AN é| H fl i i DECIR AE ESE, RY RAE MRIS. Se COTES IE $ LE Et giy EI sy. go & & & : BES cpa kl BY an ee eee QV LOU CaS Date Ua a Ss, * TAS ASE SPE TASS NASB ade be RLS 2 OE rays ‘ce Livy ose mop pay VLA HOOVER REPORTING COMPANY, INC. Official Reporters Washington, D.C, ke 246-666 SLRS i | LMc/LMc | ‘ Pa wm 10 ll 12 13 19 HOOVER REPORTING CO. INC. 320 Massachusetts Avenue, NE. DIVISION OF REGIONAL MEDICAL PROGRAMS Conference Room G/H, Parklawn Building, 5600 Fishers Lane, Rockville, Maryland, 20852, Wednesday, May 22, 1974. PRESIDING: DR. HERBERT B. PAHL, Acting Director. Sse Saree fl tag Sa ated MAE me Mit MATS S wo ‘ ie 10 11 12 ( 13 e . 16 17 18 49 HOOVER REPGRTING CO, INC. 320. Massachusetts Avenue, NE. Wachinetan At FANN? CONTENTS ee eee em ens oe Opening Remarks, Welcome and Introductions, by Dr. Herbert B. Pahl, Acting Director, Division of Regional Medical Programs Remarks by Mr. Eugene Rubel, Acting Associate Director for Health Resources Planning Recent History and Status Report of Division of Regional Medical Regions by Dr. Herbert B. Pahl i ! { ‘ { ! ' 1 ' Page 17 36 an =~ 10 jl j2 ©} ” HOOVER REPORTING CO, INC. 320 Massachusetts Avenue, NE. PROCEEDINGS DR. PAHL: Perhaps we can call the meeting to order. As Mrs. Handel distributes the remaining invitations for you to be appointed as a member of the Ad Hoc Regional : Medical Review Committee, I would like to welcome all of you back to the Parklawn basement for a three-day period and say that it is very good to see all of the familiar faces again and to have one or two individuals new to this table meet with us. You will notice that there are around the room most of the familiar faces; you will also notice that there are a number of faces missing, and we'll have a little bit to say about our current status as we go through this morning. First I would like to check whether each person on the committee has in fact signed the letter and form that were distributed to you this morning because ~- it's a technicality but it must occur under our current provisions before we can have you act as a committee. | Is there anyone that hasn't received the sheet, Eva, or has not signed it? MRS. HANDEL: Everyone here has it. DR. PAHL: All right. Fine. MRS. HANDEL: A few people are absent. DR. PAHL: Now, although we've been away from this kind of activity for nearly a year and a half, I think I would “4 10 ll 12 eo .: 24 HOOVER REPORTING CO, INC. 320 Massachusetts Avenue, NE. 4 like to take the opportunity to introduce some of our key staff to you, and then, following this, because all of you really have not met together as a group before and worked together; at least in these special circumstances, perhaps ‘we could go around the table and have you say just a few words about who you are and what your relationship to RMP has been locally or on one of the review committees so that you can get to better know each other, and I think then we can go on with our business at hand. With respect to the introductions at the head table, I would first like to introduce Mr. Eugene Rubel to my right, who is the Acting Director of the CHP Program as well as the Acting Associate Director for Health Resources Planning in the Bureau of Health Resources Development, which is the bureau that we are now functionally located in -- and we'll have more to say about that. And because Mr. Rubel has to depart for hearings on the Hill no later than 9:30, we'll rearrange our schedule a little bit so that he'll have an opportunity to say a few words to you and you can have a little bit of discussion with him. On Mr. Rubel's right, of course, is Mr. Chambliss who has been serving as the Acting Deputy Director of the RMP program and for a period of two months earlier in this year, in January and February when I was away, carried the full tN ST, ~ 6 ~! 10 11 12 13 @ ” HOOVER KEPURTING CO, INC. 320 Massachusetts Avenue, NE. Hibahinatan AP BAD 5 brunt of the office activities, which I very much appreciate, and, in turn, he will now be away for six weeks from mid-June through July -- “turnabout's fair play, so I'm looking forward to taking over his responsibilities. And on my left is Mr. Peterson, of course, with the Office of Planning and’ Evaluation. We're doing very little evaluation; we're still doing one heck of a lot of planning, and we're very glad ‘to have Pete with us. Mrs. Silsbee, whom you would expect to see here, has been quite ill this past week. She may be in today or tomorrow -~- we certainly hope so. She's been suffering from a combination of the flu, bronchitis, and a few other things, and I think the pressure of work -- I don't think anyone can quite determine except herself -- has been very heavy and that undoubtedly has led to a little bit of weakened resist- ance. So we are hopeful to have her back with us before the meeting gets too far along, but perhaps she won tt be able to take as full a measure of responsibility in directing the discussions as we had anticipated, but I know you will want to see her and wish her well if she is back this morning or this afternoon. We have two visitors that I know are with us. I'd like to introduce Mr. Don Parks, who is the Deputy Chief on the Operations Staff of the Bureau of Health Resources Development and is sitting in for Dr. Green, the Bureau cod I 10 il 12 f- - 13 © : HOOVER REPURTING CO., INC. 320) Massachusetts Avenue, NE. Washington, D.C. 20002 6 Director. And I know this is Don's first interaction with the committee, and I hope you'll feel free to stay as much of the meeting time as you can, Don. And on the other side of the room we have Dr. Roberts from the National Heart & Lung Institute, and we hope- fully will have his presence during a portion of the meeting, and perhaps there'll be some discussions you'd like to partici-+ pate in as we go along. I don't know whether I've missed any other visitors or not. If so, you might at this time wish to identify your- self if you are from another agency. If not, I think I would like to ask -~ just perhaps starting with Mrs. Wyckoff because she brings a breath of spring here in her blue outfit to introduce herself to the committee and just say a word about her relationship to the RMP activities, past or current. And if we could perhaps just go around the table rather quickly, then some of you who haven't sat with this group before will have an opportunity to know who each other is, and then you can get better acquainted at coffee breaks and so forth. | So, Florence, would you be good enough to say just | a word or two, please? | MRS, WYCKOFF: All right. Well, I used to be on the National Council of the Regional Medical Program, and I am now on the Board of the Health Services Education Council, which ee pate a cot ane gt @ se my] 10 i 12 19 HOOVER REPORTING CO, INC. 320 Massachusetts Avenue, NE. nA AARAN 7 is a baby of RMP, in california in the central five counties with a base in San Jose near my home. | I'm also with the National Cancer Institute program Review Committee for Education. DR. WHITE: I'm Phil White and I was on the National Review Committee for what seemed like a couple of decades. I can't remember when it stopped, but I'm glad be back. I'm now a practicing neurologist and I haven't had any opportunity to do paperwork like this for a long time. DR. PAHL: We hope to get you reindoctrinated. Dr. Vaun? DR. VAUN: Bill Vaun, Director of Medical Education, Monmouth Medical Center in Long Branch, New Jersey; Professor of Medicine at Hahnemann Medical College. I guess I'm here because I've been relating to the New Jersey RAG over a period of years. DR. ae Thank you. Welcome, and we're glad to have you here. | Dr. Hirschboeck? DR. HIRSCHBOECK: I'm the former coordinator of the Wisconsin Regional Medical Program and still involved as a RAG member. I am now doing a Little mini RMP work in a commu- nity hospital in Milwaukee. DR. PAHL: Dr. Heustis? DR. HEUSTIS: I am a consultant in health programs =~] 10 ll 12 c 48 38 19 20 24 25 ~ HOOVER REPORTING CO, INC 320 Massachusetts Avenue, N.E. Washington. 0.0. 20002 organization on a part-time basis working for myself. Former- ly I was the coordinator of the Michigan program for three or four years, and before that the State Health Conmissioner of Michigan for twenty~some-odd years. DR. PAHL: Well, I'm sure you're used to some paper- work, as we are here. | Dr. Hess?. DR. “HESS: ‘I'm Joe Hess. I'm a former Review Com- mittee member. I have’ done very little RMP work since we were retired a little over a year ago. DR. PAHL: We'll rectify that over the next three days. | tg | Mr. Barrows? MR. BARROWS: Ken Barrows. My background is the insurance business and I was the original chairman of Iowa's CHP A agency and more recently the chairman for two years of the Iowa RAG. I'm still on both organizations. DR. PAHL: Thank you. We're glad to have you here. Sister Ann Josephine? SISTER ANN JOSEPHINE: I'm Sister Ann, and I had originally worked with the Intermountain Regional Program and then for several years on the Review Committee, but since '72, the fall of '72, I haven't had an opportunity to work with this group and I'm glad to be back. | DR. PAHL: We're glad to have you back, too. tty ~ 10 11 12 19 20 od OY HOOVER REPORTING CO, INC. 320 Massachusetts Avenue, NE. Wachinstan Wf 200A? Dr. Teschan? DR. TESCHAN: I'm Bill Teschan. I'm a faculty member at Vanderbilt University, a practicing nephrologist, -- former director of the Tennessee Mid-South RMP, and Chairman of the National Board. DR. PAHL: Welcome. Dr. McCall. | DR. McCALL: ‘tin Charlie McCall, formerly Director of the Texas Regional Medical Program. I'm now with the University of Texas Health Science Center, Southwestern Medical School, Associate Dean of Medical: Affairs: (phonetic) :. My only current association with the Texas Regional Medical Program or regional medical programs at all has been as a member of the (inaudible) Planning Committee for the state. DR. PAHL: Thank you. Mr. de la Puente? | MR. DE LA PUENTE: I'm Joe de la Puente. I used to be deputy to Pete Peterson in Program Planning and Evaluation. Now I am with the Bureau of Health Services Research and I'm a permanent friend of RMP. DR. PAHL: We need them. Thank you. Dr. Bob Slater. DR. SLATER: Well, it's nice to be back. I started off in '66, I guess, on the first National ow % ha att ~ 10 11 12 13 16 17 18 19 © . Qn HOOVER REPOXTING CO, INC. 320 Massachusetts Avenue, NE. nan aAAnA 10 Council of RMP when I was in Vermont and then spent three years on the Review Committee and succeeded George James as the chairman of that in my last year. - And then I think I faded out somewhere along the | line, about ‘'68 or 69, and I've really lost track of RMP, and I'm happy to be back in again. I've just gone to Philadelphia -- I'm just moving into Philadelphia with what was the Women's Medical College. I'm looking forward to that. It's sort of a social challenge in this next decade, the emancipation of women. DR. PAHL: I gather you consider that a vast improvement, and I would agree with you. DR. SLATER: It certainly beats working for founda- tions. DR. PAHL: Mrs. Salazar. MRS. SALAZAR: I'm Jesse Salazar, formerly Opera~ tions Officer and Deputy to pick Russell in the Western Opera- tions Branch, now retired. DR. PAHL: Well, we're bringing you out of retire-~ ment for a short while. | Dr. Win Miller. DR. MILLER: I'm Winston Miller. I was Director of the Northlands Regional Medical Program in Minnesota for seven years, and I'm now a consultant for medical review in the State Department of Health and I have no direct connection te cate sate Ps re eet i te ea a th ~~) 10 11 12 e . 