1
McLaughlin 1! DEPARTMENT OF HEALTH, EDUCATION, AND WELF ARE
CR2219 |
2 PUBLIC HEALTH SERVICE
3 HEALTH RESOURCES ADMINISTRATION
@ 4 ROCKVILLE, MARYLAND
5 —_ ne
6
Thirtieth Meeting of the
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NATIONAL ADVISORY COUNCIL ON REGIONAL MEDICAL PROGRAMS
8
@
: 3 10 Conference Room G
S Parklawn Building
f 1h. Rockville, Maryland
3 Tuesday, July 17, 1973
ee ? A
e 7 | The meeting was convened at.9:07 a.m.,
3 13 |
“ a pr. H. B. Pahl, Acting Director, Regional Medical Program
2 14 : _
S “45 Service, presiding.
16 COUNCIL MEMBERS PRESENT:
@ “Mrs, Audrey M. Mars
M7 'é Dr. George E. Schreiner
Oy Mr, Edwin C. Hiroto
8 ! pr, Paul Haber (for Dr. Marc J. Musser)
19 ¢Dr, John P, Merrill .
Dr. Alton Ochsner
90 d pr. Alexander M. McPhedran
_ 7 Mrs. Mariel S; Morgan.
94 7 Dr, Russell B. Roth |
of Dr. Benjamin W. ‘Watkins’
§ Mr, Sewall O. Milliken .
: 22 i . ee
8 | ALSO PRESENT:
: 23
Dr. Robert van Hoek
24 Dr. Robert Laur
Mr. Robert Chambliss
25 Dr. Paul Teschan
(cont'd)

 

 

 
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ALSO PRESENT (continued) :

Dr. Harold Margulies
Mrs, Judith Silsbee
Mr. Jerry Gardell
Mr. Van Nostrand
Mr, Kenneth Baum

-~ and

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CONTENTS

Agenda _ Item
Call to Order and Opening Remarks
Consideration of Minutes of February 7, 1973 Council
Report by Dr. Pahl, Acting Director, RMPS
Overview of Legislative Chronology
Overview of Phaseout
Mrs. Silsbee
Mr. Gardell
Mr. Chambliss
Presentation by Dr. Paul Teschan for Coordinators
Remarks by Dr. Robert J. Laur and Related Discussion
Remarks by Dr. Robert Van Hoek
Consideration of Future Meeting Dates
Resolution re Construction Authority
Resolution Endorsing Adjusted Budget Periods and
Approved Support Levels for RMPs, and Delegating
to the Director, RMPS, Limited Authority for

Making Similar Future Adjustments

Discussion of Statement Submitted by Coordinators

Discussion of Development of Criteria and Application

Other Business

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PROCEEDINGS
DR, PAHL: The meeting will now come to order.
I have been waiting a few minutes because we do expect to have

Dr. Roth here. Dr. Margulies, although not officially

connected with the program, is on his way, and I! ) sure you

wish to see him, And we also expect to have Dr. Merrill

appear a little bit later this morning en route from out of
town. |

Before getting into our agenda, I would like to
welcome each of you personally and officially back to the
council table, a circumstance which perhaps some of us did
not expect to see happen at least during a portion of the —
year. | - |

We are very B1ad, ta, have the opportunity to meet. _

with you particularly during what I am sure is a very busy

summer period for all of us, and we feel fortunate that
you have been able to arrange your schedules to be with us.
We have a rather full day, and the staff has
worked very hard in preparation for the Council, and 50, |
with your permission, I will move along and try to indicate
to you, after we get through some of the general announce-

ments, what the plan of the day is and what we hope to

accomplish.

We did indicate that we would like to have you

feel free to depart early afternoon, put, ‘of course, if ‘the

 
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discussion continues on, we would be very pleased to stay
as long as you feel it is important to our mutual
understanding of the matters at hand.

Now, first, I would like to welcome Dr. Paul
Heber, whom I also haven't met but who is sitting in

for Dr. Musser from the Veterans Administration. We are

pleased to have you here, Dr. Haber.

In terms of our general announcements, in the
folders under the tab "Agenda Materials" and behind the
seating chart there is the usual statement on conflict
of interest and the confidentiality of meetings. I believe
these have been with us in each of our Council meetings.
Thus, it is not important to go over them. And, of
course, all of our Council meetings, including this one, are
open meetings. ..

Dr. Roth, welcome ‘back to. the council table.

DR, ROTH: Thank you.

“DR, PAHL: Y would like to indicate that Mr.
Ogden is unable to attend the meeting this time and sends
his regrets and Looks forward to working with the staff and
the Council in coming months.

Dr, Cannon also is unable to attend, although we

had a very long conversation by telephone concerning some of

the matters at hand, and he indicated he would be perhaps

in touch with some of you conveying his thoughts about items

 
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. perhaps we will, have, to hold those. oft until the parties

_ presenting items, ta. you today, and, pndeuptedty: they will

over recent months,

‘Council before and presented items of interest, but also is

 

 

which undoubtedly would be coming up for attention, and we
will be glad to have those comments at the appropriate time.

I did intend to make some introductions, "but .
appear. But. let me “andiecate whom we do expedt to have

be here later this orning::

Dr. Robert: Laur will be speaking with us some-
where about 11:30, quarter of 12. Dr. Laur is the Acting
Administrator of the new Health Resources Administration
and is very active and has been active, of course, in that

capacity in the Regional Medical Programs issues and concerns | |

And timing couldn't be better. Dr. Robert. van Hoek
will be meeting with us for I hope as. much as possible
during the course of the meet ing and - least after: coffee
will'have a few remarks to make. Dr. van Hoek is not only
the Program Director of the National Center for Health

Services Research and Development. and has -met with the

the Acting Director of the new Bureau of Health Services
Research and Evaluation which has been developed within this
new organization, and we will be having more to say to you

about that in a few minutes.

We may have some guests from downtown.

 
Plce-Sederal Reporters, Ine.

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But you will also recognize familiar faces around
the wall. And, of course, the other person I would like to
specifically mention is Dr. Paul Teschan as the Chairman.
of the Coordinators’ National Steering Committee and
Program Director of the Tennessee Mid-South Regional Medical
Program, who also will have to be departing early put would
like to have an opportunity to present a few comments to
you trom the Coordinators’ point of view, and we will make
opportunity for that presentation.

And the ngtrange face” sitting next to Paul
is one that you recognize full well (indicating Dr.
Margulies). I must say it feels very atrange
sitting here and having him sitting there. (Laughter)

I will have more to say about this as we go.
along. | |

Concerning some housekeeping details, some of us

will have our first cup of coffee, and some the second cup,

about 10:15. We had scheduled the lunchtime break at

approximately 12:30, but, of course, that is subject to

how you feel the day is moving along.

And Mrs. Handal in the yellow outfit will be very
interested in helping you with plane reservations and any

changes that you would like to make.

This is an open meeting. We have members of the:

public who are at the appropriate point in the agenda welcome

 
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that we have been engaged in and some matters that we will

 

 

to make comments and observations.

If any member of the public does wish to address
the Council, we would appreciate it if he would identify
himself or herself as to name, organization, and the group
he represents if other than himself.

Now, the plan of the day sounds a little
formal, but, in fact, as you know, we have not met since
the first week of February, and at least here in Rockville
much has been going on, and we would like to take this
opportunity primarily to bring you up to date as to what
has been happening from our point of view, and through
the Steering Committee chairman we will have what has been
happening in the Regional Medical Programs from their point
of view.

Thus, I will have a somewhat brief report to

give to you, pointing out certain highlights of activities

be discussing over the day, and following that there will be
a report by Mr. Lyman Van Nostrand who is the Chief of
our Planning Branch of the Office of Planning and Evaluation,
who will give an overview of the rather complicated budget
and legislative chronology, which will bring you up to
date as to where we are and how we got here.
Following this -- and there are items in the agenda

book which will be identified for you by the individual

 
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og
speakers -- we will then have a presentation of the overview

of the phaseout, and Mr, Chambliss. and Mrs. Silsbee will

describe what we did, how we went about it, what we see the

impact to have been.

Then we will have something concerning the
financial aspects, which are rather important, and Mr. Gardell
who deserves some kind of medal yet unstruck by the Government
for call beyond duty this year, will present to you the.
overview of what our financial affairs are. Mr. Chambliss
will then wind up on a programmatic note giving you gone
indication of where the regions are in terms of activities

tjat are now going on.

We are certainly far from on our knees. We

have been stumbling a bit but I don't believe that we are

beyond repair. And I believe Mr, Chambliss will indicate

that to you in his report.

We do have today two formal actions that we

would like to have you consider and take action on, and

these will be the subject of handouts. They represent

delegations of authority which will become clear to you as

to why we need these delegations of authority in order to

manage our affairs during this still somewhat difficult

- transition period.

Then, if we can accomplish most of this by

10:15 to 10:30, we will have presentations by Dr. Laur,

 
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Dr, van Hoek, Dr. Teschan, and we may have to rearrange the
order in order to accommodate schedules.

And then, most importantly, both before and
after lunch or over the lunch period, depending upon your
pleasure, we. need to discuss very impor tant issues as
to where we go from here, the kinds of programmatic
options which are under consideration, and some of the
review process and procedures which.we are facing and on
which we need your guidance and assistance.

So really the first half of the morning, if
you will, is devoted to historical presentations, what
happened and how we got here, and then we move into where
we go from here.

As I say, we sorely need your good advice, coun-
sel and participation in coming months.

That is our overall plan for the day, and you
will be hearing from a number of our staff members.

Since Dr. Merrill is not here, let us omit the
consideration of future meeting dates, but I will indicate
to you we are looking toward a two-day Council meeting the
last week of November after Thanksgiving, but I believe it
would be better if we held off the actual decision on that
until Dr, Merrill is able to arrive.

So if we may turn to a consideration of the

minutes of the last meeting of the Council, February 7th, I

 
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would ask the Council if there are any corrections to be

made in the minutes. And if not, I will receive a motion
for approval of the minutes.

DR. McPHEDRAN: I move they be approved.

MRS. MARS: Second.

DR, PAHL: It has been moved and seconded to
approve the minutes of the February 7th Council meeting.
All in favor say "aye."

(Chorus of “ayes.")

So moved.

1 would like now to turn to my report, which I
do intend to make fairly brief. We are all on a little
bit of a time schedule this morning, “and that includes the
chairman, and I will try to observe that.

The most important and singular event which has
occurred since we last meet as a Council and staff has,
of course, been the departure of Dr. Margulies from the
leadership of the program. And I must say again that I
find it quite strange to be sitting here with Dr, Margulies
on the sidelines. But I am glad even with the press of
duties he is able to meet with us today, and I hope he will
be able to meet with us in the future, since we again need
his outlook, information and guidance.

I would like to say that from my point of view

it often happens -- and I think this is a case in point -~-

 
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that people who have served the Governnent very well in a
capacity of major responsibility for one reason or another,
through reassignment, reappointment to positions of major
responsibility, seem to drift off from the program and it
is never quite recognized.

And I would like to take this opportunity I
think to make it a part of our formal record that we
note that this is an important event in the life of the.
Regional Medical Programs and that Dr. Margulies served the
program not only as the Acting Director from March of 1970 .
to December of 1970 but also, as you know, gave strong
leadership as the Director from December of 1970 through

June 17th of 1973.
There is nothing magic about June 17th except I
became the Acting Director on June 18th, which happens to be

the day the President signed the one-year extension, so I

believe I revitalized the program, not Dr. Margulies.

(Laughter)

I know Dr. Margulies is generally uncomfortable
about being on the receiving end of statements, but again
the staff, because it has been summer and we have been very
busy in our own respective responsibilities, have not had
occasion to get together, and I believe this is an
appropriate point to read a statement into the record, a

prief statement, which perhaps, I trust, expresses some of

 
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the feelings that the staff have concerning Dr. Margulies’

leadership over these years.

And so, with your permission, I will read the
brief statement: | L }

"On behalf of 211 of the staff of the Regional
Medical Program Service, both those who are with us this
morning and those who are absent or who have departed from
the program, I want to take this opportunity publicly toi

express to you, Harold, our congratulations and very best

wishes as you assume your new duties as Associate “Administrator

for the Office of Planning, Evaluation and Legislation in
the Health Resources Administration. |
"More importantly, however, I want particularly
to express our awareness and deep appreciation for your |
having set a high standard of excellence in which we have

taken great pride throughout your several years as the

Director of the Progran.

‘We note here for all to witness, particularly in
these troubled days of our country, the strength you have
afforded to all because of your personal integrity and |
your selfless dedication to the highest principles of
public interest and to working in the public interest though

at times this has been at personal cost.

"As your staff we have benefited too from your

belief in the worth of each person as an individual and the

 
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need to work for the betterment of that person, and nowhere
is this better exemplified than in your personal and
official commitment to the principle and program of pro-
viding equal opportunity both within the Regional Medical
Program Service and the Regional Medical Programs for all
persons regardless of race, sex, or other circumstances
which may compromise such opportunity.

"Harold, it has been a rewarding experience for
each of us to have worked together with you in the Regional
Medical Program Service toward a worthwhile goal, improving
the health of a11 of our people. _We wish you our best in
your new endeavors."

(Applause)

DR. McPHEDRAN: Dr. Paul, may I add something
to that?

DR. PAHL: Dr. McPhedran.

DR, McPHEDRAN: I want to add my thanks, Harold.
You have been a great help in our search for ways to
insure quality medical care for everyone. It has been a
pleasure for the same reasons given by Herbert Pahl. I
have appreciated your literate speaking and writing, but,
more than that, your friendliness and consideration for
others which informs all of your work.

I am pleased to learn that you will continue in

that same kind of effort.

 
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DR. PAHL: Thank you, Dr. McPhedran. And I know
I speak for all the members of the Council in having these
statements recorded in the official record of this Council
meeting.

You didn't expect this, I know, and so you way
now leave for vacation -- or I guess it's tomorrow you leave
for vacation. (Laughter)

Turning back to our report, which seems a little
less of interest to me right at the moment, but, nonetheless,
let me pursue the agenda I set for myself.

I would like to indicate, first of all, what is
the status of our Council. Unfortunately, I have to
relate that Dr. Gerhard Meyer has resigned, with his
regrets, by letter, most recently, as a result of the press
of business, and so I believe this leaves us, Ken, with seven

or eight --

MR, BAUM: It leaves us I think with seven

vacancies,

DR, PAHL: Seven Council vacancies. Of course,

nominations had been in for the Council this past spring,

and all of that was held in abeyance because of the proposed

termination of the progran.

So we do hope to have our Council up to full
strength in coming months, but I also have to indicate to

you that five of those sitting around the table have terms

 
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expiring this November 30th, and: we will’ be most fortunate
indeed if we can arrange matters to have all of you with us
beyond that point in time, and we will be working toward
that end with your permission.

Our Review Committee, as the next topic, no longer
exists. As you may know, there is a general interest |
within the Government, and certainly within DHEW, to reduce the
number of advisory groups to the extent that the Government's
business may still be conducted without undue detriment. |

In addition to that, with the phaseout of the
program, we had no choice but to have the Review Committee
as an established committee submitted to the Department for
termination June 30th. And with the efficiency which
the Department does sometimes show, these papers were
processed somewhat prior to June 18th, and so we find
ourselves at this point in time with no Review Committee.

To reestablish a Review Committee represents a
certain lag in time due to procedures one must go through,
so as a Council and staff we stand together and alone,
and this will have a bearing on some of the matters that we
discuss this afternoon concerning how we conduct our
affairs over coming months, because our primary responsibility,
of course, is to not only support but revitalize the
regions, and we must do this under somewhat strained circum-

stances.

 
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I I would like to indicate for those of you who

2 are not aware that the chairman of our former Review

3 || Committee, Dr. Schmidt, is now the Commissioner of Food and
4 Drug Administration, so we do have the opportunity to

5 || pass in the halls and on the elevator, but we don't see him
6 in connection with Regional Medical Programs business.

7 Now I would like. to turn to a brief review

8 of the various organizational changes that have taken

9 place since we met. We have these in your folder, but I would
7 ask you not particularly to turn to them since we have

i vu-graphs. But under "Organizational Charts" you will be

V able at your leisure to study what all these new boxes are.

i But I would like, if I might at this point, to

- run through rather quickly for you with vu-graphs these

1 changes, and we will hope that this shows what the new

6 structure of the health part of the Department looks’ like.

" (Slide)

6 I hope all of you can see this. Can you hear me?
" The organization of the health agencies is, of

" course, under the Secretary of HEW, Mr. Caspar Weinberger,

* and Under Secretary Frank Carlucci. The Assistant Secretary
2 for Health is Dr. Charles Edwards.

* Under Dr. Edwards there is the National Institutes
“4 of Health under Dr. Stone, the Center for Disease Control

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former chairman of the Review Committee, Dr. Schmidt, the

Health Services Administration under Mr. Harold Buzzell,

and the Health Resources Administration, the administration

that we are located with, under Dr. Robert Laur who will be

addressing us later this morning.

The Health Services and Mental Health Administra-
tion under Dr. Verne Wilson, therefore, has been broken

into three units, the Center for Disease Control, the Health

Services Administration, and the Health Resources Administra-

tion.

In addition to that, the Bureau of Health Man-
power Education and certain other activities have been
brought into one or another of these units.

This now constitutes the set of agencies and
responsibilities that Dr. Edwards has.

May I have the next vu-graph?

(Slide)

Now, turning to Dr. Edwards’ office, the Deputy

Assistant Secretary is Dr. Henry Simmons, and, of course,

the Executive Office is under Rupert Moure.

Health Planning and Program Evaluation is under
Beverlee Myers, who was with Dr. Wilson in HSMHA.

Program Operations, Lionel Bernstein.

Policy Analysis and Research, Daniel Zwick.

Regional Operations, Mr. Kelso.

 
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Administrative Management under John Droke.

Beverlee Myers, having been in HSMHA and worked
very closely with RMPS in past years, of course, understands
the program and I think will be a wonderful liaison to have
in this new position.

The next chart, please.

(Slide) |

Now, turning to the Health Services Administra-~-
tion, the Administrator is Mr. Harold Buzzell, and there
is a Program Planning, Evaluation and Legislation Office
and Administrative Management. But the programmatic areas
are the Indian Health Service, the Federal Health Programs
Service, the Bureau of Community Health Services under
Dr, Paul Batalden, and the Bureau of Quality Assurance
under Mike Goran, which includes the PSRO, Utilization
Review, Medical Review, and Independent Professional
Review.

Again, these charts are in your book. It is a
lot of information and new titles. You can study them at youn
leisure.

The next chart, please.

(Slide)

We now turn to the organization where we are
located, the Health Resources Administration. These are

all acting appointments at the moment. The Acting Ad-

 
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Administrator is Dr. Robert Laur.

Public Affairs, Mr. Lebow.

Planning, Evaluation and Legislation, Dr.
Margulies.

Administrative Management, Mr. Parks.

Programatically, the. Administration has been
constructed along the lines of three major bureaus. The
one bureau, the National Center for Health Statistics, under
Dr. Perrin, has a major responsibility for aggregating
all of those kinds of functions in which generalized
information and statistics are sought from various
programs.

So it does include the National Center and
also the Bureau of Health Manpower Education's Medical
Intelligence Division -- is that it, Harold? --

DR, MARGULIES: Yes.

DR, PAHL: -- and other units, And this also
has the Federal, State, local cooperative health data

system.

The Bureau that we are located in is the Bureau
of Health Services Research and Evaluation under Dr. van
Hoek, and later this morning he will perhaps have a few
words to say about the proposed organization of this.

But it does consist of Dr. van Hoek's current program

responsibility, the National Center for Health Services

 
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Research and Development, together with the Emergency
Medical Services activities of what was HSMHA, and the
Regional Medical Program Service.

I will say more of this in just a moment.

But to give you the third bureau, it is the
Bureau of Health Resources Development under Dr. Ken Endicott
of the Bureau of Health Manpower Education and consists
of the Bureau of Health Manpower Education under Dr.

Peter Eichman, Comprehensive Health Planning Service
under Mr. Robert Janes, and the Health Care Facilities
Service under Dr. Harald Graning.

All of the bureaus are currently organizing
themselves and will be submitting proposed plans of
organization over the course of the summer, and again Dr.
van Hoek perhaps will be interested in giving you a timetable
for this.

I think the point is that we are in the bureau

which includes both the Emergency Medical Service system

and the R & D activities.

I made a note for myself.that it's interesting
to me that within. the six-month period _- and I hope this
is not a prognosis by any means -- that we have had at the
Administrator Level of the agency in which I find at least
myself working Drs, Wilson, Sencer, Mr. Buzzell, and Dr.

Laur, And so if sometimes the policies from Washington seem

 
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to be changing and directions move a little differently,
you will see that this rapid turnover of top management
undoubtedly is partly responsible, and we continue to
suffer to a certain extent certainly within the health area
in the fact that certain key positions are not filled at
all and certain major positions turn over rather frequently,

We do not at the moment have a full-time
permanent Administrator of the Health Resources Adminis tra-
tion, but this is probably true across Government from what
I can understand, but it does make a difference in how
well we can act.

Now I would like to turn to the staffing of
our own Regional Medical Program Service --~

(Slide)

-- and indicate to you where we are, where we
were before we engaged in the phaseout process which
applied to the Regional Medical Program Service itself, of
course, not just to the Regional Medical Programs.

And without trying to make too much of the
numbers, we have looked at the professional people on
poard in January -- at January 1 -- and at July 1 and

our clerical and supporting staff January 1 and July 1 by

office,

First of all, the totals. We did have 234 people

in January. We are now down to 128 people.

 
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We had 125 professionals. We are down to 84.

We had 109 supporting personnel, and we are down
to 44,

This should indicate that we have been going
through the same kind of personnel loss that the Regional
Medical Programs have.

There has been within the Government a RIF, a
reduction in force program, which has a planned program for

us for a reduced number by September 30 and March 31, so

that if the personnel continue to depart -- which we believe

is no longer necessary with the extension of the program --
we would have been down to perhaps 70 people by September
30 and 30 people by March 31 and 9 people by the end of the
year.

I would like to take just one moment and publicly
again thank-- The staff knows full well what has happened
here in recent months. But Mr. Charles Hilsenroth, who
has been our Assistant Administrator or Director for the
Administrative Management and Services of the Regional
Medical Programs, has done an outstanding job.

I think only those of you who have worked in the
public service know how difficult it is sometimes to
rearrange transfers of personnel and to locate opportunities

for personnel as they move out of a program into other

areas, and without question Mr. Hilsenroth, who retired last

 
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month, has done an outstanding job in relocating our
personnel, the kind that you see have been lost from each
and every office.

I think due recognition of this was made, but
it should be also a matter of record here.

Now, the numbers themselves, either in the
professional category or the clerical category, don't really
indicate what has happened. As you know from being with
many organizations yourselves, it is who leaves, the
timing, and, of course, the morale problem. And so we
find at the moment that we have key people in each office
who have left.

And it would be somewhat I guess not necessary
really for me to indicate to you, but the fact that Dr.
Hinman is sitting over there, the fact that Dr. Margulies
is sitting there, the fact that we have people from the
Office of Planning and Evaluation, Systems Management,
this office is leaderless (indicating Office of Communications
and Public Information)-- And we can go down and down.

