 19 20 @ ; & 24 ‘@ ~ Federal Reporters, Inc. 25 in the area. 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 One of last year's concerns, in response to the Executive Board, as authorized it increased from eight to ll 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 13 14 15 16 17 18 19 20 21 oe » 23 24 e—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 yood. wed CR 7149 Rapa 1 3 14 15 16 17 18 19 20 21 e =>» 23 24 2— 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 because 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 aware 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 weli in advance of a proposal going to us. The site vitors recommend that the Chest projects, community health education services projects should in fact #9 4 Reba 2 2 10 ia @ 12 13 14 15 16 17 18 19 20 21 @ 22 23 24 e —Federal Reporters, Inc. 25 109 create four local advisory groups in the next year to provide ag they are willing to undertake the appropriate responsibilities and resources, their share. tte aid 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 co would be motivated to be concerned about Southwestern New Mexico and to look really carefully into that but if the northeastern end of it has its own LAG, Local Advisory Group, 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 informational services office of this outfit is great. 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, I 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 #9 ] Reba 3 2 19 11 @ 12 13 14 15 16 17 18 19 20 21 ® 22 23 24 ~ 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 ~~ visit. 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, included 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 #9 4 Reba 4 2 “0 Q- 1 @ 12 13 14 15 16 17 18 19 24 :e — 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 object 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 health 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 Lovelad Foundation for Medical Education and Research located in New Mexico. I think we should be strong on this, we would want e #9 «1 Reba 5 2 @ 3 11 @ 12 13 14 15 16 17 18 19 20 21 e =: 23 24 e- 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 prejects. 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. i” . #9 1 Reba 6 2 WW © 12 13 14 15 16 17 18 19 S 22 24 se ~ 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 £ 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 language and the -- the language of the application and #9 01 Reba 7 2 10 W @ 12 13 14 15 16 17 18 19 20 21 oe :z 23 24 a—Federal Reporters, Inc. 25 114 oe che “8 the thinking of the staff some uncertainty as to this issue of, decentralization versus centralization 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 feeling it will because we approached the topic trom several different directions from the point of view of projects and point of view of local representation, 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, I 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 cther 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. x 9 1 Reba 8 2 “0 mn cD 1 @ 12 13 14 15 16 17 18 19 20 21 eo » 23 24 :e ~ 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 has to day very briefly, and why don't you go ahead with recommen- dations? MR. HILTON: All right. Site visit team recommended that MMPMP be approved for triennial status for 05, 06 and 07 #9 } Reab 9 2 10 1 @ 12 14 15 16 17 18 19 20 21 @ 22 23 24 :e ~ Federal Reporters, inc. 25 116 4 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 th a 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 ~ #9 | Reba 10 2 ® 3 4 “SO ow! ©. i @ 12 14 15 16 17 18 19 @ 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 in managerial and financial aspects of HMO planning. Wo 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 te 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 HMO planning, it should bring people with appropriate experience] - Ts 118 #9 |i} it. There is also a feeling of its worth. But again apparently Reba 11 2\| they have run into something of a brick wall in terms of attemnting to get support for it. The feeling seemed to be Al, that the resources simply were not there. Everyone agreed 5|| it was a good thing to have. 6 Of course those who were closest to the project felt 7|| more strongly about it. We did suggest that more aggressive g|| efforts should be made to seek continued support for the effort. 9 They assured us they would continue to try but there io} was this feeling cf a real frustration, that the effort really 1] || wouldn't pay off so why bother in the first place kind of @ 12|| thing. That in fact efforts in the past despite the amount of 13|| work that had been put into this by one of the physicians 14|| closely involved with it in attempts to recruit assistance 15|| have been so futile that there did not seem to be any real drive 16|| on the part of the people who were supporting the tumor‘registry 17|| to go out and as one guy said you know spend days, weeks and 1g] months at trying to do something that simply was not there. 19 DR. SCHMIDT: We do have a motion on the floor. 90|| 5 there a second for the motion? | 21 DR. ELLIS: Second. } 22 DR. SCHMIDT: All right, it is seconded, so we are 23 ready for discussion. I believe first, well, let's see, John, 24|| You have got the microphone. When you are through you can is hand it to Dr. Schleris. end # 9 CR7149 #10-ter-1 © 3 10 7 e « 13 14 15 16 {7 18 19 40 sont —_ Zz JN 23 24 t ce — 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 Group: 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 1 @ 12 13 14 1S 16 17 18 19 20 eo 2 24 te — Federal Reporters, Inc. 35 way to, I believe it was Harvard for a course in fiscal 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 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, in fact, may, in years to come. 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 Albuguerque. 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 two grants in one area. DR. SCHMIDT: Miss Kerr? MISS KERR: Speaking of other Federal funds available I, too, was concerned when Bill was talking about the educationa 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 s lL ter-3 ce — Federal Reporters, Oo ~—Z o> VW 12 13 14 15 16 17 18 19 24 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 9 10 1 @ 12 13 14 15 16 17 18 19 20 21 @ ‘2 23 24 ce - Federal Reporters, Inc. 25 122 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 program. 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, I 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 11 13 14 1 e | 23 24 ce —Federal Reporters, Inc. 25 bs N) us 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? Yes. That was largely the result of the represent- ation on the RAG. And, I guess what we found ourselves doing 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 1 e. ” 13 14 onal Ox : 11 © 12 13 14 15 16 17 18 19 20 24 e — 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, technical 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 iP @ 12 13 14 15 16 17 18 19 20 21 @ 22 23 24 ¢ ~ 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 so 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 we 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 Lau dor 10 1 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 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 actuaily ran the program. 14 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 18 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 nia in the past, had been largely in the data base development dor 11 a @ 12 13 14 15 16 17 18 19 20 oe » 24 e ~ 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 vear, 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 betore, I wouid not ieave 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 2 @ 12 | 13 14 15 16 17 18 19 20 21 @ 22 23 24 e — 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 what was 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 othe rs, 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 7 @ 12 13 14 15 16 17 18 19 20 2) @ 22 23 24 2—Federal Reporters, Inc. 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 into 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 tnat 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 entirely 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. Wh mee 144 If we are going to ever be able to evaluate any , 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 e 4 is going to happen in the future in all of their areas. 5 I think this will be meaningful, not only to us, 6 but alto to other branches of HSHMA and HEW, because they do 7 have a truly significant data base and if you look at the 8 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 for 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 ® 13 about in the delivery cf health care in this area. 14 I think Late as we look at the process of their 5 organization, the coordinators very firmly moving to take 16 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 19 not really contributing, why don't you resign," or "We really - need you badly, you are the kind of guy who we hope can 21 help us make the change in the future." | © 2 Although the RAG is very small at the moment, 7 it is open-ended in reference to their by-laws, and I believe 7 the additions we have brought about will be significant. e~ Federal Reporters, inc. The RAG chairman clearly is a university man, °°." 25 dor 15 1 © 12 13 14 15 16 18 19 20 end ll 21 @ 22 24 e~ 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 concern 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 thie 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 arl 1 11 @ 12 13] 15 16 17 18 19 20 21 oe 8 » 23 24 se ~ Federal Reporters, Inc. 25 14 146 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. : 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 wiil begin to derive programs from 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 iG iB 6 12 13 14 15 16 17 18 19 20 24 ce — 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. I 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. Ww ar3 10 11 @ 12 13 14 15 16 17 18 19 20 21 e 2» 23 24 ce ~ 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 revicw 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 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 4 15 16 17 18 19 20 21 @ 29 23 24 e ~ 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 year 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 ar 5 13 14 15 16 17 18 19 20 21 @ 22 23 24 ce ~ 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- ticn 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. ar6 10 VW © 12 13 14 15 16 17 18 19 20 21 @ 22 23 24 ce — Federal Reporters, Inc. 25 151 So I think there will continue to be some real problems with this. The medical society is well aware of this,Dr. James, and their concern, the board, they have actually changed the name of this now to call it a Vermont, it now has VHSI 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 to 12 people, are sc 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 burdened, but very concerned about the situation, is Dr. 