16 17 18 HOOVER REPORTING CO, INC. 320 Massachusetts Avenue, NE. 11 with RMP. DR. PAHL: Glad to have you back again. Very nice. Dr. MePhedran. | DR. McPHEDRAN: I'm Alex McPhedran. I was formerly a member of the National Advisory Council for Regional Medical Programs. I'm currently Director of Medical Education at a family practice residency program in Augusta, Maine. DR. PAHL: Thank you very much -~ DR. CARPENTER: Last but not least. DR. PAHL: Usually that's the position I get. I'm SOrry. Dr. Bob Carpenter. DR. CARPENTER: How quickly they forget. DR. PAHL: Bob Chambliss will take over the meeting now. — | | DR. CARPENTER: Two years ago I was the Director of the Western Pennsylvania Regional Medical Program and I've retired to academic administration with the University of Michigan. ‘DR. PAHL: I'll try again. Thank you. As you know, we are down ‘from 56 RMPs to 53 RMPs, but I guess Western Pennsylvania is still with us, and I want to make that clear for the record. Keeping in mind the time, I would like to make just a few comments before turning the meeting over to Mr. Rubel. 10 li 12 ne an % a 13 e . 19 HOOVER REPORTING CO. INC. 320 Massachusetts Averiue, N.E. --. AA AANA 12 It has certainly been indeed a long time since a review committee has met. It seems to me it was about November of 1972. And I, for one, hardly know where the time has gone: It has been a very complex, difficult period with much to do with a dwindling staff, and so forth, and I don't intend to try to relate to you all that we've gone through, but I would indicate just a little chronology for you, and again refer you to the materials which Mrs. Silsbee developed and sent out to you which I think are very excellent in giving an over-all perspective of what has happened. But since we did last meet, you will recognize that in February of 1973 we informed you and everyone over the country that it was necessary to engage in a phase-out acti- vity. Dr. Margulies at that time, of course, was the Director of the program and for some five months, February through the remaining part of that fiscal year, the Staff engaged in a rather heroic effort -- much criticized but none- theless in terms of the volume of activity and the level of professional work, an heroic effort to have regions phase out in an orderly fashion, and the turmoil both around the country and within RMP was very high. But on hindsight, for what it's worth, many of us feel that it was an activity that was well accomplished both locally and centrally in view of the circum- stances that existed at that time. i ite A th SAP Name ate comnts , Ses HO: PORTING CO, INC: 32 usetts Avenue, NLE: Was) D.C. 20002 (202)-546-6666 ~~ 10 11 12 13 14 18 19 20 A bitwpwiedrimene 2 Regions responded against impossible time require~ ments, impossible demands to prepare plans. We, in turn, had to make hundreds of difficult decisions -- again, I'm sure judgment was in error in many of those -- but everyone did do the best possible, and as we approached June we had what was considered to be an orderly phase-out program of a national activity that had been in existence for some seven years. Fortunately, the Congress did see fit to keep the program alive and the President, about mid-June, signed the extension legislation and this has had its ups and downs since then, which, again, I won't relate in detail. They've been highlighted here. But, in general, the net result of that was that instead of having 56 Regional Medical Programs three programs were phased out completely and the remaining 53 programs at that time continue in existence, and we hope will have a full and vigorous lifetime at least through June 30, 1975, as a result of activities that we'll be involved in in these three days and in June, July, and August. The extension of the program did not mean that our own staff was given the sane kind of stability and, so, in a very quick fashion we have reduced our own headquarters’ staff from 247 people to a current figure of 88 or 87 or 85 ~- it changes daily, and as people have luncheons and hall cele- brations, why, it's with mixed feelings. We're happy to see “I 10 i 12 16 li 18 19 @ . Hi R REPORTING CO, INC. 320 Massachusetts Avenue, N.E. Washington, D.C. 20002 14 them gain employment elsewhere; we're very sorry to see them have to leave the program because of the continued central uncertainties. | fo lead toward whatever Mr. rubel may feel he would wish to discuss with you, I would indicate that not only has the RMP program internally, headquarters-wise, been undergoing its own set of difficulties, but the agency, as you know, has undergone a massive reorganization and, whereas, we used to be in the Health Services and Mental Health Administration, approximately July 1 last the agency was split into the two sister agencies, the Health Resources Administration, HRA, in which we are located, and the Health Services Administration, in which, of course, the majority of health services-oriented programs are located. Thus, while we were trying to gear up again for an extended year of life, we were also trying to fit into a re- organized agency, and that has had its own convolutions as always and we're still not completely settled down, but for a period of approximately six months from last June through this past January, we were in one of the three bureaus into which that agency was organized. We were in the Bureau of Health Services Research and Evaluation, which at that time was under Dr. Robert Van Hoek, who subsequently has left, and that has undergone a change of leadership. About January or February of this year, when it © + nee ts ema er taNeafoaned am sab kaptrent Sea nene 6c enn Se f @ Washington, B.C: 20002 C0?) 5A6-GA68 @..... CO, INC. 320 Massachusetts Avenue, N.E. ns ~~ 10 li 12 13 18 “49 20 ‘over in part ‘from the one ‘bureau, Health Services Research as Ls became clear that the Administration and the Congress were both thinking along the same lines of combining CHP, the Hill- Burton, and RMP programs, it certainly seemed to make good sense administratively to try to bring these programs together functionally within headquarters, keeping their separate identities, but nonetheless to try to get to work a little bit more closely together, and, so, unofficially we have moved I it's now termed, into the Bureau of Health Resources Develop- ment. And the reason for that is because that bureau contains all of the former NIH Bureau of Health manpower activities | which obviously are related to our interests and we to their interests. And, secondly, it contained the health facilities utilization Hill-Burton program, as well as the Comprehensive Health Planning program. So by bringing RMP from the one bureau functionally into the Bureau of Health Resources Development, we were able administratively within the agency to bring the three programs closer together, and in fact there has been a much more close-- there has been a closer working relationship and there obvious- ly will be an evolution internally as the external legislation becomes better defined and eventually mandated. Now, in order to help coordinate the headquarters’ three programs to function more effectively, the appointment of Mr. Rubel was made -- and, Gene, I'm not exactly sure. It 10 ll 12 13 18 "49 20 EPORTING CO, INC. 320 Massachusetts Avenue, NE. Washington, D.C. 20002 strikes me about January -- so many things have happened --~- but about January, mid-January or so, this year Mr. Gene Rubel was asked to take on a second hat. His first hat, which still continues, is the Director of the Comprehensive Health Planning program, and that's a full-time occupation. The number two and major responsibility which he has been asked to take on is to coordinate internally. and work very closely, of course, with the agency and the department in helping develop the Administration's legislative package for health resources planning. So that in a functional sense the Hill-Burton program, his own program, and our program here are trying to work together under his leadership in terms of getting together and seeing how we can move forward toward health resources planning before we actually know exactly what the nature of the legislation will be. And because Gene has to be again downtown today because the hearings on health resources planning are going on before Senator Magnuson's Appropriations Committee, rather than dilute his time, I would prefer with that kind of back- ground to ask Mr. Rubel if he would care to comment on any of these or other matters of organization or direction that he may be going, and then to a as long as. you can and perhaps be responsive to some inquiries from the committee. Gene? Seen ee ee ee ne eee ten mees “aeaeeprenafiatey mes neet ienb s oe © : 4 e. ING CO, INC. ~ 10 ll 12 13 24 Oh 320 Massachusetts Avenue, N.E. Washington, D.C. 20002 17 MR. RUBEL: Thank you, Herb. I am going to have to go, but I will do my best to be back and spend as much time with you today as I can and then on Friday as well, so let's not look upon this as the’ only opportunity we have. I think Herb has stated the organizational situation quite well. Back in January and February we went through a great deal of debate and looking at alternatives to figure out what the best way was of taking the monies appropriated in fiscal '74 and those that had been impounded in '73. and con- tinuing pursuant to the federal court order, aswell as the decisions made in the department, to take approximately $120 million and give it out to the 53 Regional Medical Programs. The process that we've come up with is not a terribly satisfactory one, but I think, under the circum- stances, it was the best that we could do. Once we put together the schedule and the