So we have been working against a difficult set
of circumstances and continue to do so. We are trying to
stabilize and move ahead. And t6 the extent that the Agency
is reorganized and the Bureau is reorganizing this has
posed or superimposed a set of problems which we continue to

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I would like to turn to the other topic of the

overall picture of our budget.

(Slide)

This chart is in the book. I won’t spend too much
time on it. The original budget request for fiscal 1973
was $131 million. The amount in the appropriation bills for
1973, which was vetoed, is $164 million.

We roughly spent $59 million in 1973, and Mr.
Gardell again will receive a commendation because out of
that we ended up with a balance of $2,449, which is again
an unusual circumstance particularly with the ways in which
the program has been going recently.

The authorization for fiscal 1974 is $159.6
million, and the continuing resolution under which we
operate at the present time for fiscal 1974-- We might as
well indicate it's either $60 or $81 million, and it’s
an academic point at this time because of matters which have
moved the whole process somewhat further along.

| I think that’s all we need from the vu-graph.

Now, I'm taking more time than I should, and I
know the staff is nervous. On the other hand, I think
it’s important that you realize some of the positions that we
have been in. |

I would like to terminate my portion of this

presentation and then turn it over to Mr. Van Nostrand to

 
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go over the budget and legislative overview by saying
that the WASHINGTON POST today -- they must have been
psychic -- recognized the position that the Regional Medical
Programs have been in. And I'm very happy to say that those
of you who got up early enough and got past the front
page and that rather startling series of things may have
gotten to see on the comic page where Charles Schulz
finally recognized the Regional Medical Program Service's
problems and expressed the philosophy perhaps that the
staff has had to adopt over recent months.

It's a four-picture comic strip, and Peanuts
is saying, with his face in his hands, "T used to try to
take each day as it came -- you know, live one day at a
time. My philosophy has changed. I'm down to half a day

at a time." (Laughter)

I'd like to indicate I think we're out of a half
a day at a time and we're back at least to the one day.
And I think with this Council meeting we're beginning to
look at weekly, monthly, and possibly even the full fiscal
year.

With that I'd like to have Lyman come and address

‘you oh the budget and legislative chronology.

MR, VAN NOSTRAND: As Dr. Pahl has said, you
could call this year almost the fall and rise of RMP,

although the novel isn't quite finished yet.

 
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It really started back in 1972, the Presidential
budget for FY 73. The figure that was proposed was $130.3
million. During the appropriations process, the bills
that came through were quite a bit higher across the board,
not only for RMP but for all of HEW.

In the case of RMP, the figure that they came up
with was $164.5 million, which was some $34 million over
the President's budget.

Because both the HEW appropriation packages were
so high, the President vetoed both of those.

This forced us to go into the situation of a
continuing resolution. The figure that was picked for
this was the lower of the House and the Senate appropriations.
Since the House figure was $150 million, that was the

figure that became our sort of current rate.

In January 1973 the President released the FY 74
budget, and this was, of course, where they made the major
decision to propose termination of RMP in FY 74. At the
same time they put in an amended 1973 level budget which
was for the amount of $55.4 million.

When they proposed the termination of RMP, they
gave what they considered a rationale behind this. They
said that the program had been going for eight years, had
spent about $500 million. They felt the program had never

really established a clear focus for itself. It had been

 
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part of the time on heart disease, cancer and stroke,
moved into comprehensive care delivery systems.

Another problem they found with the program was
that they felt too much money was being spent on the core
staffs. Over the past few years this has averaged about 40
percent, and there was some problem with this.

There was some feeling that too many funds had
been going into training and continuing education, with the
belief that this kind of thing could have been picked up
by physicians, nurses on their own, on their own salaries,
hospital costs, and so forth.

And there was some dispute too in terms of: Had
RMP really gotten the latest advances out into the system?
There was some question about this. Could it really be
proved?

An additional rationale was that there were a
number of new health programs that had come along that
could pick up some of the functions RMP had in the past.
The idea was that planning functions could be done by the
Comprehensive Heaith Planning agencies, that the Professional

Standards Review organizations could pick up on the quality
of care aspects of health care. NIH was doing more in the
way of heart disease and cancer control programs and that

they could pick up some of the things that RMP had been

doing.

 
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And also that probably another very big piece,
with the passage of the social security amendments last
year that included reimbursement for kidney disease-- The
idea was that with Medicare paying for kidney disease, a lot
of the work RMP had been doing in this area probably wouldn't
have to be continued.

On March 8th, the first evidence of some
congressional opposition to this proposal was evidenced
when Senator Kennedy introduced, with 15 of the 16 members of
the Labor and Pyblic Welfare Committee, a one-year
extension of 12 of the Public Health Service authorities.
This included RMP as well as a number of others, including
Hill-Burton, Community Mental Health Centers, R & D,

Health Statistics, Allied Health Training, a whole broad
range of programs.

The level of authorization that they put in there
was the same as it had been in the previous RMP authoriza-
tion, $250 million.

The basic rationale of why they were calling
for a one- year . extension was that the committee felt they
had not had enough time to review these programs, that the
budget had proposed phaseout in such a quick period of
time they really hadn't had time to go over and see what
the strengths and faults of the program were, what changes

needed to be made to modify it so it was a little more

 
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productive.

On March 14th an extension bill was also intro-
duced in the House, H. R. 5608. This was Representative
Hastings along with the entire Subcommittee on Public Health
and Environment. | -

The first hearings were March 22nd in the Senate.
That was a one-day hearing after which the bill was reported
out. And a few days later, on March 27th, the Senate
passed the bill by a vote of 72 to 19.

This was followed with hearings in March, March
27 through 29, and again on May 8, in the House. Along with
the Administration testimony, there were also the RMP
coordinators and a panel of RMP physicians that were on RAGs
around the country, and they presented evieemce that they
thought was contrary to the point of view being expressed

by the Administration.

They talked about some of the accomplishments RMP
had had. They admitted there were some problems in certain
areas, that there could have been more focus on certain
problems, but they thought the overall record was generally
favorable around the country.

On May 15th, H. R. 7806 was substituted for the
first House version, the idea being to lower the total
authorization levels in there by over a billion dollars

so there would be less reason to cite vetoing it in terms of

 
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budget-busting.

Because of that, the RMP authorization was dropped
from a level of $250 million to $159 million.

On May 31, the House passed this bill by a vote
of 372 to l.

On June 5 the Senate decided to drop its original
version of the bill which had the $250 million for RMP
and accept the House version, I think on the assumption that
it had a better chance of being signed by the President,
and that was passed by a vote of 94 to 0.

So, in ensence. the bill went to the President
with really only one vote against it. It was passed
unanimously in the Senate and 372 to 1 in the House. And
the President signed the bill on June 18th.

In his signing message he said that he realized,
you know-- He acknowledged the opposition they had had to
the passage of this but he said he felt if the Congress
had one year to look over these programs and recodify and
consolidate, they might be able to come up with a better
authorize some of the authorities under the

package, how to

Public Health Service law.

Once we had the authorization, the next step in

this process, of SOUrHe, was to' get appropriation, the

“actual funds. There have been both House and Senate hearings

over the last couple of months.

 
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The first real action on this was the House
passage of the FY 1974 appropriation bill. That included
a figure of $81.935 million for RMP, The Senate is
still holding hearings on the 1974 appropriation. If they
follow their usual form, they will come up with a figure
higher than that, which leads to the problem again that if
the HEW appropriation is too high -- again the House version
is already a billion over -~- will this lead to another

veto? And so that is something that has to be looked out

for down the pike.

At the same time, because the Senate had not
finished its work on the appropriation, it required the
signing of a continuing resolution. This allows us to
spend through September 30th, and the rate at which we are
allowed to spend is the lower of the House version or
last year's continuing resolution.

Since last year's was $150 million and this
year's is $82 million -- the House version for FY 74 is
$82 million -- our current rate at least for this purpose
is $82 million, at least according to the congressional
interpretation.

At the same time, at the end of FY 73, a supple-
mental appropriation bill was passed. This is something
that happens almost every year. The Executive Branch sends

in all the last-minute items that have seemed to have

 
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occurred in the budget, expenses that were not really known
in advance.

That budget was sent to the Senate and the House.
The House added $12 million under Section 304 and Title Ix
of the Public Health Service Act -- which is the RMP

authorization -- for construction for D. C. Children’s

Hospital here in D. C.

At the same time, the Senate both in committee and
outside, in the floor debate, added the $12 million for
D, C. Children's, added $4.5 million for construction of
a children’s center in the northwestern part of the United
States, very probably in the State of Washington, and
$500,000 for completion of a hospital up in Vermont which

Senator Aiken had added on to the proposal.

So the bill as passed -- and the President signed

it -- this was after the negotiations on the Cambodian

resolution -- Aneludes $17 million that is available until

: expended under Section 304, which is the RMP authorization,

for construction of these three projects that I have men-
tioned.
Dr. Pahl I guess will be speaking to you later

about those in terms of delegations of authority of how we

are going to handle those.

The only other thing I thought I might mention

quickly in terms of other legislation that is sort of coming

 
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along the pike is in terms of the HMO bill. The Senate
passed that on May 15th with a total authorization of

$885 million for three years. The House is working on the
bill I think this week, H. R. 51. They expect to have a
markup I think this week, which would mean it would be |
reported shortly thereafter.

That is expected to have much lower authorization
levels than the Senate version, more in the version of a
demonstration grant program.

The other bill that is moving along fairly well
is the Emergency Medical Services bill. That passed the
Senate on May 15th, the House on May 31st. The conference
report was reported out July 10th, which essentially put
money into planning, feasibility studies, establishment and
jnitial operations, research in emergency medicine, and
training grants. And that was for $185 million for three
years.

And the only other thing with that which may
cause some problem is the fact that the eight Public Health
Service Hospitals were added as an amendment to keep these
open, which is being opposed by the Administration. So

that may or may not cause a problem. It*s hard to tell at

this point.

A third piece I thought I would mention is the

kidney disease part of the social security amendments of

 
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1972. The reimbursement, for Medicare, began on July 1,
1973, and interim regulations on how this was to be worked
out were put in the FEDERAL REGISTER on June 29th, essentially
saying that for the time being, until final regulations are
done, they will continue paying through the normal Medicare
channels for hospitals that have already been doing such
kidney operations, dialysis, and so on, and that as the
program gets going, within six months to a year, they will
probably have final regulations that set up what the final
procedures are going to be.

DR. PAHL: Thank you very much, Lyman.

We have given you a good bit of information in
both my report and Lyman’s, and I think we might ask whether
you have any questions or points to make or observations
as a result of these presentations before we move on.

In this connection, I would like to again indicate
to you that in your agenda books, which I hope you will--
Pardon me. Dr. Schreiner?

DR. SCHREINER: When you originally introduced

this, you mentioned a continuing level of either $60 or

* $80 million, and I don’t. understand where the $60 million

came from.

DR. PAHL! There has been a debate going on as to
whether the continuing resolution from the Department’s

point of view would be at the current operating level of the

 
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program or whether the congressional, $82 million House
allowance, would be the level of the continuing resolution.

And this has been a matter of great internal
interest within the bureaucracy. At the moment , as I have
indicated, this is not of major import because we will be
taking up this afternoon the actual funding and fiscal situa-
tion of the program, so that at the moment we are not privi-
leged to be expending at either of those levels.

So although it is of still great academic interest,
I believe we'll accept the congressional level of $82
million as being at least the lower figure which we can
expect from the Congress, and then leave it to OMB and the
Department to decide what the funding level of the program
may be, looking hopefully, of course, toward full

authorization and release of all the funds that are made

available.

But it's an internal kind of consideration of
continuing resolution levels, and the lawyers have had a
wonderful time trying to decide just what the continuing

resolution means.

If you read the legislation and the report, you
will also find that the Congress has tried to make very
clear from their point of view what they believe the Ad-

ministration should consider to be the continuing resolution

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Yes, Dr. Haber? |

DR. HABER! Previously you mentioned one of the
criticisms of the Regional Medical Programs was too much
money had been put into core staff. 12 don’t understand how
that is a criticism. Can you elaborate on it?

DR. PAHL: Lyman, do you want to, or shall I?

MR. VAN NOSTRAND! Essentially what they were
saying I think is that some of the activities-- They tended
to equate core staff with administrative costs, which is
not necessarily the case.

DR, HABER! That's what I mean.

MR. VAN NOSTRAND: The idea was the money could
have gone into direct operational projects rather than into
program staff. I think when the coordinators presented
their testimony they tried to “show that the administrative

costs at least in their definition amounted to about 7, 8

or 10 Percent and that the activities carried out

_by ‘the ‘program staff were really as good as the operational

projects in terms. of getting something done.

‘So. it's really a matter of their view of how you
define what core staff is doing.

DR, PAHL: It has been looked at as a very
high overhead, when, in fact, it constitutes very important
programmatic activities included in that figure. There

has been a good bit of misunderstanding as to just what that

 
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includes, and we have tried to clarify it.

I would indicate in the agenda books that under
the various tabs again we have the Xeroxed charts of all
those which have been presented to you through the vu-graphs.
Also there is a more detailed legislative chronology,
actual excerpts from the congressional hearings and staff
relative to the RMP program this year, a section on related
legislation.

I believe you will find all of these of value
and interest to read a little bit more at your leisure.

If we may turn over to the next item on the
agenda, which is the overview of the phaseout, we have
asked Mrs. Silsbee, My. Gardell and Mr. Chambliss to
give to you-- And I would believe perhaps we could accomplish
this in a half hour. I have eaten up a little too much
time. But I believe that might be about an appropriate time
to give you a picture of what really has happened from
the period when we last met in terms of administrative

actions and where we stand.

Just by way of introduction, since you all know
Mrs, Silsbee, I would like to say she very graciously has
accepted, and I am pleased to announce to the Council,
appointment as Acting Director of the Division of Operations,
having formerly served as the Deputy Director of that

Division, and, likewise, Mr. Chambliss has graciously

 
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accepted to serve as the Acting Deputy Director to me for

the Regional Medical Program Service, having served as the

Director of the Division of Operations.

And so, you see, it's the domino game of everyone
moving upward into better jobs, bigger titles, greater
responsibilities. And we are really pleased that they
take on these responsibilities for us.

Judy.

MRS, SILSBEE: Well, when Council met last time,
we had had the first step in the phaseout, and I believe you
had just received copies of the February 1 telegram which

went to the Regional Medical Programs explaining that the

phaseout would have to occur and that we would need

applications putting forth their plans.
The telegram stated the criteria which would be

used to review the phaseout plans, stating that during the

phaseout only activities that had a short-term impact

that we could note would be considered or that had an

opportunity to be picked up from other sources and needed

., some additional time in order: to. accomplish that fact.

We sent the telegram on February 1. And since

apparently in the Department of HEW no one had ever phased

out a program in any orderly fashion before, we had to

start from scratch. We had to develop instructions. We had

to think of the kind of information that the Regional

 
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Medical Programs would need in order to do this in an
orderly fashion, and, knowing that the Regional Medical
Programs is an unusual grant program, in that it involves a
number of different organizations, not only the grantee but
all the affiliates, this was our major consideration. How
could we do this in a way that would be helpful to the Regiona
Medical Programs under very stressful conditions?

So it took us a while. And I think Jerry Gardell's
staff does need a hosanna here, because from the grants
management standpoint they had to develop this material
from scratch. | |

The instructions went out sometime in the latter
part of February, and the applications were expected back
on March 15th. At the same time we had promised by April
15th to give a response so that they would-- Again looking
at June 30th as a first part of the phaseout, February 14th
the end point, this would give the Regional Medical Programs
time enough to do with all of their various organizations
what they had to do in order to have an orderly phaseout.

Well, we received the applications, and they
came in-- I think it was probably a first in the history of

Regional Medical Programs. Just about every one of them

made the deadline of March 15th.

And the applications as a whole were very well

organized. The Regional Medical Programs under tremendous

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stress of time and decisions did a beautiful job of present-
ing their plans.

The applications broke out into various categories.
There were programs that had decided to essentially phase
everything out June 30th. There were those that had done a
pretty stringent weeding-out job at the regional level and
were recommending projects based on our two criteria and
providing the documentation. There were those that were
trying to keep the program staff intact, because the
program staffs in certain regions, as Dr. Pahl mentioned
earlier, some program staffs, do a series of studies, and
so forth, were the vital part of the program, and they had

used small amounts of money for studies, and so forth, in

_ order to make the program go. And then there were those

Regional Medical Programs that wanted to keep everything

going pretty much..

| We had no experience in reviewing phaseout plans,

but we did have some understanding of what the Department
expected in terms of phaseout and why they had allowed

this extra time, because there had been one consideration
of June 30th -- period. They were interested in allowing
some projects meeting these two criteria to go on.

So that had to be our major cue in looking at

the applications, looking at the projects, to see whether

they met one criterion or another, and then to see if they

 
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had the documentation that went along with it, and then to
develop the program staff, minimal program staff, that was
needed to monitor those projects and phase out the program.

The review of the 56 applications was done under
very intensive circumstances. We decided very early on we
couldn't do a gradual review as we usually do, with the
staff looking at it and then coming up and recommendations
being made that way, because we were having to do it and
make our own ground rules as we went along and then go back
to staff information.

So aside from a few forays to the emergency
medical clinic on my part and to the hospital on Dr. Pahi's
part, five of us sat day by day during the day considering
these applications, and night by night reading them so we
would be ready for the next day. |

Well, about April 11th we were able to send out
the telegrams to the regions stating what they could
continue beyond June 30th and a level of support that we
would allow them.

The telegrams also indicated-- Or we knew that
there would be appeals, so there had to be appeal review
afterwards. And gradually all these decisions were made,
and we were ready to phase out.

You may be interested in the back of the book

under "Phaseout"™ that the majority of the regions were

 
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approved to go from June 30th to January or February of

1974. About five were approved to phase out June 30th, three

of which had opted for that.

Of the projects that were approved-- And again
I want to emphasize that they had to meet one criterion or the

other. Of those projects -- there were about 289 -- of

the 289, 209 of them were in the regions that were going
on to January or February of 1974.

(Slide)

In terms of the types of activities that we now
find ourselves with before the phaseup again, I did an
analysis which could be challenged by practically anyone
in terms of the types of projects, and that’s in a little
vu-graph. But you can always quarrel about how you are going
to categorize. But I categorized all of them on the same
basis, which are my definitions.

As you can see, the majority of those projects

_that were approved: beyond: were in the area of

categorical diseases, or I threw in there specific groups
like the neonatal group, and so forth. And emergency
medical services about 11 percent. Health manpower, general,
which would include our support for the health services edu-
eation activities. And health manpower, specific, which was
for specific professional groups or for specific types of

training, including categorical diseases.

 
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That's all I have.

DR. PAHLi Okay. Are there any questions that
you may have concerning this rather brief but I hope
interesting view of what the staff tried to accomplish in
a rather short time frame and as fairly as possible?

These were professional judgments relative to
regions and projects, and, of a the staff stands to be
criticized and have been criticized, but I would merely
say that in the circumstances we had to operate, at least
from our point of view, we tried to be as fair and
equitable as possible; and I think only history will
record whether this was in fact as good as we tried to make
it be.

Are there any questions?

MRS. MARS! What happened to the three that were
phased out June 30th? Are they still continuing?

MRS, SILSBEE: Yell, actually, there were five
that were scheduled to be phased out. But that shows in
relationship to our former rating of A, B and C.

MRS. MARS: Take the five then.

MRS, SILSBEE: Of the five, once the legislation
was extended, two of them which seemed to have enough there
to go on requested reconsideration. They had opted
originally to go out of business on June 30th. We had no

plan B for them. We had a plan A only. So that was the only

 
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thing we could consider. And the decision was made to

continue those. They had funds that would allow them to do

it.
MRS, MARS! This was two of them?

MRS. SILSBEE! Two of them. Three of them have

been phased out.
MRS. MARS! Completely?
MRS. SILSBEE: Completely.
MRS. MARS! Which ones are they?

MRS. SILSBEE! Delaware, Ohio, and Northeast

Ohio.
MRS. MARS? Thank you.
DR. PAHL: Dr. Roth.
DR. ROTH? I don’t know when or even if it will

become appropriate to say more about a document that

has been given to me, but this came from the coordinators,

and in the first part of it there is a statement that

relates to what we have just been talking about on phaseouts.

Let me ask a question. This saysthat it is

believed that the February issuance of phaseout orders

with subsequent amended awards to each individual Regional

Medical Program was in violation of Public Law 91-515

because those orders were never approved by this Council.

Would you care to react to that? And is it of any

significance if it’s true?

 
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DR. PAHL: I feel like perhaps one of the indi-

viduals who has been appearing before the Senate. That's a

two-point question. (Laughter )

Let me answer the second point first. If true,
yes, it is significant.

With regard to the first matter, we do not concur
with that position, because as members of the Executive
Branch we feel that we really must follow what is the
Administration’s position, and, therefore, when the President
did not request support for the program for fiscal 1974
it seemed to us to be a matter of prudent administration to
alert, which is what that telegram did -- to alert, all ;
Regional Medical Programs of this fact and to ask them to
take those kinds of steps which could lead to an orderly
termination and the request, therefore, to submit plans of
phaseout.

We did not terminate the program with that

telegram. I think this is a point which should be under-

stood. That telegram was considered to be a matter

of administrative necessity in view of the fact that

no funds were requested for the continuation of the program.
The administrative actions which followed were

considered to be that -- administrative actions on the basis

of prudent management.

The decision to terminate the program, if you

 
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will, was a collective decision by the Administration, I'm
not enough of a lawyer to know in fact whether this required
Council approval or not. But we felt it was a matter solely
of management and not a question of Council approval,
because this was not seeking advice about programmatic
areas or approval of grant funds for the support of activi-
ties by the regions.

In confirmation of this point of view, I would
say that as soon as the President signed the extension
legislation, which, of course, we had been also looking
forward to ourselves daily, the first official act which was
taken -- and I happened to be the one in the chair at the
time -- was to institute the Council involvement by trying to
call this meeting together.

So, in fact, we view it as a very desirable
feature to have Council involvement in matters of
advising on policy and certainly in approving grant funds
for expenditure by RMPS, But. the termination was viewed
as a necessary prudent managerial procedure and not requiring
Council.

That I think is the viewpoint. Whether legally
this position can be sustained I honestly don’t know, and
we have been so busy trying to be prudent managers, with
both our internal staff and our external programs having

great difficulties, that we did not wait for a 4-month

 
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written opinion from General Counsel, very frankly.

That is as honest a statement as I can make. And
as soon as our program has been extended, we have come back
-- not reluctantly but quite enthusiastically -- to seek
your advice as to how to advise us on matters of great
importance to us, and also, of course, at the appropriate
time, to approve the expenditure of funds.

DR, ROTH: Thank you.

“MRS. MARS! Yes, but now that these three are
actually phased out and there is a continuation, isn't it
illegal that they’re not to receive funds or are not being

continued? The three that are phased out -- the three

programs ?

DR. PAHL: Let me go off the record, please.

(Discussion off the record.)

DR. PAHL! May we go on the record again?

Dr. Schreiner.