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 ar? 10 rT e 12 13 14 15 16 17 18 19 20 21 @ } » 23 24 ~ Federal Reporters, Inc. 25 152 in the state of Vermont, and if somebody's got red eazs over this, it is the Secretary of HEW. And this is an incredible ~~ blunder by HEW, and in effect a manipulation of a state : \ i t 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 pecple 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 were 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 14 15 16 17 18 19 20 21 rd 22 23 24 ice — Federal Reporters, Inc. 25 LI 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 to develop what he wants. DR. SCHMIDT: This would not, you know, by the two arg 10 1 © 12 13 14 15 16 17 18 19 24 ce - 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 feel 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 arlo 11 @ 12 13 14 15 16 17 18 19 20 21 eo » 23 24 ce ~ 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: : 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 popuiation, 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 2\| Say aye. e 3 oppo. sed, no? | 4 And I hear no dissent. 5 It is 1:15. Cafeteria is out of soup, but there é|| are a few other things left. 7 We will reconvene at 2:00 o'clock sharp. 8 (Whereupon, at 1:20 p.m., the hearing was recessed, g|| to reconvene at 2:00 p.m., this same date.) 12 16 a @ 12 . 13 14 15 16 17 18 19 20 @ 22 24 se ~ Federal Reporters, inc. 25 CR 7149 13 eak 1 XXXXX © on o> 1 © 12 13 14 15 16 17 18 9 @ 22 24 e — Federal Reporters, Inc. 25 i wp the region and it consists of 254 counties with a population 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 hersclf. 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 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 mach potential that I would like to share it more in detail than 1 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 moment six exist, at El Paso, Houston, Tyler, Abilene, Laredo and Lubbock. They expect to add to this eak 2 1] @ 12 13 14 15 16 17 18 19 20 21 @ 22 23 24 ce — 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 |iregion, 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 report. 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 the proposed triennial application. We eak 3 11 12 13 (14 ce ~ Federal Reporters, 15 16 17 18 19 24 Inc. 25 Loy 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 i 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 assistant 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 eak 4 11 eo 13 14 15 16 17 18 19 20 24 e~ Federal Reporters, Inc. 25 160 unbelievable what this region had done with the development of goals,objectives and priorities,. riot only the amount of work done but the process in which it was done. It involved not only the coordinator and staff, but many meeting 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 this 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 task forces coming back at intervals to compare notes and 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- fs tions to be employed and more expert consuitation 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 bec eak 5 1 ae) ° i @ 12 13 14 15 16 17 18 19 e 22 24 ce ~ Federal Reporters, Inc. 25 161 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- oriented planning councils are being developed and that potentia activities of local RMP advisory bodies would constitute 1 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 enviro] ment for Chicano health consumer participation is being supporteq par h — i eak 6 ee) ~ Q W } 12 13 14 15 16 7 18 19 20 21 oe =; 23 24 ‘e ~ 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 ee) moll oD 1 © 12 13 14 15 16 17 e 13 18 19 20 21 e 03 fu 23 24 ce -- Federal Reporters, 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 tcld, 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. Ag — Cr 7149 #44 2 eo 1 3 1] ©} 12 13 14 15 16 17 18 19 20 2) oe » 23 24 e ~ Federal Reporters, Inc. 25 164 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 continuance. 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 replacements. And we can't expect an unusualiy 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 ead tu #44 1} the biggest. Having been there before, being the one that made rf Reba 2 2l| the recommendation for increased involvement of minority @ 3|| groups, he really peppered away at this. 4 We even checked this out’ with Dr. LeMader relative to 5|| their civil rights compliance and so forth and so on. They had 6l| as I say improved the minority representation on the RAG, not 7\| as much as we would have liked but there is a strong commitment 8|| to do this. 1 : : ni : . 9 And words can be words, but it is in print. Their 10) procedure for employment of people with a focus on employing 11 | those who are of the minority groups. I think at this point @ 12|| I will say that Dr. McCall, as forthright as he is, we could 13|| not back him into the corner on this because he was so honest 14|/) about it and said, "I am looking for these people, I have been 15|| looking for these people. I will continue to look for these 16|| people and bring them to the board as soon as possible but I 17|| will not commit myself to bringing aboard a black face or 18 Chicano or a white person unless they have the competency and 19 capability that we can build on to make them an active con- 20|| tributing part of our staff and RAG." 2] The minority groups are extremely well and consumer © | 22|| groups in the subregions. Much of the program is arranged around 23|| the inputs from these people. There are a significant mmber 24| of minority personnel on project staffs. I would want to tell e~ Federal Reporters, Inc. oy 25|| you this:Dr. Sid Geroa, who sat there, and he is not a very #14 ] Reba 3 2 10 VW 12 e 14 15 16 17 18 19 20 21 @ 22 23 24 ~ Federal Reporters, inc. 25 166 vocal person, but he rose to his feet 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. McCall, the coordinator, has undoubtedly provided some of the strongest leadership with able adiutinistration 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 for a 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 Ua Ww i © 12 13 14 15 16 17 18 19 20 21 e 22 23 24 e~ 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 but we will carry on. Relative to program staff, the staff consists of 15 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 well 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 geogravhical assigned areas. The 51 member RAG group was very active from the time of the last site visit through December and continues to me . #14 Reha 5 2 10 i 12 ond qa 14 15 16 17 18 19 20 21 © 20 23 24 e~ Federal Reporters, Inc. 250 long to get it built up and he convinced us that this was 168 be but were particularly 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 But anyway Dr. Eastwood explained that with the four -- with the three medical institutions within the system, and wit Baylor and one other medical school in the state, --- MR. SAYS: University of Houston is the medical bchool. MS. KERR: Getting underway. If they were to have representation from general practitioners and so forth so on they 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 te with the RAG group, and in staff and the rapport seemed excellent. Prue. #14 1 Reba 6 2 10 im @ 12 13 14 15 16 17 18 19 20 21 oe 2 23 24 e— Federa! Reporters, Inc. 25 169 And 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 organy ized and coorindated task forces and committees. Development committee assumed an active role by establishing short term chjcctives. 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 prior to the submission of their level of request for funding. I 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 Reba 7 2 “oO =e o 7 @ 12 13 14 15 16 17 18 19 20 @ 94 44 24 e — 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 available for the community. But -- as a result it has not brought about jess 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 regicn 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, Ur e #14 #1 Reba 8 2 14 15 16 17 18 19 end # 14 90 15 fls 21. @ 20 23 24 e ~ Federal Reporters, Inc. 25 171 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, foriorities 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 period review and updating of priorities are planned. mea~-1 CR 7149 #15 sO @ 1 12 13 14 15 16 17 18 9 20 21 22 23 24 :~ 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-< 1 @ 12 14 oi w 15 16. 17 18 19 20 21 @ 22 23 24 e~— 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 included in their proposals so that three years is the limit of funding. As far as regionalization, we have talked about the different regions. It isa 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, Thougi 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 “R 7149 fake 15 zontd. @ VW 12 13 14 15 16 17 18 19 20 21 22 23 24 :¢ — Federal Reporters, tnc. 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 VW 12 wed. Ga? 14 15 16 17 18 19 20 21 @ 22 23 24 e ~ 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 should be 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 Wh wv i @ 12 13 14 15 16 17 18 19 20 21 @ 22 23 24 e — 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 ) 12 a 15 13 cake 16 14 15 16 17 18 19 20 21 @ 22 23 24 ce ~ Federal Reporters, Inc. 25 177 spent a lot of time with it, therefore, I am in a bit of a dilemma. DR. SCHMIDT: Let's see. Let mie 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 11 © 12 13 14 15 16 17 18 19 20 oe x 24 ‘@ ~ 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 up 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 HW @ 12 14 oomt Ww 15 16 17 18 19 20 21 @ 29 23 24 3~ 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? Is there enough emphasis being placed on the sub- regions or on dividing up the problem so 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 weil 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 @ 12 13 14 15 16 17 18 19 20 21 e 22 23 24 se ~ 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 qualifications." Well, I have a couple objections to that. Cne 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 so = co 11 @ 12 14 15 16 17 18 19 20 21 e 22 23 24 e — 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 te 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 oie tair. 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 - 1a & 10 11 12 awl G2 14 15 16 17 18 19 20 21 @ 22 23 24 e ~ Federal Reporters, Inc. 25 182 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, 100k at some six thousand people. If I 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 o beyond that, this is a tough area. : . histories to QQ 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. 10 iT 12 13 14 15 16 17 18 19 20 21 © 22 23 24 2—Federal Reporters, inc. 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 locking 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 11 oO ont oO i e 12 13 14 15 16 17 18 19 20 21 @ 22 23 24 3 —-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, _— 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 tit :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 hospitai may not now be able to do so. DR. SCHERLIS: Well, the lutline doesn't go that far. 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 ae) — oO 11 @ 12 14 15 16 17 18 19 20 21 @ 22 23 24 ze — Federal Reporters, Inc. 25 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 texms of an HMO foundation for medicai 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 ¥egion 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 dor 13 ] 19 i @ 2 14 om, w 15 16 7 18 19 20 21 @ 22 23 24 ‘e — 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 terms 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 as.has 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 nd 16 5 ake 17 = «@ so owt © VW @ — 12 14 15 16 17 18 19 20 2] @ 22 23 24 2— Federal Reporters, Inc. 25 187 where that money is going. DR. SCHERLIS: I second that. ~ DR. SCHMIDT: All right, there is a second, then, oo. 