process, we did consult with the steering committee of the coordinators and they endorsed our proposal, and that's, I guess, why we're here today, and perhaps later on Herb will expand on that ~- on that further. We are no doubt -- at least in my mind -- in the midst of a transition here, and any transition is difficult. The Congress is presently debating what future kinds of acti- vities that it wishes to see in the whole arena of planning, regulation, resource development, and that category of 10 ll 12 19 At, @ ' H R REPORTING CO, INC. 320 Massachusetts Avenue, NE. Washington, D.C. 20002 1& programs. It's doing that in the context of debate on national health insurance, as well as looking at other func- tions that the Federal Government is performing in research and manpower and the Like. As you probably all know, virtually all of the legislative authority that we have in our agency expires on June 30th and RMP is among those, as are CHP and Hill-Burton and manpower and research and statistics and everything else that we do. And both committees, Senator Kennedy's. subcommittee and Congressman Rogers' subcommittee, have been hard at work trying to decide what they'd like to see in the future. It's in that context that we sit here trying to decide what -~- how much funding each of the RMPs should get. It's pretty clear that we're not going to have any new legislation by June 30th -- at least it is to me -- but it's equally clear to me that before the summer is over we are going to have new legislation, and I don't think it's going to contain in it the continuation of any of the existing three programs as we know them today, Hill-Burton, RMP or CHP. I think both the Administration as well as the chairmen of both subcommittees have made it pretty clear that they're not satisfied with the structures that we have today and they would like to make structural changes, and I don't think they're going to take any one of the three that we have iy 1 today or continue any of the three for another year -- that's 21} one of the alternatives that many people talk about, "Well, e 3{| it'll be just another one-year extension." I don't see that lf” poe ~~ 4/1 in the cards. 5 The fact of the matter is that there is not a single 6|) bill pending before the Congress -- at least there wasn't ~l] yesterday morning -- I don't know who threw things in the 8|| ‘hopper yesterday -- that would continue any of the three 9|| programs as they are currently in the statute and, therefore, 1011 I see very little likelihood that the same structures that we 11 have today will exist next year and, therefore, I think ~~ at 12 least in my mind it's pretty clear that the grant awards that C. i3|| we're going to be making next month and finally those in © 14. August are going to be the last: grant awards made to RMPs as 15 such. 16 Now, I would extend a note of caution and that's that people said that about RMP and they've been saying it 17 18 about other programs two years ago, and yet we're still here 1 || today, so anything is possible. It's really up to the Congress to make its judgment, } to decide what it would like to see. I'm only telling you what I can see as an observer from afar -~ the kind of questions they've asked and the legislative proposals that they have submitted. We have had very extensive hearings before both the ®@ : REPURTING CO, INC. 320 Massachusetts Avenue, NE. Washington, 0.C. 20002 praAny ef na emcee ty ont es net roi ein iitnt ~~ 10 ll 12 oe ° 19 @ . ’ HEPUHTING CO, INC. 320 Massachusetts Avenue, NE. ~~ Washington, D.C. 20002 AO CAL COCE he Senate Subcommittee -~ several months ago now and more recent~ ly before the House Subcommittee -- dealing with the subject of what we call health resources planning, and it's now up to both committees to produce their proposals if they have any and go through the long legislative process. The Administration has a bill, In the House it's got a number of S. 3166. It is only one of many proposals. ‘Senator Kennedy ‘submitted his own version; there have been four or five bills presented by members of the House Sub~ committee. They're very complicated, very explicit as to what they want to see happen and very explicit about the pro- cedures to be used. Unlike current laws that we have, certainly for CHP and RMP today, where there has been a lot of criticism about purpose, they now seem to be going in very much the other direction and laying it out from A to Z three times over. Perhaps one of the reasons for that is their reaction to what they did back in '66 and '65, or what their predecessors did. I don't know how much of a holdover in members there really is. | Perhaps -- you know, I don't know how much I should go into the particular pieces’ of the legislation. They all focus one way or another on the three major topics, regula~ tion, planning, and implementation. To some extent or other, they cover those. SSR re comme nanan peed etter MAHON UR AN Eo Ne bh ~] 10 11 12 13 14 16 17 18 19 REPORTING CO, INC. 320 Massachusetts Avenue, NE. Washington, D.C. 20002 (202) 546-6666 I think it's fair to say that all recognize that each of these has some role, but depending on whose bill you look at, they place more or less emphasis on any or all of those three functions. It's also important to recognize that debate about national health insurance is going on and those functions are also contained in the various and sundry bills that are being “@iscussed by different committees on the Hill, Ways and Means and Finance Committee, and one of the interesting things here is going to be to what extent they actually manage to work together or somehow work separately. . You may know, for example, that Senator Kennedy's and Congressinan Mills' health insurance bill has a very large resource development fund that three or four years from now would have four or five billion dollars a year in it for the purpose of developing resources, and that's a lot of money. ‘Phat kind of puts into a little corner everything that the Health Committees have done ~~ if you add in manpower, and you can even add in biomedical research, and it still looks like a minor fraction. . a | - Now, exact ly how that kind of apparatus would func- tion, to the extent that it's actually enacted, and how it would fit in with these agencies that we're talking about today, is very uncertain. In the meantime, with all this uncertainty we have SAN tn en ta: cement jatatih MUNSON a am ts 10 Il 12 ES . Washington, D.C. 20002 (202) 546-6666 @ REPURTING CO, INC. 3zu massachusetts Avenue, N.E. RMPs functioning out there; we have CHP agencies functioning; we continue to build health care facilities, and we have lots of meetings talking about what's going to happen in the future and we have a lot of people bemoaning their fates and saying, "Gee, whiz, how can we live with this, all this uncertainty?" | Dr. Endicott on many occasions has talked about the mess that we're living in, and it is indeed a mess. We all recognize it. I hope a year from now we can look back on this period and say, "Yeah, there was a period of uncertainty there but we're over it." It certainly looks very tall and very high to me right now -- but I don't know when we're going to have enact- ment of legislation. I do know that we have worked very hard to try to structure a transition. We have attempted for all of our agencies to build in pretty much a full year of opera- tion so that during that year we _ move from what we have today to wherever we're going in the future, and the awards that we'll be making before June 30th, certainly for core staffing of RMPs, will allow each of the RMPs to function and function well, I hope, during fiscal '75, and by the time . we're finished, I hope we'll be able to more or less do:that™: same thing. for’ the’ other: orqanizations. Fiscal '75.is going to be, I think, a year of change and it will be in fiscal '76, beginning in 1975, where some ran esos er ae we hehe ett elite ered aie nite é..... CO. INC. bs ~ 10 ll 12 13 14 19 320 Massachusetts Avenue, N.E. Washington, D.C. 20002 fs CAL CLOO a3 things are going to be fading away, I would predict. Let me just say two words about -- a few words about what you're going to be doing over the next three days. We have tried to emphasize the need for RMP applica-~ tions to be reviewed by CHP agencies as part of this process, and I spent a fair amount of time last night going over summaries of the applications that we now have. And, first of all, in ‘the great majority of cases it's obvious that there is very close working relationship between the RMPs and the various state agencies, as well as the areawide agencies. In many cases I was very happy to note comments like, "Formal review was a technicality since we've been work- ing together in developing these applications jointly." And that's the situation in the majority of the cases, and it doesn't cause us any problems. On the other hand, we do have some places -- just a handful -- where there is obviously a very basic disagree- ment between what the Regional Advisory Group has proposed and what the CHP agencies feel are the priorities in needs of their communities. I would like you to look at those handful very closely and, based on whatever we have on paper now and what- ever Staff has been able to decipher, you're going to have to make some kind of judgment as to which one of those views to accept, and I think that's the kind of thing that really must @ sented niger: Maresh or cel te an se} | OD orev CO, INC. 320 Massachusetis Avenue, NE: Washington, D.C. 20002 (202) 546-6666 10 jl 12 13 14 19 aK be presented to the National Council, and they have to make a decision as well. In the papers that you have, it's been highlighted, the extent to which CHP comments have been received and what they've been, and I would like a to look at those, in par~ _ ticular in the half-dozen or so places where there appears to 1 be a problem. “The ‘second point I would ask -you to look at is the | extent to which RMPs have responded to the challenge of help- ing in the planned development process around the country. As part of the application package that we sent out to all the RMPs, I guess early in March, late in February -- I also can't remember times very well -- DR. PAHL: March, I think. MR. RUBEL: <-- we tried to suggest that it would be very useful to try to expedite the planned development process Congress passed the Comprehensive = the Partnership for Health amendments, the statute, back in 66, and we know how few areawide agencies and state agencies have actually developed the plan and have really set something down so that RMP would have no trouble in deciding, "This is where we