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Transcript of Proceedings

DEPARTMENT OF HEALTH, EDUCATION, AND WELFARE

HEALTH SERVICES AND RENTAL HEALTH ADMINISTRATION

REGIONAL MEDICAL PROGRAMS SERVICES

 

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Vary land
7 TP ee a Ov %
19 ganuary L973

ACE - FEDERAL REPORTERS, INC.
Official Reporters
415 Second Street, N.E.
Washington, D. C. 20002 ious 200) 547-8020

NATIONWIDE COVERAGE

 

 

 

 
Craft/Renzi|| — DEPARTHENT OF HEALTH, EDUCATION, AND WELFARE
© 8131 2 HEALTH SERVICES AND MENTAL HEALTH ‘ADMINISTRATION
3 REGIONAL MEDICAL PROGRAMS SERVICE

4 —-_— = =

5 . Review Committee

Conference Room GH

10 Parklawn Building
Rockville, Maryland

11 Wednesday, January 17, 1973
12 The meeting convened at 8:40 o'clock a.m., Dr.

@ 13], Alexander Schmidt, Chairman, presiding.
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CONTENTS

— ee ee ee ee

 

We lcome » e e e e e e * ° es e e e * e e es . e e e e e e e

Future Meeting Dates e« e e ° . s .o e# @ ° o 8 eo e # @ e e. «¢

Report on the Regional Medical Service Programs - Dr.

Margulies . . 2. 6 2 6 © © © © © © © we oe ew © ww ow

Dr ° Pahl eo ef ee © © © © © © © © © @© © © © © © © 8 8 ©

Program Reports on Activities supported through supple-
mentary funding: . .

Health Services and Educational Activities -
pr . Conlsy e ° * eo . e * e e e e . s e e

Emergency Medical Services ~ Dr. Ros@ .... .-

PSRO, TT.R. 1 - Dr. Margulies o © @¢ © e¢ # # # @

Verification Visits to Regions - Mr. Chambliss
Review of Applications:

Washington/Alaska . . 1. 6 6 ee ee ee ee eee
Louisiana a
Connecticut . 2. 6 6 6 ee ee eh ew ee ee ee
Metro D. Cw. 2 2 © © © © © © ee ee we ee ee

North Dakota s e s . e ° , e e « e e ° * . » e e * e

 

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1 | PROCEEDINGS
© 2 DR. SCHMIDT: I have been waiting for some juice to
3 get. through the PA system here, and we are still having a
_ 4] little technologic difficulty. But I think that we can get
5 through, at. least my part of the meeting, without the benefit
6] of the PA system. Years of lecturing in large lecture halls
7|| which also have preblems with PA systems have led me to
8|| develop a penetrating voice that I hope carries to the back of
9}| the room.
10 So I will call the meeting to order and welcome every;
11] one here, this first meeting welcoming the members of the

1211 committee and staff and also at. this meeting any public members
© 13]| who might be here. This meeting as you all probably know, is

14]| the first one that is being conducted in accordance with the
15|| Federal Advisory Committee Act, P.L. 92-463.
16 And all committee members have with your agenda
17 materials the rules for conduct of RMPS public advisory group
18]| meetings. And there is no particular need to look at. this now,
19) but it is kind of interesting and gives some ground rules for
20|| the conduct of these meetings and the participation of the

21|| public guests who may choose to join us during the open portion

C) 22\| of the meeting.
23 I would direct your attention to at. least one guest.
@ 24\| that I know of. Dr. Al Florin is here representing Dr. Ingles
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25\| and the steering committee of the coordinators. Later on today,

 
] Dr. Phil White will join us, an old committee member, to cover
© 2l| one of the applications.

3 We have found it necessary because of a conflict with
4]| another meeting that is scheduled to look at change of date
5|| for the May meeting. And we need to pick days ‘during the week
6] of May 7 to 11. Those of you who bring your calendars may want
7\| to check that. out and pick days of the week for this. Wednesday
8|| and Thursday would be the 9th and 10th. As I recall previous
-9!/ discussions, the committee is kind of settled on Wednesday and

10|| Thursday as being good days which would make it the 9th and

11] 10th.
. we Are there objections to those days? »
©} 131l-. (No responss.)
Ale. 8 If not, then we will settle on those.
15 The other days are September 12 and 13 in 1973,

16] January 16 and 17 in 1974, and Hay 15 and 16 in 1974. We hope
17|| that is not anticipating anything too much.

18 ‘I have a letter to the Regional Medical Programs

19] Review Committee that was given to me a minute ago by Dr.

20] Margulies from Vern Wilson, And I would like to read that

9)|| letter to the commnittsa. It says:

‘Se 22 “Ladies and gentlemen:
23 "By the time this reaches you, I will have already
@ 94|| left the position of Administrator of the Health Services and
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25|| ental Health Administration to return to the University of

 

 
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Missouri. I feel I would be remiss if I did not express my
sincere sense of gratitude for the considerable advice and
counsel you have provided to me and to HSMHA during my
incumbency.

“Please accept my thanks and most. sincere wishes for
the successful pursuit of your personal goals. I hope we will
meet many times in the future in our joint efforts to improve
health care for the people of our country.

"Best personal regards, Vernon Wilson."

Some people have asked me what Vern was going to do
in Missouri and particularly was he returning to his academic
vice presidency. And the answer to that is he is going back as
a tenured professor and will be teaching and in activities
having to do with community medicine and perhaps his discipline.
I am sure that the opportunities for Vern will be many, and hs
will be able to select among many excellent opportunities to do
what h2 wishes. But he won't be going back as the academic
vice president.

where is a reorganization of the Medical Administratior
in Missouri as many of you know. And they will be choosing some
vice provosts and so on. And how that. will settle out no one

knows.

But it is appropriate, then, to lead froma note from

wee

Vern Wilson to Dr. Margulies and the third agenda item, the

report. from Dr. Margulies and the Regional Medical Programs

 
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Service. So I will turn the microphone over to Harold.
DR. MARGULIES: Thank you, Mac.
The Review Committee may feel a little more prestigicu

than usual for the moment. If you have read what has been

happening since the election, there is virtually nobody left

between you and the President of the United States in HEW.

So you are very close to the seat of power.

We tried to arrange the meeting to be at Camp David
but the roads were bad and the helicopters weren't. flying.

I have a few announcements to make to you which have
to do with specific situations within the REgional Medical
Programs and would like to go through a number of other
information items before we get to the reviews themselves.
Some of them have to do with changes in leadership in Regional

ilgdical Programs which are very key events as you all know
from having reviewed RMPs.

There are three Regional Medical Programs.which
you knew were seeking new coordinators and which have in fact.
selected and officially appointed new coordinators. One of
them is Albany where Frank Woolssy has resigned and has been
réplaced by Dr. Girard Craft. who has been with that program for
some time and is fully familiar with the activities and
purposes of it. Frank resigned with a very positive feeling
that he had bsen able to do a good many things that he would

like to gat done and with the strong feeling that. it was time

 

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1 for him to take it a little easier and have a different kind
© 21 of leadership. And it looked very positive.

. 3 | As you may recall, in Iowa, there was also a search
Al for a new coordinator because the one who had been there had
5 teft so that he could move with his family to Florida. The

6] new coordinator there is Charles Caldwell who again is an

7\| individual who has proved his value as a member of the staff

a

8l| and is a very capable individual. He was acting from the time

9 that Dr. Weinberger left and has become coordinator since
10] October.
W . And in Oklahoma where Dale Groom retired around
12|| September of 1972 of the past year, a new coordinator has been
© 1311 sslected. what is Al Donnell, peo-n-n-8-1-1, He is a lifstime
141 oklahoman as I recall and has been very active in the general
15 hospital field and is keenly interested in the whole concept. of
16] regionalization, has worked with the RMP and appears to be a
17|| very attractive choice.
18 There have also bsen some resignations since we were
19 last. here, Ana I will just go through those quickly.
2011 Dr. Wentz from Metro D.C. has resigned, and there is
21|| a search for a new coordinator.
C) 22 Dr. Jay Brightman in New York Metro RMP has resigned,
23 and Dr. Aronson is acting. And there is a search for a new

@ 24|| coordinator.
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25 pr. John Lowe in South Dakota left. in October. And

 

 
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Donald Brekkee is acting there. And they are searching for a
new coordinator.

And we just received that Dr. Henry Clark is
resigning as of Hay 1 from the Connecticut RMP. I talked
yesterday with Mr. Rogers who for a good many y2ars was

chairman of the Regional Advisory Group in Connecticut. He

described the way in which they are setting up a search committ,

We were especially interested there because there has been a
kind of uneasiness in the Connecticut RUMP between themselves
and the State Medical Society or at least some members of the
Exacutive Committes of the State Society.

They appear to have good accord in the method of
search for a new coordinator. And the president. of the
State Medical Society is on the search committee.

There aré some ragions which have not yet. made a
final selection of new coordinators where there is an acting
arrangement. Indiana is one where Dr. Beering is acting.

He is Associate Dean, as I recall.

In Intermountain, Richard Haglund who for years has
been on the staff has been acting coordinator for quite sone
tine since Dr. Sadavik resigned. And they are still trying
to find a new coordinator. I will get back to that. in a moment
because there are sone issuss there.

In Western vennsylvania, br. Reed had agreed to

stay on for one year. That year will be ending in the near

 

a
1 future. There is a search committee for a replacement for him,
© 2 In the case of western Pennsylvania, you will recall that the
31 coordinator had resigned to seek another academic position
41 so that that one has been open for a period of time.
5 One other change which is of some interest is in
6l| pexas where a new grantee has been arranged for. This was done
7\| with mutual understanding on the part of the university, the
81 state Medical Society, the Regional Advisory Group. It appeared
9, that the involvement of the medical school could remain very
10} full with a grantee which was a nonprofit organizational
im structure and was actually done under the aegis of the
a 12|| university and with their strong support. That began on
© | 13], January 1 and appears to be a satisfactory activity. And there
14) will probably be something similar which will evolve from the
15] Metro New York RMP although that is not yet official.
16 You may also recall that we did distribute during the
17]| past several months a very explicit policy statement regarding
18] the relationships between the grantee, the Regional Advisory
19], Group, and coordinator and his staff. This is something which
20|| had long besn asked for. There had bsen uncertainty in many
21l| instances about what that relationship should be.
CO 22 We have had discussions here. We had extensive
23|| discussions with the Council. It finally did receive endorsemen

snes

@ 24|| and was distributed. With one exception, it has been greeted
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adjustment in the organization of Regional Medical Programs.
Most people felt that it was overdue, that. the statement was
clear cut and did not represent an unsatisfactory way of
conducting the business of a Regional Medical Program.

The exception most notoriously is in the Intermountain
Regional Medical Program where the administration of the
university feels considerable discomfort with the idea of a
Regional Advisory Group making decisicns which they feel sheuld
be made exclusively by the grantee. That issue remains unresoly
And as r hinted a moment ago, it is probably one of the reasons
why there has been some delay in the final selection of a new
cocrdinator. I really don't know what decision they are going
to make in Intermountain about adjusting to that policy or

selecting a new grantee, whatever may be the situation.

But aside from that. and some restlessness at least
in Tennessee mid-South, we have had no real difficulties with
that statement. And for the most part, the response has been
a very positive one.

I think that it would be fair to say in Dr. Florin's
name that New Jersey is making some changes in its organiza-
tional structure to accommodate it, but it doesn't appear to be
too much of a problem. In that case, as was rarely the
situation, the Regional Advisory Group and the grantee were

essentially the same, And this requires some new organizational

 

structure to continue doing business, but to be consistent. with
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HEW policy.

Now, let me get on the subject of the budget for a
moment because there may be some casual interest in the subject
We continue to be operating under a continuing resolution
which for those who have not fully enjoyed that. kind of an
arrangement, I will provide an explanation.

When there has not been an Appropriation Act passed

Congress may pass a continuing resolution which allows the

program affected -- in this case, those in HEW for which
appropriations have not been made available --. to continue to
operate on the basis cf one of two alternatives -- either the

-lavel of budgetary allowance of the preceding fiscal year cr

the budget which was proposed by the President to Congress for
the current year, whichever is lower.

Now, there was no gress difference between 1972 and
the proposed budget for 1973. So we have been operating at
essentially the same level of activity during that. period of
two years. There were two Appropriation Acts passed by.
Congress, and they were both vetoed. Congress is now in
session and, of course, can pass another Appropriation Act.,-
can continue under the continuing resolution, and can do the
latter for an indefinite period of time. And we don't know
what they are going to do.

During the period of time when we are on a continuing

resolution, we continue to act according to those kinds of

 
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rules. However, when it is as late in the year as it is at
© . 2 the present time, it requires a certain amount of fiscal

3 prudence on our part and on the part of OMB. And so the one
41 accommodation we have made until the budget for this fiscal
5 year which is now more than half over has been determined is
61 to limit the duration of grant support for programs which

7 began January 1 -- not the amount, not the level, but. the

8! auration of support.

9 , We could not for programs which had their beginning
10], aate of January 1 provide funds for the full 12 months. So
1) what we were allowed to do was release grant funds at the

12) devel anticipated for the full year, but. only for the first.
© 1311 6 months until there is an appropriation and a final decision

141 on fiscal 1973 and some action on fiscal 1974,

15 Now, I suspect. that what. will happen, and it is
16]| really more than a suspicion -- it is based upon what informa-
17] tion I have received -- is that when the President does

18] present his budget message which is scheduled for January 29,

19} at will include some recommendations for fiscal 1973. These

20 will not necessarily be the same as those that were proposed

; 211 by the Administration at the beginning of the fiscal year, but

oi 22|| will be adjusted to the fact that we are well into this fiscal

23|| year and will reflect. whatever kinds of recommendations are
@ 24]| made for the subsequeéat. fiscal year, I think it is fairly

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to remain reasonably consistent.

Congress will, of course, receive that information
and act according to the way in wnich Congress feels that. it
should. It has the choice of passing an Appropriation Act
at any time, of course. It could do so today if it wished to
do so or wait. for the budget message or act on the same day.
and there is no way of predicting what will actually be done.

So we are really no clearer in our understanding
of what our level of support will be now than we have been in
the past. That means, although I am getting into the issue
of review now which is a closed part of the meeting -- I may as
well comment on it -- that we will continue, I hope, to do
what we have in past years. And that is carry out a review
process in which we lock at. what has been proposed by a
Regional Medical Program, examins the application and draw a
judgment based upon the merits of that. application and not try
to figure out what the budget is going to be when we don't know
what it. is going to be. That is an issue which is separate
from the review of programs based upon their individual
merit. And this Review Committee has been able to do that.
quite effectively in the past, and I am sure they can in the
future.

Are there any questions about that illuminating
statement? a

(No response.)

 
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I would like to mention to you that the steering
committes of the REgional Medical Programs will be meeting
in January, and there will also be a general meeting of all of
the cocrdinators. And I would like to take a moment if I may
to refer to the activities of the coordinator steering committe,
so that you can appreciate what kind of an assistance they have
been,

During the past several years, the coordinators
have felt that. they can establish a more effective working
relationship with the Regional Medical Program Service if
they have selected representatives who meet together as a
steering committee to bring to us information which they feel
is not readily available to us and which represents a consensus
of coordinators’ concerns, and to receive from us information
which can be distributed rapidly to the coordinators.

Now, the coordinator groups within themselves are
organized on a sectional basis. And so they meet Northeast,
Southeast, West, Mid-continent, and so forth. They meet at
regular intervals arcund-the meetings of the steering committees
and around their own kind of business. When the steering
committees meats in January, it will take advantage of the fact
that there is to be a conference on quality assurance. It. will
also be an cpportunity for all of the coordinators to meet. to

elect new officers and to consider any business they want to

consider.

 
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VW That particular meeting is not one which is called
© 2], by the Regional Medical Programs Service. That is, the meeting
3|| of the coordinators is not. They call that to conduct their
4) own business, to examine their own affairs, and do what they
5|| think they need to do. If they want to invite us to be present,
6|| we are present. If they have some other business to conduct,
7|| then we are not present, And it. seems to be a very effective
8|| kind of arrangement. -
9 . The meeting which then follows for the next two days
101 on the examination of the professional issues involved and
11i} quality assessment and assurance is an invitational meating
12 and is an official part of Regional Medical Programs Service
© 13 activities. That. mesting which is to be held in St. Louis

14|| looks awfully good. We have been working on it. modestly begin-
15|| ning a little over a year ago and with an increased tempo
14 during the past several months. We made several decisions
17|| about it early on which we have stuck with and which have
18], appeared to be a pretty good idsa.
19 The basic one is that the mesting is to provide an
20|| opportunity for Regional Medical Program coordinators and for

91|| others who are interested to examine in a professional way the

22|| major issues which are involved with quality assessment and
Me .

23|| assurance. There is no effort involved in this activity.
@ 94) The quality assurances conference is not designed to examins
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1 special kinds of activities. And it is very scrupulous in
© 2|| its approach. It is entirely designed around our understanding
3 that there has been a whale of a lot of work going on for the
a 44 last several years to look at all of the aspects of quality

5]| assessment and assurance,
6 There are some very competent. people who we would
7i| like to hear from. And that is exactly the way it is designed.
gil put in order to make sure that what appears to be unusually
9] good input will be rapidly available, we have done two things.
10 One of them is to limit attendance and make the
11} meeting pretty much theater kind of performance with the rapid

12|| presentation of cogent papers grouped together under general

 

@ 13]} subjects, a very limited time for discussion, with a clear-
14|| cut understanding that there will be rapid distribution of

15 printed copies of the papers which are presented.

16 Now, there will be approximately 28 people who will

17|| have something to say in a formal way. We have plans to

18|| bind and distribute the papers within no longer. than about 30

19 days after the meeting. _We have already recsived something

20|| like 20 completed papers which is remarkable in itself. And
91|| I think that we will probably get, if not all, virtually all,

() 22|| of the papers completed, ready for binding and for distribution
23 by the time the meeting occurs, That means that we can

@ 24|| achieve our major purposes which is to have a discussion of a
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Because of the quality of the conference, we are
going to print an extraordinarily large number of volumes of
the quality conference material and give them very wide
distribution. This allows us to feel more comfortable with the
limited attendance. If wa had opened the attendance even by
word of mouth, the number of people we would have to accommodat¢
is staggering. We learned that within a few days. And since
there was no way to compromise on that, we decided to make it.
a Regional Medical Program activity and restrict it accordingly.

We do know that. some members of this committes are |

planning to attend. At the present time, we understand that

this will include Ancrum, Anderson, Ellis, Kerr, James, and

Thurman.

There is an agenda which is in your book which is
Attachment. B.

Now, one final thing that I would like to mention
to you -- well, there are two or three things which we should
mention in passing -- just to make sure that you do get all the
news about. what has been happening within our structure. I
think you all know that Dr. DuVal has resigned as Assistant
Secretary for Health. You do know that Dr. Wilson has left
as the Administrator of HSMHA, that Dr. Marston has left as
the Director of the National Institutes of Health -- has not

left, but has resigned as the Director of the National

 

Institutes of Health. At the present time, the Acting
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Administrator -- and it. is clearly on an interim basis --
for Health Services and Mental Health Administration is Dr.

David Sencer who is the head of the Center for Disease

Control in Atlanta. That is a program director within HSMHA.

This is an arrangement until a new Administrator has been
selected.

Dr. Stone who is acting as Deputy has also taken over
the role of Acting in the position which Jerry Riso was serving
as the Deputy Administrator for the development group. And
that also is obviously an interim arrangement until the new
positions have been filled.

I think that there is just one other thing which I
would like to comment on and then perhaps, Herb, you might want
to pick ip on any other items that we need to present for
information purposes.

As a reminder, the REgional Medical Program legisla~
tion has to be extended in whatever form it will be extended

within the current fiscal year. It is one of several programs,

one of an extraordinarily large number of programs, which will

terminate June 30 without new legislation. There have been

a number of activities around the country in preparation for
new legislation... What the form of that legislation will be,
whether it will modify the directions of RMP, whether it will
address other pregrans in conjunction with RAP, is a matter of

speculation. It appears likely, however, that there will be a

 
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1] good many suggestions, and I know some testimony to Congress,
© 21) proposing more specific kind of language to describe the mission
. 3]| of Regional Medical Programs and probably increased attention,
4) whether it is in the form of Congressional language or in

5!| legislation, to the relationship between Regional Medical

6 Programs and other Federal health activities, most specifically
7\|| Comprehensive Health Planning. The relationship between the

8i| two, the definition of the two, has continued to disturb people
9|| since the legislation was first passed. And despite some

10] strenuous efforts to reach some clarification, it continuss to

11]) be confusing.

12}. So that we may see anything from language of clarifi-

 

© 13]| cation to some modification to some restriction or some new
14 direction, I am not sure what. But I think you will all be
15 interested in following the progress. And in this particular
16) cas2, I think that.if you want to take the time, and it is

17 easier to do it as it goes on, some of the congressional

18], discussion may be of more value in some ways than the final
19], form of the legislation because it is extremely difficult. to
20 write legislation which is as explicit as congressional

9}|| understanding would have it be. ‘This begins to bind the

7 22|| legislation so that it is not mansuverable. And I believe you

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23\| will be interested in following that kind of an activity.
@ 24 I do not. knew what the schedule is for congressional
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Are there any questions on these issues?

(No response.)

Let me just get on two other subjects which are more
specific and have to do with professional activities with which
we are concerned. Both of these, we have discussed in the
past and they have to do with the development of stronger
working relationships and a more effective programmatic link
for both cancer and heart disease;

As you know, during the past year, there was an
incrsased amount of emphasis put on cancer in the National
Cancer Instituts, haart disease in the National Heart and
Lung Institute, with some reorganization, with the proposal for
gr2ater support, greater financial support, for both of these
areas of activity. We have had, therefore, during the past
year a number of activities which have looked toward an
identification of the ways in which those Institutes and the
Regional Medical Programs can work effectively together.

As I have said to you in the past, what we would

Like to see is a definition which is evolving of the roles

cf the Institutes and of the Regional Medical Programs which

I think from our point of view are fairly evident. It is

clear that the NIH is a source of research, biological research,
as RMP is not. It is also clear that the National Institutes

are in a good position to identify maior disease activities,

 

major kinds of approaches to disease control, which they are
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interested in seeing developed or which they think are ready
for devalopment and for which they can turn to the Regional
Medical Programs for rapid expansion and for extension into the
health care delivery system, This, in fact, is totally consist¢4
with the original concept of Regional Medical Programs which
was to do exactly that kind of thing.

Now that the RMPs ere nationwide and are dealing in
a kind of a network of activities within their regions and
across the country, the possibilities of doing this have been
increesed. One of the better examples cf what has already been
selected as a major target, I am sure you know, is the
secretarially sponsored program to establish a national
hypertension control activity. During the last two days, on
Monday and Tuesday of this week, there was another national
ageting to address this problem.

‘It is the general understanding of the people who
have been involved that hypartsnsion is a dissase of great
prominence, that.it is probably afflicting some 23 million
people in the United States. Of that total number, a relatively
small number, perhaps not mors than one in eight, is diagnosed
and under effective treatment.

It is also believed by those who have been working
most fully in the field that the methods of management by

drug therapy are at a point of great enough effectiveness so

in

 

that a nationally designed -- nationally in the sense that it.
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covers the nation but is regional and local in effect --
program is perfectly possible developed around the concept. of
screening, of referral, of drug therapy, and of maintenance,
understanding that this will require networks which will utiliz:
physicians not exclusively, but rather for general guidance,
and a good many other people for screening, maintenance, and
for control. _—

The energy behind this is very great. In the
meeting in the last two days, there were assembled people fron
many, many sources -- from medical societies, from voluntary

health agencies, from industry, from labor, the pharmaceutical

‘industry. The persons who were presented represented the

views of the Secretary himself, speaking for himself, the
current Secretary, Mr. Richardson -- and he gave us assurance
that Mr. Weinberger had already accepted the importance of this
as something he would continue -- the Commissioner of the FDA,
NIH, HSHHA, all were fully committed to this activity. And we

anticipates that.it will be a major part of RMP activities in

the future as well.

In fact, it was sort of heartwarming to me, excepting
for oné minor problem that they never mentioned, that a good
bit of what was represented as examples of how to control
hypertension was RMP supported. I was sitting in the front.

row listening to-one example after another of the way it had

 

been done. And I never heard the words "Regional Medical
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Program" com2 out of it. Well, we are sort of used to that.
anonymity, but it happened to be a season in which I could
have selected a little different way of describing our work.

Jerry Stamler presented a magnificent summary of
current knowledge on the subject of hypertension, diagnosis
and treatment. And I would say that 8 out of 10 of the
examples that he chose of ways in which the disease could be
managed were based on something which had been sponsored by
Regional Medical Programs.

So it will not be a new undertaking, but it will
certainly represent a channeling of energy which I think would
be very exciting. It is one of those kinds of things which
can be achieved in a relatively short period of time which I
am sure you will hear a great deal more about.

Now, in the field of cancer, it will require further
definition than wa have had at the present time. But. we are
lcoking to those Institutes -- NHLI and the National Cancer

Institute -- to give us a definition of those directions in

which they would wish to-go. We will need to work out more

clearly the arrangements for staffing activities, for funding
activities, and so on. But I think that we are now ina
position to serve the public interest and to take advantage of
a momentum which has been regenerated rather than newly

generated.

Do you have anything?

 
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DR. PAHL: Just one thing, perhaps. We have been
talking somewhat seriously, and I would like to just share a
personal cbservation with you and then make one point. of
information.

In recent days, it has become very important to me
to go back to President Truman's observation as to when the
presidency fell into his hands. and I just want to share with
you that Dr. Margulies didn't take full vacation time last.
summer and so some time back decided that over the holidays,
he would take a few days leave. And it was my good fortune
perhaps to have on the very first day that he was not in charge
of cur pregram and therefore I was completely in charge the
Washington Post indicate just how important it is to have our
Director here full time. And I believe that from now on, I
would prefer if you didn't take leave, at least, and notify
everybody. |

The only point of information I would want to share
with you is that in a continuing effort to improve the
management of our program, we have indicated to you that over
many, many months a policy manual has been under development
so there will be a single reference point for both our own
staff and all of the staffs of the regions when it comes to
what. our policies are relative to the governing of the program.
And that policy manual through the cooperative efforts of

many, many of our staff has now been developed. And we have

 
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even managed to clear it through all the official channels

so that we are in a position probably immediately after the
St. Louis meeting to mail it to the regions where we will be
asking the staffs to comment on the content and then following
a consideration of those comments, we will revise it and send
it out in completed form. So I believe that we are trying to
pursue what we believe to be improved management practices.
And this, I think, is a very major step forward and is, I
believe, so recognized by the regions.

And I want to take this somewhat public opportunity
to again thank our own staff for really the many months of
effort and intensive effort in recent weeks to get it to this
particular point.

DR. SCHMIDT: All right, thank you very much.

Dr. Ellis.

DR. ELLIS: May I ask a question of Dr. Margulies,
please, Mr. Chairman?

Dr. Margulies, we are hearing quite a bit. about
specialized revenue sharing for health, And I was just wonder-
ing that in the event that a decision is made to fake bloc
grants to the states for health, do you see that this in any
way would affect the way the Regional Medical Programs would
cp2rats or the legislation? I ask this because it is necessary

to know in talking to so many people exactly how to comment.

on this to the best advantage.

 
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DR. MARGULIES: As I said the last time that question
came up, that is a very good question. However, I will bea

little more helpful this time. That is all I said last.

‘time.

I think there is no question about the interest in
the Administration in promoting the concept of State revenue
sharing. That has been the President's position. It was
initiated during the last session of Congress.

There also has been an interest in what is probably
incorrectly called revenue sharing in health. It really is a
matter of grant consolidation with State management of the way
in which the funds are being used, with greater latitude on
the part of the State than they have under present categorical
circumstances.

I think there is no question also that that kind of
arrangement is one which could be proposed only by the
Administration, but which would either be accepted or rejected
by Congress. And I think there is some likelihood a an .

increased effort in that direction will be mounted by the

Administration. But I think it would be rather useless

speculation to try to answer the question beyond saying that
there will really be two issues.
One of them is whether that kind of an approach to

the support of health activities is acceptable to Congress.

And that would be debated, I am sure, very vigorously by

 
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Congress.

and, secondly, whether if that did pass, it would
include Regional Medical Programs.

Now, if one were to include RMP in a kind of bloc
grant arrangement with the determination of support to be made
at the State level, it would obviously mean a different.
Regional Medical Program. About that, there is no question.
But at the present time, I have seen oo legislation introduced
which describes that kind of an activity.

I am-not in any doubt that it probably will be. But
until something of that kind does get introduced, until there
is debate, until there is decision about it, there isn't
any reason for us to consider it as anything other than an
idea which is going to have to be somehow deliberated between
the Administration and Congress.

The nature of Regional Medical Programs, as you
understand better than anyone else in the Review Committee,

requires a different kind of an approach as we have currently

understood it to be. And so if there should ba that kind of

a basic change, it would really change all the rules of play.

And then w2 would have to go at it in a totally different

manner. But at present, there is no proposal of that kind

which has been presented to Congress and which is under
eneral consideration.

DR. ELLIS: Thank you.

 
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_ SCHMIDT: I won't ask if that answers your
guestion. I will ask if that satisfies you.

DR. ELLIS: Yes, it helps greatly.

DR. SCHMIDT: I don't think there is an answer to

the question. Basically, of course, the problem is there

isn't enough monsy to go around to do things everybody recogniz¢

as good. So in this instance, somebody has to decide where
the money is going to be. And my own personal interpretation
of things is that Congress is unable to make these decisions
right now. It isn't equipped to do it.

There is some question about whether or not. they have
the authority to do it. If you looked at the Washington Pcst.
this morning, I think it was Congress is talking about some
kind of their own super budget agency, Congress' own Office
of Budget and Management, +hat would vie with the executive
OMB. This sort of a thing could share in the decision-making
of where limited numbers of dollars are going to go. But Il
don't see that in the next four years myself.

and what. I do see is an increasing number of dollars
placed at the State level with the decision-making being put
at the State level. ‘And in Illinois, since you are familiar
with Illinois, I now see the amusing business going on of
everybody trying to divorce themselves from the health centers,

ee

for example. The Mile Square, which is very well known, is

 

having its funding pulled back by the Federal Government. And

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Presbyterian St. Luke's Hospital is trying to pretend like they
have never heard of Mile Square. martin Luther King is being

peddled to Cook County Hospital of the University of Illincis

‘because their funding which is now about $2.5 million a year --

I think they see a couple hundred patients a year, something
like that, for that money -- everybody is pretending like it
doesn't exist.

And what is going to happen is that I think that
President Nixon will say to the State of Illinois, "I have
given you this money, you now have these programs, and you
decide what the State will support." And the State will be
deciding what to phase out, what to keep, what to put together,

and I suppose might sven be deciding what of RMP should bs

‘supported in another few years. a

Whether this will last when Congress really does find
out that the money that is accrued by its taxation authority
is being spent by States in the next Administration, I would

rather doubt. These things are kind of fun to think about and

to predict the Future with. But I don't think people really

know.

DR. MARGULIES : I think you should realize that the
idea of Congress having a sort of super OMB of its own kind
was generated in the period of depression following the Supsr

Bowl and they felt they needed to reconstruct the conflict at

a higher level. I don't know wheather they worked out the

 
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‘all that interesting myself.

a few progress reports on various activities that have been

 

30

television rights, but it should be an interesting show if
they bring it around.

DR. SCHMIDT: I don't think the Super Bowl was
Well, we do have a number of progress reports, or

supported through supplemental funding. And the first of these
relates to health services and educational activities. And
Veronica Conley will give us a report.

Veronica. |

‘DR. CONLEY: Thank you.

Dr. Schmidt, Dr. Hargulies, as was reported to the
committse at its last meeting, 57 health service education
activities which are located within 25 RMPs were funds in
June 1972. Since that time all conditions for funding which
were imposed during the review process haves been satisfied.

At this point in time, all but a few projects have
full-time directors and are moving ahead very satisfactorily.
They are in all stages of development, varying from the
fully operational San Fernando Valley Consortium, LAHEC in
Erie, Pennsylvania, and TAHEC in Tuskegee, to the Batesville,
Arkansas, HSEA whose director just reported last week,

| The directors appear to be predominantly from the

field of education, some of whom have had little experience

with the health services delivery system. Many of the directors

 
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have expressed the need for more orientation to the RHPS

concepts for HSEAs and to RPS policies.

Communications batwsen the projects and the RMP

‘staff is complicated by the great. geographical distance between

the RMP office and the project sites in many regions. They can
be 150, 200 miles from the office.

Over the last few months, the nesd for more
orientation became so acute that two of the Directors of HCs
planned a national meeting of lc directors. This was cleared
with Dr. Margulies. This meeting was held Monday and Tuesday

cf this week in St. Louis. One hundred fourteen persons were

in attendance representing 36 RMPs. On the basis cf attendance

e :

at that meeting and as a result of many contacts which we had

in the past. with the developing HCs, we hava made some observa-
tions which we would like to pass on to you.

The directors have reported a gensral lack of manpowey
planning data in the comaunities where they are establishing
HCs, even in some cases in the presence of a CHP agency.
Invariably, under the circumstances, the director sees as his
first task to conduct. a nanpower survey. All directors need
encouragement to look at health services nesds as a data bass
in addition to the more traditional types of surveys.

In the area of consortium formation, two problems

have arisen -- one the issue of whether to incorporate or not,

and the issue of consumer involvement.

 
~ , | 32

1 on the positive side, through these consortia, the
@ q|| RHPs have on a broader scale than ever before been able to

3|| involve educational institutions -- the technical schools, the

4 community colleges, and the senior colleges -- none of whom are

5|| necessarily in medical centers, but all of whonr are participatin

6|| in the education of our health workers.

7 In six RMPs, there are AHECs which overlap with the

g|| HC projects. And we have two very fine examples of coordina-

9 tion -- ons between Northlands RiP and the University of

10 Minnssota, and the Wew Mexico RUP and the University of New

11 Mexico AHEC. ‘The area of overlap in Hinnesota is in St. Cloud

12] where there is an HC which has developed and is the farthest

© 13 in davelopment of tha Northlands projects. This is also the
4 outreach community under the AHEC contract. ...

Through coordinated efforts, the RiP supported St.

1S}
16 Cloud consortium will serve as the community arm of the AHEC.
17 All relationships batween the university AHNEC and St. Cloud
‘sg will be conducted through the consortium and not through
19 individual agencies, institutions or hospitals.
20 In New Mexico, the AHEC contract is directed
9} exclusivsly to the Navajo nation. The non-Indian population
C 22 in the geographical area covered by the AHEC approached the
23 Wew Maxico RMP because they wished to have the same services
© 24 as the Indian population. And the Naw Mexico RIP is developing

“ee Federal Reporters a section to take care of the non-Indian population in the area.

 

 
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Areas of activity which may illustrate the potentially
broad scope of activities of HCs include, for example, the
Rhode Island State Medical Association which has requested that
RISEC which is our HC in Rhode Island under Tri-State RMP
requested that RISEC participate in PSRO planning particularly
te provide advice on continuing education..

In Arkansas the School of Nursing has askad the HC
to establish some affiliations with rural hospitals so that
its persons trained at the university will have rural
hospital experience and, therefore, would be encouraged to
serve in rural hospitals.

There is also a growing surplus of nurses in Little
Rock which has brought this about.

And another HC has been asked to represent the
health community to work with architects in the planning of
a hospital.

and, of course, several have been approachsd by
State medical societies and local medical societies as they
move towards mandatory continuing education for relicensure or
For continued membership in the State association.