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 i. @ 12 13 14 15 16 17 18 19 20 21 @ 22 23 24 —~ 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 haif-time “health advocates in each barrio, under the supervision of Chicanos. This Gove-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 14 15 16 17 18 19 20 2) @ 22 23 ‘ 24 ~- 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 Se me suoG 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 sO Po) 11 ) ; 12 13 14 15 16 17 18 19 20 21 @ 22 23 24 e— Federal Reporters, Inc. 25 190 discussions, about the size of these groups. This one, I think, is 50 or so people, and I wonder how well they are really able to meet and’ set some of these priorities and particularly how do some of the underserved get their prioritie 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 that in the application he said he was going te spend it for. You are saying can we force him by earmarking discretionary funds and the answer 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 think what happens at times is that people propose these 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 therd is not some other proposal at that point in time competing for those dollars. Frankly, I suspect at times the problem of dor 18 sO a cD 1 @ 12 13 14 15 16 17 18 19 20 21 @ 29 23 24 e~ 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 ke 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 14 15 16 17 18 19 20 21 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? one 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 seconder, 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 XXXXX 14 15 16 17 18 19 20 e 22 24 e~ Federal Reporters, tnc. 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 nave 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 been 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 1 © 12 13 14 15 16 17 18 19 20 21 eo » 23 24 e ~ Federal Reporters, Inc. 25 194 RMPS recommended the submission of a one-year anniversary application which would lead to a much stronger triennial req uest 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 r 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 sof 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 to change that is recorded in this, not only in the application, but by other mean. 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 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 1 12 @ 14 ont ae 15 16 17 18 19 20 21 © 22 23 24 3~Fedetal 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,chave stated-toBill:and to others that they have been misinformed on the status of IRMP. And that the tight ship that had been identified and I guess these are words that both Al and our group used, tha this man was running what was evidently heading for very rocky shoals. | With his departure, Dr.Behring, Associate Dean of the Medical School, has been appointed the interim or acting coordinator and a search committee has been set up for his replacement. I recall Dr. Behring, he has served with this group and with the RAG for a considerable period of time, perhaps an indication, however, that this RAG was not that active and not that involved. dor 23 an @ 12 13 14 15 16 17 18 19 20 21 @ 22 23 24 2—~Federal Reporters, Inc. 25 196 Already the relationship, and I would put this as a strength, already the relationship of the Medical Society and other health agencies have indicated a marked improvement in the few months recorded since the resignation of the coordinator. Dr. Behring reports, as the interim coordinator, tha there are improved relationships withthe Indian Hospital Association, many of the health associations that have been identified in relationship to this program, that they are, indeed, sharing with them their request for help in putting this region into better shape. The RAG, with many of the problems,..I-will list under weaknesses. I feel, however, the complete review that is taking place with the RAG today is absolutely essential. It is still in the process of major revision. Although the larger number are from Indiana University, and there have been comments on this from the beginning, Indiana, in that setting and in that state, certainly Indiana University deserves and should be in a major relationship to this RMP. But in addition to this group, we find here other institutions, other groups, their relationship with CHP, which I will speak to further her e, other organizations throughout Indiana are being represented in some of the planning that is going on. dor 24 end 17 ce ~ Federal Reporters, 10 11 12 14 1S 16 17 18 19 20 21 22 23 24 Inc. 25 197 There is no question about the still great need for consumer input. Representatives of some of the other health professions, the.health professions-are physicians and nurses only. Dr. Behring, however, again has expressed his eagerness to the members of the RMPS here. He plans to answer the criticism that IRMP has received and that, indeed, the Medical School will assume a different kind of relationship on the RAG and in relationship to the total program. Cp 7149 418 1 Peba 1 2 3 e so ed <> 11 @ 12 13 14 15 16 17 18 19 20 21 eo » 23 24 e~ Federal Reporters, Inc. 25 198 Perhaps the most exciting strength to mention is the regionalization that although begun several years ago has culminated in the past few months with some very strong effects. Nine area action groups have been formed and the formulation of active relationships with five existing CHP agen- cies has been carried out. The formulation of two oth@r CHP's are being planned with IPMW now in a working assisting relationship with them. On just a personal level I had the opportunity of speaking at my home town which is Richmond, which does not have any I guess problem here in terms of interests in the project. I was speaking to the Medical Society of Wayne County and it invited Liberty County to this meeting. They did not know my relationship to RMP in any way and in the business agenda of that meeting it was pretty exciting to hear them putting together, having received a request for Indianapolis for the first time to get involved, to select the people to work with them. To be a part of action groups. There was certainly to me as I look back and as I read this application, an indi- cation of the little small town out there of 40,000 that had heen asked for the first time t sarticipate in this project Q and this nroqram and really their excitiement that Indian- anolis was looking out to them for them they felt for the first time. #18 1 Peba 2 2 so mw oO 1 @ 12 13 14 15 16 17 18 19 20 21 @ 22 23 24 ie ~ Federal Reporters, Inc. 25 199 So this regionalization plan is a most important plus. Development of effective comprehensive data base which is one of the major Pee of the 1970 site visit which deplored the lack of any really major statistical basis for planning priorities and needs, this has been accomplished al- though there are parts of it that need to be looked at out in these separate parts of the areas that are being put together. The state-wide basis has been accomplished and listed in this. I am sure Dr. Brennan will be happy to see that since this is one of his major pushes at the 1970 visit. 23 now major data sources have been obtained. These have been obtained through contract sources and such there in the state. and cert ainly there is a working set to work with here in looking at the regional characterization. Their set of objectives, broad objectives that have been put together certainly has to be better defined than they are at the present time. But they have this basis for the first time to look at it and really to work with it. The strengthening of the program staff has been looked at as one of the major commitments and needs of this program. And already there is a reassignment pf responsibilities of some of the people on the program staff. This is a relatively small staff those of you that are looking at any of the material and whether one considers that the amount of money at an annualized level for the program #18 1 Peba 3 2 10 11 @ 12 14 15 16 17 18 19 20 21 @ 22 23 24 e— Federal Reporters, Inc. 25 200 staff is around $379,000, this has been a small staff that the former coordinator wanted in relationship to running ~~ the program. | ' | In the projects area, particularly those of a categori cal continuing educational nature, it is exciting to find that there has been a transfer of many of the larger funded projects to local funds. The coronary care project that they have carried for years, their stroke project, these have been taken over hy the other levels and other kinds of funding. More about this also in the recommendations. As I said you know and I will go back to that as another major strenth attitudinal desire now to change, it is very strong and i happen to feel that they do have the capacity to bring this What are the weaknesses? The major weaknesses, program staff, there must be additions to this. There are only two: vacancies, in the list of what has been requested. This must be Gone in certain areas particularly, planning, evaluation essentially. They have an educational psychologist there, and he needs additional staff help. He needs a model, he needs some: help on how really to relate their projects and evaluate them toward program goals. Mr. Smith who I had the privilege of knowing through this project and have had a working relationship in many other ways who was responsible for allied health and nursing has been #18 4 Reba 4 2 so © 7 @ 12 13 14 15 16 17 18 19 @ 2 ae 24 :e — Federal Reporters, Inc. 25 201 so succesful in that area and he really got quite a bit going there, he is so successful he has been moved into another job there and he is going to be head of all the active planning in the regional parts of the program. May I say that leaves quite an opening, however, for allied health and nursing there, and they do need staffing up in that area, particularly since they have begun to turn the people on there in that area in relationship to this. As a weakness again, from personal background, they have no one fu vet from there mator at ivision cf allied medical proféssivous which is in the medical school at Indiana which is recognized as one of the most broadly developed programs because there is only one medical center in that state, has responsibility for all the community college programs throughout the state. Still they have no voice in any way although some projects in the RAG or in any of the relationships there to the program I do not know for this is an excellent program. They have people of national stature in that setting, some of them serving with me on two AMA committees in relationship to allied health. A weakness, the revitalization of this RAG, a spelling out of responsibilities, certainly a leadership role, planning role, rather than just a reactor role to what has been bubbling up or coming in is essential. Must be a major reassessment of the regions review process. If one looks and one has pointed thig #18 1 Reba 5 2 sO md 2 1 @ 12 13 14 15 16 17 18 19 20 2 24 e ~ Federal Reportess, Inc. 25 202 out in the last two reviews there when we have had site:” visits. Many members of the Executive Committee of the program have made all of the major decisions in this. They have a very poor history of turning anything down. The indications are that this review process again being looked at and already in the works, some of the planning and things that must be done. Minority representation in the total program, there are no minority professionals yet on the core staff. Two professionals are working in some of theists projects and three minority people are on the RAG. It is an inadequate representation still but it is an improvement over two years ago. They still have quite a ways to go. However, in the project orientation, the programs they have had and I remember quite well visits with one of the black physicians who was heading up one of the community health projects, neigh- borhood health projects in Indianapolis, they do have some good projects going in this area. Of approximately 15 projects implemented in this program only three old ones are requested for continuation. Of these the neighborhood health care center, nurse tractitioner are two of these. There are eight new ones they feel are ready to go. These are, some of them getting away from the categorical. They have some health care emphasis and relationship Ui #18 Peba 6 2 10 11 @ 12 13 14 15 16 17 18 19 20 21 e =: 23 24 e ~ Federal Reporters, tnc. 25 203 to their newer goals. I will quickly make a recommendation to get this on the table then I certainly want Bill and particularly Al, who has been on site visit and Bill who has been there recently to respond to this, but let's get the recommendation out in relationship to this. They are currently funded in this region at $1 million 121,000. They have re- quested a million five hundred thousand in round numbers. The staff having looked at this total plan have re-..