can put our money.” | | And we've all heard about the endless struggles, "Well, there isn't any plan and, so, we have to do the plan- ning," and the like. ae metas taba ett. ee ean tee teat met sgaterttne Sik eR @ @ REPORTING CO, INC. ~I 10 il 12 13 14 16 17 18 19 320 Massachusetts Avenue, N.C. Washington, D.C..20002 POMS CHL LOLOL 23 We have tried over the last year to focus CHP atten- tion to the planned development process. We have gone through an extensive development of what we call performance standards and, as some of you — know, we've actually gone out and assessed or are in the process of assessing every single CHP agency in the country to determine how well they meet those standards. : “But it's clear that that planned development process is not something that's going to happen overnight, and we sug- gested that it would be very useful. -- not necessarily to support CHP, but to support the planned development process, and, again, here I think it's fair to say that many, many of the RMPs have responded and have responded very well to that challenge. | . | ‘It's something that I'd like you to look at as you go through the various and sundry applications. Again, I go back and emphasize we're in a transition. We have the possibility of organizations, once this funding cycle is over and the funds are spent, facing extinction -- not just RMP agencies, but all of these that we've been talk- ing about. ‘the challenge that they have had has had to attract good staff, how to put together good proposals with that kind of uncertainty in a very short timeframe. We do have another cycle coming here and I think © . 14 @ ceeiat eins Neinacttert en nae iether oe it Wea u 10 11 12 > . 13 © 49 2h REPORTING CO, INC. 220 Massachusetts Avenue, NE. Washington,.D.C. 20002 (9097 SAR-BEBR 26 some of the newer things will probably be in there for most regions. We can't expect a perfect kind of process here. The Administration has stated unequivocally, I think, that it is committed to obligating all of the funds available here ‘to the extent that there are applications that you, that our Staff, and that the National Council feel should be funded. It's a lot of money by any standards. It can have a Significant impact, I“think, as‘has much of the funding that's already been done over the last six or seven years. Therefore, you've got a big job ahead of you here and you have thirty or forty minutes to talk about each one of these, and I don't envy you. Based on those thirty or forty minutes, you've got to make a judgment. But like it's been said so many times about our system of government , it's a lousy way to do things, but nobody's come up with a better way. It's very much the same kind of situation we find ourselves in. I'd be delighted to respond to your questions that you have. DR. PAHL: Dr. White. DR. WHITE: I've heard about the dissolution. What do you feel is the root cause of this? Why? Where does the dissatisfaction arise from? Is it due to quality or political situations -- A VOICE: Can we hear the question, please? lected megs Stent tect hemlet tts } REPOHTING CO, INC. ~l 10 il 12 13 19 320 Massachusetts Avenue, N.E. Washington, D.C. 20002 1980 BABBRER DR. PAHL: ‘Use the microphone, Dr. White, please, DR. WHITE: I was asking for the root cause for the dissolution of these programs, from whence arose the dis~ satisfaction and from what did it stem, quality, political: considerations, what-have-you. MR. RUBEL: I presume you're talking about all three ! of the programs ~- | DR. WHITE: “Yes. MR. RUBEL: First, Hill-Burton, I think there's a feeling pretty much on the vart of everybody that a program that was very important back in the late '40s, with all the problems of nonconstruction of anything during World War II, plus the imbalances between urban and rural America, those problems are not with us any wore, and structures that we had set up then perhaps were not appropriate today. | One very important point, as part of the Hill- Burton program, we had a planning part -- you know, that wonderful, magic state plan, and there we set up a nice little bureaucracy to do its thing, and at the same time we had a CHP agency, both statewide and areawide, and they were con- flicting with each other, and we had GAO presenting very embarrassing reports sayina, "They come out with different answers." So that -- I would guess that by the time we're over here we will have a federal program for construction of some =~} 10 11 12 13 19 REPORTING CO, INC. 320 Massachusetts Avenue, NE. Washington, D.C. 20002 INAGS carrece eu sort or other, but it's going to be very different from the Hill-Burton as we know it today. RMP suffered, I think, from the very beginning with a lack of any clear-cut goal. I think this has been pretty much recognized. I've heard Dr. DeBakey talk about his original com- mittee and what they were thinking about and what finally came ‘out ‘of “the Congress, and you ‘talk to the -staff people on the Hill -- you can give them a couple of drinks -- and they'11 tell you that they were ordered to write a bill that. said beautiful things but really didn't include anything in it. It was a compromise. They had to come up with something, but they took out all the guts. | . ‘And I think it's fair to say that RMPs, together with the administration here, were trying to put something into that nice framework where there really wasn't anything in the first place. | . CHP, perhaps more than the others, was enacted before its time. The forces -- our society just wasn't ready - for the kinds of activities that were contemplated then. It was only when Medicare and Medicaid really took a strong hold that it was recognized -- and the federal budget kept going up and up and up -- that there was more of a recognition that perhaps we just can't let the system do whatever it wants, passage of certification-of-need laws in 23 states and all of 1|| them using the kind of CHP mechanism, that we had amendments bo of the Social Security Act, Section 1122. @ 3 But I think there's a feeling that the structure 4 41) that was created then perhaps isn't a good enough structure 5|| for what we need today, and Congress feels, and the Administraj 6 tion as well, that we've got to make some modifications in the 7l| way we do health planning. “8 But-perhaps most important dealing with both RMP and 9|| CHP, that we don't need as many structural units out there as 10|| we have created -- "we," the Federal Government ~~ that it's ull far better to try to put these together in fewer organizations y2|| and perhaps the reason for that stems from the observation (: 13|| that many of these organizations spend a good deal of their @ . 14|| time trying to figure out whose turf is whose. 15 -It gets worse, because we have things called experi- mental health services, delivery systems, and exactly how they Fit in is not entirely clear. We still have remnants of hospital planning councils, some purely voluntary and some i || fostered by the Hil1-Burton program back in the early '60s. _There are a lot of organizational elements out } there and I would, in looking at the scene, say that one of . the purposes here is to tighten things up. ey La Now, there are some people that would respond and say, "That's too simplistic and you really can't; you need different kinds of organizations," and we've heard that kind @ REPURTING CO, INC. 320 Massachusetts Avenue, N.E. Washington, D.C. 20002 O09" GAR SEER rte Coy @ REPORTING £0, INC. tw ~~ 10 jl 12 13 14 16 17 18 19 320 Massachusetts Avenue, NE. Washington, 0.C.20002 JU testimony over the last several weeks. MR. BARROWS: We've developed a very rich back- ground of experience back in the states in trying to make these programs do the job that Congress intended. Is that’ background going to be called upon in trving to fashion a new program -- I mean, if the dogs don't Like it, do you put out any package of the canned food that you want? ‘How about the people that have been trying to make | these programs work? Have they been heard in this -- MR. RUBEL: Well, I would say very definitely. - There's very extensive testimony by all kinds of people -- governors, directors of programs, national organizations that represent them -~ the record has been made. Now, whether any- body's been listening is a different question. DR. TESCHAN: I'd like to ask whether in the last three or four months your office has issued to CHP B agencies any particular direction as to how they are to request pro- fessional and technical assistance from their RMPs in plan- ning development? In other words, what has emanated from your office to stimulate B agencies particularly to utilize the professional capabilities of the RMPs in planning? MR. RUBEL: We took the whole application package that we sent to the RMPs and we sent it to all the CHP agencies with a covering memo explaining that this process was going on and we thought it was very desirable for CHP agencies Sind rte ae Sate Se me cepaneh t a) anh Se NRE ERNE @......: CO, INC. 320. Massachusetts Avenue, NE. Washington, D.C. 20002 fONTN RAC ECER a 10 il 12 13 14 16 17 18 19 Foe to work together with RMPs, particularly towards the end of how we expedite the planning development process. That was done in early March, as I -- DR. TESCHAN: This is to help the development of: those applications we're now seeing, if I understand you cor- g rectly. oe MR. RUBEL: That's right. “DR. TESCHAN : Tld Tike to get off the present package, if I can, and talk more generally in terms of an on- going CHP planning and need identification and plans to meet those in the various CHP B areas. You see, the development of these applications is a matter unto itself. I'm talking about the ongoing CHP areawide planning. What direction, if any, comes from your office to B agencies as to how RMPs should be contacted and involved at CHP's initiative, to involve professional and technical expertise on the RMP side in their ongoing plan development? MR. RUBEL: Well, I can't recall that we've said anything specifically, you know, responding to that directly, although it has certainly been implicit in -- well, it's been implicit for a long time. In some places it works very well. and other places it works -- it doesn't work at all. DR. TESCHAN: Well, the thing I'm interested in, for example, if you've talked with Herb or are aware of the legislative and administrative history of:CHP-RMP interaction, SZ 1 you may be well-aware of not only the mandated -- the legisla- | 2'| tively mandated clause but also the regulations coming out and @ | 3|| the instructions coming out of the RMPS saying how these two i 41} shall interact. 