irc 1 ee 10 ll 12 e i4 16 7 18 19 20 21 ® 7 25 HOOVER REPORTING CO. INC. 320 Massachusetts Avenu>, N.E. Washington, 0.0. 20002 DEPARTMENT OF HEALTH, EDUCATION, AND WELFARE PUBLIC HEALTH SERVICE HEALTH RESOURCES ADMINISTRATION THIRTY-FIRST MEETING OF THE NATIONAL ADVISORY COUNCIL ON REGIONAL MEDICAL PROGRAMS -— = oe Executive Session Converence Room M Parklawn Building 3600 Fishers Lane Rockville, Maryland Monday, November 26, 1973 The meeting convened at 3:20 o'clock, p.m, Dr. Herbert Pahl, Acting Director, Regional Medical Program Service, presiding. _ | | COUNCIL MEMBERS PRESENT; MRS, AUDREY M, MARS GEORGE E, SCHREINER, M.D. MR, EDWIN C, HIROTO DR, LAWRENCE FOYE JOHN P, MERRILL, M.D. BLAND W. CANNON, M.D. MRS, MARIEL S, MORGAN RUSSELL B, ROTH, M.D. BENJAMIN W, WATKINS, D.P.M. MR, SEWALL 0, MILLIKEN MR, C, ROBERT OGDEN 2 1 CONTENTS 2 Projects Page 3|| Northland LL @ 3 4 Motion 16 Vote LT 5 : ® Hawaii 18 : 6 Motion 33 Vote 35 7 Arizona — 37 ~ 8 Motion 40 Vote 43 9 Louisiana 43 10 Motion 47 11 Vote At 12! South Dakota a 47 6 13 Motion - g 51 Vote 7 7 52 i4 . Colorado-W yoming . 52 15 . . . “Motion 55 16 . S Tri-State - Le 59 17 - Motion . 4 66 18 Motion a. a 70 Vote m4 80 19 20 6 21 e °* 23 24 25 HOOVER REPORTING CO, INC. | 320: Massachusetts Avenu, N.E. Washington. D.C. 20002 an 10 i 12 @> 14 16 17 18 19 20 eo ° 25 HOOVER REPORTING.CO, INC. |) 320 Massachusetts Avenu>, N.E. Washington, D.C. 20002 PROCEEDINGS DR. PAHL: May we reconvene the Council, please. At this point I would like to turn the meeting over to Mrs. Silsbee, who will lead us through what we have been trying to get to for sometime today, and she has it well © organized, which is no mean matter in view of the circum- stances that a number of people have rearranged schedules, and so forth. So without further ado, I would Like to have Mrs. Silsbee conduct, if you will, our session here on the actual review of applications and discussion of those areas that we think are important for you to consider, Judy. MR, OGDEN: I want to enter a complaint on behalf of}: one minor member of this Council in that I desperately miss the existence of the review committee, I think a great deal o what we are facing from here on out in this executive session is something that the Council shouldn't be doing. And a good deal of what Judy is doing of necessity is being brought to us} at sort of a last minute situation. Much of the discussion that we had this morning abou the thrusted purpose of this program is what we ought to be spending our time on. That is what we should be doing. Not trying to review ten applications which are in a somewhat im- perfect state and make value judgments individually, which we hope other people will accept. f nn 10 11 12 e * 14 16 17 18 19 20 bo al 25 HOOVER REPORTING CO, INC. 320 Massachusetts Avenu2, NE. Washington. D.C. 20002 4 I hope that this is the last time that we function without an effective review mechanism before these things get to the Council. DR, PAHN: Thank you. I appreciate that statement more than I think you c&én possibly realize, We undoubtedly have the opportunity now, if what we discussed this morning holds true, of reestablishing such a committee, And it is our interest and we know it is yours to have such a group. In fact, if we cannot formally reestab- lish the committee, we have a fall back position of trying to constitute an ad hoc group, if you will. But we sorely feel the need to give both you and our- selves that kind of professional assistance and overview, and we have sorely missed it. So I appreciate that statement and I am sure we didn't really bring it up as an agenda item. I think it is most appropriate, MRS, MARS: Under the current legislation, can it be reestablished? | DR, PAHN: It is not a matter of the Legislation. It is a matter of Departmental policy, which is in part govern- ed by a federal policy now for reducing and eliminating where possible those kinds of review groups that don't seem to be necessary. | Ken has his hand up, but I believe it is promulgated by the Office of Management and Budget and is being enforced 10 11 12 13 14 16 17 18 19 20 25. » HOOVER REPORTING CO, INC. | - 320 Massachusetts Avenu2, NE. Washington, D.C. 20002 ‘functioning and need for such groups, 5 by them across the federal government. And, of course, HEW, apart from Defense Department perhaps, has more review committees, study sections and advisory panels, I Suspect, than any other department, it is very much in the OMB's purview to look at the Now, the reason that the review committee was term- inated, of course, was that there was a phase out of RMP. In all honesty, with other matters pressing, we did not try to revise the Department's impression on that point, because we felt we had. some..higher priority issues to bring to their attention, We have not had the opportunity even to get those full attentioned by the Department. But at this stage, with what seems to be the future of the program, tiowvever tenuous, we already have, as I say, dis cussed not ily our interest but our need for and are making the kinds of plans internally to see if we can't reestablish a standing committee and failing that, if we can't call together groups that are functioning in the same fashion anyway. MR, OGDEN: We have excellent staff people, those who remained I think are highly experienced people who can do @ great deal of this themselves. You certainly have regional people who can give us this kind of input prior to the time it gets to Council. DR. PAHL: That's right. an 10 il 12 e = id 18 19 20 25 HOOVER REPORTING CO, INC. 320 Massachusetts Avenu>, NE. Washington. D.C. 20002 6 MR. OGDEN: And they need to be coming around review- ing this with each of us before it got down to this point in discussion, MR. MERRILL: I think policy matter, you could make-- a review committee would save a lot of time. I am sure the eight to ten hours I spent reviewing this were absolutely wasted, could have been saved for toher matters if you had a review committee go over the leg work. DR, PAHN: There is every good reason, and I would say we are in accord with your statement and understanding, and the only problem we have is a federal overview one, which is even beyond the control of the Department, But we will do what we can because we certainly are in accord with it, Is there further discussion? MR, HIROTO: Inasmuch as there are many vacancies on the Council at the moment, perhaps those vacancies might be filled with people who have a review capacity and they could become @ subcommittee, something of that nature, DR, PAHL: We have taken into account that very point in making nominations for the Secretary's consideration, and if our nominations were to be accepted, a number of individuals would already have first-hand RMP experience; because they come not only from former review committee members and possibly former Council members, and ones who have served local RMP's in various capacities, so we are very hopeful that the Secretary an 10 il 12 eo - id 16 17 18 19 20 25 HOOVER REPORTING CO, INC. 320 Massachusetts Avenu, NE. Washington, 0.C. 20002 7 will help us move ahead quickly by accepting some of the nom- inations,. Well, thank you very much, I do appreciate that, MRS, MORGAN: Do you think we should go on record on the fact we do have a quorum of the members who are on Council present, although maybe not a quorum of the total number who should be on Council due to the Secretary's lack to appoint members to the National Advisory Council? DR, PAHL: Yes, I think it is perfectly appropriate, because we have investigated this with the Department and I wouldn't want to leave you under any misunderstanding. We do have a quorum of the members who are actually serving on Council and it is Departmental policy, which we have Looked into and discussed with the Department's Committee Management Office, that this does in fact constitute a quorum for this Council and we can conduct the government's business. Mr. Baum, in fact, has conducted this inquiry and has confimed this Departmental policy in writing, so we are not operating without a quroum, ALL right, Judy, would you please take over. MRS, SILSBEE: I am beginning to feel like RMP coordinators, trying to do the flipflops to keep up with this review. This is the first time we have had 53 applications ir one meeting and we had to take a choice between allowing the oO 10 11 12 ee - 14 16 17 18 19 20 @ ~ 24 25 HOOVER REPORTING CO., INC. 320 Massachusetts Avenu2, NE. Washington, D.C. 20002 8 regions more time to prepare their applications when we sent out the September 7th instructions, the choice was between the regions and staff and Council, And we felt that under the circumstances, the regions probably needed the time. So we apologize for the fact these green sheets had to be here walt- ing for you rather than set to you at the time the applications went out, but we were undergoing a review at the same time they were being mailed to you. Just as a little background along this Line, there was a staff group within RMPS that looked over all 53 of the appli cations, This included the four Operations Branch chiefs, Mr. Peterson, Mr. Ott, Mn Chambliss, and Dr. Pahi. The latter two were not present all the time, but as they could be, This step of an overall group served to identify and develop some uniform type considerations of the problems and the issues that these applications presented; For example, the kidney projects, the fact that some regions indicated that the technical review had been completed but the RAG was not going to have a chance to look at everythirg until after the application was sent forward to us. The requests that were over the allocated amounts for which regions were instructed to apply. Negative CHP comments if there were some. CHP comments to come, because not all regions were able to get the comments in with the application, on 10 11 12 e » 18 19 20 25 HOOVER REPORTING CO, INC. | 320 Massachusetts Avenw>, NE. Washington, D.C. 20002 9 The status of the review verification of the region. The lack of full-time direction, And then some tougher problems. This overall staff review tended to screen out the problems which needed attention immediately, These were regio that we felt needed some attention with regard to these partic lar applications, Then in addition, this process screened out those regions which might need attention if additional dollars are forthcoming or mandated by court. The actual analysis of each application was decen- tralized to the operations officer who is responsible for that RMP, The green sheets that we gave you this morning for the regions that you were asked to review and are also included in these four books in front of you reflect the above consider ations for the most part. The discussion today may bring out others which are n& reflected, Time has been very short and staff has worked hard, The operations officers, the branch chiefs, the support staff, and the coordinating staff have worked overtime I think in terms of effort and deliberation. | I would like to call attention particularly to some Support staff who often have the unglorious job of making sure that pieces of paper are available and on hand in time, but q an 10 11 12 oe » "44 16 17 18 19 20 e »° 25 HOOVER REPORTING CO, INC. 320 Massachusetts Avenu3, NE. Washington, D.C. 20002 10 don't have the public recognition that the operation staff has in being able to talk with you and to talk about the specific RMP's, So I would Like to publicly thank Mrs, Edith Leaven- thau, Mrs, Filimina Green, Mrs. Joan Williams, and Mrs. Shirl Simon. This staff has done a tremendous job. Friday afternooh we made it. We didn't think we were going to, but we did, We started out with the plan today, that is why we have these four books, we were going to go through each of the books by operations branch with having an opera- tions branch chief identify those regions which staff elt need: ed some attention, and then to give you a briefdescription. Because Mr. Ogden, we are concerned too that we don't have the review committee, nor does this Council at this point have very much first-hand experience with the 53 regions. Then our plan was to go first with the South Central then with the Western Operation, then with Eastern Operations, and finally with the Mid-Continent. Well, the plan was slightly changed when we knew that Dr. Cannon and Dr, Merrill would only be with us for today, and added to that was Dr. Roth, so that plan went out the window, So we started with another plan. (Laughter ) But I want to call attention to these books, because unfortunately, with that plan, that is the way we put materials Ww ’ on 10 ll 12 e * i4 16 17 18 19 20 25 HOOVER REPORTING CO, INC. 320 Massachusetts Avenu, NE. Washington. D.C. 20002 11 together, so we are going to be jumping from one color to the other. But the way we are going to do it this afternoon is to identify those regions by branches that we think -- we think -- might need some attention, am then we are going to ask Dr. Roth, Dr. Cannon, and Dr. Merrill if among the other regions -- and I will read them out ~- that they have been asked to review, that they feel need special discussion, or whether we can hold this off until tomorrow. We would Like