DR, SCHREINER: Since one of our previous drives
was to get Ohio consolidated, I just wondered if it would
be appropriate to simply reassign the territory to an
existing, ongoing regional program. This really punts the
legal question, because you haven't phased out anything.
You're simply redistricting. And maybe this is the right

time to think about it.

DR. PAHL: I believe we will be considering

 
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territorial questions at some point.
At this point it is fair to say, and for the record
it should be stated, that RMPS did, in fact, phase out the
three Regional Medical Programs, so at this point that

action has been taken.

I believe, Bob, perhaps you might care to comment,
if it was you who had that conversation, or-- Who had the

conversation concerning the activities from Northeast

Ohio in perhaps reforming-- Mrs. Kettle? Mrs. Kettle, would

you care to make a statement, please?

MRS. KETTLE: As far as I know --

oR. PAHL:’ Would you care to use the microphone

so everyone can hear? .

MRS. KETTLE: The acting coordinator who
stepped in to administer the phaseout procedures of Northeast
Ohio met with the chairman of the Regional Advisory Group
for Northeast Ohio, and they called a joint meeting of the
board of trustees. Northeast Ohio had a corporation as a
grantee.

And they met with the board of trustees last night
I believe to see about courting Mr. Milliken, Mr. Cashman,
and called for assistance in tracking down some Ohio --
Columbus -- people so that they could just discuss and
explore coalition.

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I would indicate that in terminating these three
regions the staff officially and the coordinators officially
indicated that both groups would be interested in providing
as much assistance to these regions as may be desired in
reforming, but at this point the Council does have 53
programs existing and not the 56.

Mr. Milliken, would you care to comment on any-
thing that you may know of?

MR, MILLIKEN: This is all news to me. This is
the first time I have heard about it.

DR. PAHL: Well, we're all trying to get caught
up.

MR, MILLIKEN: I'm sorry.

DR. PAHL: Dr. Teschan, do you want to speak
for the coordinators in this?

DR. TESCHAN: No, everything has been said
exactly as we understand it.

MR. CHAMBLISS: I might call to memory of Council
that the Northwest Ohio Regional Medical Program did set
a precedent in Ohio. If you recall, that region at the time
was one of the, shall we say, weaker regions, and it was

merged into the Ohio RMP.

So we have had some history of this kind in

Ohio, and this action that has been taken does not preclude

them from reapplying.

 
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DR. PAHL!: All right. If we may move on, with
your indulgence -- I know blood sugar levels may be a little
low -- but if we can just get through a few more minutes I
believe it would be helpful to finish this part of the
presentations with Mr. Gardell at this point giving you
what our fiscal activities have been and then Mr. Chambliss
just winding up. Then we could break for coffee, delaying
the actions we were considering taking until a little bit
later.

At this point I would like to welcome Dr. Merrill
to the Council, who made a special effort to be here from
out of town. Thank you, John, for making the effort.

And then we will again have to rearrange our

"agenda in order to accommodate Dr. Teschan's

presentation before he has to depart at 11:30.

So perhaps we will just take a few minutes longer
than we had originally proposed for the meeting, but I
think it will be better if we can continue the present report.

Jerry.

MR. GARDELL: Thank you.

As you can tell, we have had some fun this year.

And I might thank my predecessors here in their
presentations because they have helped considerably to lay
the groundwork for the presentation I am going to make,

which is very brief, but to try to show you that we tried

 
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to stay within our legal limits, if you will call it
legal, as far as the amounts of money are concerned, both
from the standpoint of the Council levels, our funding
levels, and the amount of money available to us.

If you will excise we, T will read from a
script prepared for me -- and I was the writer -- that hits
all the highlights. And I don’t want to miss any of them.
So I hope you will understand what we had to do.

‘We were prepared. initially in 1973 to fund 56
regions on a 12-month basis, as usual, using a projection
of at least $96.6 million. And, therefore, after the June
NAC meeting, we funded 17 grants for one year with a Septem-
ber 1 start date.

However, our allocation of approximately
$52 million for grants under the continuing resolution
caused us to announce on December 29, 1972 that we would
fund the additional 18 regions coming up with a January 1
date for six months only, in line with the NAC levels,
at annualized funding levels, but with the understanding
that the second half of the budget period would be made

at a later date when additional funds were made available

to us.

This was based on the assumption, of course,

that the appropriation act would be passed with an alloca-

tion near our projection or maybe even better than that.

 
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Finally, when the President's budget was sub-
mitted and did not include any funds for RMPS in 1974 and our
1974 allocation remained the same, we informed the
RMPs on February 1 that no grant awards would be made
beyond June 30, 1973 except that we would provide for phaseout
purposes but not to extend beyond 2/15/74.

The 17 September awards in accordance with this

decision were reduced by two months, because they normally

would have ended August 31. And the May 1 awards which
should have been made for 12 months were then extended for
just two months .

So an aside here is that what we are now
faced with is a possibility of one budget period involving
three separate fiscal years, so you can see we are going
to have some problems in reconciliation as well as just
plain making the funds available.

Budgets for all the programs were to be
negotiated in line with the criteria contained in the
February 1 telegram which Mrs. Silsbee mentioned to you.

Then the phaseout plans A and B were reviewed as
indicated by her and the programs were funded with
ending dates at that point ranging from June 30, 1973
through 2/14/74 depending upon a realistic assessment
of the staffing needs to complete the approved projects and

activities as reviewed and provided RMPs in our April

 
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telegram.

A balance of approximately $6.9 million remained
from this process which could not be made available at that
time to the regions because of the phaseout decision.

Now, this is a combination of what our
normal operation is of offsetting against unexpended balances
that the regions report to us, so that is how we came
up with the $6.9 million, which was in line with our

projection of our lapse anyway.

On June 27th, after the legislation was extended
on the 18th, the phaseout restrictions were lifted and
discretionary funding authority was reinstated to the
regions but with the understanding that they would not receive
additional funds at that time.

On July 11th, however, after the continuing
resolution was signed, authority was granted to us to
negotiate budgets with each RMP for funds from fiscal 1974
continuing resolution that would be necessary to maintain
the program's viability, providing for adequate staff
and activities at a level not to exceed three times the
average monthly expenditure rate for the period April 1
through June 30 to be made available for the succeeding

period July 1 through September 30, 1973 out of fiscal 1974

money.

It also permitted us to distribute the remaining

 
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$6.9 million out of 1973 money but not to be used
until approved by us. And that was because the mission as
yet had not been defined and we wanted to make sure |
that that money would be used hopefully in line with the
mission.
This distribution was accomplished by prorating on
a monthly basis the program staff costs for each region as
of 12/31/72, which we thought was a good operating point,
for a six-months period ending 12/31/73, but offset again by
the funds presently available to the regions for the
program needs for that same period.
| This process resulted in, as was mentioned by
Dr. Pahl, a balance of $2,449 of the funds
available to us for grants in fiscal year 1973.
We are presently reviewing the requested funding
needs of programs for the period 7/1 through 9/30/73, and
we will amend the current awards as the requests are

approved.

Now, currently, the continuing RMPs have ending dates

as follows, and this is because we had to distribute the
$6.9 million and give them additional time to use it, but
that date is negotiable.

We have one program ending on November 30, and
that happens to be Florida. And the only reason is it

didn’t get any additional of the $6.9 million, so, therefore,

 
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we will extend it through 12/31 so that everybody is at least
up to 12/31/73.

Now, they have asked for an extension without
additional funds, so they have enough at least to remain
viable.

We have 21 ending on 12/31, four ending on 1/31,
and 27 of them go through 2/14/74.

So these figures do change from the ones that
were mentioned previously, but that was prior to the time
that we have amended awards.

Depending upon decisions regarding the coming
review process which we are going to be facing, it may be
necessary to extend further these programs that have a
termination date of 12/31/73 to assure their continued
support until we can make them an award for 12 months or
whatever period of time is decided out of fiscal 1974 funds.

It may also be necessary to provide certain
programs additional funds beyond 9/30 to maintain their
viability provided for through the use of the first
gquarter’s allocation. In other words, some of them really
are taken through 9/30 with additional funds.

Now, if that is not enough to take them through
12/31 until we can reach them with a 1/1 beginning date for
a new budget period, we will have to extend them again.

It should be clearly understood by all of you that

 
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in these changes to the existing grants we have always
utilized the NAC levels of record annualized, and the
annualized funding levels, so we have not exceeded both. In

no instance have we exceeded the NAC levels and we do not

anticipate that we will between now and the next review
| cycle, and 1 think that is extremely important because it was
hard to do in our machinations to keep abreast of the

“amount of funds available to us.

So that is the story of what we have done. I
have tried to do it in a nutshell tor you. Now, if you have
any questions --

DR, PAHL! This is a very technical presentation,
and perhaps the major thing you have gotten out of it is
how complicated a set of procedures we have had to go through
in order to account for budget periods, ending dates,
fiscal 1972 funds, fiscal 1973 funds, fiscal 1974 funds,
continuing resolution, balance out of 1973, phaseout periods.

And one reason for having Mr. Gardell present it to
you was, first of all, you should have the information,
which I’m sure you couldn't absorb. Secondly, it should be
a matter of public record for one point in time what it was
that we did do.

And, thirdly, again I think it does indicate the
high level of professional activity which has gone on

internally in trying to accommodate both the congressional

 
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intent and the Administration's position. And I believe
I can speak for Dr. Teschan's group of 53 but formerly 56
coordinators who have repeatedly given public commendation
to Mr. Gardell and his grants management group throughout
this most difficult period.

So we are ready to entertain questions on any
matter, but it is a matter of record what we did try to
accomplish.

Mr. Milliken.

MR, MILLIKEN: What were the two programs that
were reinstated?

DR. PAHL! The two programs that had been scheduled
for June 30th phaseout and were reinstated were North
Dakota and Puerto Rico, and there is a written record as to
why these actions were taken, and we will be glad at some
point to mention that to you.

But both were on the basis of very valid
reasons and merits of the case.

Are there any questions?

We will be talking a little bit more after coffee
about this $6.9 million balance in fiscal 1974 funds. I
wouldn't be unduly concerned about all of the kind of
problems we have been involved with. It is very technical,
very complicated. But we at this point end up with all

regions being assured of funding for a sufficient period of

 
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time that we can accommodate the legislative requirement
of Council approvals, at the same time accommodating the
Department's position of still trying to determine what
the direction of the program should be, and this represents
a complicated set of actions going on simultaneously.

Dr. Roth.

DR. ROTH: I don't know whether this is a fair
question, but it would seem to me personally in trying to
adjust to the situation I would like some kind of a notion
about. what happens.

You have got a one-year extension. Should one
be making two sets of alternate plans, an orderly phaseout
presuming that there is no further extension or
revitalization of the program, or do you simply have to wait
for what is going on downtown in the Rogers Subcommittee,
for example, of considering ways of putting this together with
other programs for extensions?

DR, PAHL! Well, that is part of the heart of
what we should be talking about today, and with your
permission I would like to defer it and put it in a larger
context after we have had an opportunity to get you some
coffee and ourselves impart a little bit more information to

you.

We need advice from you not just today but in

 
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coming months about this matter. ‘But it is an important
topic for today's conversation, so I would like to defer it
with your permission.

Jerry, thank you very much. And, of course, we
will be ready to answer any kinds of questions you may have
over the course of the day on this, but we did want to give
you a picture of the convolutions which we have had to go
through in order to maintain this period of activity in the
program.

And now, as the last brief presentation, Mr.
Chambliss does wish to end up not on a fiscal note
but to tell you what our overview is concerning the
programmatic activities of the regions today.

Bob.

MR, CHAMBLISS: I would like to end on a program-
matic note. As we worked towards the impending phaseout of
RMPS, the Director sought to pull out certain specific
project activities for support beyond the June 30, 1973
deadline, and these projects fell into three specific areas.

First, projects in the area of hypertension.

Second, those in the area of health services
educational activities.

And, last, those in the area of EMS, or

emergency medical service systems.

In the area of hypertension, RMPS had under

 
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support about eight projects totaling approximately
$1 million, and these were selected out for continued support
as far as they could go depending on the determined phaseout

date of an individual Regional Medical Program.

Also in the area of health education activities,

as you recall, this is the area, health education type

activity, supported by Regional Medical Programs that took
off on the initiative as set forth in the Carnegie Report.
As Mrs. Silsbee pointed out in her expression to you, we
are supporting about 11 percent of all the projects that
were identified for continuation in the area of health
education activities.

And in this health education activity area
the staff has endeavored to visit all of these projects

that had high potential for viability.

If you recall, about $6.8 million was awarded to
the regions for this type of activities, and these activities
went on in 27 Regional Medical Programs. About 38 of these
projects went for developmental or operational activities,
and about 41 of these projects were for the support of

feasibility studies or planning studies.

Now, as we began to contemplate the phaseout, we
felt that there was a need to site visit each of the
identified projects to assess their progress, to update our

knowledge on them, to see what type of evaluation was being

 
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conducted, and to determine if possible their potentialities
for continued support perhaps from some other source of
support in HEW.

Now, to date, out of 15 RMPs that were identified
where site visits should be made, we have conducted 11 of
those site visits by members of the staff, and there are
four of those site visits to RMPs yet remaining to be con-
ducted.

We have set up a task force of Regional Medical
Program staff, and this has been augmented by representatives
from the Bureau of Health Manpower. They have been
augmented also by representatives from the
Veterans Administration and also from the regional offices,
and representation has also come from the Secretary's office,
to see how these projects were moving along.

We think that this perhaps has been one of the
most worthwhile areas of support that RMP has engaged in.
These independent, community-based consortias have proven
to have started a new type of activity at the local level
bringing together educators, providers, health institutions,
and consumers, all sitting around the table to discuss
health manpower needs at the local level.

As one of the site visitors has reported, one
person at one of the RMPs indicated that this is the type

of activity that should have been engaged in at the local

 
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level 30 years ago, to bring this coalition of people to-
gether to discuss manpower needs of a specific location.

Then in the area of emergency medical services,
funds were awarded to the RMPs out of 1972 supplemental
funds in the amount of $8.6 million. These funds went to
28 separate RMPs for the support of 34 emergency medical
services planning and operational projects.

| Now, these projects ranged in dollar amounts from
$16,000 up through. over $1 million, the highest being $1.7
million. However, the majority of saa projects ranged
in amount from $25, 000 through $100, 000. and there were
three that exceeded the $1 million level, Wisconsin, Tri-
state, and Hawaii.

Here again a task force was established of RMPS
staff members. This staff has been augmented by staff from the
National Center for Health Services Research and Develop-
ment headed by Dr. van Hoek, and there has been joint
planning effort toinvolve their staff in going to some of the

larger and more critical EMS activity projects, and they

have done so.

Out of a total of 28 RMPs, 20 site visits have been
made. There are only three remaining to be done at the
moment. And the objective of these visits has been to again
update our knowledge, to assess the project being made to

determine whether the plan for a given project was being

 
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carried out in | accordance with the application, to assess

the developient ‘going on around emergency medical activities

sponsored by RMPS, and to see if there were involved in the

ongoing program activity an evaluation component where

some assessment could be made as to the productivity, the
viability and the strength of a given EMS project.

of course, these projects touched on communica-
tions, planning, transportation, public education, training,
equipment, and the development of local EMS councils.

We feel around this activity there has been a
significant developmental activity to improve emergency medi -
cal services and to develop a high sense of awareness of
the need for concerted planning and systems development for
the care of the emergency patient at the local level.

I might say one thing that came to my attention
about a visit I think you would like to know. In the
Alabama Regional Medical Program an award of about $150,000
was made. There was to be training for a total of 1,200
people, trainees, in the program. With that amount of money
they have trained in excess of 1, 400 people. —

At one of the hospitals where a training program
had been conducted and completed during the hurricane
season, ten days after the training project was completed
that community was hit with a tornado. There were 47 victims

brought to the hospital wherein the training program had

 
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been conducted just ten days prior thereto, many with
very serious traumatic injuries. The staff was
alert and ready to perform under stress, catastrophic
circumstances. The patients were treated. Triages were
set up. The emergency medical plan, involving the health
department, the police department, the fire department, and
all other emergency activities, was brought into play, and,
as was pointed out, it was a great demonstration of the worth-
whileness of this type of activity.

Here again we thought you would like to know
that just as a matter of information.

If I may summarize then by shifting over to
another set of activities that is ongoing in the RMPs,
we thought you would like to know that of the 53 RMPs, all
have coordinators. However, there are ten acting coordi-
nators on duty now. Three of those coordinators you
already know were acting, but the new acting coordinators
are Mr. Edward Morrissey in Connecticut, Dr. Francisco in
Northern New England, Dr. Harrison Owens in Nassau-Suffolk,
Dr, Stephen Langfeld in Greater Delaware Valley, Mr. Chad
Combs in Susquehanna Valley, J. L. Robertson in Alabama,
and Mr. T. R. Newman in Ohio Valley.

This gives you some indication of the viability
of the RMPs, that they are still engaged in holding on to

their leadership and recruiting leadership for the support

 
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and continuation of the RMPs.
Time is short, and let me say if there are
any questions I will be glad to answer them for you.
DR. PAHL! Thank you, Bob. And I apologize,
because I think it was my exuberance this morning which

perhaps shortened your time. And since I have been in the

game position, I apologize and appreciate your summarizing.

I think we have had quite a bit of material, and
with your indulgence I think it would be perhaps well if
we broke here for coffee.

Dr. Teschan has repeatedly indicated to me he
has to leave at 11330. I think it is very important that
you have his presentation before he departs because he does
represent the other coordinators and it's important you
hear from them through him.

So if we could break for coffee now and reconvene
at no later than ten after-- And please bring your
coffee back with you, but get a stretch, and then we will
have time I think-- Paul, will that be sufficient?

DR. TESCHAN: 11:05 would be better.

DR, PAHL: Make it 11:05, if you can, please.

(Whereupon, a recess was taken.)

DR, PAHL! May we sit down at the table, please,
and come to order?

Without taking further time from Dr. Teschan's

 
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presentation, I would like to say that we are very pleased
to have him here because what we have been presenting to you
so far, of course, is the RMPS' view of what has happened,
why it has happened, and where we now stand, and it is most
important that you have directly, firsthand, the view from
not only a coordinator of one of the programs but
the spokesman for 211 of the coordinators of the RMPs.

Paul.

DR. TESCHAN: Thank you, Dr. Pahl.

First of all, I think it's important that you
understand that we of the coordinators and the members of the
regional advisory groups are enormously appreciative of Herb
Pahl and Jerry Gardell and the staff's activities in
support of the RMP. The facts are 53 of the 56 programs
have come through this very difficult time.

I feel that the degree of digcouragenent,
the erosion of morale and the damage which has been done in
the regions would have been far greater if we hadn't had
the kind of steadfast support and the kind of very
careful attention to our individual problems which this staff
has continued to give in spite of all their problems in
dealing with the shifting administrative pressures that
you have had just a little glimpse of here.

So I'd like to say I fully agree with the

comments that have been made today, and we are fully in

 
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accord with the idea that what procedures the staff has

undertaken, with the possible exception of convening this

Council once more in the area of March and the awards --
with that possible exception -- we are fully appreciative
that, given their situation and their direction, they have
proceeded as best they could, and we appreciate it.

Now, I think the important message, quickly, that
I would like to-- There are several important messages I
would like to communicate to you, and I much appreicate .
this opportunity to do so. |

The first point, and the overriding point I
think, is that RMPs are still under attack within the
Administration, in our view. The coordinators’ consensus
is that the evidence is clear that the phaseout has not, in
effect, been rescinded, that the practical operating
circumstances of the programs are not compatible with what
has been called here revitalization. It's not the case.

And, therefore, I want you to understand the
way it looks in the area where we operate. For example,
what has come by a rescinding of phaseout restrictions is that
within the phaseout order we now can rebudget between
continuing projects and staff. Well, that still spells

phaseout.

And in view of the one-quarter authorizations

t recruitment

which you have also heard about, it follows tha

 
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is out of the question.

Commitments of any substantive or significant
scope are also out of the question.

I have also determined this morning that
the reduction in force program imposed upon RMPS is still in
effect.

We understand through our various communications
that the Secretary still maintains precisely the attitude
that he had when we last met together on February 7th.

Now, the particular point I think we should get
into more specific detail on has to do with the telegram
from this office on July 5. In that telegram there was
a notification that negotiations would be underway for
a level of support to assure viability through the first
quarter. Well, everyone knows through five years or more
of experience with this program that the RMPs do not
operate on a quarterly basis, that the intent of the law is a
one-year extension. The intent of the authorization and
appropriations is a one-year extension.

Therefore, a quarterly allocation and authoriza-
tion are in contravention of the intent of the law, and this
is the way the coordinators see it.

Now, you understand, and I want to reiterate
here, I am stating a viewpoint from the way we see it. This

is in no way to be interpreted as a criticism of Dr. Pahl

 
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or the situation in which the RMPS staff must operate.
I am not holding them responsible for what I am seeing,

but I am leading into what I propose and offer to you

for your consideration as to action or position which this

Council might wish to take.

| The second element of the telegram of July 5th is
that the RMPS has: been authorized to utilize $6.9 million of
unexpended FY 1973 funds but that no expenditure may be
made until the Department announces the mission of the
Regional Medical Programs Service for the rest of 1974,

Again let's recognize that the Congress extended

RMP. It did not write a new law. It did not create a
new situation at all. This Council has approved an
authorized mission statement under which all RMPs are
operated. There is at this point no Council-approved or

Council-authorized change in the mission.

Classically, the RMP has generated the mission
statement from this Council and not from higher up in the

Department.

So our view is that we have a mission and that
there is no basis for a further mission statement at this
time under the intent of an extension of the law. And
certainly, therefore, the idea that then the $6.9 million
may not be expended until there is this new mission statement

is an additional obstacle, obstruction. That is, in effect,

 
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the money does not flow in spite of the intent or the
language saying that we now can obligate it from RMPS. In
fact, the money does not flow. It has another contingency
which we see to be virtually illegal in view of the extension
concept which the Congress intended.

There is another element in this July 5 telegram
that says that proposed RMP activities, presumably reviewed
at intervals, will need to meet review criteria to be
established -- another sense of obstruction and delay and
interference with the purpose of the Congress to extend the
programs.

And the RMP coordinators are somewhat exercised
as you might understand on those points.

DR. PAHL: Paul, if I may just interrupt for a
moment, we have included these telegrams in your folder. I
don't think you have to turn to them right now, but we can
consider them after Dr. Teschan has to depart.

It's the last set of yellow sheets under the tab
called "Phaseout," which is the third tab from the back. And
the last yellow sheet is that July 5 telegram Dr. Teschan
has been referring to. We can take that up at greater
length following his presentation.

DR. TESCHAN: The point of this discussion is

really not the detail of the telegram assuch but the

Significance of it as its effect is felt in the regions

 
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where the action is supposed to take place.

I think the overall issue that I am indicating is
that the intent of the Department is to continue the phaseout
of RMP, to place obstacles in its way and essentially to
proceed despite the fact that the congressional support as you
have just seen and the President's signature exist.

Now, our feeling here is that the Council needs
to take a stand, and a stand has been prepared as an offering
for your consideration. Dr. Roth has already referred to it.
And it reads like this in the draft that we would offer for
your consideration?