5 The mandate so far has been directed, as I under~ 6|) stand it -~ and that's why L. brought up the question -~- to the ~] RMP, as to what initiatives we should be taking -- the RMP | 81) should be taking. That's very explicit, in a lot of prose -- 9|| and Ken Vaun is one of the authors of that prose -- in con- 10|| siderable detail. 11 I am looking in the current batch and I will be 12|| interested in the next several days' discussion as to what c5 - 13|| initiatives I hear that are reciprocal, and it's the reci- © 14|| procity that I'd like to -- in echoing Dr. Barrows’ comment 15 {| that enormous enterprises of five or six or seven years' dura- 14 || tion now have azsenbred a tremendous capability in the regions 17|| which in “many respects -- in my own experience certainly -- 1g || have been largely ignored by the areas ~-- at least ignored to ig || the detriment of plan development. 20 And so, therefore, it's really in terms of your original hat and continuing hat in the CHP agency as to whether or not this might not be an excellent time in the waning months of needing to have some plan development (inaudible) for this to occur. I'm looking for it in the applications here as well @ REPORTING CO, INC. 320 Massachusetis Avenue, NE. Washington, D-C. 20002 dnens rhe nae PACA rem er ona neg «cap “MG tlt tigen g Nate ( @ REPUR TING CO, INC. 320 Massachusetts Avenue, NE. Washington, D.C. 20002 URANO Re 3 10 ll 12 13 i4 16 17 18 19 33 as -~ MR. RUBEL: I'm not sure how to respond. I would agree with you by and large. I don't know how you direct that) to happen, and I don't know particularly how you'd direct it. to happen when we're on the verge of making some substantial changes in what goes on. There is no question that there have been many, many “problems on “both. ’s ides . I would think that in these coming months we've got to focus most of our attention on how to forestall those problems from coming in the future, rather than trying to play with them in these waning months, as you call them. DR. PAHL: Gene indicated that he would be able to be back with us some more both today and -~ Friday? “MR. RUBEL: Right. DR. PAHL: Thursday you're out of town. So I think there will be opportunity to discuss further with him some of these points because they're very crucial to what both RMP and RMPS and CHP are trying to accomplish. Gene, thanks for taking as much time. We look forward to having you back when the hearings are over. My staff has thoroughly instructed me to deliver any number of items of information to you. At the same time, what Mr. Rubel told you about thirty to forty minutes per \ @. REPURTING CO, INC. bo “Tr 10 il 12 13 14 19 24 O85 370 Massachusetis Avenue, N.E. Washington, D.C. 20002 (207) 546-6666 application is quite true, and we've made all of those calcu- lations here and calculated your time. So r want to assure you before we go on that what we're going to try to do is run through a number of things - which I think should be of interest and in some cases are important to you to know, and then break at 10:30 for no more than twenty, twenty-five minutes, and you can bring your eoffee -back-here--- let's say 25 minutes -~ and during that interval you will find that these tables are going to be pull- ed apart at the divider line so that we will be able to break at the appropriate time -- we may have to reconvene for a few minutes after coffee as a total group to wind up one or two points if I don't get finished, because we do have to talk about funding and what it is you're to do and a few other things, but I'll try to just give you highlights, not too many details. _— | But when we come back, the tables will have been separated and there will be a Panel "A" and Panel "B," which you're familiar with. Mr. Chambliss will be in charge of Panel ~- | MR. CHAMBLISS: "A." DR. PAHL: -~ "A," and Mr. Peterson in charge of Panel "B," and after this morning's discussion, which will end either just at 10:30 or shortly after we return, you can get to work on the applications following perhaps a very brief \ Washington, D.C. 20002 (OP RAR-BRGR @...... CO, INC. 390 Massachusetts Avenue, N.E. 10 il 12 13 14 16 17 18 19 20 review of exactly what the parameters are for running the individual: panels. | | Then you're on your own for the rest of today and tomorrow up until -- we'd like to target the hour of 11 o'clock Friday morning when we would like to reconvene the ‘two panels into a whole again and bring back as a group the findings of your reviews because, handling the applications in «two separate panels, we want to make certain that the same ™~, kinds of issues are handled as equitably and consistently as we can, and we'd like to have the group as a whole hear any- thing which seems important to know before we take the com- mittee's recommendation on to the Council, which meets in mid- June -- the 14th and 15th, I believe. | So I'm urging you, first of all, that the Staff has used these little computers to calculate that you can't get the work done by Thursday night, we urge you to stay until mid-afternoon on Friday -- we realize it's Memorial Day week- end, but we also realize that there is a need to do justice to all the applications whether they happen to be discussed first or last, and to the extent possible we tried to gear our own Staff work -- the chairmen are being held responsible for keeping you to about a 40-minute point, and we'll both have some things to say as to how to manage this activity, but in fairness to the regions and what they have been through in trying to bring these materials to you, I'm sure to the extent IO possible you will accommodate that final discussion, and if 2 we get together at 10:30 or 11:00 on Friday for a group meet- @ 3 ing ~- perhaps early afternoon would suffice, but we have to i 4 have a full committee discussion, I believe, so the two panel 5 chairmen will be able to resolve together with you any of 61 those matters which perhaps have not been handled equitablv ~~ across regions. 8 | ‘Now, with that apart, let me try to take the next 9|| period of time and go over with you a few matters which I a 10|| believe should be of interest -- hitting the highlights, | 11|} recognizing that we will be here for a few days. . Mr. Chambliss 12|| and © On HOOVER REPURTING CO, INC. 520: Massachusetts Avenue, NE. (foi ae MS AS - ing very closely with Dr. Edwards' office and there were 46 about immediately as is customary and there were difficult times over the summer, and as Mrs. Silsbee indicated we had to cive emercency funds to certain programs just to try to keep some people on a salary basis from week to week. I would indicate that those were difficult times because we were work- € i veriods of creat uncertainty. At times it was indicated that perhaps it . would be best to fund recional medical programs on a monehty basis until thev could decide what to do with the program, and you can imagine some of ene turmoil. Then we graduated from that proposal, not made by us, to a quarterly funding to see how the PMPs were doing and that brought its own set of complications; and somehow we survived over the summer. There were many long distance telephone calls: Mr. Gardell's office of grants management was quietly going crazy with the numbers and the dollars; the communications between downtown and parklawn Buildina were frequent and at variance with the preceding conversations, so that we never ouite knew wheme we stood. But at the end of fiscal '73, in June of '73 just before the start of fiscal '74, there was a balance in our program of nearly 7 millions of dollars which, according to the directions of Dr. Edwards, we did finally distribute to regions, so that about midnight of June 30th, in good govern-~ ment fashion, we distributed to all regions or to most of the te =~} 16 17 Js 19 HOOVER REPORTING CO, INC. a20 Massachusetts Avenue, NE. |, Washinetan. BC 2080? 47 regions, I‘m-sorrv, all except four or five, an allocation of nearly “7 millions of dollars. | Unfortunately at that time we had been given | instructions that this allocation could not be used by the’ regions, just hand it to them, and after the department decided what the program should be, we would then let the regions spend this money. So we found ourselves in the months of July, August, and September in the peculiar position of having given money to the regions but they couldn't use the money and they were in certain cases borrowing and trying to es - keep staffs together, and this seemed to be a paradox, but that's what continued on not only through the summer months but all through the fall. But by that time the wheels of government moved, and as Mrs. Silsbee indicated, eventuallv through a lot of negotiations the department gave ‘us “17 millions of dollars for the first quarter funding -- it came rather late for a first quarter funding, but we were very happy to receive it and distributed those funds te regions which sort of kept them alive up to December 31. Then later in the fall we were successful in prying loose twenty-four additional millions of dollars and that money was designed to keep regions alive from January of '73 until last june. é You'll recall that there was a government-wide te ~] i 12 | 13 pete | 38 19 20 @ 25 HOOVER REPORTING CO, INC. 320 Massachusetts venue, NE. Wachinetan 0 C-20002 in my life, but, anyway, we had fiscal '74 funds in the order 10 48 crisis with impoundment of funds, and obviously we were caught very heavily in that, and, so, we had a bank reserve, i | if you will, of about $89 millions of fiscal '73 funds and something in the neighborhood of -- I keep getting these fiqures mixed up, but perhaps -~ Jerry, fourteen? ~~ How much did we have released, $19 million MR. GARDELL: Actually, it was about twenty-five. DR. PAHL: I've never seen so many budget documents of $25 million which were not available to us. and fiscal 173 impounded funds of approximately $89 million, and we had this little $7 million kitty distributed around which nobody could seem to release, and we were on emergency funding, and that is the set of circumstances under which the regions ware oper ating and, so, when I tell you our problems, I do want to o indicate that the regions’ were having their own. Then things became a little bit clearer and this was) because of an activity which the Regional Medical Programs initiated. ‘There was the development of the National Associa- tion of Regional Medical Programs. They became incorporated and they introduced a class action suit against the government to force the government to release the impounded funds. The lawsuit was filed in September and it has been a most interest ing period since September -- I've never had legal