And, finally, in the meeting in the last two days,
although they originally called the meeting to talk. about
program development, the issue which became an overriding one
was what thé directors call their survivability. They quite

realiz2 it will take many months and psrhaps a year or more

 
34

1] before they can become self-supporting. And they are, of cours,
@ “911 very concerned about RMP support and the possibility of its
3]| discontinuing. They explored many possibilities at length for
4|| obtaining funds, one of which was revenue sharing. And they
5|| were encouraged to immediately begin to set up relationships
6|| which would be important. in any revenue-sharing activity.
7 And before they left yesterday, they appointed one of
gi the directors to publish a regular newsletter so that. they
9|| would be informed on the activities going on throughout the
10) country in HCs and also about what. is going on in RMPS.

11 And their last action was to appoint a steering

12|| committes. And its first charge was to explcre ways and means
© 13]) how the directors both individually and collectively can.

44) assist. the RMPs in the months ahead and in particular in regard
154, to the upcoming legislation. And the chairman of that.
16 steering committee will be in touch with the chairman of the

17 steering committee of the coordinators.

18 Thank you.
19 DR. SCHMIDT: I thank you.
20 Are there questions?
21 Bill.
on 22 MR. HILPON: Just a couple of small points. The

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DR. SCHMIDT: That is a nomenclature for peer review
group.

MR. HILTON: Another thing, in your comment for the

‘developing needs of the AHEC director, you mentioned the lack

of manpower planning data and a couple of other comments you
made which suggested that the system that. is being developed
among these project directors may be forced to replicate some
of the things some RiPs -- I have visited and talked with
people -- think they should be doing. Are the coordinators
of RiPs familiar with these needs and is it your feeling they

are responding to those things they can best. do or CHPs, for

“that matter.

DR. CONLEY: Well, there is a continuing.nead for us t

_work with our regions in reorienting their thinking about. how

ons arrives at what kinds of manpower we need and how that
manpower should be trained. It is usually to conduct. surveys
and send questionnaires to find out how many vacanciss thers
are, how many people are being trained. But. it is our feeling
that one must first look_at the health services needs. And this
is a new concept and one that is not easy for people to under-

stand.

ct

MISS KERR: I would like to ask a question if there

is any distinction between "needs" and "demands." As you do
. —

surveys, we find so many indicate néeds, but the employment

opportunities are not there.

 
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DR. CONLEY: That did come out at the last meeting
and was stressed as a responsibility of the develcping HCs to
be sure that people trained would have positions to go to.

DR. ELLIS: Doctor, do any of these programs extend
to education of peopls in the communities?

DR. CONLEY: They ars moving into this.

DR. ELLIS: And how do they relate to the professional
health educators as we understood it in years gone by?

DR. CONLEY: In the consortium representation, you
would have representatives of the various health provider
groups. And there are consumer ‘representatives on the consortiu
as well. And as they move into the operational phase, they

will move into consumer education, although each of these will

‘probably develop quite differently from the’ other.

DR. ELLIS: Because one of the really great. needs in
health education is broad, across the entire population of
consumers from childhood eon through adult life. And I was

'

;ust wondering if this wouldn't be a very important thing to
J

build into some of those training programs. It really could

be done without altering the pattern too much,
I think it. would make a tremendous difference in the
cverall contribution of the program to the needs of people.
DR. CONLEY: This is one of the elements in our

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concept, Dr. Ellis, which we are trying to promote.

 

DR. SCHMIDT: Thank you very much, Veronica, That
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was a very good report.

Emergency Medical Services. Dr. Rose will give us
a briefing.

“I believe he has a handout.

DR. ROSE: A rather large amount, about half of what
I am passing out there, most of you have seen previously.

It is a reminder and updating as to where the supplemental
RMP awards of last. spring went. and in a general sense for what
purposes they were to be spent.

As you will also see, there are some lists of
applications, both those that went through November Council and
those which are coming up new, which are offered more as an
indication of how much intsrest has been stimulated in the
R¥Ps to work in problems of emergency care. ‘And I am not’
suggesting that is a complete list. We are still a little way
from a real definition as to when a coronary care training
program is heart disease and when it is EMS.

There is also a list of the regions that we have
visited over the last few months and those that. we hops to
contact within the next few months. Again, a list of visits is
not set in any fashion. t is largely a matter of where we
feel the priorities for visits may appear and where the regions
feel a need for these trips.

In the visits, we have bssn talking with a variety of

people in the RMPs -- thoss specifically interested in one

 
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‘attend the one in New Jersey. And I found them very interesting

 

38

particular area of emergency cars, members of the RAG,
executive committees, coordinators, evaluators, various kinds
of people within each of the RHPs.

A few words about the status of Emergency Medical
Services within some of the other programs around the building:
CHP, the Comprehensive Health Planning Program, has expanded
its interest somewhat over the last few months. They have
done a series of planning sessions around the country for
members of B agency staff. - They have had threes such meetings.
The fourth one is coming up next month in New Jerssy. They are
designed to acquaint members of the CHP staff with the concept
ofplanning for emergency care and the value of this care.

I hope to

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I have attended two cf these meeti

although I am not sure that the audience has seen in these kinds
of sessions what. thay would like to see.

As is usually the case, there is a lot of eonesen
about how much money are we going to gst and how are we going
to get it and that kind of a simple qusstion.

The Comprehensive Health Planning Service has
also printed -- it is in the final stages now, should be out.
next. week -- a general. statement of their approach to
emergency care which will be distributed to the CHP A and B

agencies. And we will send it out to the RMP as well. It is

 

an cverall policy statement, not much different. than the sort we
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‘time -- this is the office which sst up and monitors the

 

39

put. out last spring.
What used to be called the Special Project Office

for Emergency Medical Services -~- I mentioned this to you last

contracts for model emergency medical services in five places
around the country -- is likely to become, probably already

has become as of this week, the Emergency Medical Systems
Service. And it. will include personnel from the Divisicn of
Emargency Usalth Services as part of their organization. A
large part of their activities will continue to be the
monitoring of the five model programs plus a sixth which was
activated in December in Maryland and a likelihood of the sevent
one which is in an innocuous phase now, baing carried forth
within the next few weeks or months.

As far as Emergency Medical Services legislation is
concerned, which at the moment it. appears will not affect RMP,
hearings are scheduled or planned to be held on legislation
very much like the Rogers bill of last year. The hearings are
tentatively set for next-month, It is likely that this year
there will be the same bill introduced in both houses.

You may remember last year there was a Senate bill
and a House bill. And they never came to conference, That
bill relates to rather categorical DMS activities -- ambulances

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with people to ride on ambulances, very straightforward

 

almost highway safety oriented type approach.

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exists. A number of the regions are still treating emergency

 

40

One final statemant, if I may, about some of the
concerns we have been having in talking with the regions. I

think the overall concarn that I mentioned last time still

medical services as a separate sort of health activity apart.

from the rest of the thing that the RMP is interested in or per:

should be interested in. And a large part. of our conversations
have been trying to encourage the:idea of emergency care as
just a requirement of the total health system rather than as a
separate project.

In some places there has been concern about the
responsibilities for contractors who have received monsy from
these supplemental earmarked funds versus the responsibility, -
the management responsibility, of the RMP itself. And this
has generated a fair amount. of concern on our part and I think
is a fairly significant problem in some of the RMPs which we
hope to be talking with over the next. few months.

Who is responsible for designing and evaluating
the project? Is it the contractor or is it the RMP? The
hardware orientation is still there. Where can I get money to
buy radios is a common question. And we try to get away from
that.

I think the key issue which is coming along now both

in the RUMP activities and in the model systems is the matter

 

of how one valuates the effectiveness of the system both in

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terms of the project goals and in terms of its effect on the
rest of the health problem. We have been working rather hard
in this aréa with our Office of Planning and Evaluation here.

The National Center for Health Services R&D has
stimulatsd a fairl amount of interest. in their staff in this
area, And, of course, there is a major requiremant for
evaluation techniques of this sort. in the model systems.

| DR. SCHMIDT: Are there any questions or comments in
this area?

DR. SCHERLIS: Are future requests for Emergency
Medical Service funds as they come from the individual regions
being leoked at by your group or are they being looked at as
part of the gansral review mechanism without. input from your
group? How are these to be considered?

DR. ROSE: There are some in the present cycle. We
are trying to pick them out for our own interest, but they are
being thought of at. least by us as another activity of the
RMP in no way separates or distinct from their other activities.

DR. SCHERLIS: _In short, are you including in any of
the data which we have specific evaluation by yourself as
far as the EMS proposals as they come in from individual
regions at the present time?

DR. ROSE: No. There may be staff input just as
+heare might. be for any other kind of activity, but there is

no specific EMS-related input which is included because it is

 
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EMS. There is no such.

DR. SCHERLIS: There are no earmarked funds, I assume,

then at this particular time. This is just that one go-around,

DR. ROSE: Yes.

DR. SCHERLIS: They come in as part of the total
overall requests.

DR. MARGULIES: Correct.

MR. HILTON: Len's question raises a peint that is
precisely what I wanted to ask with regard to the EMS. Is that
floated in exactly the same way?

DR. HINMAN: Yes, it is.

DR. SCHMID? : Ave there other questions or comments?

DR. SLOAN: Would you like to mention the conference
with the American Heart. Association on emergency care of
cardiac patients?

DR. ROSE: No more than t guess just. to say I am not.
as up on thet. as I should be. There is interest in a conferencd
There is to be a conference which I believe is Nay.

DR. SCHMIDT: Dr. Sloan, would you care to comment?

DR. SLOAN: Well, the American Heart Association
asked us to cooperate with them in development of a conference
on the emergency handling of cardiac patients in relation to
our interest, the RMP interest, in general emergency medical

services. And I think it is just worthwhile to note that we ard

 
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trying to cooperate with them and that. such a conference will
be held, the proceedings of which will be made available to
all Regional Medical Programs.

DR. SCHMIDT: We have learned in Illinois through a
disastrous train wreck, two airplanes crashes and Florida
recently learned that the real trick in this whole area is
to have the emergency occur where you can handle it. And if
that doesn't work, you are out of business.

Len wanted to say something.

DR. SCHERLIS: I was going to ask in reference to
Dr. Sloan's statement if the interest to RMP extends, I would

hop2, to participating in the financial support of this .

conference cr is it as one of the many agencies, and.there. ars.

many, which are listed as cooperating in this conference?
It is an important. one. It is for emergency cardiac care. It
is being held at the National Research Council much like the
earlier one was several years ago when CPR was stressed. This
is for total early care.

Have you been asked for financial support?

DR. MARGULIES: I don't know that we have been asked,
Len. I am not sure.

I understand wa have not.

DR. SLOAN: The AHA has a sufficient appropriation.

DR. MARGULIES: We have, as you know, a continuing

and to be renewed major contract activity with American Heart.

 
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Association. So if they need funds, they know the channels.
And if we haven't heard from them, I assume they can do for
the moment without us.

I would also assume from that they have something
else in mind later.

DR. SCHMIDT: Well, Bill Hilton mentioned PSROs, and
this stimulated our thought. that there is something going on
in this area. And Dr. Margulies perhaps could comment on the
H.R. 1 type of activities with PSROs and even perhaps the
kidney preblen.

DR. MARGULIES: Let me take those in reverse order
for the moment. I suppose that we will forever refer to what
really has another title as I.R. 1. As I recall, it is 92-607
or something of that kind. But H.R. l is a catchy title.

That, as you know, is the very, very large and
complex series of amendments to the Social Security Act. And
it includes some striking new activities, the full extent of
which is still to be realized. One of them had to do with a
new method of reimbursement for the services required fer
individuals requiring dialysis and transplant. vhis is designed
in such a way that the source of funding for the payment of thos
critical services will bs relatively ample compared with the
way it has been up to the presant time.

As I recall, that becomes effective, is it, April l,

Ed?

 
ad DR. HINHAN: July Ll.
© 2 DR. MARGULIES: And it is at the present time being
31) worked out by the Social Security Administration.
All What we are hoping for, and we have had good coopere-
5j]} tion up to the present. time from the National Kidney Foundation,
6l| from the people in NIH, from Social Security, from CHP and
7! others, is the recognition by those who must reimburse for
8]| payments of the need to identify those settings for dialysis
91 and transplant of patients where the quality of care can be

10] well attested to.

iH There is always a risk when something can be paid

1211 for that there will be people available to provide the services
© 13]| becauss it could’ be paid for rather than because they are

14] expert at it. That is not a pejorative statement aimed at

 

15] the profession; that is a sort of general human reaction.

16 In this particular case, it is urgently important
17] that the institutional setting -~- and by that, I mean broad
18! institutional setting -- in which patients are to receive

19] dialysis leading to transplant or without transplant, be well

20 identified, w2ll qualified, and that reimbursement be limited
21}| to those situations where the patient will get the best

oe 22|| possible care without interfering, of course, with his access
23} to care.

Meee,

24 It fits in extremely well with our own plans for

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tion of the various Federal agencies and the professional bodies

Organization which has been very, very broadly described in the

 

46

kidney network which has been making good progress. We have
been meeting regularly with the psople in SSA, And at. the

present time, I feel quite encouraged that. through a combina-

which are involved, we will come out with something which
represents both access to patients and protection of patients
with assurance that they will get good quality care. But the
final definitions have not been reached, |

On the subject of PSRO, let me just spend a few
minutes on that one because it is an extremely important subject
and one which the whole health community is interested in and
so also are patients or certainly organized consumer groups.

It is essentially a proposal which was known usually
as the Bennett Amendment which states that there must. be a
mechanism associated with Social Security-SRS reimbursement
mechanisms to give assurance that the quality of care which
is being provided meets acceptable standards. And for that
purpose, it was agreed that there should be established what

has already been described as a Professional Standards Review

legislation.
The main elements of it which are clear at the
present time are that the initial phases of this kind of

quality assessment anc assurance will be confined to institu-

tional settings which means hospitals, intermediate care

 
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long series of regulations which must be written, They will,

‘and Scientific Affairs. It is now Assistant Secretary for

 

47

facilities, and nursing homes; that. thers will be a total
dependence upon a peer review mechanism, but with full access ta

this peer review mechanism on the part of all major providers

The circumstances in which a PSRO organization

will be established need to be described so that there is a

as presently planned, consist of opportunities within States |
and within portions of States for professional groups to
establish peer review organizations which will then set some
kind of criteria, measure performance against those criteria,
and use these as a basis for giving assurance to the public
that the quality of care they receive is what it should ba with,
of course, the controlling ¢lement being reimbursement. for the
services being provided.

The present state of development of that consists
approximately of the following: The Office of the Assistant
Secretary for Health -- Incidentally, that is a new name for

the position which Dr. DuVal was occupying. It was Health

Health. There has been a new description of the position in
the Federal Register with a fuller understanding of what. their
function is. The basic responsibility for the development. of

the PSRO lies in that office.

There is under way, and I have been out of touch for

 
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a couple of days so I don't know if it is completed -- I think

I would have heard if it had been -- the search for a director

for the PSRO activity who will be located within that. office.

It will then from the Federal point. of view be necessary for a

number of activities to be carried out which range all the way
from the establishment of a National Council for PSRO to the
definition of what the PSRO is to do, to the establishment of
regulations, to the creation of reimbursement mechanism

through the Social Security Administration, to the establish-
ment of a rang2 of technical and professional advisory functiong
which will have to be carried out within and outside of
government.

From the HSMHA point of view, there has been
established within the agency a group of people to work on PSRO
as a general activity for us to understand more fully and to
allow programs to be as prepared as they can be for whatever
responsibilities they are given.

‘There has been no explicit assignment. of responsi-

bilities excepting for preparation for whatever support. the

Department is going to need when it does make its assignments.

Within HSMHA it is organized as follows:
One individual who is one of the Deputy Administrators
Emery Johnson, is the key person involved in the PSRO activities,

There is, then, an agency-wide coordinating body which

represents a number of programs, including RMP, National Center

 
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for Health Sarvices R&D, which has basic quality R&D responsi-
bilities, Community Wealth Services, National Institute of
Mental Healta, and so on, which are all on this PSRO coordinat-
‘ing committee.

It also has an executive committee on which I sit as
the Director of RMPS which includes some of the same groups I
just mentioned -~- NIMH, the Office of Planning and Evaluation,
National Center for Health services R&D, Community Health
Services. They haveassociated with them a working task force.

Now, this executive group and the coordinating
committee and the task force are working very closely beth with
the Department and the Social Security Administration as we
begin to develop'an understanding of what a PSRO prototype
would be, what the elements would be, how criteria are to be
established, what kind of continuing education will be
required.

We have also primarily on the urging of RMPS, R&D
and CUS, been asking groups outside of government to come in and
share with us their own interests and their own activitiss.
‘And we are going to sét up a series of such meatings so that we
can make sure that the interests of the American Hospital

Association, the American Medical Association, the foundation

groups, etc., are involved. And we see -- and this is really
a judgmental statement rather than a bureacratic one ~~ a

great responsibility on the part of the Government to assist.

 
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the health activities, the organized health activities, outside
of government to act together to coordinate their activities
rather than to go about it separately even when they are not. in
conflict. Because if there is dysjuncture between groups like
AMA, American Hospital Association, foundation groups,
associations of medical cinics, and so forth, it will be to
everybody's disadvantage and certainly will not help to

develop an effactive PSRO structures.

So far we have been deeply encouraged by the great
willingness of groups to not. only come in and share their
interests with us, but to join their organizational peers in
meeting together. |

At the same time, I rathsr suspect that some of those
same groups are going to have to help us from the outside
coordinate our activities.

Generally speaking, as a kind of a basic principle
which Paters has not approached so far as I know, bureaucracies
can be organized better from pressures from outside than they
can by energies from inside. You may quote me on that. So we
will look to those outside us to bring us together, and we
will: look at ourselves to bring them together. and I think
that the prospects are very good. It is hard to predict what.
the actual impact of PSRO activities will be.

Two or three things are clear. There will have to be

developad data and information systems which serve not. only

 
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existing utilization review, but also PSRO activities and as
well the kinds of basic informational demands for health

services which Veronica Conley was referring to when she was

We must have a common, well-defined, consistent
source of data which can serve planners, which can serve PSRO,
utilization review, and do it in such a way that we know what
we are talking about or at least we are all looking at the
same set of data rather than at. a whole range of incompatible
data which mean whatever you think they mean at. the moment.

There is real movement in that direction. And I
think that SSA is going to telp a great deal as will be the
rapidly expanding Federal-State-local health data system which
is emanating from HSMHA. oy

Secondly, it is clear that there has to be a continuur
and a linkage between utilization review as it is presently
carried out in institutions and the PSRO activities which have
to do with the quality of services which are being provided.

And, third, there is limited, very .limited, recogni-
tion of the need to be prepared to do something about what it igs
you are discovering when you carry out this kind of a review
activity. There is an almost reflex tendency on ths part. of
the inexperienced dealing with PSRO to speak in terms of

sanctions against those institutions or individuals who don’ ¢.

 

come up to the mark as though the only solution if someone
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does poorly is to cut them out of the system. This is clearly
not our intent. And it won't work in any case.

The real problem will be not only to develop effect.ivg

‘information systems which certainly have to include a revolutioy

in medical records and standards of reference and comparisons
between performance and those standards, but. some techniques
for remedying what is found wrong. And the responsibility for
doing that will certainly include Regional Medical Programs,

not only in the kinds of educational activities with which we

have some familiarity, but some organizational improvements, son
a «

manpower extension activities, some improvements which overcome
the problems of deficiénciss in services due to shortages or
maldistributicn of health manpower. And of all of the
activities in PSRO, it seems to many of us that. the remedial
aspects of this have been least attended. They will be addresss
not in the PSRO structure, but as broad issues which are
important in any setting at. the St. Louis conference, but I havg
the feeling that we will do less well on that subject than on
a good many others that we are going to bes considering.

I think there is little doubt, for example, that
there will have to be rapidly heightened, even above the present
pace, attention to sensible, logical, recordable, transferrable,
medical record systems which can be used for audit purposes.
And this in itself is an undertaking of no mean proportions.

So what is happening is a rapidly growing response

 

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on the part. of Government to legislation which was passed very
late in the last session of Congress, but which must bscome

effective by January 1. So that the time involved is vsry,

very brief.

DR. HESS: I wonder if you could comment. a little bit.
more on what is going on in the area of medical records because
this is of extremely critical importance in this area.

DR. MARGULIES: Well, in RMPS, but. certainly outside
of it, there is a crescendo of interest even above what it was
a year ago in the problem of oriented medical records.

Recently a conference that. Willis Hurst held down in Atlanta
had a huge attendance on the part of people who realized that
this may very well be the best available kind of record systen..
We see growing evidence around tha country of hospitals, of
groups of people, beginning to recognize the fact that there
must be a rapid change in medical record systems. I don't
belisve that this agency or SSA has rscognized a need to put.
official pressure behind the development of that kind of a
medical record system, but it would not surprise me if that
kind of thing should cccur.

I know that’ Representative Rogers has been strongly
tempted to introduce legislation requiring that kind of a
medical record system which I think would be most unfortunate.
I would prefer to see the profession reach in that direction.

We have not, however, and this concerns me, been

 
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able to reach a conclusion in this agency that we should take a
position and promote a kind of medical record system at this
time. I am impatient with the tendency to continue to researcn
‘and wonder and study on something which at least is well

enough established so that it would be a vast improvement over
the kind of patchwork we have at the present time. I would
like to see us come to the conclusion saying this or. that.

I don't know if anyone is going to have courage
enough to require under PSRO at. the central level a medical
record system of a specific kind, but I rather suspect that
a gocd many of the aarly developments in PSROs where the
progress has already been great are going to come to that
conclusion right at the beginning this will be the only medical
record system acceptable. But the action is general and not
coordinated.

MISS ANDERSON: - Dr. Margulies, I know it is hard to
mention all the names of people involved in this planning, but
are allied health groups or nursing groups involved in this
initial planning phase?

DR. MARGULILS: You mean within the Department?

MISS ANDERSON: Well, planning for this national
council. You talk about the AMA and Hospital Association and
so forth. I was wondering about the nursing association or
the allied health group. |

DR. MARGULIES: Well, the question is how extensive

 
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has been our involvement in bringing in groups to work with us.
We have only just begun. This particular PSRO activity is not
more than 6 or 8 weeks old. And so we have actually been
responding initially to those who have come to us with some
interests of their own.

For example, the QAP of the American Hospital
Association was of immediate and early interest as has been
the Social Security Administration. And we had already been
working with the National Kidney Foundation. But we will
certainly find it necessary to work with those other kinds of
professional groups like nursing associations, allied health,
where there has been developed an approach and some under-
standing or whers there is a need for it in establishing the
PSRO,

Even though it is keyed very clearly in the legisla-
tion around the physician peer review mechanism, it should be
self-apparent that PSRO as it is going to develop will require
an effective review for those who provide medical care which

means a small minority of physicians and a great majority of

‘others.

And I should mention one other thing that. although
the legislation require~s PSRO in the institutional setting,
it does allow room for some experimentation and somes early
entries into the ambulatory care delivery system with the

implication that as PSRO develops in the institutional setting,

 
56

YH at will bs expanded out of that and into the ambulatory dslivery
© 211 environment. ; /
| 3 . Now, that was a decision made for practical reasons.
4! tt is tough enough to do it in the institutional setting. And
5|| the feeling was wa really aren't ready to try to take on the
6|| ambulatory PSRO type of thing. And in fact, if you reflect
7\| on it for a moment, the institutional setting sounds tough
8] when you think of hospitals and agonizing when you think about
?|| nursing homes. |
10 We have somehow or other never gotten ourselves to
lili really talk seriously about. PSRO in nursing homes. . I think
12|| everyone is well aware of the fact that that is a very, very
© 13]| a@ifficult field.-
14 DR. ANCRUM: Dr. Margulies, for the institutional
15 settings, isn't that only if they are involved with reimburse-
16]} ment for Title XVIII and XIX? I am thinking about an institutio
17}| may not want to come in, Do they have that choice?
18 DR. MARGULIES: This is based around the Social
19]) Security amendments. That's right. What usually happens,
20] however, and it doesn't take very long, is that all third
21|| party carriers fall into the pattern of what has been establishe
© 22|| through SSA. So that it would seem to me highly unlikely that
23|| other methods of reimbursement would remain isolated from the
24], PSRO activity if it appears to be a method of giving warrenty

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But it is a requirement only under what used to be
known as H.R. l. . /

DR. SCHMIDT: All right. Thank you.

Are there other questions or comments?

Yes, Dr. Brindley.

DR. BRINDLEY: Not specifically related to that.

This may not be appropriate, but where do we stand on HMOs
as far as RMPS is concerned?

DR. MARGULIES: The question is on HMOs.

This is a great morning. How do you think those
things up?

Well, as you recall, the legislation for Health
Maintsnance Organizations did not pass during the last session
of Congress. As a consequence, there is nothing officially
known as HMO. The RMP funds which were used during the last
fiscal year went to some 29 HMOs which were in developmental
phase. There is no more RMP money identified for that purpose.
There will be no funds used for operational support of HMOs.

There is a hope, of course -~ and again Mr. Rogérs
has indicated his interest in it -- that the Health Maintenance
Organization legislation will pass very rapidly. There then
will be appropriations. And in those circumstances, it will be
existing as a separate, self~sustaining activity in which the
RHP interest will be cnly as it is appropriate to the RIP

mission.

 
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succeeds and has its own independent appropriation.

 

58

I think that the kinds of conduits which were used
in the past. for this will either no longer be necessary because

the UMO activity fails or no longer necessary because it
y

DR. SCHMIDT: Other comments?
MR. TOOMEY: Dr. Margulies, what has been considered
in terms of the composition of the membership of the PSRO?

DR. MARGULIES: At the State, you mean, at the local

level?

MR. TOOMEY: State or local.

DR. MARGULIES: Well, that is described again
rather loosely in the legislation. It must. include -- and I

don't know the exact terms, perhaps someone else here does --
physician representation which is not limited to M.D.s. We
are talking about M.D.s, osteopathic physicians and other health
care providers. It cannot be designed, for example, around a
county medical society because that is a selected group. If
you have to be in a county medical society to be in the PSRO,
then that is not an acceptable PSRO arrangement. |

On the other hand, members of county medical
sociatias can make up. PSROs as a separate activity.

The intention, as the language was developed and as

it was understood in the Department at that time, was to give

the PSRO governance a very broad base which would mean that

-it would represent quite frankly the best description of a fairl;

Lt

 
59

1 characteristic PSRO base as Dr. DuVal was understood at the
© 2\| time it was passed was a good regional advisory group of ap
3 RMP, a good many health care providers, paople representing
A institutions, allied health, and some consumers. But it is not
3 really a consumer-oriented thing. It is a provider-oriented.
6} and in the final analysis, it is the physician peer review
7\| mechanism which dominates in the legislation and in the manage-
8] ment of it.
? and as I recall, the National Council is an all-
10 physician group. Is that right, Bob?
a MR. MORALES: There is a requirement to include other
12 providers such as nurses and that type of officials.
© 13 DR. MARGULIES: It was designed in such a way that
14] it would not become the private fiefdom of physicians.
15 . MR. TOOMEY: Will foundations be able to move in as
16]| a PSRO without changing the composition and foundation and
17} board itself?
18 DR. MARGULIES: I would say yes to the first part
19] that. the foundations will very likely not only be able to move
20 ‘in, but they are likely to be early beginnings in PSROS.
21 , I suspsct that a good many of them will have to
© 22|| change their structure in some way because they tend to be

23] restricted to physicians and will have to embrance a larger

  

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60

Vi written to to identify. And I could be wrong on that.
© 2 DR. SCHERLIS: In its broad phase, can this get.
3 involved initially with categorization of facilities as it
4 sets up professional standards or is it looking at individual
S|} rather than group service?
6 DR. MARGULIES: The question is could this get
7\| involved in categorization of institutions. I think the answer
8] to that is probably yes, depending upon, again, interpretation
9 and regulations. But one of the aspects of the PSRO is
10) instituticnal quality review which is again almost. self-
11} evident. Ons can hardly expect a group of health car@ providerg
121] to meat a standard of performance in an institution which does
© 13|] not. And certainly, if a hospital is to be utilized, there mus}
14] be evidence that it meets some kind of quality criteria for
15) its own diagnostic and care facilities.
16 When we began to think about our own Section 907
17! activities which I will remind you of in a moment, we realized
18 that these needed to be moved into the PSRO environment. for
19], our own group to look at. And we are going to be doing that.
20 Now, the Section 907 activity is one which has grown
211) out of the original legislation through which RHP was establisha
MS 22 || You may ‘recall that it is a section which says that at that
23|| time, the Surgson General, now the Secretary, will publish
@ 241 a list of hospitals which have the most advanced facilities
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61

disease was added. We are currently in the late phases ofa
very vigorous contract carried out with the Joint Commission
for the Accreditation of Hospitals to establish some kinds of
criteria which conform to the current intent of that section. —

What has been done is the distribution of a very
complete questionnaire to hospitals all over the country with
a remarkably good response which will allow us to identify
hospitals in accordance with their capacity to deal with
heart diseases, cancer, stroke, and kidney disease.

It will also allow us to establish a kind of tier
of quality which could roughly, depending upon how it finally
evolves, identify institutions which are able to do the most
sophisticated referral type of activity, a good example being
transplant of kidnsys or chemotherapy which can be done only
under very specialized circumstances for patients with cancer
and so forth, the so-called tertiary institutions. Wea should
be able to identify the criteria and perhaps the institutions
meating those criteria for tertiary care, for secondary care -~-
that. is, institutions which are able to accept referral
patients, not necessarily for the most advanced, but for scome-
thing which requires referral -- and other hospitals which are
adequate for primary purposes.

Now, if the PSRO is designed around the medical
care system of a region, of part of a State or all of a State,

then the identification of institutions which are competent to

 
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do some kinds of things and apparently not to do others would bq
of real value in trying to set up criteria for performance and
in trying to identify where therapy, where diagnosis and
treatment should be carried out and what the resources are for
better teaching and for systematic regionalization of health
care delivery systems. This, of course, would mean that.

they would be linked in closely with planning agencies. And
we propose to utilize this list of criteria in hospitals so that
planning agencies will be able to take advantage of them as

“pn

well.

I rather suspect that PSROs could if they wished to,
Len, use this kind of thing and decide whether they: want to
anter into that kind of definition of where a particular servics
should be provided and where it should not. You can easily
appreciate the hazards which are involved in that decision, but.
in some cases the hazards would certainly not be great.

‘It would not be difficult for a PSRO to say that. this
institution is not prepared to take on open heart surgery and
this one is. The gross distinctions would be relatively simple.
It may get a little tougher if you try to make decisions about
where you can manage a patient with an initial infarction who
is already in congestive failure or something of that kind.

It is a little bit more doubtful. But you have no difficulty

in distinguishing between a small primary hospital and a

secondary referral hospital in that case.

 
C)

 
  

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63

I would suspect. they would want to take advantage of
it if they are imaginative and aggressive. But the
decision will be theirs.

MR. TOOMEY: I believe the legislation also said
that if you have an adequately functicning utilization review
committee within the institution, that. this can act as a PSRO.

Has your group given any consideration to this particular
situation? And what is an adequately functioning utilization
review committee?

DR. MARGULIES: The question, if you couldn't
hear it, is related to the fact that the legislation indicates
the acceptability in hospitals of existing utilization review
activities.

When the Administration was preparing its own
position on H.R. l, it expressed its skepticism regarding

existing utilization review activities throughout the country.

-

@here will be no objection to the use of existing UR activitiss,
but there will be considerable doubt about whether they could
do the PSRO kind of activity if their performance with the
utilization review is a criterion of what would happen under
PSRO, |

I think as a matter of convenience, what they are
saying in this is there will be increased attention and demand

to both utilization review and PSRO. And since they will be

dealing with the same patients and same kind of information

 
64

1|| systems, it is reasonable that that be an element in the PSRO.

© 2) But I rather suspect regulations will require something more

3 than what has been established for utilization review up to the

4\ present time.

5 And there is concern with those who are working on

él it that the use of the utilization review mechanism might tend

7\| to restrict what happens to utilization review rather than

8|| really get into issues of quality which are not the same

9|| issues. I think that, however, you have touched on something

10] which is as likely to be a difficult issue as any in the whole
l1|| process. |

am, 12 MR. TOOMEY: Because there is a tremendous opportunity

@ 13|| for conflict within the medical profession itself. of cours2,

14] the American Hospital Association is pushing its QAP, Quality

15|| Assurance Program, to be melded into the utilization review

16|| simply to allow for the physicians who are using the institution

17|| to continue not only to evaluate the quality of care, but also

18|| the utilization of the institution or vice versa.

19 | DR. MARGULIES: I think it would be unwise where there

20|| isan effective atilization review activity to set up another

21{|) and parallel activity. That should be the core of it. But it

 

©) 22 should not be restricted to that core. That is the problem.
23 MR. TOOMEY: That is why they are going into the QAP.
@ 24 DR. MARGULILS: TI think the QAP makes very good
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MR. CHAMBLISS: Does this not, Dr. Margulies, require
the expansion of the review utilization committee? It has been
pretty well a hospital-related function.

-DR. HARGULIES;: I think so.

DR. JAMES: May I make a comment along that line?
When you mentioned earlier regarding standards for hypertension
in terms of perhaps the nation has come to the point now
where it could set up standards for the adequate treatment of
patients, I think that is the way I understand it. It seems
to me like while we are talking about utilization and quality
control, where are the standards for good medical care as you
would see them related to the total program?

DR. MARGULIES: One of the responsibilities of the
Department. will be to guide the way toward the development of
what will be effective standards. There will be two issuss.

One of them is the creation of acceptable standards
which represent a professional output like those that we have
done, say, through the Inter-Socisty Commission on Heart

Dissase Resources or througn the National Kidney activities,

the things we are doing with stroke and so forth. And there

aren't encugh of them, We need more of them. and we are
developing some contracts in RMPS and also in HSMHA to move in
that direction.

But the other and thorny part. will be to see what

the relationship is between those kinds of general standards

 
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66

and local concepts of practice. The PSRO, I suspect, will be
asked to develop its criteria, but it is gcing to ba looked at
very carefully to see how it goes about that.

. Those who are being critical of the profession are
afraid that a development based upon local standard setting
will be established at a point of kind of mutual self-protection
instead of aiming toward high quality. I think people who
say that are being a little foolish. our experience has been
that. those who step aside from their practice to work toward
the establishment of criteria which they think thsy should
meet tend to set them too high -- actually higher than they
can achieve. Because when they get away from day-to-day
practice and say, "What should I be doing for the identification
of a patient for a tonsillectomy ox eye surgery or whatever,"
they tend to become a little textbcokish rather than practice
oriented.

But the real question, and I think the profession is
going to have to play a very, very alert part in this, is the
translation from national standards to local practice or local
circumstances, And I would like to just say on this subject
in géneral that if ever there was a time for the health
professions to mest a responsibility which is probably the
most important individual responsibility they can possibly meet,
it is in this one subject.

Last month I was asked to attend a conference in

 
67

} England to compare the health delivery systems of the United
© 2. Kingdom, Canada, and the United States. And one of the issues
3 we dealt with was quality assessment. And it was apparent that
4l\ when other countries, including Sweden and some of the eastern
5| countries, began to look at the United States in this subject,
6] they agreed at that conference, the people from the other

7 countries, that. we do far more at the present time without

8] psSRO, without utilization review and so forth, to measure the
9| quality of medical care than do any of the others. They don't
10], have tissue review committees, they don't have record review
11|} committees, they do relatively little both in Canada and the

12]| united Kingdom, and that includes Sweden as well. We are well

© 13})| ahead of them.

14 But now they are looking to see what we are going to
5 do, what the profession is going to do -- and this is really
16] a professional issue -- to prove its basically conservative

17|| professional character which is to protect and promote the

18] quality of medical care.