to have what we have identified as the problem regions Looked at by this larger group if that is all right with you. So we will start out with the South Central Branch, ant that is blue. The region which we identified that needs some special attention is Northland. Mr. Van Winkel will give a brief over, view and then we will ask Dr. Cannon and Mr, Ogden if they hav any discussion or any action they would Like to propose. MR. VAN WINKLE: Well, if I could, I would like to start off by saying the staff review was done by looking at all the things Judy mentioned, I think all of us. The staffing, the review processing, Liability of RA CHP review and comment, their ability to find other sources of funding, their ability to respond to new initiatives, we flag- ged kidney as a special part of the review, we looked at their Ww on 10 il 12 e : id 16 17 18 19 20 25 HOOVER REPORTING CO, INC. 320: Massachusetts Avenu>, N.E. Washington, D.C. 20002 12 past performance, and we looked at it in terms of whether they were in accordance with Council and RMPS policy. Now, what I would Like to do is not make a Lot of coy ments about each of these and go only by exception and if you don't hear of those things, you know that they are fully cov- ered in the application, if I might. Our concern with Northland I think was the fact that when they phased down, they really phased down, They wound up with one professional staff and a couple of secretaries, Mr. Wilkins who had been the Deputy Coordinator under Dr, Miller. Now, when they got word that they had some new Life breathed into them, they didn't have time to recruit new staff nor could they possibly have recruited new staff for that time). period, So what they have done, they have used RAG and board members as staff to develop projects, part of their contract offerings, this sort of thing. So on the one hand, these people are developing projects, doing the staff work on them, and then sitting on the other hand in the process of reviewing their own work, so to speak, Now, we have checked this out with management in terms of paying these people and we find that there is nothing {illegal abow this. I suppose what we are raising is a moral issue or possible conflict of interest as to whether this should be don and it is the staff's feeling that the Northlands RMP should fe» ~ 10 il 12 © 13 14 16 1? 18 19 20 21 25 HOOVER REPORTING CO. INC. 320 Massachusetts Avenu, NE. Washington, D.C. 20002 13 recruit needed program staff so as to elminate any possible criticism on the use of board members and RAG members as paid staff, There igs a kidney project in here where the region — will have to be alerted as to the new regulations that Mr, Spear discussed this morning. They have requested their full allocation of $458,586 to support ten activities, and we recommend approval of this application as submitted with advice on the staffing, and we have some difficulties with their bylaws, They are not totally in accord with the NID that went out with reference to bylaws that was sent out by this Council. MRS, SILSBEE: Mr, Milliken. MR. MILLIKEN: I think this is related to something some of us are concerned about, have talked about. This is the ability of the staff, this staff, as sparse as it is, to provide the kind of surveillance necessary to assure this Council and staff that if at any point in time there is evi- dence of an inability to deliver on these in the right way, th this be brought to proper attention, MR, VAN WINKLE: Could I respond to that? Certainly in any areas where we thought we had difficulties, we are in touch two or three times a week by telephone with these regions. We also had an opportunity to visit a great number of these regions on the EMS issue and also on the health 6 ~T 10 ll 12 e - 14 16 17 18 19 20 20 HOOVER REPORTING CO., INC. 320 Massachusetts Avenu, NE. Washington, .0.C. 20002 14 education activities. So we did have first-mnd know Ledge of many of these problems. I think we stayed up with them fairly well. These will be revisited under the schedule that Dr, Pahl mentioned to you this morning, we hope to bring back to you at the March Council or whenever that happens to be. MR, MILLIKEN: I think even more, I am thinking about certain questionable regions would get more attention if they are running on a more questionable basis, MR. VAN WINKLE; That is absolutely true, MRS,SILSBEE: Mr. Milliken, we shared some concern it terms of this particular period of time, this process is try- ing to identify those,we feel may need some special attention, We also reoognizé that we aren't really on top of all 53 and we have been able to identify those that don't have the review process, We have some that have been identified as having known. management problems, We will be trying to bring that out as we go along. But we too feel we have a lot of spade work to do to assure you as Council that these regions are on top of things, But in terms of this particular application, Dr, Cannon had to go out and make a phone call, but, Mr. Ogden, do you have any comments? MR, OGDEN: I would just read you my notes, which wer based largely on the yellow sheets which came out, which I on 10 li 12 e » i4 16 17 i 19 20 21 20 HOOVER REPORTING CO, INC. 320 Massachusetts Avenua, NE. Washington, D.C..20002 15 agree are useless, being what they had before. On the back of the material sent out. This I felt was a well presented application and I thought it demonstrated considerable advanced planning, which has been typical of Northlands all along. MRS, SILSBEE: Mr. Ogden, could you speak up? MR. OGDEN: My notes simply read this is a well presented application demonstrating considerable thoughtful advanced planning typical of the Northlands effort. Again, Northlands has used &@ contractual approach in what appears to me to be both constructive and a successful manner. After review by the RAG and allocation of perspec- tive funds to the several categories, the funds for EMS activi tles were negotiated for five CHPB agencies for implementation to state plans and Minnesota State Department of Health for Statewide coordination of the EMS effort. Funds also were allocated to seven community based groups for health education and to two CHEC's, at University of Minnesota clinic; 15 contractees, who have potential statewide impact, same situation, Kidney hypertension. Application indicates if additional funds are avail- able on January ist, a similar technique will be followed. My opinion, this is an application well deserving of full funding, but I would recommend that the RAG needs to 10 li 12 13 i4 16 17 18 19 20 25 HOOVER REPORTING CO. INC. 320 Massachusetts Avenu>, ALE. Washinotan. D.C. 20062 evaluate the cohesiveness of the program MRS, SILSBEE: Dr, Cannon, as I mentioned, had to make a phone call and before he left, he whispered he would go along with approval as requested. Do you want to make a motion, Mr. Ogden? MR, OGDEN: I will move that the application be re, approved for the funds requested. — nant ype eae . MRS, MORGAN: I second it. MRS, SILSBEE: For the record, the funding that is peing requested by Northlands is $458,586, There is a kidney proposal and there will be follow- up with regard to the staff and the bylaws. Before we go on to another application, it is pro- posed, when we mentioned kidney here, that there will be a statement made that the RMP may not release funds for kidney project X, which is being identified, to support a new facility, a new or expanded services. in an ongoing facility, until the facility receives interim approval or exception from the Bureau of Health Assurance, Social Security Administration Now, the other regions that either Dr. Cannon, Dr. Roth, or Dr. Merrill have been asked to review, as one reviewe in the South Central Operations Branch, are Florida, Georgia, Memphis, Michigan, Mississippi, North Carolina, and Ohio Valle If you have any points that you would like to bring up or would Like to have those regions brought forward now, 6 9 10 li 12 e = 14 16 17 18 19 20 to Rh 23 HOOVER REPORTING CO, INC. 320 Massachusetts Avenu, NE. Washington, B.C. 20002 17 would you speak up. DR. PAHL: Pardon me. Judy, in the press of time, I think although they did move and second, we are just moving a little too rapidly. We should take a formal vote, all in favor say "aye," just for the record. (Laughter ) I know I talked too long this morning, but you shouldn't feel that pressed for time, DR. ROTH: Also parliamentarian, MRS, SILSBEE: All in favor? _ ret ag ct (Chorus of "ayes.") MRS, SILSBEE: Opposed? (No response, ) MRS. SILSBEE: Motion is carried, Motion that was before I talked too much, (Laughter ) MR, OGDEN: Incidentally, before we leave that, I should have mentioned in reading through this material, I looked on RAG, board member, staff, purely as emergency measures and J can't imagine they Looked on it any other way. MRS, SILSBEE: Okay. In the absence of anyone want- ing to bring up those other regions at this particular time, we will bring them up when we get through with this other group. In the Western Operations Branch, two regions that were identified as needing some discussion were Arizona and HOOVER REPORTING CO, INC. 10 11 12 13 44 16 1? 18 19 20 21 20 320 Massachusetts Avenu, NE. Wachinotan NC 2002 18 Hawaii. Mr. Russell. MR, RUSSELL: Do you have any preference which one to start with? MRS, SILSBEE: How shout Heuer: MR. RUSSELL: The Hawaii regional medical program presents some very special and serious issues, Just in the wa of background for those of you who haven't had an opportunity read the yellow sheet and green sheet, both of which are quite lengthy, when Council reviewed the Hawail application in October, the program was approved for triennial status. How- ever, Council chose not to award the developmental component f the first year since the program had just recently revised its review and management processes and Council felt, rightly so, that the program would need at Least a year to really’ test their new procedures. As a result of an EMS visit, site visit in June, we found the program had deteriorated substantially since we had last looked at it, when we site visited it and had taken it through Council reviéw; we were encouraged through the regu- lar processes, a review, staff assistance following review, that we could have continued to assist the program. The basic problem as we see it is a lack of leader- ship in the area of management. Specifically, the director is on a 40-hour basis. However, his 40 hours are not J to or HOOVER REPORTING CO, INC. | 6 10 I 12 13 i4 16 V7 18 19 20 21 25 320 Massachusetts Avenu>, N.E. Washington, D.€. 20002 19 coterminous with the regular office hours. Therefore, he is not literally available to his own staff or to RMPS staff. The director seems to place more emphasis on the individual staff members standing in the community rather than on professional competence. I do not mean to imply there are not competent program staff members in most cases. The program staff has limited rapport as far as management goes with the director, Those who do choose to question him wish they hadn't, The director has two sets, at least two sets of mana ment philosophy. One is that in the presence of RAG members, pest we can remember, he readily admits recognized management practices should be used in the conduct of a regional medical practice. However, when, under local pressure in the decision making process, he reverts to other than sound management practices. Quite frequently he will point out to RMPS staff that the multi-ethnic background of the people in Hawaii precludes objective management practices, It appears to us that the director gets his power from the amount of money available to the program, rather than from his Regional Advisory Group. We have worked with him quite closely on this to try to get him to use his RAG as the buffer between the decisi that are made and the community. Due to the absence of the director during regular ge- as ons 6 ~ 10 ul 12 oe 13 i4 16 17 18 19 20 RO oot 25 HOOVER REPORTING €O, INC. 320 Massachusetts Avenu>, NE. Washington, D.C. 20062 20 office hours, we have to rely very heavily on the deputy director, whom we haven't had the opportunity to really watch him in a situation which demonstrates his effectiveness, As a result of the inadequate management of the very large emergency medical services project, RMPS, with Bureau approval, chose to transfer that project from the regional medical program, pull the administration back to the central level, and with coordination of the Emergency Medical Services Branch have gotten that branch now to direct it from a pro- grammatic standpoint of view. And the EMS Branch visited the Hawaiian Medical Association shortly after the transfer and he said already the improvement was very, very noticeable, So the point I am trying to make is the Hawaii RMP really failed to adequately handle a very large segment of the program, The next issue, critical issue, at the local level, national level and regional level, being HEW regional level, is the Gommunity Health Services project in the Waianae, coast area, which is an underprivileged area, We have pointed out in the paper here that the Community Health Services out o San