- commended an increase of only around $80,000 to a million 200,000. And the breakdown for this. As I said, they are in -- their major needs as I see their projects in this core staff so I am recommending or approving actually the recommen- dation made by the RPM review staff here of approximately $500,900 of this amount for staff. This will give them increases in salary. This will provide for the new director, This will add some to their evaluation staff. It will give them an opportunity to really staff up there where they are really going to need it in staff that has been held certainly to the bare bones. In relationship to one of their other major needs, and that is to continue with the projects as they relate to the regionali- zation and into these areas, they have requested $500,000 for this. In contractual services. The recommendation of the review staff here was that this be cut to approximately #18 1 Feba 7 2 sO -—ll © 11 @ 12 13 14 15 16 17 18 19 @ 29 24 ¢ - Federal Reporters, Inc. 25 204 $300,000. With this they should indeed be able to go on further with their feasibility studies, their expansion of subregional planning, and staffing in relationship to the regional program. They have made a request for approximately $600,000 for continuation projects and for new projects.The recommendation is breaking this down to $200,000 each, $200,000 for contin- uation and $200,000 for new projects. Adding this $500,$300 two $200 ones, we come up with a total of $1 million 200,000. What this does give this program an opportunity to do with even this small increase of $80,000, which is recommended, is to -- they have turned the corner and made the decision to change. They have a long way to go to make this the kind of program that we really can believe is ready for a triennial review and I believe with discussion with Bill that any recomm- endation that we make with the changes and things that they need to do, rather than insist or even ask for a trieenial review next year, that they be held at this level for two years, during this period of transition. They have turned the corner, they have got a lot of plans going, things they have to do during this period of time. Getting a new director although T am sure they are going to be moving right ahead with this, with the Associate Dean of the Medical School that is working with them but I think they need a period of time and we are not increasing the amount in the recommendation more than this $80,000. CR 7149 #19 @ : e — Federal Reporters, nae sO andl ° 11 12 13 14 15 16 17 18 19 24 Inc. 25 205 That is my recommendation I put on the board. DR. SCHMIDT: Okay. I am the secondary reviewer and I will try to just bring out the issues as I see them. At the time of the site visit last year there was just a god awful program. They got F's straight across the board and it is a program that if substantive changes had not occurred one would be considering whether to just stop all funding and just declare the thing defunct and tell them to start over gain. Problems with ineffective coordinator who had a small staff they ran tightly and the staff really was not doing the right sort of things. They had the worst kind of possible relationship with the medical school. The medical school completely dominated it. The majority of people on the executive committee than ran the program were from the medical school. The principal person involved, George Lucameyer, Associate Dean of the School, did not and does not understand regional medical programs. For reasons easy to understand the medical school is scared to death of the Indiana Medical Society because their legislative support comes from the Indiana Medical Society. Indiana Medical Society did not like the cocrdinator or regional medical program. The medical school dictated exactly what RMP could and could not do. The coordinator's primary allegiance was to t} medical school. ne #19 1 Peba 2 2 10 12) @ 12 13 14 15 16 17 18 19 20 21 @ 22 & 23 24 :e — Federal Reporters, Inc. 25 206 He said if push came to shove his medical school appointment was far more important than anything having to do with PMP. The Executive Committee was not functioning well, there was no data, no objectives, no priorities, there was no programs, there was no plan, there was some projects. There was no subregional effort. And it was just terrible. The site visit two years ago told them this, they got real mad, said it was an unfair site visit and they just stayed mad for a whole year. And I walked into the biggest trap I have ever seen set by a region that was pulling site visitors up against everybody and the coordinator took a day to realize that we had been set up. And we left essentially escorted to the state line by the highway patrol. And I doubled back to one ray of hope who was a bright and new lady of the regional advisory group and we just did suggest that the program leadership needed to be changed, the medical school put off at arm's length. We had to get the people in the school who did not know what RMP was about out of the picture. And so on. One member of my institution is for liaison purposes 4 member of the Indiana regional advisory group. Done Casely. And he would come back from Indiana RAG meetings just cackling with glee and hand me the minutes of the meeting which took apart one by one the site visitors and challenged the integrity and so on and so on. #19 4 Reba 3 2 sO ~e Q 1 © 12 13 14 15 16 17 18 19 20 eo 2» 24 3— Federal Reporters, Inc. 25 207 But largely through Haver and some other people, and through the supportive staff I would like to point out to the review committee the importance of staft support and consistency of staff support in taking to the regions the recommendations of the review committee and sticking by them and really accurately reflecting and confirming and supporting review committee in this. They came in to see Harold, they probably came in to see Henry Kissinger, I don't know who all they came in to see but they got the same message each time and there was a revo- lution. The coordinator resigned and RAG decided he did not resign quick enough and threw him out. Baring, I think it is a cop out. Medical school is suddenly saying we did not know. Well, you know it was impossible that they couldn't have known what was going on because they were the program. They just were not paying attention. And I really think that they did know but they are having a change of heart and they are withdrawing. The program is doing some things that I think really are terribly important and if we are going to have a program there, merit the support of the RUPS -~- they do have a data basis. They have new leadership there worganizing the staff, recruiting a new staff. They have a different relationship to the school. They have a very strong and excellent RAG chairman who seems #19 1 Peba 4 2 ‘oO —" Qo 1 © 12 13 14 15 16 17 18 19 @ , a 24 e~— Federal Reporters, Inc. 25 208 to have taken over. They have the new goals, priorities, and plans. There is an excellent exercise in subregionali- zation. They have phased out projects and they are phasing out projects. They are restructuring their committee structure and they have for the first time a really pretty good relation- ship with the Indiana State Medical Society. Their area, groups are very important, they are finally recognizing the fact that their CHPB agencies are around and they are beginning to ase with fantastic amounts of dollars that poured into Indianapolis, millions into OEO and RMP just said man, we have to stay away from that power and that influence and all those dollars and so on, because the medical school said we have got to keep a low profile. They are beginning to interphase with the things that are going on in the real world about them. I think that I will support the idea of funding them at 1.2. I think they need this money to do the things that they are doing. I don't know if they are falling into the trap of continuing the ola activities. The ones they are continuing seem to be in the right direction. I think there must be absolutely strong word from here that what they are to do with these funds is to build their staff, to continue the subregionalization efforts and put money into that, to use their data base to get specific #19 1 Peba 5 e~- Federal Reporters, 14 15 16 17 18 19 20 2) 22 23 24 Inc. 25 209 program plan, to get a specific.action plan in conjunction with the agencies and subregional people but to evolve where they are going. That is the third thing. To continue the involvement with Indianapolis OEO and all of the other multiplicity of programs that are active in the State of Indiana which range from a very rural thing in the south and so on up. Finally to keep that damn medical school out of the RMP headquarters and let them be the fiscal agency but get this terribly op- ressive school out of the nicture. T would seek the recommen- dation then, feeling that if they do get a good coordinator, I think Baring will bring this program along and he has gotten tne word. If they will get a coordinator who will continue what he is doing. Whether they can come up with a triennial next year or not I am not sure. I think it would be good to give them the business of you know here is one year's support, you can have another year's support without a triennial if you need it. We will look at you on a mini site visit in a year or staff site visit in a year to see how you are doing and offer staff support while they are in this transition phase. Discussion? DR. SCHLERIS: Would you like the mostion seconded by a member of the committee rather than by the chairman? #19 Reba 6 2— Federal Reporters, oO me Q 1 12 13 14 15 16 17 18 19 20 24 Inc. 25 210 DR. SCHMIDT: Let's see. Yes, somebody get me off the hook. DR. SCHLERIS: JI second the motion. DR. SCHMIDT: All right, thank you, John? DR. KRALEWSKI: We are moving this then for two years instead of the one. DR. SCHMIDT: That is right, at the level funding. And with, you know, if they can come in with a whiz bang triennial next year, great, but if they can't, let them have the feeling they got a little time. DR. KRALEWSKI: ‘Thank you. DR. SCHMIDT: Other comments or questions? It is an example of a region that was turned around. Florida was another one I can think of and so on. I think the main things that have turned it around were the site visitors, who had the strong support of staff who said yes, they are right you know, quit looking for an out. All right, I will call the question then. All in favor please say aye. Opposed, no? Last but not least then it is Memphis. And the primary reviewer is Dr. Ellis. DR. ELLIS: “Thank you, Mz. Chairman. 