19 Now, there has_never been within the profession any

20|| dissention over whether this is an acceptable and basic purpose

21\| in what we do. In fact, the whole issue, everything we talk

WS 22|| about in the Federal Governmant and outsids of it, comes down
23|| te the question of whether medical care is of good quality,

@ 241 whether you are talking about the how many psople or what is

ic

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think very few people realize the full involvement, the full

 

 

not only evaluate practice here and make a difference in the
whole professional environment, but set a pattern for the whole
world, Because if what w2 can achieve can be done effectively,
it will influence the practices i Canada, in Western Europe, .
in Eastern Europe and, of course, throughout the rest of the
country. t is being looked at with great, great interest.
And as it develops to a higher level, it is going to set the
pace for generations to come.

If it fumbles, if it is not done effectively, somebody
is going to come along with some kind of further regulation |

which is not as good. I think it is an exciting time, but I

difficulty, which it presents.

DR. SCHMIDT: I think you have given us a logical
break point. The next activity will be to synchronize watches,

It is approximately 25 minutes to 11, And we will
now break end reconvene not later than 10 minutes to ii.

(Whereupen, a recess was taken.)

DR. SCHMIDT: We still have a couple of items to
cover. We have talked a little bit about revenue sharing and
the subject. of sharing of authority and responsibility is
something very much being discussed in a number of arsas., We
mentioned the sharing of decision-making and priority-setting
and so on that will bs going on as part of future developments.

and the next agenda item really kind of can be umbréllaed by

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that general topic.
We all have been told from time to time and have

baen briefed on ths activities having to do with the

individual RMP review process and what. have been called verifi-

cation visits to regions, looking at specifically their review
and decision-making processss. And Mr. Chambliss is going to
tell us a little on how that has been going. _

_ MR. CHAMBLISS: About a year ago, RMPS developed a
document in response to recommendations from the FAST Task
Forcs, entitled "RMP Review Process Requirements and Standards."

and this document set forth the requirements for the dacentrali-

zation of project review and the decentralization of funding

authority to the RiMPs.

A handbook was produced setting forth certain
definitions and certain requirements in this area. And the key
issue was to have the regions abide by certain standards that.
would make for overfunding decisions and having to do with the
technical adequacy of proposed operational projects and also'

those activities which were funded within the approved amount.

‘of the grant award.

There were mininun standards set forth on review
criteria and program priorities, on staff assistance, on CHP
reviewing comnent., technical review, project arranging and
funding, faedback, and appeal procedure.

Now, during the past year, the Division of Operations

 
70

] and develcpment staff has set a goal of visiting to certify
© . 2\\ cr to raview the verification processes of all of the 56 RMPs.
3 During the year, then, 51 of the 56 iiPs have in fact been
‘4 visited, Five regions were not visited, and those five regions
5! are California, Arizona, Northeast Ohio, South Dakota and
él pelaware. There were specific reasons why these regions could
7|| not be visited within the specified time. _
8 In the case of California, there were tremendous
9}| logistical problems that you could well imagine there. The
10|/| staf£ is now planning to make that visit soon. As you can
i appreciate, there will probably be a period of two weeks that.
a 12]| the staff will have to be in California looking at the 9 areas
© . 13]) of that RUP..:
14 There were cther technical problems having to do with
15 Arizona, Northeast. Ohio. And jin the casa of South Dakota and
16l| pelaware, those two regions are still in their planning stages.
17 Now, cf the 51 Regional Medical Programs visited --
18] and I might say it has taken a yeoman effort. on. the part. of staf
19|) to get thess visits in within the prescribed time -- there has
20 been unusual staff cooperation batween the components of RNPS
21|| and I should say here and now before the committees, before the
he 22|| staff and the public, that the support. given the Division of
23|| Operations and Development. by Planning and Evaluation and by
@ 24|| the Division of Professional and Technical Development has
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say that these regions are, as you know, organized along the
desk structure, the Eastern Operations Branch having 20 regions,
the South Central Branch having 16, the Mid-Continent. Operations
Branch 14 regions, and the Western Operations Branch 6 regions,
including California -- that of the 51 visited, 36 regions

have been fully approved or certified to date. There are 15
regions which have been provisionally certified or which have
been disapproved due to substantive shortcomings in applying
the standards. And as a consequence, staff is working with
those regions very closely in seeing that whatever the

deficiencies or whatever the bases for disapproval are cleared

Up.

You would like to know that most of these visits
have been made in the last six months, and the nsarest being,
of course, Metro Washington and the furthest away being Hawaii.
And I think you would like to know that one of the visits was
made at 27° below 0°. So you can get a vision of the zeal and
enthusiasm that our staff has had in carrying these out.

But. in some, we would say that we proposed to finish

‘up the remaining visits within the next two months ‘and will

give you a report on that activity later.

DR. SCHMIDT: I am sure that some of the visits must.
have generated some heat.

MR. CHAMBLISS: They did indeed.

DR. SCHMIDT: The general topic, though, is kind of

 
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an interesting one. And I was musing in the last. few days
as to whether or not this report would generate any discussion.
So now I am going to find out.

_Is there any discusion?

MR. TOOMEY: What.were the shortcomings you found?

MR. CHAMBLISS: The shortcomings? We have undertaken
a study of this, but many times the application may not. mest.
the criteria set forth in the standards i maybe there was
improp3r or incomplete review and comment by CHP agencies.
Many times, the priority ranking system was not adequate f.0
ensure that the proper funding decisions could be made in
keeping with the criteria. Occasionally, we found there was
inadequate feedback to the applicant who had not been successful
in having his proposal funded. So there were a number of
reasons why they did not. meet. the review criteria.

MR, TOOMEY: When you disapprove them, what happens?

MR.CHAMBLISS: Generally, the region is told what. the
basis for the disapproval is. It is itemized. And then if it
is a technical disapproval, we attempt to tive the region a
time in which to meet that. particular standard. And the staff
usually works very closely with the region in tryin to overcons

that.

 

MR. TOOMEY: ave you had enough time to see how

oe

quickly they attack these shortcomings that you have pinpointed?

MR. CHAMBLISS: We have been most. pleased with that.
73

lll gust this week, we had three responses from regions saying that.
© 2|| the technical basis for the disapproval had bean overcome. SO
3 thsy are closing those deficiencies as much as possible.
Al Now, there are some with more substantive bases for
5|| @isappreval. And the staff is working with them much more in
6|| detail.
7 MR. TOOMEY: Do you find at. all they will disagree
8) with your judgment?
9. MR. CHAMBLISS: This has been a very interesting
10]| phenomenon. Many times the region has said to us, "We agree
lll with the bases," because it has given them an opportunity to
12 trengthen som2 of their internal procedures. . Occasionally we
© 13) have had a region somewhat disagres, but in the precess of
14] discussion and negotiation, these have been overcome.
15 | . DR. LUGINBUHL: Could you give us an example of one
16] of their substantive problems?
17 MR. CHAMBLISS: one of the substantive problems had
18 to do with CHP relationships and revisw and comment and
1911 especially in one of our regions under the Mid-Continent
20|| Operation Branch.
21 DR. SCHMIDT: First, Judy, did you haves a comment?
‘
WY 22 - GIRS, SILSBEE: I was going to say in answer to Hr.

23|| Toomey's question, our goal is to get all of these regions in

aww,

 

@ 24|| compliance because the stated next step would be to take away
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74

technical review and funding decisions are. And that is
something that we don't want to take back into Rockville. And

so the incentive on both our parts and regions is quite great

‘to get these things straightened out.

MR. TOOMEY: What. happens at the rank level when
you point these things out? Are these psople conversant enough
with your operation to understand the deficiency you point. out?
Do they have problems?

MR, CHAMBLISS: Dick.

MR. RUSSELL: I would like to respond to that becaus¢
we have had on a couple of occasions going in -- of course, we

do meet with representatives of the Regional Advisory Groups.

wn
)

4

m

4

And as a result, when we have cur feedback session, they. s
greatly relieved in some cases that this has been pointed out.
to them. And in some cases, this gives the RAG the clout that
they perhaps have exercised in the past. So they have been
very receptive to the feedback.

MRS. SILSBEE: I don't think any of us mean to
imply the millenium is here. These are minimum standards. And
all of the visits have pointed up need for monitoring and kind
of continued seeing how these are working out. and whather they
are following them.

DR. SCHMIDT: First, Mr. Hilton and then Dr. Thurman

we

and Dr. James.

MR. HILTON: I just. had two questions or maybe

 
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emotional stress and strain.

 

75

comments.

The procedures manual that was referred to earlier,
dogs that go into this area of technical review to provide
guidance so that when it is released, we know it is documented
somewhere?

MR. CHAMBLISS: Yes, it will contain these standards.

MR. HILTON: With regard tc the CHP, was staff able
to make any determination as to the degree to which the problem
originated with CHPs understaffing contributing to that. and
the other kinds of problems where the RMP might have tried to
make the proper communications with the accepted guidelines, but
couldn't? a Lo ies 4.

MR. CHAMBLISS: Mr. Peterson, would: you care to
coment there? |

MR. PETERSON: I think we might say two things about
the CHP review and. comment procedure. I think there have been
perhaps three levels or three different kinds of problems wé
have seen. Some of them are essentially technical, but some-

times they get beyond the technical problems leading to

There ars technical problems relating to a 30-day
reguirsment. and what you give a CHP and whsther some things
are baing technically complied with. I think in a few of
the regions, at least, that I am aware of, we have sensed that

they really were symptoms of lack of adequate cooperation and

 
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“used in this battle.

 

applications, the oppertunity for CHP review, a comment be. .

 

-summer. And we have bséen trying to analyz? to the extent that

 

76

understanding, that they were simply the clubs that were being

I think a more substantive aspsct of this which really
one in part comes out through the verification visits -- and
I personally only participated, I guess, in three or four and
none within the last. six months -- comes to light as a result
of an analysis that. my office has done, is in the process now
of gatting out, in the way of a program analysis memorandum on
the scope and nature of CHP comments during the first. year in
which that was implemented.

We required as of the ilay cycle, 1971, that. all RMP
provided. Sco we had a year's experiences as of this past

there was written comment. letters supplied with the applications
sort of the nature of those. And I think there are some strikin
things that. can be said in that regard.

First and foremost, I think wa find that much of
the CHP comment is of a general natur2. They comment on the
application as a whole or the RIP. and it tends toe be of the
Good Housekeeping Seal of Approval. It doesn't. say much, and
I question it. |

Phere is very little CHP comment to date in terms
of spscific activitiss being proposed ~~ this home care project

or that EMS planning effort. Phere is some of that, but on the

re)

 
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applications, thea Oppertunity for CHP review,.a comment be

 

provided. So we had a year's experiences as of this past

‘Summer. And we have bsen trying to analyz2 to the extent that

 

understanding, that they were simply the clubs that were being
used in this battle.

I think a more substantive aspect of this which raally
one in part comes out through the verification visits -- and
I personally only participated, I guess, in three or four and
none within the last. six months -- comes to light as a result
of an analysis that my office has done, is in the process now
of getting out, in the way Of a program analysis memorandum on
the scope and nature of CHP comments during the first year in
which that was implemanted.

We required as of the May cycle, 1971, that all RMP

ther

WH

was written comment letters supplied with the applicaticng,
sort of the nature of those, And I think there are some striking
things that can be said in that regard,

First and foremost, I think we find that much of
the CHP comment is of a general natures, They comment on the
application as a whole or the RMP, and it tands tc be of the
Good Housskesping Seal of Approval. It dossn't say much, and
I question it.

There is very little CHP comment to date in terms
of specific activities being proposed -~ this home care project

or that EMS planning effort. There is soma of that, but on the

 
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77

whole, it is comparatively small. To the extent it exists at
all, it tends to be favorable,

That may simply mean that there are other forms in
writing in which they express themselves unfavorably. But
certainly in discussing these findings with some of the CHP
staff here, I think there is a general agreement. that what. this

\
points up is that in most CUPs, whether they are talking about.

_areawide or State, but principally areawide, there really

aren't the kind of specific priorities or plans that have been
developed yet that permit them to comment in terms of a
particular kind of activity or a specific proposal. And lI
think that goes beyond the verification visit, process, but
I think it has soma implications for CHP review. and comment.
DR. SCHMIDT: Dr. Thurman.
DR. THURMAN: I am out.
DR. SCHMIDT: Dr. James,

DR. JAMES: I don't know quite how to ask this
particular question related to what. you are speaking of, but I
think you mentioned that primarily what. was involved had to do
with the decentralization of the revisw process.

MRS. SILSBEE: The technical review, pr. James, of

projects.

(b

DR. JAMES: At th local level. And lI wanted a
clarification on that so that I would be sure that LI understand

the focus here relative to the larger applications coming into

 
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78

this review committee or is the focus relative to applicant's
at the local level in that the local RMP is following the |
guidelines? I wasn't. quite sure where the focus was.

MRS. SILSBEE: Well, the background of this
particular verification was when the FAST Task Force which was
before your time, but it was an organization for streamlining
grant. operations and application procedures and 50 forth,
when they looked at the Regional Medical Programs and saw
what was developing out there -~ and this was several years
ago -~ it seemed to them that the national review process was
duplicating what was occurring on the local level with |
regard to looking at. the individual projects, looking at the
technical adequacy of then. They recommended, and DY.
Margulies implementsd, the procedure that the national review
process would no longer do that particular thing.

Before your time, this review committees used to take
a project and the applications came in with the full material,
all the background information on a project, and go through
the project. and look at it. to see if they thought. it was
technically adequate and whether the project itself should be
approved or disapproved. This was creating problens since
the regions in many instances were doing this also and the
national review did not have as much information as the people

that were doing it et the regional leve So the FAST Task

force recommended that this be stopped at the national level.

 
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And this process that Mr. Chambliss has been describing was
to verify that. indeed each of these Regional Medical Programs
did have a process by which the projects were looked at from
a technical point and other standpoints.

The national review then looks to sea’ what the effect
of all of these activities is, what the composite effect is,
rather than the individual projects as such.

DR.JAMES: Then, I can relate very well how you may
pick up in your visits the relationship of the CHP agencies in
that respect.

Now, when you get down to the area of what happens

‘as far as local applicants are concerned in the appeal mechanisny

how are you able to sift that information out? . eee
MRS. SILSBEE: The process by which the team looks
at. this is to look at. the documentation that has occurred in
the local review, to look to see what the records are, to sse
at what stage a project proposal gets stepped in the process,

what. the feedback is to the procedure, whether the Regional

Advisory Group -~- what kind of information they have about

these ideas that. they haven't been asked to act upon, These

are all steps in this review process to make sure that someone
who has an idea gets it considered and. knows, if it. hasn't

been considered and approved locally,why.

ly

 

DR. MARGULZES: For example, there is an effort made

to interview unsuccessful applicants to see how they perceive
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the process, how they got. involved, what. occurred when they
were turned down, if they had an adequate explanation of why
it: was rejected, whether they feel the process was fair and so
on. So that they try to get verification of the true dynamics
of the review process.

DR. SCHMIDT: In previous discussions of this in the
review committse, we have gone back to something that we are
all very familiar with. and that is the project grant type cf
review conducted in NIH where, indeed, the technical review of
a research grant is carried out by the study section on a

one-by-ons basis. But within NIH, there are developing

-centers. The so-called centers of excellence approach, for

example, is one in which NIH will fund a center and then the

center locally can fund research grants. And they must have

the ability to do technical reviews then of the research
projects within the center locally. And then the study
section and the Council rsally serve to accredit the center to
do this job. |

So than you can translate that to Regional Medical

‘Programs wherein the function of a review committee at times

we have said is to accredit the region to do this job that as
Judy pointed out used to be cone by the review committee, in
many cases not as well. And, finally, the people who we do

it with come from regions anyway.

And when you play with this a little bit, you see

 
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that within this committes, wa have a right. to decides the

 

 

 

 

81

that in the kidnay reviews, for example, recommendations have
been made to get experts from without the region. And all of
these sorts of things get into this. The triennial review
and this sort of thing becomes an important. aspect of this
also there.

First. Leonard and then ~~

DR. SCHERLIS: Tf think your analogy as far as
centers of excellence is an analogy, but. not, I think,
paralleled by RMP type of organization because in each regicn,
you do have an RMP. And in each region, you do set up 4
verification system. You aren't saying that is a center of
excellence which really has all of the necessary technical
skills to decids about each individual project.

L£ you select the center of excellence, it. is in
compet.ition with many other centers. And you are selecting
from a large pool in determining which ones do have over and

above a system of review the basic ability, talent, and necessearx

A

raview officers in that area who can look at it technically.

What I am getting to really is that I still believe

quality of a progran submitted by a sampling mechanism. And 1

find it invaluabl2 in reaching a conclusion about an aree to

 

look at a project. or two in order to determine whether they are
just forwarding up to us some what otherwisé would be very low

priority items. And we have the decision and I think, indeed,
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the responsibility to determine by such a sampling mechanism
whether or not the overall grant request is a valid ons.

I would like to interpret the results of whatever

this discussion will be that you are not removing from our

responsibility and purview the right and indeed the responsi-
bility if we chose to look at individual projects as a sampling
mechanism to determine our overall reaction to the entire
request. Will you comment cn that, please?

MRS. SILSBEE: That seems like a very reasonable
approach. And in order to answer some of the questions that
are asked in the review criteria, you would have to do this.
But it doses differ in that you don't go through sach one and
say this ons is approved and this ons is disapproved.

oo - pr. SCHMIDT: I agree. What you have dona really is
described how we have been operating in the last year or two.
And when you get right down to it, the program is a kind of

a nebulous thing that is something more than the projects, But
what you have in hand to look at really are the projects . And
as we all know, even now regions are not making some decisions
they should, but booting them up hers. And, of course, what
this means is that thers is something wrong with that process
and we have to continue to work with the region.

Dr. Florin.

DR. FLORIN: I might report on 4 recent visit. We

thought our review process was quite adequate. It was pointed

 
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out in the Regional Advisory Greup meeting some of our short-
comings. And it was accepted with underst anding and with
appreciation. and we have since modified some of our

review mechanism to do it.

I think the major concern they had at‘our site
review visit was that those applicants be informed of their
right to appeal to the Regional Advisory Group at any time
even though decisions have been made at a lower level before
that. time.

I think also to comment on another statement that was
made by Dr. Scherlis, as funds bscome more competitive, the
problem within the Regional Advisory Group was, one of fairly
good review in that they tried to cull through the. projects
so they didn't have poor projects. Hopefully, if the staff
allowed them to come up that far, they would be aventually
filtered out by the Regional Advisory Group. This isn't
always possible, but I don't. think the undue influence of
people that early existed in that program is now evident cer-
tainly in cur areas.

DR. SCHMIDT: where was a comment along this sides of
the table

MISS ANDERSON: I think I was going to comment on the
fact that the site review teams hava an opportunity to see

some of the proposals in depth and bring it to this review
g

committees. for discussion.

 
84

1 DR. SCHMIDT: The comment for those who may not. have
© 2 heard it was the site review teams certainly can and do look
3H oat projects and use this as an entry point into the survey of
- the local decision-making process.
5 One question I would have is what are the plans for
.611 some kind of -- well, let's say, are the forthcoming site
7 visits then as part of the triennial review the mechanism for
8 looking at compliance or does staff intend to go back in a
9) year or what mechanism of seeing to this process have you
101 considered?
li MR. CHAMBLISS: This will probably be done in a variet
121 of ways. The staff is making regular visits, technical
@ 131) assistance visits, to the regions. And they will be monitoring
14]| and checking through with the provisions of these the
15|| verification as they go to see how they are being maintained
16] and what the status of the region is as it relates to this
17|| decentralizing process.
18 DR. SCHMIDT: Yes, Mr. Toomey.
19 MR. TOOMEY: One of the things that bothers me is
20) the number of times that one of the Regional Medical Programs ~
21 , DR. SCHMIDT: I am sorry, let me interrupt and ask
s,
Ci 221) you to talk into a microphone becausé there are people in
23) the back row. .. Se Do cee te eee

ee

@ 24 MR. TOOMEY: One of the things that. bothers me is
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25| the number of times that a region is visited and the number of

 

 
85

1]| purposes for which it is visited and the number of reviews that |
© 2} a region has. I know the last time that I visited as. a site

3 visitor, I think that within the period of four months, there

4l| had been a management assessment report, there had been a field
5i'trip, a technical review, And it just seemed that. there was .

6 almost an unconscionable amount of visiting to that particular
7\|\xregion, although I am sure each trip was justified. And we did
8] get a report on it.

9 But the thing that bothers me is the fact that when

10l|lwe take the rating sheet, the review sheet that you spoke of,

ll}jJudy, it really doesn't reflect the number of visits, the kind

 

12llof visits, the results of the visits. It doesn't give the site
© 13||ceview team real specific knowledge about what was found, what.
14l'wasn't found. |
15 I am not saying it. right because really this discussiol
16||/has brought on something that bothered me. And I am kind of |
17|)struggling for the words a little bit. But in any event, it.
18||seems that there should be a more specific kind of indication.
19 . I know what I was going to say. We do get the problems
20 Now, this is for sure. We get. them at the RAG level, the
21||program development. level, the field level, the staff level.
92 \|\We get. the problems. And then you use another sheet to provide
23,2 rating mechanism for what has goné on. And sometimes the two

© -  g4lldon't jibe actually.
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I look at the problems. And then as the review mechanisn of
what has gone on, you don't focus on the problems, you focus
on process, performance, program, and some other things.

and this whole thing, the number of visits, the
kina of visits, the purposs of the visits, the results of the
visits and then the result of the site visit, don't seem to
meld adequately.

DR. SCHMIDT: Let me ask for clarification.

MR. TOOMEY: . I would ask, really, if anybody else
has had this same kind of problem in bringing all this
material together.

DR. SCHMIDT: Let. me ask for clarification of one

a

iy

thing you said that I didn't understand. I recently mad
site visit to a region that had been visited a number of times.
And ¢ach group that. went in pointed up the same deficiencies
and the same problems. and we did, indeed, I thought, concen~
trate on their problems.

What did you mean when you said that. you go in and

really don't concentrate on the problems? I missed your

point. -

MR. TOOMEY: I think the point is that you do concen-
trate on the problems, but. the problems that you find as a
result of one are the problsms as @ result of three visits.

And you actually have made a number of visits for a number of

differant purposes presumably, and they all come out the sane

 
87

way.

© 2 And then my last point was that the assessment, the
3 in-depth assessment, that starts with process and performance,
4! these questions do not always relate to the problems that have
5|| psen identified by previous visits except by indirection.

2 DR. MARGULIES: I think that is a valid problem, but
7 I think that it has little to do with a sort of an accident in
8 timing, Mr. Toomey, although staff may want to add to this.

9|| We have had an excessive concentration of necessity con two kinds
101 of visits -- management assessment and the review process

ll] verification. These were necessary because we had undergone

12} a profound change in the way in which we ran our affairs. This

 

© 13]| has meant in some cases a deluge of visits which include not
‘14 only the regular visits, but the specialized ones for management

15) assessment which wa had to have and for review verification.

16] process as well.

17 I think in the future, there will be less of this

18] kind of specialized attention to programs and a better

19) opportunity to integrate them. I am suggesting that this is
20|| an erratic phenomenon rather than a consistent one which movad
21]| us from where we were to where we need to be.

_ 22 Mr. Chambliss commented a moment ago on what. we would

23|| be doing in the future. What we would like to believe is that

ee

@ 24|| this intensive period which we could not possibly duplicates
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88

| plateau from which we can qerate with attention to what comes
© 2} up as a variant from the norm, but which we will then have to

-31| re-examine at some point to see if anything more intensive

41, has to be done.

3 In fact, the responsibility for the two kinds of

-6]| processes rested in different parts of the Operations Division.
7\| And we had our own difficulties in bringing them together becaus:
8|| they did put a great strain on RMPs. and added an amount of
9|| information which was not necessarily a part of the regular

10!| review process, but was rather a buttress for it.

iW DR. SCHMIDE: Of course, the review criteria and
| 12i that kind of a laundry list and form for site visitors and
© 13/1 so cn was clearly intended to ba a guide and not all-inclusive.
14ll And I know that many site visit teams have gone far beyond
15]} that guide. That was not intended in any way to restrict site
16l| visitors or the review committee or anything else. Of that,
17] I am sure.

18 Judy.

19 MRS. SILSBEE: I was just going to say to Mr.

20|| ‘Toomey in terms of trying to plot out these visits where they

21|| could be combined, the verification visit and management survey

an

o 22|| ware put together. And the strategy within staff was to try to

23|| do that. enough in advance if there were going to be a triennial

Re

24|| site visit so that tha region would have the benefit of the

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correct some of these things before their three-year funding
request got considered by the national review process. This
didn't always work out.

DR. SCHMIDT: O.K., any other comments, then, on
this subject?

MR. HILTON: I just need to follow Hr. Toomey 's
comment for just a little clarification for me.

From what Judy was saying, as I understand it, these
visits, management, technical review, etec., etc., are they
deliberately then timed to precede a visit by the review
committee, Council, that kind of mixture, so that we in effect
follow up to assure that what has bean discovered in the
fgarlier visits has begun to show returns? Leave the verifica-
tion for staff?

MRS. SILSBEE: The thought behind that, Mr. Hilton,
was that in some instances, this would relieve the site visitors
of having to go over that same old ground and be able to
concentrate more on the program and the activities and the

effectiveness of those activities so that they wouldn't have to

focus on the organizational structure so much,

MR. HILTON: Is that to say, than, as this develops
there would be no nzed for us as we did, for example, to ask

them to go through projects, that we are sure that the processes

wwe

is legal and that kind of thing, we won't have to be bothered

with that?

 
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90

MRS. SILSBEE: I don't think that is indicated I
think at any point in terms of the perspective of the applica-
tion that these things have to be checked out as Dr.

Scherlis was saying.

“DR. SCHMIDT: I would get. alarmed if anybody thought
in any way they shouldn't do anything that. their brain and
tummy told them ought to be done on a site visit. And you know,
you smell something, you go right in and find out what smells.

I think the thing that bothers me about this is as
will come out in our discussion of regions in the later part
of the meeting, why is it that there can indeed be a series
of visits all pointing up the same thing? And what. is wrong
that. over a psriod of even two consecutive triennial -- do we
have any two consecutive -- the same things are there? And
there is a cartain obstinancy sometimes that one needs to
change. |

Well, fine. Bill.

DR. THURMAN: In no attempt to match the wit and
eloquence of our chairman, lat me point out Mr. Nixon's
statement was the carrot~and-stick procedure was designed for
the jackass.

(Laughter.)

DR. SCHMIDT: I think we have to take a recess to
figure that one out. |

I did hear a marvelous line, though, tha other day

 
sce meantime aot are

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91

that came from Congress. in talking about this congressional
budget bureeu and so on, one Congressman said that the Congress
is fiscally irresponsible and if you added up the monies that
Congress appropriates and spent that the country would obviously
be broke. And one Congressman described Congress as a fiscal
junkie which I thought. was a great line.

I will us¢ this for transition into the next subject.
Those of you who read what I think, Dr. Margulies, was @ very
interesting and informative summary of the council meeting -7-
I hope that Review Committes members read the Council highlights
you will recall there was reference to the developmental
component including 4 Little bit peculiar fact noted by the
Review Committees often. And that is the developmental component
was often most needed by the yegion that didn't merit it. And
for this and other reasons, the developmental component has peer
under serious discussion by the Council.

and Judy will review this for us and get. us Up to
date on the status of the developmental component.

MRS. GILSBEE: Well, we were talking a Little earlier

about the fact that this review committe? used to bs involved

camera nan rhea or

b

 

with project review and the developmental compenent was
introduced as a tool to help regions about the same time that
wa were trying to get. regions in the habit of submitting an
application for funding once 4 year rather than every tims a

raview cycle came Up. and the developmental component was at
92

Vi] that point, which wasn't tco long ago when you really get back

© 2|| and look back and see what actually happened -- it was in

8 1970 -- a revolutionary idea that the regions would request

‘41 funds for projects and at the same time would request funds

5l| for activities that they didn't specify at the time except in

6 texms of the areas in which they would want to develop programs,

7|| And at the time this committee and Council considered the

8|| developmental component, they decided that there had to be

' 9} certain standards for those regions which were to be approved

10]) for the developmental compcnent.

11 and in practice, this bacame a way. of sifting out. theg
12|| regions which had Regional navisory Groups which were able to

© 13]| make decisions, withstand the local pressures of some kind of
14]| technical review. vhere were a number of different qualifica-

15|| tions.

16 And in terms of the way this review committee

17|| recommended the regions receiving developmental components,

18|| looking back over the past two years, it sifted out pretty

19 well. If wa look at the regions that are roughly in the A

20|| category and the B category and C category, in the ‘A, most all

21|| -- and one region had not requested a developmental component -~

22|| of those were approved for developmental component. In the B

23|| area, I think of 26 -- and when you do these categories, it

24|| dapends on what point in time you are doing it -- 20 of them

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terms of a way of si ting out regions, it has been effective.
But since the developmentak component was introduced
and has been utilized, the regions themselves, the ones that
have decided to allocate their funds in this direction because
we have never actually given additiomal money for that purpose,
we have had a number of other things happen. We have decen-
tralized the project review. The RMP review processes havea
bsen studied. This triennial system has been inaugurated.
We have the RAG grantee policy which states very clearly what.
the Regional ADvisory Groups! role is in a more succinct
fashion than ever before, And we have the policy for discre-
tionary funding which provides the opportunity for a region

te do everything that the developmental component allowed them

to do if they are approved for triennial status. And then regia:

have the opportunit to shift funds tm initiate activities
within oné application time to another.

And at. this point in tine, it seems that. the
developmental component as such, a request for it as such, has
served its purposes, and it is no longexy a necessary part of
this evolution into decentralization. —E

In looking at the results, there are a number of
regions that. have requested developmental components two or
thres times and been disapproved each time. So as a mechanism

for getting them to do the things that Mr. Toomey says he kseps

seeing coming up in every report, it didn't seem to be effectiva.

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94

And at the sam2 time, there seemed to be for those regions

that needed to initiate some new ideas or move in different
directions, thay were using their disapproval for developmental
component as -- they interpreted that. action as disapproval of
the typs of activities they wers going into rathar than some
difficulty with their decision-making and local review.

So at this point in time, staff feels that the
developmental component has been a very useful device. It has
served its purpose. Regions have had amples opportunity to
request it and that it might be better to eliminate that as a

special thing ~- not eliminate the developmental idea, but

‘to sliminated the component as such which has created some

problems intsrnally.

DR. SCHMIDT: tr think that is an excellent review.
And, of course, the existence of discretionary funds really is
to me what renders the developmental component a little bit
unnecessary now because the developmental component was
intended to provide, indeed, discretionary funds. It got. to
be sort of like the stamp on meat, unfortunately.

I forget. what. the current grading Ts now. But. if
you got ths developmental componsnt, you were stamped choice
or whatever the top grade is which is sort of ridiculcus.

MR. CHAMBLISS: Prime.

DR. MARGULILNS: You have forgotten about it because

it. cost so much.

 
95

1 DR. SCHMIDT: I am on the verge of forgetting
© 2|| about meat because it costs so much,
3 . Dr. Scherlis, you had a furrowed brow at several point:
4 DR. SCHERLIS: That is a lack of good vision rather

S|} than any reaction to your comments.
6 (Laughter.)
7 DR. SCHMIDT: Then put on your glasses because we
8 need your clarity of vision on this committee very much.
md Joe.
10 DR. HESS: Just a guestion for further clarification.
ll] as I have understood the use of ths developmental component,
12 this has bsen some funds that they could use in a variety of
@ 13] ways. How will that. be requested now in the future in
14] applications?
15 MRS. SILSBEE: At the present. time and through March,
16] it will be requested just as it has been. But if there are
17|| some revised instructions, it would provide an opportunity to
18 put that in the program staff budget as developmental activities
19] which is where they have been putting some of these funds anyway}.
20|| In looking at the situation right. now, regions sometimes are
21|| requesting a developmental component, then under their program
22|| staff budget, they are requesting money for feasibility studies,
23|| they are requesting money for contracts and a number of things
© ' 941 which have the same purpose, | So we thought if we could get
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96

1 DR. SCHMIDT: What will be interesting is when we

© 2|| arrive at the point this afternoon or tomorrow morning when a

3]| region has had a review verification visit and has had this

(4 “project approved and the recommendations of the site visit

5] team will be in that region that they do not merit a develop-

6 mental component. And we will see how that comes out, I will

‘7|| predict. we will have that. situation.

8 Mr. Hilton.

oh. MR. HILTON: Such terms as aside from developmental

10} component, growth funds, rebudgsting or budgetary flexibility,
11 discretionary funds, I am assuming there is no substantial
12|| difference between those terms; they all are really saying the

© 43] same thing. t am surprised, however, to note that I have

14|| seen at. least one application in which more than one term is

15 used for one application. And so they are kind of doubling

16|| up on flexibility.

17 How many different. ways do you provide incentive

“18 and low much of that do you tolerate? I guess I am seeking

19], guidance. -

20 MRS. SILSBEE: Mr. Hilton, this has been a concern

21 || and is part of the reascn why staff locked at this whole area

C) 22|| of deveiopmental component.
23 - In terms of the discretionary funding policy which
@ 94] came cut about the sane time as the RAG grantee policy, it
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25 again puts a burden both on our staff and this review committes

 

 
97

1} of looking at the results of a lot. of flexibility after they
@ 2 have already initiated it rather than before. And in looking

3]| at the ways in which regions have used devslopmental funds, they
4] have been very exciting things that have occurred, And there.

5l| have also been some of the other kinds where they have put it

-6} all together and started a project.

7 So we have to moniter this very carefully. But if

8i| we could put it all in one spot, we think it will be more helpful.
9} MR. HILTON: So you are saying if we get an applica-
10|| tien like that and they are asking for four different kinds of
lll £1exible money, we could sasily disallow three out of four or

azasibl

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121 something if that seened to b: .
© 13 MRS. SILSBEL: If it seemsd like an undue proportion
14] without any, kind of justification. .And this is. certainly

IS within the line --

16 MR. HILTON: This whole question of degrees of

Mm

17/1 extra money like everything els

18 DR. SCHMIDT: All right, let me seek out now any

19} comments from anyone around the table, anyones wno is hers

=a .
20] as representative of the public. Are there any general comments

211) or questions not necessarily directed at the last topic frem

or,

22|| anvon2 in the room?
Y

23) (No response.)
@ 24 If there are none, then I think that we will declare
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25|| that this section of the Review Committee meating is closed.

 

 

vty
98

1 We will reconvene at 1l o'clock in then the first of the closed

© 2\| sections that. will be devoted to pregram review.
3 Leonard.
4 DR. SCHERLIS: I have no comment. except an inquiry. .

5|| Have you determined who would or would not be here tomorrow in

6 terms of making sure that. the review can be done today?

7|\ Has this bean taken care of? _

8 DR. SCHMIDT: ‘The information I have == we can do

9] this little bit of housekeeping right now -~ is that Dr. White

10, will be here this afternoon only; that we must do today -

| Alaska, Connecticut, and North Dakota in part because of your

12|| schedule. -

© 13 Is there anyone else who is involved in a conflict?
141, _ HR. HILTON: Nes, Mr. Chairman. Unfortunately, Ty .

15 too, will only be able to be here this afternoon. |

16 DR. SCHMIDT: All right, we have got Washington/

17|| Alaska scheduled also. So I intend to work the committee very

1g|| hard this afternoon and do the most we can today with this so

19|| that we have the bensfit of the members who may not be here

20 tomorrow. So eat. heartily and have a good strong cup of coffes
21 || and come back with loins girded.

(> 22 (Whereupon, at 11:55 o'clock a.m., the meeting

23 recessed, to reconvene at. 1 p.m. the same day.)