Francisco, after months of negotiating with the Waianae. _, Board, that Board is responsible for administering pro- jects not only from RMPH but other federal funds, Community Health Services has laid out specific conditions on the family 10 il 12 e « 14 16 17 18 i9 20 21 24 20 HOOVER REPORTING CO, INC. 320 Massachusetts Avenu2, N.E. Washington, D.C. 20002 el Health Center project. If the board does not accept these conditions, then the Community Health Service will have to terminate its support, The board has had, oh, 15, maybe 20 days in which to f respond, They had to respond within 10 as of Friday. We undex Stand that the .Walanae “~, Board had not responded and the scuttlebutt is that they will not accept the Family Health Center-Community Health Services Conditions, If that is the case, then the Waianae, Coast: will not get the $400,000 for the Family Health Service project. Now, the RMPH involvement in the Waianae,Coast has been significant, Effective as a catalytic agent, it was Supposed to help with administration of the board to get it in shape, The first conflict that we noticed was when the Com- munity Health Service would not accept the project director-- this gets complicated, so stop me if I lose you, please -- it has taken me a couple of years to get it straight -- the Waianae .., Board is a voluntary board, its administration, some of its aspects have been funded by the Regional Medical Program of Hawaii. Now, the board in turnappoints its adminis- trator, who is salaried, That administrator automatically becomes the project director for the projects coming into the Waianae area... The Family Health Service project would be one. 10 ll 12 oe = 14 16 17 18 19 20 bo wt 24 25 HOOVER REPORTING CO, INC. 320 Massachusetts Avenu>, NE. Washington, D.C. 20002 22 However, the Community Health Service would not accept that individual, because he did not have the backgyo und in marketing a prepaid plan, so on and so forth, The Regional Medical Program of Hawaii was providing that individual's salary. The director of the Regional Medical Program, for whatever reasons, political or what, en- dorses that individual. And so here is where the RMP got involved and additional conflict came about, During the last site visit, the site visit team, and this was fed back in writing to the Council from the Council's review, stressed very strongly the Regional Medical Program of Hawaii had primary responsibility in seeing that the EMS project in Hawaii was successful and that the RMPH ais¢ had primary responsibility in seeing that the total program ‘of the Waianae Coast was held, ~— , They were, you know, instructed to provide surveil- lance to help that group meet the other problems. From all appearances, the RMPH has failed in that area too, Now, I will stop at this point and respond to any questions, DR. ROTH: Geographically, where is the :Watanae Coast? 4267 MR. RUSSELL: North of Pearl Harbor, 45 minute drive from Honolulu. Used to be a large sugar plantation, on 10 11 12 oe = id 16 17 18 19 20 21 nN Nm No ww = 25 HOOVER REPORTING CO, INC. 320 Massachusetts Avenu, NE. Washington, 0.C. 20002 23 which closed down. Left a pocket of poverty. A VOICE: On the Windward Island, MR, RUSSELL: Same side as Pearl Harbor, DR. MERRILL: I have a couple of comments, having read this application, give more of the flavor of the vital- ity rather than factual information which I clearly agree. I must say it is a very weak application, couched in very general terms without in my mind evidence of careful planning. And it looks certainly, at least the first part looks as if it were made to fit very carefully into the so- called categories, I note with interest at the end of fitting it into the categories, they then resolve the thing, that these cate- gories do not reflect the needs or concerns of American Samoa, Guam, and territory trust care and would like to go back to earlier guidelines. But I think on the whole, the application reflects kinds of weakness of construction and gives me the idea the activity in Hawaii is not a vital and vigorous one. MR, RUSSELL: I think that is correct. I would like to say as I tried to point out in the green sheets that the PacificBasin has really been a most exciting program, and it is for all practical purposes a separate program, Mr, Hiroto was on the site visit and, please, you kn OW ; 6 =] 10 il 12 13 i4 16 lf 18 19 20 21 24 25 HOOVER REPORTING CO, INC. 320 Massachusetts Avenu2, N.E. Washington. D.C. 20002 ey chime in. MR. HIROTO: At first I thought I was being offered a rare opportunity of being a site visitor, now I see it is rather difficult to attempt to review this with what we have, and try to come to some reasonable decision. As you will note, following the site visit of 1972, there were nine recommendations to site visit made, and these are symptomatic of the poorly managed RMP for which this was gathered, From what staff has found out in recent past, it was apparent we were only discussing, looking at symptoms, not the problem. The problem obviously is management, of RMPH. So I would recommend that we follow the staff recommendations in regard to the approval of the RMPH; that is to say, to approve the remainder with the limitations as indicated, And that would be page 8 of the green sheets. MRS,. MARS: I the program really worth trying to save or would it be better to let it phase out and start all over again? Are we just wasting money there? Because it is need in so many places, MR. RUSSELL: Mrs. Mars, I think that what is going in the Pacifié Basin is well worth saving. The Little amount of money that-- ed on ee 10 11 12 oe » 14 16 17 18 19 20 21 25 HOOVER REPORTING CO, INC. 320 Massachusetts Avenu >, NE. Washington, 0.0. 20002 25 MRS, MARS: But if there is no management-- MR, RUSSELL: In the Basin you do have the manage- ment. MRS, MARS: That is a lot of money. MR. RUSSELL: I guess what we of staff hate to see is when one has a group of very dedicated, talented volunteers to do away with that system completely, MRS. MARS: I know that is very hard to accept and very hard to do, but still -- MR, RUSSELL: This is why we needed this group's advice very, very much, MRS, MARS: It is still taxpayers' money, you know. If it is going down the drain, it just doesn "t seem right, does it? MR. RUSSELL: No. MR. HIROTO: There are certain parts of this program which are apparently going quite well, that would be the Pacifilc Basins. MRS. MARS: You can always phase it out and start all over again with new management and still save what is being gone before, because if its worthwhile, it will endure, can be picked up again. MR, HIROTO: Would there be anything to gain, rather than phasing out-- MRS, MARS: Yes, if you need all new management. HOOVER REPORTING CO, INC. | 10 11 12 13 14 16 17 18 19 20 21 24 25 320 Massachusetts Avenu>, NE. Washineton. D.C. 26002 26 MR. HIROTO: -- to get new management. MRS. MARS: Certainly. MRS. SILSBEE: For the benefit of the entire Council the recommenda t1ons of the staff, Mr. Hiroto suggested, might be considered, the “Pacific Basin component be approved at the amount requested of $75,564. But further, that this amount be earmarked for that purpose. Approval of the remaining $252,688 for the Waianae component is recommended with the following wonditions: One, 4 to be determined percentage -- Dick, you will have to explain what that means -- of the $252,688 restricted and not availab} for expenditure pending further review of the RMPH at the next Council meeting. Two, the RMPH be site visited by Council representa+ tives prior to the next Council meeting. Three, the RMPH should be advised not to fund the Waianae Coast Comprehensive Health Center project until RMPS receives assurance that the RMPH RAG from them that it clearly understands the issues and problems involved and will ensure that RMPH funds and program staff activities will be used in a coordinated manner to strengthen the capabilities o the Waianae area to manage local problems. Fourth, the RMPH should assure that the kidney pro- ject for the Marshall Islands is in compliance with the Socia Security Administration interim regulations. e Or ~I 10 11 12 e oo ‘4 16 7 18 19 20 bt _ 25 HOOVER REPORTING.CO, INC. 320. Massachusetts Avenu3, NE. Washineton. DC. 20002 27 Then I hear you suggesting perhaps number five. DR MERRILL: The Limited care facilities in Marshall Islands was 95 percent completed at the time the application came, MR, RUSSELL: This request is for training. DR. MERRILL: I see, MR, MILLIKEN: It seems one of the basic concerns here is that the coordinator is not about to deal with this RAG in @ proper manner, The evidence points he has not been willing to or able to. I would agree with Mrs. Mars that if we are going to deal with the problem this is the problem we have to deal with rather than five others, MRS, SILSBREE: Dr. Roth. DR, ROTH: On this Marshall Islands project, maybe John knows or maybe you can tell me, they have got one of the more advanced home dialysis training programs there at Saint Francis Hospital in Honolulu; but if you are going to have home dialysis for people who get trained on it in Hawaii who then go back to American Samoa or Marshall Islands, or some- where, you have got to have somebody there, you have to have somebody there who can give a little backup to it. Isn't thatessentially correct, John? DR, MERRILL: They propose training of paramedical person for limited care dialysis. 10 ll 12 e i4 16 eevee 17 18 19 20 25 HOOVER REPORTING CO, INC. |, 320 Massachusetts Avenu2, NE. Wachinetan DC INA? 28 DR, ROTH: Isn't this where they go back to after they have-- DR, MERRILL: Limited care? DR. ROTH: Yes. DR, MERRILL: No, no, that is a satellite, It would be as though we had a five-bed facility out here in Rockville, go to Georgetown for a backup. I presume they would fly to Hawaii, Honolulu, for backup. DR, ROTH: But don't they get their training in home dialysis at Saint Francis at Hawaii, then they go back to these facilities? DR. MERRILL: Yes. DR, ROTH: So it would seem ~-- what I am trying to get.at is this is part of an integralwhole, —E am sure the Saint Francis dialysis center in Hawaii, in Hawahu, Honolulu, is an approved thing. I am just wondering: whether you really need to go through HEW appro val of one tech and one nurse for a thing in a special situa- tion like this? DR. MERRILL: You do in Massachusetts. I don't know about Hawaii. That is very definite in Massachusetts. MRS, SILSBEE: According to our kidney reviewer, they would be very wise to apply for exception approval. They don't think there will be a problem as soon as this is ironed HOOVER REPORTING CO, INC. | 10 il 12 13 i4 16 17 18 19 20 25 320 Massachusetts Avenu>, N.E. Wathinotan AC 2AAN? 29 out, but they do advise they go through this process. MR. HIROTO: May I ask where there have been coor- dinator difficulties in the past, are there any tools avail- able to solve that problem? MRS, MARS: Fire hin, MRS, MORGAN: Can you fire them? MRS, SILSBEE: There have been coordinator problems in the past. Council and review committee have used a number of different methods, Council site visit might be one way. MR. HIROTO: Instead of phasing out a program where you have excellent members of staff, phasing out the program, just to remove the ulcer, would seem to be somewhat a waste of time and effort too. DR, PAHL: Let me add a comment as I have been in- volved as some of the staff have in these situations, and it is a bit difficult but I think under the former leadership and to a more Limited extent under mine; we have been abie to effect some changes, indirectly, by perhaps talking with both coordinator and at times with RAG chairman and representatives and sometimes things can be ironed out in an informal fashion and at other times the local RMP has to take some kind of action which does appear drastic, But I think it would be inappropriate to recommend phase out at this stage without trying the next few steps, 10 il 12 13 i4 16 17 18 19 20 21 bh N ho ey = 20 HOOVER REPORTING CO, INC. 320 Massachusetts Avenu>, ALE. Washington. D.C. 20002 30 Gifficult as they may be, I do thirk that it would be most helpful if a site pete visit with Council representation could be made, That certain — i, whatever support we could, both before and after such a visit. Sometimes these things do drag ona little bit and I would think the best thing would be to review the situation at the next meeting of the Council, but have such a visit between now and the next meeting. MR, RUSSELL: Along those Lines, some of the other Western Coordinators have also noted that there may be a problem there and have offered to assist as appropriate, So we do have some peer review which we can build into this, which can be extremely helpful. MRS, MARS: They have been on a triennial basis for how many years? MR. RUSSELL: Just one, MRS, MARS: Just one. MR, RUSSELL: And they blew it. I don't thirk this was because of the Regional Advisory Group, because they were reacting only to the informa tion they were receiving, and it is very difficult to know for sure how much information the program staff fed to them, But each time we have gone there and it does present a problem in working with the RAG members, which we can do in has been