"The National Advisory Council on Regional
Medical Programs believes the February issuance of phaseout
orders with subsequent amended awards to each individual
RMP was in violation of Public Law 91-515 because those
orders and awards were never approved by this Council. —
therefore, the Council hereby recommends to RMPS that all
previously issued phaseout orders be rescinded immediately."

We would also offer for your consideration the
possibility of your recommending that the awards
actually made under what has been called phaseout be retro-
spectively legalized -- that is, approved by the Council.

Now, all we mean in connection with Dr. Roth's
previous question on this point is that the language in

section 904(a) simply indicates that awards are made as

 
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standard procedure by the Secretary on recommendation of

this Council. The so-called phaseout awards and these inter-
vening awards now have not been so processed. But I

think the Council could undertake that at this point.

“Dublic Law 93-45 continues RMP for one year, or
until June 30, 1974, The law's substantive language remains
the same. This Council has approved the mission statement
for RMP that is consistent with the provisions of the present
law. The Council regards this mission statement as still
valid and any subsequent mission statement at this time
is unnecessary and inappropriate. Likewise, previously
adopted policies of this Council shall remain in effect
until altered or revoked by this Council.

"The Council hereby authorizes RMPS to issue
amended awards up to the existing 1973 approved level of
each Regional Medical Program, and that these amended
awards be made to all RMPs for the entire 1974 fiscal
year as soon as money becomes available. Future awards to
the regions should not be made for less than one year al-
though supplemental awards for the remaining months in this
fiscal year may be made after appropriate consideration
by this Council. All interim awards which have heretofore
been made for maintenance of program staffs are hereby

approved."

And that is the issue I indicated.

 
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"Finally, the Council reconfirms its faith
and confidence in the concept of RMP and urges the Department
to reconsider its position relative to RMP.”

And I'll leave this copy with Herb if he finds it
useful.

I think the issue could be summarized further
this way. The RMPs today are the remaining long-shot
chance of a cooperative enterprise between the Federal Govern-
ment and private providers and private enterprise in the
health care field. There is really no other way by which
the panoply of the bureaus and agencies which you saw in
the organization statement and charts can see their effect
actually occurring in the towns and cities and neighbor-
hoods and crossroads untess there is an in-place mechanism.
There is no other competitor for an in-place mechanism to
get it to happen.

Assuming for a moment, therefore, that if it is
intended that there will be effects in EMS, that there be
effects in the quality assurance area, etc., these effects
will occur because they happen in localities, not because
they happen only at the bureau level.

We see also, as Mr. Van Nostrand has
clearly pointed out to us today, an erosion of RMP*’s
mission by the Administration assigning to new bureaus and

new agencies the kinds of activities which have been RMP

 
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prerogatives and responsibilities up to now. However, that
is a fraudulent position, because you won't get it to happen
by the establishment of a new bureau on an organization
chart or filling additional offices with additional
personnel in Parklawn Building. I'm sorry.

Therefore, our presentation to the Assistant
Secretary's office has been that RMP be recognized as the
local in-place organization for the implementation of the
whole variety of Federal health initiatives which need
local application. We in the RMPs could very easily see
these bureaus that you have just seen as the resources on
which we call to implement these things.

You will see I think shortly some further comment
that the regional offices, the ten of them of HEW, are
supposed to have this type of activity and role. Our
feeling is that in our area, for instance, in Tennessee,
that the regional office in Atlanta is as remote to the
hills and valleys that we are familiar with and work in
as would be a bureau in Washington.

So I think the critical issue here is that we still
have a fighting chance, an uphill fighting chance, to
establish and to develop public and private partnership
in the effect -- that is, in getting the activities to
happen in the communities of the region if RMP is so

recognized by the Department, the Administration, and by this

 
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Council.

We believe that there are, secondly, four areas
of mission which the RMPs are able to do!

First of all, we do believe we have a role in
quality assurance and would cooperate with the bureau with
that name in implementation activities.

Secondly, we believe that we have a track record
in the proved utilization of manpower and a track record
in developing the community-based area health education
consortia. We are able to do that and should be mandated
to continue it.

Thirdly, we have obviously demonstrated
capability, as Mr. Chambliss has indicated, in improving
primary care services, including EMS. We should be
mandated to do that from the EMS office.

We have five years’ established experience in
regionalizing specialized services and the HEW should be
using RMP for that purpose in their communities rather
than in each of these instances eroding the RMP's energies
and contribution by separate bureaucratic mechanisms
for these localized fragmentary initiatives in the health

care field.

Now I would like to go off the record for just

2 moment.

(Discussion off the record. )

 
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DR. PAHL: Thank you, Paul. I know you are
dashing for an airplane. Is there any point that-- Dr.
Merrill?

DR. MERRILL: I'd like to ask Paul a question.

Is it your opinion that the vehicle through which an
expression of opinion by this Council should be made is a
resolution written out and transmitted to the Secretary?

DR. TESCHAN: I do believe so.
| DR. MERRILL: I'm not convinced that action would
be greatly effective.

DR, TESCHAN: You're asking that at two levels,
John. My answer to that is, yes, a resolution that is
resolute and clearcut and unequivocal may have no immediate,
direct effect in moving affairs, but it doesn't detract
from its value, because the National Advisory Council
will be on record. It will raise a standard around which
others can rally. And essentially this is a very important
area if private and voluntary participation is to enter the
health field and continue in the health field.

So don't underrate the significance of your
action.

DR. PAHL: Thank you very much, Paul.

I am afraid that because of the need to return
to the Southern Coordinators’ meeting Paul will not be able

to be with us this afternoon during the discussion. We have

 
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assured him that we will get to him what does transpire.

Before we move on, I would like to say as the
acting director of the program that we do endorse the
statement that Dr. Teschan just made. That is, we do believe
that this Council should play a very real role in the
policies and activities of the program. And the reason we are
meeting today in July is to not only bring you up to date but
to look to you for that kind of advice and formal advice to
the Departnent, the Secretary, the Assistant Secretary for
Health, the Administrator of Health Resources Administration,
and myself as to your interests and concerns.

And so I would like to fully support Dr. Teschan
in this plea for very strong Council involvement regardless
of what position that may be on your part.

Now, with that, I would like to say one more
thing and then perhaps open it for discussion.

One of the things we were not able to do this
morning was to distribute prior to the coffee break our
one proposed Council resolution which at least includes
one part of that which Dr. Teschan distributed. And, Ken,
if you will distribute that.

I am not asking for action on this at the moment,
but I think you will be considering the proposal that Dr.
Teschan made, and you will see in the proposed resolution

that we have drafted for you, if you will, the need to

 
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endorse actions which we have taken particularly as regards
the adjustment of budget period and the proration of funding
levels and Council ceiling support levels of regions that
Mr. Gardell was telling you about, technical aspects which
we had to engage in in order to keep the programs alive
and which we may still have to engage in during the coming
months.

So I'd like to have you read that and consider
that doghther with Dr. Teschan's more inclusive proposal.

DR, McPHEDRAN! Dr. Pahl, --

DR, PAHL: Dr. McPhedran.

DR. McPHEDRAN? -- I wanted to ask a question
about this telegram, that is, the telegram that Dr. Teschan
read, which is the last yellow thing in the phaseout section
of the agenda, particularly about this matter of atipula-
tions that no expenditure be made therefrom until the
Department announces the mission of the Regional Medical
Programs Service for the remainder of fiscal year 1974 and
that proposed RMP activities meet review criteria to be
established.

‘You must have had some reason for putting that in.
I must say I would agree with Dr, Teschan's interpretation
of that, and I wondered why this was put into the telegram.
Why were those stipulations made?

DR, PAHL: These stipulations, although the

 
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wording is ours, were put in the telegram on the basis of
requirements which came out of the Department.

Now, let me amplify that a little bit. I think
I would like to go off the record for a moment, please.

(Discussion off the record.)

DR. PAHL! Before continuing the discussion,
because I am not quite certain what Dr. Laur’s schedule
might be, having just come from downtown and as Acting
Administrator of Health Resources Administration undoubtedly
having to leave shortly to do other things, and being
fully aware and involved in all of the activities I have
just indicated to you plus others which I have not been
privy to, I think if you will permit we might hold Council
discussion and take advantage of the fact that he can be
with us and ask him to either address any question that he
may care to or respond to some questions from you.

And in this connection I would like to welcome
you, Bob, to our Council and ask you to take as much time
as you might have to reflect on matters either of
organizational or RMPS variety, the latter being, of course,
the preference.

DR, LAUR! Thank you, Dr. Pahl.

These are times where I'm not so sure it pays to

| stop and reflect.

I would like to do a couple of things if I may.

 
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First of all, express greetings to you from Dr.
Edwards. He and I were just now at a meeting with Secretary
Weinberger on some other matters, and Dr. Edwards had hoped
to be able to come out here and visit with you during this
meeting. He still has that hope but Y think it is diminish-
ing as the day goes along and other events intrude on his

calendar.

But he did want me to convey his greetings to
you.

Secondly, of course, to convey my own. This
Council has not only served our predecessor organization,
HSMHA, exceptionally well over the years, but your willing-
ness to come in now under short notice and with so many
uncertainties I find very gratifying, and we are most
appreciative of your willingness to help.

I guess I'd like to keep the remarks short
for two reasons. One is this spot on these agendas always
provides an interesting time for the staff, especially
now where there is a new person, not new to the organization
but new to the day-to-day workings of RMP, I'm sure the
staff always wonders, "What will that damn fool say next and

get us in trouble over."

So, you know, it's an interesting little tense

time for them when these sessions occur.

And from the point of view of the Council it

 
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means sitting through another 20 minutes of inanities
from an Administration official who isn’t very much
involved in the process and it’s a little difficult to endure.

So I thought for both of those reasons I
wouldn't say much. (Laughter)

But I would like to respond as best I can to any
questions you might have or observations you have about
this rather difficult situation we all find ourselves in.

And I would only make one observation that may or
may not help you understand the kind of direction that
we will be trying to provide RMP in the new Health Resources
Administration.

It seems to me that the first question was
the question that motivated this Council originally,
that motivates the people who work in Regional Medical Programs
around the country, and that motivates the staff, and
that isi What will be best for patients in the country?

What can be done to make the greatest contribution to the
improvement of health of people?

And if we start with that concern, other considera-
tions I think begin to fall into perspective as to whether an
organizational arrangement is or is not very critical to
improving the care of patients or the health of people.

Well, I only offer that as an observation which

I think motivates the staff, which I know has motivated this

 
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83
Council, and its predecessor members. And I would always
like to keep that as one of our fundamental concerns as we
plow ahead.

Even with that noble motivation, we will have
difficulty doing the right thing. There is no question but
what in the weeks and months ahead we are going to make
some mistakes in the Health Resources Administration as
we try to administer these programs. I will probably
make more than anybody else, first because I probably am
better at it, and also because of my naivete in some of these
areas.

It seems to me that the only contribution
I might be able to make is that we would like to have our
mistakes called to our attention as rapidly as you discover
we are making them, and on that basis urge you to
be in touch with myself and with Dr. Pahl and the staff of RMP.

I simply do not believe in advisory councils who
don't contribute. This Council has certainly not had that
reputation, It has been an outstanding one. And even in
the situation we are now in I would like very much to have it
be a functioning Council that you believe is important
and you believe is making a contribution to HEW's efforts.

So I want to say as we struggle through the next
period please let me know if you think that will make any

difference, if that will be helpful to something, how we

 
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could do things better, and remain in touch with Dr. Pahl

and the staff.

Well, enough of a preamble. If anyone has ques-
tions or observations, I'd welcome them.

MRS. MARS! Do you see any real future for RMP

beyond this year?

DR. LAUR! Okay. That is certainly a very good

questions, Mrs. Mars.

DR. PAHL: I held off answering Dr. Roth
until you came because I wanted also to hear the answer.

DR. LAUR! You were all waiting to hear the
answer. (Laughter)

MRS, MARS! Right. You realize this is a very
frustrating experience for everyone concerned, particularly
the Council members.

DR. LAUR! I'd like first of all to ask if
someone would kind of keep track of me and not let
me respond too long. I could go on at some length on that

question.

I'd say two things. There is absolutely a future

ie

for the kind of fundamental activities that RMP has been
cmeememanernnns a

addressing itself to across the country. By that I mean the
involvement at the aoce® operating level of the key
participants in. the provision of care in a way that causes

them to make things happen that would not otherwise happen

 
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85
or would not happen as rapidly.

Now, that is a long, sort of abstract statement,
but I believe at the local level or regional level, if you
will, in assembling resources to improve the delivery of
care to patients, Regional Medical Programs have been an
effective instrument at least in some instances and that
there is no substitute for the kind of involvement that
those effective instances have demonstrated.

Now, whether it continues as Regional Medical
Programs -- in capital letters -- federally funded by HEW,
and so on, that I think is yet to be answered. There is

quite a ways to be gone eas to what the Department! s position

 

is going to be, what the Congress’ position is going to be,
what your recommendations to us will be. All of that lies
before us.

I simply cannot myself envision a world, given
the kind of health care problems we have and the limited
resources with which we have to work, where we would ignore
the kind of activity to which the RMPs have been addressing
themselves. That would astound me if that were the case.

I will hazard on the record a personal observa-
tion about the specifics of RMP in the sense that it is the
challenge to the Health Resources Administration, the
staff and the Council right now in the next several short

months to come up with a proposal to the Administration

 
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86
which will be accepted which will foster the kind of activity

I have already alluded to.

Now, I haven't sensed personally -- and my
involvement in RMP is fairly recent, fairly superficial --
but I haven't sensed an outright opposition on the part of the
Administration to the concept of Regional Medical Programs.

The concern has been one over has the concept (a) been mal-

en rai a ciel

addressed. you know. Have we simply gone at a good idea

_in an ineffective wav? Or have we devoted more

 

resources to the concept than the concept merits? You know,
at least at 2 given point in time?

It has been those kind of concerns that I think
were addressed. And I would have to say also that
those concerns were raised at a time in which it was
absolutely necessary to make very substantial cutbacks in

the Federal budget.

In other yords, questions that otherwise might
have been not so deeply and poignantly saeressed were
addressed under those budget-cutting circumstances.

Whether those circumstances are still with
us or not I think other people have to determine besides
myself. They certainly haven't totally gone away. And
that will condition how much we can aspire to with RMP.

But I believe the Health Resources Administra-

tion-- I expect-- I wouldn’t even be interested in working

 
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in HRA right now if I didn't think we were going to come up

with some continuation of RMP-type activities.

    

MRS, MARS! But not as RMP as such?

DR. LAUR: I don't know about RMP as such. I think
that has to be thought through.

Given-- How can I put this and not sound unkind?
I was about to say given the barnacles which RMP has
accumulated - and that's not a very kind way to put it --
but there are a lot of associations with RMP right ww, and
some of those may be impediments to doing what we can to

improve the health care of people, you know.

RMP in my estimation-- I had a very satisfactory
relationship with it. It doesn't have barnacles from my
point of view. It's something that I wouldn't mind
continuing as, you know, capital Letters, Regional Medical
Programs. But I think - have to weigh that as to whether
those words are the right words.

The first question is! What is the activity, what
is the function that can be addressed, and what is the
Federal role in that function?

Then if it ought to be called RMP, we'll call it
RMP I think.

DR. PAHL!: Dr. Merrill?

DR, MERRILL: No.

DR. McPHEDRAN: I have some things to say about

 

 
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me PhedDRAN as

that.

You know, the Council wasn’t mute on February 7th.

At least I wasn’t. I had something to say at the time.
This is in response to something that Dr, Teschan said in
his remarks.

I think that I thought at the time that it was
too bad to see the whole thing apparently being discontinued
at that time, and I said at the time -- I cantt remember
exactly how it was said _- that it was done out of ignorance
more than out of wisdom. And I still feel that that's so.

And I think the ignorance, for example, is
reflected in this statement in the telegram that I referred
to -- that no expenditure be made until the Department
announces the mission -- for example _- when this was done
as part of continuing resolution. There was a mission and
there were review criteria that had been established, and
this could have been put in the telegram.

Obviously, Dr. Pahl put it in because someone
else told him that he should. But it couldn’t have been put
in by anybody who knew how the thing had been operating.

So that I think that it seems to: me that the
actions that were taken were taken in blissful -- or perhaps
not so blissful » -- ignorance and not in wisdom.

It doesn't seem to me to have been a sensibly

planned kind of activity.

 

 
 

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89
I really find myself, as I have reflected on the
suggested statement prepared by the coordinators, pretty
much in support of what the coordinators have felt about

this.

I think that it’s surprising in the site visits I |
have made to find the number of Regional Medical Programs that
did as good a job as they did. I thought it was
surprising to find as good staff work from RMP as there was.

This is a new kind of activity for me. I never
knew anything about it before 1970, so I learned everything
about it right here and on the site visits.

And I know that the barnacles are there, but it
seems to me that what is implicit in your suggestion,

Dr. Laur, that there might be some other vehicle to carry
on this mission is that the RMPs in the various regions

would probably be disassembled. And some of them are really

very good. They are not all, but some of them are really

very good.

|
And it would be just a shame and a pity to do that,

I think, just as it would be a shame and a pity to take away
their activities in quality assurance and manpower need
assessment and their activities in improvement of primary

care and EMS.

I agree with Dr. Teschan that the more of those

things that are taken away, the less effective will be the

 

 

 

 

 

 

 
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90
Regional Medical Programs.

I think that it would be far better to go back,
if we could go back, to where we were eight or ten months
ago and try to scrape some of the barnacles off, as probably
will be possible with some of the phaseouts that have been
done. It may be easier to get some of the barnacles off
and go on with the organizations that were good and pursue
the policies of this office before, which were in the main
selection for funding of programs that were good and were
satisfactory, if there were hard times not to make across~
the-board cuts. This is a policy of the previous Director
which I concurred with and I think everybody on the Council
did as well. | | | |
| I think it would be realty : a shame to take apart
these various regional organizations. Some of them we could
do without, but many of them are really very good.

And I cannot help but believe that the direction
for the phaseout, as I said before, was done by people who
really did not know what they were talking about.

DR. LAUR! I don't know how to respond to that.
If I say I totally agree, T have got a problem on one
hand. It seems to me we are saying the same thing, which
is there is a useful activity there. If it ought to remain
as Regional Medical Program, then let’s try and do that.

If it ought to be strengthened or if there ought to be some

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91

changes made in certain aspects, let's decide as best we
can what those changes are and see if we can get them
accepted.

But this group probably more than-- I'm sorry.
Does this microphone bother somebody's eardrums? If we've
got cardiologists or somebody in the room who are so care-
fully attuned to listening to little thumps and noises, this
probably drives them crazy.

This Council perhaps more than any group we
could assemble does understand, I think, the very real
world we now face as we move ahead with the kind of program
you have described, Dr. McPhedran, and that's that some
very important and very well intentioned Administration
officials have decided, under the circumstances decisions
were made in, about what the future of RMP should be. If

—_——
we are to ask them to change their minds, I think we are
going to have to a roach it in a way which they
will find persuasive. And, you know, I think that's the job

we have in front of us.

I don't think they are about to be steamrollered.
I don't think they're about to suddenly decide - |
that the analysis they went through, on whatever basis, is
suddenly wrong and they wish they hadn't done it and so they

are going to do everything differently. I don't believe that

is going to happen.

 
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personal opinion -- to express what it is’ that Regional

Medical Programs do in a way that people not intimately

 

 

92

I do believe that we have not found a way --

 

involved in the activity can understand.
Time after time after time, even among knowledge-
able health professionals, I have found it necessary to

take a half an hour to articulate what it seems to me

was the real function of an RMP as opposed to the kind of

transitory projects with which an RMP might be engaged at

that moment.

And if you have to do that with knowledgeable
physicians and hospital administrators and health officials,
then it isn't surprising to me that economists or budget
officials in the Federal Government or Congressmen might have
some difficulty with the whole concept.

So we have a challenge I think as a staff to
find ways to articulate that, and that’s in part, Mrs. Mars,
what I meant earlier about maybe a new word will be required,

MRS. MARS: Yes.

DR. LAUR: -- just to express the same activity.

DR. PAHL: Dr. Merrill.

DR, MERRILL: This bears a little bit on om |
question I asked Dr. Teschan, because, although I don't have
it in front of me, it seemed to me his statement was really

kind of affirmation of the status quo. I'm not sure how

 

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93

effective that is in the present climate of opinion.

And I wonder if perhaps a more forceful and effective
instrument emanating from this body might not be a

revision perhaps embodying things such as no across-the-board
cuts, but paring specific parnacles, if you will, and some
positive suggestions to which the Administration might be more
receptive than simply strong affirmation of the status quo.

DR. PAHL: Dr. Roth.

DR. ROTH! I'd like to ask a couple of I think
related things. |

“We teterred to this: ‘telegram with the implication
at any rate that there shall be a new mission statement. Do
we have anything cooking on the stove in terms of staff
suggestions for a revised mission Btaroments

And is it contemplated ~ -~- we mentioned the possi-
bility of a November meeting -- that it would be debated
and discussed by then? Is there any chance we'd get a
new mission if we went that route before the expiration of
the present extension?

DR. PAHL: No, not really. Somehow the
discussions got into mission statement when actually what
the Department currently is doing is attempting to make a
determination as to what programmatic option or options
it wishes to pursue with the program over the coming year.

Now, there have been a number of suggestions

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PA E OPTIONS,

PARL RE OPTIONS,
made to the Secretary as to the kinds of activities
which the regions can profitably engage in for this one-year
period, and at his request an options paper and
subsequent revisions have been transmitted internally. And
I'm sorry. Because they remain internal, we are not able to
distribute them to you. But it is not doing a disservice to
that position I believe to state very clearly that all of
the options in this internal communication are statements of
activities which the regions have been doing and are
very familiar and comfortable wi |

For example, quality assurance activities.

Strengthening CHP programs, particularly the (b) agencies.
EMS. Hypertension. Kidney activities. And the communi ty-
based area health consortia.

When you hear this, you wonder what is different

than what we have been doing. And the point is nothing
LE

that I know of that is under active consideration by the
Department is different than what we have been doing.
The difference, therefore, is that perhaps one ox several of
these activities will either bé specifically excluded
trum thle year's set of functions or perhaps all of them will
still be considered permissible by the Department.

So it is not the Department or RMPS -- separating

ourselves for the moment -~- are trying to devise a different

mission statement. It is that the Department feels that

 
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with the one-year extension and working in good faith with
the congressional intent there is a need during this one-year
transition period | -~ _ which begs the question of transition
to what -- “put during this one-year transition period the

Regional Medical Programs ‘ghould be active in activities

 

—_ -_
which themselves do not perpetuate the RMPS as RMPs, yet
INET ECA TTT I TNS
@T11 strengthen administration in Federal health programs

ET
or health priorities and perhaps provide a bridge into a

 

suet IE

cen
new state of affairs after the one-year extension is

ee
terminated.

And so the kind of activities that we have been
asked to suggest for the Department's consideration are those
I have mentioned. We believe that there can be useful work
done in the areas of emergency medical services, hyper-
tension control programs, end-stage kidney disease activi-
ties, CHP strengthening, and activity of health planning
agencies and certain manpower development and utilization .
programs and quality assurance programs.