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99,

AFTERNOON SESSION

 

(1:00 p.m.)

DR. SCHMIDT: I think I will call the meeting to
order.

Let me first suggest an order, kind of doubling back
to the last topic. And it would seem to me that -- let's see,
Phil isn't here yet. and will be coming about 1:30, I think.
And giving him a little while to get. here, it might be 2
o'clock. So I would suggest. the following order: Washington/
Alaska first, and then Louisiana, then Connecticut and North
Dakota, then Metro D.C,

Now, those seem to me to be the musts this afternoon.
And if we go on beyond that, it would be good.

Is that, acceptable? Have I left out some imperative? |

(to response. a | | ;

If not, then let's start with Washington/Alaska. .

primary reviewer is Mr. Hilton and then Dr. Luginbuhl is

BF
oie’
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the secondary reviewer.
Oh, yés, I forgot to bring to the attention of the
. . oo, . <
rzview committee the conflict of interest statement and the
confidantiality of mesting statement. You know that. we cannot
participate in situations in which we may have a conflict of
interest. Committee members will absent themselves when

regions in which they have an interest are discussed,

I don't have to read this, do I?

 
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100

MRS. SILSBEE: No, since everyone has it in front of

tnem.

DR. SCHMIDT: You all have a copy. This is a requirs4

ment of meetings.

Then, before we do start with Washington/Alaska,

Mr. Chambliss will inform us as to the Council recommendation
stemming from our last. review meeting.

MR, CHAMBLISS: As a result of the September-October
review cycle at which time 13 regions were reviewsd by this
committss, 9 of which had applications in for the trienniun,

3 anniversaries prior to the triennium, and one anniversary
within the triennium, w2 certainly thought the committes would
like to know that all of the committes recommendations were —

accepted by the Council witn the exception of one. And that

. 4 5 . . ag ee dawg
wt ay lw Met ee co teeter

‘was the case of New Mexico.

In the New Mexico application, there was a site
visit reconnendation of a funding level of $1.3 million. The
conmittea recommended $1,150,000. And Council upped that
level and recommended a level of $1,250,000 which was $100,000
above that. recommended by this committes. etl

DR. SCHERLIS: Was there a reason given?

MR. CHAMBLISS: And I simply thought you would want
to know of those proceedings.

Thank you.

DR. SCHMIDT: Let's take Leonard's question. What

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101

was the reasoning behind this?

MR.CHAMBLISS: The question is the reasoning. And
vould you speak to that, Mr. Posta?

MR. POSTA: I might pass the ball over.

However, actually, Dr. Kamaroff was on the site visit
to New Mexico and did differ with the committee's report and
actually brought in a number of the improved activities which

had taken place in New Mexico in a complete reorganization and

felt perhaps they did deserve a little bit more what we used

to call until this morning developmental component funds. And
that was the primary reason for it to be increased in a slight.

amount.

Is there any cther comment?

MR. ZIZLAVSKY: An additional comment, Dr..Kamaroff —

who chaired the site visit felt it was a little bit stringsnt

and they should have alittle bit more in funds and not in
Flexibility. The actual amount of funds awarded, however, was
more in line with the committee's recommendation.

MISS KERR: I notice on the summary sheet requests,
it is footnoted No. 3, Review Committee rating gavé Connscticut
312 which would place it in the B category. And it was changed
by Ccuncil to be an A region.

I wonder if you could give us the reason for that
or why this was cheng2d?

MR. CHAMBLISS: Let's see, Mr. Nash who is the Chief

 
102

1} of the Eastern Operations Branch -- Miss Kerr raises the questid:
© 211 on the rating for Connecticut.
3 . MISS KERR: The rating changes for Connecticut from
4) B to A.
‘5 MR. NASH: That was raised by Council itself.
eee 6 MRS. FAATZ: That was a year ago,
7 MR. NASH: It wasn't here.
8 MRS. FAATZ: We are reviewing Connecticut again.
Fi. MR. NASH: It was a site visit, by the way.
10 MISS KERR: Well, I notice it was on this shest..
YH DR. SCHMIDT: We will be doing Connecticut so maybe

121] we can hold that off, then.
© 13 Are thers any othsr questions specifically directed
V4] toward the council actions? a yg te
“15 7 (iio response.
16 If not, then I think that dogs bring us to the
17) program reviews. And for those of you who have just. coms in,

18|| the order will be Washington/Alaska, Louisiana, Connecticut,

19]| North Dakota, and Metro D.C., beginning with Washington/Alaska

. —
20] and Mr. Hilton.
2] , (Dr. Ancrun absented herself from the room.)
i *
ae 22 ' WR. HILTON: Ted Mcore from the staff will previde

231 a’ few minutes of introductory infermation using the audio-visual

Se a

@ 241 and then we will go into cur report.
ace= .

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25 DR. SCHMIDT: We will have audio-visual presentations

 

 
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103

on Washington/Alaska, Louisiana, and Intermountain which we
hope will be helpful. And once again, we will want your |
critical evaluation of these presentations.
; MR. MOORE: | We don't. have a speaker, but. of the
3.5 million people in the two States.

(Slide.)

As you can see, this is Washington State. And the
3.2 million people in the population areas of Bellingham, Seattl:
to Tacoma, 80 percent of the population resides in this area
here surrounded by the Olympis Mountain Ranges and the
Cascade Mountain Ranges. The rest of the State is flatland.
And the other 20 percent of the population is in Spokane and
Walla Walle and a few other small places in this area,

One large river, ths Columbia River, stretches 1500
miles into ae and, |
| Next. slide.

(Slids.)

Alaska has 310,000 population. Population bases are
locate here -~ capital at Juneau, Anchorage the largest city,
Fairbanks in the central part with a scattering population on
the coastal regions.

You have the Brooks Mountain Rangss in the north and

th

wD

Alaskan Ranges in the south with Ht. McKinley's 20,000

1]

foot. peak her

Next slide.

 
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allowsd for such meetings... ..

 

104

(Slide.)

The region encompasses 700,000 square miles. As you
can ses, it is approximately one-fifth the land area of the
United States.

Along with the size, the terrain density of population
weather and so forth, you can see whsre this would add problems
to health care planning and health careé services.

Next slide.

(Slide.)

These are air mile distances between the larger

cities in the area of Seattls, Portland, Spokane, Fairbanks,

‘and Anchcrage. As you can see, it is quite a problem to travel

+o RAG meetings and other committee meetings. Three days are
It is very hard to consider that. the time that. we
leave National Airport. in Washington, people are leaving
Fairbanks to attend the same meeting in Seattle.
With the isolation that. contributes to the goals of
accessibility and availability of care, howéver, the pscple
were able to see the Super Bowl via satellite communications.
Next. slidea.
(Slide.)
This is a view of Bethel, Alaska. It is Main Street.

Bethsl, 1500 population, in scuthwest Alaska.

Next slide.

 
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105

(Slide. )

This gives a population percentages breakdown within
Washington and Alaska. In Alaska, of the 310,000 psople there,
you have around 9,000 blacks, you have 52,000 Indian-Eskimos, -
2,000 other, and the remaining is 79 percent Caucasian.

| In Washington, you have 3.5 million population.
71,000 blacks, 53,000 of Orisntal extraction, Indian populaticn
33,000, ramainder Caucasian, or 95 percent.

In Alaska, there is around a 40 percent shortage of
primary cars physicians. they have a total of 320 physicians,
half of whom ars military or Pls physicians.

In Washington they have a little above the national
average of néalth manpower in terms of physicians and hurses.

a Newt slides,

(Slide.)

These are the arsawide planning agencies. There are
7 in the State of Washington. There is one in Alaska in
anchorage.

AS you can see, ths shaded portions are covered.

. 7 basin -
fhe unshaded portions are not covered by any Federal or State
planning health agency. |

Next slide.

(Slide.)

This is a cemposition of the various comnittees,

Washington/Alaska committe¢ss. Some are technical and others

 
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106

are on the broader committee functions. As you can see,
around the populated areas, you have representation in kidney,
continuing education, Community Health Servica, héart,
cancer, and health care technology. So representation flows
with the population bases centered around the university.

Next slides.

(Slide.) _

As a result of some of the earlier planning -- this
is the total RAB membership. There are 46 members in the State
of Washington. This gives a geographical distribution of the

membership. Advice given by the management assessinent team in

February cf 70 indicated that they nesded a larger geographical

spread, professicnal spread, consumer and other groups on the

RAB. |. And this, shows tne geographical spread.

Also, of the 46, 8 members are frem Alaska. And
there are around 9 consumers on the total Regional Advisory
Beard.

Next. slids.

(Slide.

< .
This is the Alaskan Advisory Committee cemposed of

22 members. They assess the health needs in Alaska. And this
is a communication device into the RAB. . Eight of these 22
members ars also RAB members.

Wext slide.

(Slide.)

 
107

1 As a result of some of the earlier planning -- this
© 2 is the Providence Hospital in Anchorage, Alaska -- prior to

3, 1969, there was no super radiation therapy available to the

4) Alaskans. Many cancer patients had to travel 3,000 miles to

5l| other States for their radiation therapy. RHP purchased the.

6 cobalt unit and the community provided the financing and built
‘7|| the facility you see here.

8 In its first year of operation, 135 patients completsd
9|| therapy at the unit’ which was twice as much as had been expected,

10|| Today, 300 to 400 patients receive cobalt. treatment at. this

11] center.

 

21. This is one of the first successful RMP projects
@ | 113i which, of course, have been taken over with other ressources,
4) Let's have the transparency, —
—_ 15 oe ur. alton, would you Like to present. the planning

16] process for their triennial application?
17 MR. HILTON: I think probably, Tsd, we can hold off
“yell on that. planning process slide unless questions arise.

19 Is that the one you are about to show? We will hold

<>
20|| up on that one.

21 Here is an additional audio-visual aid, andl also

92|| have a handout to share with you.

Set

. Basically, our approach to the Washington/Alaska
E
© 24|| region was wnat. might be qualified as a ~~
ae eral Reporters, Inc.

- 25 DR. SCHMIDT: Could you kind of cozy up to that mike

 

 
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a little bit?

things as not providing adequate feedback to applicants. And

 

108

MR. HILTON: O.K.

Our basic approach to the Washington/Alaska region
was what might. be described as somewhat negative in that we
sought initially to identify what the preblems were, what wae.
wrong in the region, understanding from the literature that it
apparently has a rather good history, that. it is really very
highly rated by staff. Still, there were problem areas. And
really, I guess we can probably break them into two typés ~--
what might be called minor league problems, problems, for

example, revealed in the management verification visit, such

there was a quastion at one time about the number of vacanciss
on staff and the lack of an evaluation director and a number of
other preblems.

There were also major concerns, some of which were
not. entirely resolved as of our site visit. And we have some
recommendation as to that these perhaps ought to be watched.

Anong the major concerns as I have characterized
them, there were really five. One question that. arose was with
regard to the future of the coordinator or director, Donal
Sparkman, of the Alaska Regional Medical Program who has been
apparently a very strong leader in the region since it became
active. Hs is approaching retirement age. He has indicated to

us that it is an option that he is not going to pick up and that

 
Waco

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109

he will be able to continue to provide leadership.

Part of that whole package in terms of leadership,
of course, depends on the appointment of a rather strong
deputy director. And we have received assurances that this,
too, would be dona and that such a person is presently being.
sought.

There was a legal concern raised, legal in terms of
RHMPS policies and procedures, with regard to the memorandum of
understandings which the RAB: staff have been drawn up with ths
grantee organization, University of Washington Medical School,
in that the memorandum of understanding includes a stats ant
which in effect says that the RAB can override the grantee

should the grantee decide to fire thea coordinator,

_. And staff called tnat to the attention of thea RAB, @

it is cne of the things that should be called attention to in
the advice letter. And staff should lcok again at that at some
point in tha mt too distant future to see that it has besn
corrected.

There were reports about a possible degrss of competi-

<>
tion between two health education type activities in the

Washington/Alaska region. Ons of them, one that was established
first, called the WAMI program -- that's W-A-M-I which
stands for Washington/Alaska/iiontana and Idaho -- is a coopéra-

tive program in which medical students can come to the

University of Washington for part of their clinical training and

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110

then go back home, and the whole idea being to sort of centralids
this kind of activity on the medical student.

When the local RMP cam? up with another HSEA program
a little later on and sought cooperation of the grantee, there
was some difficulty there. There remains some uneasiness on thi
point, although we were confident after talking with Dean van .
citters of the Medical School and the staff -- we had, I think,
some very helpful open and frank discussions with him on these
problems -- that it wasn't a problem that. couldn't be resolved.
There have apparently been very good relationships betwsen
the grantee and the RHP.

This seens to have been the only problem that can be

really regarded as a significant. problem that has evolved in

the. 6-year relationship. . between the two, bodies. And it.is not

one that we necessarily see as jeopardizing tne relationship
at this point in time. But again that is something staff.
ought to be aware of and be mindful of. .

Phere waS a concern about the degree of planning

input that was bsing received from the CHP agencies. And

: ee
considerable discussicn centered on this point. Répresentation
&

from the Region 10 office was on hand,

Apparently the blame for the problem rests in both
parties, both the RP and CilP. The CHP has not been responding,
making appropriate msaningful kinds of comments on materials as

they come to them for review. And the RMP has not. felt it

 
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Lit

necessary, apparently, to give the CHP sufficient leadership
or respect on their commentary at all. And there has been
this kind of emotional friction between the two.

Again, our feeling was that an advice letter to the.
RMP or an item in the advice letter to the RHP, on this matter
would help to resolve the problem.

It was also my feeling that some similar step
snould be taken on the other side of the confrontation to get
CHP's cooperation a little better. And staff assures us this
will happen to Region 10 staff. It is going to be resolved
that. way.

Another kind of major prcblem we got. involved with
the Washington/Alaska progran centers was on the lack of any

real comprehensible system of arranging operational requests,

of establishing prioritiss.

Now, apparently prior to the visit, some serious
thought had bsen given to this between the time of the
applicaticn and our actual site visit. And some mors thought
had been given to this.

We did spend some time with staff fn which period
a system was described to us. And admittedly, it was a new
system, somewhat. complicated in seme respects, but neverthelsss
a system. Whether or not it is workable, will be workable, :

is something to be proven in time. And again we are advised

that this is something that staff might. look at.

 
° | | | Oo 112

} . These were the major problems. The other problems
© 2 < mentioned that evolved from the management review team,

-3]) problems on feedback letters to applicants, problems on the
All structure of the review bodies, etc., were for the most. part.
5| to the best we could determine -- and we sort. of subcommittesd
él. ourselves to deal with these issues -- were resolved by the
7 time of our meeting.
8}. We ranked this particular region -~- and I say we --
9] the site visit team ranked this particular region. And most.

10|| of the site visit members, by the way, had not had the

 

11|| opportunity to do this before and had not. had-any in-depth

121] background information on the region. And even so, from our

-

© 13] own indzpsndent observations and inquiries and conversations

14 with staff and others who had been participating with the RMP, |
15) we ourselves came up with a pretty high rating. and in talking
16|| to some of the staff, I understand they rated themselves a |
17|| little bit lower. But nevertheless, this has been a pretty

18 good region as far as we could determine in our investigations.
19 ~ They axe requesting funding for a triennial period,

20|| 06, 07, 08 years. Their requests are recordsd on some of the
2) || materials here. This document has a good brief statement on

22 it.
23 For the 06 year, $3,173,000.

ee

@ oA 07, $4,480,900.
Ace ~Pederal Reporters, Inc.

25 08, $4,421,000.

 

 

 
113

| — Our recommendations are that for the first year,
© 21, 06 year, $2,500,000. $3,000,000 for each of the subsequent.

3], years. And we have not involved ourselves at. all with the

 

A" g10° | application centering on the Fred Hutchinson Cancer

51 center there and have accepted their requests as they stand...
6 I can best proceed from here on the basis of

7|| questions which you might want to hold until after Dr. LuginbuhJ
81 has made his comments.

9 By the way, the handout I gave you tends to break

10] those figures down and make it more easily assimilatable.

it Did everyone get one of these now?
a 12 DR. LUGINBUHL: I followed the instructions laid
© 13|| down by our chairman, and I went out trying to smell out the

14|| problems in this program. And in lecking over the material in

 

15|| the meetings prior to meeting with the group cut there, I made
16] a list of areas that I thought we should dig into. And they
17|| included program management, planning process, program evaluatiad
18])/ and the budget. I will comment briefly on each of these and

19], try to be quite brief because I think you did cover then, t.co.
mae .

20 As far as program management. is concerned, Dr.

91|| Sparkman is due to retire. And he was allowéd to stay on one
22\| y2ar on the basis of a waiver by the university. And the head
23|| of the RAG and Dr. Sparkman seems to feel that he would bs

24|| allowed to stay on indefinitely on an annual review basis.

we ® Reporters, Inc.

25 I did have the opportunity to discuss this with the

 

 

 

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it comes to approving projects, thsy do this and then sort of

 

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dean of the medical schocl, and he told me that. it was with
soma difficulty he get this clearance. And I think this is an
unresolved question therefore and probably should be addressed.

There was also question of the continuity of leader-
ship in the RAG in. that the chairman appears to be a very strong
individual and vary capable, is up for reappointment. And I
think they have a limitation on reappointment. He, however,
felt that there were other people that would provide continuity.
And, indeed, there is a waiver provision so that he might be
reappointed.

My impression was that it. had been a very strong
group and there were a number of individuals who were very
important to that group. But. there doss appar to be -the
potential for continuity.

The planning process, as Bill said, we did pursue in.
some depth. md I.think none cf us were completely convinced
that the planning process is as well coupled to the program
goals and priorities as we would wish. I for ons got. ths
impression that they have set up goals and pricrities, but when

aS

relate them back to the priorities after the fact.

I feel that is an area that dcas require continued
attention.
~~.
As far as evaluation is concerned, they have put a

lot of effort into evaluation. I don't think they have solved

 
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the conclusion thesa might be well reduced, especially consider-

 

Lilo

the problem by any manner of means, but I was impressed they
were making some real progress in this area.

Do you want me to talk about budget now in more
detail?

MR. HILTON: Yes.

DR. LUGINBUHL: The budget for the three-year period
as submitted was a total $12.1 million. And the first. year
was $3.1 million, the second and third year were each
approximately $4.4 million. The budget in the current year is
$1.8 million.

I for one and I think other members. felt. it was
virtually impossible to adequately analyze a budget. of this

time allotted. But we did the best we could.

”

magnitude in th:

(

We really felt that we would have to almost delve
into somes of the individual projects and review soma staffing
and staff assignments to tell whether that is a logical budget.
or not. And we just simply couldn't do that as you all can
well imagine.

We reviewed the proposed nsw positions and reached
ing the number of unfilled positicns,.

We also felt that funds could be cut from the
proposed developmental aspects. This conclusion was reached
in part by the realization that these developmental activities

were designed to yield an increase in the second year of

 
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ALU

$1.3 million in new project. activity. And this could almost.
certainly not be funded even if developed.

And we did review their ranking of projects. And
some of them had a low priority. And we felt that. they could
well be reduced. And therefore, we made a cut in that area as
w2ll in our thinking.

Using this approach, the budget for the first year
of the triennium of $2.5 million was recommended and budgets
of $3 million for the second and third year were recommended,
recognizing these latter years would be subject to additional
review.

The increase of approximately $700,000 between the
current. year and. the coming y#ar was theught to be a genarous
award and one that would tax the capacity of the progran.

In summary, I thought it, from my limitsd experisnce,
szemed to be a pretty good pregram and deserved enccuragement.
The strength had bzen because of the staff and the leadership
cf the board. There were deficiencies, and it was impossible
to really deal with effectiveness of individual projects.

We did feel that they could handle“additional funds,
but certainly not the amount that they requested,

‘MR, HILTON: I guess we could hold staff comment and
handle questions.

DR. SCHMID’: Let's go ahead, then. Are you prepared

to make a motion at this time to get something on the floor?

 
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LL/

MR. HILTON: I would move then our recommendations of
$2.5, $3 and $3 million for those three consecutive years.
DR. SCHMIDT: $2.5, $3 and $3. Now, this is exclusiva
of the 910. prejects. That is not a part of it.
MR. HILTON: Actually, it includes the 510 |
projects. |
MR. MOORE: No, no. It includes the davelopmental
component and kidney projects, but not the 910.
DR. SCHMIDT: It does includ the developmental?
DR. LUGINBUHL: And the renal.
DR. SCHHIDT: And renal, but not. the 910.
MR. HILTON: Not the 910.
“DR. SCHMIDT: Then, you are seconding the motion?
DR. LUGINBUIIL: Yes, sir.
DR. SCHMIDT: So that we de have a motion on the floor
I will do three things very quickly. I want to remind
the committes of your rating sheets, these big long things.
The other one is to welcome Phil White.
Welcome, Phil. It is nice te sse your face in the

~ wr
room.

The other one is just for the fun of it. I spent.
part. of last week with Dave Rogers, a good friend of RMP.
We had him out for visiting Professor of Medicine. Those of
you who know what he is doing know why we had him out as

visiting Professor of Medicine.

 
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Washington/Alaska, that visit. and RMP.

‘tha middle range as you look nationally of resources and

 

ils

(Laughter. )

And we spent a fun evening drinking and talking. And
a good part of the conversation revolved around what. I think
has become a kind of a legendary site visit -- the first one
in Washington/Alaska where Dave went. and Martha Phillips went,
and I was there. And this was a magnificent visit. I still
start shaking when I think about it.

But. he spent a great amount of time talking about.

The floor, then, is open for ccmments or questions.

Joe.

DR. HESS: I would without knowing a great deal of
detail about the program, but accepting your svaluation as a
quite good one, concur that the recommended increase of
$700,000 a ysar is a fairly generous one. And I am wondering
about. the further increment of another half-million dollars in
the second and third years.

It. seems to me that is a rather substantial escalation
for a region who though it has problems probably is at least in

se

geographic and other kinds of things which get. in the way of
delivering health services.

And I wonder if you might comment a little bit more
on your rationale for that steep an escalation.

MR. HILTON: Welj, Bill has done an excellent job,

 
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example. Thsy don't have as many RAB members from Alaska becausy

 

119

I think, of recounting much of the thinking of the committee
as we struggled with this item of budget. in terms of some of
the elements he mentioned -- reasonable projections as we saw
them, really looking at what they wanted, really looking at.
their xvanking systems, and in effect in terms of our, for
example, projects budget, working with their recommendations
and shaving that back somewhat.

You mentioned the cost element beacause of the resourca
I think it was very much impressed on many of us that. this
region does have some pretty excessive costs because of the
broad expanse of land territory. And their emphases are upon
not only accessibility which I guess would account for a greater
-- in fact, which does account for the greatest portion of
their budget, but they also have taken into account acceptability
of health care which becomes very important in terms of the
diverse kinds of populations they are trying to serve in Alaska
and elsewhere.

And they do have some considerable extra costs. It
takes them three days travel time to come to.a RAB msaeting, for

. <a

of tha transpertation problem largely.

Those kinds of things in addition to as careful a
study as we could make in time, although thsir projects and
their staffing requirscments really led to that kind of --

DR.HESS: My question is can you justify a half a

 
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120

half a million dollars a year further escalation for those
kinds of things?

DR. LUGINBUHL: Let m2 say at the outset. I really
don't feel that I could go through this budget either in the
first of the three years or in either of the subsequent two -
years and justify it in the kind of detail that I wish I could
give you. I simply don't think you can take a $12 million
program and in two days break down a budget in the kinds cf
detail that I would like.

I think that we concentrated on the first year. And
we did make a very concerted effort in the time allotted to
build that budget up by looking at the staffing pattern, by
looking at the kinds of projects that they had ranked, and thoss
that we thought could be eliminated, what they might reasonably
be able to expand, and so on,

‘They were very ambitious about expanding that program,
and they felt that they would put. a great deal of effort into
the development. of new projects in the first year and then
ask for money to carry them out in the subsequent two ysars.

<= .

I would say that our $3 million figure, the half-millj
dollar increases, is going along at this stage with their hops
they can expand their activities. I would regard it as a very
tentativs recommendation. It is one that I certainly wouldn't
want to have firmly sat at this point in time.

And I can only make a recommendation for any numbsr

 
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fund in the second and third years. I certainly don't. fsel

 

projects. Are we funding hers projects over a long period of

 

Let

with the understanding it is going to be reviewed. And I think

when it is reviewed, particular attention’ has to he given to

)

what kinds of new projects they develop that. they then want. to

that that. should be a firm figura at this point in time.

DR. HESS: We ought to do something about it. because |
that recommendation is a firm recommendation...

DR. SCHMIDT: John.

DR. KRALEWSKI: I am concerned over that budget also.
and I was wondering if you might provide us with a couple
other pisces of information that might help to evaluate it.

One, I would be interested in whether or not they
have some unexpahded funds for this year that might. be carried
over.

Two, the question over their core staff, the vacancies”
they now have. Will they be able to fill those and will they
ba able in your estimation to then add the people that they
are hoping to add to expand it to this budget?

And then, number three, their record of phasing out

brit
time or arse thay phasing out the projects or are these new
ones? And are there a large amount of new ones and are they
all solid projects?

UR. MOORE: Yes. In answer to the first question, we

were told they would be zero balance. Thay would not be

 
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‘their gcod management processes, they have been able to look

‘might show up in anether project. further down the road.

 

L224

carryover funds.

DR. KRALEWSKI: How can there be with all the
vacancits they have?

DR. TIURMAN: They rebudgeted. That is what Judy was
talking about all morning.

DR. SCHERLIS: They knew you were going to ask that
question. —~ |

MR. RUSSELL: Historically, this program has managed
their finances extremely well and have because of discretionary
funds the flexibility RMPs have who have very consciously and

carefully budgeted their unexpended funds which because of

dewn tha road and see what was going to lapse when and where and
plow that money back into the programs.

MR. HILTON: On the question of phasing out, they do
have a pretty good histery of gathering continuing support.
We had ons question about one project, No. 5, which apparently
has been or will be by a set date in fact effectively phased
out. We had some questicn as to some of the resources that

° <a

But they have been pretty successful in getting

continued support for projects.
| You also asked a question about. core staff. And as

I recall our dalibsrations on that, I can only say that I

would imagine the site visit team was confident in the ability

 
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123

of the leadership there to fill the position. We didn't. give
them as many positions as they wanted. We were reasonably
confident they could fill the ones we allowed them to have.

MR. RUSSELL: There are a number of candidates under
consideration now for the deputy position. They have been
actively recruiting.

DR. SCHMIDT: John. ~

DR. KRALEWSKI: Can I follow that with one question?

Under your plan here, then, how many positions would
they have to fill this coming year?

MR. MOORE: We were told that. within two months they
would have the depty director, the director of professional
education, and the director of medical services. So there
would be three positions, top positions, filled within two
months.

DR. KRALEWSKI: How many additional positions would
be in this budget?

MR. MOORE: ‘The additional positions below directors
grade, I believe, are around 15. And most. of those are in
. <ué
community health services, spread out in Spokane and Alaska,
to be above those subregional offices.

DR. SCHMIDT: Bill.

DR. THURMAN: Could you give us just a little bit. of
a rundown on the relationship of the Fred Ilutchinson Cancer

Center? I think the only reason I ask it, and I think it is

 
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which basically is going to go into the Fred Hutchinson. Do

 

 

 

AE

pertinent, is that over a quarter of a million dollars and
going up ¢ach year of this budget. is for relationship to it.
And probably more than that if we really knew.

MR. MOORE: The direct relationship to it is the
910 application which is $66,000 which would provide the
Regional Cancer Council --

MR. HILTON: Are you asking about. the background of
the center?

DR. THURMAN: No, how this relates to it. Because
I think if you look at. several things down here requested for

06, 07, and 08 and add them up, they are half a Million dollars

we understand how that is going to work cr is that just down the
pike?

DR. ‘LuGINBULL: Dick.

MR. RUSSELL: The 910 figure shown there represents
the support of the Regional Cancer Council which will covsr
more than just the State of Washington. We advised the
Washington/Alaska Rep that. we did not think it would be
appropriate for the Washington/Alaska RMP to support totally
the Fred Hutchinson Cancer Research Canter, that Regional
Council,

Does this help any?

DR. THURMAN: It helps some, Dick, but there are

other things like Project 52 that really basically are going

 
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to be Fred Hutchinson Cancer care. And they are worth a quartey
of a million dollars right there. Yet we don't have a building
yet, do we?

_ MR. RUSSELL: No, not. yet. The status of the
building is that w2 funded the one phases of it which is worth
$5 million. NCI has just. recently approved, and their award
is expacted scon for the rest of the building,

So, no, it is not up yet by any msans.

DR. LUGINBUHL: Could I ask a question?

DR. SCHMIDT: are you asking what the relationship
is of the RUP program funded projects in cancer?

DR. THURMAN: Related to the Fred Hutchinson,

DR. SCHMIDT: To thet upcoming center. In other
words, is a good part of the dollars going to the Washington/ .
Alaska Regional Medical Program going in point of fact. to be
spent in that center?

DR. THURMAN: Right. And that is why x think it is
pertinent. Becaus2 going back to Joe's initial question, they
are asking, and we are projecting, a vary large slug of money.

. . ~ << .
And yat we really don't have any bricks and mortar on which to
spend the money. That is a littls bit nebulcus.

DR. SCHMIDT: Those are new projects that you were
adding up?

DR. THURMAN: Yes.

DR. LUGINBUYL: I don't think it is correct to say

 
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we are projecting funds specifically for the Fred Hutchinson
Cancer Center in that we simply gave an overall recommendation.
And I would point out that we did cut $1.4 million out of the
second year and the same amount approximately out. of the third
year. what was obviously not a categorical cut; it is a |

general cut.
I would like to ask a procedural question and that

is if we approve tentatively a $3 million figure, what is the

further review that will occur?

DR. SCHMIDT: I was going to make this point ina

minute in regard to what Joe is saying. The dollar figure that

we put on is in effect a ceiling. And unless Council would)

ovarride our recommendation, the $3 million for the subsequent.

.two years becomes a ceiling which they. could not exceed.

DR. LUGINBUHL: It is a ceiling or a floor?

DR. SCHMIDT: It is a ceiling and not a floor. There
is really no floor. The floor is set by the availability of
funds which is the first one.

And then, secondly, when this comas up, there will be

Pr
a staff anniversary review of the application. And staff will

 

mak2 a recommendation. And we have later on some recommenda-
tions coming before the committee.

And staff, of course, is guided by the instructions
given from the site visits and review committees and is guided

by the concerns expressed by the committee during this discussic
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DR. HESS: Just as a matter of further emphasis, I
don't think we ought to take that ceiling too lightly. Because
what it says in effect is that if there is enough money to go
around and do everything that they could be funded up to that
level. And I think the question that. we have to -= or one
question that we have to -- be concerned with here as we are
trying to leok at the country nationally is not just do they
have a good program and would these things be worthwhile doing,
but. in relationship to all other programs countrywide can we’
justify spending this much mcney for this program?

The site visit team goes in with a narrow view, and

‘wa should take the broad view when it comes here to this table,

And it. is from that base that I have some serious reservations,
DR. SCHIIDT: . There is a real trap here, though, and
that is that the conmittss must act. consistently. And I will
listen very carefully for the committee's actions over a two-
day period because if the committee looks at one region and has
that in mind and then tomorrow morning after a night's sleép
and so on makes judgments without the total number of dollars
, <<m .
available for ths country in mind, then really there is an
inconsistency in the committee actions.
And the business of reviewing and making judgments by
marit kind of irrespective of availability of dollars is

something that Dr. Margulies talked about a little bit this

morning.

 
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128

The decision as to the allocation of what funds
are available, cf courss, is made at a level superior even to
the Council. And there is some balancing here between regions,
depending.on availability of funds.

DR.HESS: I don't disagree with what you are saying. |
In most respects, Mac, we don't know. We won't know tomorrow
yhat. the availability of funds is. But I think there is a
kind of a general fseling or balancing that. we need to try to
do here in terms of looking at both the quality of the RMP staff
and the elements that go into the program, the needs of the
region, the relative resourcss which they have, and so on,

And as a general practice in order to be consistent,
I think we ought to be trying on a national basis to channel
the most help to the reqions which have the greatest number of
problems. And it is that kind of balancing and consistency
which I am arguing.for. And I certainly agree that we ought.
to be consistent, but I think consistent with the broad
picture in mind, what. the overall goal is.

DR. SCHMIDT: Well, let's ses -- Leonard.

a = .

DR. SCHERLIS: I was interested in one particular
project -- the patient care appraisal and continuing education
one. Bécause over a three-year period, that absorbs well over
$l million. And although I don't like to review small projects,

think in view of our discussion earlier today about peer

review and quality control, I would be very interested in this.

 
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three years. This is the plen ground approach,. the tri-cycle

 

LG?

It is sponsored, I think, by the medical society.

I was wondering what sort of a progarm it is. It
is a million dollars, and I think it is worth spending a little
time on.

MR. HILTON: I think we broke ourselves down into
committees, and it seems to me we had some discussion on that
patient care appraisal. And I arm not certain now, Bill, in my

a.

memory, who handled that.
DR. SCHMIDT: Ceci.

MISS CONRATH: This is the implementation on the
tatewide basis on a program that has been going on for about
?
approach cf physicians within an institution determining what
criteria they are going to use for quality of care, looking at
records and determining deficits, implementing an educational

program and evaluating results.
The State medical societies became very much intereste
in it and has undertaken this as their major activity.

About two years ago, they passed a resolution for

. . Baie
assessing a portion of the annual du¢s -- namely, $10 per
member per year -- to help underwrite the expenses of a

continuing education program that has as its goal improvement.
of patient care. And this is their major program thrust.
This is prebably the most extensive program in the

country in terms of implementing on a statewide basis this

 
130

?

1] plen ground approach in community hospitals throughout. the

© | 2| State.

3 . Alaska is also interested in this and plans next year
4l| to implement it. They have a core of faculty; they have

5|| probably cone of the most thorough community crganization schemes
-6ll in the country to really test out the principles of this

7\| approach.

8 DR. SCHMIDT: Leonard, do you want. to push that a
9] Little mors?

10 DR. SCHERLIS: Only if any other information is
1] available. Perhaps you could comment in the view of our

1211 discussion earlier today how this fits in with H.R. l.

© 13 DR. SCHMIDT: Lst's s

14] that or relate that to what must. come along in peer review or

s, do they have plans to extend

yp

15|| PSROs?

16 MISS CONRATH: This is the first cut of peer review.
17|| Itis a peer review appreach. And it prebably means that.

18|| Washington would be able to move, depending on how PSRO

19] evolves. They will have_a cadre of people who are more

, Based .

20|) sophisticated in terms of peer review and also in terms of
9)|| criteria setting than is true in cther places.

at 22 "pr. THURMAN: Ceci, do they have an EMCRO in addition

23 to that?
@ 24 MISS CONRATH: I don't know. I don't think they do.
ce

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131

with the State Madical Society, the School of Medicine, and
RMP, There is a film on it that has been used, I guess, in
about. 25 States -- on the patient care appraisal. We saw
portions of it.

MISS ANDERSON: Does it include the other health
professionals, Ceci?

MISS CONRATH: They are beginning to in the last.
six months through Larry Hulbart and the group. Both nursing
and allied health ars involved and some other projects --
namely, the laboratory projects -- have long-range plans to
interface with the projects. At the moment, it. is physician
oriented, but the continuing education program in nursing is
patterning its approach on this particular program.

~ DRe- SCHMIDT: ; Hrs. ‘Flood. - «>: See gt ta ea is

MRS. FLOOD: I have a question to ask in regard to
that particular project, too, with respect to the $3 million
within a three-year period, Have they developed a mechanism
for the continuation of the program without RHP support?