effective in the past. And we would, of course, addf ly on 6 - 10 i 12 @ 13 i4 16 17 18 19 20 th ree 20 HOOVER:REPORTING CO, INC. 320 Massachusetts Avenu>, NE. Washington, D.C. 20002 31 many cases, where we do have a 6,000-mile difference, Ang you know, some people look at 1t as a junket, a joy ride to Hawaii, and I assure yo it is not, DR, FOYE: There is another approach in this kind of thing where the top man is inadequate and you want to get rid of him, you can say funding is provided for one year and at that time the program will be phased out unless the following changes are made, and then you list a series of organizational changes that you feel are necessary: improved relationships with RAG, better supervision of the office or whatever You list a series of them, Then you phone a friend on RAG and you say this is what we mean, get rid of Joe, (Laughter ) And only that will satisfy conditions one through eighteen, And that alone will satisfy one through eighteen, (Laughter ) And it seems to happen. That is another way. MRS. SILSBEE: Would you put that in the form of a motion, Doctor? ee (Laughter ) MRS, MARS: I don't see how any changes that would drastically affect them for the better can possibly be made between now and the next Council meeting. Whereas, if the program is gently phased out and then picked up again and re- stored, and taking the best elements out of it, then you have *¢ HOOVER REPORTING CO, INC. 10 11 12 13 i4 16 17 18 19 20 25 320 Massachusetts Avenu2, NE. Washington, D.C. 20002 32 got something that is worthwhile. In the meantime, grant them enough money to grace- fully get out. You still have your RAG members who will re- volunteer, who are good. You get rid of the ones that aren't any good. You get a new coordinator, You start the whole thing and pick up the programs that are worthwhile picking up, All I can see is we are goimg to pour a lot of money down the drain, | DR, FOYE: Iam afraid that kind of move, taken 6,000 miles away, might be misinterpreted by very competent, productive members, say of RAG or others, as a slap at them as well. A phaseout of the program, And even though its intent is clear in your mind, what would it be if it were the approach? I am afraid it would have a deliterious effect on GChe entire program. I don't know. MR, RUSSELL: I have a tendency to agree, I think a phaseout would be extremely detrimental to the Pacific Basin in which so much hard work and effort has gone into it. I think that might be lost, because the Regional Medical Program of Hawaii ~- really we have to limit this to Dr, Satura, who has worked so hard, he has sort of gone out and restored faith in any federal program, When he first went out they said, "We are tired of pepple coming out and planning." Through Dr. Suzitsi's efforts 10 11 12 e « i4 16 17 18 19 20 i) Nm i WW 29 HOOVER REPORTING CO, INC. 320 Massachusetts Avenu, N.E. Washington, D.C. 20002 33 they have gotten some very effective project, It is Like dealing with different programs, MRS, SILSBEE: Mr, Milliken. MR, MILLIKEN: For informtion, is there any policy that discourages or prohibits anything other than full- time coordinator? MRS, SILSBEE: I wish you hadn't asked that question We do have in our RAG grantee policy a suggestion that there be full-time direction, but in this interim period, this has been very difficult to really implement and administer. I think if we used it in this particular instance, w would have to use it in other instances too. DR. CANNON: We tried for three years to get rid of a director, coordinator in Ohie. We found it almost impossible even with Dr, DeBakey as the whip. And I would say that our chances of accomplishing this in six months is prac- tically nil. I would like to move that we follow the recom- mendations outlined by the staff, Oo On (is, MORGAN: | second tt. MRS, SILSBEE: The motion has been made and seconded that we accept the staff recommendations, which I read. "MR. RUSSELL: I want to explain. MRS, SILSBEE: Okay. (Discussion off the record. ) MRS, MORGAN It has been moved and seconded. He 10 11 12 e : 14 16 17 18 19 20 tw N bo LS x 25 HOOVER REPORTING CO, INC. 320 Massachusetts Avenu, NE. Washinetan. D.C. 20002 34 can discuss, MR, RUSSELL: Under staff recommendation number one, to be determined percentage, all that means is I didn't have time before Council to sit down and come up with a percentage. So what we would suggest is to be determined by RMPS staff if that would be acceptable to the group, we could look at this very carefully to make sure we did not harm something as well as improve the situation, MRS. SILSBEE: Is that agreeable to the seconder and the firster? MRS. MORGAN: Yes. MR, MILLIKEN: I would like to speak to the point made earlier; would it be helpful in carrying out this motion that there still be a Council visit assumed? In order to put the fear of God, or whatever it is, in the people we are dealing with. MRS, SILSBEE: That recommendation was one of the four points under the staff recommendation. MR, MILLIKEN: Okay. wa MRS. SILSBEE: If you want me to repeat that, it was approval of the Pacific Basinfor full amount and earmarked approval of the remaining part with a portion to be restricted and not available for expenditure until the full review at the next Council meeting; site visit by Council prior to the next -- well, I think we had better change that wording because if 10 11 12 13 i4 16 17 18 19 20 WN Nm nN oes = 25 HOOVER REPORTING CO, INC. 320. Massachusetts Avenu>, N.E. Washington, D.C. 20002 35 it is January -- prior to the March meeting of Council, DR, PAHL: March meeting. MRS, SILSBEE: Advice to the RMPH not to fund the Ces - mtn nn symapusanneeone me cy mt VRC wt ageing wt Waianae Coast project until RMPS- receives assurance from ‘RAG that it clearly understands the problems involved; and would ensure that, RMPH. fund. and program staff activities wild be “sacemeettastnepei2ERES used in avccoordinating manner to strengthen things. And that the kidney project undergo. its.exception approval. Senay ieee DR, CANNON: Question, MRS, SILSBEE: ALL in favor? (Chorus of ayes." ) MRS. SILSBER: “Opposed? MR. OGDEN: No. MRS, SILSBEE: "No"? All right, one "no." MRS, MARS: "No." MR, OGDEN: May I just state what my feelings are, I think when you have got a situation that is fail- ing, you might as well face up to it. And if the management and review process is extremely weak, I would simply say so, And tell them this is not being funded for that reason, MRS, SILSBEHE:; When you say this is not being funded you mean the entire-- MR, OGDEN: No, 1 would go ahead and fund the outer islands part of it, Marshall Islands part of it; simply with- hold the rest of it. For the simple reason the management on 10 11 12 eo : i4 16 17 18 19 20 25 HOOVER REPORTING CO, INC. |. 320 Massachusetts Avenu>, NLE. Washineton. D.C. 20002 36 and the review process is not adequate. And the application is considered rejected until those things are corrected, MRS, MARS: None of it is adequate, that is what I have been trying to say. MR, OGDEN: So I vote"no." MRS, MARS: I vote "no." MRS. MORGAN: Seven, DR. CANNON: Do you want a count by hands? MRS, SILSBEE: All right, all in favor? (Show of hands ) MRS, SILSBEE: Six, All opposed? (Show of hands ) MRS, SILSBEE: The "ayes" have it, six to three. MR, OGDEN: Would you mind entering a minority report? MRS, SILSBEE: Not at all. MR, OGDEN: Send it to them That might do them some good, MRS, SILSBEE: All right? MR. RUSSELL: We would see this visit unlike any other site visit. MR. OGDEN: I would hope so, MR. RUSSELL: It would be going in to look at that particular problem, and we would utilize others for just ~] 10 li 12 14 16 17 18 19 20 25 HOOVER REPORTING CO, INC. 320 Massachusetts Avenu?, NLE. Wachinetan AC 7ANKP 37 Council, DR, FOYE: Just take the minority voters, (Laughter ) DR, ROTH: Don't send me;every time I go over there @ volcano goes off. MRS, SILSBEE: Dick, do you want to go through Ari- zona? aon rence MR, RUSSELL: Yes, Arizona I think we took the last time. If you remen:. ber, at the last Council, after a site visit, the Arizona triennial status was taken away from it and Council gave Arizona one more year, and the recommendation was that it be site visited to determine, you know, funding in the future. The problem really was the Arizona was involved in too much process and not very much outcome, deeply involved in planning; not getting out to the community. Well, phase out came and it seems now that Arizona is beginning to get the message, that had been given to them for three or four years in the past, We bring this to Council to point out they have be- gun moving into the community. We of staff have some concerns as to whether or not the staff they have now, if this is really their bag. We do know they are adding a couple of staffs-- it appears these might be real community organizer types. We are not sure. So we are suggesting,as we said in the recommendatian, 38 1 that Arizona be visited, 2 We didn't specify Council at this point, because we 3 wanted to get your feelings as to whether or not you felt it @ 4 was necessary at this point to go back as Council and see what @ 5 they were doing or if you would be satisfied with staff going 6 back and getting a feel for what has actually happened, ad We do have to go back to look at their review pro- 8 cess, which we did not get verified prior to phaseout, and 9 we also, in that process, will look at the organizational 10 Structure which will perhaps get into some of the other prob-~ 11 lems in terms of regional advisory group and its representation, 121 MR. MILLIKEN: How does staff feel about this? Feel @ 13 they can handle this at all as backup or do they feel, visiting i4|| backup or do they feel Council ought to go too? 15 MRS, SILSBEE: Dr Cannon, you were one of the prime ig|| Site visitors before, W DR. CANNON: They sent me out there to do that job ig|| Guite a few times, 19 I would say looking over this, staff is still grade 20 two staff, focus is still there, little evidence of teamwork; @ 31 CHP hasn't. improyved..and I: doubt ifsit will, 99 Yet RMP is progressive, productive. CHP seems to be e 93 reactive, oA I vote green for money for the program, I would say os if you are going to visit, it is nice to visit there in the right HOOVER REPORTING CO, INC. 320 Massachusetts Avenu3, NE. Washington, 8.0. 20062 ~ 10 11 12 i4 16 17 18 19 20 24 25 HOOVER REPORTING CO, INC. 320 Massachusetts Avenu>, NE. Wachinntan 1M INN? 39 season of the year. But you are not Likely to change either the direction or the action. (Laughter ) That I would focus my attention in the site visit not on trying to threaten them as we have done in thepast, but to some way win them over and let them think we are trying to help them. I don't know. It is a hopeless situation. MR, RUSSELL: We have some indication this particula: program is reaching out to--it's recognized as being very strong programs and perhaps asking for some assistance from another RMP, DR, CANNON: You can't blame them because CHP has been fighting them, yet RMP has been doing CHP's work. We ought to fund them, MRS, SILSBEE: Mr, Milliken asked specifically if we thought staff needed help on the visit. MR, RUSSELL: I think at this point we of the staff could go out and see what-- just a minute, Dr, Cannon. (Laughter ) To verify what we have been told over the telephone and we do have a feeling that they are attempting, and I am afraid to bring a Council member out after the way you scared them last time, Dr. Cannon. They might not Let us see them. (Laughter ) om} 9 10 il 12 13 i4 16 1? 18 19 20 RO BO BS Lo 24 25 HOOVER REPORTING CO, INC. 320 Massachusetts Avenu, NE. Washington, D.C. 20002 4O No, in all honesty, I think this is something -- Mrs, Sadin, do you have any comments? MRS, SADIN: No. DR, CANNON: I move that we accept the staff's “ee Segoe peg sie beau eter i . recommendation, vote favorably on the program, and they can ee o go out as they see fit, MRS, MARS: Are you including a visit from Council? DR, CANNON: Are you going out there anyway? (Laughter ) MRS, MORGAN: Just staff. DR, CANNON: I think it would be nice if a Council member went along, but I do not think we ought to go out there and threaten them, We have been out there every visit I have been on, we have been saying, "Look, this is it.” I think thalt doesn't work with them, I don't believe it is going to work with them, I think we need a different approach, MR, RUSSELL: I think we were trying to make the dif- ference here was I see no reason why a Council member couldn't go, it would be very helpful, just on a visit, rather than what we term as a site visit. I don't think they are ready for that. MRS, SILSBEE: How about an ex-Council member? MR, RUSSELL: Ex-Council member, MRS. MORGAN: Dr. Cannon! 