1 have been told that I did not have to many minutes to do this by some of my friends and I am going to try to he brief so that they won't be unhanwy with me this time. | Reba 7 2 10 1 ) 12 13 14 15 16 17 18 19 20 21 e 22 23 24 @—Federat Reporters, Inc. 25 211 Memphis is a very interesting region and I would just like to mention before we go into the discussion of the visits something of the background and demographic information because this is a very large region and it is culturally diver- sified. The region actually consists of parts of five states, and it is made up really of what is traditionally a trade area. Also the area that is based on hospital care that is given to people in this 75 county area. 21 of the counties are in Tennessee, West Tennessee. 16 in Arkansas. 27 in Mississippi. 6 in Missouri and five in Kentucky. And yoy know that in this it is extremely difficult. There is a population of two and a half miliion, that is the 1970. It is interesting also that there is an essentially rural area, except for Memphis which has about 800,000 people, 600,000 people, and then the next largest city in this whole area after that is Jackson, Tennessee, with 50,009 people. In terms of the racial composition there are 31 percent roughly a third, black. A few orientals and the rest are white. Many of these are poor. It is also interesting to note that in the Kentucky section there are quite a few old people, the largest number of people over 65 in Kentucky. With reference to the racial matter while I am here I will say that this 31 percent does not reflect the situation 14 15 16 17 18 19 20 21 e 22 23 24 e — Federal Reporters, inc. 25 212 in some of the counties. In Tunica County, Mississippi, there are 73 vercent of the population is black. While in the Ozark area you will have about the same kind of thing with reference to white people. And nine of the 27 counties in the Mississippi subregion having populations of more than fifty percent are black. The infant mortality rate, I will mention this because it is very significant and will have a lot to do perhaps with the long range prograns which can bring about institutional And while we have here an infant mortality raie ilis is 28.9, compared for -- to this region and this is compared to the national average in 1970 which is 21.7, it is lower than that now. The thing we want to point out, that in Mississippi, in the subregions in two counties the infant mortality rate was more than twice the national average. When you see an infant mortality rate of 28 and you recognize that there are counties with more than half, I mean twice as much the national average, you really know you have a very, very serious problem and oftentimes this is overlooked. Now Memphis region did not have a site visit. This time. The last, well, I might just tell you in passing that this region became operational in 1967, I mean started its planning in 1966 and 1967, became operation in 1969, and in 1971 had site visit in response to the triennial application. #190 | Reba 9 2 11 @ 12 13 14 15 16 17 18 19 20 21 e » 23 24 e-- Federal Reporters, Inc. 25 213 I will just go briefly through what the site visitors had to say. The main -- I will point out the main oroblems. And the main problems that they found in the site visit and that was really known before the site visit was made, was that the RAG, the Advisory Group of a health council, and that this advisory group consisted of about 156 people, and most of these people were in the priors class. And this was a purely untenable thing to have the -- this committee and council combined in this way so that the coordinator of the program really was not in a position to carry out the program in the way that was in keeping with the expectations of the regional medical program. Also the administrator, the coordinator of the program, was thought by everybody to be greatly overextended. And he, Dr. Culverson, was the only medical person in the program. And he did not have a good manager under him to carry out the administration of it, the administrative aspects of the program. So it was felt that because of the conditions existing in the regional advisory group and because of the lack of proper supportive staff, that the -- a developmental qrant could not he given. Now there was -- with some definite strengths noted at that time. These concerned the fact that the University of Tennessee had given the program the authority. While the #19 ] Reba 10 2 @ 3 sO ved © 11 @ 12 13 14 15 16 17 18 19 20 21 eo 8 » ¢ 19 24 e~ Federal Reporters, Inc. 25 ‘of the visit. Now with the suggestion that there be a complete 214 regional medical program grew under the guardianship of the university, it really changed, after the visit in 1969, and made it possible for the PAG to develop on its own. \ The excellent thing about the program seen in 1971 was the fact that five CHP, five agencies and probably five or six B agencies worked very closely with the RMP program. It was described as being a really excellent, because RMP provided staff to help the B agencies with their work, and also worked with them in planning and all kinds of outreach activities in the community. The staff really developed well. And in the community they were described as excellent brokers for the RMP program and also they were not just trying to sell programs but they were really architects, too, after they got over the operational] phase in the program. I said that the coordinator over extended himself but the people, the site visitors felt that the program had potential for being one of the best programs. And while they did not fund, I mean suggest a develop- mental component, they did grant triennial status as a result overhauling of the RAG and the administrative structure and that some effort be made to correct certain things. #20 arl 1 iW © 12 13 14 15 16 17 18 19 20 @ 99 ae 24 ce ~ Federal Reporters, Inc. 25 215 Now I have said before that this is a very difficult region to describe with so many people who are very poor. Black and white. But one of the things that was pointed out was that there were -- there was only one black person, female, on the staff. And also there was very little input, opportunity for input from the people being served. Now I will go right on quickly to say that for a year after this visit, after this 1971 visit -- and there's nobody from the advisory committee who made that visit, we did have members of the council who were on that visit, these recommendations were made, and I would think, I said I didn't make it, but I would think from reading the records that Dr. Culverson made every €fort to begin to do something toward correcting the things that have been pointed out. The -- there was a site visit made in the summer by staff to take a look at what the situation was at the present time. And I would like to say that Mrs.Kyttle knows this situation very well and can add to it after I have just said a few words. It seems now that the RAG has been reconstituted. I didn't tell you that that 156 member group has executive committee of about 45 members. And it was just absolutely impossible to get anything done that they didn't themselves want because they met every month, while the RAG met only once a year, I guess. Twice. Once or twice a year. ar2 10 1 @ 12 13 14 15 16 17 18 19 20 21 oe : Z 23 24 ce ~ Federal Reporters, Inc. 25 216 Now the situation has changed quite a bit. The RAG consists of 36 members. They are well chosen from the geographic areas. They are old and young, reflect the racial composition, and women, I think that there are nine blacks and six women on this new RAG. And it is a freestanding group, not encumbered by the old pattern. Dr. Culverson has moved immediately to see that guidelines have been developed, bylaws, that is, and also that three committees, policy -- the planning committee, and the policy and review committee, and also reference committees. Now, these reference committees are made up primarily of the people who had to do with categorical programs There has been also a change in focus. The program activity actually is looking at the underserved. In the subregional areas where, like in the crowded areas of Memphis and in the rural areas there is an attempt to extend services to the people through cardiac clinics. Also there is a very important high risk infant component which is regional. I think this is funded jointly with the other agencies, too, isn't it? Yes, it has just started. Also family planning services. It is hard in this brief time to tell you everything that's been done here. I think it is extremely significant that the regional program has applied staff to other agencies in order for them to get very much needed services in the . ar3 1 ©} 12 13 14 15 16 17 18 19 24 ce ~ Federal Reporters, Inc. 25 2i/ family planning area and also to do something about getting ambulatory services to these greatly deprived areas that they are working to develop Lee County cooperative clinic in Arkansas and so on. I said before that the University of Tennessee has been supportive, has helped in making decisions, but has not forced its own views. And I think that the management aspects of the program have not been reviewed yet. Right? . MRS. KYTTLE: That's correct. DR. ELLIS: But it is expected they will be. I mention this because the visitors in 1971 talked about the kinds of positions which should be filled and talked specifically to the point of not having the staff expenditures be -- grow any larger until some of the operational aspects could be shored up. I believe there was a recommendation that, by the staff, though, that because of the fact that the eoordinater is greatly overextended, that he be given an assistant administrat to look at the management affairs particularly. We have said there is no problem with assessing resources and so on. Now the evaluation component is not strong because of the fact that, well, they can't work too well because one of the weaknesses that still exists in the programs, there is not a clear statement of the objectives, goals and priorities. They have stated some broad goals, ar4 1H 13 14 15 16 17 18 19 20 24 ce ~Federal Reporters, Inc. 25 218 very broad, to make health care more accessible and to make it more available, and to compare the health costs, lower the health costs where possible in doing these two things. But there are no clearly stated objectives as to how broad goals can be accomplished; consequently it is hard to evaluate the program because most everything can fit into what has been stated as objectives. I think the staff, knowing the whole story, and unfortunately I have never been mto this section at all, I just know what people have told me about certain things, I feel that the direction in which this program is moving is very very excellent indeed. And the staff feels that the changes that had to be made as recommended by the site visitors in 1971 have been made in the main. Mrs. Kyttle is here, and I would like her to add a few things because she has visited the area twice rather recently, and has talked with the coordinator and the other people. DR. SCHMIDT: Okay, would you make any comment that you