training, but © feel like a half~baked lawyer; I've certainly been ~ 10 “i 12 (a8 \ 14 16 |} 17 18 19 20 ei ’ 25 HOOVER REPORTING CO, INC. 320 Massachusetts Avenue, N.E. Wachinatan HE FN? about to file a arievance action, but I didn't. the country is in. It seems to go on forever, and, actually, 49 involved in the process. | There were a number of defendants cited in this lawsuit. That includea Secretary Weinberger -- it included the Honorable Secretary Weinberger and the Honorable George Schultz and the Honorable Roy Ashe and Herb pahl, and I was A The lawsuit was entered in September and due process| occurred so that we anticipated an action on this by the first week of December. . That was something’ which J found doesn't occur. It's sort of like the present litigation that today is May 22 and I still don't have the final answer, although the court finally decided on February the 7th to accede to the plaintiff's request to release all funds. So, actually, on February the 7th, a Federal District Court Judde aia ¢ssue an order which required the release of all impounded funds, $89 million from fiscal ‘73 as well as the rest of the fiscal '74 funds. So all of the funds from 1973 and 1974 theoretically became available to us. , That order also required the Administration to remove the various kinds of restrictions which we had placed on local RMPs from the preceding February, so we had the opportunity to learn how to draft rescinding notices and semi-. legalistic documents which basically out the program back into its prephase-out set of circumstances without a number comet to ~ 10 “di 12 13 24 2h HOOVER REPORTING CO, INC. 320 Massachusetts Avenue, N.E. Washington, D.C. 20002 50 of restrictions that the department had placed upon the programs relative to the funding or how the funds could be used, and so forth. ‘Since February the 7th there has been an interesting series of events which I couldn't possibly go through the chronology without looking at files, but merelv to say that - the government felt that the amount of money that had been released en toto which would be available for support of RMPs was too much to be used effectively by RMPs and there have — been a number of activities, one of which was filing an appeal “to the court order by the government and requesting that funds) be permitted to be used for some other purposes. - This has resulted in a series of negotiations across the table which have not quite been completed and the initial request, which was to use as much as up to $30 million, has now been whittled down to ferhaps $5 million, and hourly I hope to know how much money you all mav be talking about, but I can give you a figure within $5 million of how much we may have -- the only thing I know is that by June 30th I will have the answer because we have an obligation to distribute some funds. I do want to indicate to you that it has been a very, very complex period through the class action suit. What . that suit basically does, though, is it did release the funds. The actual amount available to RMPs -- I will give you in a ~ ~ “4 3 ~ i . x 2% HOOVER REPORTING CO, INC. 320 Massachusetts Avenue, NE. Weacehiaatan MP FUN? 51 minute -- is known within 5 millions of dollars at this point and that's pretty good compared to where we started from. The court order also did remove the various kinds of restrictions and it says that RMPs may engage in. those kinds of activities in the current set of applications and the forth; ‘coming set of applications to be submitted July 1 which are in accordance, obviously, with the enabling legislation of Regional Medical Programs, Title IX, as well as the Mission Statement that you' re all familiar with, as ‘well _ whatever Council policy has been, but it does not put restrictions or requirements on the regions to do one thing or r another. Therefore, your applications will show a wide spectrum of activities. Some of them will not be as "balanced" as perhaps you might like to see, but there are not requirements on the regions that they engage in emergency . ' medical services or that they have a kidney activity or that they engage in this or that. And this is important, because Mr. Chambliss and I have been trying to operate under what has been not only our interpretation, but with the General Counsel's Office here =- and we've formed many close and enduring friendships with a few individuals in that office -- what has been the interpre- tation of the court order. I think that's all I'll say about the litigation. We hope to have an answer shortly, but basically it won't ' 10 uy 12) 13 HOOVER REPURTING CO, INC. 320 Massachusetts Avenue, NE. Histt ee NO INA 52 affect your decisions right now because I can give you a rather close figure. And I would like now, therefore, to turn to what kind of funding we are talking about and give you a picture of that. And, Bob, why don't -~ Pete, would you want to -- ° what I woud like to do is heave you zoek just briefly at the ‘table which we're distributing ‘and which came out of our office of systems management -- that's to show you that it! s. a viable ortece -- and this has a good deal of information and Tr don't want you to get too absorbed in the details because there will be an opportunity for you later. to refer to this as you go through individual applications. What we have tried to do here is to give you an over-all picture of the dollar amounts requested by regions and the dollar amounts available. The first column gives the name of the region, just. alphabetically. The next column is what their current annualized level is, which represents the six-month funding level of support which was provided in the current award starting January 1, °74, and which we have projected over a twelve- month period. Basically that is their operating level if they had received a full year's award most recently, which they did not. We gave them all six-month awards up through to 10 i 12 - 13 HOOVER REPURTING CO, INC. 290. Massachusetts Avenue, NE. 53 this June 30th, and all this does basically is show you what | 1 | their yearly operating level is. . The second column is targeted available funds and at the bottom of that column are the totals, and you will see that there is a figure of $114 million. That is the Sgure which we believe will be available for support of “| programs totally from the released impounded funds together w th the available remaining '74 funds. “In other words, we have that much money to support the programs from their curren applica- tions together with the applications that they will be sending ‘in July 1 and that you'll be looking at in July. This is our total amount of money left to support RMP prograns and this money will be used to support activities through June 30, '75, to support “RMPsS through June 30, '75. that figure is | soft by perhaps $5 million because the litigation is not yet ‘ended and, if anything, the §5 million will be reduced from that, so you might say we have $109 to $114 or $115 million. Exact figures are not known. But that's pretty close; that's the best I can do for you right now. Let me come back -- well, no. Let me discuss the. targeted available funds right now. That column opposite the individual regions reflects the total fiscal 1973 and fiscal 1974 funds which we believe will be available for distribution to the RMPs and was ty 7 10 “Vy ~ 12 oe, 16 li 18 18 @ DA HOOVER REPORTING CO, INC. 320 Hassachuseits Avenue, NE. we wed MOAT -able to us over last fall as I indicated to you in those 13 54 derived by using the same percentage factor as was used in distributing fiscal '74 funds provided in the current budget period. | | ‘Now, that sentence doesn't mean much to you except to say that when we finally had fiscal '74 funds become avail- separate allotments, we had, you will recall, no review com- , - i . mittee. We had to make a decision as to how to distribute those first and second quarter ‘dollars to regions. What we did was try to fine out how much in the pre- phase-out period of the total ‘amount during the fiscal '73 i -prephase-out period each region had received on a percentage basis. So if Region X had received 6.2 percent or 12.1 per- cent of the total prephase-out ~~ immediately prephase-out dollars, then we took that same percentage and applied it to the fiscal '74 funds that “nad just become available to us and made that calculation and distributed those dollars to the region. That was the only fair way we could because we had no review committee, we had no applications; all we had received was dollars from the Bureau of the Budget and’ an immediate order, like, "Why didn't you do it yesterday?" to get the dollars distributed. So we had to do a formula and we, therefore, kept the relative merit of the regions intact by using the same percentage allocation for the fiscal '74 dollars as we had be ~1 10 “WU 12 18 > 16 17 38 19 @ on HOOVER REPURTING CO, INC. 320: Massachusetts Avenue, N.E. Wachiastan HL-2N0NN7 fair: the Administration felt it was fair; and that's what we. 55 found resulted from thorough reviews in fiscal ‘73 prior to the phase-out. I hope that makes sense. We used a formula which we felt was fair. This was also checked out with the steering committee of coordinators who felt that it certainly was * | did. | | | So those available targeted figures that you see in this column now represent that same percentage for each region applied to what we believe will be the total funds available for distribution, namely , the $109 or the $114 million. In other words, we are perpetuating in that column, merely as a reference point -- we're perpetuating the relative order of regions that was in effect immediately prior to phase-out. Now, that's sort ‘of a complicated history and if there's a question on that, I'il try to respond to you. If not, let me go on. The next column -~ $he next three columns are the May 1 requests and the total figure for Alabama requested is seen there in the current application; the next column, the difference, is the difference between the May 1 request by each region and Column C, the targeted available funds, and then that shows the percentage difference. So, for example, Alabama has come in with a request which is 136 percent above nN ~ 10 11 12 | @ 25 HOOVER REPURTING CO, INC. 320 Massachusetts Avenue, NE. RA AnAAA which are headed May 1 plus July i, and you'll see the July 56 the available funds targeted for that region on the basis of the calculation which I've. indicated. Now, I want to come hack and make sure you do under- stand about targeted available funds when we finish because I don't want any misunderstanding on how that's to confine in any way or restrict in any way your discussions or evaluation» of applications -- but we've been working in the transition period and we've had to have some reference points. Then as we gO. across the page you will see columns . estimate. We have asked each region to provide. to us what they believe will be their requested amount in theiz July 1 application if, in fact, they intend to submit 7 July 1. application. And as you run down that column, I think you will: find six or sever regions where there are zeros which indicates that they only intend to use the current application). and do not intend to submit a July 1 application. The next column would be the total of the May 1 and the July 1 application to show what their total program would be -- what their total requested program is through next year. Then the same difference between that total request and Column C, that is, the available funds, and the percentage of that that that difference represents. And then the last column on the right you don't have to do anything with, but we thought you might be ts | i, @ 25 HOOVER REPORTING CO, INC. 320 Massachusetts Avenue, NE. “Wachinetin DE 7o0i? ti -that $114 million. 