10 li 12 eo =: id 16 17 18 19 20 bo — 20 HOOVER REPORTING CO, INC. 320 Massachusetts Avenu>, NE. Washinetan. D.C. 20062 AL (Laughter ) MRS, MARS: You are elected, DR, CANNON: You know, they almost ran me out of town last time. MRS, SILSBEE: Dr, Cannon has moved, which has been seconded, the recommendation be accepted funding as requested, $359,623, with the condition that the region be visited to determine whether they really have changed direction and respor ded to previous concerns. DR, CANNON: That is where Ichanged it. MRS, SILSBEE: So that should be amended to-- DR, CANNON: I changed it to go out there with a dif- ferent attitude, one of-- MRS, MORGAN: Helpfulness, DR, CANNON: One of assistance, Not to change direc+ tions, but see if you can't coerce them a Little bit. MRS, MORGAN: Take your box of candy. MRS, SILSBEE: The problem is how to word them. (Laughter ) DR. CANNON: You can't threaten them and change them, that is what we have done, MRS, SILSBEE: Be visited in a nonthreatening manner to determine how they are doing. DR. CANNON: Be hélpful, consultative visit. MRS, MARS: Are you going to fund this program, then 10 il 12 13 44 16 17 18 19 20 2] 25 HOOVER REPORTING CO, INC. 320 Massachusetts Avenu>, NE. Washington. D.C. 20002 42 before the site visit by staff? In other words, whether they change or not, they are still going to receive the money; is that what you are saying? DR, CANNON: That is my recommendation. Because they are doing a job, they still. have the momentum, they still have the staff, They are not going in the exact direction as RMP asks,Council would Like for them to go, but they are doing 4 job in Arizona, MRS, MARS: You feel they are filling the health needs of the community? DR, CANNON: Yes, but they are filling the needs of ‘some other programs, too, they shouldn't be. MRS, MORGAN: In other words, they are doing CHP. DR, CANNON: They are doing a lot of work for other organizations that other organizations should be doing. MR, RUSSELL: I think at this point, if T may say so we have some indications that they are attempting to change and as has been pointed out, I think on a number of occasions, we as staff have had very little face to face contact with any of the RMP's, and I do think we should give them the bene- fit of the doubt. MRS, SILSBEE: Motion has been made and seconded to recommend funding as requested, $359,623, with the condition that the RMP be visited in @ consultative manner, ALL in favor? vr =} 10 il 12 oe.» id 16 17 18 19 20 20 HOOVER REPORTING CO, INC. 320: Massachusetts Avenu>, NE. Washington. D.C. 20002 43 (Chorus of "ayes.”) MRS, SILSBEE: Opposed? (No response, ) MRS, SILSBEE: Motion is carried. Now we are going to move-- this is a switch, Frank - to the Mid-Continent Branch, and that is red. The reason for that is there are two regions in this group where there will be nobody who was a reviewer here tomor row, so we have to get at it today. Louisiane Tirst. MR, POSTA: Thank you. I would like to note from the green sheet, Mr, Zivlavsky is the operations officer. This region is brought up for problems 1 guess more Like the one that Lee just brought up with reference to. Northlands. We are concerned with the number of staff now "én board and the staff that is proposed for the calendar year 1974. Just a little background, the request that you are looking at now calls for $270,000, Oddly enough, another $269,000 has been approved for the region for the same amount of time for the topic of pediatric pulmonary. The grantee is a free-standing corporation, It has had good management in the past under their past grants ~} 10 il 12 e = i4 16 17 18 19 20 21 bo tw bo QL x 25 HOOVER REPORTING CO, INC. 320 Massachusetts Avenu; NE. 4y management officer, RMPS has made a management visit there, They came through with flying colors. Last December, the satff also had a verification re- view process visit there, and RMPS did certify the review process, However, I think we are concerned not with what it was @ year ago, but what it is going to be, what it is right now, and wnat it is going to be in there next three or four months, When they came in, when Louisiana came in for their extension plan back in March, the staff went down to one grans management officer and a 25 percent program coordinator, Staff did approve nine continuing activities, A couple of thae were for only two months. However, the seven that they did approve through 1/31/74 was primarily under contractual arrangement and since this is a free standing corporation, incorporation, those contracts were considered binding and there was a good chance for continuing once they had been consummated, and therefore that was primary reason why seven additional activities were approved for a small staff, Now, we have been notified by the coordinator if he did get a good review by this particular body, that he would consider coming onboard 100 percent of the time. He is now on 10 il 12 13 18 19 20 20 HOOVER REPORTING CO., INC. 320 Massachusetts Avenu, N.E. 45 board 25 percent, That might be good, It might be bad. I think maybe you folks might like to discuss that a little bit further, However, upon being notified that Congress had ex- tended the program for another year, Dr. Sabatier did go back and has hired his former deputy coordinator, a dentist, And also one of his evaluators, on a part-time basis, Also the grants management person who has done a gooi job in the past is available for consultation purposes with reference to grants management. We as staff, if you will, back in December LO71, had an official site visit, That was an application for triennial status. The Council and review bodies did not think that they had qualified and therefore gave them an approval for a two-year period for one million dollars each of two years, This past December, the program decided not to come in for a triennial application but to only come in for their one million dollars, Again, to reiterate,.a year ago, when staff went out and looked at this review process, we could find nothing wrong. This is a particular program that has specialized ina categorical approach. Most of their activities that they have Solicited has been to more the leading institutions and those institutions themselves have gone about their particular job ~J 10 ll 12 eo i4 16 17 18 19 20 ko a 25 HOOVER REPORTING CO, INC. 320 Massachusetts Avenu:2, NE. Washinetan. D.C. 20002 46 in their own individual way. In other words, what I am trying to say is that there are ne& too awfully many cooperative agreements in many of the activities that have been funded to Louisiana. A good example, this last July, staff went down and took a look at three or four VMS activities, Each of those activities were being funded by a particular institution, if you Will, and there was very little evidence that one program knew what the other program was doing. So, again, I bring attention to the fact that this region has not been in the past one of our better ones. We are concerned because of the number of staff on board and we would recommend perhaps that you would consider a site visit to this region before March. Dr. Roth, I notice thatyou were one of the reviewers. Did you have any comments? DR, ROTH: No. I don't have anything to add on that, Louisiana is sort of a place apart in many of its relationships and things medical, and this information about th program director is something that I did not have available, I would support the recommendation of staff. tt NN I A enna DR, CANNON: If that is a motion, I second it. _ nav Ls ae a cern eet “ MRS, SILSBEE: Dr. Merrill was the other reviewer. Did he have an opportunity to talk with you, Dr, Roth? DR, ROTH: No, I didn't talk to him about it. e ar 10 Il 12 e : id 16 VW 18 19 20 21 bo Nm ne QM 25 HOOVER REPORTING CO., INC. 320 Massachusetts Avenu, NE. Wachinetan NC INNA AT Of course, in the view of my earlier comments today, I found the grant application and the track record along categorical lines as probably being on the credit side of the ledger with relatively Little of this other stuff, but I didn't have a chance to talk to Merrill at all. MRS, SILSBEE: The staff recommendation for the a et tt ttt gpg nent sapere no record is that the request for $270,323 be recommended for approval, but the program should be encouraged to recruit additional staff, particular reference to the program direc- =e tor, Because of the marked change brought about through planneg phaseout, site visit to the region is recommended prior to the March Council meeting. MR. POSTA: Right. MRS, SILSBEE: Do I hear -- DR, CANNON: So move. MRS. SILSBEE: Second? DR. ROTH: Move approval. emt DR, CANNON: Second. nent ey MRS, SILSBEE: Any dicsussion? DR, CANNON: Question, MRS, SILSBEE: All in favor? er tema I Ny, (Chorus of "ayes.") MRS, SILSBEE: Opposed? (No response. ) MRS, SILSBEE: South Dakota. pee ence wd 9 10 11 12 e 14 16 17 18 19 20 nh pan 20 HOOVER REPORTING CO, INC. 320 Massachusetts Avent, NE. Washington, D.C. 20002 48 MR. POSTA: South Dakota. Staff had no real concerns with this particular application or with the region, Again, they have a very small staff. However, the total amount requested is $120,680, $42,000 of which is earmarked for staff. As a result, you only have about $78,000 rounded off for four or five activities. We do feel that four full-time staff can handle. The reason we bring it to your attention today is the fact that this region has been considered a so-éalled planning US region after its divorce with the Nevada program about a year and a-half ago, I think that the program has quite a bit of poten- tial, could probably do an awfully lot more with additional money, because of the fact that they were in planning status, because it is a 9-1 starting date application, meaning that when they came in for their terrenial application last March Ist, neither review committee nor the Council had the oppor- tunity to review it. As a result, their funding Level of the so-called percentage of the formula is extremely small. I think if I am right, Judy, our main consideration today would be to consider them now an operational program? MRS, SILSBEE:; Yes. This was the recommendation of staff, We felt that the planning grant was a fluke in time; whereas, its companion, Nebraska, broke off also. It has been ~)] 10 11 12 13 18 19 20 2D HOOVER REPORTING CO., INC. 320 Massachusetts Avenu, N.E. Washington, B.C. 20062 49 operational for sometime; South Dakota hasn't, It is carry- ing on activities and we felt it would be neater if it re- mained operational, MR. POSTA: This program is rather unique in that it has a Regional Advisory Group which serves as the council tA for the CHPA agency. So every time either one of the groups i called to order, business is conducted for both, As a result, during this past year, when Regional Medical Programs was in a more rather shaky status, this region did continue to meet with its Regional Advisory Group and has been quite active with things directly concerned with RMP as well as with the CHP agencies. MRS, SILSBEE: Dr, Roth or Dr. Cannon, do you have any comments? MRS, SILSBEE: Suggestions? DR, ROTH: Well, they stressed in the material I had available that this was entirely concerned with salaries, wages, fringe benefits, and indirect costs, And no program- mic support other than what they had going. So lI saw abso- Llutely nothing wrong with it if they were to continue in RMP at all. MRS, SILSBEE: This is one of the things, the appli- eation that you have is just a portion of the program, They have money from the first award we gave this year, and then in the case of South Dakota, they had a couple of activities 10 11 12 13 i4 16 17 18 19 20 25 HOOVER REPORTING CO, INC. 320 Massachusetts Avenu, NE. ’ Washington, D.C. 20002 50 funded during phaseout, so there is more to the program than staff. DR, CANNON: I gave it a grade one on staff and pro- jects, but thought they ought to have their money and thought they ought to be operational. They are just barely making it. MRS, SILSBEE: Any other discussion? MR, OGDEN: Could I ask if the regional director-- do you really feel the small amount of money involved in these projects will do any good at all? MR. POSTA: Lil, would you like to respond to that? MRS, RESNICK: They had a great deal of voluntary support, which hasn't come through in the application, but it has come through on their estimates, available funds from other Sources. MR, POSTA: Mr, Webster, from the Regional Office in Denver. UR, WEBSTER: If I might, I have watched the South Dakota Regional Medical Program for quite awhile, and Like poth of the Dakotas, those people seem to know how to stretch a dollar pretty well. They dont have that many to begin with. Actually only I think of the total amount requested, they only have four staff right now, two professional and two secretarial backup. That accounts, with fringe benefits, for the some 44, The have three major projects, which would have 10 ll 12 e : 18 19 20 21 22 23 24 25 HOOVER REPORTING CO. INC. 320 Massachusetts Avenu2, NE. Washington, D.C, 20002 51 continued even had the RMPS actually terminated. One was Support the EMS program with the moneys being directed to the State Health Department, which heads up that program; one to Mount Marty College for an extension health educa- tion program reaching on to Indian reservations, and similar one in the northern part of the state at another university. They have in here put in a number of small starts, all of which would be to support other organizations and agencies to do their thing. They really were not trying to do much except to coordinate and try to stimulate, They are a farming out type of operation that has been looking for good applications even though very small in money, and I think it is quite viable. DR, ROTH: I move approval. ony httanmepy icin Sse omc ar MR. POSTA: I think your point is quite well taken. DR, ROTH: I move approval as recommended by staff. natant tO EL ef sty . DR, CANNON: Second, ey POM tay en OO LT tangy RENIN AE Saas nantes mts nk SEMEL ee neon Maks tectesprarttys Sms aa ndr bang MRS, SILSBEE: That is approval at $120,680, Does that include operations? DR. CANNON: Change to operational status. DR, ROTH: Yes. MRS, SILSBEE: Change to operational status. Any further discussion? MR, WILLIKEN: Question, MRS, SILSBEE: Ail in favor? 