would? MRS. KYTTLE: Dr. Hess has to leave at fourish, so perhaps he would like to make his comments now. DR. SCHMIDT: Okay, Joe? DR. HESS: One certainly is at a disadvantage in trying to evaluate the region from what appears on paper alone. ar5 10 1 ©} 12 13 14 15 16 17 18 19 20 21 e 22 23 24 ce— Federal. Reporters, Inc. 25 219 And I must say when I first started going through this and looking carefully at what was there, the first question that came to my mind is how with all these problems with the RAG and what-not did this region ever achieve triennial status. And, but, however, in talking with Mrs. Kyttle, I gather that what is actually going on down there is probably much better than what was reflected in the paper and so that one has to somewhat separate the activities that are being carried out from the -- what you might call in a general way the organizational structures of the region. But I would like to point out a few things that are of some concern to me in looking at this total picture and trying to render a judgment concerning the funding request. One particular feature of this region we need to keep in mind is that it overlaps with three or four other RMPs in terms of geographical area and population, so that there is the potential for funding coming into certain areas from more than one source. The problems of coordination have been worked out fairly well and a couple of these others remain to be resolved. Tt is alluded to in the presentation, the RAG has recently been redefined from the original 150 some odd person group to 36 person group and the bylaws have been approved now. But a lot of the further reorganization in terms of factories, ar6 16 11 @ 12 13 14 15 16 17 18 19 20 21 ® | 22 23 24 se — Federal Reporters, Inc. 25 220 so on, remains to be done, and so that at this point it is unknown to us exactly how that is going to shape up. The new bylaws do spell out certain subcommittees, but there is a broad category of -- appointive committees which we have no information on what is going to happen there. So that the new RAG is one question mark. Another question that came to mind was the size of the staff and the way the staff is organized. In the submitted budget for this upcoming year, there is a place for 59 core staff situations, 54 of them full time, and there are 13 vacancies shown on the staff budget list. I haven't taken the time to go through and enumerate other core staffs, but this certainly seems to be close to a record for number of staff people in relationship to the size of the program and funding and so forth. So that is another question. And in looking at what one can tell from the internal organization of staff, the data that is in the application, I have some question about the tightness and adequacy of internal organization of staff. As mentioned, there aw goals and some related objectives, but the priorities are statements which, as one looks at them, may or may not be related to goals, exactly how they fit into their system of logic is not clear to me from the application. In summary, I perhaps would have to say that I 22ZL ar7 1] am taking on faith what I have learned from Mrs. Kyttle's 2 comments to me informally, that they are doing many good 3|| things. Some of these are enumerated in their progress report. 4|| But I do have some gestions about it, what is happening in 5 terms of the program management system, including the RAG 6|| and core staff. 7 The new projects which are proposed, there are two g|| o£ these which stand out in my mind as most consistent with oO some of the things stated in their goals and objectives. One is project 36, extension of services, neighbor- Q 1} | hood health centers,and the other, 42 -- © 12 13 14 15 16 17 18 19 20 2) @ 2? bn 23 24 ce ~ Federal Reporters, inc. 25 CR 7149 21 eak 1 YW 12 13 14 15 16 17 18 19 20 24 ce — Federal Reporters, inc. 25 222 DR. SCHMIDT: Let's continue on and get a data base, ask Mrs. Kyttle if there is anything she wants to say. MRS. KYTTLE: The Committee work -- DR. SCHMIDT: Could you put the mike right in front of you. MRS. KYTTLE: The Committee work and task force Meu Mervin: Somed TD It was done so recently that it could “ nor not get into this document. The staffing pattern is a proposed staffing pattern. It does not list vacancies. Those vacancies are new positions and that is what we intend to have.) There is only one vacancy in existing positions and that is the vacancy that Dr. McCall left quite a while ago and it has never been LSA AE filled and it(separately needs to be filled but to say that there are 56 positions in this regional medical program is not guite right. There are 44. One is vacant. I have attended the three meetings of the new RAG. It has kept me down there a lot but I thought if this is the new blood here, then that is where the action will be. It wasn't a redefinition of the regional advisory group. It was creating a new one and it did break off from its parent, which was the 14-county CHP'B", to the Memphis-Shelby area, mice fuse about everything. It was also regional medical programs. And It was not easy to get away from that parent and still have good parental ties. And Drs. Culbertson and Cannon have done it, and in my view done it very well. eak 2 iB © 12 13 14 15 16 17 18 19 20 21 @ 22 23 24 ce —Federat Reporters, Inc. 25 223 Dr. Johnson at UT was helpful in getting it done. The old regional advisory group was. representative of only those 14 counties, and that is what raised the legality of the regional, advisory group and that was the single factor that disqualified them for developmental component funding when they were placed on triennial status. The big funding issue or one of the big funding issu . WA hhw be LAE the I believe, is the @iiddle’ contract under core. And when staff met to try to identify issues, that was one that came up immediately. Essentially Memphis is pursuing two things, its own concept of area health education centers which it calls model learning centers which it thinks should be in the hospital and then development of the involvement from that rather than developing the consortium and including the hospital. They competed unsuccessfully for health services money last June. Then the second large component of it is, Memphis submitted AEMS application for supplemental funding, received one year planning funds to sharpen a data base which if Memphis has anything it has a sharp data base. Coming from MMCC, it has received as the collector of the data since 1966, so Memphis is writing back saying by January 1, which is their next year, we will have sharpened our data base and they are reapplying for the operational dollars the applied for before for emergency medical services and that ties into something I said before. Their task forces have been Y eak 3 i0 i @ 12 13 14 15 16 17 18 19 20 e oe 24 ce ~ Federal Reporters, Inc. 25 224 established and one of them is a task force for emergency medic services. And at a metting of the regional advisory council las week, I heard Dr. Cole who is the new RAG Chairman and Dr. Culbertson feeling this group out on beginning to think now abou priorities on funding levels that might not approach the 3.2 that they asked for. And where -- beginning to think now about where the emphasis would be. And I heard this regional advisory council say that if we have to make choices under that million dollar contract category, then the choice will he emergency medical services. The whole state of Tennessee, Dr. Turbshen and Dr. Culbertson have worked together quite sometime on the state — fof Tennessee's program. Dr. Culbertson has all buy revived the Mississippd Emergency Medical Plan: that was almost in disarray. No work yet is underway with the Arkansas Department of Transportation, hospital association, traditional linkages. But the State of Tennessee and State of Mississippi -- a scale of 1 to 5 are about 3 on emergency medical services and they are so deep into it that I don't know, it would be difficult to turn back. DR. SCHLERIS: A few questions. A few questions first then perhaps a comment. If I read this correctly, their RAG met once last year, is that correct? MRS. KYTTLE: That is traditional with the old MMCC m bY) aw 1b so a 11 © 12 13) 14 15 16 17 18 19 20 24 ce — Federal Reporters, Inc. 25 lfor the first time a regional advisory group three months ago. 225 which was their RAG at the time this application was prepared. That is the old RAG. DR. SCHLERIS: Right and emergency health services met accordingly at the time of the application, zero? MRS. KYTTLE: That is the emergency medical group out of the old RAG. That is MMCC. You are right. DR. SCHMIDT: Wait a minute. DR. SCHLERIS: I am trying to get an indication of activity. DR. SCHMIDT: Right but the RAG now, recently has met how many times, the new RAG. MRS. KYTTLE: The new council is three months old and it has met three times. DR. SCHMIDT: Right, okay, so that --~ DR. SCHLERIS: Well, this is important because I think in terms of developmental component and reaching deci- sions according to priority, according’ to what would be supported it is of interest to see what their past record is for the past — year and not just for the past three months. DR. KYTTLE: Dr. Schleris, it is not the same group. DR. SCHMIDT: Do you see they have constituted really DR. SCHLERIS: Well, you see my dilemma. I know this. I try to count the number too of RAG, and the old group, and it is their application we are looking at. And what you are ‘ eak 5 14 15 16 17 18 19 20 21 @ 09 23 24 :e-— Federal Reporters, Inc. 25 220 doing is supplying us with additional and very important new data. I appreciate it but at the same time, it is difficult to get an objective judgment on this. In other words, the new group which is how many now, 36, but the program here was put together by the old group, isn't that right and the report we are looking at in the application is from the old group, is that correct? MRS. KYTTLE: Dr. Schleris, you can appreciate that a regional advisory group of 151 members that had R&D's experimental contract, CHP and RMP, didn't give a lot of time and this was quite a bit of the Memphis regional medical programs application but it nevertheless had to go through a regional advisory group that had EMS committee that never met. DR. SCHLERIS: I am not trying to put a qualitative judgment on it. I am just trying to get an understanding from this document. Looking at some of the specific proposals, I will ask out of curiousity about the proposal to improve death statistics by teaching, individuals, examinations, post- mortem, where they don't have legal rights to do autopsy and so on. I wonder if you have any more information on what appears to be a’ very intriguing and difficult proposal, how that cleared RAG and what priority. Did you see that. It is. project number 33. MRS. KYTTLE: No, I am afraid -- I can tell you that it must have cleared RAG with a priority that was at least it) su y 3y Oo one a 1 @ 12 13 14 15 16 17 18 19 20 2) eo 2 z 23 24 ce ~ Federal Reporters, Inc. 25 227 in the first five because it was one that Memphis chose to drag up from an approved but unfunded when they were extended and had money to activate, they activated that one but the tech- nical aspects of it I don't know. DR. SCHLERIS: I don't know what communication you got as far as emergency medical services was concerned. They haveapplied for let's see, $1,100,000, were given $80,000 for the planning. It goes to more than just data base, I assure you. I don't know the details but, perhaps Dr. Rose does. This was one of the requests for iarger amount of funding. It was felt that they for