57 interested in that these are the figures for the arthritis ‘applications requested from those regions. These applications in arthritis are not coming to this committee, unless there's gome reason that the two committees should confer on something Those funds have been earmarked and they are above and beyond So we have 43 applications which will be competing for approximately $4.2 million and that $4,2 million is above and beyond that $114 mitiion or the $109 million which mr! ve indicated to you is available for Support | of the regular RMP programs. . - a / Now let me come back and mention again about the targeted funds because I think it's very important that you understand how this figure is to be used and how it's not to be used -- how it is not to be used is more important perhaps. It is not to be used as a’ predetermination on our part here at headquarters that this is what the region deserves. You are free to review the applications and make your recommendations and exercise your judgment as in the past You have in that second column current level annualized | basically what a projected twelve-month funding is under the current operating conditions, which gives you an order of : magnitude of how the dollars are flowing around the country currently on a twelve-month basis. The targeted funds are merely a calculation within ws ~T HOOVER REVOURTING CO, INC. 7G Massachusetts Avenue, WE. Yashinzton, B.C. 20202 i 4 what we did was make the best estimate possible and this came 58 the office here, knowing that we would have ~~ I've tried to indicate to you how uncertain the Litigation has been. I haven't known within thirty to forty millions of dollars since February how much money I had, and when we had .to make some decisions, we had no wav of arriving at firm figures, so out to be finally that we think we may have $114 million + available. re | And on that basis, in order to help guide regions in preparing applications -- because they knew less than we | did -- in order to guide regions and give them some benchmark, 1 we decided that we would have about $115 million available. We applied the percentage figure from the prephase-out relative awards. We applied that figure to what we thought we would have available and notified regions -- for example, to Alabama, just as an example, we would have indicated that they had just perhaps under $2 million which, if everything had stayed the same as it had been just prior to phase-out, they could sort of expect that that would be their "fair share." .O£ course, everything hasn't stayed the same. ‘There have been vast changes which are reflected in the applications and in the Staff discussions on these applications it will come to your attention. | | Some of the regions are being treated unfairly by this targeted column because they were at a certain point in. 10 “ii 12 | 413 18 1 20 rw {2 ww s 24 ¢ 2h HOQVER REPORTING CO, INC. 820 Massachusetts Avenue, NE. Washington, 0.620002 - quently -- and, thus, these merely represented benchmark 59 their history either at a very high point or at a very low point when phase-out came -- all 53 regions were not being treated similarly. Consequently, you'll have to take into account that there have been dramatic improvements or perhaps even in the other direction -- although I hope not too fre- € figures by us to the regions to sav, "Please submit an appli- 4 “cation to us, but the sky is not the limit. We think we may have around $115 million. If so, and if everything existing prephase-out were not changed and we had no review process except a formula, we would probably give.you this, but we do expect to have a review committee, we do expect to have a Council, we do expect to have good applications; therefore, all of these factors will be taken into account. But so that you don’t submit a $10 million application, we'll give you something to shoot at, but’ you're not restricted," and this:is not a formula being applied to the regions; it was a guidepost | for the regions and a guidepost for us, and you may increase or decrease on the basis of your judgments, exercise of discretion, and specific funding recommendations as in the past. Now, as we go -- well, let me ask: are there -- I don't expect you to particularly look -- well, I should make one or two points. — = First of all, on July 1, the total at the bottom of bh 6 ~~ a) 10 11 12 ( oS 13 » 16 17 18 19 @ Qh HOOVER REPORTING CO.INC. 320 Massachusetts Avenue, NE. 60 the page, we have been told by the regions that we can 1 expect to have about $42 million come in. in requests and those $42 million will come in from perhaps 47 regions. Again, these are estimates. The region may elect not to come in on July l or if it savs now it isn't, it may elect to; it may increase its actual application request or it may decrease it. These are their best estimates made in response to my request for a realistic estimate so we can try to manage it with some degree of orderliness... So we now have before us, if you look at the total line at the very bottom of the page a what we . have before ‘us under column -- the second total, $114 million, is probably ‘ what we will have, although it may be $109 million, but it's $109 to $115 million. The current total request for May 1 applications, that is, the ones that are in hand before us this period, totals the same amount at $114 million as the total funds that are available for award by both the June and the August Councils, that is, after the next review cycle, too. 50, for example, if evervthing that came in was approved today or this period by both committee and Council, we don't need a July cycle. We could have -- MR. CHAMBLISS: It's coincidental. DR. PAHL: It's coincidental ~~ I'm going to get to that in a moment. atten, 10 “i 12 13 16 17 18 19 20 to ~~ HOOVER REPURTING CO, INC. 320 Massachusetts Avenue, N.E. Washington, D.C. 20002 61 And this figure is just coincidental, yes. If you now go over under the July 1 total, you'll see that the regions have indicated ‘about $42 million from 47 regions will be coming to this committee in July and in August Council mestendg The total coming in, therefore, for. May 1 and July is approximately $157 million in requests against about $110, $115 million available funds. That's the lial in which you, Staff, and Council are operating in the real. world. . _Now, this is not vastly different than it would have bees had we had seventeen or eighteen applications’ in. three review committees and three Councils, because requests always - total more than available funds. But I do bring it to your attention because we have an unusual opportunity this period: to look at the entire program of all 53 regions knowing ” _ therefor that we have sométhing in the neighborhood of $45 million plus or minus $3 million more in requested sum between now and the July 1 applications than we have available funds to support, and in knowing this, therefore, you must recognize that you shall have to exercise the same kind of judgments and discretion as you have in the past, namely, look at the programs, look at the priorities, look at the qoals and objec- tives, look at the capability of the staffs, look at the RAG involvement, see whether it's a: cohesive and coherent program, look at the feasibility of the activities, et cetera. nN ~ 10 11 12 18 19 20 @ 25 HOOVER REPURTING CO, INC. 320: Massachusetts Avenue, N.E. MAlnahinedian RP FANN 62 And for this purpose Mrs. Silsbee and Staff have outlined for you in the materials that went out to you and are | in the front of your blue book those criteria and factors which should be forming the basis of your judqment as in the past. Again, we're in a program review; we're not going to duplicate local technical review which is done in the regions, as you know. We are not trying to have you exercise the same . -degree of sensitivity to all the problems as you did in the - ‘past because we know that you have not been visiting regions ; and, to a large measure, our Staff has not either. We know that we have inadequate information relative to the way we used to have it, but, yet, we do have the job to do. So within the framework of where we have to work, we believe the Staff has done a very thorough job and will be able to fill you in and answer questions. They will be able to highlight key issues, sensitive areas or something of this nature, but you do only have a limited amount of time per application, so we ask you to focus on those issues which are really key. And in that connection I would like to point out — that because you have not been meeting with us and because so much has. happened in other. areas, such as emergency medical 7 services legislation, PSRO, HMO; and kidney, that the Staff... has been instructed -- and I'm sure you'll find this on) ws “1 HOOVER REPORTING CO, INC. 320 Massachusetts Avenue, NE. Washincton, D.C. 20002 Lf vou cannot come to a decision, we will highlight that and none of us around here can do. 63 occasion from both Mr, Peterson and Mr. Chambliss -- that if in your individual discussions of applications vou come to an issue as to whether this is within policy framework of RMP to support something like this, the two chairmen have been instructed, if you will, to request you to. do the following: « trv to just have the National Advisory Council and ourselves make the decision; if the: information is inadequate to make a decision about a policy issue at that point, let's not try to take the entire forty minutes to wrangle over something that Most of the time the Staff will have sufficient information to tell you whether that project is within our guidelines, and we've tried to point out to our Staff where there are issues, and I believe that everyone is rather well wv. - prepared. To our knowledge, there will be relatively few such kinds of issues come to our attention. So if you think, for example, that the emergency medical services project submitted by Region X really belongs over in emergency medical services' program in the Health Services Administration, be assured that we as Staff have already sat with the DATeCtOr and the Deputy Director of that program, that we will be doing so after com- mittee and before Council, and to our knowledge what we're bringing to you in that area is legitimate for you to consider =] 10 “ - 12! 