52 1 (Chorus of "ayes.") 2 MRS, SILSBEE: Opposed? 3 (No response. ) @ 4 MRS, SILSBEE: That is carried, r 5 Now, the next one is Colorado-Wyoming which Dr, Roth or gi| is going to be gone tomorrow, and Mr. Hiroto are the two review- ers on that. co) 8 MR, POSTA: Minor point concerning this particular 9|| region, their share of the 44-1 is actually $335,604. 10 This region, for one reason or another, has come in u|| for about $37,000 too much, We recommend that the exact amount - qgl be given to them, ® 13 To give you a Little bit of background about the i4 region, Dr. Nicholas is the coordinator, has done a real good 15|| Job in about a year and a-haif he has been there. 16 Colorado-Wyoming, like Mountain States in the Western 17|| Branch and Inter-Mountain in the Mid-Continent Operations 18 Branch, has had turf problems in the past. We haven't heard “ay too awfully much about the turf problem this past year pri- oo || marily because closeout directives, phaseout directives, has stipulated that there would be no new starts, As a result, the Interagency Council of the three bo — medical programs have not met on a periodic basis. 23 oA We will be discussing Inter-Mountain a Little bit 95 tomorrow, more in detail, but we do feel that the Colorado- HOOVER REPORTING CO,, INC. 320 Massachusetts Avenu 2, N.E. Washington, D.C. 20002 10 ll 12 13 19 20 21 2 HOOVER REPORTING CO, INC. 320:-Massachusetts Avenu, N.E. Washington, D.C. 20002 not as requested, but in the amount of $335, 604, 53 Wyoming program as well as Mountain States would be in a posi tion to respond to us, meaning RMPS; that the monthly ses- Sions would be convened to discuss all activities to be funded in each of the three Regional Medical Programs, in order to avoid duplications of services funded by one or more Regional Medical Programs. The CHP comments from Colorado have been quite favorable, We have not yet received those from Wyoming. Ever though we are not anticipating any problems, They have good management. The only thing that you might notice in the green sheets, the allocation by option seems to be an awfully lot of money earmarked under program staff. However, if you would look at the similar graph located on the yellow, page 2, you will note that they have about 17 feasibility planning and central service activities earmarked. We would z= commetd that the 2pplication be _&pproved MRS, SILSBEE: Dr. Roth, DR, ROTH: I have no particular quarrel with any of that. You recommended what amount? I got into a little mathematical problem with this thing and I wouldn't quibble over $184, but one place it said they over-applied for $36,682 and in another place it says 7 54 1} $36,796, and I come out with $184 difference in that, 2 MR, POSTA: Doctor, what they actually did, if you 3]| will look at the yellow allocation by option -- 4 DR, ROTH: Yes. on MR, POSTA: -- project number 34, Regional Pediatric 6|| and Nephrology Center, calling for $22,210, was not initiated, nor will it be initiated, So they, meaning Colorado-Wyoming 8| program, came in for that. 9 In addition, they came in for $14,472 over that, 10 So what we were trying to state is just go back to 11|| the former approval, whatever the former may have been, 12 I agree with you, some of those figures don't add-up eo 13|| to LOO percent, id DR. ROTH: Well, my intent, as I say, I have no desire 15|| to quibble over that odd amount of $184, but whatever the 16/) thing really works out to be, on their percentage formula 17|/|/ application, I move it be approved, al peel 18 MRS, SILSBEE: We had another consideration in this jo |} particular application which Mike sort of glossed over, because 20|| he happened to be missing from staff review, happened to be @ 91|/ on review of the Mountain-States Medical Review Program, ® 99 You may remember, about a year or two years ago, 93|| it is hard to remember, we had a problem with the rezions o || Inter-Mountain, Colorado-Wyoming, and Mountain States, which 95 || had overlapping areas, That was not the problem so much as the HOOVER REPORTING CO, INC. 320 Massachusetts Avenu, NE. Wachinstan Al FANN 10 li 12 13 id 16 7 18 19 20 21 23 24 25 HOOVER REPORTING CO, INC. 320 Massachusetts Avenu>, N.E. Washington, D.C. 20002 55 way in which the regions were not working with one another. And so in some instances, the localities were being split apar depending on which staffs they were relating to. So two Council members, Dr, Milliken and Dr. Spelima from the Review Committee, were sent by Council to go out and try to work out some kind of a procedure, and they were met by the three coordinators with a proposed procedure in which the three coordinators agreed that before they started on something and certainly before they funded anything, that they would keep one another informed m a regular basis on what they were doing. And their respective RAG chairmen would also be involved. We have found during the phaseout that particular methodology seems to be working better with two of the regions than with their two with the third region, So we feel this needs to be put in as a condition again, to get this back on target. Beoause it is creating some problems, So we would like -- I don't know that Mike would, bu I think we would like to have a proviso put on each of the applications of these three, DR, ROTH: T_move what Mrs. Silsbee just said. _DR. CANNON: Second. insane ret senescent Teter rete IMS emus spn (Laughter ) MRS, SILSBEE: We took that proviso, we receive written assurance this procedure is still in process and being cr 10 il 12 13 i4 16 17 18 19 20 25 HOOVER REPORTING CO, INC. 320 Massachusetts Avenu>, NE. Washington. D.C. 20002 implemented. MR, MILLIKEN: Question, MRS, SILSBEE: Okay? Motion has been made and seconded. DR, CANNON: Question, MRS, SILSBEE: Does anybody have any further comment DR. CANNON: Question. MRS, SILSBEE: All in favor? (Chorus of "ayes.") MRS, SILSBEE: Opposed? (No response. ) MRS, SILSBEE: Mike, there was one other aspect of Colorado-Wyoming ,I dont' know whether you want to bring it up. It didn't have anything to do with review of the application, but the letter that came from the RAG about the genetic counsel? MR. POSTA: Right. Last December, the Council approved a genetic counseling program that was initiated in January of this last year. When they came in -- well, the comments from the various reviewers, including some staff consultants, they felt that entirely too much effort was being placed in two areas, one sicklecell anemia and one in Tay-Sachs disease, The program completely revised the program and de- veloped some genetic counseling based in the areas of heart, cancer and stroke. They have had considerable interest on HOOVER REPORTING CO, INC. 10 11 12 13 i4 16 17 18 19 20 25 320 Massachusetts Avenu2, N.E. Washington, D.C. 20002 5f the part of the Regional Advisory Group, that program was subsequently funded in those particular areas of heart, can- cer and stroke, And about, on, $35,000 or $40,000 at the most was spent for the first six months, Because of the negative comments that staff related back to the region, the region decided they had better not come in for a request to continue the application. However, when the: RAG did meet this last time, the RAG chairman and the coordinator were directed to submit in writing to RMPS their concerns that they had received relatively negative comments because they really wanted to carry on this particu- lar activity. The reason I bring it up here and had hoped that we-~ I am glad Judy reminded me of it -- that in case this particular region comes in for request with unexpended balance in December, whether or not you would wish to reconsider further funding of this particular program for the next year, They have not come in as of this date, but we do kno we are going to get several letters from the coordinator as well as the RAG chairman, DR. ROTH: Well, I don't know how much -- what kind of price tag are they putting on that one? MRS, SILSBEE: They haven't put any price tag on it yet, Dr. Roth, but if you are looking-- in the letter you are looking at there now, there just seemed to be such a point of 10 11 12 13 i4 16 17 18 19 20 25 HOOVER REPORTING CO, INC. 320 Massachusetts Avenu, NE. Wachinotan Nf 7000? 58 the kind of conflict of the national priorities as to how the Regional Advisory Group saw tremendous need, that previous action had kind of interfered with what they saw as a regional need that was being met. DR, ROTH: Because my reaction to it, to be con- sistent with all the oratory I heaped on you before, was I would heck of a lot rather see them spend some money in the genetic counseling concept that they have out there rather than most of these ten or twelve projects that they have Liste under supportive quality assurance, Working with PSRO in Wyoming and utilization review organization, PSRO in Colorado, and so on, I just think it would be much better use of RMP money and I would rather switch and I would put that motion. to then. MRS, SILSBEE: RAG, I don't think you need to make a motion. It just gives us a sense, because it will probably be coming to us. We don't need a formal motion, Now, we have about five or six regions that we have identified that don't have to be considered today, but we will have to Look into them tomorrow. Originally about four of those we were going to take up when Dr, Merrill was still here, MR. NASH: Excuse me, I have one Dr, Roth is review on, Tri-State, a 1) KS on 10 il 12 e i4 16 17 18 19 20 25 HOOVER REPORTING CO, INC. 320 Massachusetts Avenu>, NLE. Washington, D.C. 20002 A tt i ea oe 59 MRS, SILSBEE: Okay, there are a number of those kinds. MR. NASH: This is one I have flagged special. MRS, SILSBEE: Okay, fine, let's do that one. ~.ki-State, orange book, | MR, NASH: This would be in the orange book. MRS. MARS: Which one is it? MR, NASH: Tri-State, MRS. SILSBEE: Mr. Nash, MR, NASH: This is a request for $569,609, which is the remainder of the FY-74 Tri-State fund. Mrs. Murphy is executive program -- replaced Dr. Leone. Baumgartner.Dr, Ike Tay Lor has recently rejoined the program on a full-time basis as deputy coordinator, This region received triennial status in 1970, It was last reviewed by Council in February of 1973. Council at that time considered recommendations from the Review Committes staff anniversary réview panel, which met in December of 1972, expressed serious concerns over this region's progress, recommended a funding Level of $2.5 million in Lieu of the requested $3.4 million. Council concurred in the lower funding level. The key issues at that time were lack of adequate minority involvement, lack of discernible program thrust among projects in contract activities, and evaluation process failed ~T 10 1 12 13 ‘j4 Hh 17 18 19 |} 20 21 22 23 24 20 HOOVER REPORTING CO, INC. 320. Massachusetts Avenu>, NLE. Washington, D.C. 20062 60 to identify achievements related to the regional's objectives. Prior to the phaseout notice, Tri-State RMP main- tained four subregional offices plus a central office. The subregional offices were in western Massachusetts, eastem Massachusetts, Rhode Island, and New Hampshire, Each had subregional advisory group and representa- tives from each subregional advisory group were also members of the Tri-State RAG, During the phaseout, that is between February and June, the subregional offices were closed, The subregional advisory groups were no longer active and the central staff wa reduced to three professionals and four secretaries. Thus we find that in June of this year, with only seven staff members, and,by the way, in this particular pro- posal they are planning to reopen the subregional offices and boos their staff to a total of seventeen, There is no men- tion in the application of the reactivation or the subregional advisory groups, Now, Tri-State ,Regional Advisory Group is a 57- member body which met only three times last year. We aren't really sure of their continued interest in the program, Only 19 members were present when this application was considered. Moreover, the Tri gave approval to more projects in the region's FY-74 support. Their answer was they would meet again on December 12th to prioritize the program, select =) 10 ll 12 13 i4 16 17 18 19 20 21 bo rN 2A 25 HOOVER REPORTING CO, INC. 320: Massachusetts Avenu>, N.E. Washington, D.C, 20002 61 activities actually to be funded, This region's review process was given conditional approval prior to our phaseoutactivities and we noted that although the application was sent to the appropriate CHP agents to review and comment, the comments from those agencies were not received in