many reasons weren't at that stage. It wasn't just getting numbers of cases. There was % |a lot of homework that had to be done. Can you comment on that, Dr. Rose? DR. ROSE: Yes, in fact a large part of the concern of the reviewers related to how this Memphis or suburban, if you will, EMS-type activity was going to relate to what else was going on in Arkansas and Mississippi and in the rest of that particular state. In speaking with Loraine subsequently on several occasions about that, I tend to believe that they really did have considerable more information than was included in the application which, of course, the reviewers had te act on. DR. SCHMIDT: Okay then. John? DR. KRALEWSKI: I am not sure we have a motion on the board here or not. eak 7 ce — Federal Reporters, sO 1d 1 12 13) 14 15 18 19 20 21 22 23 24 Inc. 25 16] 17| 228 DR. SCHMIDT: No, we are going to return to Dr. Ellis for proposal. DR. KRALEWSKI: Okay, I will hold up then. DR. ELLIS: The application which is before us requested roughly 3.267 for this year five. The staff reviewing this made the recommendation that the amount to be granted be 2.25, and that this would inlcude $162,700 for a developmental component. Also, in talking about the supplementa request that we have been talking about, staff suggested that. $237,000 be granted to support selected new activities, includin the expansion of component number 36. That is greatly strength- ening the neighborhood centers and giving them something in orde to really build the program and extend it. And then $225,000 to pursue selected activities under the contract request, this being primarily to be used for EMS. I would move that this, these recommendations be accepted. DR. SCHMIDT: Is there a second? DR. HILTON: Second. DR. SCHMIDT: All right. That is a second so the motion can be discussed. John and then Joe. DR. KRALEWSKI: I am inclined to believe that in viev of the organizational, some of the organizational concerns that have been expressed here even though they are changing, there is a new direction and I know you have new information = eak 8 1 © 12 13 14 15 16 17 18 19 21 20 21 e. 23 24 :e — Federal Reporters, Inc. 25 229 you really believe this organization is going to really do it. But we are giving them substantial developmental component plus a fair amount of contract money and that is placing a fair amount of bucks in their organization without many restrictions on it and that makes me a little bit nervous. DR. HESS: I would like to make a substitute r motion. DR. SCHMIDT: All right, before I accept that, I will let Dr. Ellis respond. DR. ELLIS: it is my understanding that the monies which they have now are very tightly budgeted and that there would be very little room for growth and expansion in these new directions. And so it seems that a developmental component of some magnitude might be very desirable in this instance. In order to give the new director, I mean he is not a new director but he is almost like a new director beca he does not have all of those 156 people and all of the problems with no committees or anything to work with him. That has been eliminated and I think he does need a chance to show how he can expand the program. ASE CR 7149 # 22 kar 1} 2 11 © 12 13 14 15 16 17 18 19 20 21 eo =x 23 24 e ~ Federal Reporters, Inc. 25 230 MRS. KYTTLE: Dr. Kralewski, the original structure complication arose not so much because it wasn't working, Memphi made it work, And it very quietly went about a very good program, It was the legality that raised the issue about the CHPB, MMCC, with a mandate to serve 14 counties being the decis] making body that was serving 75. I would not want you to think that it was a compli- cated, unworkable structure. It was a complicated, of doubtful legality, structure. DR, SCHLERIS: It only met once that year, didn't it’ MRS. KYTTLE: The full body traditionally met twice, that year it met once, The real decision making was in the board of trustees, 45 members, still’ serving 14 counties, DR. SCHMIDT: Let's see, do you have a comment -- in order here we have someone who wants to make a substitute motion. If you have a comment on what is being discussed now, please speak. DR. ELLIS: I do. I wouldn't think a program, regar less of legality, that only serves 14 communities when it is supposed to serve 75, is really functioning and functioning properly. And neither will I think that the guidelines, which they were using in terms of developing the new programs, were appropriate to get services to the underserved, which is part of the thing we are talking about. But I do think that this legality thing. was a point on kar 2] oO Q 1] © 12 13 14 15 16 17 18 20 21 eo z 23 24 7e~ Federal Reporters, Inc. 25 ‘this out of order legally? I know it was requested that he 19 231 and I wanted to ask the question, did the regional council rule give a ruling. MRS. KYTTLE: We thought we might work with’ the regid in obviating that necessity and they got a new council and so we didn't have to seek an opinion, 4 MISS KERR: I would like to make a comment, but I would be willing to wait until after the substitute motion and action is taken on that. DR. SCHMIDT: Joe, the floor is yours, DR. HESS: Perhaps somebody might just make some not¢ of this other paper there. I would like to suggest for program staff, eight hundred thousand. For contract, two hundred thousa and I am assuming here that some planning has gone on and that as far as this emergency medical service is concerned, I gather that that owuld be their priority use. It is somehow, some proven need in the community. That developmental component of a hundred thousand included, and projects of nine hundred thousand. To provide money to accompli n Ss nd sh Project No. 36, which I gather is a key project in their strategy, and through re-examining some of their currently funded projects that they should be able to find money to fund tne other project or two in their new list, which is compatible with the new directions in which they say they are going. That adds up to a round figure of two million dollars , S ° kar 31 sO © VW @ 12 13 14 15 16 17 18 19 20 21 @ 22. 23 24 ce ~Federa! Reporters, Inc. 25 232 DR. SCHMIDT: Is there a second for the substitute motion? MRS. FLOOD: “Second. DR. SCHMIDT: All right, Mrs. Flood's second. We are now discussing a two million dollar funding level. Miss Kerr? MISS KERR: While it is late, it is not so late and I am not so tired, but I feel I have to speak my piece, In view of decisions made earlier by comparison and in view of ingredien cf a viable potentially excitiny program, I cannot, in ali con-. sciousness, support either one of these recommendations at this point, DR. SCHMIDT: You say either one? MISS KERR: No, DR. SCHMIDT: Lorraine? MRS, KYTTLE: Miss Kerr, this is an anniversary withi a triennium and it comes to committee without any site visit report that would give you the flavor of some of the exciting things that this region is doing. But it is a quietly efficient region. It has some very exciting things ongoing and even though it is late, I don't know if you would have the time to hear about them, Can TI just tell you about one? Memphis has two multi-phase screening projects ongoin and they just didn't happen, One is a mobile, white northeaster ~ kar 41 14 15 16 17 18 19 20 21 @ 22 23 24 se ~ Federal Reporters, Inc. 25 233 Mississippi, two and a half years ago, MISS KERR: Was this thrust of RMPS? MRS. KYTTLE: Two and a half years ago it was started It is just widening up. The companion one with an intercity Memphis, predominantly black stationary multi-basic screening. In anticipation of this year, they will have completed the targeted screening, The multi-phasing screening activities acra the country have gotten together and they met here in Washington to develop a protocol to evaluate what we have done and nine were sélected, and both of Meimphis' were. Memphis! multi-phasic screening have screened more people than all the others combined. They are going to be a pivot for a contract to evaluate what we have done. And they have just gone about it very quietly. Inter-mountain is in there, Ohio vallies is in there and so is Memphis'. And I just -- if you would like to listen to some of the things that they have done like that, there is more excitement there, but this is not that kind of application. It is not a triennial. It doesn't have a site visit report and I think it is at a disadvantage here, DR. SCHMIDT: Mrs. Flood? MRS. FLOOD: Well, again, recognizing the disadvantad of trying to evaluate on paper, looking at the print-outs for the components sort of descriptor devisions that are provided in the print-out for the staff and of regional functions done ss kar 5 1 e~ Federal Reporters, so ant oO 1 12 14 15 16 17 18 19 20 21 22 23 24 Inc. 25 234 under’ the previous contractual fundings we have talked in the history of the region of the tremendous impact of the 21 and under, of the minority groups, yet if you study the print-outs, which is not a very good way to evaluate, but there is no emphas utilized from the central core staff activities to address these high priority needs of these particular types of populatid and as Dr. Schleris pointed out, our point of reference has to be the track record and, again, I will realize staff is ata disadvantage trying to present to us this changing flow, But I am not sure that we are adequate in giving them the requested funding and perhaps even at the level that Dr. Hess has propose DR. SCHMIDT: John? DR. KRALEWSKI: Would you refresh my memory again on the contracts, what do they hope to accomplish with that? MRS. KYTTLE: On page 19 of the document, I have written out the five categories of the million dollar contract. And the three large portions of it, one half of it is for emergency medical services and we have seen their application on that. And, here is emphasis, Mrs. Flood, Through the work of the staff, which surveyed emergency rooms, its needs, their uses, the population that they serve, the State of Tennessee in developing a statewide emergency plan zeroed in on the regional medical program as the lead role for the emergency, stemming directly from the staff work. is ns L. kar 6 | W © 12 13 14 15 16 17 18 19 20 eo x 24 e~ Federal Reporters, Inc. 25 235 DR, KRALEWSKI: Well, have they applied for emergency health service grant? MRS, KYTTLE: Right. DR. KRALEWSKI: And they have been partially funded? MRS. KYTTLE: Right. DR. KRALEWSKI : Why is that showing up as five hundré thousand dollar contract? MRS. KYTTLE: There is no mechanism for them to reapply for the operational dollars. DR. KRALEWSKI: Have they completed their pianning? MRS. KYTTLE: The region felt they had completed their planning before we told them to plan. Very strongly. DR. SCHLERIS: Is there anything to prevent their coming to RMP for emergency medical service plan in the future as part of their RMP program? MRS. KYTTLE: That is what they are doing. DR. SCHLERIS: But they are asking for a contract here to do it locally, isn't that right? MRS. KYTTLE: Yes. DR. SCHLERIS: Without there being any documentation of what it is they are actually planning to do, At least a part of their document is concerned. MRS. KYTTLE: They look activate the same plan they presented to us back in June. DR. SCHLERIS: I want to make one point clear; that kar 7 | 10 im © 12 13 14 15 16 17 18 19 20 21 © 22 23 24 e~- Federal Reporters, Inc. 25 236 is, there is a great deal of difference between putting somethin in writing and then verbal reports. This disturbs me a great deal, I know you are familiar with the area, but going through volume one and two, I don't come out with