MISS CONRATH: Namely threugh the Hashengreon State
Medical Association through the membership dues. How this is
going to work out, I don't know, but it has already got about.
$38,000 ayear going in through mambership dues about. the last
year and a half, How it goes in from this point. on, I don't.

know.

 
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et tees Prk get
we

 

132

MRS. FLOOD: Up to $375,000.

DR. ELLIS: That is just about one-tenth of what they

eed to operate in the year.

MISS CONRATH: This is the beginning.

DR. SCHMIDT: Joe.

DR. HESS: I have a process type question. And that
is how did they through their goals and priorities arrive at
a project of this type funded at this level?

MR. HILTON: We took them through the process on a
couple of projects, not. this particular one.

Would it be of help maybe if we went through the
process as thsy do it generally?

DR. HESS: No. I was just curious. This is a very
expensive project for this kind of thing. I am not arguing.

I believe it is: a very excellent _ type of thing * to be doing.
I am just questioning the amount of monsy that is going into
it. And I am wondering if this in relation to all their other

problems and needs is the most effective way to use that much

money.

I am trying to use this as an examS®® of ‘their
decision-making process to see how they arrived ata recommendea-~
jon of that nature bscause to me it seems a little out of
balance with what I would expect. And I just wonder if they

had good justification for it.

DR. LUGINBUIL: As I said, we really did not try to

 
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133

review individual projects. We aid go spend quite a long time
with them on their ranking, their mechanism of ranking. And
once again, as I said earlier, I for one was not convinced that
they had a sound coupling of their projects in all cases to
their priorities and goals.

What we did with the projects, as I recall, is lock
over the list. And our feeling was that there were a number
of projects that were either of lower priority or were very
large in the amount: of funding requested. And rather than
try to make recommendations on them individually, we made an
overall cut. And the overall cut was about $1.5 million per
year in the second and third year.

But once again, I really don't feel that I could
build up a budget, for $3 million .any more logically than I.
could build one up for $3.1 or $2.9 million. I am sorry, but
I honestly don't think I have the kind of confidence in this
figure that I would like or that you would likes.

And I don't. know how you can do it given the nature
ofthe review process. -

<<a .

MR. HILTON: I ama little confused at this point. on
one thing. And, again, in the area of process, we talk about. an
overall, and it was indeed as Bill says, an overall cut. It is
true that we did look at some particulars, but. generally it was
a figura that we shaved out. And we think we built in enough

flexibility for the leadership of the pregram, leoking at

 
LI

1) program primarily, to handle.
© ; 2 | With regard to any single project that appears on the
3| printouts, there is no specific guideline. We could have had
4|| we the time gone down project by project and shown what was
5ll cut out or what percentage was cut cut. But as long as there
6j| was an overall cut and as a percentag2 of one million plus
7|| dollars are extracted, I don't know what. the decision of thea
g|| leadership would be in the face of that. They don't. know yet
. 9l| what we are talking about.
10 But we can't really say that this project, in other
‘}}]| words, is going to cost that much. We didn't say specifically
12 -and have not made it known to you or to them that we are saying
© 13) only 50 percent of their patient appraisal. Maybe they will
14 elect that the million or so we cut. out is the patient.

15|| appraisal.

16 DR. SCHMIDT: Leonard.
17 DR. SCHERLIS: One or two questions.
18 In your faedback session or during your actual reviaw

 

19 site visit, did you have occasion to ask their leadership if

20] they had set up a priority rating so if they got $1 million

21|| instead of $10 million or whatever the sum might be, that

  

~~
vd 92|| they were able to delete certain projects?
23 MR, HILTON: Yes.
© ay DR. SCHERLIS: Did you have presented to you that
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135

MR. HILTON: In fact, we raised that several times
because if you look at. the application, it is somewhat confusing
there. Their explanation which involved a system of attaching
if I recall correctly numbers, weights and values --

MR. MOORE: A, B, C, high, low.

MR. ‘HILTON: A, B, C, high, low. They have a system
which they explained to us, and we asked for a sample of what.
would happsn. And I do recall in this particular area, there
was some concern especially on the part. of Dr. Ogden that. we
ware suggesting what the budget might be. And we tried to
point out we simply wanted to see them go through a dry run of
the project. - | .

DR. SCHERLIS: Can I ask ons more specific question
about. a project? And that is Emergency Medical Services which
looks like a good system except it seems to be sponsored by the
Tacoma Community College. And it isn't just training. It
talks about setting up a total system, grading emergency rooms
and so on. }

And I was just curious, having had experiences locking

~. —
at various sponsors of EMS, this was uniqus, having a community
colleg2 being sponsor.

Do you have any details on that?

MR, HILTON: What project number is it?

DR. SCHERLIS: 64, 064.

DR. SCHMIDT: Miss Conrath?

 
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usual. And in this case, I think this is probably what is

 

136

DR. SCHERLIS: I don't want to belabor the point. I
just asked as a question of curiosity. |
MISS CONRATH: I den't have particulars on that.
But the -plan in Washington is different than in many other
places -- namely, the community college is a recipient. for
many community programs which are not training in which
the community college system in the State of Washington under-

takes wide, broad-scale community activities way beyond the

happening. They serve as the sponsoring agency.

It is a much stronger community force than is trus
in many other parts of the country.

DR. LUGINBUHL: I think the most serious question
about this program is a question about continuity of leadership,
And if indeed Dr. Sparkman doss retire becaus2 of university
regulations and if indesd they do not gat a replacement or sven
now a qualified deputy for him and if there is a significant
turnover in the leadership of the RAG, then I would be very
concerned about the lavel of funding. I frankly feel that
the level recommended would be too high. =

If these problems are not solved as we were told they
would be solved -- we identified the problems, we discussed
them, we were given assurances that they were being addressed -7

if in fact they are not addressed and these basic problems are

 

not solvad, than I would feel very strongly that the funding
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137

should b2 scaled down in keeping with their capacity. Because
I don't feel that without continuity of leadership, they would
have the capacity to expend this amount of money.

_ But once again, I visualized it as a ceiling, but
certainly not. as a floor.

DR. SCHMIDT: Joe.

DR. HESS: Primarily with concern for consistency
with what we have done at past mestings and what. we are
probably going to do in the future based on past experience,

I would like to offer a substitute motion for funding for this
region, something which I think is more in line with what we
have done in the past with regions of similar capability and
similar needs as bast we understand tham under these limited
circumstances. And that is for the first year, the funding be
$2.3, for the second $2.4, and for the third $2.5.

| That. gives them a half-million dollars increment.
over their current level of funding which I think is a fairly
generous one and 4 pretty good vote of confidence in the
program and also gives them a gradual increment of dollars
$100,000 a year ovar whe next three years to“provide for some
expansion, Within those funds, they still have the flexibility
for reazllocating monies as they see fit.

So I would just like to offer that as a substitute.

ene ok,

DR. SCHMID?: The dean here has a great ploy. He

just whipped out a slide rule.

 
e :

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I installed a computer terminal in my office. And
whenever I really don't know what to say, I whirl around and
start punching my computer terminal. And usually when I whirl
back, the person I am talking to has turned absolutely white.

DR. LUGINBUHL: We can't afford that.

DR. SCHMIDT: The computer terminal isn't. hooked up
to anything, it is just a computer terminal.

(Laughter. )

We have a motion on the fleor, than, which I will
accept as a substitute motion. Is there a second?

MISS ANDERSCN: I will second it.

DR. SCHMIDT: All right, there is a second so we are
now discussing a substitute motion of $2.3, $2.4, and $2.5.
and I do two things in this case.

Assuming that the site visit team has looked at this
very carefully as have staff, I ask specifically if anyone
feels that there might be some breakage or some damage done to
let the committee know about this sort of thing if thsy feel
that this would do harm.

; _ —

Mr. Dean, what. does your slip stick say? ~

DR. LUGINBUHL: I don't think that the $2.3 recommenda
tion for the first year would produce serious damage. I would
be a little more concerned about the increase of $100,000 in
the next two years. vhat is about a 4 percent increase, there-

abouts. And I think that the escalation of costs would be

 
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139

probably greater than that.

Their increase in the first year is based in part on
a rather ambitious planning of new projects. And I think that.
if wa gave them $2.3 and they then planned the projects and
had $2.4 the following year, they wouldn't be able to carry
many of them out.

I would be happier to see at least the potential for
a greater increase in the second and third years, although I
think the actual award should be based on an assessment on
how they have dene during that first year and whether they have
indeed solved these potential management problems.

DR. SCHMIDT: Again, as we said, there would indeed
be an assessment. And if theses if's that you talked about did
coma to pass," then the staff. review would surface these concerns

All right, let me ask the staff if any staff has
comments on the substitute motion?

MR. RUSSELL: I have been sitting here trying to
separate emotional reaction and applying it to reality. I
would just like to point_out that this is a program that has
ae —
had, I think, probably ons of the strongest Ragional Advisory
Boards in the country.

The board has been deeply involved. Thay do make the
decisions. Through the review process management. survey,

wa have found out they do have very good management. review

processes.

 
140

1 They have responded to criticism in the past and have
© . 2 in the last, I believe it is, year, Ted, they have really

3|| expanded their community service organization.

:4 MR. HOORE: Subregionalization.

5 MR. RUSSELL: And I guess I am saying I would like.

‘6ll to see them get a little bigger vote of confidence. But I do
Jil think the concerns about this next year are valid, are real,

8 But going along with Dr. Luginbuhl, I would like to

9i| make a plea for greater movement in subsequent years if their

10]) plans do materialize.

nN DR. SCHMIDT: Bill.
12]: MR. HILTON: I was just going to say, Mr. Chairman,
© 13]| £ am following your suggestion and am not. thinking about next

14] year. And I am assuming that is what. we are supposed to do in.
15 our review of all of these programs and to concern ourselves
16l| with the information before us which I think is more consistent.
17|| with what has been the case in tha past before next. year looms
-18l| so close to us.
19 DR. SCIMIDT: If what you are saying is we should

, 7 .
20|| not base decisions on a supposition of what might happen two

21], or three years from now, I would agr2e.

22 * MR. HILTON: Exactly.

23 ‘ DR. SCHMIDT: However, with the triennial review, we
24\| must mak2 a recommendition for the three years of funding.

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25 MR. MOORE: There are about six activities which --

 

 

 
141

| DR. SCHMIDT: Use the mike, would you, please?

© ; 2 MR. MOORE: There are about six activities which they
3}/ araplanning for 1974 which axe not included in the first year's
‘4 request. And these, of course, are patient cars appraisal

-5i| in Alaska, rural health care programs, hypertsnsive programs,’
6 Emergency Medical Services. So these and also health service
7i| s€ucation activities, they are moving vsry slowly as you heard
8 earlier in the health service education activities. But. with

9 the first year's planning through various studies, they had

10]| planned to do some of these things for the second and third

lll year of the triennial. And thess ars the things that really

121 -tock up the half-million dollars in the $2.5 and $3.0.

 

© 13 So they are moving ahzad in these areas for the

_14] second and third year. |
15 | | DR. SCHMIDT: r think we are drawing to the time
16]] where we must begin testing sentiment of the group. If someone
17|| has some new point directed toward the substitute motion, they
18|| may have the fleor. If no one demands the floor, I will call
19], the question on the substitute motion.

. ae :
20 MR. TOOMEY: I would agree with the dean. I think

91| if we are --

NeZ 22 DR. SCHMIDT: Would you us¢ the mike, please?
23 MR. TOOMEY: I would like to suggest to Dr. Hess
@ 24|| perhaps he might change his funding from $100,000 perhaps to
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25|| increase the two additional years to $200,000.

 

 
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DR. HESS: I would say at 5.5 percent. increase annualf

something like that, that might end up $150,000, something of
that nature.

TOOMEY: I think that would be more reasonable.

- MR.
DR. SCHMIDT: A 5.5 percent annual increment is what.

is usually calculated as the amount necessary to meét infla-

tionary costs. This would not give them new program dollars
probably.

MISS KERR: That is what concerns me in view of his
statement in what they are planning in the years ahead that
it is hardly enough room to move.

MISS ANDERSON: Wouldn't they be discontinuing some
propcsals?
MR. TOOMEY: . May I suggest the 5.5 percent ison.
wages? And if you take the whole ball of wax as the Wage
and Price Control Board has looked at it, you are closer to

7 to 8 as far as they ars concerned, although I don't want to
argue about the 5.5, 1.6, or -~-
DR. SCHMIDT: Well, we have got $2.3, $2.4, and $2.5.

<— .
I won't accept another substitute motion. I would accept an
amendment to the substitutes motion.

If not, then I will call the question.

MR, TFOOMEY: I would recommend it ba amended to be
$2.3, $2.5, $2.7.
DR. LUGINBUHL: I will second it.

 
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143

DR. SCHMIDT: All right, I will accept. that as an
amendment to the substitute motion which is proper parliamentary
wise.

Any comments on that, then?

(No response.)

I think it is time to test sentiment, then. We are
voting on $2.3, $2.5, and $2.7.

All in favor please say, "Aye."

(Chorus of ayes.)

Opposed, "No."

DR. KRALEWSKI: No.

MR. HILTON: No.

DR. SCHMIDT: To my ear, the eyes clearly have it.

DR. KRALEWSKI: No, that was the amendment.

_DR. SCHMIDT: Oh, that was the amendment, that.'s
correct. So now we are to the substitute motion. That's right.
Thank you. Which is $2.3, $2.5, and $2.7.

All in favor of that, please raise your hand.

<= -

We are voting now on the substitute motion of
$2.3, $2.5, and $2.7.

DR. SCHERLIS: You have thoroughly confused me.

You control your faculties obviously by not letting
them know what they aze voting on.

DR. SCHMIDT: Wo, I write the minutes. That is where

..cs -IT.am running the motion through.. .I. think: we.are dons, .

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’ SO 144

I control thein.

(Laughter.)

The original motion was $2.5, $3, and $3. We then
had a substitute motion which was $2.3, $2.4, and $2.5. We
then successfully amended the substitute motion to be $2.3,
$2.5, and $2.7.

We will now vote. And if we adopt the substitute
motion, the funding levels then will be $2.3, $2.5, and $2.7.

Is that clear?

DR. SCHERLIS: Yes, sir.

DR. SCHMIDT: Is it correct?

(Laughter.)

DR. THURMAN: Dr. Scherlis is suggesting you ought to
hook up the computer.

es SCHMIDT: The chair declares that out. of order
and what I said to be cerrect.

Does anyone wish the floor before the vote?

(No response.)

If not, all in favor then of the substitute motion

ae
as amendsd please raise your hand.

(Hands are raised.)

It is nin¢ ayss.

Oppos2d, no, raise your hand.

(Four hands wore raised.)

Nine to four vote. The motion carries.

 
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Thank you very much.

The question is do we need a special action on the
910? Who can answer that?

MR. RUSSELL: It is being considered as a separate
application. Yes.

DR. SCHMIDT: All right, then, we have a separate
thing to act on which is the application for funds under
Section 910.

DR. THERHAN: Move their approval.

MISS KERR: ‘Second the motion.

DR. SCHMIDT: There is a motion to approve that is
seconded. Is there wish to discuss?

(No response. )

If not, all in favor, please say, "Aye."

“(Chorus of ayes.)

Opposed, "No." a

“he ayes have it. You have your recommendation.

We will ask Phil to come up and join his old team-
mates at the table. And we will move on to Louisiana.

DR. SCHERLIS: Mr. Chairman, I wouf¥@ submit if you
wars to have a poll for that last vote that. you just had, and I
would urge you to ask that -

DR. SCHIIDT: I have a growing suspicion you are out

een,

of order, but go ahead.

wa

DR. SCHERLIS: No, I question very much whether or

 
146

TH not the people who ~ voted knew wnat they were voting on

© ; 21 with that last bit. Would you please ask whether or not. that.
3]| is indeed so.
4 I, for one, abstained because I didn't know what. the
51 vote was about. Cculd you clarify what. the 910 was?

6 Am I alone in that?

7 (Indications he was not alone.) _
8 DR. SCIUMIDT: If Mr. Hilton agrees with you, we are

9], in bad trouble.

10 Would the primary reviewer please address the

11) question?

12 |) - MR. HILTON: No. I heard other questions like that.
© 13 DR. SCIRIID?: Well, I gave you all at. least two

14]| seconds to comment.
15 MR. TOONEY: Take a moment, will you?
16 DR. SCHMIDT: I will accept. a motion from the flcor
17|| to reconsider that if anyone wishes to make such a motion.
18 DR. SCHERLIS: I would ask for a point of information

19} first to explain what it was, that last vote. I am not being

~~.

. , a
90\|\ facetious. There is somes question here as far as what it. includ

21)|| This is the intent.

-_ ,

: 22 DR. THURMAN: Can I spsak to that, Mr. Chairman,
23|| since I made the motion?

@ 24 DR, SCHMID?: Please do.
sce ~Pederal Reporters, Inc.

25 DR. THURMAN: I think the move for approval of the

 

 
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147

910 application basically relates to somewhere between $66
and $89 thousand that is floating around in reference to
organization structure and continuing communication for
development of the cancer center concept. It does not. relate
specifically to construction funds or operational funds at
the presant time. And that was the genesis of my motion and
the gist of it as well.

DR. SCHMIDT: Thank you.

Judy.

MRS. SILSBEE: No, he stated it very well. There are
two separate applications in from this area, ons having to do
with the Regional iiedical Program and the other a 910 having
+o do with this Fred Hutchinson Cancer Center that is now
bsing constructed.

And in order to clear our books, we needed an action

on that request which is for the first yaar $66,402, the second

year $72,130, and a third year $75,346.

Our reason for asking for that is again shorthand.
The site visit team didn't make a specific recommendation for

_ xe

funding with ragard to this application, although they locked
at it and talked about it. And we needed this action in order
to clear our books. |

DR. SCHERLIS: And this is not in violation of ths
Council's statement. wnich said in addition except as outlined

in discretionary funding policy, no special approvals are

 
143

| required by an RUMP program to carry out activities authorized

© 2 by Section 910? ‘This is not in violation of that?
3 | MRS, SILSBEE: No.
‘4 MR. HILTON: Judy, I have a question. My figure for

Sill the first yser, the 06 year, for the 910 was higher I got out
-6l1 of some of the documents here. I have a $86,000 figure. You
711 said $66,000?
8 MRS. SILSBEE: You are probably talking about total
9 costs. I am talking about. direct cost. |
10 ; MR. HILTON: Oh, I see.
YW MRS. FLOOD: Wo, there was one copy with $86,000, but
12]| that has been corrected.
© 13 MR. RUSSELL: Ted, wasn't that budget reduced after
14]| submission of the application?
15 MRS. SILSBEE: Where is Mr. Moore?
16 MR, MOORE: Yes, it was reduced half-time salary for
17|| Dr. Spielhelz. So there should bs an amendment. in here with

“18i) the $66,000.

ig] DR. SCIMIDT: The figure is $66,402.
~ <a ;
20 Does that give you the information required?
21 Really, my reading of this was this was something
Lf 92|| in a way we were at. least politically committed to.
23 : All right, we will move ahead then to Louisiana, Dr.

ee

  

@ 94|| Brindley.
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25 DR. BRINDLEY: Louisiana, the region encompasses the

 

 
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149

entire State of Louisiana, a population of 3.6 million. They
have three medical schools. The avsrage income is considerably
less than the national average.

it has been an interesting complex to study. They
made the criginal application in June of 1566. It was denied.
They had planning funds in December of 1966. They asked for.
operational funds in 1968. That. was denied. The second
operation application was approved in August of 1969.

In November of 1971,. we had a site visit. Dr. White
was chairman of the site visit and will discuss that some a
little bit later. |

They related that. they were impressed with the sound
deta base and that the planning framework was excallent. but
there were some deficiencies that we would like to show on the
screen a little bit later.

The RMP is requesting $1,040,233 direct cost. This
figure is $40,233 above the Council approved level for the foury
year. And although they were approved last year for $1 million,
they actually received $738,818 for pregram staff and for _—
projects, =

However, in addition to that, they also were awarced
$705,969 in earmarked funds for three EMS projects and four of
the HSEA and a pediatric pulmonary project.

Now, the application for the triennial status was

denied last year. They are not applying for triennial status

 
Vi this year. They have indicated that they probably will apply
© 2 for triennial status next year.

3 | They did have a certification visit to the Louisiana
»4 Regional Medical Program. I have a letter of January 12

‘5|| about that. The visit. was made on December 14, I will give.
6] you a 12-word summary.

7 They thought everything was in good shape, and they
8|| recommended that it be approved. We can look at the details

9] of that if you wish to.

10 A management. survey visit. was performed on November 7

11]} through 10 of 1972. And a number of their items, we would like
12|| to discuss as we project. some of these on the screen, But in

e :

14 ' There does seem to be some room for improvement as

wp

ssence, management seams to be good.

15|| far as program direction is concerned and perhaps in planning.

}6|| But. the management. seemed to be good according to the survey.

17 Now, if we might show some of these, please. |
' 18 (Slide.)
19 I have had a question about whoths grantee was, and I
~ <a

20 will just mention that that in March of 1970, a nonprofit.
21]| corporation of LRP, Incorporated, replaced the Louisianzé
22|| State Department of Hospitals as the grantes. There were sone
23|| problems related to that. ‘The corporation was governed by a

@ 24] 9-member board of trustees, They w
sce ial Reporters, Inc.

25|| according to their bylaws, they seemed to pretty much have the |

rea not RAG members. And

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a | . 151

authority of decidingwho would be on RAG and what the monies
would bs used for.

Our first map up here shows the CHP B agencies that
can see here, And we have four funded agencies -- New Orleans,
Baton Rouge, Monroe, and Alexandria -~ and thrse operational,
but unfunded -- Lafayette, Shreveport, and Lake Charles.

Now, we will try anothsr one. |

(Slide.

Phis shows the projects that have been terminated.
And largely the conclusion is that it shows that. the projects
havs been moved away from concentrating largely on New Orleans.
Actually, nearly all of the projects were in the New Orleans
arsa..

Next.

(slide. )

Here are the ongoing projects thatyou can see.
What is more, now we are becoming much more regional in dis-
tribution.

We have only one statewide project, but 7 subregional

~ aE
projects have bsen added.

Now, can we show the chart?

(Slide.)

This emphasizes the new projects. It does show the

regionalization much better than we have had before.

Next chart.

 
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(Slide.)

Now, Dr. White will prebably discuss again in a few
minutes some of the recommendations of their site review
committee. But to relate to some of these as we go along, the
first one, improved RAG involvement, Dr. White's group found.
that the RAG was not. very much involved, that the grantee
organization at that time was largely calling the shots and
deciding who was going to actually be involved and mostly how
their program might. develop.

After this recommendation and after staff had been
there and related these suggestions to them, three fundamental
committees of RAG had been appointed -- program development,
avaluation, budget and finance. There are a number of othar
subcommittees that have been developed also, but these major
committees have been appointed. And RAG has become much more
involved in the direction of the program,

The site committee did recommend revision of the RAG~
grantee relationship. As I mentioned a while ago, this was not

very tenable. The grantee group and especially the executive

-ccommittse was largely controlling the membersnip on the RAG and

the dirsction of the program.

Now, the grantee bylaws have been altered, and they
have removed this restriction. And the RAG has become much
nore autonomous.

As a matter of fact, the evaluation groups that have

 
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firm data base and a planning progran.

 

baen there have said that now RAG doas seem to be the group |
that is determining the direction of the program.

And in our management survey that. went there, they
felt. this was even so good that it might be considered as a
model, demonstrating the relationships between the three groups 4

Dr. White's group suggested wa should have incraased
minority representation. And it was not. very gocd at the time
that this group reviewed them. Thsy have improved this,
There now are five members cof the minority on RAG and one on
staff. And they have increased the assistance to the agencies
serving the minorities.

There is still room for further imprevemant. We do
not. have encugh sither on staff or on RAG, but they are moving
in the right diraction and do show a recognition of the importan
of this and of the intent.

They have recommended that they clarify the RAP/CHP
implementing and planning agencies. initially, there were not
many funds in CHP and RAG took over the important planning
group in developing the data. And they did establish a very

wa

It. seems important new that. that. largely b= reversed
and CHP would go more into planning as indicated and implementa-
tion be done by RiP. .

RMP has indicated that it wished to take on this

function and CHP actually has agreed to it and is ccoperating

 
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-agencies in gaining another $612,000 in Federal support which

 

 

154

with them. They actually are the sponsors now of some of the
projects. |

Next.

(Slide.)

One of the criticisms was that it become more
action oriented in their program. They had more planners than
they actually did psople who wers developing on program. And
that they needed to stimulate funds from other than RMP sources,

In improvement, we have noted that the staff now has

four project developsrs and three planners. They have securad

$131,000 of outside support, and they have assisted other

is a rather remarkable acnisvemsnt.

It. was indicated they need to refine their goals
and objectives. ‘The goals they had first were large. They
did not have many subgoals. There were very few means of
evaluation, time of achievement, how much was being accomplished,

They have five pages of goals in here which I can
rsad to you, but they now are relevant and understandable.

. 7 a=
They do have systems of recognizing priorities. There is a
gocd criticism there that there is no time frame.

And I think one also might recognize the deficit
that there is not a good method of evaluation of program,

There are projects, but not too much of evaluating

pregress or program. However, it. seems like nearly all RMPs

 
ton,

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155

we review have that deficit, too.
| Criticism was made they needed to develop more

rélevant action plans. And in response to this, there has bsen
a reorganization of the committee structure and staff. About:
five more committees have been appointed, |

The action plans now are developing in primary care,
rural and urban health care delivery and reading to more
relevant projects. Those are a little bit superficial. They
areshowing intent to move into those areas, and they do have som
projects that are related to them. But they are not really as
comprehensive as they need to be yet.

Now, in improving RAG involvement, the orientation
is planned for néw RAG members to include a new group oriénta-
tion. The criticism was made that the group really needed to
find out more about what. was going on in Louisiana and how they
could relate to them. So they are having an orientation
program and a site visit by RAG going to the various projects
and programs and evaluating their progress.

They haves added more CHP and consumer and minority

: a :
representation. I told you about. their forming three new

committeas.

in the $612,000 that have been gained in Federal
support, these were related to the New Orleans areawides Council
on Aging, the New Orleans Sickle Cell Anemia Foundation, the

Naw Orleans Health Development in Charity Hospital to davelop

iD

 
156

| a statistical program.
© ; 2 And the mors relevant projects that they have

3|| developed, some examples of those, are the homebound rehabilita-
4 tion program, the continuity of care demonstration, the extensigr
51 of the Lallia Kemp Pediatric Outpatient. Service -- this is a
6 nurse program -- a family nurse practitioner progran and a

7|| hypertension surveillance program.

se

8 One of their weaknesses is that some of their
9 projects really don't fit into their new emphasis of their

10|| plans that they have outlined themselves such as the training

11|| program for CCUICC nursing personnel, the outreach counseling

 

12||.pregram for diabetics, the care and transport of high risk

e |

14 They justify these as seeing that the psril of the

onat.

(p
(

s and the Louisiana Drug Information Center.

15) high risk neonate is a very first priority. And if thsy can
16|| accomplish this, it will not. only relate a number of hospitals
17|| to the program, but they think it will bring the private and
18] charity hospital systems together in providing what they

19 consider to be a very scarce service.

20 You have had a staff analysis. I asked Dona if

+.

21|| she could help tell us about how they are going to pay for

f
5 22|| these programs after RMP support is concluded. And she has
23|| given me these impressions.
Ongoing procrams: The Metropolitan New Orleans
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95|| Organ Bank Charity Hospital will continue the service. State

 

 
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157

funds in Federal third party payment. ‘The Louisiana Health
Date Information Centar program, State Health Officer says
his office will assume this resources.

_ Tumor registry ccordination and assistance -- Well,.
I won't read all these to you, but they hava means of providing
support for most. of their programs at the conclusion of RMP.
And they have shown recognition of the importancs of this

and the necessity for having someone to pick up the bill. And

I have all these docunented if you wish to look at. them.

The Louisiana Regional Medical Pregram does haves

two kidney disease activities that are included in the staff

-yaview. One of them was the Netropolitan New Orleans Organ

Procursment Program. And this is a lecal organ precurenant
program centered around New Orleans. And it largély relates
to their renal transplant service.

They are requesting $29,295 of direct costs or
$41,344 total cost for their final year of support. And the
review committee that saw them that was headed by Dr. Jiramny
Roberts, the health consultant, thought this was a good program
and that. it probably would be worthy of support.

They did meke the criticism that no significant
efforts. had been made to get third party reimbursement for the
cost of the organ procurement.

The othar cna that they have is a feasibility study

on mass scresning for renal and urinary tract dis#ase using

 
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‘going to be research models of use in private care sector, in

 

 

low radioactive ranal Scanning. And this is for $19,500. and

the consensus of opinion is that this probably was not too

good a program and perhaps shouldn't be worthy of our support.
. That. is included under core and $19,500.

Then, I have from Dona ~~ 7 asked her what they
plan to do next. year, and she has given me these promises for
us to lock at. _

(a) They plan to demonstrate extensions of primary
care services in madically undeér-ssrved areas. Ana they have
undernsath that five ways,

They plan to have nurse extenders, And those ars

désprived rural clinics, and in urban neighborhood clinics,

They are going to work with private care sectors, especially

mo

pediatricians, and they plan to haves an outpatient ambulatcry
car@ in public health clinics as an extension of tha Charity
Hospital outpatient service,

They have access clinics around the parish health

2

4

unit, and those would ba related to the northeast Louisiana

t

<<gm
tri-parish model,

They plan to demonstrate the use of a Charity Hospital
medical:school resident in outpatient care in underutilized
rural hospital. And that would be in April of 1973,

Mobile health clinics in August of 1973. And they

have specific ways in which they hops to accomplish that.

 
159

rH And (b) ~- that is their second major category --
© 9 they plan to denonstrate impact. of expanded third party

3 payer such as Medicaid. And they have PAR study, a State

4|| Department of Hospitals contract, contract with the Calcasieu
‘5 Medical Society, and then next to the last in primary cere

‘6|| strategy, they plan to look into program and develop a strategy
gi for the care of the rural and underprivileged. They have the
‘gi men indicated that will do this. ‘hat. will start in December
“gif or January.

10 and quality assurance, they have both the project and
11] the workshop that they plan to use to try to evaluats quality
12 assurance and guarante2 it improvement.

© 13 As a 12-word sunmary, it seemed to me that this is
14|| an area that does have great need, that has made significant.
15 improvement, that has responded to each of the reconmendations

16 of the site review team and is worthy of support.

They have requested $1,040,000. Council approved

17
18 last year $1 million.
19 I do have a suggestion to make as soon as we have ths
the ume . <a
20|| ° har comments
1 Phil, do you want to talk now or after Dorothy?
22 DR. WIITE: Why doesn't iiss Andarson go along?
23 MISS ANDERSON: I think you covered it very well.
@ 24 I would just like to mantion the things that came to my mind
aCe om e

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169

CHP, And it seems like they are working a little patter with
CHP rather than taking over CHP's responsibilities. And their
HSEA has been developed in cooperation with CHP.

Another area when we talk about minorities, I was a
little sensitive to the fact that there are so few women on
the RAG and so few women on the staff. And I think this is
another area where they nsed to concentrate.

The projects aré very good. Fifty-fifty.

DR. BRINDLEY: Did we mention the extra monies they
got. for the other programs?

MISS ANDERSON: No, I didn't. Go anead.

DR. BRINDLEY: Phil.

DR. WHITE: I think I must. be here mainly to lend
some perspective to the Regional Medical Program of Louisiana.
Your reviewers have given you the details.

I would like to give. you a recall of my visit. I
found myself -- and the other site visitors, I think, agreed --
in sort. of an encrusted reactionary atmosphere rather than

just a conservative one. And I think this is important to

<a

understand because it gave rise to some difficulties in the

genesis of the Louisiana program to begin with and continues
to giva rise to some problems.

These comments are not meant to denigrate the State

ee,

of Louisiana. This is just the way things were.

I think that Louisiana Regional Medical Program was

 
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-the ground. And I think Dr. Sabatier is probably the Christ.

an acceptance for Regional Medical Programs by casting it in

 

 

| | oe 161

looked on with suspicion from the very onset and barely got. off
figure for the Louisiana Regional Medical Program, Ue was the
savior indsed and was acceptable to the professions and
providers of health care at that. time.

But even he was not stalwart enough to plunge into
a great deal of activity. He felt that it was not. wise to put.

too many burrs under tceo many saddles at the beginning and found

the image of a planning agency, a data collecting agency. And
h2 proceeded to do this. And by virtue of that, I think he

was non-threatening in that area and therefore did indeed

3
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bscome acceptabl

{t

I think that even before our site visit, some members
of the Regional Advisory Greup had begun to rscognize that. it
may not be playing the role that it should. Mr. Smith was
the head of a committees at that time analyzing what the role
of the Regional Advisory Group should be, And he is now the
chairman of that group and I think will indeed implement the
changes which are necessary. =

At the time we ware there, there was sort of a
nébulcus shadow-like multiple-headed ereature in the background
which w2 finally came to identify as the Regional ADvisory
Group. We are not. sure they knew what their role was. And the}

ware not sur2 what their role was. And thay were even a little

 
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confounded on why they were there at the site visit at the time,

But Mr. Smith and a few others have taken lsadsership
and at least from the written comments I have available to me
have made substantial changes in the role of the Regional
Advisory Group and I think are taking leadership.

I think their new structure clearly points out that
they do have some dedicated members who will participate in
the establishment of the program and hopefully evolving in the
avaluation of the program eventually as well.

There is no need to dwell on the grantee relationship.

This cams cut clearly in the site visit at the time. The

‘grantees was sort of a patriarchal group that. deigned to let

the Regional Advisory Group meet from time to tims, but not
do tco much. But this has been corrected, I think.

Minority representation -- there were some token
representatives there at the time of the site visit. This, I
think, has been improved and certainly needs improvement more,
I think not only bscause it would be helpful to have their

input, I think it would be helpful if some of these non-white
Bai tod

mat on some of these groups and found out. the problems that one

is confronted with in trying to get the changes made in the
existing systems that. occurred.

I recall my own amazement. and consternation when I
moved from a simple faculty member to the dean's office and

began to recognize that maybe the dean wasn't. the all-powerful

 
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163

figure that we all thought he was and that he couldn't wave
a wand and create changes overnight even though he thought he
could at times. But I think it would be helpful fer minority
groups to sit on a Regional Advisory Group for that purpose if
for nothing else.

It was interesting, as we discussed the role of the
RMP and CHP on that occasion, Neither group really knew what.
it was they were supposed to do. RMP had effectively filled
the role of a CHP, filled the vacuum that existed. We queried
a number of visitors who really felt that. this was the proper

role for RMP, and they weren't quite sure what the proper roles

for CHP was. ‘There was just no clear understanding of what

this was all about or what the relationships should be.

Apparently there is still some confusion existing,
althcugh a coordinating committee is in existence which will
help clarify their respective areas of activity.

I think Dr. Brindley and Miss Anderson have fully
related to you the change in direction that has taken place.
Their projects now ar¢ indeed more action oriented.

. —

I did not recall with great clarity what ‘the goals and
objectives were in the original application prior to ths last.
site visit, but on page 39 of the present application as was
pointed out, there are a number of pages beginning on page 39
which outline their goals and objectives. I think they are

clear, understandable and quite pertinent to the needs of

 
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7 164

Louisiana. And if this does indeed form the framework for
their action, they will forge ahead.

I think also that as they have reviewed their own
projects, they have taken seriously the comments made in the
advics letter and in other cral communications. They have
clearly looked at. each of their projects to determine whether
or not they are relevant to the comments that are made in those
letters and in subsequent advice. So they have taken to heart
what was told them.