And we are awaiting a determination by the
Department, which we had hoped to have for you by today
but unfortunately we don't, which then places the Department's

stamp on what should be the set of activities for this one-

year period.

But I see there is nothing here that_is really

a new mission. It is a set of determinations on activities.

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96
And in that framework the first of the two steps in the
telegram was incorporated. Namely, we are awaiting the

Department's determination for programmatic direction either
ed

to use the $6.9 million which om the

fiscal 1973 balance or to indicais to ihe regions what
should be their set of activities uisdizing fiscal 1974

funds, which as yet are going to be at an unknown level
and will be determined following the selection of options. a.
And, of course, this is ‘of great interest to
the Council and your roles and prerogatives in the program.
DR. ROTH: This gets to the second part of my
question, because I have heard of all these figures from
$6.9 million, $60. million, $82 million, on up, $159 million,
and so on. Being relatively naive about these things, I
know that there was this administrative phaseout decree
and it was then said that if Congress wanted to pull
together an extension law there would be some question as
to whether they could get it passed.
Well, they did under the circumstances. It was
then postulated that it might be vetoed. It was not.
But it is still unanswered in my mind. There is one further
stop to funds, and that is impoundment or simple failure
to release.
Now, is this essentially what we don’t know the

answer to as yét; whether we are really talking about money

 
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in hand that you can fund the program with?

   
  
    
 

DR. PAHL: I think you are perfectly correct in

your observation that there is from our point of

view as a service an unknown figure, and that is what funds

will actually be made available to us.

FSO We

To try to clarify the figures, because it is
difficult, the House has recommended through the appropria-
tion process a figure of $81.9 million. Since we do not
have a full appropriation, we are on a continuing resoll-
tion. Under that continuing resolution we certainly, under

any objective view of that, would be permitted to go as

high as the current operating level, which roughly is $60

million. It was, Jerry, $58 --
MR. GARDELL: $55 million this year.

DR. PAHL:! $55 million this year. But the

AP P

Department has by administrative action determined that
it is in the best interests of the program to state initially
at this point in time only that all programs, all 53

programs, will be given sufficient funds under the continuing

PE

resolution, 1974 resolution, to make sure that they

remain viable through the first quarter of the fiscal year,
through September 30th, and we are actively negotiating
now through Mr. Gardell's staff with each region to make
sure there are sufficient funds that 53 programs will not

only be in existence but will have some complement of
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98
professional and supporting staff, space, equipment, and so
forth, through the period September 30th.

What we haven't been able to give to the regions
is a clear statement as to what kinds of activities they
should be engaged in at this point in time or
what they will be permitted to do or should be
encouraged to do with either the monies that we just
distributed at the end of 1973 or any additional funds that
come to them through 1974. And that is the status of
affairs with respect to the Department's looking at these
options.

I hope that clarifies it.

DR. ROTH! I promise to stop with this one. But
given those ne is it an essentially correct over-
simplification of the status of this Council-- We have
got a few options. We could go the route which is at least
started with the resolution that staff has circulated to us
which says, "We thank you for and approve, retroactively
okay, the way you have adapted to a difficult situation."

And we could append to this, since we don't know how much

 

money we are talking about, how much we are going to get,
that we ought to go along on this basis and trust our staff
to do the very best they can with the money available for

the best kinds of projects. That's one option.

ROT W Re Reco. orion

The other option is to go in, in rather starry-eyed
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99

    

fashion, with the resolution put in by the coordinator cee
which directs the way money should be spent that we aren't

even sure we're going to have.

Or we could I presume as a Council go over
the whole batch of 53 programs and pick out the things we.
thought were good and we would md&e the recommendation for
where the money ought. to go. And that seems totally

Amprachded! in the time frame. .

But is this about the options up to the Council?

DR. PAHL: Yes. I think t perhaps would-- I
find myself in a difficult position. The Council under the
authorizing legislation has been established to advise the
Secretary on policy for the program, 50 it seems to me
perfectly appropriate, at least with my experience with
councils, for this Council to take whatever kind of formal
action it wishes, and it could be in the form of a resolution
or statement or discussion as to what it views either to be
concerns or support of the Administration's current
position.

We have not been able to bring to you -- and that
may be an administrative failing - but we have not been
able to bring to you the rapid changes which have occurred,
and thus you have not been brought into position in which
in fact you could advise us or the Administration about

program directions. Today you do hear what the status of

 
100

1 | affairs is.
2 To my knowledge, the determination has not yet
3 | peen made by the Secretary, although Dr. Laur may be able

4 || te comment on that, as to what the Department would

   
 

fo see the programs do this

      
  

I think it is most appropriate, therefore, that ant
kind of statement that you would wish to make to me as

the Acting Director, to Dr. Laur or certainly to Dr. Edwards

  
    
    
   
      
    

9 | or Mr. Weinberger and which we would transmit to the
10 appropriate office -- to make whatever statement you feel

1 is appropriate in exercising your prerogative under the law

accporlers, Gare.

12 and advising us on programmatic directions, options,

emphases, priorities that you may see or endorsing your

a
bs
2 prevaous positions. ;
5 And that’s something that we feel-- And I think Dr.
16

Teschan was indicating before that a position by the Council

17 oe
perhaps would be of. great assistance to the Secretary.

18
After all, the Secretary and officials below him are that

” much further removed from the actual program operation

70 and direction that perhaps they would value very highly the
21 advice of this Council.

22 In addition to that, I believe that the question

23 of the actions taken through the phaseout period and the
24 legality of those actions we have attempted to answer,

a9 and I think that's a point which I have to leave to the

 

 

 
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Council to decide how it best wishes to handle it.

    
       
 

I would like to make one more statement, and that
is that in the resolution -- and if you have not really

had time to look at this, and again IT am not asking for

 

 

 

action at this point -- the resolution which we proposed
for your consideration merely would ‘endorse a very Limited
set of administrative actions that we have taken. Namely,
the adjustment of budget periods and the adjustment of
funding levels on a prorated pants and the adjustment

of the Council-recommended levels on a prorated basis, which
had to be taken in order to carry out what we knew to be
your intent and the Administration's intent and the
congressional intent, and that is to meet the tests of
viability for all of the regions over this period.

The resolution that we have proposed for you does
not in any way state -- very clearly does not in any way
state that the Council has approved those professional
judgments concerning either the phaseout of individual
RMPs or anything concerning the decisions made relative to
which projects, contracts, etc., could or could not be
continued.

We are in this resolution asking for that endorse-
ment only of what had to be done in a technical fashion
in order to arrive at a continuity of the program through

the phaseout period and as we go into the fiscal year.

 

 

 
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Hallowed to 3 whose programs.

 

 

So I do want to make that clear, and we as a

staff bear the responsibility for the professional judgments

| which were made throughout this phaseout period of the

| individual Regional Medical Programs and the activities

That is more than you asked for, Dr. Roth, but
does this help you in your options for the Council?

And perhaps Dr. Laur or Dr. van Hoek, from whom
we haven't heard, might care to comment, because they do
sit in on some of the meetings that I am not privy to and
they may be able to shed some light on this.

DR. VAN HOEK? Well, to respond specifically to
Dr. Roth's question, it seems to me that there are two
parts to the question. One is the question of retroactive
actions, retroactive approval oy ‘endersement of actions
that were taken. The other is what happens from today on.

And what happens from today on again is two

VAN Haw we

parts. One is the immediate question of what do we tell
the regions in terms of priorities or program activities
that they can carry on during this fiscal year, whether that's
at the use of $6.9 million or some higher figure, and the
other part being how can the Council working with the

staff develop program statements, justifications for the
continuance of the activities beyond this fiscal year --

in other words, participate in the development of options for

 

 
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VAN HOe
103
legislative proposals. Whether that is a continuation of

an RMP -- in capital letters -- or whether that is some

- other substantive program with a different process should be

 

 

examined.

Now, that is not an immediate question. That can

be done over the next several months. But I think it is

tied in with the shorter-range iasue, because the point-- And
as usual telegrams always use the wrong words and give us more
problems than we anticipated. But the term "mission" I

meant to mean the fact that within the existing mission of
RMP, through the continuing resolution, that we would

tdentify priorities or specific activities that could be
carried out over this next fiscal year which would be of

an important nature but would not lead to commitments which
would conflict with either legislative proposals or budgetary

aes

proposals that would be forthcoming

 

months.

and so, therefore, that is really the question.

We are really involved in two processes. One is a

legislative process where, despite the continuing resolution,
there is nothing on the books that carries it beyond June 30,
1974. And then there is the appropriation process which,
despite the continuing resolution, means the funding level may

be anywhere from zero to total authorization, depending on

what we propose to the Department and to OMB.
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104

And I really think it’s our initiative, as we
have done with the options, once the Secretary suggests

support of certain approaches -- and we would like your

advice on that -- it’s up to the Department and us then to go

to OMB and justify the release of the funds to carry out
that activity.

DR, PAHL: Dr. Schreiner.

DR, SCHREINER! I like that analysis. But what
bothers me is I have this cartoonist vision of a construction
elevator that’s been stopped with the motors running on the
89th floor pending study to see whether there is enough
energy to go higher, and the banker sais, “Well, while we're
studying this we're going to cut off the electricity."

And it's just innocent, but I think it's incredible

that this can be a serious proposal or that this Council can

 

foster standing still for three months.

Now, there are certain basic activities in the

perpetuation of a local resource at the very, very minimum.

SCHR

The electric bill, the salary of the coordinator and the
secretary to the coordinator are very, very minimum.

Now, it seems to me completely incredible to
say that you're going to have people who are losing
coordinators and losing secretaries not having the authority

to contract for a year to hire somebody for a year to

keep this activity going.

 

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You simply cannot-- I don't think it’s viable
to say you are going to go out and recruit somebody for
a three-month period. And that's where the rub comes.
The rub doesn't come in in your studying the things. The
rub doesn't come in in your wanting. to prune off the barnacles.

The rub comes in that the method of going about it is to me

a totally inoperable, totall unfeasible -- and so lacking
in insight that I don’t see how anyone can believe it.
Because you end up September 1 with one of two
possibilities. You cut the program here, in which case
you have wasted three months of funds, or you say we're
really going to continue it to the end of the continuing
resolution, in which case you have lost a quarter of
momentum and you have again wasted three months, so that
there is only one activity that can happen. That is, you
are going to waste a quarter's budget in the whole thing.
And it seems to me that I agree with Russ, or
John, that a resolution is going to get us anywhere, but I
wonder if we can’t at least ask for a workshop or a meeting or
something concrete to get that three-month business out of
the way, because it seems to me that is just so untenable,
given all the circumstances, that I just can't see how as a

Council-- At least I couldn't personally endorse that as
caer)
a method of operation.

ee

DR. PAHL I think, Dr. Merrill, were you trying tq

 

 
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get a comment in?

DR, MERRILL! I wanted to point out what I was
saying consists of two parts, one of which George talked
about, which is the immediate one. But the other one is
long-range clout other than simply endorsement of the status
quo.

This is perhaps something we can talk about this
afternoon. But a lot of specific suggestions have been
made in the last hour which if put into the form of a resolu-
tion would give it some teeth rather than, "Just let's
get on with what wetre doing." That certainly is the

sential part, but there is something I think which would

 
 
 

make RMP durable for a good many years, not just three

months, which we might be able to entertain this afternoon
in specific points, a number of which have been made in the
last hour.

DR, PAHL: Mr. Milliken.

MR. MILLIKEN! I'd like to ask Mr. Gardell if
there is any information in the past or any way to find out
in the future that this quarterly funding thing is any

different than in the past -- that is, circumstances of not

-appropriations but resolution funding -- or if this is a

deliberate intent manufactured for this special situation.

WR. GARDELL: We have never extended any program

in the beginning of a fiscal year for a quarterly period of

 
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107

time, so this is the first time we have done that.

Normally, your continuing resolution gives you
enough money to be able to get on with the business and to
make your first set of awards for the 12-month period,
assuming you are going to function on a 12-month period, which
is exactly what I said in my presentation.

MR. MILLIKEN: Then it's quarterly?

MR, GARDELL: No, it's not necessarily quarterly.

MR, MILLIKEN! Are there any other parts of
Government where this has been done before?

MR, GARDELL: There are some programs that fund
on a quarterly basis, but I'm not aware of any of a categorica
nature.

DR. PAHL! Mrs. Silsbee has a comment.

MRS. SILSBEE! In answer to your question, Mr.
Williken, I have not been privy to any of the discussions,
but I think perhaps it's an understanding of a grant process
that may be lacking.

I having made my entire career in trying to
develop review procedures that are in line with the under-
standing of the reviewing groups and the staff, it has
been difficult, and one of the things behind the resolution
we have there is, as you know, we developed a triennial
system where regions were looked at and you as Council

approved some for three years, and then we had an understandir

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At the same time you as Council frequently did not

2

of how the review would be accomplished in year 2 and year 3. R
recommend triennial funding. You recommended anniversary Q
~

funding.
Well, at this point in time, going back and

  
 

looking at the review record, we have 13 regions that

are in an anniversary situation, and as of this moment six of

those really in terms of our understanding should be looked

at by the Council.

Now, we're trying to work all of this

around because we don't have an application for you

to look at. We have got to get this back into some kind

of working arrangement between the Council and the staff.

We don't know what to tell the regions to apply for. We are gu»

2
in a bind. And in a sense that resolution, which may be > }

improperly worded, was to try to get you to let us !

a aa :
extend until such time as a region can come in with an vy

application.

‘aaammeareneemnmnenenennCmr .
MRS. MARS: Dr. Pahl, --

DR, PAHL! Mrs. Mars.

MRS, MARS! -- is there enough program staff left

in the majority of the RMPs to be able to carry on effective-

ly any major activity?
DR. PAHL? Yes. We have made a survey on that.

Mr. Chambliss may wish to respond in more detail. But the

 
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109
answer is yes. In the majority of the regions that is
true.

MR, CHAMBLISS: Yes, there has been a survey,
and there is a minimum of staff on board in each of the RMPs,
including the coordinators and their secretaries.

MRS. MARS: That isn't what I asked. I said is
there enough program staff left to carry on major activity?
Not just coordinator and minimum staff. In the actual
programming part of the staff.

MR, CHAMBLISS: My impression is that there is
a minimum of staff that could --

MRS. MARS: Could effectively carry out major
activities?

MR, CHAMBLISS: Yes. Also our survey has shown
that’ the regional advisory groups are essentially intact
and will be ready to respond once they have more knowledge as
to what the real missions of the RMPs will be.

DR. PAHL! Mr. Hiroto.

MR, HIROTO! I have a couple of questions I
think that have some legal implications.

Your definition of the Council's role would
indicate to me that if it is merely advisory then this
resolution. is not necessary for, statt, for RMP here, to do
what they have done, and so y wonder if the enabling legisla-

tion had a little more meat to it than the fact that the

 
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Council was merely advisory in nature,

DR, PAHL: | The Council ‘is advisory in nature
relative to the policies, program directions, and so forth.
It has a very real function in recommending to the
Secretary approval for expenditures of grant funds, and,
in fact, the Program Service may not expend grant funds without
the specific recommendation for approval by this Council.

So it has a very well defined role in the

. |
approval for expenditure of grant funds -- not contract, but
grant funds -- and is advisory in terms of program
policies.

And it was in the program policy area that the

resolution would be advisory.

But I believe it is fair to say that all Govern-

ment officials take very seriously statements by advisory

 

councils relative to such policy matters. And my own
personal opinion is it would be very helpful to know what
the Council may feel about these important matters.

When it comes to grant funds, the purpose of our
resolution _- and what Mrs. Silsbee was trying to allude to -
and I don't want to come back to our resolution all the
time because it's not really in conflict with what Dr.

=o

Teschan.said -- is that it is giving to us your post-action

endorsement of that which we had to do and providing us

TTth a delegation of authority in a very limited fashion to

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111
continue between Council meetings to do that which actually

hnecessar

will be if regions are to remain viable, which is

      

 

everyone's intent.

And again I think that it is important to
separate then the fiscal actions which we have had to take
and the authority which we really need from you to take
those actions when we don't have applications or have
ceiling levels which are meaningful for regions until such
time as we can get back into concert with the recommendations,
which we expect we will be able to do by fall.

We are trying to put the brakes on phaseout,
stabilize, and move forward -- with serious question marks

in this area. But we have certain legal obligations

    
 

 

whicn we recognize, one of them being that the staff does

not have the authority to continue to support regions and fund

them without approval from this Council.
nS

On the other hand °

bring to you and no way to advise you and no review committee

   

  
 

to recommend ceiling le

So this is an interim procedure of delegating to
us necessary administrative authority. That is what our

resolution is intended to do.

This does not encompass all, of course, that is

in the coordinators! resolution, which is broader,

Dr. Haber?

 

   
   
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DA HadER »

DR. HABER: I must say I am extremely sympathetic
to the position of the staff in this, because there is a
basic kind of schizophrenia involved here. On the one
hand, as an effective bureaucrat, there is an apparent
mandate from the Administration which one must take
seriously. On the other hand, there is, as all of you know
who are purveyors of health care and interested in the
delivery system -- I think Dr. Laur mentioned it -- the
concern as to what happens to the people out in the regions.
One would want to continue certain promising kinds of
activities.

It seems to me that some historical perspective
might be useful here, and I'd like to ask the question of
you or Dr. van Hoek or Dr, Laur. That is, part of the
problem, it seems to me, is due to an evolution of the
mission. The Regional Medical Programs started out to
do something somewhat different from what now or laterally
appears to be the mission.

If one could address that, that as heart, cancer
and stroke centers some good was accomplished, much good
was accomplished in the dissemination of this kind of
expertise throughout the system, if that could be developed,
then I think one ) might have a clue to what your immediate
posture might be ‘for the ensuing 12 months.

Because then again it seems to me that out of the

 
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113

array of options you chose, one could say, "All right. The
part of the mission that is available to us for this

year is changing. Yet over the course of time RMP has

|

|

|

done these following things all under the rubric of |

disseminating effective health care." |

And what I'd like to ask is could a case be |

made that the heart, cancer and stroke centers concept was |

indeed helped by the RMPs and that the mission evolved into

something else which you were not able to complete because
the program was caught in mid-flight?

DR. PAHL: Dr. Laur may wish to address the | |

point, because I believe some of the recent meetings he has |

had entailed those very considerations.

Dr. Laur.

DR, LAUR: I'11 try to respond first to that

the case cannot be made that heart, stroke and cancer centers
rendered that kind of a positive service. Now, if the
Council can make that case or if the staff can, you know,

that would be certainly a starting point. |

My impression has been that there was considerable |
disagreement around the country especially at the local |
level as to whether those ideas were, in fact, the best
way to disseminate improved health care to the people.

Now, I would welcome comment from staff on that.

 

 

 

 

 

 
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114

But that sort of goes back to the original notion of

Dr. DeBakey and the Commission and what finally became

law and what finally happened in practice, and I am only
trying to read the tea leaves at the bottom of the cup now
that we have all had a deep draught from it which says

to me that since it didn't happen that way in the real
world there was probably something faulty with the idea in
at least many parts of America.

Now, I would like to have my own understanding
broadened if that is not the case.

DR. HABER: Well, I am not sure I can make the
answer, but I am sure there are people who can make the
answer that the dissemination of techniques in care of the
coronary patient and the education of a great variety of

allied health professional people was in some definite measure

{

attributable to the deployment of the Regional Medical |

 

Programs, and maybe the same thing is true in cancer, less

so possibly, but certainly in stroke.

I think if that case could be made, or at least
if the issue could be raised enough so that people could not
definitely negate it, I think that would give you a clue

as to what the situation might be, what the position might

be.

DR. LAUR: I wonder if I could take a slightly

different cut at the same question by saying I do not believe

 
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that this Council or this staff or the people whom you suffer

under as administrators of HRA right now can make that
aS

case within the time available to make any difference. That

goes back to Dr. Merrill's long-range question of! Is that

the way we ought to go in the future?

But I thought Dr. Schreiner's question was much
more short-run, which was: Somebody made what to him
doesn't look like themost intelligent decision, which was
to fund up to September 30th the core support of RMP so
that they would be around to do some good mission for the
remainder of this year while the long-run fate gets
settled in Congress and in the Administration.

Now, it seems to me he had a very specific idea
in mind, which was: ‘Dummies, don't try to do it that way

because it won't work. At least assure core support through

the year."

Thatts a quite different level of decision and
recommendation to us than, "Go back to’ the centers idea as
to the way to get york done."

“DR, HABER: No, no, permit me. I was trying to say
if one could say the mission had been evolving, that part

of it could be accomplished, then you have a line on what you

are to do for the next year.

Dr. Pahl read for us a list of seven or eight

different options. Real case could be made that the accom-

 
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116

plishment could be furthered during the course of the year.

I would agree with Dr. Schreiner's analysis. I'd
say don't lose a quarter of the time. But you could do a
great deal towards, say, hypertension control demonstrably
in the course of the year, or kidney prograns, or --

DR, LAUR: Perhaps I read much more into your
observation than I was entitled to. Every one of the
options which we have developed and suggested to the
Secretary, the ones you heard, are ones we deliberately
picked on the ground that we thought RMPs were superbly equip
to make a major contribution in the time available.

In other words, we wouldn't have suggested them
had we not thought they were appropriate to the mission of
RMP and to the health needs of the country and that we
had a reasonable chance of getting the money to do those
jobs with.

We tried to be quite selective in what we
recommended.

I was extending your thought to say what we ought
to now be doing in the coming year is to establish regional
centers for hypertension, which left me less than enthusi-
astic.

DR. HABER: If the mission is changing, the
agglomeration of these could be subtended on the mission,

which would require the continuation, of RMPs.

 

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DR. PAHL: Dr. Ochsner.

DR. OCHSNER: I would like to speak to the ques-
tion of the centers. It seems to me the idea originated by
the DeBakey Committee was the centers, but I think they
failed miserably in establishing what we have in mind in
the RMP. And to go back, they did fail I believe, and
that's the reason why this mechanism was set up.

Now, whether this is the right one or not=- But
I don’t believe that they did a good job in hypertension
and cancer and stroke. They were given a time to do it,
and they didn't.

DR. LAUR: From this or other groups I think,
Dr. Ochsner, your observation is quite important in the
sense that Dr. van Hoek at the end of the table now
serves as the Director of the Bureau of Health Services
Research and Evaluation, and it seems to.me after years of
exploration ve have at least uncovered an important question
that ought to be studied by the Federal Government, which is
how do you go about accomplishing aims like that?

At least we ought to be doing some research on
it if not actually moving forward with an action program if
we think we have the answers.

But what I am trying to separate out today in
the remaining hours of your time is: Can you give us

advice, which we may or may not follow but I assure you we

 
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118
will welcome, on: Given the circumstances right now, what
would be the intelligent thing to do, the most useful thing
to do?

And you suggested some already.

I think we in turn will have to say: Now, under
the constraints with which we have to work, with the
Secretary's office, with the legislative situation, with the
Congress, some things can be envisioned and others cannot.