a great deal of in- formation about what it is that they are going to do with these funds and the Memphis application as it came in for emergency medical service didn't reflect all the planning that you indicat took place, and this is troublesome even to be told that well, they had already done all the planning.:: They. thought every bit had been done. It wasn't reflective of what they said. I do have considerable concern about the level of funding. I question whether emergency is the way to go as the first step. MRS, KYTTLE: It is a part of civil steps, That is RMP's role, RMP's role in this state consortium is the emergen room, DR. SCHLERIS: As I see it, if we aprove’ these: funds we are saying we think that contract is a great idea. I, for one -- if -you want me to have faith, believe me, on a Friday afternoon after two days, my faith increases more and more and more and I will become a believer if you like, but it takes an awful lot of conversation even this late in the day. MRS, KYTTLE: No, we didn't think it was worth five hundred thousand, that is why the staff recommended 225,000 for all contract work and they are going to have to make their Le kar 8 1 E # 22 @ — Federal Reporters, 11 12 13 14 15 16 17 18 19 20 24 Inc. 25 awe choice, And they have told us their choice is still EMS, DR. SCHMIDT: Okay. Where we are is with the substitute motion at the two million dollar level, #23 arl 1 so 10 1 © 12 13 14 15 16 17 18 19 20 2] oe =» 23 24 se ~ Federal Reporters, Inc. 25 238 Are there other points to be brought up? If not, then I will call the question. On the $2 million level with the breakdown of 900, 100, 200 and 800, as you see on the board -- DR. JAMES: I would like to make a comment, I believe. I think I am still hung up on -- and will be as long as I possibly will remain on this committee, in regard to geographical locations of RMPs, especially as they are related to populations. Like Mississippi. Like New Mexico. Like Memphis. And I think that we have heard that there -- in the Memphis area that there has been a restructuring of their administrative structure, which is too young yet, I think, to have a real impact in terms of what really are we going to do, because we just haven't had time, but I believe from the statistics and information we have received in terms of, again, going back to the neonatal infant mortality which is an indicator of the lack of health services in the area, and I don't think that that needs any further elaboration, I would feel that these are the areas that need the strongest support of staff continuing technical advice to the RMP, to stay on ton of the RMP to be sure that it is creating the kin of program that will benefit the people. And this is what I hear are services. | I am aware of some problems Memphis had not too pas ar2 VW @ 12 13 14 15 16 17 18 19 20 21 @ 22 23 24 ce ~Federat Reporters, Inc. 25 239 long ago in another area. I don't want to get anything confused, but I realize that this is an opportunity for RMP to begin to shore up some of those ends that were not covered in some other areas that have to do with the same kind of circumstances. I realize that I don't have as much information as even maybe some of the rest of you have, because you are famili with some of the programs that were going on prior. But just in terms of the situation and the effort that is being put forth and the direction, we may be at a disadvantage wnen we heard Memphis yesterday morning to start out with, we may be a little bit more, would have been a little bit more under- standing of the problem that exists there. But I think that I can only say that if we can go with Vermont and a 400,000 population, with the excess amounts of money that have been poured into that community and that state, then we can go with Memphis and help them to improve their services. DR. SCHMIDT: There are some issues raised there, Leonard. Do you want to comment? DR. SCHLERIS: Be outrageous to try to answer that, but perhaps I can try only in one way. This is not meant at all as a rebuttal because I share your concerns. Our problem, though, is I think a little different than looking at an area that has needs. I think it is a question also of looking ar ar3 10 11 @ 12 | 13 14 15 16 17 18 19 @ 29 24 se ~ Federal Reporters, Inc. 25 240 at whether the funds requested really go at those needs and whether they would be handled effectively. I think RMPS would fall flat on its face many more times than it already has if it were to say that because an area has desperate needs that therefore we should be uncritical in our judgment as far as these needs are concerned. My reason for referring to the fact that it is late in the day is that I think the group is getting more lenient late in the day and not harder late in the day. My concern about these funds relate to looking at the projects as submitted and some of these are frankly experimental. The one about more accurate death certificate, certification, I question many @pects of it. I wouid like to know more about it. It is essentially a research project. I am surprised it has cleared RAG. . The problem with multiphasing screening is of interest, too, because of certain RMPS statements on this sort. Included in this is a project on home care, which again many of these have been supported around the country, there are certain statistics on this. One ‘can go through the various projects and come away with a feeling that RAG has not set its priorities. I am a little unhappy about the response of the emergency medical services and how they are going about this, and it would be better if we had the full information, but again ar4 ~o =a a 1 © 12 . 13 14 15 16 17 18 19 @ 22 ba he 24 ce ~ Federal Reporters, Inc. 25 241 on faith the contract of 200,000 or part of it, even though there is need and heaven knows there is need all around the country for EMS, $200,000, I don't know how they are going to use it. We are being told we should depend on the group, but if you go about their decision-making capability reviews to what we have been told, RAG met once, the county three times, the EMS met zero, so I don't know what went into that formulation, so it isn't a question of feeling Memphis doesn't have need. It is a question of my inhibitien in terms of whether or not they are going about meeting these needs in the most effective way they can. I am just trying to equate it on that basis and I think $2 million as advised here is for what we have seen, I think, a very generous way of meeting it because they still have the developmental components. I, for one, will support the $2 million. I may have come up with a lower sum. If this fails, I might svill offer that as a suggestion. DR. SCHMIDT: I think unless there is something new to put before the group, we should call the question. John? DR. KRALEWSKI: I would like to offer an amendment to this alternate proposal here and that is that we strike the contract money, we keep that project money at the 900,000 that's being suggested, and we give them a full developmental ar5 10 i © 12 13 14 15 16 17 18 19 20 21 e@ 23 24 te —Federal Reporters, Inc. 25 242 component to the limit of what that would run wild be about there, essentially what they are asking, 162, maybe a little more than that as it would work out in the final budget, but then out of the contract they can rethink their whole plan of slipping into an emergency program here that might not have been outlined and still have some money under developmental for some discretionary kinds of activities. DR. SCHMIDT: Well, if I am with you, you'd give them the 800, program staff, and the 900 for projects, and that is 1 million 7. 19 percent of that is 170, and that would come down then to 1.87 million. That is an amendment to the substitute motion to the main motion. Is there a second? DR. SCHLERIS: I will second it. DR. SCHMIDT: All right, it is seconded, so now we are down to discussion of the amendment to the substitute motion. Anything not germane to that is out of order. MRS. KYTTLE: I think some of the flavor of the amendment came from comments by Dr. Schleris and we have got to do something about these printouts that led you to think that this home health care is less than winding up. It was something that was started two and a half years ago. The multiphasic screening projects were started two and a half year ago, and if you are going to look at these printouts and not equate proper time with them to realize that that is the part ar6 sO wat co YW e 12 14 15 16 17 18 19 e 2 24 ce ~Federat Reporters, Inc. 25 243 of this program,that that is the part of this program that is phasing out, then they are misleading. I have heard this group several times today get hung up on that. That's the phasing out program. The high risk infant. The expansion of the home health center. The satellite clinics. That is the new part of this program that is building up and the part that disturbed you is the part that was started two and a half years ago. DR. SCHMIDT: The current level there is at 1.627. What is being recommended now is 1.87, which is not too much of an increase. I think we will test the sentiment then by vote on the amendment to the substitute which is 1.87, with a 170,000 developmental and no contract. All in favor of this, please say aye. And opposed, no. All right, the "noes" have it, and the amendment is defeated. We are back to the 2 million level, and T will call the question on that. All in favor, please say aye. Opposed, no. I will have to ask for a show of hands. Please raise your hand. I have four ayes. Noes? Four. ar7 14 15 16 17 18 19 20 21 @ 22 23 24 ce — Federal Reporters, Inc. 25 244 The chairman will vote to break the tie. And vote aye. So that the substituted motion has it. Before we adjourn, I would like to ask the one question. At the request of staff, we did prepare -- DR. JAMES: Excuse me, sir, I didn't quite under- stand that. You said the substitute motion passes? You voted aye for which motion? DR. SCHMIDT: The substitute motion. DR. SCHLERIS: $2 million. DR. SCHMIDT: 2 million level; which is 800, 200, 100, 900. DR. JAMES: Thank you. DR.: SCHMIDY: is there a question about procedure? DR. JAMES: No. MRS. KYTTLE: I am sorry, which one? The 2 million? Okay. | DR. SCHMIDT: It is approved at a 2 million level. DR. JAMES: Yes. Okay. DR. SCHMIDT: Staff has requested that I request the committee recommendations remaining, if there are any comments about this chapter four that I asked you to look at last night. It has to do with the functions of review committee and council and so on. This will go to council. For their essential, essentially their approval. I am asking if there are any substantive queries or comments on that at ar8 10 @ 42 Ag 14 15 16 17 | 18 e23 19 20 ® =: 24 ce — Federal Reporters, Inc. 25 245 this time? . - MR. HILTON: I would say only that I would have appreciated having that document of that upon joining the committee. I have since that time just about: figured it out, but it was an awful loss in productivity while I figured it. So I am very glad to see that this will be available to the future members who join the committee. DR. SCHMIDT: I will strongly urge that a letter be sent to review committee members asking for specific comments prior to this going to council. I will express my personal appreciation to a most -- somebody turn off their mike. -- To a most hardworking and understanding committee, particularly for understanding and tolerance exhibited to the chairman. Thank you. Be sure to pull out your rating sheet and have that available for staff pickup. Thank you. (Whereupon, at 4:40 p.m., the hearing was adjourned.)