I think that perhaps we could be a little impatient
with how they haves expedited these suggestions, but I think
the atmosphere has not changed that. great. There may be a

or them to kind cf subtly invade the care system in

+3
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J+
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program of some sort will provide that without general
threatening attitudes of any kind. Perhaps a drug information
service will provide that and certainly the extension cf the
pediatric clinics, the nurse practitioner and so on will.

So although there may be some question as to the

~ <<

total relevance of sone of their new projects, I do think it is
a méchanisn from which they can enlarge.

I guess the only exception I would take as to the CCU
coronary nursé training which is something that. you have besn

~~

dealing with for years and years, and it doasn't sesm to ever

want to phase out, so perhaps somebody has to take the bull by

 
_ | 165

2 the horns and say no once ina while. And if that. were so in
© 2} this particular case they wouldn't need that extra $40,000 more
3] than they requested above the ceiling Council suggested and

‘4) they could get by on the $1 million.

5 ' Those are about my only comments. I would like to

6] state that I have enjoyed being here today. I used to look

7|| forward to these meetings remarkably well, not because I enjoyed
:8|| all of you so much, but the trips were always kind of exciting,
‘9! theairplane rides.

10 One time I had lunch with Diana Ross. Another time

 

111 < met with a Mr. J. C. Agsrgani who owns racing cars at the
12]| Indianapolis speedway. I think it was time before last I came
© 13] in on one engine. and this time I was with a bunch of
14] apparently Democrats for Nixon from Texas, And they were all

15 coming for the inauguration. And there was a very festive
16 plane ride.
17 The only difficulty was I happened to be sitting
18|| behind a rather generously proportioned lady who did not join
19 into the festivities. And she promptly put her ssat full back
20]; into my lap. And I was kind of sitting there unable to snjoy
21) myself or the festivities and was thankful when we landed

22|| finally and she was able to put her seat. back up and I got here.

23 It is nice to be here. Thank you.
@ 24 DR. SCHMIDT: It is nice. to haves you,
sce e1al Reporters, Inc,

25 he planes will probably be empty going home, I would

 

 
166

© 2 I am watching the clock because -~- let me test ths
3]| sentiment of the group on a very important. issue. How many

All fas] like they must have a cup of coffee in the next little

6 (Hands were raised.)

7 All right. ‘Then what we will do, let's go ahead and
8], get the funding level to meditate on while we go get coffee.

9 I would sugg2st that committes members get their

10|| coffees in cups and bring it back here and wa keep working.

1] . Dr. Brindley.
2]- DR. BRINDLEY: We would like to recommend a level of
© 13] $1 million for one year. We feel that is a considerable

_» 14 improvement over what was. actually granted to them last. year.
15]/ It is only $40,000 less than they have requested,

16 | And then they intend next year to ask review for

17|| consideration of triennial application.

18 So I would move that we recommend $1 million for them

19]| for one ysar.
™ <=

20 - DR. SCHMIDT: Is there a second?
21 , MISS ANDERSON: I second,
f 22 DR. SCHMIDT: There is a second. Is there a wish
23|| to discuss?
@ 24 DR. KRALEWSXI: I have one question. The
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167

1 year was that just a one year?
© . 2 DR. BRINDLEY: Those are earmarked funds, one year.

3 DR. KRALEWSKI: ‘They will not have a need for those

‘All funds this coming year?

"9 - DR. BRINDLEY: They did not. say that. They indicatsd
‘61 one of the programs -- I believe that was the pediatric
7|| pulmonary program -- that Tulane University intends to apply

-8ll gor funds. And the Health Service Education Programs when
9 funds become available. And then they may try to apply for
10] those, But that is not part of the application,

an DR. SCHMIDT: The earmark was a one-shot deal, and

12|| they knew that. So that. this application is to cover that.

 

© 13 DR. BRINDLEY: They are not. applying for any more
Aji. funds, 9. ...+
15 DR. LUGINBUHL: I would like to ask about. the leader-

16|| ship of this program. They have been active since 1966. They
17| still do not have triennial status. It is obvious that there
18) have been problems with this program from reviewing the

19|| material.

. =
20 The amount of money they are requesting is $1 million

21]| for a population of 3.6 million. We just approved the
Ms 22|| washington/Alaska program of comparables population at. a much

23|| higher level, obviously a much more developed program,

  

@ 24 In short, I am concerned that this population may
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168

Is that actually the case, or are there reasons to believe that.
this will develop into a program that will really adequately
serve this region?

_ DR. SCHMIDT: Phil, let me ask you to field that.

DR. WHITE: I was hoping to clarify that in my
remarks that there has indeed been difficulty with this region
because of the attitudes that existed. It has not been 4
lack of leadership, I don't believe.

Well, partial lack of leadership. Let me put it that
way. It has been a lack of leadership by the Regional Advisory
Group, by the citizens who were participating. I think Dr.
Sabatier has been a good leader. I think the staff members

that he has around him ars good leaders, good in working with

the groups, both the consumers and providers .in the Louisiana
- .! eh . toa ie a bie. Ons oot 2 oer oN ea eg bos te - oa :

area.

But there has been a lack of leadership. It has been
at the level of the Regional Advisory Group and perhaps to some
extent at the grantee level, too, and perhaps even to some
axtent at the medical school lavel, but not at the staff level.

; = — .

I think that this is turning around, Clearly in ny
mind, it is. If we wers to dany them what they have asked for
particularly since the additional sums this year, $368,000 or
something of that. sort for the new projects, now are action

oriented projects rater than data collecting and planning ones.

But they would question cur understanding of their problems, thé

 
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169

would question the sariousness of any advice that we sent them 4:
they have ind2ed done what we told them to do and now we do not
reward them by giving them substantial sums to do what they
need to do.

DR. SCHMIDT: O.K., I see there is a need to discuss
this, and I don't think we would be too well served by trying
to jam this many people into the coffee place as they are trying
to slam the doors. So we will adjourn now for going down and

stting coffee. And I would ask the committee members to get.
it. in a cup with a cover on it and bring it back. And we will
try to reconvene here in about. 10 minutes.

(Whereupon, a recess was taken.)

DR. SCHMIDT: All right, to recapitulate, then, we

are talking about Louisiana.

“We have atotion on the floor for funding leval of
$l million Sr one year. This is essentially exactly what. the
Ccuncil reccommended for this year. It. is $40,233 below their
request.

Dr. White pointed out ons $40,000 project in there

that wasn't all that exciting. =

We were discussing the funding level. And the
question has been raised as to the leadership. And the point
has batn mads that the program leadership was really quite good.

It was in a very conservative, more than conservative,

atmosphere, meaning the problems went much beyond the pregram
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L170

staff leadership which has besn quite good.

Yeas.

MRS. PLOOD: I have some concerns about the minority
and really down to earth non-knowledgeable consumer representa-
tion in the development of these great five pages of
objectives and priorities that they developed, And whether
the objectives and priorities are valid is probably not.
questionable.

pr. White has assured me they are valid, and they do

give a trué picture of what need to be done in Louisiana. But

my concern is then that the emphasis in apportioning funding

to projects is questionable that it answers these needs that

they have so well documented in their many years of data

gathering. And 3 if there Was no input from minorities. and ee

consumers into the - aevelopnent of ‘the objectives, then there is
also no constituency to coerce or -- Il “won't use the word
“coerce” -~ to encouargée the Louisiana Regional Medical Program
to spend their project dollars to answer the well-documented ©
needs, especially in the urban poor. And the rural poor, too.
~ . * * s nae +
DR. WHITE: I think the point is 4 valid-ons. It was

pointed out by our reviewers there wes at one time practically

no minority representation at all. ‘These data were accumulated,

These statistics were compiled at. a time when this was an

end in itself, I suppos®

There have been some actions taken to improve this,

 
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171

I think, “rs. Flood. There is at least some minority represents

tion at the present time.

I think regardless of that, the most encoureging thing

to me at least is it is no longer the staff of the Regional

done, but

medical Program which is defining what needs to be

indeed the Regional Advisory Group.

Now, as <I was saying, it depends upon your definition

as to whether you feel the Regional

of consumer, I suppose,

advisory Group is consumer oriented. I think there are 17

out of 44 that are physicians, ana the rest are in a variety

consumer input. at

of walks of life. So perhaps there is some

Perhaps it needs improving. and I wouldn't

deny that.

this year. They were attracted by the

earmarked funds, and I presume spent 4 considerable amount of

time developing what. were presumably first rate programs becauss

they were funded for those funds.

At the sane time, they were trying to reorganize
<a .

their Regional Advisory Group and have substantially done that,

"g youtd -1ske, tp, point, ont toasty, tha, SHES TPES |

 

put nged to do more.

So that perhaps the projects which they ars now

may have of time and

presenting to us suffered from a lack

people in developing them as fully as we would like to sés.

should can't. do it in

oo. + annt+ think this persuade us they

 

 

 

 

 

 

 

 

 

 
172

ll the future.

© 2 This is the beginning, at least. And I think a
3 fairly decent beginning in view of the circumstances that.
4 existed, .

5 DR. SCHMIDT: Any other comments or questions directed

6]) at the funding level?

7 (No response.) 7
8 If no one wishes the floor, then I will call the
9) question.
10 All in favor please say, "Aye."
VW . (Chorus of ayes.)
. 12]. Opposed, "No."
© ae 13 (No response.)
oO TE. ae eee joe Pee hel SETA Ue STP eM
_¥6 DR.HESS:. I would like to suggest that. along with

17] this recommended funding level that. we include our hope that
18|| there will be further vigorous development of programs which
19] are more effectively addressed to the health needs of the
201} people of Louisiana. _—
21 , I reviewed the yellow shests here, pag2s 10 and ll,
f 22|| things that ware pointed cut a year ago. And thsre has been
23) rSlatively little movement. And perhaps that nseds some
@ 24]| reinforcement along with these recommendations to try to move
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25|| the RAG and the other forces there that may be tending to

 

 
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173

resist what Dr. Sabatier may indeed like to do, but. can't
becauss of the internal forces. And perhaps this would help
that process along, try to bring this region up to a level of
funding and the kind of activities they really ought to be
engaging in.

DR. SCHMIDT: All right, that is approval with
advice about the activitiss.

Dr. Ancrum.

‘DR. ANCRUM: ‘This is not related to the funding; it
is somewhat related to what Mrs. Flood, I beliave, said.

I don't. think RMP has defined what they mean by
consumer for this group. And I think frequently it means
anybedy who is net a physician or some health profession.

And. ons, definition I saw for another, program was. that.

a “le wb.

a fee > 2 Ow get

a consumer meant people who ware eligible for the services.

So that. maybe this might make it a little bit better. I think

she is speaking mors of grass roots consumer rather than having
a retired banker who is not a health professional, but not the

type of consumer she is talking about.

DR. JAMES: I could carry that one step further to bs
sur2 thea consumer might sometimes be a provider. And it.
depends what role he is playing in the community.

DR. SCHERLIS: I think the best definition I heard

that excluded previdzr was that by Dr. Speliman. I think you

recall that. He said at best a physician really can't be a

 
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174

consumer, at best, he is a sick provider.

DR. JAMES: In one of the programs that is included
here today, I think there is a description of providers being
consumers. “that is in the role that they are playing on the
RAG committee. And I think that. often as I have locked through
many of he programs in regard to minority interests that if
it is a general opinion that the consumer who represents the
minority must be a grass roots level who is not knowledgeable,
I think that the RAG committes would be better off not having
that consumer on the hoard.

But. I would like to think that this committee would
think. in terms of minority consumers being those who are
knowledgz#able in the field so that they can best contribute.

And that. sometimes is a physician, He might be black or he |.

acts in that. capacity aS a provider and can then support.

DR. SCHMIDT: O.K., I would like not to get too far
into a discussion of what is a consumer for RMP purposes.

ALL right, I will take one more comment.

MR. TOOMEY: I think I would just Tike to join the
crescendo which is kind of a P.S. to the action that has already
been taken and say in different words than Mrs. Flood and Dr.
Ancrum that with the known nesds that exist in the State of

Louisiana, with the onpportunitiscs that are potential through

Rup, that probably are short-~stopped because of the inadequacy

 
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funding level with advice. And the committee has bsen

 

 

of representation of people who ars in need, that everything
possible should be done to encourage the Louisiana RMP to
expand its services because its rate of poor psople, people in
need who are underserved, probably are as great as they are
anywhere in the country.

And I think as a P.S., there should be encouragement.
The encouragement. should come about in terms of gstting a
larger rspresentation of people who can use the services of
RMP. And I think that it is a shame to say, "Here is a
million dollars, you are doing fine."

Perhaps it ought to bs, "Here is a million dollars,
now go ahead and do the work necessary to expsnd the $5 million]

DR. SCHMIDT: All right, I will accept that as a

very valid P.S,..to.what Joe said.that this is approval of a. .

discussing a number of points that should be conveyed to the
region.
Thank you very much, Phil.

DR. WHITE: My pleasures. “¢

DR. SCHMIDT: We will moves on way op in the northeast
part of the country to Connecticut. The reviewers are Dr.
Scherlis and Dr. Ellis.

Dr. Scherlis.

DR. SCHERLIS: First of all, I should express a

certain note of thanks for the various site visits that heave

 
. 176

1] been arranged for me over the years. I think I am batting
© 2{| about. 80 pereent replacement of the ccordinators after I hava
3 been in these areas.

4 And I guess among the notches that. I have on my

5| site visit sleeve would go North Dakota, Oklahoma, and as of

6l| this week, I guess, Connecticut. There is one I have missed,
7|| but that fortunate coordinator was better than you all thought.
Bi} so he stayed.

9 The visit: to Connecticut was one which was really

10|| dons with a great deal of fear and trepidation by some members

Il} o£ our sits visit group.

 

12 DR. SCHMIDT: Pardon me, can ycu hear in the back
@ 13) of the room? If you sver can't hear, stick your hand up.
14 You have to kind of get within four or five inches

ote rar fe,
oe

jg of thee mike.”
16 | DR. SCHERLIS: The members of our site visit group

17|| included Mr. Hircto from L.A. I had the pleasure of bsing

- gi) with him on another site visit previously to Hawaii. Miss

19], Jackson, Mr. Noroian; frem staff Mr. Van Nostrand, Miss Faat2
20 || who is Miss Connecticut of 1972 and 1973, Mig@"Woody and Mr.

2] ricKenna.

ce _ The visit itself a a very interesting one because

22

the Connecticut program is a different program and not just

23

by evaluation of outsiders, but certainly from the point of

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saying there is a great. deal about the Connecticut Regional
iwadical Program which is excellent and deserves a great deal
of commendation.

_On the other hand, there were some aspects of it which
had been subject to a great deal of discussion previously for
reasons that I hope will becone apparent as the discussion goes
on. =

A little reference was mads before about some of the
preblems with Connecticut. And I think you noted its rating
was bumped upward at. a Council meeting. And this, I guess,

basp2aks the fact thers are difficulties in evaluating thse

‘Connecticut progran.

We were there under rather unusual circumstances to

begin with. And that is that they are operating within. a .-

triennium period having been approved by ths Council for

roughly $2.0 million for the fourth yaar, $2.3 for the £ifth

a”

and $2.5 for tha sixth. And they requested an increase in th

Council-approved levels for ths fifth and sixth years. And

a

ct
QD

therefore the si visit was made.
_ <= ;
The setting for our visit was the Naw Haven Lawn
Club, The facilities were excellent. We were told as the

visits began that. we were there at the invitation of the
Connecticut Regional Medical Program and w2 were there becauss
of the fact that they wanted to enlarge their progran aleng

the levels that I have indicated.

 
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178

It also requested a developmental componsnt that I
will get to.

And sarly on, wé were raminded that the Connscticut
program has, and these aren't. words of my own ~-- these are
words that the staff and the coordinator used in describing
the Connecticut program -~ that we were there because this is
the only program in the country that set a grand design early
on and that. this grand design was really what was baing
presented to us to enforce by our approval hopefully of
inergased funding.

And this then was the import of the mesting to either

_approve or not approve the grand design. It became apparent

very #arly cn -- I just want to get some highlights bsfore I
get into the details -- that there was some disagreement in the
state of Connecticut as far as the acceptance of this program.
The state Medical Socisty was represented by an articulate --

I won't say an official -- spokesman, but. certainly an
articulaté spokesman who when he was scheduled came to the

head table with a suitcase. And there was a tape recordsr.

‘And he opened the suitcase te indicate the wealth of material

which is circulated by the Connecticut Regicnal Medical Program.
And this was quite a large suitcase,

And then h2 put cn his tape recorder to indicate that
he would use the taps recorder for his presentation. And I

questioned whether the tape recorder was to be his speech or to

 
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179

be a recording of his speech. I reminded him if wa vere going
to listen to a speech on tapes, I was prepared toe leave my taps
recorder there to listen to his tape recorder.

(Laughter.)

It turned cut he wanted to document what he had said
in some detail in case any questions arose.

Again, another representative speaking on a totally
differant project, the Emergency Medical Service project,
at. the conclusion of it stated he wished to use the time to
make public his attitude towards Dr. Clark, the coordinator,

And again began a rather strongly worded statement. which I,

using the prerogative of the chair, chose to stop, indicating

it was not. scheduled for this, and we would be willing to
receive any statement, in writing at the national office. I
don't know whether you have received this statement or not.
He agreed this was the proper executive statement for
the chairman to have made under the circumstances..
We had equally strong statements made by Comprehensive

Health Planning agencies. There were two, each one of whom

<a .
made very strong statements to the fact that the Connecticut.

Regional Medical Preygram was not. cooperating with them, had

not supported them, was not. giving them an ear. And thes2 were
not. just. objectively given, but I think rather emotionally
given.

It became apparent, though, in questioning them that

 
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180

at no time had they really evolved any plans nor had they
presented any plans to the Connecticut Regional IMadical
Program and that they ware now being very well represented on
the RAG group.

There were also just as strong statements made to
support the grand design of Dr. Clark.

Iam giving this introduction to indicate that. pzople
are not. lukewarm in Connecticut about the Regional Medical
Pregram. You are é¢ither for it or against it. And if you

don't state ons attitude or another, then you just don't. know

that. there is a REgional Medical Program in Conhnscticut.

ch
fu
ct
rT)

Dr. Clark has in his grand design divided the S
horizontally so that on2 part. of the State is allied with the
University of Connecticut, referred to as UCON, the cther
with Yale, and chatmost of the hospitals in the State are now
affiliated with one or the other by way of full-time coordinatoy
And in discussing the success of the program, Dr. Clark
enumerates that over the years the numbers have grown as far

as ths chiefs are concerned and the hospitals are now approxi-

exes
mately 55 and some 25 hospitals. And that as he points out,

the troops ara marching, the numbérs are increasing, and this

vr

has been going on progressively over the last several years.
In terms of the goals as set under the design, there

is no question that cne would have to indicate that there has

besn an amazing success of this program, The number of full-

 
_ _ 181

lis time chiefs have indeed increased, the number of fully
© , 2 affiliated hospitals working with UCON or Yale have increased.
31 And he used this, as he states, as a threshold of fulfillment.
4i| of local medical leadership based on community general
5]) hospitals.
6 And it is this program that he wished to have reviewed
7|| that. he wished us to understand and become familiar with. le
~8i| used community hospitals as becoming community health centers
9|| and that the local leadership would be basad on creating local
10) medical leadership by way of thse chiefs in the hospitals and
1l|| that they would be the new level of medical leadership in
121) Connecticut.
@ 13 He describes this as ramarkable linkags of the
14]) university and of the various hospitals.
15 There ars sequels to our meeting. One is I have
16 received latters from the Connecticut State Medical Society --
17 |} Dr. Hargulies received the original -- indicating that the
18|| words which were heard were, I guass, official for the State

19|| ii¢dical Society as far as what was expressed at our meeting.

. a ~~ . SS
20 MR. TOOMEY: I didn't hear that.
21 DR. SCHERLIS: The Connecticut Medical Society
Md 92|| forwarded a letter to Dr. Margulies stating their attitudes

23|| towards the Connscticut Regional Medical Program. They have

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© 94] felt that. the needs cf the State transcend just the full-time
25|| ccordinators. They felt there are local needs they felt

 

 
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L82

‘obviously should be met and be given a higher priority than

what. the program has been to date. .

Let me review our site visit draft because I think
this will give a more coordinated presentation of some of the
problems which came up. |

As I said, the national reviewers have over the ysars
baen gensrally impressed with the concept of the grand design
as I have outlined it, although there has been some obvious
disagreement. at times with it. But nevertheless certain
criticisms were expressed in the past, and this was one year
ago at the last site visit.

The suggestion was made that. increased attention be

)

given to the further development of outreach activities relating
to primary care.

| Other sources of funds be pursued with long-term
support of university-based regional faculty. I have alluded
to tnat.

That the core capabilities be strengthened and that
in filling staff positions minority representation in the
professional ranks should be given considsration. ‘This has
net yet, by the way, been done.

That. the Regional Advisory Board and Executive
Committes increase or change its membership to include active

~~.

involvement of minorities.

That the Connecticut Regional Medical Program work

 
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183

vigorously to improve conmunication with the Connecticut. State

Medical Seciety Compr¢hensiva Health State Planning perscnnel.

I have alluded to what has taken place over the years, at. least
as reflected in our mesting.

That. a system for organizing the full-time chiefs
be developed and that they pay increased attention to
crsating positive public relations.

I told you the reason for our being there. They
wished additional support for the fifth and sixth year of the
already approved Council levels for the triennial period.

Connecticut also wished this to be dons, to look at
their tetal program. We were there then to assess the progress

they had made since the last site visit and thet as I have

(D

said we review their total prosram.

The grand design has been their basic instrument.
for affecting change in the systam of health care in Connecticut
And they view thsir function as being essentially that of a
catalyst. And there is no question that. they have been somewhat
successful in this regard.

Connacticut is divided into 10 health service areas.
And basically by RNP, but this has now bean agreed to by most
of the other groups such as CHP, Hil-Burton, and sc on. And
the key to undsrstanding their system is to understand the

—~

community hospital viewed as their base of entry into the

system of care.

 
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. 184

Ovar 40 percent of the basic program monsy is devoted
to the support of full-time chiefs and university back-up. So
this is a very heavily based university and community hospital
program. It is a partnership between tha medical schools and
the various hospitals in the State. And as I have said, the
State has been divided between UCON and Yale.

In this State, unfortunately, the Comprehensive
Health Planning has been comparatively new and is just getting
organized. ‘There is a wide disparity as far as the effectivenes
of CHP. And one cf the criticisms which they have made is that.
they have not. been given the documents to review in time.

There was an argument about the calendar on this.

The RMP said yeas they had, CHP said no thay hadn't. And we
have recsived a dossier of some exchange of correspondencs
which I won't have ths temerity to judge as far as who was
told what when.

Suffice it to say thsre could be better liaison and

coordination of their functions.
They have set up full-time formal affiliation
ne . ; ~ 4 oy om . tgs
agreements between the community hospitals, the universities,
and I need not remind those of you who are deans that this is
a very significant support to university function. The
cadre of university faculty, which has been developed is large

which would assist the affiliated hospitals. And the attempt

to set these hospitals up as centers of excellence is really

 
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185

the key to Dr. Clark's progran,

Twenty-nine of the 33 comaunity hospitals in
Connecticut are affiliated with university centers -- 29 of 33.
Seventeen with UCON and 12 with Yale. There were no such
affiliations before tne program. There are now 30 full-time
chiefs receiving partial support which is up to $15,000 for
three years. The total number cf full-time chiefs has
increased from 6 to 50 since 1968. And then these are usually
phased out after a three-year period,

It. should bs emphasized that. this is not just cne

ex hospital. These insome instances gst to be 2, 3, or 4
Pp

ag the hospitals facilities increase and as thsre become

1

neregased demands for this.

fee

Now, we felt that in evaluating this entire progran,
the only real evaluation one could give is the fact. that the |
numbers are increasing. And there are bits of anecdctal
information available. But there is no other svaluation which

one can speak to. And this is, I think, trying to be objective

about it.

Bed 7
The amount of money which has gone into the system

is tremendous. In terms of saying what it has eccomplished,
what would hav2 taken place otherwiss, one can't say.

The affiliated programs do serve the universities
well becaus2 they do Give additional beds, previde for training

of students, house staff, and by affiliation provide for some

 
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186

degres of care on a stratified basis. I am sure it improves
the hospitals themselves.
Whether or not this can be the primes mission cf the
Connécticut Regional Program is a significant question.
During the course of the discussions, Dr. Clark did
indicate that hs thought that the request for the remaining

two ysars of both thse university and community components

were at thsir peak level in the next triennium would ses a

-gradual decreases. There was soma question about this, I

think, in tsrms of how realistic this was in terms cf the

overall goals of the Connecticut Regional Medical Program.

wo

Minority interests, I think, on RAG, it appsars that
there is somewhat adequate representation, but certainly no
evidence that there is adequate minority representation in the
professional group, no minorities in the professional program

staff nor executive committee. And only one of the 24-msember

review and evaluation committees is a minority member,

3

1g members of minorities,

r

I don't regard women as bsi
but they are also inadequately represented. No inadequate
u Y
age
persons of this sex are on that committee.

There is no question that Dr. Clark provides strong
leadership. He has a very devoted, although small, but very
strong program ‘staff. And lr. Morrissey who works with hin,

Mr. Bradley, these are very, we think, strong people.

The statement is in the site visit report that he is

 
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137

personally dedicated to the successful implementation of the
grand design. I would say that that is inadequately a weak
statement. of his devotion to the grand design. Dr. Clark
really views the grand design as being what should be the
model for RHUPS.

And I was told this bafore I went there, and it.
certainly comes across as per his presentation of this. He is
devoted to the concept. He feals it should be a model, that
this is what RHP is all about, and that unless one understands
+he concept of the grand design -~- and ha was willing to come

to Baltimore and spend some time with me to make sure that. I

‘thoroughly understeod the grand design. And I don't mean any-

s devoted to what in Connecticut.

IH:

thing more except that he
has proved to be a very effective link. It depends on your
judgment whether these are the primary needs of Connecticut. and
whether this should be of the highest priority of RMP. It.
has not bsen a successful organizational accomplishment.

The Regional Advisory Group does have six CHP

representatives. We were concerned about the review process.

rae .
There is a very, very, very strong review and evaluation

committee which screens the projects, performs site visits,
cenducts technical and scientific reviews, determines program
relevance and funding allocations and so well documents its
sugg2stions that by we time it gats to RAG, I don't think

anyone would have the gall to dare differ with any of the

 
188

1|| recommendations of the review and evaluation committes.
© 2 | And this was discussed in the feedback session

3i pecause I think it is such a strong group and averything has
-4]| bean handled so effectively and the documents are so
5|| impressive, there is no way I think for RAG to-really become
él| as mature as it should in passing judgment on making decisions
7|\| as far as what should go on in that area.
8 The grantee organization is yale. And apparently

.

9|| this is satisfactory and in line with RMPS policy.
10 I have discussed the medical scciety in CHP. This
ll] is a very, very difficult relationship and ons which has not
12|| been solved ovar the ysars. I think Dr. Clark's attitudes that

@ 13] they are forming a new power basé through ths medical leader-

 

14]| ship of the community hospitals has to be taken as an attitudes
15l| which he has to express in terms of what has taken place.

16 There were somé projects presented to us that

17 concerned us. There is an ENS pregram which is being formulated
18|| They have gathered some good data, but in questioning the group
19] -- and Yale has’ been very helpful as far as getting data for

20|| many of their studies -- it became apparent. at their emergency

2111 system is alinost purely trauma.

22 In asking whether or not -- and here my personal
23 tas came out -- I asked what the cardiac input was to the

Emergency Medical Service program, And there was a moment. of

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25|| silence. and then tney stated they are still in the planning

 

 
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189

stage, but along the ling somewhsre they would get. some
cardiac input to this.

Is this your impression?

MR. ROSE: Very much so.

DR. SCIIERLIS: And their stating that they had
probably done the best. job of anyone in the country as far as
avaluating services in the emergency reoms and so on.

I asked two questions. One, if there had been any
feedback of any of that date to the hospitals. And they were

thinking of doing that and hadn't. decided if they would.

They had gathered data and really hadn't been able

‘to make use of it.

So I think they have a long way to go, but apparently
the people2 who are involved with this I think can with some
planning money move along in that. regard.

I should say that one of the CHP agencies, the
South Central Agency, provided one of the best reviews we saw
provided by any CHP agency. There is unevenness, but this

agency was a very effective one.

<ae
There is a peculiar aspect of their developmental

request. And that is that we had presented to us two projects
by two individuals wnich were pressnted beautifully in terms of
what. could be looked at as model types of programs.

One for mulriple hospital ambulatory pediatric care

system, the other forlmspital-based medical care system for the

 
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bev

elderly by two extremely knowledgéable groups. Dr. Markowitz
was one group and then there was another.

I am wrong. I forget. Not these two. I forget the
two who presented them, But both of these men were excellent.
They presented their systems, and they have bean introduced as
presenting medel systems which the Connecticut Regional
Medical Program would then submit to all of the different.
hospitals in the State. And they would all come in and say
whether or not. they could handle it. And there would be some
méthod of determination who would get the programs. This is
how Dr. Clark had presented it.

But in asking each of these individuals, it became
apparent that each was presenting something he was ready to do
and set it up for his own area. And they were both upset that
this was going to go out for others to bid on.

They really should have bsen submitted as projects
and would have received the whole-hearted endorsement becauss
they represented excellent outreach pregrams involving the
potential and in many instances good community support. They
_ ~ . <x
had been excellently researched and had the potential for good
staffing.

And it gets down to how you define developmental
component. We did not think these were developmental component

These should have been projects which ware ready to become

(D

rational.

Q

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Ok

We spent two full days there. And I think the
committees came away with, I hope, a full understanding of what
the Connecticut Regional Medical Program has been and may very
well continue to be unless there is firm indication that. there
is tine to changs from having 30 or 40 or 50 or 60 full-time
men in the community hospitals and having most of the funding
go to the universities and that this is a time where decision
had to be made as far as changing direction of the grand
design of the Connecticut. Regional Medical Program,

And we made sevéral recommsndations at the end of our
meeting which included the following:

Number one, thay should reconsider the goals and
priorities in terns ef developing efforts in community outreach,
this sounds like what. they said a year ago. Although they
had developed an excelisnt network through their system of
university-hospital affiliations, these should not. be
supported furchsr as far as any expansion is concerned, but the
new programs were available as shown in beth their supplemental
and davelcpmental components and that. these should be supported
in preference to their expanding university and hospital
affiliation.

That. they have to set up some criteria for measuring
the effectiveness of the full-time chief system. I don't see
how one can measure it, really, but they have to at least try

to do something and get some data which they at least can say

 
oe
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State Medical Scciety because this is a must if they are to be

 

 

means it has been successful or not.

That they nesded a more affirmative action plan as
far as employment and training opportunities for minorities
and women.

That. they should make their RAG more responsible
in program decision-making.

That. they should do and we suggested a task force as

far as Connecticut Regional Medical Program and Connecticut.
g

able to affect that area.

And that their B agencies "have to. come into some
agreemant with Connecticut Regional Medical Program about
details of logistics of review. And that their evaluation
needed a better coordination.

We suggested some levels of funding which I don't
want to refer to at this point.

I do have to give a follow-up which came to us as a
surprise -- namely, that Dr. Clark submitted a letter indicatind

that he wished to leave his position as of May lst and was

Cm
is

willing to serve until that and to be an advisor after that

until they got someone who could handle his position.
I don't think this really reflects on any hostility
or animosity at the site visit. We certainly did not feel that

way. We think that in Connecticut, and we told them so, the

network he has set up is a most effective one for the mission

 
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would have liked to have been on the program to have expressed

 

193

that he had defined and the Connecticut Regional Medical Prograr
had defined.

I can't help but feel that the obvious need for this
working with the Medical Society and with Comprehensive
Health Planning, this probably played a role. ‘Of course, this
is no better off than it was before. And at an open meeting,
it is embarrassing to hear the sorts of things that. were said

at this meeting by both of these groups and by others who

this.

I would like to leave it here and then give the sums
recommended after there has been additional discussion.

Hiss Faatz.

MISS FAATZ: Dr. Ellis is secondary.

DR. SCHERLIS: Oh, I am sorry.

DR. SCHMIDT: Dr. Ellis.

DR. ELLIS: I did not have ths advantage of making a
site visit, but I would like to just make a few comments -~

maybe just really one.

ut
I think that the grand design which really brings

togéther the community hospitals with the teaching services

does provide the opportunity for bringing about institutional

change in the way health services are Géelivered to the pocr.
ee :

Because it will only be by utilizing the community hospitals

that these kinds of people can be admitted in larg? numbers

 
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194

to teaching hospitals.

In some of the States with which I am very familiar,
one of the big problems in getting poor psople admitted to
hospitals is that you have no full-time staffs. We have nobody
to take care of them, Medical education and health in general
ispoorly funded. And so ws can't take them.

I think we would all agree that this certainly‘is
institutional. change. And what we are simply saying is that
the grand design could and must be extended to do some other
things.

Now, I have listened to the wonderful discussion that.
Dr. Scherlis made and really can't add much there. But I have
heard over and over again that minorities have not. been involved
in this program and in many other programs. And it is one cf
the things that I spent my time with every week, at least.

‘I think that maybe one of the things that needs to
be recommended in addition to what we have recommended is
that there be some gecial consultation on how program leader-
ship that. is not leadership of the poor or blacks or browns
cr reds or poor whites -- and we don't understand the culture --
on how we can communicate with those groups and actually find
out what they are thinking and what. their needs are. I really
am not impressed that the kind of communication which takes
place between ths groups is done in a way that puts both the

leadership of the program and the people being served ina

 
195

] position so that they talk respectfully.

© 2 This is a serious problem. And I therefore would
3 suggest the use of specialized people with special skills in
4 cross-cultural communication to be brought in as consultants |
5 to the program director so that they can immediately move in
6 the right direction.

7 Then, the other thing I thought it was interesting
‘8 pr. Scherlis brought it up, but he aid not. mention the kinds
Ol of things, you see, that we are still talking about. like the
101 need for health education in primary and secondary schools in
i the State. This is the medical push.

12 If you do not have community hospitals to whom theses
© ; 13 children can be referred for services, you don’t. gat. anyplace
14 either. So it is just a constant up and down kind of thing.
15 DR. SCHERLIS: Let me respond to ong point which you
16 raise which was troublesome to me as well and to our whole
17 group. Imagine if you will that most of the hospitals now are
18/1 affiliated and indeed the full-time chiefs have bsen funded
19 through Regional Medical. Program, How wonderful this would b=
=
20/S£ you could utilize that network.

21 , Well, Dr. Clark had about three of his full-time
92|| staff there who were working in the various community hospitals

23|| to discuss what they did in their hospitals. One such person

  

@ 24|| spoke and obviously @ very capable individual. And after he
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196

what his hospital was like and how they had upgraded the level
of care in the hospital, I said, "What is it that you do for
which you are supported that really fulfills any of the
Regional iledical Program aims in Connecticut?"

I would still be waiting for the answer. And it was
embarrassing because the silence was absolutely formidable.

I think it is the first time he had ever been asked what is
the Regional Medical Program in Connecticut about. And this
in many ways answers the question that you posed.

I think that the relationship tc the community
hospital can be utilized as one cf the best networks I know
anywhere in the country for really affecting outreach by the
hospitals, for looking, at a system of peer review in each. of
these hospitals to look at quality of delivery of care, It
hasn't. been dene in this way.

These individuals in their own hospitals serve
several functions. They attract house staff. They maintain
training of house staff. Students rotate through. And the
help teach the students. In one or two instances, maybe a

a
few more, it may even be beyond this, but there is no attempt.
to even form these people into a cohesive group.