What the staff I think is looking for are two
kinds of help from you. |

One is let's put the past behind us, kind of seal
it now and be done with that, and give us the kind of
guidance you are willing to give us to govern our future
actions, recognizing that we will have to take some action
before we can get together again and discuss it thoroughly.
That is, in the interests of getting on with the job of
RMPs , some funding decisions will have to be made between
now and September. The sooner the better in our estimation.
And we need some guidance from you on how to do that and
leave you feeling comfortable with our actions.

I guess I would add one other point in defense
of the Septenber 30 date, since I was in-at least some of
the discussions. “There were really two major concerns.

They weren't exactly compatible but that governed that

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FAVA, 119

One of them was the view by some of the officials
in the Administration that they were right all along
about RMP, that basically it was not fulfilling a
worthwhile enough mission to deserve funding and it ought to
be phased out. You might come back with a new approach --
that was okay _- but RMP was essentially a failure and it
ought to be phased out.

So that concept is governing some of the
kind of decisions that were made. They didn't wish to
reverse that decision so they were trying to come up with
ways of satisfying the intent of the Congress with the
extension legislation without reversing that basic decision.

Now, that's real. It's there. And the staff has
to struggle with that.

On the other hand, there was another dimension whic
said, "In reality we want to come up with a useful
mission for RMP. We can't do it overnight. So let's at
least get enough money out there to sustain them" -- and
here's where they may have made an error in judgement as
to what it takes to sustain -- "at least let's get the money
out immediately so no RMP will be in dire straits while we
get all this straightened out," in the factual circumstances
which are that most of the RMPs were carrying out activities

into February.

You know, December and February were the times in

 

 

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120
which under the phaseout plan they were continuing on into
those dates.

So I think their perception was that not very many
people are in dire straits right now and that to avoid
a hasty decision that seems to commit the Administration to
continuation of RMPs full blast, we'll have this time-

limited one.

But we picked a time -- "we"! meaning this is how
the conversation went -- a time was picked which provided
what they thought was ample opportunity to come up with an
ongoing funding level and a set of HEW expectations of RMP.

DR, SCHREINER: This is precisely where I find
the problem, because if the assessment is that this was
a polite gesture by Congress and there is no real intent to
go beyond a year, then to have full: funding of the non-
programmatic portions is really a waste of the taxpayers’
money. : |

MR, HIROTO: I think so too.

DR, SCHREINER: If you're talking about allowing
somebody to recruit a coordinator so that he can extend
the existing programs, then somebody has got to be able to
recruit a coordinator on the basis that he is going to be
here for a year.

As I read this telegram, you know, there are

vacancies all over the country, but you can't recruit anybody

 
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121
for more than three months, but he is supposed to then
arrange for the extension of programs beyond -- at least
from February to June at the very, very least if you are
going to meet the intent of Congress.

And so here you are recruiting a guy, you know,
and saying he is going to have a job for three months, but
his real task is to be sure this program is running well
June 30, 1974.

And I find that administratively untenable. You
either have to decide certain parts of it are going to
be extended for the full year of the extension so that
you can carry out the intent of Congress, or you are going
to say that the whole thing is impossible and is a gesture,
and then you ought to cut it down.

What I'm saying is there are three possibili-
ties. Of the three, it seems to me the one you have
chosen is the least tenable of the three.

DR, PAHL! Before continuing this most important

discussion -- because this is why we wanted you to assemble on

the 17th of July -- I'd like to come back to some practi-

calities.

We are very concerned that we have as much dis-
cussion and advice from you today as: we can possibly derive.
I had indicated earlier that we hoped to be completed by

2 o'clock, and some of you may have made your plans on that

 

 
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basis. I should have realized, of pores, that, having
lived with all of these parameters these many nonths-~ We
thought we could perhaps summarize them more rapidly than
we aid, and if we took too long we apologize for that.

but we felt we had to give you a flavor and a background set
of data so that you can go into the considerations of the
future a little bit better prepared.

So what I would like to ask is what kind of
schedule we may look to with you for the rest of the day.

If you can stay somewhat longer than 2 ofclock, for example,
we could profitably continue this discussion perhaps to

1 ofclock or so and break for lunch in the cafeteria, during
which time you could discuss some of these matters which

I don't think we have gotten quite enough to the point that

you feel prepared to propose a4 position of the Council,

and then reconvene.

But if we do break for lunch, it is going to be
relatively short after we do reconvene, and it may not
provide that kind of opportunity for further discussion
that both you and we would like.

So, as a simple question, is it possible for you to
stay beyond the 2 o'clock period or do you not wish to
break for lunch and we'll try to guide our own conversations
here and the other material which I have to present to you

which is part of this discussion and which I'd like to do

 
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123 |
before we broke for lunch? And I'd like to be guided by

what your schedules are.

DR, McPHEDRAN: How far behind are we in your
proposed agenda?

DR. PAHL: I would suspect if we could continue to |
3 ofclock we would have the kind of opportunity that at
least I think staff would appreciate having, but I don’t know
what that does to your schedules.

MRS, MARS: Three is all right.

MRS. MORGAN! I have a 5 o'clock.

DR, ROTH: 4:30.

DR, OCHSNER? I have to leave at 1 o'clock.

MR, MILLIKEN: I have to leave at 2:30.

DR. PAHL: Why don’t we try to stay as much
through - but terminate definitely at three.

Let me inject one or two things here which I
believe should come into the conversation at this point and
try to recap -- not "recap" but give you what I consider to
be some important elements which perhaps have gotten lost in
all of this general discussion.

That is, where do we stand now and what is the
staff thinking about in trying to react to all of this?
Because I think this should be part of your Lunch-table

conversation and afternoon thoughts.

Facts: We now have 53 Regional Medical Programs,

 

 
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all of them guaranteed to be viable through the first quarter
of the fiscal year, with a clear intent of the Department I
believe to try to make determinations which will permit
all 53 to continue throughout the fiscal year with some
kind of profitable activity along the set of options that I
have indicated.

My best information at this point is
that there would be a series of options supported by the
Department, and, thus, regions would not be confined to
doing this or that but that there would be some electivity.

The decision has not yet been made.

MR, MILLIKEN: Is there readily available by staff

a breakdown of this sort of thing now, regional program by

program?

DR, PAHL: A set of what now?
MR. MILLIKEN: Identification of existing projects

that --
DR. PAHL: Yes, we have, although not for you today

but we do have knowledge on each program as to what activi-
ties are being continued and, of course, can derive the
Latest information on that. So we can get for you where we
stand, but we are not : prepared to do that today because of
the time considerations.

MR, MILLIKEN: I understand.

DR, PAHL: However, the set of activities in any

 
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one region now going on have already been funded through the
phaseout awards that were made. In addition to those
activities, in some regions there are no activities going
on. They have just discontinued. They have just terminated
their last activity. In most regions there are a handful
of activities going on, and in some regions there are quite a
few activities going on.

Most regions have more than a minimal complement
of staff, but it varies dramatically from region to region.

Next, $6.9 million has been distributed to
the regions at the end of this fiscal year which at
the moment they are not permitted to use pending instructions
from the Department as to purposes for which they may be
used. And within those purposes certain criteria must be
met.

I want to address myself to that in a moment,
because that is the second part of the telegram we
haven't talked about which you should be aware
of and which we have given much thought to.

Thirdly, we are operating under a continuing
resolution, and it is my understanding that as soon as the
Department makes a determination as to what the regions
may do, we will then develop a spending plan and submit this
through the Department to the Office of Management and

Budget requesting those funds which would be appropriate to

 
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the options decided upon by the Department.

So I do not know what the spending level is for
fiscal 1974. It will not probably be greater than $81,9
million, and it probably will be not less than $30 or $40
million.

This is the result of many conferences and
inferences, but we do not know. I don't believe the
determination has been made since the options haven't yet
been selected.

Now, the options that are under consideration
are all those kinds of things which the Regional Medical
Programs have been doing. There are no surprises to the
Council, and there are no surprises to the coordinators
or to the community groups. Thus, it is a question of
making a decision, not starting off in a new direction for
any given Regional Medical Program.

Now, let me turn for a moment: to that second
stipulation in the telegram, because it is important that you
understand the thinking at least that staff has given
to that cryptic phrase which says, "Regional Medical
Programs Service has been authorized to utilize the balance
of FY 1973 funds (approximately $6.9 million) with the
stipulations that no expenditure be made therefrom until
the Department announces the mission of the Regional

Medical Programs Service for the remainder of FY 1974 and" --

 

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now the second stipulation -- "that proposed RMP activities

meet review criteria to be established."

What this really says is that the Department has
indicated that in expending either the $6.9 million
balance from fiscal 1973 -- which has already been
distributed in individual awards to the 53 regions but
they are not allowed to spend it _- or in permitting
expenditures from the fiscal 1974 funds yet to be made
available to the regions, not only will those funds have to
be spent in certain programmatic areas now under consideration
by the Department, but within those areas the actual
projects which are funded and activities which are engaged in
must meet certain review criteria which at this point in time
are not developed. | :

So we have an obligation placed upon us by the
Department to develop reasonable criteria of a general
nature for those programmatic areas which are approved by
the Department and to have these criteria be applied by the
local Regional Medical Program in consideration of the
activities they would like to engage in with either the
balance of 1973 funds or the 1974 funds and to have a review
process involving you, the Council, and we, the staff, which
would certify that the projects are in fact meeting the
criteria.

And since telegrams cost money, we didn't write

 
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all that. We just thought we would put that all down on
July 5. And since July 5 we have been trying to
determine how as a staff we might accommodate these
various constraints or, if you will, requirements.

In a sense, we are returning from program review
which you are familiar with with the triennial application
to a modified project review.

Now, I would like to give you the thinking of
staff because it does involve both advice from you and
hopefully your participation with us over coming
months, and the best way I can phrase this I think is to
reflect back upon how we managed the earmarks on the emergency
medical services funds and also on the community-based
AHECs where we involved Council in the development of
criteria and the subsequent review of these and yet
had a type of project review back here at the national level,

not depending solely on the review process at the local

level.

What we would propose is in accordance with the
Department's interest in not waiting until the end of
September before regions can get moving, but to provide
that kind of framework which will permit regions to move
ahead as quickly as the Department decision can be made known

to regions.

What we have considered is the following, and I

 
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would appreciate it if staff would react or add to what I
am about to say because I do want to make it as clear as
possible so that we can either get your endorsement or
advice as to how to proceed otherwise. And I do mean that.

We have given much thought but I am sure there are
other ways of doing this.

We do expect a Departmental decision on these
various options within a very short period of time. If
indicated to you we had hoped to have that decision today,
which wéane we may have it this week or next week. I.
believe we are that close, because I understand that the
Assistant Secretary's office is in a position to make its
recommendations to the Secretary's office, where the final

decision will be made, so that we hope for a decision very

quickly.

Once this decision is known, the only thing
holding up the regions from, therefore, utilizing the $6.9
million that is already out there and from developing a
spending plan for 1974 is the fact that we don’t have
these criteria which the Department believes we should
develop and apply against the specific projects to be funded
within the constraints or possibilities provided by the
Department.

So in developing criteria, what we propose to do is

to ask the Council if they will with staff and with selected

 
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coordinators who are closest to these kinds of activities,
be they hypertension control programs, EMS programs,
quality of care and assurance programs, or what have you,
to participate with us in the development of these
criteria by forming yourselves or with our guidance into
small subcommittees of two or three Council members who
could meet possibly in the very first part of September to
approve a general set of criteria for the programmatic
areas determined by the Department, and to then make
these criteria immediately known to the regions, the
regions then having the opportunity to immediately provide to
us those applications for projects in those areas which,
since the criteria are now known to both the region and
the Council, would be a simple certification process here
to indicate that these projects can "be approved, approval
sent to the regions, and the regions immediately then
engage in the kind of staff hirings and initiation of pro-
jects or staff service that are requested.

We believe that the actual criteria could be
developed very quickly over early Auust and we would hope
that in the early September meeting we would make it a little
bit more clear. The actual applications for specific
projects to be funded could come in from the regions.

So this would be very much like the EMS and the

health services education activity program that we had

 
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about a year ago.

This would get regions started immediately with
the funds that have been made avai lable.

Now, we would believe that if this process
were one which you believed would be effective and in which
you would participate, we would have to ask that there be
an understanding by the Council that these subcommittees
had delegated to them the authority of the full Council for
making the decisions for the actual award of grant funds
either out of the $6.9 million or the 1974 funds for these
specific activities without bringing them back to a full
Council meeting.

Again we are working within a time constraint, but
this would get the regions moving in a very definite
programmatic direction.

It adds an additional layer of review which
perhaps everyone would not wish to engage in but which seems
to be the appropriate method for proceeding right now.

We are open to other suggestions as to how to
proceed effectively.

We do believe that it is not possible to rate
in any numerical way the projects that may come in. I may
be very mistaken about this. But.certainly some kind of
ranking in priority order will be required because we will

have to pay on some graded scale, again in accordance with

 
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what may be indicated by the Department to be preferences
or even certain levels of funding for certain directions.
Now, that is a modified project review for the
immediate future which is merely designed to get the
regions moving faster than waiting until September 30th,
and we believe, therefore, this could all be done over
August .by perhaps one meeting on criteria and one
meeting in September of the individual committees, sub-
committees, of the Council with staff to review the
specific projects that came in.
The more important thing, of course, is to
look at the regions as a whole over the fiscal year and
the future of this in the longer tern, so what I have just
proposed is a short-term expedient arrangement to help us all
get back into some kind of functioning within the regions.
The longer-term considerations of each region and the
program as a whole would be presented at a November Council
meeting where we would have two days, if your schedules
permit, to look at all of the regions collectively and
individually and these longer-term considerations as to
what happens beyond June 30th and the kinds of things which we
neither have time for now nor are as clear to us as they
should be, and over the course of the coming weeks and a few
months I believe we will have a better appreciation for what

the stands of both the Congress may be and the Administration.

 
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Now, I just wanted to mention this to you because
as a staff we are under an obligation to the Department
which is, of course, my problem to somehow release
those funds already made available to the region and
those funds which can be made available to the regions provided
we have criteria and provided projects can be developed
which meet such criteria.

Now, the kinds of criteria that I am talking
about are broad in nature, general in nature, and generally
revolve around the idea that whatever project would be
submitted would be one which would have an impact in a real
way in a community over this one-year period.

There is no coercion from the Department in any
sense of the word to design criteria along a certain line
or to make things impossible either here or within the
regions. The idea is to use what funds are made
available out of the 1973 funds or the 1974 funds to
accomplish something in 2 relatively visible
way within the communities over the one-year period but
not to start those kinds of activities which would if initiates
have to be continued by an RMP as an RMP in order to make an
impact in the region.

Because, gain, we are probably talking about the
continuation of the program in some new form, or alternatively

an actual termination, and this from my point of view here

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has not been finally determined. But the intentions as I
best perceive them are to continue the program in a modified
form, the structure of which is at least for me 111-
defined but which by November Council meeting may well have
much greater opportunity for discussion and useful input
from you.

If it turns out, of course, that it is
possible before that time, we most certainly would want your
advice. But it is not too helpful today to speculate too
lengthily I believe on what happens after next June 30th
except perhaps to indicate an overall concern or point of
view by the Council.

Now, again, that is rather technical, but we have
very severe administrative constraints, and we not only
need your advice as to how to proceed over the next 60
days but we from our point of view-~ With this recommendation
to you, it would involve your actual participation with
staff and with selected coordinators to help: develop
the criteria very quickly and get your “approval and then to
have possibly a September meeting with the subcommittees,
a subcommittee probably established for each option, 2a
subcommittee for the strengthening of health planning agencies
in the community and a subcommittee maybe for the EMS
activity, who could be given the authority by this full

Council today to act on behalf of the full Council and thus

 
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to start the regions moving ahead very positively with what
funds are available.

I hope I haven't muddied the waters. All of
that is contained in those few words of the stipulation
No. 2.

. Dr. Roth. | |

DR. ROTH! Well, I'd like to react to that. As
I look around, I guess I'm the only one that was on the
Council back in the days when we were reaching a decision,
which may have been an i11-advised decision, but we
always had the dilemma with limited dollars do you put
them into places with a demonstrated capacity to use them
to put on a good program or do you look at the areas which
are backward, deprived, who probably need the kind of stimu-
lus that RMP thought it was prepared to give without
putting on such sophisticated programs?

Our decision was that indeed we weren't going
to deprive the backward, underprivileged areas in
order to pour more money into Boston and Philadelphia and
places where there was all this capacity.

Now, that may have been a wrong decision at the
tine, and it certainly is a luxury that we can't afford if
we believe that the RMP philosophy is right, that the
catalytic role of RMP has demonstrated a capacity to do good

in areas, and if we would like in the time available to us

 
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and with the funds available to make RMP as visible as
possible, build its credibility and hope that it will
attract further funds and congressional and departmental
support, it seems to me that this is important, because what
has high visibility may be a very rudimentary program in
rural Mississippi and what has value in Philadelphia or
Boston or metropolitan Washington may be something very
different.

And I would think that committees would have a
terribly hard time looking at 53 regions and coming out
with hard and fast criteria of these sorts.

It tends to suggest to me that there may be

an awful lot of wheel-spinning involved in this simply in

order to involve Council in a relatively nonmeaningful way.

If we are officiating at the demise of a
program, you go one way. If we are struggling to save it,
you go another.

And I believe that the RMP staff as I have
observed them in my connection with the program want RMP to
survive and believe in it. I have been on enough site
visits with them and enough Council meetings with them to
know that I think they want it to work.

And with the limited number of dollars it seems
to me that the only practical thing in this short time

period is for the Council to charge staff with picking out,

 
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in the areas which appeal to me that you have listed-- I
mean EMS has high visibility. AHEC support may have high
visibility. -These kind of things. And with the money

you have got available and geographic distribution the best
you can, try to put on a final flare of fireworks, if that's
what it is, and see if you can't be spectacular enough with
it that Congress and the Department and the Administration
will want to continue the program.

I'd be willing to consider putting faith in a
staff that we have been working with long enough.

It's sort of like we have been saying in the
regions. You build a good core and then you depend on
core to exercise its judgment on how the available funds
should be used. We never realy let them do that, but there
is the opportunity to do that with this central core staff.

DR. PAHL!: Well, thank you.

Are there other expressions by Council?

We will be breaking for lunch in a moment.

Dr. Schreiner?

DR. SCHREINER: I always feel guilty mentioning
kidney and hope somebody else will. But I notice it was
left out.

DR. PAHL! We had our coffee break. (Laughter)

DR. SCHREINER: I think if people are going to

talk about strengths of the program, even though that came

 
ds; we.

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in very much later than the original heart, cancer, stroke
routine, we have got a real talking point in focusing
against H. R. 1 where we are going to spend $250 million
next year in implementation.

Where would this be if there weren't a State-
wide program in Wisconsin, for example? Where would this be
if there weren't a State-wide program in Arkansas?

And these were things that were set up by RMP,

and I haven't even, heard them mentioned once, but they are

“

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very, very practical points.

And I think that we. obviously ought to continue
during this year while we are interdigitating with a big
pay progra _- There's no danger we are going to have
to take over the cost of the patient care, because it is
already taken over. We ought to work on methods for
better distribution, better techniques for coordination of

programs, develop tertiary care centers, all these kind of

things.

Because our focus is right there in a way that
is going to interdigitate with the spending of big dollars.
DR. PAHL! I thank you for calling my attention
to really a very major oversight, because in trying to
keep 211 these points in mind I did fail to say that one of
the key options is the kidney option. It's right here in the

paper, so you will have to accept the veracity of the

 

 
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statement.

DR. HABER! You did mention it.

MRS, MARS: You did.

DR, PAHL! It must have been in passing. Let me
emphasize it most certainly here.

Now, if we might, since we have until 3 o'clock,
entertain with you whether you would like to use this as
a point to break for lunch and consider some of these

matters-- Let me tell you what we see to be at least two

necessary items, or three necessary items, of business,

all of which I hope are relatively short.

One, our own proposed resolution to you, or some
variation thereof, is necessary to give us that kind of
administrative legality to continue on in the next two
months. This is apart from the development of these criteria

and the application of the criteria. But adjusting pudget

it

periods, and’s0 forth.
The second thing is there is a2 resolution we

have to hand out to you dealing with the construction

funds which way back in the early morning were mentioned by

Mr. Van Nostrand, and again for us to conduct the Government's
business in an expeditious way over the next period until

we meet. We will have to take a few minutes and tell you

what that is and ask you if you will approve the resolu-

tion we are proposing or some variation thereof or else

 
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we are always going to be answering the telephone to the
Congress. But we have to get into that.

The third thing is while most of you are still
here we would like to have a two-day meeting for November
set, although we may have to either adjust that one way or
the other depending on circumstances.

We believe it would be helpful, and if we
may just get that first point out of the way because people
may have to leave as we go through the day, I believe
there was a calendar provided to you and we'd like to have

you look at the month of November.

Staff has determined-- Is the 27th a holiday?

MR. BAUM! Yes, Thanksgiving is the 27th in red.

MRS. MORGAN: The 22nd is Thanksgiving.

DR. PAHL: Does anyone know for’ the purpose of
Government business what --

DR, ROTH! It is Rosh Hashanah. No, I'm sorry.
I'm corrected. That's September 27th.

MR. PETERSON: According to the Esso calendar
the 22nd is Thanksgiving.

DR. PAHL! What we'd like to have you do is look
at the week of the 26th, the last week of November, and see
if we can select a two-day period which is such that
most of you can attend, hopefully all of you but most of

you can attend, and at which time we would not only review

 
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141
what had happened, of course, between now and then but look
at all of these longer-term questions and bring to you the
Department's position, the Congressional position, and so

forth.

The reason for that is by that time we would be

 

able to anticipate formal applications from each region

for the total fiscal 1974 funding and you would be

acting on those applications for the entire fiscal year,

not this piecemeal trying to use the $6.9 million, but

if, for example, we are given $40, $45, $50 million for fiscal
1974, the request for the total fiscal 1974 picture from each
region would be in an application which had been reviewed by

staff with recommendations to you and that would be part

 

of the business of the Council, together with these
longer-term considerations. |

And there would be staff papers for you and |
positions that we would hope to give you from the Congression-
al and Administration point of view.

DR. ROTH! Just a question. Are the five of us
whose terms expire still alive for this meeting?

DR. PAHL! You're alive through November 30th,
and it is our hope, of course, with your personal interest
and permission, that we will be permitted to extend all terms,

and we are looking into the niceties of advisory committee

regulations and requirements.

 
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But we would propose to the Department that it
is important for us to have the continuity of your partici-
pation, so although the terms do expire November 30th, that
meeting would be legal, and beyond that we have to get
special action from the Department.

We would always be trying to act with filling
some vacancies with people knowledgeable about RMP program
so we could have as effectuve, full complement of the Council
as possible. That is a lot to be done in that period.

DR. ROTH: Then I would propose Monday and Tuesday,
the 26th and 27th.

MRS, MARS: Fine.

DR, PAHL! How does that fit with other people's
calendars?

Fine, All right. The schedule then is for
November 26 and 27, Monday and Tuesday, and, of course, we
will be in a position I hope to be much more logical about

the proceedings than perhaps today.

Let us break for lunch, and if we could reconvene

perhaps at 2 o'clock --

MRS, MARS: Letts make it before that.
DR, PAHL? Let's try to make it quarter of 2.