time for true consideration, It was also noted comments from some of the technical reviewers were not received in time for consideration by the RAG, Now, this particular proposal, as far as staff can determine, all of the activities proposed appear to fit the RMPS options built on previous staff and operational endeavors. I note 41.9 is in quality assurance, 5.1 percent in strengthening local planning, the remainder is in program stafi Support. There is no request for kidney in this particular application. I think if you go back to my former statement, that back in December of 1972, the staff anniversary review panel expressed some serious concerns about this region. I think these still remain. I think we are not really sure of their review process, We have some concerns about the management capability for the program, I think an example of this is that in the writeup, you Will find that a site visit was made to the Rhode Island ~~} 10 11 12 13 i4 16 17 18 19 20 25 HOOVER REPORTING CO, INC. 320 Massachusetts Avenu, NE. Washington, D.C. 20002 62 health activity in June and that produced a favorable report. However, Dr, Margulies visited that activity subsequent to tha and he has some concerns that this particular program perhaps is deviating from the RMP concept and is drifting into the usual university-based type of activity. We also hear the program director for that activity either has or plans to resign, In the prior application, this region was awarded a Sizeable EMS project to develop an EMS program in three states and in the region. Massachusetts was supposed to get about $775,000, A visit to the Massachusetts EMS activity revealed the fact that the plan they developed was not at all accep- table so RMPS restricted use of those funds until an accep- table plan could be presented. This was done and it was finally approved by the EMS technical review panel, But I think some of these things give you an idea of our concern over the management and direc- tion of this particular program. MRS, SILSBEE: Dr. Roth. MRS, MARS: But you are still recommending funding of half a million dollars? aS A AE REA OM ERO A cua te not é MR, NASH: DR, ROTH: Well, I have familiarity with this regior because of a site visitation that took place on a peak betweer 10 ll 12 e = id 16 17 18 19 20 e » 20 HOOVER REPORTING CO, INC. 320 Massachusetts Avenu, N.E. Washineton. D.C. 20002 63 two valleys evidently. This is a region that had been in deep trouble until Dr, Leone Baumgartner went up there and direc- ted them out of it, and now that she has Left, apparently they are going back into it. I certainly have nothing to add to that staff analysis, but if one looks at their projects out of that half million dollars, roughly, $302,235 are direct contract sub- sidies to medical schools, Tufts University School of Medicine, Boston School of Nursing, one thing and another, for the development of PSRO standards, Ithink it is just a beautiful example of the kind of inept use of our RMP money. MRS. MARS: That is just what I think, too. MRS, SILSBEE: Mr, Hiroto, you are the other reviewd MR, HIROTO: I don't have much to add, except it continues to have the same problems that were pointed out in the earlier review. And I don't know what importance was placed upon this thing called minority involvement and evaluat procedures, but apparently those who had those problems in the past continue to have them. MRS, SILSBEE: Well, this region did decide when the phaseout to lower their staff considerably, they had-- Dr. Roth, they had, I think the high continued beyond the site visit, but they did get rid of most of their staff, And Mr.. Murphy, who is a very adept coordinator, had decided he, re Lor 10 il 12 13 i4 16 17 18 19 20 ai 25 HOOVER REPORTING CO, INC. 320 Massachusetts Avenu3, N.E. Washington, D.C. 20002 64 having gotten rid of a lot of the staff, he did not want to get them back until he saw which way the program was going. And he has been doing sort of a holding operation as far as employing new staff, However, he is employing consultants to work on programs. And there has been a difference in view I think wit in the staff as to this Tri-State program. I don't think any of us have a real understanding, certainly not from being up there and observing how the Region al Advisory Group works, how the staff works, That is a missing plece of intelligence, DR, ROTH: Everybody optimistic enough to think you can get a bunch of those New Englanders, get the New Hampshirers agreeing with the Rhode Islanders agreeing with the Massachusetts people -- (Laughter ) MRS, SILSBEE: You are suggesting the concept of Tri-State-- DR, ROTH: That was the big outstanding trouble that was left over that not even Leone had solved at the time of our site visit, and it just frictionates more, About the one thing you can put your hand on, get a handle on here in the present activities 1s Limited to Rhode Island and coordination with the Rhode Isiland program and Brown Medical School, h ~l 10 il 12 e : 14 16 17 18 19 20 © 21 @ 22 23 24 hs) HOOVER REPORTING CO. INC. 320 Massachusetts Avenu2, NE. Washinotan. B.C.20002 65 MRS, SILSBREE; Well, having put all the problems out on the floor, do you have a motion to make, or, Mr. Nash, do you have a recommendation? DR, ROTH: Well, as I understand this whole proceduye, which I very freely admit I don't completely understand just what we are doing here now, we have a sort of one option; there a maximum thing we can do, which is give a formula grant appli cation to whatever money turns out to be available after a few more Divine revelations come about. And so what would be the effect if I said I want to give them half of what they asked for, and I said this on the basis that it would shut dow some of this quality support thing but not interfere with their other programming, is there any way you can do that? MRS, SILSBEE: Well, there are ways to restrict funds. There are also ways of not recommend ing the award of those funds. But in that latter event, we would have to spell out very clearly why we were doing it and under what circun- stances, DR, ROTH: Well, this strikes me as being an inequitl able procedure applied to one RMP if we were going this route across the board, I would be in favor of it. But as it stands now, I think the equitable-thing is to move that they get a their formula amount. sp pTLA DS AI A so eaten: sete He al MRS, SILSBEE: Then an alternative in that situation would be possibility of restricting some funds. n 9 10 ll 12 e * i4 16 17 18 19 20 21 25 HOOVER REPORTING.CO, INC. 320 Massachusetts Avenu>, NE. Wachinetan AT 2ARA? 66 On the other hand, Dr. Roth, the very words that are coming out of this Council meeting, that these options are options and not restrictions may solve some of the problems thet you are talking about if they have an opportunity to go back to the drawing board. DR, ROTH: I would hope so. I would hope so. I will move approval of the staff approved formula eee amount. MR, MILLIKEN; Second, MRS, SILSBEE: Any discussion? DR, CANNON: Just another comment. I would really Like to know how do they get started so quickly in the PSRO's? | We have been in quality audit, but you know, new legislation comes out and it seems like across the board, every RMP gets the action started. Who started it? We didn't, DR, ROTH: No. DR, CANNON: The Council didn't, We just see it after the fact. What you are talking about is tryire to make policy after the fact. DR. ROTH: Yes, Well, Bland, you have got to under- stand that out of a PSRO legislation, those that are still working on funds that have not been released and not one of these outfits has a federal buck from the Professional 10 ll 12 14 16 17 18 19 20 21 25 HOOVER REPORTING CO, INC: 320 Massachusetts Avenu>, N.E. Washiaetan TC IANAD 67 Standards Review Organization to pay the salaries of staff they have already hired all over this broad land of ours. DR. CANNON: So we pick up the tab, DR. ROTH: So where are they getting it? I haven't looked at the Pennsylvania Medical Program Review, but I will tell you right now, the State Medical Society is paying $10,000 a month out of Medical Society funds to keep this thing alive until they can get their hands on the first federal buck, and I assume they are going at it through PSRO, CHP, and any other way they can get it. And lI am sure Massachusetts is doing the same thing. DR. CANNON: Tennessee, at a meeting the other day, presented a program fir R&D money. MRS, SILSBEE: Mr, Nash, do you have any comments about what this project number 31 is? MR, NASH: Do you have a project 31? Use the microphone, MR. STOLOV: Yes. DR, ROTH: What is project 31? MRS, SILSBEE: The big one. MRS. MORGAN: Southeastern Massachusetts, ss MR, STOLOV: I know it by heart. It is Dick Egbert 's project, also is an adviser to the President on this issue. DR, ROTH: Not on this issue, MR, STOLOV: Well, on other issues. And it is ~~ 10 11 12 13 i4 16 17 18 19 20 21 24 25 HOOVER REPORTING CO, INC. 320 Massachusetts Avenu3, NLE. Washington, D.C. 20002 68 for southeastern Massachusetts, which is part of the eastern Massachusetts region. They divided the State of Massachusetts} western Massachusetts and eastern Massachusetts, and the State of New Hampshire is a subregion, and Rhode Island is a sub- region of the Tri-State, This is a $177,000 project to develop PSRO group that is called the Pilgrimage Foundation, which is an independent foundation of the Medical Society of the south- eastern region around the Cape and above the Cape, DR, ROTH: Does this interlock with the Commonwealth Foundation? MR, STOLOV: No. In the first allotment period, Tri-State gave a similar grant of over $100,000 to the Commonwealth Foundation for development of the Boston area, This is south of Boston. DR, ROTH: My understanding is the two are not com- petitive, | MR, STOLOV: That is correct. That is my understand4 ing also, The overlaps I see is the nurse's project which links up to that which is in the grant, but they are both separate corporations, Pilgrim Foundation and the Commonwealth. DR, ROTH: Well, this clues it in perfectly, because Dick is one of the directors of the American Association of Foundations for Medical Care that covers the country, started in San Joaquin Valley in California, and so on. 6 ~l 10 il 12 i4 16 17 18 19 20 nh — 25 HOOVER REPORTING CO, INC. 320 Massachusetts Avent, NE. WWachinatan AC OANKD 69 MRS. MORGAN: Came to New Mexico. DR, ROTH: So they are getting operational money out of any federal grant program, DR. CANNON: And you voted for it. (Laughter) MRS, MARS: You just recommended it. DR, CANNON: Recommended -- MRS, MARS: Recommended us approving it. DR, ROTH: I expect to thank you later (Laughter ) MR. NASH: We, of course, will be, remaining staff will be taking a Look at the review. process. Travel funds have been unfrozen and we have been directed to ago that. I do think some sort of site visit to this region could be made if not too distant future, it would certainly help us get a better handle on exactly what is going on up there. MRS, SILSBEE: By site visit, do you mean with Council? MR, NASH: I think it would be helpful if we could have a Council member, MRS. MORGAN: I hope you get more Council members, because we are going to be a busy group. MR. HIROTO: Dr. Roth, have the guidelines and 10 11 12 i4 16 17 18 19 20 rn at 25 HOOVER REPORTING CO, INC. 320 Massachusetts Avenu, NE. Wachinetan AL 910K? 70 regulations related to PSRO's been established yet? DR, ROTH: No, sir. They haven't made decision num- ber one yet. MR. HIROTO: I didn’t think so, How is it possible, then, that you fund a program -- are you establishing it? Is that the idea? DR, ROTH: My earlier speech today against using RPM money -- you know, I think it would be just great if this Counci would move on notifying all regions of RMP that the money that they use should not be used An Support of PSRO. sna i see DR, CANNON: Seconded. MRS, MARS: Make a motion. We. are ali for ite DR. ROTH: ALL right, I will make it, be happy | ‘to mal it, DR, CANNON: i second 1 ite DR, ROTH: Be glad to make such a motion. MRS. SILSBEE: Could we just for a moment-- MRS. MARS: Get back to this program? MRS. SILSBEE: No, I think we can hold on that. But I think some reading of what our guidelines said. Jerry, you have got September 7th guidelines? Might be timely here. DR, ROTH: I have great faith in the ingenuity of th coordinators and directors if you just tell them this isn't to go into PSRO support, put it some place else, then we are ce Om aon 10 11 12 6 48 i4 18 19 20 25 HOOVER REPORTING CO, INC. |. 