We suggested that there might be an organization of
such dirsactors working with Regional Medical Program to
establish an organized basis when it would occur, The

orisntation isn't that way. The orientation is to have more

 
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137

chiafs in the community hospitals affiliated with the
universities. And it is sort of the university responsibility
to saek out ones to work with them.

It doesn't take too much alteration to affect the
sort of things you referred to.

DR. ELLIS: No, it doesn't. It really doesn't take
much. It just. takes an insight into how to pregram. You could
pull these two things together very easily, I think, if you
knew how to communicate with the people. .

DR. SCHMIDT: Eilsen, do you have any general
comments before we do get a motion on the floor?

MISS FAATZ: No.

DR. SCILMIDT: All right, then, back to Dr. Scherlis.
DR. SCHERLIS: No comment, after all your years with
Connecticut?

MISS FAATZ: No, I think you covered everything.

DR. SCHERLIS: If you differ, I wish you would so
state. |

MISS FAATZ: No, I don't.

7 Ra .

MISS ANDERSON: Dr. Scherlis, did thsy show any
interest in being flexible or adjusting their roles from the
old patterns?

DR. SCHERLIS: We had a feedback session, And at.

the f2zedback session many of the positive points were referred

to. The success of the full-time chiefs, the increasing

 
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198

number, the good affiliation and acceptance of the community
hospitals. This is an important aspect. They do accept. and
they do welcome this. There is no question they benefit as
well as the universities do.

But as we pointed out to them, and I headed this in
our site visit feedback as the dilemma of the site visit group,
we cannot discern any attempt. to set. priorities as between the
new programs which had been presented to us under the
supplemental development component and getting more full-time
chiefs. We wanted to know if he had another $500,000 would he
get another 30 full-tims chiefs or would he davslop some of
these developmental components or fund some of the ones that

had .bsen presented

And. I, guess we really don't..know-what. he .
would do under these circumstances unless there was some
firm indication.

We have no idea at what point in times he will say
he has enough chiefs. Because those hospitals that have one
would like to have two. And those that have two would like

to have three. And those that have three would like to have

ae

“four.

And the point that we mada vsry strongly was that.
as far as our recommendations are concerned, we felt that the
point. had now been reached, and he was told this in the feedbac}

session, that the medical schools and the community hospitals

would have to find alternate funding as far as any @xpansion

 
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level fund the projects and no more chisfs.

 

buy

of this program.

Now, as far as dollar marks, we have a dilemma.
Remember, I said at the beginning we were there at his
invitation. We were there to view the grand design because
they wished increased funding. A lot of the increased funding
could go to expansion of the full-time chiefs all thrown in
with these other primary projects.

What we recommended is that they fund these new
projects, not as developmental, but as real projects including
he supplementary ones. But they do this at the expense of
their full-time chiefs. So wa recommended no increased funding,

no developmental component, but that they with their same

And I guess the response, I guess Dr. Clark sensed
that in our discussion. This may be the reason for the letter,
Dr. Margulies. I am not privy to the exact reasons for it.
But I don't think we should consider that in our decision.

DR. SCHMIDT: Let me be sure I understand now. The

previous levels that had been approved were going up.

ae
DR. SCHERLIS: Let me tell you the full recommendation

DR. SCHISIDT: Yes, let's havs that.
DR. SCHERLIS: We recommended that for the five years,
they receive $2,332,820 which is what had been approved before

instead of the $2,737,000 they had requested. And because

of the nature of our recommendation that they be site visited

 
 
  

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Pye gtee: Sigedl eae

$2,332,820 as you “said. And then the next: _ year $2.5 million.

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200

again for the next year.

I did this knowing full well that the request. might.
be that I would be one of those site visit crews. And that is
not a trip I would relish. But under the circumstances since
this does require a complete change in their program direction,
we did not feel that they should have two yéars without a
site visit. And so, therefore, the recommendation was for
one year approval and that we come back before the sixth
year.

I don't see how else we can move into this, The
grand design is there, but it has to be altered if there is
to be any change at all in direction of the CRHP.

Dh SCuNEDD The Council rec cnmends da for year 02

er C :
ape SN ed eh start viet oh a fee ae ste wo ee at y os. me ete ei ty + ele gett tome
: : : -

DR. SCHERLIS: We are only going along with
$2,332,820 with the significant recommendations that we have

made as far as program change

DR. SCHMIDT: With then a site visit before the
$2.5 million year.

DR. SCHERLIS: Yes. I don't know TSw else we can
handle that.

DR. SCHMIDT: Is that kosher now? They have been

approved for the triennial.

‘DR. SCHERLIS: The Connecticut program is one that

has excited a great. deal of interest in both the review

 
 

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4 wa,
Leta file:

 

201

committes and council level, I take it. The point that even
their rating gests bounced upwards at Council mseting.

If we appreve for two years, there is absolutely
no indication in sight that they would not continue as they
have been, funding new full-time chiefs instgad of getting
involved with additional projects.

If you have another mechanism to assure this, such
as a staff review, I would certainly prefer that to a site
review. But now the fact that they are also getting a new
coordinator may make it even more imperative they be seen at
thea end of this ons yar.

I would like to have some direction on this.

DR. SCHMIDT: I just want.to clear. the point.is. ..
bee Pita tte Pan Dt pare tat Dae Un ee PECTS II bee Pete :

Ne eg OL ett eed eee Bas
eed oS Medan alt ws

what he proposes legit?

MRS. SILSBEE: Ws don't have any precedents for
this. But in relation to the reason the site visit was held
this year, Dr. Scherlis, in terms of the fact that Connecticut
requested developmental, that. wouldn't automatically call for

a site visit. The fact that they requested more monsy wouldn'
: <=

“call for a site visit.

Actually, the reason the site visit was held was
because Dr. Clark requested it. And after much deliberation,
we dacided --

DR. SCHMIDT: Are you going to stick with the word

"request"?

+

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MRS. SILSBEE: After much deliberation, we decided
the only way we could handle this request, knowing about. his
program, was to send a team up there to see whether any of the
things that had been suggested in terms of changes had occurred.

DR. SCHERLIS: Thank you.

DR. SCHMIDT: All right, Dr. James and then Dr.
Luginbuhl.

DR. JAMES: There is something that bothers me in
regard to what. is afoot here. I hear you stating that there
was a Meeting with representatives from the State Medical
Scciety, but he was not an official representative, he did
not represent the medical society officially.

I wonder perhaps if there is not in this grand design

tog ete et te we
wt fee ee .

an area of threat to the private practicing physicians
represented by the State Medical Sociaty that looks like there
might be a town and gown taksover of the private practice of
medicine that possibly could cause some anxiety among the
State Medical Association people.

Yet, if what you are saying that the grand design

-does represent an institutional change in th®™delivery of healt!

services, what is it all about?

And relative to a continuation of the old, if there
could be some clarification of somsone here today relative to
wnat is the stance, s-t-a-n-c-2, taken by the State Medical

Association and the CHP agencies and the other agencies in the

 
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‘thing for the Stats early on. And there was not. a CHP in

 

203

community, is it that the university and thse community hospitalg
who are for the first time moving into delivering a community
service, something that should be continued or is this
something that offers a threat to private practice of medicine?

DR. SCHMIDT: If I might try to tackle that one
myself, I think from the beginning the grand design was somethin
that. was held up by the Connecticut RMP as a model. And
certainly Dr. Clark who really kind of devoted his life to
this general subject of regionalization considered this to be
the best way to go in Connecticut.

The Medical Scciety very early on did not necessarily
agree. And indeed, they did look on this as a threat. And in
the past number of years, there have been various number and
kinds of steps taken by the Medical Society, including
telegrams in requesting there not be any action until they had
a chance to be heard. There have been special visits of the
Director of RUMP to Connscticut. There have been meatings
up ther and so on,

And as someon2 said, the RMP really did do the whole
evidence.

What has happened gradually is that people got used
to the grand design, The Medical Society and RMP are kind of
settling down into some kind of a coexistence, The Hedical

Sociaty is awkward about stating its case. And what really

 
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happened was that the official representative. didn't show

at the site visit and the site visit team was a little confused
as to whsther they were hearing an individual dector and

chose to hear the doctor that did come as an individual rather
than an official representative of tha Medical-.Socisty because
he had not been so designated and they were just left without
this official voice.

CHP is struggling, and the grand design in a way
umbrellas some of the things that ordinarily CHP would do,

I think that the site visit team is suggesting that
the RMP must do some other things and not ksep expanding this
grand design in the way Dr. Clark might. And so we are
obviously in the recommendation putting a stop to that, giving
them strong advice that they implement new types of activities
and do this with the funding that they might otherwise have ussd
to further what indeed the Madical Sccisty has in the past
objected to.

The question you asked could be answered with the

word "yes," but I doen't think that anyone would necessarily

imply by that yes that the Medical Society we" right and the

RUP was wrong.
As I take a long view of the Connecticut situation,
it is that they are kind of settling down and in a little bit

more, perhaps they will have settled down into a relationship

that won't create all of the sparks and so on that it. has in

 
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-happsns to be there.

assumed to be criticizing the values of such relationships and

 

 

the past.

Is that an unfair statement?

DR. SCHERLIS: No. I think to assume that you are
going to change either the delivery of health care or make it.
more accessible on the basis of the network that has been
described for Connecticut is an assumption. It isn't set up
to do that. The purpose is not to accomplish that. And unless

the goal is altsred, it won't do it merely because the network

Being university based, were I a dean, I would relish

the financial support that RHP is giving. I in no way should b¢#

affiliations with community hospitals. I think it is very
important. I just question whsther you should use 40 percent
of Regional Medical Programs money in order to accomplish that
when there are other needs.

So you know I am waring two hats in this as I am sure

the chairmen is and others around this table.

is ther

@
oO

DR. JANES: The only question I would hav
~ <a
any evidence where there would be a takeover of the funds that
ware initiated by RMP, say by the universities? Is this
possible? Or is it possible through any other agency? So
where RMP may have initiated this and certainly if there is

evidence that further chiefs would be funded, there must be

evidence for additional health care nseded in the communities.

 
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thet a certain number of these full-time chiefs every year

_ funding this.

 

 

I wonder could you comment in regard to whether or
not there is evidence for continued support on the part of

other agencies?

DR. SCHERLIS: Two responses. One is I did indicate

have reached the three-year period of support. And they get

supported through other funds.

—

The Blue Cross representative was there. We, of
course, asked can you include into the cost. of care of a
patient in a community hospital the cost of a full-time director

And he said of course® you can. So there are other ways of

and 1 think thet whether or not such sources are ther?
is an issue. Whatever is done in the educational basis may
nave to be supported through the medical schools affiliation.
And one could really question whether you nesd 29 of 33
affiliated with a medical school, It may be wiser for the
medical school to have a smaller number and concentrate quality

in those.

DR, SCHMIDT: Mr. Toomey. a

MR. TOOMEY: Yes, one question and then a statement.
And let me ask the question first, please.

Did you have any input from the hospital end of
this program?

DR. SCHERLIS: Yes. When the various hospital full-

 
  
 

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toured

ime chiefs were there, Girectors of the hospital usually came
with them. Theare were representatives from Hospital Associatioy
They spoke strongly in favor of this as you might. gather thsy
would, | |

MR. TOOMEY: The statement is really it is a strangs

thing, but hospitals are changing in terms of (a) moving
away from the community, (b) moving in an attempt to parallel
the changes in medicine which, cf course, are more finite.
They are greater, bigger pregrams, more equipment and this

kind of thing.

The medical schecl is making a dual attempt as I see

it. at the moment which is to move ahead in terms of research,

knowledg?, education, and to move backwards in terms of primary

care through their community practice programs. Hospitals

,

hav2rt achieved this yest. They are still at the end of the

Mb

spactrum in which they are attempting to provide more complex
and complicated services.
And I am really in agreement with you. This is not.

the mschanism to be uséd in order to gst services to people
. . ~ <u i,
in the community who are underserved. Becauss the ‘community
hespital is really now a misnomer in my opinion.

DR. SCHMIDT: Mrs. Flood.

MRS. FLOOD: Well, historically, this review body

has criticized and sent strong advice to other regions who

have augmented the staff of university settings through their

 
 

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manpower issue. And there are data that would suggest that

 

in the hospitals, though? Are medical studefZ8 actually in

 

part-time coordinators of categorical areas, etc. And I see
really no difference in concept. from the actual formal
university setting, medical school setting.

And then, too, this affiliate health delivery
institution in the community hospital. And I just. don't find
any other comment to make except to firmly feel that they should
be urged to discontinue this and perhaps even sooner than the
triennium completion. 7

DR. SCHMIDT: Well, I don't know. I think if you
look for firm evidence as to what this sort of thing does,

you really gst into principally the distribution of health

this sort of thing might do something with the distribution.
If they are putting medical students and residents across the
State, then there is evidence to support the contention that
this will distribute health manpower and services across the
State,

Dr. Luginbuhl.

DR. LUGINBUHL: What about the effect on health care

all of these hospitals? Are these full-time chiefs of services
doing teaching of students? Have thsy developed residency progr
Are they delivering care to the indigent in their communities
or are they simply supervising the guality of care that is

given to private patients?

 
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‘take a hospital and put in a knowledgeable individual who is

 

 

aU

What is the actual effect of these full-time chiefs
in community hospitals?

DR. SCHERLIS: You are asking me the very question
that we would like to have information on. I can give you
numbers. I have tables here which show how many medical studen4
there are in each one of these hospitals and so on. In terms
of whether or not -- you notice, they are clustered around
what are the two or three chief teaching hospitals. But you
do get soms distribution in some of the others.

In terms of doses it. affect the quality of care, I

would hava to assume that it must. I would assume that if you
+

going to be chief of medicine, he is going to ride herd and he
will attract house officers, he will get his own hcuse in

order before he gets into teaching students from the medical
school. Once he does this, then he can be thinking about going
into the community.

The question that I raise is is this essentially the
goal of the Regional iedical Program to the exclusion of other
at .
goals? I think it is good. I think it is great. Being in
a medical school and needing teaching beds, I think this is
fabulous. and if I could get funds from RMP, I would be after
it.

I think, though, it is a cuestion of the overall goalg

and priorities of a Regional tedical Program. Should this be

 
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oa kh

first? That is the only point I am making.
DR. LUGINBUHL: If this dces become first, lst me
know very early on so I can apply.

_DR. SCHMIDT: You missed out because you had been
all the way back with Connecticut's grand design as one of the
early programs and get it established then.

Of course, they defend it as vigorously on the basis
of the planning of the Connecticut grand design by a number
of committees and so on that they set up.

Bill.

DR. LUGINBUIL: It may be a very worthwhile program,
but I really must add my voice to those that are expressing
concern over the appropriateness of this being maintained in

the Regional Medical Program. To me, it is an anomaly. Here.

you have one of the wealthiest States on a per capita basis

that has put $80 million in capital into a medical school, yet
the RMP is being asked to fund their developing programs
to the comnunity hospitals.

And you couple with that one of the more affluent
private2 medical schools, and again ws ars being asked to fund th:
development of community-based programs.

They may be excellent programs, but I really do have
avery hard time with accepting that as a major thrust for a
Regional Medical Program and with maintaining this. I really

feel it should be phased down if not cut and that there should

 
VW be plans for having this taken over by other funding sources.
@ 2 DR. SCHMIDT: Dr. Thurman and then Sonn.

3 DR. THURMAN: I would like to ask Eileen what. she
4l thinks Clark's departure will do to the grand design. Do
3 you have a feel for that at all?
6 What I guess I am really asking is ara we joisting
7\| with shadows? Is this going to collapse when he walks out
8) the door?
? ; MISS FAATZ: I don't think it will collapse becauss
0 many of the influential RAG membérs ars not. mesmerized, but

Il} they believe in it as strongly as Dr. Clark.

12 However, I think it will be easier for the program
@ 13], to add different sorts of things, perhaps level fund and then

 

4 _seale down full-time chiefs in the universities and do some
15|| aiggerent things. |
16 | DR. SCHMIDT: They may not be addicted, but they are
7 habituated.
18 DR. SCHERLIS: Well, the question asked the chairman
19])| of RAG by the past chairman sounded very much like a carbon
~ <a

20] copy of Dr. Clark. So I talked to the present chairman who

21]| sounds 1ik= the original.

oy

{

ML 22 -  (Laughter.)
23 . They xe totally convinced that this is the way to go.
24 DR, SCHMIDT: I am sorry, John is next.

 
 
 

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25 DR. KRALEWSKI: I like your suggestion on the funding,

 

 
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oe ote te

but I wonder if they will really do it or continue the same
program they have now and not implement anything else. As I
sit here, it seems to me that. I have heard a good bit of this
conversation a year ago and a good bit of that the year befors.
And the program is just going straight on in one direction.

Ana I think we had advice letters to them with this
in it, didn't we, or didn't it get through Council?

DR. BRINDLEY: We sure talked about it.

MOR MORALES: If I can interject at this point,
going back to previous review, as Len has indicated and some
of the others, the differences in perspective in the reviewers
towards this program has nade it quite hard for us to gain

review committee

w

a consistent. kind of viaw toward it. Th
took one positicn, the Council took another position. | And it
was a complicated and in many ways an unsatisfactory review
process.

I think cne cannot overstate, however, even with the
position of the Regional Advisory Group the significance of
Dr. Clark's departure. Because he describes himself as a

missionary, and ha is. Hs believes and has believed all his

The question now and one that I think you are beginniy

al with very effectively is what are the possibilities

ct
Oo
GQ
w

of doing something useful with what has been designed.

I was terribly disappointed sometime ago, and we

 
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AHA approach to it or some other kind.

 

ed

discussed it in ons of the review committee sessions when
a proposal was made for supplementary funding for Emergency
Medical Services, and there was just no relationship betwean
that request and the grand design.

Now, if there is to be a Connecticut. statewide
Emergency Medical System and you have an affiliation batween
university health science centers and hospitals and between
hospitals, one would think it. would just drop into place
very naturally and produce an appropriate effect. Or if one
looks at something like PSRO activities in which you have
linked together institutions with somebody in them who is
concerned with quality of care, it would appsar to be a

very appropriate kind of a setting in which to establish the

« « a oY o%

We have talked with them in the past. This review
committee has. So has the Council about trying to make the
hospital now a part of the community and extend out. so that it
includes a way of organizing ambulatory services, all of which
are potentialities. But I think that if there is to be a

; _ <= /
decision mad2 on what. happens in CRHP with Dr. Clark's dapartur¢?
with this current review process, we are at. a moment when we
can be effective in making some very strong advice to then
about. just. what exactly ought to happen,

I think it will be susceptible. But any time you

spend on it is going to be of grsat assistance to us, It is

 
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“14

 

the time to take some kind of action.

DR. LUGINBUHL: Is there a motion on the floor?

DR. SCHERLIS: Before I make a motion, perhaps I can
ask -- There is a motion on the floor, and the motion that
I made was that they be approved at what has been the Council
level for the next year; that strong recommendations go out 4s
we have indicated. And remember, there will be a different
coordinator, And I understand the selection committee has
already bean or is being appointed for that representation from
the Medical Society. And that the fcllowing year take into
account. the fact. there is a new coordinator, there be another
site visit.

I think it puts tham very much on notices they are
going to be looked at. very hard. I think we drop down their
funding, we ars goirg to be in a position of a new coordinator
coming aboard who is going to begin by antagonizing half the
State by firing full-time coordinators. They are going to be
phased out anyway. A group gets matured every third year, and
they fall by the wayside.

<< .

DR. SCHMIDT: The question isn't maintaining those.
It is doing the rest of it by soms other means and doing other
things with RMP and RHP money. And thet advice can strongly go.

So that the motion, then, is as he said the level,
no developmental ceompcnent, the strong advice, and the site

visit in one year.

 
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what. Dr. Clark has done, it may destroy a very important bass,

 

 

215

Dr. Ellis, do you second that notion or not?

DR. ELLIS: Yes, I would like to second the motion,
but I would like to make one change if he will agree to this.
I think we should have very careful staff work with them so thay
they clearly understand the options and the things that they
can do. Because I am afraid that with the difference in
feeling about delivery cf cars, with one group feeling that whey

they are saying is decidedly different and doesn't relate to

And I think that the staff really needs to work perha}
morz closely with this than they have with other things
because it does have a very important facet.

As I said before, there are so many placss where the
community hospitals, community affiliated hospitals, — are not.
available en a people in. And “we he have all of the
friction that we have in the large cities. So it is so
important to keep what has been built up and to relate it to
the other important aspects which we discussed here.

DR. SCHMIDT: I am sure Dr. Scherlis agrees with
that. It is complementary to the point Dr. Tiexgulies made.

And it really is an assessment of what they have created and
to build on that without destroying what they have accomplished
to get at some of the pressing health needs of the States.

All right, Dorothy.

MISS ANDERSON: I was wondering if maybe? Dr.

 
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Z16

Scherlis' suggestion earlier about enlarging the RAG and
broadening the RAG might help make this change possible, if
that. could be included.
_ DR. SCHERLIS: This is part of the recommendation

that they do. |

DR. SCHMIDT: John.

DR. KRALEWSKI: Could you repeat the advice that will
go along with this again? I am not sure I understand exactly.

I would be in favor of some very, very strong
advice like within one year show us how this program is going
to lead into a broad program to improvs the dslivery of health
care to underserved, to tie in with Emergency Medical
Program that you ars develeping, etc., down the line.

DR. SCHERLIS: Actually, these are listed in the site
visit report on ‘pag? 27. ‘t can refer to it yery quickly. :

} The program must reconsider its goals and priorities
in terms of developing efforts in community outreach and
delivery of health care to inner city and rural areas. -Althougl
an enviable network has been developed through the university
and hospital affiliations, the site team feels CRUP should not.
support. further expansion of these areas. Rather, the new
program, dirsctions exhibited should be supported by new
pregram priorities.

Over the next year, there must be develcped

measurable criteria for an analysis of the effectiveness of

 
217

“1 these full-time chiefs.
© | 2 CRMP must immediately develop and implement an
$i affirmative action plan which provides equal employment and
4 training opportunities for minorities.
5 CRMP must take immediate steps to restore to the
6|| Regional Advisory Board its responsibilities.
7 These are listsd in datail and one or two have besn
8|| added in the discussion.
9 I think any new coordinator coming aboard, I assume,
10|| would receive this full site visit report.
11 I assume he would know that he isn't going to begin
12|| his first year by saying, "We are not going to follow anything

14 Maybe I am naive in this regard, but I think if he

Ww

y tell mz.

¢

wom, ~ . . tee -

45 “knows he is going to be sits -visited in one year, he is goirg

16 to have to shap2 up and follow these recommendations. He

17|| isn't. going to have the longevity of having been there for

1g|| several years and having built it up.

19 DR. SCHMIDT: Eileen,

201° ' MISS FAATZ: When the Connecticut Program makes its
91|| funding decisicns, it very likely will not have a coordinator

Co 92|| on board. And I would like a point of clarification. Wes are

23|| saying do not sxpand your full-time chiefs and the university

ome:

@ a4|| counterparts. Are ws saying do not expand tha number of
aces .

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people supported? Do net support any additional full-time.
chiefs? And let those who are now being supported phase out?
You know, that is the sort of information that I
think may be --
DR. SCHERLIS: May I respond to that?
The intent of the group would be that no new full-
time chisf be appointed. In effect, this reduces the number.
So if you ware to accept. that as a modification, no
new additional, no new full-time chiefs are appointed.

DR. SCHMIDT: In other words, they stop appointing

‘them. If the case hasn't been made for the value of these

now, it never will be.
DR. JANES: That wouldn't have anything at all to do

with thea influence that CRMP would have on encouraging the

toe we On

universitics or others to follow suit in the developing of
this kind of service in areas that have not been assigned new
chiefs, vould it not?

DR. SCHMID’: Well, they have gone statewide with this

now. And I believe that essantially all of the hospitals are

ae

“tied in.

All right, we have a motion on the floor then,
Unless somzone wishes the floor, I will call the question.
The motion is understood?

All in favor please say, “Aye."

(Chorus of ayes.)

 
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Opposed, "No."

(No response.)

All right. Thank you.

MR. HILTON: I probably should have made my position

clear earlier except I don't like to bother the committes with

such personal problems. But the Hiltons are expecting a baby

sometime in the next 48 hours, and I would like to discharge
my responsibility toward Washington today so that. I can gst.
back and be a delivery room daddy.

DR. SCHMIDT: Then, we will move to Metro D.C.
Jos, did you have something?
DR. HESS: I didn't want to prolong getting to a
vots, but just ons additional comment or two perhaps.

Pirst, I think part of our ongoing preblem with

‘Connecticut has bean that Connecticut has disagreed with us.

I have been hearing the same thing. This is the third tine

now I have heard Connecticut discussed, tha sams issues were

raised. And then the thrust of what we have said has seemed

to have been blunted at the Council level and things sort of

. <>
go on as they have besn before,
DR. SCHHIDT: Maybe we ought to cut off the funds to
Council. |
(Laughter.)

hat

DR. HESS: there somehow needs to be a

mesting of the minds at that. level.

 
22VU

ai But. the other major point I wanted to address had to
© 2|| do with tha recommendations. And that is to actually strengths:
3l what is stated hare in the number two recommendations having
4|| to do with the evaluation of the effectiveness of the system.
5 I had thought that Dr. Thompson and his group in
{| Connscticut. were developing one of the better data-gathering
7 systems in the country and that I had assumed as we went along

g]| that this scmshow was going to be used by Connacticut. RMP to

%

9], determine what the impact of their grand design was on the

p

pzople of Connecticut.

{

10|| 2salth care of th

11 ‘And yet when I see the report there, is apparently

12|| next to nothing in terms of evaluation, I am rather appalled
@ 13 when there is the telent in that State and in the grantee
14] institution that we know is there. And what I ara leading up
“15 ig'is T think that ought to-be stvengthaned by saying that they
16] Cught to get. if necessary more ccnsultation participation of
17] the people who have that kind of capability within their region
18 to help them strengthen that evaluation aspect.

19 DR. SCHMIDT: O.K., staff.

90 DR. SCHERLIG:: We Gid mest with th, and this was

21 referred to.

DR. SCHMIDT: O.K., on to Metro D.C.

22

23 DR. SCHERLIS: Well, Mr. Hiroto was with us. He is
© 24|) OF Council, he strongly ‘supports the site visit. findings and
aCe eral Reporters, Inc.

would b2 a voice to this group there.

25

 

 
22)

Vy DR. SCUMIDT: John,

© 2 -opR, KRALEWSKI: Well, the Metro D.C. area, the area
31 is outlined in this briefing document that is included in the
4) report here today. It covers the District of Columbia,

S|} Montgomery and Prince George's Counties of Maryland, Arlington
61 and Fairfax Counties of Virginia, and the City of Alexandria.
7 This is an arga of a great many resources. It is an
8] arsa of about 2.3 million people, an area that is rumored to
9i| be an area of high unsmploymant soon -- ; Gon't. know about that
10/) but anyway it has a lot of resources including thrs2 medical
11} schcols.

12 Now, this program was sponsored with the D.C.

 

© 13) Hedical Society as the grantes. And it has had a very stormy

a ee

14] history right from the beginning.

15 oo at the présent time, now, they are ‘in the third year
16]| of their triennium. It. has not been site visited this ysar,
17|| although the program has besn site visited for the last. thres
18|| years.

19 A great deal of advice has been given to them each
~ <x ;

20|| year. Some changes have been made as a result of the advices,

2)|| but. progress is very slow.

22 As I said, they are in their third year of the

23|| triennium right now, coming in fer an increase in funding, a

  

© 94|| substantial increase. And the application has been reviewed
ce eral Reporters, Inc. |

by the staff here at RMPS, has baen reviewed by SARP, and I
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‘reviewed the application. But we did not site visit the

 

.Off the ground.

5|h

 

222.

program,

Last year, they requested, as you may recall, $2.1
million. After a grsat deal of anxiety and discussion, we
awarded them $1.1 millicn. And they are now coming in with
an application for $2.3 million. So it is a substantial increag
again for the program. _

A bit. of the history. As I mentioned, it has been
site visited many times. And each time, it undergoes some

rsorganization, some restatement of the goals and objectives.

But. they have a vary difficult time really getting the program

To start off with, they had their staff disbursed

into many agencies. What. they were doing was funding staff

rembars in health departments, etc,, with these individuals
supposedly then carrying on a specific role for an RHP,
Unfortunately, they didn't have the strong central
staff to handle that kind of activity. And they never were
really getting much production out of these individuals.
. ~ se
The leadership and the core program was not strong.
Dr. Wentz is a nice guy, and he is plsasant to chat with, but.
his leadership, I think we have to admit was minimum, His
staff was disbursed, as I mentioned, into a numbar of organiza-

tions.

He had some of the cers staff with him at his house

 
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223

with him in the core building. But that staff was quite

ambiguous about their rolés. They didn't know who they
reported to, Theres was a great. deal of dissatisfaction among

them. And in general, it was just not a working unit and had

never really become a working unit.

There was a lack of minorities included in their

core staff and lack cf minorities on their Regional Adviscry

Group.

To make things more complex, given that set of

~

circumstances, the grantee organization, the Medical Society,

did not give them a lot of support. And as a matter of fact,

-gome cf their regulations re arding salaries and fringe
g g g g

benefits, etc., over the years wsre quite restrictive and

hindered the real advancemant. of a core staff.

0

ate gee ue

Similarly, they daveloped a large: Regional Advisery

Group madé up of various health agen iss in the area. And as

a result of the largs regional Advisory Group and the weak staff

they really were unabla te get the group to work as a4 concise

unit.

<a
As a result of that, they had a large number of

Regional ADviscry Group that didn't attend the meetings,
didn't participate in setting the goals and objectives, and

‘

really in many cases were unaware of them, This is all data

(a

past site visit.

from th

Jo make things further difficult, the program becan2

 
ms | . 224

Vi involved in a number of subcontracts. Again, while you can
© 2 carry out subcontracts to great advantage, you can't unless
3 you have a real strong central staff to initiate the contracts,
‘4! @stermine what they are supposed to do for you and to monitor
$i) them, And, again, they just didn't have that.” |
6 So again and again the site visits come up with these
7\| difficultiss. And again the program would sit down and record
.8] these suggestions from the site visit teams. They would bring
-9| their tap2 recorders along to the meetings. They would pay
10|| supposedly attention to the written advice.
i And in a way they kind of remind ms cf somes of my
12|| graduate students who have this poster that they bring along.
@ 13] Andwhen they talk themselves into a corner on some issus, thsy
14] have this poster they put up. And it says, "I am not. sure that
15 you understand what I mean because I don't. know what I am
16] saying."
17 “phis is the kind of thing we have between the
18 Regional Advisory Group and our Review Committes here.
19 Anyway, following last year's raview, we suggested to

. a
20|| them that, number one, they bring their staff togsther in one

 

211 cohesive unit physically if nothing else.
\ 3 22 _ And then, number two, try to reorganize the staff

23|| into a functioning unit so they know who they report to and

© 94\| what they are supposed to be doing in the organization.
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225,

and get a large advisory group involved and make sure some
minority members get involved in this whole process.

Again, they reminded us of the difficulties of

 

 

 

getting minorities involved. And we discovered that there were
some available in the area and made some phone calls and
brought them in that afternoon at our site visit and so we put.
them in contact with some of their minorities right there that
day. And we had hoped that that would grow into some kind
of mutually agreeable errangement.

Well, we have now had this application. And as I
mentioned, they are asking for about $1.2 million increase.
And the situation is this:

The Regional Advisory Group has been reorganized

4

somewhat, has not bsesn c

ut down, but rather has been expanded,
It has been expanded in an attempt to bring some minority groups
into it. And I think that is a plus, although now they have
a larger group to handle and mora problems organizationlly.

DR. SCHMIDT: What is it up to in numbers?

DR. KRALEWSKI:_ Sixty-thres, I belisvs.

on .
ternates, it. is arcund 120.

he

MR. CHAMBLISS: With the a

DR. KRALEWSKI: They hav2 primaries and then they hava
alternates, but the alternates only come if the primary doesn't.
I think 63 is their primary.

They have brought their staff tcgether in one setting,

and they have lost a few staff members in the process. But

 
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‘our advice letter was really to turn it over to RAG and form

 

226

the ones now that. they have are in a closer unit.

The coordinator has resigned, Dr. Wentz, and has
left. So they have now an acting coordinator, a fellow by the
name of Choatewho was there before as a deputy. And he is
a pretty good guy administratively. He is a pretty good guy
in terms of internal administration. That. is where I think
his abilities lie. And I don't think he is going to de much
in terms of taking these goals and objectives and doing some-
thing with the program for the community.

fhe Regional Advisory Group looks as though it is
batter organized than it was in the past. They have more
committess formed, and they have minorities on those committess |
So it shows some, promise.

And they have been able to bring more minoritiss
into their core staff with some changeover in, I bélieve it
is, at the secretarial level, however.

They have revised their goals and objectives, and
the revision locks as though they are making progress.

The way Dr. Wentz chose to do this after he received

eo

subcomnittess and gat them involved in the goals and objectives.
And he started phasing himself out of it.

I think they are at the point now where they have
trisd to lock at. these, they have tried to pick out a couple

of areas they want to deal with. And what they need now is somg

 
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227

kind of leadership to put the whole thing back together and
make it. work.

This is kind of how they sit today. And it is the
kind of program you would like to put into receivership ina
way, but there is no one that wants to receive it. And we have
invested a fair amount of money in the program. And the
question now is what we should do with it. ~

As you recall last year, they had an application in
for a kidnay project. And that. was funded. and perhaps it.
will continue on. And they have funding also for a

pediatric pulmonary regional program, And that. essantially

they are tied into.

They have a couple of new projects that they are

_ submitting along with the grant application this year. | But

they are projects essentially that are warmed over from befors.

Really nothing new has been developed to fit into
any nsw goals and objectives that have been developed by their
Regional Advisory Group. |

Now, as I mentioned, there has been a review by the
~ ea

staff here and SARP. And there is a recommendation that I

would raad from SARP.

Maybe I better wait until the secondary reviewer
makes some comments.

pr. SCHMID? : O.K., Bill.

MR. HILTON: I would add just a few things to John's

 
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good overview on this. He and I -~ or I was with him actually.
He was chairing the site visit that he referred to to
Washingten. Ons of the first obvious positive things I neted -+
well, there are several positive things cver last year, very
small steps, however. They do talk about. addressing themselves
to underserved populations.

I recall stressing, I vividly recall stressing one
of the ways that might be done would be to involved minority
staff on the core staff, on the project staff, to really
provide some effective tentacles into the community.

One thing that became very clear when we had the

-lady in who had been a RAG mamber and had not really been

lf, one of the things that

iD

involved in RAG from D.C. its
became clear was that no ons in the outside community, she
told us, really had any awareness of what. the Metro D.C.
Regional Medical Program was all about. There was no
effective dialoguz. There weren't snough people from those
communities who would talk to RMP, And I stressed at that
time that. increased staff would certainly help in their

<a
District itself.

(D

outreach efforts in th
Thea increase has been slight on the professional
staff end of it. And I den't. know that it is adequate to this
day. And I don't believe it is adequate to this day to handls
ths proportion of work that they sheuldbe doing in the District

in addition to the other commitments.

 
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RAG disallowing responsibility for considering individual

 

 

229

I have not heard Dr. Kralewski's funding reconmenda~
tions. I would suggsst I favor a censarvative level of funding,
far more conservative than they are asking for, not only
because of these continuing prceblems, but. because of the
prospsct of a new coordinator about whom we don't. know what
directions he might take. Certainly, we hope that he would
bring a stronger leadership to the program than Dr. Wentz has
had. I don't recall Mr. Choate very well in terms of what
his abilities might be even now as an acting coordinator.