If you have indigestion, it's a result of Council action.

(Laughter)
So let's try to make it back by quarter of 2 and

 
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hopefully discussion takes place so that we can get our

business out of the way along the lines we have been talking

about.

(Whereupon, at 1:12 p.n., the luncheon recess

was taken.)

 

 
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AFTERNOON SESSION
1:50 p.m

DR, PAHL! Mrs. Mars informs us that it's five
minutes past our lunch hour self-imposed limit. So with
that liberty that I have just taken, perhaps we can recon-
vene. We have approximately an hour and ten minutes.

In thinking about how we may best utilize our
time and also feeling that it's important before you take
your final actions that Dr. van Hoek have a few minutes
to present some matters which he believes you should
consider before taking whatever actions you believe are
appropriate, I'd like to have Dr. van Hoek present his
thoughts to you first.

Then, following that, I think we should deal
in a businesslike way with at least the resolutions that
are in hand and then take up whatever additional points you
feel are necessary.

So, with that, Bob, would you like to address the
Council?

DR. VAN HOEK: I just wanted to briefly give you
some thoughts based on my experience over the last several
years, most recently being involved in both the
reorganization task forces and some of the legislative issues
that we have been faced with. I think they serve as a frame

of reference for you to consider both in terms of looking at

 
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some of the options that might be considered and how RMP could
impact on those or implement those options as well as any
ideas that you might have for the future of the program.

There are several issues that we are currently
faced with. As you know, RMP was only one of 12 programs
which were to be allowed to expire this fiscal year and which
received a one-year extension, Furthermore, along with
that extension, most if not all the health manpower
legislation which HEW currently administers is scheduled
to expire on June 30, 1974.

So what we are working on over the next several
months in essence is the development of health legislation
for virtually everything that we are doing in terms of
health manpower and the delivery of health services
aside from the financing programs, Medicare and Medicaid.

Secondly, as Medicare continues to be expanded
and Medicaid continues to be evaluated, there are the ques-
tions of restructuring those programs, if not looking at
the various options of national health insurance.

The reorganization is tied in with that, in that
the basic concept behind the reorganization was in essence
to bring together the various programs or functions that
are carried out in the health agencies which in many cases
have been separated into separate programs because of the

legislative base and the appropriations structure, and the

 
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reorganization was predicated specifically on the basis

of pulling together similar functions and leading probably,
undoubtedly, to significant revision of legislation and
appropriation structures over the next fiscal year.

Now, walking you through a process which we in
essence did in part of our reorganization work, if you
take a look at some of the functions which are carried
out and you look at various programs, the question is asked:
What was the basis for that program functioning as a
separate entity? And you then have two issues, two
primary issues. |

One is program content. In other words, should
the Federal Government be carrying out this program
activity or are there significant gaps in which the
Federal Government should be involved?

And then, secondly, if the Federal Government
should be involved, what is the process by which that
function or program should be carried out?

So you are really facing two issues with RMP.

Now, let me point out two separate things. In
the reorganization, on the flip chart here, I have
diagrammed part of the health agency structure, with the
Assistant Secretary for Health mving an Office of Policy
Analysis and Research. This was the office that Scott

Fleming headed until he left in June, now headed by Dan Zwick.

 
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‘And then HRA in which RMP is located, as well
as the National Center for Health Services R & D, considered
to be the principal agency for carrying out studies, evalua-
tion, analyses, data collection, and supporting developmental
activities in the delivery of health services. It is the
principal R & D agency aside from Biomedical Research, which
is NIH, and because of that responsibility it has the
primary resources to assist the Office of Policy Analysis
and Research which has the responsibility for the Assistant
Secretary and for the Secretary of carrying out analyses
and the development of health policy in HEW.

So that shows you the importance of the location
of the RMP program, the RMP staff, as well as other activi-
ties in HRA.

Now, if you look at the blackboard, what I have
done is just quickly sketched -- and this is just in essence
a rough example of some of the program content, some
examples of program content or functions which have been
identified both in looking at the organization of HRA and
other programs in the health agencies and also looking at it
from the standpoint of where those activities are currently
carried out.

Now, some of the priorities that were discussed
this morning for RMP and which are considered high priority

in the Department and in the country as a whole are listed

 
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there:
Quality assessment.
Standard setting.
Health dtatistics:

Planning and resource allocation.

All of these functions have been identified as
key functions that need to be performed and in which the
Federal Government has some part to play, whether just by
subsidizing community activities or actually conducting
some of these in a more direct fashion.

I have not completed the second column, but if
you take those functions and look at the way HSMHA and
other agencies were operating and the way we were structured,
virtually every one of the programs in HSMHA, for instance,
was carrying out that function in one form or another, with
very little coordination, very little joint planning or joint
funding. And it was driving HEW, the communities at large,
and the regional offices, who were trying to link some of
these resource and research activities with the service
delivery program, to despair in terms of trying to find out
what was going on and what information was coming out of all

these activities.

And I can duplicate that for every one of those

functions.

In addition, you can also duplicate it in terms

 
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of legislation.

The question should be asked then in terms of
column 3: What is currently on the books which provides
the legislative authority and the funds to carry out those
functions either in a primary responsibility and then,
similarly, secondary responsibilities? -

For instance, quality assessment. The primary
implementation in the Nation is going to be. through PSRO,
But there are a series of other activities related to PSROs
which need to be carried out in terms of research and evalua-
tion of the effectiveness of PSRO, the development and
evaluation of criteria, methods, the techniques of
quality assessment, and so forth, which are based at the
moment primarily in HRA.

But here again in terms of quality assessment
in PSRO you can identify more than five agencies which have
in one way or another had some involvement in the early
stages of the PSRO development. And so on through.

The question then can be raised: Are there
program functions or content which are not being met
through any existing legislation or any existing programs
which should be carried out? And whether that is carried
out in HRA or RMP is one question.

Second, if there are gaps that need to be filled,

is a program like RMP the most appropriate route to go?

 
150

In other words, what is the content of the program?

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And then what is the process by which you implement it? Is
there a need for the Federal Government to subsidize

community organizations to carry out the functions that

have been carried out by RMP in the past or to carry out some

new function in the future?

My own reaction in some cases has been that RMP
has been used more in addition to a number of the
standard functions -- has been used to a great extent in
those special initiatives. That is, at some point in time
the model cities was a big initiative, so RMPs got
involved in model cities. Then there were HMOs two years
ago, and EMS one year ago, and so forth.

And it relates to Paul Haber's question earlier
about the changing mission and priorities that have
occurred over the period of time.

And I would like to throw out just one problem
that I have identified as the Director of NCHSR&D looking
both at quality assessment and the problems of health
services delivery. And I think there is a major gap that
is not being addressed by any of the health agencies at the

present time.

And that is methods for studying medical care

effectiveness. And by that I mean medical care effectiveness

in the Archie Cochran-British sense of the word and in terms

 

 

 

 
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151
of evaluating the effectiveness of medical care in an
actual practice setting rather than. in the research setting
where many of the treatment modalities are being tested and
evaluated at the present time and again that would link
logically PSRO, Biomedical Research, and some of the things
for which RMPs were originally established.

So I just wanted to bring out some of those
thoughts that have come up among the staff, and it’s not
just limited to RMP, but I think it's particularly pertinent
to RMP since we are in process of looking at both what it

should do this year and what the nature of the program might

be in the future.

DR. PAHL: Is there any discussion on the points?
These are some of the broader considerations that I think
are well to have in a way classified for us, because we
will be dealing with them both in the immediate future
but more importantly in the longer-term considerations.

I don't know whether you have comments now
or over the course of the afternoon or-- Dr. Laur, do you
have any comments?

DR. LAUR: No.

DR. PAHL! Well, if not, I would again thank you
and suggest that there are two or three items of business

which perhaps we can address.

And because one of them is brand new and doesn't

 

 
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152

get into the resolutions from the coordinators and ourselves,
I would like first to treat the construction authority
resolution, because it is an isolated point.

Ken, would you distribute our proposed resolution
to the Council?

And if you will bear with me while I try to
just go through this very briefly, as Mr. van Nostrand
indicated this morning, there has been through the legislative
process a sum of $17 million authorized for the construction
of specified facilities.

Although you don't have to turn to your book, |
under the tab marked "Quotes" -- in which there is a summary
of excerpts from the legislative activities that have
taken place on the next to the last page -- at the bottom
there is a section which deals with the construction
authority, and perhaps I should just read it to you. This
is excerpted from the Second Supplemental Appropriations
Act, Public Law 93-50, July 1, 1973.

"Health Services Planning and Development - For
an additional amount for 'Health services planning and
development', for carrying out, to the extent not otherwise
provided, section 304 and title IX of the Public Health
Service Act, $17,000,000, to remain available until expended."

That mears that $17 million has been made available

in no-year money, so it is not a question of whether the

 
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153

money will be spent or has to be spent in this fiscal year.
It is just a question of how effectively we can discharge
the obligation for funding the facilities which were further
identified as follows:

In the Senate Report No. 93-160 and also in the
floor debate it was indicated that these funds are for the

following items:

First, $12 million to permit completion of

the new Children’s Hospital National Medical Center in Washing

ton, D. C.

Secondly, $4.5 million to meet the initial needs
for a children's medical center serving the Northwestern
regions of the United States.

And, thirdly, $500,000 to complete a hospital
in northern Vermont, the North Country Hospital and
Health Center at Newport, Vermont, by providing additional
grants for hospital construction.

Now, in the press of activities, I will have to
admit that we have not been able to devote quite as much
time to this particular part of the end-of-the-year
legislative activities as we would have liked to, and there
is some question at least in staff's mind as to what our
authorized level of expenditure for construction within the
Regional Medical Program Service can be, since under the

authorizing legislation we are permitted to spend in one

 
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. 154
fiscal year no more than $5 million. Yet here in the legisla-
tion we have a total of $17 million for these three facili-
ties. | | _

This poses a kind of problem which I have not been
able to resolve prior to the Council meeting, and rather
than face it directly I felt I would perhaps try to
come to you with a resolution which is an innocuous
one but will let us proceed once we are able to resolve the
legal issue, which perhaps is very simple but which is
at least in my mind at this point a little confusing.
The second matter is that it is quite clear
that the funds have been given under section 304 and
title IX, and two of the three facilities clearly are within
the Regional Medical Program Service responsibility,
and those are the North Country Hospital, Newport, ¥Yermont
and the Children's Orthopedic Hospital in Seattle, Washington.
What again is not clear, because several authori-
ties have been cited in the legislation, is just which
program element in the Health Resources Administration
is responsible for building or assisting to build

the Children’s Hospital in Washington, dD, C,.

Consequently, in view of the somewhat uncertain
state of affairs from this end of the table relative to
this legislation, and not having had the opportunity to

obtain legal opinion on this, we have developed what I think

 
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is an appropriate resolution for you to consider and

hopefully act upon favorably, which I would like to read for

the record. And if action is appropriate on it, it would

permit us to conduct the business in accordance with

whatever is determined by counsel of the Department to be our

legal responsibilities and possibilities.

So the resolution that we have provided to you
states: |

"WHEREAS the Congress has appropriated $17 million,
to be available until expended, intended for construction
of facilities identified as follows in the Congressional
reports:

"Childrens Hospital, Washington, dD. C,

"North Country Hospital, Newport, Vermont

"Childrens Orthopedic Hospital, Seattle, Wash.

‘and WHEREAS the construction of such facilities

would contribute to the purposes of Title IX through the

strengthening of primary care, enhancing the quality and

capacity of facilities, strengthening linkages between

primary and specialized care,
“and WHEREAS the Congress has authorized the

allocation of said funds under Title IX and other authori-

ties of the Public Health Service Act,
‘land WHEREAS the RMP legislation authorizes up

to $5 million per year for new construction,

 
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156

"the National Advisory Council on Regional
Medical Prograns, recognizing the clear intent of Congress
that construction of the above facilities be assisted,
delegates to the Director, Regional Medical Programs Service,
the authority to award funds up to the full legal limit under
Title IX for that construction determined to be appropriate"--

And I believe the wor "Provided should be
included, Mr. Baum.

MR. BAUM: Yes.

DR. PAHL: Following "appropriate," please insert
the word "Provided."

"1, appropriate application is made therefor, and

"9, the applications, plans and specifications
meet all HEW and local requirements applicable to the types

of facilities to be constructed.

"The Council, further, strongly urges that funds to

 

be awarded for construction of said facilities shall be in
addition to, and not part of, the total allocation for
support of RMPs in Fiscal Year 1974,"

Again, the purpose of asking you to take
favorable action on this draft resolution is to provide
to the staff the authority to proceed within the legal
limits of expenditure for those facilities which are

determined to be appropriate for construction under RMP

authority as: quickly as possible rather. than to delay longer

 
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157

Since it would not be in the best interests of the communities .
In some cases the construction already being underway and
the funds being no-year funds. there is no need to delay
unnecessarily since the funds in fact will be spent
as soon as all of the requirements can be met.

Now, I am sorry that I do not have identified
for you, therefore, the exact funds that we will spend this
year, since it’s up to legal determination, and I do not
have the knowledge at this point as to whether the RMP
program is responsible for Children's Hospital, Washington,
D. C., and, of course, we will discharge whatever the
Department determines to be our responsibility in accordance

with congressional intent.

MRS, MARS: I move we accept the resolution, Mr.

Chairman.
———"" MRS, MORGAN: Second.

DR. SCHREINER: Question.

DR. PAHL: It has been moved and seconded to
accept the resolution. Dr. Schreiner?

DR. SCHREINER: I don't know whether it's in order
but I would like to propose that a slight amendment be

made -- that is, that the wordy trongly urges" }

    

and that the word "agrees" be substituted.
MRS, MARS: Where?

DR, SCHREINER: Last paragraph.

 
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MR, MILLIKEN: Second.

_ DR, ROTH: Is there any possible relationship
or parallelism between this and the $15 million of our
money they stole for HMOs ? |

DR. PAHL: | There is construction authority in
the authorizing legislation for RMP, $5 million per year.
This has been exercised I believe only once, and that had
to do with the Seattle --

MRS, MARS: The Hutchinson --

DR. PAHL: The Fred Hutchinson Cancer Center.

So, to answer your question directly, I believe
there is only the palest of coincidences which may appear on
the surface. This is a perfectly appropriate expenditure
at least up to the $5 million for projects.

The identification of these projects, of course,
came through the legislative process. So it is not quite
in the sense of having an open competition for these
funds. And the question, therefore, is not making
these available for competition but to assist in the con-
struction of these specific facilities.

I don't believe there is any relationship between
the HMO funding of last year and these specific requirements.

DR. VAN HOEK: There was an attempt to put the
$12 million in the 304 authority last year and it fell out

because of continuing resolution-appropriation problems, but

 
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159
they did submit an application for funding as a research
facility and that application was disapproved.

MRS. MARS! I accept Dr. Schreiner's amendment.

DR. PAHL: The proposed amendment to the
resolution, which has been moved for approval and seconed,
is that the phrase "strongly urges" in the last paragraph be
replaced by the --

MRS. MARS: The word "agrees."

DR. PAHL: -- word “agrees.” Is there further

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discussion on this by the Council? gl% oct
MR, MILLIKEN: Question. U

DR. PAHL: If not, all in favor of the amended

resolution please say "aye."
(Chorus of "ayes.")
Opposed?
(No response. )

It is so ordered.

By the way, we, of course, will inform you at an
appropriate time what the resolution of these legal issues
is and what funding is proposed from the Regional Medical
Programs.

I would like to turn now to the resolution
which we proposed for your consideration, and without
attempting to in any way lessen or bypass the resolution

el
introduced by Dr. Teschan for the coordinators, I would like

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160

to treat this particular resolution separately, because
it does something a little different and it's more limited.

And since we have had a chance to look at it
again, let me say very clearly that the intent is to both
approve a limited set of administrative actions taken by
us, limited to the adjustment of budget periods, the
proration, the forward proration, of funding levels and
of Council-approved levels for regions, as actions which
we had to take in order to accommodate the intent of the
Congress and the intent of the Administration until such
time as we could have a Council meeting, and, secondly, to.
delegate to us in this limited fashion -- that is, .
adjustment of budget periods and funding level and Council-
approved level on a proration basis -- so that we merely
prorate those levels over whatever period of time is
necessary and whatever sums are necessary in the near future
as necessary until again as a Council we can meet to look
at applications from regions and act on them in the way in
which we are accustomed.

And at this time that would appear to be the two-
day meeting in November, although if that proves to be
unnecessarily far in the future with respect to how things
go, we may have to be in touch with you and see if we can
construct an earlier Council meeting.

We are still trying our best to predict how events

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161

will flow.

Mr. Milliken. / ae

MR, MILLIKEN! Are you ready -for a question? Go
ahead if you're not.

DR. PAHL: Yes, but I think I will have to read
this into the record so we make sure it is there, with your
permission.

MRS, MARS: May I just ask are you saying that
unless we pass such a resolution your hands are more or
less tied? Is that the --

DR. PAHL: Yes, it's staff's best impression
that we are skirting administrative flexibility here. We
know we have a Presidential extension of a bill. We know the

Council must approve the awarding of grant funds. And

 

 

 

 

we are not quite certain about our schedule of Council |
meetings and what actually will be necessary until |
we meet again.

So we are asking you to give us that authority
of the kind we have already exercised in this limited
way to permit us to conduct the business until such time
as we have applications and a bona fide review and recommenda-
tions from the Council in terms of new applications.

DR. MERRILL: Doesn't approval of this resolution
mean we are in essence approving the quarterly funding

principle as outlined in your telegram?

 
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» All regions are now guaranteed viability

162
DR. PAHL: No, it really isn't related to the

quarterly funding as such.

I think what we are basically saying is that

the quarterly funding, which is a departmental-- By the way,

 

I'd like to strike that. That carries an implication which

I think is not really true.

 

   

the first quarter, but I believe the Department's clear

   

intent is not to fund the program on a quarterly basis.

   

And this resolution merely lets us, depending upon the

   

availabi

available before we meet again, move ahead to both adjust
Council-approved levels and funding levels in order to
expend funds in the way in which we mentioned before we
may have a full Council meeting and full applications from
the regions.

The problem really has to do with the fact
that regions don't have applications waiting on their
desks to send to us because we yet don't know what to tell
them to construct in the way of program areas and the
criteria that I have mentioned.

And yet we may have a continuation of fiscal
1974 continuing resolution funds made available to us which,
if we have this authority, we can ‘help regions move ahead

functionally without actually having a Council meeting and

 

 

 
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163

incomplete applications for you, and we can't see having

real applications much before perhaps October for staff
review and analysis to present to you in November.

So this is not really in any way to be interpreted
or related to a quarterly funding principle. The staff
did not construct it that way. It isn't viewed that
way, and it won't be implemented that way. And we could
reconstruct it in some fashion if that is the interpretation.
But they are separate issues.

DR. MERRILL: I think this statement that you have
just nade, read into the record, will solve the problem.

DR. PAHL: Okay.

DR, SCHREINER: But, Herb, as a matter of fact,
no RMP that has a vacancy for a coordinator can hire a man
on a year's contract even though they have congressional
authority to do that.

DR. PAHL! The technicalities are complicated.
What we have said to the Department is that we will guarantee
the viability of the regions through the first quarter,
and by viability I have indicated to Dr. Laur and Dr.
van Hoek he must accept our professional judgment as to
what viability means, and if there is not now a coordinator
present, then a region without a coordinator still as of
September 30th would not be considered viable from a

prudent manager's point of view.

 

 

 
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164

And so actually although there is still the
schizophrenia and the technical complications, in fact as a
staff we are negotiating with regions to have them hire
staff, to retain their current staff, and the necessary

supporting staff and space and equipment.

So that if it is the desire of the region to
hire a coordinator, from our point of view that constitutes

a reasonable definition of viability to permit that.

‘ ae
a The question more is whether you can hire a man

on the basis of the kind of telegram language that

we have had to send out. So it's not that we are restricting

the region by not allowing them to hire people. It is that

the communications which have gone out dontt make it very
reasonable for responsible people to want to take on this |
until there is some greater sense of stabilization from
Washington.
— And, of course, we are very hopeful very quickly
of giving that stabilization. And such things as the
resolution that we are considering here would help us
implement such a situation.

DR. SCHREINER! We're not trying to give you a
hard time, because we really appreciate --

DR. PAHL! I know you do.

DR. SCHREINER! -- your situation. On the

other hand, I would have great difficulty, because if I were

 

 

 
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165
on record voting for that, someone could pick up that paper
and say, "What are you beefing about? You okayed it."

And it seems to me that it would strengthen your
hand maybe if we got specific, if we feel strongly enough,
or at least I would feel if I felt strongly enough on that

point, to make that as a specific exception, so that there

is a clear record.

But I'm afraid that, you know, when this
gets translated in the newspapers it's going to mean that

the Council is all in favor of this.

DR. PAHL! Well, I think we could certainly --
and we would be certainly pleased to have incorporated into
this document or into another resolution the clear sense of
the Council that it does not endorse any principle other |

than full-year funding.

Perhaps, Bob, you might like to comment. Itm
not sure, because it is a lot of material I have presented
on a complicated topic-- Perhaps it would be-- If you had
a point to make --

| MR. CHAMBLISS: - We do feel, Dr. Schreiner, that
this resolution will keep the RMPs alive until such time
as -- |

DR, SCHREINER: I understand.

MR. CHAMBLISS! -- there is adequate release of

the constraints of the telegram and adequate release of

 
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funds.

To answer specifically Mrs. Mars' question, I
would say, yes, this does tie our hands unless we do have
this kind of authority.

DR. SCHREINER!. We appreciate all that.

DR, PAHL: It's the quarterly funding --

DR. SCHREINER! How many unfilled positions for
permanent coordinators are there? Seven?

MR, CHAMBLISS! We have no unfilled positions.
We do have, as I reported earlier, ten acting coordinators.
Three of those have been acting for an extended period of
time, which has been brought to your attention prior to
today. There are seven new acting coordinators.

DR. SCHREINER: Has any one of those signed a
year's contract?

MR. CHAMBLISS: Fortunately, they come from the
professional staff in the main, and that problem has not
been a very acute one. They are members of the staff who
have been promoted to the coordinator -- the acting
coordinator -- slots. .

MRS. MARS: Why don't you just add a few words
in here in this last paragraph as you'd like it.

DR, SCHREINER: That's what I think would

strengthen you.

”

DR. PAHL!: Yes, we would appreciate having that

 
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made explicit, because it is the intent to divorce this
from any support of a quarterly funding principle.
MRS. MARS: The only thing I don’t like about
4t is this part here where it says “endorses the specified
administrative actions taken to date." We never had a chance

to endorse them. We were simply told what was going to

happen.

So we have to accept what has been done, so

there is no question about that.

MR. CHAMBLISS: Well, it can be an endorsement

‘with retroactivity, Mrs. Mars.

DR. PAHL: The position is a difficult one --

MRS, MARS: I know you can, but _-

DR. PAHL! -- that we have placed you in. And
what we basically are asking is endorsement with understand-
ing of the constraints, and, of course, that's been clear
all morning.