320 Massachusetts Avenu>, NLE. Washington, D.C. 20002 71 going back to a Little trust in programming direction in the regions. I don't think this would catch any of them-- DR. PAHL: Let me add a note here while Dr, Gardell is looking for the right piece of paper. It has been the policy of RMPS to permit regions to engage in those kinds of activities which would assist in estab lishing standards of quality, and so forth, But not to use fun to actually operate or have the RMP itself become a PSRO, Iam not familiar with this particular project under consideration and what Mrs. Silsbee just showed me, it seems to me we are walking very close to a line of what I have jst said. I don't want to take a position, lecause I just gave it a quick glance now. But the thought has been that the RMP's would be allowed to support quality of care efforts, but that is not meant to be operating or becoming a PSRO in itself. DR, ROTH: Well, I would submit if there is anybody on the Council that is not aware of the present state of PSRO. implementation, that that is a bit of an unnecessary injunction because the first PSRO has not cracked its shell yet. There is no such thing as a PSRO, DR, PAHL: Right. DR, ROTH: We haven't even gotten out of HEW the definition of what a PSRO region will be as yet. T Hs 10 li 12 eo * i4 16 17 18 19 20 20 HOOVER REPORTING CO, INC. |. 320 Massachusetts Avenu>, NE. Wachinetan NC 2ANN Te MRS. MORGAN: Everybody is trying to make one, and hope they will head it, I think, | DR, ROTH: That is what we have got, everybody run- ning around in support of their own peculiar notion as to what PSRO is eventually going to turn out to be. It is sort of inept for our slender funds to get caught up in that whirlpool. MRS, MARS: In other words, we are just going to giv them $379,000 to try one? DR,.ROTH: iI would be very happy, but I think it should be an injunctive sort a@ thing for all PSRO's, not just pick out Tri-State, because it happens to be the largest amount of any of the ones that were in my group. MR, OGDEN: I really feel I have to speak against that. onsctane et csvset veg a“ I think one of the things we are charged with, I hop W O as Council, issome effort of cost containment as well as quality assurance. And even though nobody knows yet what a PSRO is necessarily going to be, people didn't know what HMO's were going to be either and we have allowed a lot of money for that We have allowed a lot of money for PHRO in the past. I think i a region, that is its regional advisory group, has determined that this is something that they want to expend funds on, I for one would be will-ng to see it done. I really think this is something that we want to loo into. “~l 10 ll 12 e : 14 16 17 18 19 20 6 21 @ ooo 25 HOOVER REPORTING CO, INC. |. 320 Massachusetts Avenu3, N.E. Washington. D.C. 20002 73 DR, ROTH: I think it is a very-- well, I think it ji very unsound to build on past mistakes, MR, OGDEN: I just dont think it is a past mistake, DR, ROTH: Well, I gave my earlier opinion that that is the reason we are in the shape we are in with this whole program, And I would also submit that the only reason that th v0 RAGs are now or the coordinators are now couching their requests in terms of PSRO support, quality assurance support, is because out of this office they got a directive that was priority number 2, when HMO support was high on the priority list, that was the popular set of initials, and that is what has been wrong with the whole bloody effort. | MRS, SILSBEE: Dr, Roth, I think,if I can find the wording, that what you were saying is sort of in our guidelines. If indeed we are proposing the approval of moneys that are to set up a PSRO, then there is difficulty in our staff workup, which if Council would direct us, we. can-- DR. ROTH: You aren't doing that ,though,: Judy. I read this application and, for exampie ; just take number 1, A, mmber 1 on your white sheet under PSRO, "Quality assurance criteria, pulmonary ambolism and venus ulcey This is a single well circumscribed diagnosis. It ig an addition of one single diagnosis toa list that was started in an EMCRO in Albemarle County, Virginia, with the University of Virginia, in Charlottesville, which took carcinoma of the rs, 7 er or 10 11 12 e i4 16 17 18 19 20 25 HOOVER REPORTING CO., INC. 320 Massachusetts Avenu>, NE. Washinton, D.C. 20002 74 breast with biopsy proven. It took fracture of the femur in a person over age 65, It took middle ear disease in children. So it is seven diagnoses. Now, here is another one adding an eighth. The federal government has just given half a million dollars to the Kaiser Foundation in Southern California, Los Angeles, to do another kind of these things. Now, you could use ten times the total amount of money we have got to parcel out around the country to do these outcome standardss, outcome evaluations for the approval of standards. You have got the College of Surgeons and the AMA work ing on projects, We in the AMA have poured $200,000 of our dollars down the same drain. Just because they did it doesn't mean that I think any higher or anybody else should do it right now. When the federal government has passed a law, there is an appropriation to make the thing work, and all you do by diffusing the expend] tures for this effort is hide how much it is going to cost. Because one of the inevitable things about this is it has a chance of improving quality of care in which it may be worth the extra amount it costs, but anybody’ that thinks that this is a cost-saving mechanism is whistling Dixie and that is just what the Congress has been so enthusiastic about. on 10 il 12 eo = 14 16 17 18 19 20 25 HOOVER REPORTING CO, INC. 320 Massachusetts Avenu>, NLE- Washington, D.C.20002 come in through the VA, NIH, and every other doggone place, 75 So if you get the cost piecemeal between RMP and CHP, and OBO and SRS, and AMA and-- | MRS, MORGAN: American Hospital Association. DR. ROTH: Nobody is ever going to know what it is going to cost, Now, when they pass a law, let them put up the money in one definable package from the federal government to pay for it. This has been our trouble with so much of the frag- mentation in the entire health care field. You can't idenfity what it costs to educate a physician today because the moneys We ought to be knowing what we are paying for edu- cation, We ought to be knowing what we are paying for quality control, And a diffusion into a program like this, which started out categorically, can't get much further afield, MR. OGDEN: Might I just interject here for a moment, I had thought that this material that is in the enclosure mailed out to us and is the application instructions for FY-197 which went out to all the RMPSwith a letter from Dr. Pahl on September 7th, had been approved by this Council. And it under part B, on page 5, simply states: "Under strengthening local quality assurance "2, Assisting with the development of norms criteria standards and techniques associated with » 10 ll 12 14 16 17 18 19 20 he bo ho Qe 25 HOOVER REPORTING CO, INC. 320 Massachusetts Avenu3, NE. Wachinotan HL AHN? implementation of the PSRO Division, Social Security amendments of 1972, RMP will be engaged in pilot efforts only and will not be responsible to the actual operation of PSRO's," This is the material this Council sent out in September, DR. ROTH: Sure. MR, OGDEN: Asking for these applications to come in. Now, what you are saying is the meeting in which these applications come in, you tell them you don't want this, But this just went out from this Council. How flipflop can we be? DR, ROTH: I don't:know, but having lost round one doesn't mean I am not willing to get back in the ring in round two. (Laughter) I think the Council made a mistake on this, I think it is good to reognize mistakes, DR, PAHL: Mr. Ogden, I think it would be appropriaté to state again, since I believe you were absent at the Last meeting of the Council, that these options were prepared basicé ly by the Department, ourselves included, at a time prior to th July meeting of the Council, because that was the timeframe work in which the Department was operating. What we did was wv re on 10 11 12 eo » i4 16 17 18 19 20 25 HOOVER REPORTING CO, INC. 320 Massachusetts Avenu3, N.E. Washington, D.C. 20002 77 present to the Council in July what was a fait accompli, that these are the Departmental priorities which at that time were under active consideration, but which became over the course of the summer and fall months frozen into restrictions, which were incorporated into the instructions for preparing the September applications, I don't think we need to make again apologies for the Department or RMPS, but this was never-- these options were never developed by this Council, They were given to the Council as Departmental policies, soft as it was at the time, which subsequently became frozen as Departmental policy, and which we have been operating upon, So you are correct, the regions were advised by us to respond to these in these applications. They have so re- sponded. And in that sense, the country has been following Departmental announcement. It has not been following what undoubtedly would have been a different set of priorities had the Council had that option of being in on the ground floor, rather than coming afterwards, MR. OGDEN: That may or may not be the case, but that is what we asked for and certainly the applications came in in response to that, That being the case, they feel if that is what they want to do, I am willing to let them do it. DR, ROTH: Well, I would remind you that I made the a asl 10 ll 12 eo ° i4 16 17 18 19 20 2 HOOVER REPORTING CO, INC. 320. Massachusetts Avenu, NE. Washington, D.C. 20002 78 speech once this morning. Most of these things this Council, long before you got on it -- Dr. Cannon is about the only one that can bear me out on it -- I am not being critical; this is what prevented the program from ever developing any iden- tity or accomplishing. When you consider the millions of dollars and man- hours that have gone into this thing around the country, it ought to be outstanding. And unhappily it isn't outstanding. We haven't got much chance left to do anything about it. Now, I doubt that any coordinator is. really inter- ested in Losing his money down his quality assurance drain right now for the next six months, Sure, they have got other things, but if this is. the only way theyare going to get their grants approved, they are good grantsmen. MRS, MORGAN: It is the same way we got funding. Wasn't it? It seems it was the first Council meeting I attended a couple of years ago that unless we took HMO, or by taking HMO, we got additional money that we could spend for RMP by taking a certain percentage, and this is how it happene We got stuff,so much money for HMO's, then we had a Little additional money we could use for RMP. DR. PAHL: Unfortunate as it is, I think it is fair to say present circumstance, by having the agency develop a a. & at 10 i 12 eo i4 16 17 18 19 20 °. ° 25 HOOVER REPORTING CO, INC. 320 Massachusetts Avenu:, NE. Washineton. DC. 20002 79 set of options which were known to be favorable to the Administration, we were over a period of months able to pry loose in fiscal 1974 funds. The shame of it is that the duly mandated Council was basically bypassed in this, and instead of asking this Council for advice as to program direction and priorities, the Department presented the Council with the priorities and asked for endorsement -- and, very graciously, the Council gave endorsement. But that is the posture of the program, DR. ROTH: I have to point out for Mr, Ogden, I argu- ed about it then, too, (Laughter ) MR, OGDEN: Had I been here, I think I would have bean on the opposite side from you. I do feel this is something that we really should be involved in, As a member of the public I speak now. I think this is the kind of thing that the public is interested in. DR, ROTH: You think every agency in the government ought to be interested in it because it is good, not just the agency that is given the responsibility for running the program but they ought to be getting money out of NIH grants, VA, and everybody that is interested in medical care ought to be contributing to this thing? | I think that is ridiculous. I think we are giving co 10 11 12 eo » i4 16 17 18 19 20 @ 7 25 HOOVER REPORTING CO, INC. 320 Massachusetts Avenu2, NE. Washineten, D.C. 20002 80 money to do a job and we ought to do it instead of giving our money to other people to do their job. MR, OGDEN: I think it depends on what you consider quality service, MRS, SILSBEE: The Tri-State application has a motion | it Should be approved £¢ for the remainder of the RMP 's FY ge ean SAE TH allotment » $569, 7036 eo 7 There has been a good deal of discussion about some of the aspects of that application, but I havent heard the motion amended, and I wonder if there is any further discus- sion? MRS. MORGAN: Question, MRS, SILSBEE: Or can we take action now? MR. OGDEN: I move it be approved. MRS. MORGAN: It has already been moved, MRS, SILSBEE: It has been moved and seconded, All in favor? tt ame et AMC II a ger e eae ner (Chorus of "ayes.") MRS, SILSBEE: Opposed? (No response, ) MRS, SILSBEE: Okay, DR, PAHL: I think this will conelude our executive session for today. We might reconvene Eonorrou morning at nine o'clock in open session, and again before we do adjourn, I would like 10 11 12 eo 14 16 17 18 19 20 s ~ 25 HOOVER REPORTING CO., INC. 320 Massachusetts Avenu>, NE. Washington, D.C. 20002 81 to thank Dr. Cannon-and.Dr. Roth for their many years of participation, They won't be with us tomorrow. I believe we are going to miss them sorely. So again, thank you very much, Perhaps we will see you on site visits. (Applause ) (Whereupon, at 5:30 o'clock, p.m., the meeting was recessed, to reconvene in executive session following open session Thesday morning, November 27, 1973.)