I need to touch base with John on something I don't

understend in the application. Thsare was some talk about the

cr

projects. Did I gst that right? Was this their feeling that
the RAG should not. be involved in setting priority?
| - OR. KRALEWSKE: No. re was my impression they
were quite involved in it at the moment.
Spence, you might want to comment.
MR. COLBURN: They review projects and set priorities
and so forth through a subcommittee system for all RAG members.
DR. SCHHIDT: All right, Jchn, let's gst a recommenda-
tion cn the flcor.
DR. KRALEWSKI: I would like to read this recomnenda-
tion from SARP and then ask Spence if hea would mak2 some

comments on it since he stayed pretty clese to this. And

then w2 might go from there.

 
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230

SARP would recommend that program be placed on a
one-ysar probation and that they be funded at $850,000 level.

Within that $850,000 level, the kidney project would
be funded not to exceed $144,000 which is really what they
nesd, and that the pediatric pulmonary project be funded at
$147,000.

And they recommend that. no funds be budgeted for
project 51, the cancer detection clinics, until they clearly
establish that. this project will not support basic education.
It gozs along with policy.

The developmental component be denied.

And that the Director of RMPS be authorized toavard
an additional $200,000 to the preject if he bslieves that thsir
progress so merits during the year.

- TL think that this is a good suggestion.

Really, what we are saying is we will authorize
them about $1,050,000 and that that last year, as you recall,

I mentioned they had $1.1 million which is awfully close to
this.
It. gives them some running roon and yet you give
them only thse $850,000 to start so they have some indication
they are going to have to make some progress before they gat
the other $200,000. But the level is there.

Now, the probation bit, I believe the staff might

clarify this for me. I believe we have had some other

 
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294

programs on probation in the past and essentially what it means
is that you have a year to really show that you have been able
to reorganize the program and make some substantial progress
or we are really going to stop it all at the end of that
year.

Can I get the staff to comment on that?

DR. SCHMIDT: All right, Spence.

All right, we have a motion on the floor, Bill, do
you second that or not?

MR. HILTON: Yes, I do.

DR. SCHMIDT: All right, Spence.

MR. COLBURN: I really have no additional comments.
I think the overview was very good.

- We did question the terminology used, the word

“probation” in SARP, end really didn't come up with any

defined definition of what it means. But essentially this was
the intent.
DR. SCHMIDT: I think we will say that probation

means at the end of a year obviously there will be a site
. _

visit and that if substantial progress has not been made

toward m2eting the goals sst. cut in the advice given, the
program will go to zero funding.

MR. WILTON: Mr. Chairman, hav2 we ever canned one
of these things?

DR. SCHMID’: Well, in previous times, the Director

 
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232

‘of Regional Medical Programs has in effect said this to

regions, y2s. I am not sure we have ever kind of officially
usad the word "probation." There have besn a number of regions
combined, as you know, and in effect phased out and phased

into a larger region.

I personally see nothing wrong with saying this.

MRS. SILSBEE: In a sense, isn't this the third year
of its triennial support? By putting that probation in, you
are really making a stronger messag2 than you would bs by just
talking about this year.

‘DR. SCHMIDT: Mrs. Flood.

MRS. FLOOD: May I ask a question?

DR. SCHHIDT: Please spzak into the mikes.

MRS. FLOOD: They were budgeted for $787,000 and
$800 for staft. pid they expend that. in year two, this current.
year, entirely?

MR. COLBURN: I don't. know what their exact. rate of
expenditure is. But they don't expect to have any funds left.

ever. About $200,000 of that goes into contracts. $195,000.

Bet

So it is ebout a $500,000, $600,000 for the staff.-

MRS. FLOOD: Is that actually staff?

MR. COLBURN: Staff, some consulting activity, rent,
that type of thing.

MRS, FLOOD: My concern was that the recommendation

of the SARP was a potential expenditure in kidney and a

 
233

1 -potential expenditure in pediatric pulmonary of $290,000. And

© . 2|| if they ware expending $787,000, it didn't add up to $850,000.
3 MR, COLBURN: Now, this is a reduction of funds.
4 MRS. FLOOD: Yes, but I mean it. will actually mean

Ԥ|| also cutting staff.
6 MR. COLBURN: t is going to require some hard
7, decisions, They will not. necessarily have to cut staff, but

—

8] they will not. be able to fund all their activitiss within the
9], period of continued support. There was a project which was 4
10|) numbsr ons priority which they wanted to renew for a year.
11} And they will not have any funds for contracting activities in
12 new arsas if they continue to keep the same level of staff

© 13]) support.

14 DR. KRALEWSKI: They will have four vacancies they
i5|) can £111 With that Lével, a
16 | DR. BRINDLEY: And they can get another $100,000 if
17] they do a good job.

18 DR. LUGINBUUL: Is it really feasible to zero fund

 

19|| a program? Is that actually a political possibility?

20 DR. SCHMIDT: Sure, The President“83 talking about

21|| doing this.

\

22 (Laughter. )

{i

23 DR. LUGINBUHL: I em not sure that answers the

94|| question, a
a8 tal Reporters, Inc. ‘
DR. SCHMIDT: The answer is yes.

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DR. LUGINBUIL: The other question I have is who is
going to be threatened and who is going to be challenged so
that. they do address the serious problems of this program?

You have no coordinator at this point. You have a very large
RAG, 65 or 70 psople. And in my experience, large groups
rarely are able to seize initiative and direct. a program.

There has been a sericus problem, I gather, with the
grantes. It is the Medical Society of the arsa., And they have
clearly not shown leadership. Who is going to respond to
this challenge that we ar2 placing on this program?

‘Are we simol cing to hav2 no ons to respond? And
i g g

-should wa think about. other measures such as merging the

pregream into another program or trying to gst another grantee
or other dsvices to strengthen management?

DR. KRALEWSKI: 1 didn't nean to indicate that the
Medical Society at the moment is not supportive. In the
initial years, they were not very supportive. And as a matter

of fact, in our site visit last year, they had a changeover in

a leadarship of the iedical Society. And they at that time

. . . _ eae
indicated a great deal more interest in the program. And I

think that they will come through on this.

I also think that RAG, if what I read in this
application has any bearing on the truth, will initiate or
exhibit more leadership than thay have in the past as they becor

more organized,

 
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235

It. is iffy, and I don't know. But I think that is
where it will come fron.

DR. SCHMIDT: Dr. Ellis.

DR. ELLIS: I would just like to ask one question.
When we made the site visit befcre, there was a woman physician
there who Dr. Hentz told us really worked to coordinate all of
the programs and make the changes as had been suggested several
times. What. happensd to her?

DR. KRALEWSKI: t believe you might be referring to
Dr., I believe, Woodside is her name. ‘and she is no longer
with the program. But. as I understand it, she is one of ths
candidates for the coordinator's job and I think that. probably
would do a good job if thay can get her.

DR. (SCHMIDT: Spence. a ;

MR. COLBURN: That. is correct. Dr. Woodside is a
candidate. They have had a search committees. They interviewed
about, or they considered about eight candidates. And this
is ae search committee of the RAG. And they made the recommenday
tion to the grantee and gave them three candidates that would

: <a
be acceptable to them. And the grantee has interviewed them
all. And there is some indication, although it is not
official, that Dr. Woodside is the first choice.

However, du2 to the uncertainty of the future of

RMPS right now, she is hesitant. to make the decision, I think

if in the future it becomes evident that. RMP will remain in

 
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business that she will accept the pesition. I think she is
interested in the job.

The question was where is she now? Shs is at
George Washington.

DR. SCHMIDT: Are there other issues?

MR. COLBURN: I wonder if the committee has a
reaction to the size of the RAG or has any definite recommenda-
tion or suggestion to make to the program. Because this is
kind of a --

DR. SCHMIDT: My reaction is that across the country
there are some large RAGs that are effective by virtue of their
being advisory in nature. They give advice and consent. That

is all a very large group can do. The successful ones have

very sound subcommittze structure that does the, work. —

And a large ons like this can meet two or three
timss a year and vote yes or no. But the measure of the
effectiveness, the strength to which the individual RAG
members in groups of six and eight and ten get at the work of
the program and the size of the RAG per se isn't as important.

<a

as what they do on the subcommittses, what type of subcomnitteed
they ar? and what effact they have on the program direction in
some way.

HMR. COLBURN: But this RAG dozs have the ultimate

system and has a volwia of about 120 people thet ars eligible

te serve ona time or another sither in the primary capacity or

 
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alternate capacity.

There is a jeopardy, I feel, by accepting this

alternate system. You dilute centinuit .
_ I just want a reaction.

DR. SCHMIDT: The alternate thing dossn't sound --
everyone on the group who has a serious concern about that
alternate system please raise your hand.

(A numbsr of hands ware raised.)

We could convey to them the weakness of not a 60-man
RAG per sé, but certainly 120.

MR. NASH: I think cne of the problsms to the RAG

is thet each member has to represent an organization. This is

p
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wher the alternate syst: ms

.
(

MR. COLBURN: It is not each member, but it is a

. ~ ~

i)

It is probably 85 percent of ths mambsrship

{

high percentags.
institutionally affiliated or an agency or something of this
naturz. That is the basis for the RAG,

DR. LUGINBUHL: Do they have a strong executive
committes?

<=... .
DR. SCINIIDT: Is there a strong exécutive comnittes

of the RAG?
MR. COLBURN: Yes.

DR. LUGINBUUL: Uew large is it?

ee

MR. COLBUILI: Iti

tink it is seven members.

~

MR. HILTOU: I think Bill's question is he asked

 
238

1] how strong.
© 2 MR. COLBURN: They are meeting more frequently, and
311 T think it is becoming stronger. Some of the chairmen of the
4 subcommittees are new and have shown a lot of interest and
5l| promise.
6 DR. SCHMIDT: John.
7 DR. KRALEWSKI: I think the whole question over the
8|| Regional Advisory Group and how functional it will be is really
9 one that is only going to be answered after they get the
10|/| core organized. If they organize a core, I think they will be
11]| able to handle that large RAG group without any trouble and

_ 12|| organize them well and get them to participate pretty well and

 

@ 13] an executive committe: to do the same thing.
| 14 At the moment, they don't have that. organization.
15 “and as a result, you have got a disorganized 63 ox 119 or whatey
16], shows wp at the meetings coming in. And that is difficult.
17 “Now, on the other hand, during our site visit the las?
"18 time, we visited with a number of the individual RAG members.
19 And there are some real strengths in that group. And I think

<=
90] that these strengths will coma cut. once that second level

21|| group gets organized. And I suppose that is really where we ar¢

Le 22|| placing. our bets.
23 DR. SCHHIDT: Spence.
@ 24 MR. COLBURN: Just a correction, There are 13
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239

they only net two times last year, although I know they
have met more recently than that since July.
DR. SCHMIDT: That is not a very strong committes.
_ MR. COLBURN: It is really on the threshold.
DR. SCHMIDT: O.K., we have a motion-on the floor
for probation for one ywar, site visit at the end of the
year, $850,000 level with the director having the authority to

add to for good behavior and progress during the year if there

is a strong coordinater who does indeed need the money to

advance the good causs of the program with zero funding for

project. 51 unless some substantive issues are answered by the

progran.
With this, they would fund the kidnsy project at
no more than $144,000 and the pediatric pulmonary at $147,000.
“are there questions to the motion? : |
(No response.)
Is that the motion?
DR. KRALEWSKI: Yes, sir.

DR. SCHMIDT: All right, then I will call the

question. All in favor please say, "Aya." “a
(Chorus of ay2s.)

Those opposed say, "No."

(No response.

And that rotion is carried.

DR. KRALEWSKI: Shall we rate this one? Do we rats

 
240

* TH all of them or just the ones that are site visited?
© 2 MRS, SILSBEE: Rate them all,
3 DR. SCHMIDT: Heretofore, we have rated them all.

4] sarp did rate it. They rated it down if you look on this ons

5]) shest here.

6 DR. KRALEWSKI: Right.
7 DR. SCHMIDT: Metro D.C., SARP, 176 from 207.
8 | MR. CHAMBLISS: I might point out it is your option

91 to accept or rerate. .We lsave that entirely to the Committee.
10 DR. SCHMIDT: Let me ask just speaking for myself,
nN I could hold out through North Dakota. Would the Comnittes
12 like to go on?

© 13 DR. BRINDLEY: One more.

14 DR. SCHMIDT: All right, Miss Kerr.

15 So MISS KERR: r am pleased that you did because I

16} know pr. Scherlis has to leave.

17 Let me just. say that the raview materials and I

18 ended up in the same place finally late Saturday.

19 Nerth Dakcta Regional Msdical Program and I haves

<a
otten acquainted between the hours of 3 and 6:30 this morning.

20

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21|| But I feel fairly well acquainted with it, and I am glad that

VT , 2211 Dr. Scherlis who was chairman of the last site visit team in

5
23|| December of 1970 is a secondary reviewer and also Dr. Jamss.

momen oe

@ 24) And I have asked Harold O'Flaherty. from the Mid-Continent
ce etal Reporters, Inc. ‘

 
 

25|| Branch Operations Officer to join us because he has spent so

 

 
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241

much time with this region in the last year.

First, lst me tell a little bit about North Dakota.
North pakota is the most rural Stats among the 50 with a total
population of 618,000 is all. I was amazed. Three percent —
Indian population, 3 percent non-White population, average of
9 people per square mile. And yet I look at the available
physicians and registered nurses and combined registered

and licensed practical nurses, and I will bet you Nerth Dekota

is better off than any other State I know of as far as ratio

is concerned.

But they do have geographic problems. And the
capital, of course, is at Bismarck which is in the south c#ntral
part of the Stats. And Grand rorks is where the Regional
Medical Program is based. And that is in the very northeast
part of the State.

And I tell you this because the grantee agency is
located at Bismarck... And the grantess is North Dakota Medical
Research Foundation which is a subsidiary of the State Medical
Society. And so there is soma distance between the grantes

<a .
and the Regional Medical Program based at Grand Forks in which
city also is the University of North Dakota which is ths
fiscal agent for this Regional Medical Program, although this
sesms to be working very well,

This is an inniversary review prior to triennium.

There were somé problems, and I would like to identify those

 
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as they were shown following the last review.

Early in the process, the RAG was made up of physicias
period. And, of course, this was questioned, and thsy vere
advised to broaden their advisory committees. ~

The staff have characterized the Regional Medical
Program as being ruggsdly individualistic. And I think I |
would have to agres.

To date, the project that had been funded had
bsen centered around providing continuing education for the
physicians. There was some continuing education for nurses,
however there was no nurse educator or nursing service input.
into these,

The offarings ware developed by the physicians for
the nurses. So there was concern about. domination of the
pregram by the State iiedical Society. There was concern about
the failure of the region to delinsate an action panel which
includes tims frame objectives and terminal points. of evaluatior

‘The failure of the program to recruit a deputy

diractor and an assistant director for management planning and
~ <a

’

evaluation.
Another concsrn was the lack of involvement of

minority group representatives on the program staff in the

A

[+=
Yu

Regional Advisory Group in the committee structure, and it was
felt that the Regional Ilsdical Proyram had not develeped its

activitiss in terms of changing RMPS mission.

 
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243

Therefore, at. that time, it was not accorded trisennial
status. It was interesting to ncete that when Dr. Arnescn
became the coordinator in August cf 1972, in his letter, cover
letter, for the proposal on October 27, started out by saying
the Regional Medical Program is at. a critical stage in its
growth, faced with problems that. verge on dilenma.

And having reviswsd wnat. has transpired batween
then and now, I don't think he would make that statement
quite so strongly, at least.

There have been minimum of six staff visits out to
assist. this region. And it. would ssem to me that they have

responded pretty well to ths preblems that were identified

{+

at. that particular tims.

They do have a new executive director in Dr. Arneson,
2s I said. And he was appointed in August of 1972, Apparently
his public relations are superb. Ile evidently knows the

stata real well and has good contact within the State...And

he works well with the core staff.

He by his own admission is not. as competent in the

wD

field of budgeting and finance as he would itke to be,
Just teday since having arrived hsre, there is informa.

ion before me that says that a deputy director and assistant

irector for management planning and evaluation has been

amployed as of this menth and also there was a third person

employed as dirsctor for community and public relations which

 
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244

‘gives them, as I counted, a total core program staff of
18 including 5 secretaries which means 13 highly prepared
professional people.

In speaking of the program staff, I would have to
say at. the risk of being called a feminist which I profess
not to be, I do think a lock at. the differentiation of
salaries and level of preparation on this staff between the
men and women is quite remarkable.

At the time, itwas thought that ténsions existed

among the several CHP B agencigs and the RMP. Apparently
since Dr. Arneson has come aboard, these relationships have
improved considerably. and there is much support, there is
mutual representation on the reéesps tive advisory groups, and
they sesm to be working much better together.

| at that time, thes objectives were felt to be vague.
I note by the material that they do have them delineated.
The goals are within keeping of the mission of the RHP.

They had not at. this morning's reading shown too
much progress in the area of setting priorities. However, in
the information that. came to me today, they now have set
their priorities.

The review process was not. certified because of
several major identified deficiencies at the last time in the

staff cbssrvations. However, the information beforg me today

says that their review process has been approved.

 
245

Vy The CHP agencies were involved in reviswing thse
© 2 proposal prior to the time it was admitted. And of the four
3 who responded, three were very supportive. One felt that they
4 could not support the funding for four projects requested,

5 and I think this needs some explanation in that it was

6|| determined early that this Regional Medical Pregram had much

7|| to do to get. its house in order. And I think it was not felt
8|| that it probably could do it as readily as it has nor as

9 rapidly as it has. And so at that time, it was recommended

10/1 to them from the staff that they may want to consider spsnding
ll] the next year picking themselves up by the bootstraps rather

12] than te get involved in a lot of new projects.

 

© 13 However, as they moved along and felt themselves

14] that they were maturing, it was the RAG itself that, identified
15 four projects which they would like to be pursued and for

16|| which they would like to request. funding.

17 So again it was a CHP B agency in Bismarck which was

18i| theons before that. was 2 little cantankerous, but of the four,

19] this was the only one that had reservation about this particulay

aie
20}) proposal.
21 All the projects which thsy had undertaken before were
( + . . a .
Nu 22|| continuing education as I mentioned earlier. All cf those
23) have been taken over by other sources of funding. So they ars
@ 24 rsally in essenca starting from scratch at this point in time
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246

vheir third year, they received funding at the level
of $323,401. At this particular anniversary review, they are
asking for $707,025 with no identification as far as develscp-
mental component.

In Dr. Arneson, it would seem that they have a@ person
who is going to be able to provide better lsadership ina
batter atmospheres. And he has a cors staff evidently that are
highly motivated, I would say fairly sizable in number for the
size of the operation to dats. However, I do need to draw
attention to this group. And I have strong feelings about.
this in view of theaadequacy of thea review committs2s about the

lack of minority representatation. And it was treated, I

av

thought, quite adamantly last time to my disappointment. And

b

s-
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perhaps I am a little biased on caus2# it was from my

a . wena ae

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*

presentation last time relative to
But I have heard this afternoon three or four times

we have talked about regions where the minority representation

is noticeably lacking or absent. And yet I haven't. heard that

adequacy today. But this particular region has bsen told

.
about this a number of times, and wa still find only one

minority on the RAG. And this is an American Indian.
There is no minority repressntation on the program
staff cor among the committees of which there ara two and

provision for othsars es needed.

The Regional Advisory Group, the grantees and the

 
247

1 coordinator evidently are working very well together. And
© 2|| they have set out and accepted the policies of their own and
3 describe their roles and relationships. And it seems to be
4|| working well, So this is apparently a major improvement.
5} over the last, and they did follow the recommendations.
6 So their review, their technical review process
7|\ has bean approved. Their relationships with CHPs are
‘8 considerably better. The policies on the relationships of
9i| the coordinator, Regional Advisory Group, grantee organizations,
10|| ssem to be moving very smoothly.
iH ‘It is my overall opinion that it has made an
12|| about face. It has found other funding for its formerly
® 13) ongoing pregrams. And in submitting its request for funding,
14] the funding would cover program staff and four projects. _
15 Program staff of this $707,000, $411,000 of it. is for pregram
16|| staf£ which is 7.6 percent which sesms pretty heavy. However,
17|| they have also asked funding for four projects, And just
18|| grossly, those are Emergency Medical Services, .Regional
19 Extension Canter for Rehab Services, communications to serve

<a
20|| diabetics and educational center for allied health personnel.

5} , They have in their pricrities put Emergency Medical
22 Service assessment No. 1, asking $63,241. They have put ths
23]| education center for allied health personnel No. 2, the

@ 244 regional extension canter for Rehab Services No. 3, and

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these changes althou hy both were ocd, before I make a
SG ' g g

-recommendation for funding level, however, I would ask Dr.

248

The EMS would b2 an assessment in feasibility and
the educational program for allied health, I would like to
speak to in a positive manner because this would be done with
North pakota State School of Science at Wahpston. It is not
for preparatory pregrams. They have many ongoing preparatory

programs at less than the baccalaursate level. Ths purpese

o
j++

for this is for in-service education of allisd health
workers. And they have developed a good network to get this
out throughout the State, take it where the workers are,
yvather than require that. they come into a central place for
continuing education which is tco often impossible for many of
oux people as I know from where I sit in our State

So they hava asked $707,900 for pregram staff and

for theses four Projects. Becaus@? they have recently made

wae
* cans

Scherlis and then Dr. Jam2zs and Harold O'Flaherty if they
would havs any comments.

DR. SCHERLIS: Will you reverse that and ask Dr. Jameg
—<—
MISS KERR: All right.
DR. JAMES: Well, my comments are going to be very
few for the first. time. However, I was very much impressed
to Learn of che compicte about-face that the new director of

Worth Dekota RUMP has taken.

 
249

1 I think parhaps that if we had had one of the

© 2\| relief maps that. were passed around, we could really see the

31 vastness of the terrain in North Dakota because I think it

4] like Alaska and so forth probably offers the greatest. problem.
5 toward. the dispersion of services in the area and because

6] of the paucity of the population. Their clusters of population

7|| are into saveral areas.

a

8 I think that, too, the efforts that have come about

9|| in the development in the proposal of the four new programs

10]) involving all the CHP B agencies which was not before, I think.
11} a part. of their program probably lends support to the fact that
12|| there is going to be mor2 community involvement. Because I
© 13) hed understood that prior te this tine there was a tremendous
14|| hold on the organization through the State Medical Association.
15 . | I would have to say something in regard to ninoxity
16|| representation when cne looks at. the figures. That. is if

17|| the Census people counted everybody bscause we are wéll aware

18 of the fact that a lot of pseple just don't get. counted. So

 

19{| I don't know whether or not there ars 16,000 Indians or 2,500
: ‘ i .

20|| blacks in North Dakota or not. But anyway, we have to take

21| what the figure says. It says that. But I would have to

22|| strongly wonder how many people on the reservation still

23|| haven't besn counted or vice versa.

 

24 But the fect of it is that you can only have in

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I think I hear you stating in that. apparently aftsr many

 

to say that everybody should be represented on any kind of
Council or anything by a quota. That is out as far as I am
concerned, But I certainly believe that because there is
an Indian, large Indian population that certainly the
organizations should be represented.

I understand that the Indian is a very intelligent,
highly articulate person wno is a representative of the
Indian Council.

MISS KERR: Chief.

DR. JAHES: He is a chief? He is a big man.

Well, he is President, then, of the Indian Council.

MISS ANDERSON: That changes frequently, though.

DR. JAMES: I would just simply echo the sentiments
years of really being sort of stynisd that this progran
looks like it may begin to take off. I am especially impressed
with the cooperation between the medical school and I believe
the North Dakota State school at Wahpsten.

MISS KERR: Yess.

. eas -
DR. JAMES: To establish the residency training

program, the internship progran, to bring the medical students
again out into the community, into a community network, which
as far as I am.concernsd is combined also with general

eo .

education. And I think that this will have a tremendous

effect on the distribution of health manpower. And I believe

 
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+o 39 members, broad representation from all health professional

 

 

this is one of the areas we are really confronted with --
distribution.

I have no other comments to maké.

MISS KERR: Len, would you excuse me if I make just.
two comments before you?

DR. SCHERLIS: Go ahead.

MISS KERR: I neglected to say that the advisory

committee has bsen expanded from 16 physicians historically

from community people , from consumers, and so forth. There
are 16 physicians on it, one from sach of the ten, I guess it.
is, county medical secisties. And that doesn't seem unreasonab]
I felt.

And I was very much impressed with the change that .
has been made in the Advisory Group.

The ther thing I wanted to say is of any bylaws
I have ever read anywhere for any organization, I think thsse
are the most outstanding, the ones they have recently. They
rescinded their’ original bylaws, and they have a whole

~ ee

new set of bylaws. And they are just worth reading. I think
they are wall done.

DR. SCHMIDT: I hop2 you will forgive me if I just
interject. a comment here. I was sort of anused,

~~,

I think a relief map cf the Stats of Nerth Dakcta

would be a waste of money. The highest point in the State of

 
252

Fil North Dakota is in the Turtle Mountains up near Bottineau,
© 2) North Dakota, up near the Canadian border. The lowest point
3] is in the Badlands in the southwestern corner, The differance
All in those two heights is less than the height of the John
5\| Hancock Building. And it is a lot. of land area, though, I
6| will agres.

7 Leonard.

8 DR. SCHERLIS: . When we made our site visit to Grand
9|| Forks, the point you just made was brought. home to us because
10] when we went out that evening to Dr. Wright's apartment, as
11|| we approached it, we were struck by the fact that it was one

121 of several units in a large brick building in which there wasn't¢

 

© 13) 2 single window outside. And this was built on the basis that

14|| everything faced inside where they had built for all of the

15 units an environment of plants and sone gresnery and some

16]| water. And it was. the only place I have ever been where you

17 effectively insulated yourself from the outsids, both by view

“18 and everything else. Everything faced in instead of out.

19 And if you have besn out. there, you would know why
. = _

20|| you faced in and not cut as you pointed out.

2) When we were there, the progran was totally

22|| dominated by the Medical Society. Dr. Wright. provided a vary

23|| strong leadership by virtue of the fact that he in the State

@ 24) was onze of the strongest pgople medically. I think his plan
con :

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' 253

have the county medical society serve for the B agancies and
the State society for the A agencies.

But anyway, it is very, very medically dominated.

After a feedback sassion which I remember very well,
he thrust his index finger in my chest and told me that you
people from Washington just don't know what is going on out
here.

As we droves to the airport, he obviously didn't get

+
Ce

any happier because w2 had a minor acciden
. I think the feeling cut there then was that the
knew what they were going to do with their program and didn't.
want to have any direction, And I am impressed with what you
have described in terms of new direction.

I was interested did we know anything about the

Medex pregram. Is that. being funded through RMP at the pressnt

time? Because they were very excited about it then because the}

f+.

make reference to it. But I don't know who is funding it.

MR. O'FLAHERTY: Department of Labor.

t-

DR. SCHERLIS: It is being funded through then,

Also, at that time that was the onf$" Regional
Medical Program that wasn't receiving covernnent funds for
overhead,

MISS KERR: It is asking for then.

DR. SCHERLIS: It is now so they have learned a great

 
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I think the change in direction is apparent. The
programs do show outreach. They have always had good physician
educational pregrams, and they have had a base for developing,
I think, further ones. And I would be interested in what the
financial recommendations are going to be.

I think the document at least indicates a
significant change. I don't know Dr. Arenson, but the

document would relfact a change which is a significant one

from essentially a pure county medical socisty or State
Pp

medical society based program to a broader base.
MISS KERR: It certainly reads a great changes.
DR. SCHMIDT: Herold, do you have anything to add

MR. FLAHERTY: I think the group has very aptly

--

depicted the jesues, the growth and again seme of the weaknesses
that are apparent within the North Dakota Regional Medical
Progran.

They are inordinately more outreach criented, and
there is a sincare desire on the part of the staff to change
the image here as well as to do something tangible in the State
cf North Dakota. And I must add when Dr. Arneson first came
here, he met most of the key RiPS staff. He had bean a
practicing surgeon for a while, for a long time, and left ths

mee.

staff with a mixed inoression. I guess that would be kind.

*

But he has stuck to it. He has engrained himself in

 
255

Vy the process and has learned a great deal and is again very
© 21) much committed and believes very much in the concept. of

3 participative management. He takes his staff, and they sit

4} around the room and they manage by group style. He has gone

S|} from ons end of the continuum almost to the other.

6 . And I was telling him the last time I was there I

7|| would sure like to see North Dakota hit a balance bstween the
8] complete participativ2 management and management by fiat which
9|| had been the case for four years previous. But. I think we

10} have somes reason to bea encouraged.

YW I met this summer with the Board of Directors of the
12|| Medical Research Foundation, the group that tenaciously had

© 13]} clung onto this program and went cover with them the RAG grantees

 

14] policy statement. And it was their perception that they
15 could live with it, and they have adopted it, which is before
16] you in the application, the set of rules that are most pragmatic
17 for a State such as North Dakota.
18 Their house is in order with respect to the RAG
19 grantee policy. Representatives from Grants Managsment. Branch

<=

201 hav viewed this and have schosd Miss Kerr's sentiments

it)

x

ti

21 with respact to the efficacy and feasibility of thse bylaws.
22 * They need to lay out for themselves a three-year
23|| plan which we should ses ons year hence and time frame their
@ 24) objactives and to build in mors of a viable system for
66 ~ Fede

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25|| evaluation. But they are well on their way to doing this.

 

 
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DR. SCHMIDT: O.K., let's get us a recommendation

MISS KERR: All right, because of these areas that.
still need some strengthening and because of the areas that.
already hav2 besn strengthened and because there is a feeling
that. perhaps they will be expending a great. deal of time inhous¢
still to continue strengthening themselves, I am recommending
funding at the lavel of $525,000.

DR. SCHMIDT: This is a ons year?

MISS KERR: Yes.

DR. SCHHIDT: And then thsy will bea coming in.

All right, then, the secondary reviewer was. Dr. James,
licw dces that hit you?

DR. WANES: I was looking at the funding of the

eter

previous years, and I could very well, I think, understand why

the funding levels were all of such a small nature when it is

iD

obvious that one can s¢e perhaps a changs in direction with

obvious involvenent of the community resources and the progress

a

is to be madés.

<a .
I wonder perhaps if w2 would not want to consider

not to put a program in jeopardy because of insufficient.

ct

fue

funding to give them a little bit more, Because I think
looks like that they just had $431,000 and to give them

‘

$70,000 more with sucn a +remendcus cn

@

ng@ in direction, I

wonder would wa not stynis their efforts and prcebably break
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their spirit.

DR.

MISS KERR:

DR.

annuslized lavel was $323.

additicn in essence.

DR.

DR.

a motion on the floor.

if the motion

DR.

notion

on

MR °

annualize

DR.

Dr.

DR.

increase is for core staff. And I

what that was

We do have a letter here

currently budgeted staff positions

you have a

will do for thet program?

Toomey.

those dollars for salary.

gocd feel tor

257

SCHMIDT: They ware at $323,401.
For 16 months.

SCHMIDT: The 431 was 16 months. So the

$0 this would be $200,000

JAMES: I would like te recommend around $600,000.
SCHMIDT: Well, that is out of order. There is
I will ask for a second. And then

dies, we will have to --
LUGINBUHL: Second.
SCHMIDT: All right, there is then a seconded

flocr a* $525,000.
TOOHMEY: No, that answered my question when you

is $323,401 annualized.

SCHMIDT: it
Hess.
that substantial part of thsir

HESS: I notice

Bsc ood
didn't hear too’much about
going to do.
which says all their
And do

are now filled.

what the additional core staff mons

 
Vy MR. POSTA: Excuse me, if you take a look at page 6
© 2)| on the yellow sheet, there is last year's request and also

3] an attempt to break down to thse annualized level for the

4] last year. So that that would give you-some basis for

‘3 “comparison all the way down the line.

6 | MR. FLAHERTY: In a nutshell, to compromise the two
7\|| positions that existed at the time of their RAG meeting

8|| approving this application, one was to come in for the full-
91 blown package with no feasibility studies. The other was to
10] come in with core staff and feasibility studies only. So what
}lji they did was to come in with a full-blcwn opsration one-year

a 12i|-package with feasibility studies. So there is $120,000 of the

 

© 13] program staff request. that is for feasiblity studies as was
14], recommended by their planning and evaluation committee to furthgi
15} design and assess thsir needs that exist in North Dakota.
ié MISS KERR: The orientation of these three new
17|} psople who are in key positions will take a spet of tims, tco,

18! as we talked about it.

19 DR. SCHMIDT: Leonard, comments on the $525,000 level
~ , <é .
20 DR. SCHERLIS: I think that is realistic. It is a

21 very significant incrsase over what. they have now. And it is
Le 22|| compared to what. As compared to $323,000 that we are talking
23 about. $525,000.
@ 24 I don't. know Lf they could spend as much as they ars
ces

eral Reporters, Inc. || 2Sking for with naw leadership. I am sure they will spend
25 _

 

 
259

2 the $525,000 very well. They would probably spend $550,000
© 21 or $575,000, too, but I think $700,000 is high. Where you
3] place it in between, I think is a matter of judgment.

A | MISS KERR: If there is a strong enough feeling
5] among the group, I will rescind the motion for’a compromise.
6 DR. JAMES: Let me say that now that I have had a

7| clearer understanding cf what the annualized funding was, I

9 DR. SCHMIDT: John.
10 DR. KRALEWSKI: This committee is getting too

lif) friendly.

12 I like the --
© 13 DR. SCIRIIDT: I am interested in what is coming now.
14 ' DR. KRALEWSKI: I like your suggested amount, but I

is wondsr if you would have some advices to them as to how much

16 of that should be spent for core staff and how much should be
17], spent. on projects er can we do that? Maybe we can't. I think
18|| their cores staff is gstting pretty large for that small area.
is . DR. SCHMIDT: We can give them advices. Generally,
36 ‘our funding level we arrive at by saying so much £6xr ocre,

21 so much for projects, but then the monsy is theirs.

22 DR. KRALEWSKI: If thay keep using it up with core,
23|| they are going to do some really fantastic studies that really

© 24|| look great, but --
“ eral Reporters, inc.

25 MISS KERR: It is a little over 70 percent of the

 

 
260

total amount budgeted for core.
© 2. | DR. SCHMIDT: Again, it is 70 percent of what?
3 MISS KERR: Well, their total.
4 _ DR. SCHMIDT: All righty. Going once, going twice.
5 All right, I will pit the question then. And the

6} motion is one year at $525,000.

7 All in favor please say, "Ays."

8 (Chorus of ayes.)

Oh Opposed, "No."

10 (No response.)

VW And that motion carries,

12 All right, the group has done well. We have five
© 13 major reviews out of the way. Tomorrow i have five more

14 and then a number of anniversarics within the triennium of

15) anothsr 9 regions.

16 So that in answer to some questions about how long
17|| we would go, I would wish that people not change thsir planes
“18|| to too early in the day. I would think we would prebably go
19} until after lunch unless we don't discuss regions an hour at
«cue

20|| a crack wnich is kind of what we have bean doing.

21 , So I will predict wa will finish at 2, 2:30 type of
22) thing tcmorrow.

23 ‘ DR. THURMAN: Metro New York will carry us to there,

@ 24\| Mr. Chairman,
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25 DR. SCHMIDT: All right, let's make it 3:30. In

 

 
261

ll other words, I don't think we are going to finish at noon,

© 2 Your rating sheets, you can leave right here with the
3 material, and we will reconvene at 8:30 and begin sharply

4), then.

3 ’ Thank you,

6 (Whereupon, at 5:30 o'clock p.m,, the meeting

7 recessed, to reconvene at. 8:30 a.m. on Thursdey, January 18,

81 1973.)

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