Put the other a if you do not endorse these
actions, since it is a matter of history one can't undo
the actions, and I prefer to adopt the point of view I
think that Dr. Teschan tried to convey to us, and that is if
we can kind of close a door on the past, because it

ee
has been difficult on all parties concerned, and move

ahead-- And we feel this would help clear the way both

psychologically as well as in any legal and program sense

 
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1 | ¢nat would give us a better basis for moving ahead.

2 But it is placing the Council in a most awkward
3 || position.
A DR. MERRILL: Could one amend this paragraph (4),

YY? article (4), so that it reads at the end of the second line

   
  

the clear wu nding that funding of programs be

   
    
 

undertaken on an annual basis"?

Most assuredly, yes.

9 Would the Council accept that amended version?

10 | phat would be most suppar tive of our position.

"i MRS, MARS! And with a clear understanding,

12 )' py, Merrill, that --

13 DR. MERRILL! That the programs be funded on an

14 | annual basis.

5 DR. ROTH! I second that.
. _—
» DR. PAHL! The suggestion has been made and

M seconded to amend the section (4) of the draft resolution

1
8 with the words added "with the clear understanding that

7 programs be funded on an annual basis," that phrase being

“0 inserted at the end of the second line.

21 DR. MERRILL: ‘ And in place of the third line.

22 | DR, PAHL! Yes, and elimination of the third line.
23 | MR. BAUM: Herb, do you want to read the whole

#4 thing into the record?

25 | DR. PAHL! All right. Let me ask you, Dr.

 

 

 
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Merrill, to insert your exact wording, but let me read the
entire first part so we have it for the record, if I might.
I think it's an important resolution.

This would be Council resolution endorsing
adjusted budget periods and approved support levels for RMPs
and delegating to the Director, RMPS, limited authority for
making similar future adjustments.

"(1) WHEREAS: the President in his budget
message to the Congress of January 29, 1973, did not request
any further support for RMPs for 1974, thus necessitating
‘that a planned phasing out of both the RMPS and the RMPs be
instituted for the orderly termination of the program, and

"(2) WHEREAS: in implementing this phaseout
process the RMPS found it necessary to adjust selectively
the budget periods of the RMPs and to prorate both their

funding and Council-approved ceiling support levels, and

"(3) WHEREAS: on June 18, 1973, in accordance
with the strongly expressed intent of the Congress, the

President extended the program for one year, then" --

Section 4. And now, Dr. Merrill, may we have your

complete section?

         
    

 

ERRILLi: (4) BE IT RESOLVED that the

  

 
 

National Advisory Council accepts and endorses the
specified administrative actions taken to date and, with

e clear understanding that the programs would be fund

 

 

 
170

on an annual basis, delegates to the Director, RMPS," etc.
DR. PAHL: All right. " . . .delegates to the
Director, RMPS, authority to act in similar fashion

as he deems necessary until such time as the Council can

1

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qn applications from RMPs and determine new support
\

 

 

levels for the individual regions."
MRS, MARS: That's good.
DR. PAHL: It has been moved and seconded to

accept this amended resolution. Is there further discussion?

*
x & >? MRS. MARS: Question.
yy DR. PAHL! If not, all in favor please say "aye."
4 B (Chorus of "ayes.") |
@ 5 13 Opposed? wr ys ort

; id (No response. ) KU, 58
It is so moved. ae?

Now, the third matter is one that is on the

 

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broader issue and involves I believe the Council's
18 .
recommendations -- to accept the resolution or the statement
19

. which has been prepared by the Steering Committee for

° consideration by the Council or to amend it in any way it

** | deems advisable or to take any other such actions as you
6 ae ‘feel is appropriate under the circumstances.

23 - And may I remind you that before we broke for

2
4 lunch there was a suggestion made which perhaps could

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a little further by the Council, so that there is no mis-
understanding as to whether staff will have delegated to it
the authority by the Council for the development of
criteria and the use of these criteria to award funds
either from the fiscal 1973 balance or from fiscal 1974
continuing resolution funds for the support of specific
regional activities in accordance with whatever program areas
are designated by the Secretary for this fiscal year.

MRS. MARS: How important is it that cancer,
stroke and heart be brought into -- and kidney -- be brought
into this criteria?

DR. PAHL: How important?

Let me remove the first non-obstacle. The
kidney is involved. This is a very clearly specified
program area which we have every reason to believe will be
sympathetically viewed by the Secretary.

There is a hypertension control program option
specifically proposed.

There is nothing specifically in the cancer or
stroke categories, although these could be appropriately
included and would be appropriately included in such things
as the quality of medical care and the manpower development
and utilization categories.

MRS. MARS! Because I'm sure you will recall the

directive that was given to us that we must turn back towards

 
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more emphasis on heart, stroke and cancer, and I'm

| wondering whether this would influence Congress at all in

their thinking and perhaps in furthering and continuing
the Regional Medical Program if such emphasis were directed
at this time.

DR. PAHL: Well, this might be a point of view
which the Council may wish to include in a statement
which could be forwarded to the Department and may have a
bearing. I'm afraid the state of affairs _-

MRS. MARS: Do you know what the thinking of
the Department is in this?

DR, PAHL: Yell, at the moment I think we
feel as staff that we could accommodate all of these
activities within the broad options that I have identified
for you, although the cancer field is not singled out, nor
is stroke, as a separate area of activity. At this point

the opportunity for further input into the Secretary's

office is limited because of the time that we are working.

So the only thing that could be done is to have
an expression of the Council's interest and to the extent
possible have this expression of interest implemented within
the options selected by the Secretary and with the

Secretary's approval.

MRS, MARS: I was solely thinking of how this

would influence Congress when this came up next year for

 
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refunding possibly or for reconsideration of continuation of
the program.

DR, PAHL! I honestly don't know, because
there are the two points of view that the Regional Medical
Programs has in fact done well by broadening beyond the
initial categorical disease orientation. At the same time
there is a very real interest on the part of individuals and
groups to emphasize these areas and less some of the other
developments which have occurred in recent years.

And I'm not sure I can really speak for how
Congress would really view this, because it's too many
people speaking for Congress and I don't have that sense.

MRS. MARS! From whence came the directive that
we were given by Dr. Stone, if it wasn't Congress, so to
speak, or was it Dr. Wilson? Where did that
come from? We were given a very strong directive.

DR. PAHL: Off the record, please.

(Discussion off the record.)

DR. PAHL: On the record.

DR. VAN HOEK: I think it’s fair to point out
that the options that we have discussed and presented to
Dr. Edwards and presumably are going to the Secretary,
although they speak of hypertension and renal disease, are

very specific, targeted activities.

The renal disease option is specifically

 
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geared to RMPs assisting in the implementation of the
H, R. 1 provisions, the support under Medicare of
renal dialysis and transplantation, and hypertension area
is specifically targeted not to a broad national program
of hypertension and hypertension centers but to supplement
the National Heart Institute's program in consumer education,
professional education and screening and to assist in
organizing community resources to do hypertension screening

and treatment.

DR. PAHL! On balance, and being subject to review
of the transcript, I would have to say it is my best

impression that the Department's posture at this moment

is to include in this year’s activities, and as a strong

consideration for any continued program, certainly emphasis
on those categorical disease areas which were the
dndtial development of the program in the legislation, but
not by any. means to restrict the programs, Regional Medical
Programs, or the mission, to those activities, but, rather,
to have them a part of broader areas of activity such as
we have been following over the past perhaps two years now.
And yet I don't think I can honestly say what the
Department's final position will be.
We will certainly take into account administrative-
ly and also bring to the attention of others whatever the

Council's position on this might be. Because this is advice.

 
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It is a transition year. And certainly it does bear on

what the Department and the Congress may think the future

of this program could be.

So not only now but as we go into other Council
meetings and through the year I believe these points of view
should be discussed and positions or recommendations made.

DR. McPHEDRAN: Dr. Pahl, I just wanted to ask
something about these things that Dr. van Hoek put up on
the board. I'm really asking is it thought that a Federal
agency in order to be viable should undertake one or so of
these functions? I mean in the reorganization plan?

And my further question is! Isn't it likely that
there are going to be some kinds of activities that will
have to include all of those?

For example, any intelligent medical care plan
would have to include everything on that side (indicating).
So that a Regional Medical Program would have to do all
of those things really in order to be a Regional Medical
Program. And would not they have to have an agency here _-
and again I don't know about that -- but an agency from whom
they would get direction in this and who would be their
resource here?

I mean is it conceivable that a regional agency

that was designed to foster cooperative arrangements between

local health agencies and voluntary cooperative physicians,

 
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and so forth-- Would not that agency have to have
some kind of single central agency like RMPS?

I mean if you didn’t call it RMPS. wouldn't you
have to have that by another name in order to make the
concept of an RMP dealing with all of those things on a
regional level-- Wouldn't you have to have it? Or could
you call it something else? Or what -- just in your thinking

about reorganization?

I don't think that anybody here -- maybe I haven't

understood it -- but I don't think anybody here has quarreled

seriously with the idea that there is a place for some

kind of regional -- maybe State would be better -- but we
have all in the past said that maybe the State health agencies
never could do it properly and that was the reason for
starting Regional Medical Programs in the first place --
but that there was real reason for them to get together
to help coordinate these activities.
And I don't see how those regional agencies
could ever be expected to do it unless they had
some central Federal agency like RMPS to deal with.
I don't really pretend to understand these
things very well, but if you would explain that to me
I'd like to know what your thoughts are.
DR. VAN HOEK: Well, under previous health agency

organizations, and particularly under the current proposed

 
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ones, you can identify a primary responsible agency or
organization which deals with each one of those functions.
They may be doing that effectively or not, to varying
degrees. And they may have varying degrees of

Federal funds to carry out that activity.

What you're really asking is how at the
community level do you integrate the technical resources |
that come from both Federal agencies and from local
agencies and how do you integrate the resources in
the community to do an effective job of planning and
operating a delivery system?

And the question can be asked: What is that
process in the regions? Is that a Regional Medical Program?
Is that a State health authority? Is it, you know, just
in essence the laissez faire economic market system?

And I think that is one of the problems we
are facing right now, why RMP is being looked at, why
other legislation is being examined so closely, in that it
really deals with a political and social issue in which I
don't think, you know, there is a clear direction for the
country as a whole or even at the community level for any
particular community.

In some areas they are moving toward, you know,
State authorities, and so forth, but they are primarily

focusing on cost control through certificate of need

 
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legislation and rate-setting rather than the overall
integration of health services and resources.

DR. McPHEDRAN: Well, I am persuaded by Dr.
Merrill and Dr. Roth that we ought to have, rather than the
statement suggested by the coordinators, a statement from
this Council that would give at least some new ideas of ours
about thcedspgtion of Regional Medical Programs .

And I also don't think that I can imagine how-~
At least I couldn't write one in ten minutes. I don't
think I could write one in ten hours probably. But I
wanted to have a chance to think about this. And I
guess I want to clear up in my own mind some of these
questions about this particular point.

You a I really think that the idea of the
Regional Medical Programs, at least where they were well

functioning, the few I could think of -- I could name them

 

 

but I won't -- I think the really good ones took
into consideration many of those different things.

And had they had to deal with that many, as many
functions as they worked on, had they had to deal with that
many separate agencies here, you know, to get support
funds or to get advice, or so forth, I think that they would
have been less effective than they were, much less effective

I suspect.

And so that I think that having a Regional Medical

 
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Program Service that was really well done, as we have
said today -- we weren't just kidding about that;
it was well run on the whole: they got good staff support --
then I think this enabled them to do a great deal of
what they did or it facilitated that a lot.
7 What it would have been like without that I
don't know. Goodness knows.
But I think that just as in proper medical
care you have to take all those things in consideration --
I mean if you're any good at all you do all of them or many
of them -- so would you in the Regional Medical Programs
where you are trying to foster voluntary arrangements
between the doctors and hospitals and nursing homes. I>
think all those things would have to be-- And the nedical
schools, goodness knows. A11 those things would have
to be taken into consideration.
So that I don’t think that from what I know about
State health authorities-- I don't think that without
being completely done over they could manage that, |
But I think in the places where it was well
done that the Regional Medical Programs at least did
that part, and they were the only agencies, it seems to me,
that did it. And that's why my special plea is for them.
Now, I know that didn't work out everywhere, but

that certainly is the way I feel about it. I think that the

 
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180
mechanism ought to be preserved for that region and the
hull should be cleaned in places where it's needed, or
scrapped if necessary in some places perhaps.

DR, PAHL! Thank you, Dr. McPhedran. I think
that is a very eloquent statement about what the
Regional Medical Programs and Program Service has been all
about, and I don't think certainly we could have phrased
it as well.

Is there discussion?

Time is moving along, and I know your schedules
won't permit you to stay much longer, so we would
appreciate having whatever kind of thoughts you feel are
important.

Dr. Schreiner.

DR, SCHREINER: Yes. I think it's very
important when representing this program to the
Secretary's office that you point out that duplication per
ge is not necessarily immoral or unethical or evil if there
is an appropriate rearrangement.

Now, you know, everything is fine if you're
going into a pure State situation. But where you go to
the four corners of Utah or 16 counties around Syracuse,
and so forth,-- And a lot of this program's slow start
came because it took us a couple of years sometimes to

accumulate the statistics. Not that they weren't duplicative,

 
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you know. They are there in Utah. They are there in
Arizona. They are there in the New Mexico Health Department.
They are there in the Bureau of Indian Affairs. But nobody
is going to put them together for that natural
region except a local entity which looks at it through those
eyes.

So what is really important is not what is going
on with rural New York State or urban New York State but
for those 16 counties what is important is that somebody
pull together those “duplicate” statistics and rearrange them
in a way that makes some regional sense.

And this is really what RMP is about. And what

‘makes it difficult to express is because you can sit back

and look at any one of those yellow sheets we used to have

 

 

and say, "Oh, yes, this piece is there, and this piece

is there, and this piece is there," you know. There are
. nn ..

the eggs, but there’s no omelet unless somebody puts it
a ll ll i lili rT

together.
_——.
DR. PAHL! Well, thank you. We perhaps will be

calling on you more and more to help us express this in ways
which will be meaningful to the Administration and the
Congress.

Before we move along too much further, is
there 2 consensus by the Council relative to our rather

limited field of view at the moment that in the development

 
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182
of criteria, which is a departmental requirement, that you

delegate to the staff -- and, of course, we will keep you

fully informed -- the development and application of

ad
these and the authority to award funds on the basis of

a Te

staff evlow of applications which meet these requirements,

 

at least until such time as full applications from regions

can be brought to you for review and action?
Now, please understand we are not request ing

this authority of you. This was my understanding of
‘Dr. Roth's statement as to how perhaps we could move
ahead. But I would caution you to understand at this
—
point that if criteria are developed we would do so in
conjunction with coordinators and individuals who are very
familiar with the program areas under consideration and
perhaps would be bringing these at least to your attention
for comment before sending them out to the regions,
because it is a very important step that would be taken.
Because the criteria that would be developed and
employed would govern not only the utilization of the

$6.9 million from 1973 but would be the same kinds of

 
  

criteria which would have to govern the use of whatever
spending amount is allowed us for the entire FY 1974, which
could be five, six, seven times that $6.9 million,
depending on what spending plan is approved by the Department ||

So we would feel comfortable at least in contacting

 
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those members who would have most interest and
ability to comment upon the specific criteria selected
even if we didn't formally call you together, because we
do not intend to try to have long hiatuses of no information
and then spend most of the day trying to catch you up on
matters.
But I do want to understand what your feeling
is as to whether we are to proceed with your delegation

of authority to make awards and inform you i our

   

‘actions or whether you wish to at least at the ‘time that

    

applications of specific projects may have to ‘be reviewed,

 

approved and funded by staff that you would ‘like to be

 

in on this specific activity in the form of subcommittees as
TL a TD

we had announced earlier.

| It's a very important point for staff

because we don't want to get back into the process where:we
are through expediency bypassing you without, of course,
your full knowledge and endorsement to be bypassed.

MRS. MARS: I think we should certainly permit

staff to make the awards as necessary. Certainly it's
ee

our vote of confidence in you, and surely your knowledge is

   

such that it would be far greater than ours could possibly

be.
|
I do think that some of the criteria though --

that it should be based on the fact that the programs that

 
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are accepted for funding are those which certainly
will do the greatest good in the shortest tine, and also
with the thought behind them that they will be programs
that can be so ottect ae and so essential to a Ce

that a community will be willing to pick them up and go

op tbblieie™: or some other organization such as the v

State itself continue with them. <=

I think that probably would be one of the
bases of the criteria that I would suggest.

DR. PAHL: Thank you. That is a very important
kind of consideration which we too had felt would be the
type of criteria that we would wish to develop.

Dr. Roth.

DR. ROTH! Herb, does it throw any sand in the
gears to include in that --~ I agree with everything Mrs.
Mars has said _- but would it in any way vitiate the intent
to add the words, “It shall be the intent of this Council
to authorize staff to proceed consistent with the
existing mission statements achieved by the Council"?

The coordinators have asked for this, and I tend
to agree that we have worried this mission concept maybe
unduly, and it may have been an unfortunate word in the
telegram, but wouldn't that clarify things?

DR, PAHL: Yes, I believe there is nothing

that is being discussed within the Department or the

 

 
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Service which detracts from the mission statement which the

Council endorsed for the program some time back. And what

we have been talking about is a set of programmatic

activities within that broad mission statement.

And from what I have tried to indicate to you as
well as I can, it is my belief that the Department will,
in fact, provide the regions with the opportunity to
engage in activities of the kinds that we are all familiar
and comfortable with within that broad mission statement
that we still are living by and which the coordinators wish
us to live by and which you have just indicated should be
our reference point.

So I think the record can show that we are
working within that mission statement for this fiscal year,
and during the course of this year we all will be. concerned
with the longer-term directions and organizational structure

and processes.

DR, ROTH! If the staff would appropriately
word a statement which --

MRS. MARS: Right.

DR. ROTH! -- would clearly say that the
Council authorizes staff to proceed consistent with the
existing mission statement and according to criteria
properly and appropriately adjusted to the regional

‘situations in order to achieve greatest visibility and

 
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project the program in the best possible light, I would so

 

move.

MRS. MARS: ee ccna

DR. PAHL: 411 right. It has been moved and
seconded for staff to develop this statement. And may I,
because I believe this is an important step by the Council
and one that we will feel most comfortable with if we
can make sure that our words do reflect accurately-~ If
we could perhaps take the statement which we develop and
come back-- And let me just suggest that we do this by
telephone. We are doing a lot of things in order to move
ahead. But we can have this as a matter of record
that you as a Council individually will approve or we will
so see to it that our words do in fact convey this for the
record, because we are working within departmental and
congressional intents, and at times the cross-currents are
difficult, and we would like to make sure that we have
that. But we know how to act and proceed and will be in
touch with you.

DR, MERRILL: Are we talking about a separate
statement now simply for your purposes? This has
nothing to do with the coordinators?

DR. PAHL: No, we're talking about a separate

statement for our purposes. We will develop it and get

your --

 
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DR. MERRILL: Because there is a second paragraph
to which I object in what is in the coordinators’ state-
ment which sounds vaguely like that.

DR. PAHL! The coordinators! statement is open
for whatever action the Council wishes. It can be
accepted as a reflection of the coordinators’ interest and
concern or it can be acted upon in any way in whole or in
part I'm sure, and that is a matter for you following Dr.

Teschan's discussion.

MRS. MARS: Well, I think really we can table it

for the moment.

MRS. MORGAN! I move that we table this to our
next Council meeting.

DR, PAHL: All right. It has _-

MRS. MARS: And let them perhaps come back with
a revised statement or something, I don't think this is
acceptable.

DR. PAHL: Staff will inform Dr. Teschan that
the Council has received this statement, has tabled
it for consideration at the next meeting of the Council,
and that we will advise them that should they care to
revise and resubmit it --

DR. MERRILL! Could we also give them some
direction in how we think it ought to be revised?

DR. PAHL! Yes indeed.

 
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DR. MERRILL: Because I think these first
two paragraphs are really, as I said several times, kind
of a slap on the wrist and a blow for the status quo
and would be totally unacceptable to any administrator after
a long, hard day. And if one could stress positive

aspects of what we intend to do rather than these negative

ones --

‘ne .
DR. PAHL! Well, we will take the full record of

the Council --

DR, MERRILL: I think in the discussion we have
had here there are all the points I would like to make.

They can be pulled out.

DR. PAHL: That will be done and we will

transmit as full information as possible to Dr. Teschan.

 

MRS. MORGAN: Don!t you feel in these criteria

that we have said for staff to come up with where there

 

is input from Council in establishing it this will be

something that ith also alleviate a lot of the problems

here?

DR. PAHL: Yes, it would.
As we just close --

MR. BAUM: Before you close, I have something I

would like to clarify for the record. As one who has

 

to write the official record, let me see if I have this

straight.

 

 
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189

The proposed resolution presented by Dr. Teschan
this morning is tabled for further consideration next
time with certain advice to be delivered as to where the
wording can be strengthened. In the meantime I gather that
we have a-- I don't know whether it’s a motion or
we voted on it or just what by Dr. Roth that we as
staff develop a statement which would reflect those things
which were put on the table by Mrs. Mars, Dr. McPhedran,
Dr. Roth, and others in the afternoon discussion indicating
the general intent of the Council with respect to the

delegations that were approved and that we check the

wording out with you by phone or some other communication

before we write it into the minutes of the meeting. Is

that correct?

MRS. MARS! It was seconded but I don't think we
voted on it.

MR. BAUM! Do we need a vote on that?

DR. PAHL: Well, to make it official, all
in approval of that description of our action please say
"aye."

(Chorus of "ayes.")

Opposed?

(No response. )

It's carried.

DR. ROTH: My thought was if we had to go

 
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190
retroactively and approve something that we hadn't
approved before, I would rather give you approval now.

DR. PAHL: All right. Okay. Well, we appreciate
that vote of confidence.

Before we adjourn -- 30 seconds -- one, I would
like to indicate to you the CHP Council has not only an
interest in but the requirement for a liaison member from
our Council, and Dr. Watkins has been our selection, and
he has very graciously consented to represent this Council
on the Comprehensive Health Planning Council. I believe
that first meeting is in September, but we will be
getting information to you.” And at Council meetings
we would look forward to having reports from you about the
activities of that service.

Also I again have been remiss in noting our
pleasure at an event that you all are very well aware of.
That is, Dr. Roth's presidency of the American Medical
Association. And I'm afraid my own limited set of problems
made me overlook that announcement earlier today.

Is there any other business?

(No response. )

Almost all of our public members have left,
but if there is any public participation this is the last
closing moment that one has.

(No response. )

 
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191

If not, I would like to thank all of you for
a very long day and for trying to absorb a
tremendous amount of detailed technical material, for your
understanding, both personally and officially, in your
capacity as Council members, and to say that from this point
on we really do look forward to keeping you informed, and
we have set up arrangements to do that, so that we will
not try to burden you with things but to keep you abreast of
high points as we go through still a somewhat complicated
year concerning the technical matters internally but giving
you points of view from the Administration, the
reorganization, the congressional intent, and, of course,
our activities relative to the regions.

And again thank you for a very understanding |
Council and full day.

The meeting stands adjourned.

(Whereupon, at 3:07 p.m., the meeting was

adjourned. )