13 HOOVER REPORTING CO, INC. 320 Massachusetts Avenue, NE. Washington, D.C. 20002 that project is, then it's legitimate on policy grounds to. 64 and, therefore, we shouldn't even really try to resolve such issues here. . The same thing with the PSRO. We're not permitted to provide out-and-out support for PSRO. If in your opinion the information in the application indicates that that's what ° say, "No," and move ahead. If you can't tell from the appli- cation, then a recommendation by committee that would be. appropriate would be, "If it's within policy for RMP to support this particular activity, we think it oe in with the goals and priorities and capability of the ‘local Regional Medical Program," and leave it to us between now and Council and with Council and with the other program to make that determination, because we've all been overating under very heavy time pressure with inadequate firsthand information about the regions, mostly”just with papers, precious few site visits, and we just can't have the. same amount of information that you and we have had in the past. So I think we can move ahead in that framework without undercutting in any way the quality of your review, but it may give us a few more things to do after committee to work with the Administration and Council. Now, that's the best we can ao, and I don't think those will be too numerous. e Mr. Chambliss and Mr. Peterson will be meeting with w =~ 10 il 32! 14 18 19 20 9: “HOOVER REPORTING CO, INC. 320 Massachusetts Avenue, NE. ‘questions of funding EMS, kidney activities, and so forth. 13, - questions between our activities and the program that is being 65 you in your separate panels when we do reconvene, and they will be going over a number of specific items relative to the review and, again, will be emphasizing what Mr. Rubel said, the need to highlight critical comments by CHPs and to try ‘to come to some recommendation on those, if appropriate; the | Please be assured that our Staff is aware and heavily involved with what is going on in the other areas that I've alluded to. So, for example, we're very semi lier and working very closely with Dr. Goodman and the vhole new kidney network program which is in the Health Services Administration} We've been working with him for months and, so, when you see kidney diolysis and kidney transplantation activities in these projects, you may exercise your judgment and discretion in the same fashion as you always have, and as there are any policy y started by the Health services Administration for a national network, we're all involved and will be taking care of these policy issues, so don't try t8 get tied up in whether it's appropriate for us to do this or that. We'll be facing these over the coming weeks and in most cases they are not issues because we've already been able to talk with them prior to this meeting. If you'll give me just five more minutes, I think I won't have to reconvene as a total group. Bs rs ~) HOOVER REPORTING CO, INC. 320 Massachusetts Avenue, NE. 65 First of all, conflict of interest and confiden- tiality. I don't think it's necessary to say this, but you have in your book the usual statement, and I do wish to make it a matter of public record that not this session, but during the closed portion of the meeting when grant applica- ‘tions are being reviewed, it is. important that all proceed- ings be treated confidentially, as well as the papers you're . handling. | Be | . We also ask you to leave the room should there be a known conflict of interest either because of geography or t something that you, yourself, know. | The second point has to do with our Council. Our National Advisory Council -- which I am sorry I did fail to mention as we were running down this list of items -- has been gradually depleted over the months and this has been a . source of great frustration because fewer and fewer members have had to do the work of the Council. We met with them severel times from last summer on and have tried to work effectively with them, and I believe we've gotten some very helpful support and advice from them, but at best it has been difficult because the number has gotten down to seven Council members, and the department, upon repeated reauests from us, has not seen fit to augment ¢ that Council. As a result of a great activity on the part of a te =] ‘ 25 HOOVER REPORTING CO, INC. 220 Massachusetts Avenue, NE. ‘very happy with the composition because there are many -- Tt 67 large number of people, both inside and outside, I'm happy to report to you that within the last few weeks the Secretary has seen fit to augment the Council. Letters of invitation have been sent, and I believe in your folders there is -- or, if not, we will give you a list of the current Council, and we're think thirteen letters of invitation were sent out, twelve were accepted, and many of the people have close past | alliances, understanding, and involvement . with RP so there re relatively few individuals on the Council now who are completely unfamiliar with RMP, | and we feel, therefore, we'll be able to work very effectively with them this June and this August. tHe are planning to have an orientation meeting for council members , I believe at the end of this month, at which we'll try to bring them up to date so that when they do come to the June Council meeting following this meeting they will have an understanding of the issues and concerns and be able to interact and advise in a mere intelligent fashion. We have some additional committee members that I'm happy to see have been able to make it with us this morning. Mr. Toomey is with us here. We're glad to have you. Dr. Thompson is here -- and did Dr. Thurman come in?) € Yes. Dr. Thurman. How are vou? We're glad to have you here and work bo ~~ 10 Uy 12 13 18 19 20 wel 6 » HOOVER REPORTING CO, INC. 320 Massachusetts Avenue, N.E. Washington, D.C.20002 wan Man aan sessions and should feel free to participate as appropriate. Philadelphia, and Mr. Wiley from the Atlanta Regional Of fice-- 68 with us. I think we have Dr.. Scherlis -- A VOICE: He's not here yet. DR. PAHL: He is perhaps still to arrive. “Otherwise, we're complete. Two additional visitors have come to participate not only with us this morning but in the closed panel Mr. Smith, who is from Regional Office 3 in 5? I'm sorry. Regional Office 5--- I'm sorry, I had it down as 3 -- and they'11 be interacting with you on some of the applications. ‘ ‘Before we break there are just one or two more short issues. One has to do with the fact that I'd like to confirm with you that thefe is the July 17th and 18th meeting scheduled, and we realize the difficulty this places on you and just assure you that it places the same difficulties on Staff, and 7 hope, to the extent possible, that you will be able to make this, and should you not be able -- and that is not an invitation ~-- but should you not be able, please advise us ahead of time because it is in fact going to be a rather large review with a majority of applications and, again, many recuests, and we have assured the coordinators over and over again that this is a bona fide review. | 69 1 For example, I have allocated funds last March so we that there will be funds available without question following @ 3i| the August-Council. We do not intend to spend all the funds 4 after June Council should your recommendations be even to 5i| fund everything today, because we have assured them that when 6|| they come in July 1, both the review and the funding dollars il] will be there. | : | | 8 oe In terms of just other matters, I wanted to make 9}| sure in reference to Mr. Rubel's discussion about the forth- 10 coming legislation and the number of bills that are there ~- ui|| I know that a number of you have been following rather closely 12!) perhaps this rather complex set of bills on health resources 131| Planning and others of you have not. It is very difficult to keep up as to the differences in what these may mean, and % 14 ~ 15|| Miss Morrill -- Marge, why don't you raise your hand and show 14 || them what you have? -~ she “has prepared -- let me just use the uv ‘microphone -- she has prepared sort of an abstract of the key 33|| features of the various bills both Administration and Con- gressional now being discussed relative to the health resources planning. | | Because it is bulky and because some of you, frankly have enough to do without wading through all the things which may happen and would prefer to wait, we decided not to over- burden our Xerox facilities and Staff and automatically © distribute these. We thought we would leave a set over here 25 JOVER REPORTING CO, INC. Q Massachusetts Avenue, NE. ishington, D.C. 20002 OV fee cece tw «l hd oo ‘ @ 3h HOOVER REPORTING CO, INC. 390 Massachusetts Avenue, NE. Witectinnsad PO TATAD 70 on the table where you registered, together with a sheet, and if you would like to have a copy, we'd be glad to have you sign up your name and we'll have a copy either at the meeting for you or mail it to you ~~ but many people, frankly, don't need to keep up with all the vagaries of Congress and the ‘Administration -- so to the extent that you find it -- this is an important kind of activity for Mr..Rubel and Pete's office and Miss Morrill, but it is, frankly, most. difficult to find just what is actually going to happen and what is proposed. Now, I believe, if there are no further matters, Bob, from you, I'd like to -~- are there? .-- well, ‘first, I was going to ask if there are any questions or comments from the public? This will conclude the open portion of the meeting -- Let me, if I might, Dr. Vaun, come back in just a moment, because I want to make sure -- I think some of the public members may have to leave. | Let me just ask if there are any comments or state- ments to be made by anyone who is here from the public? (No response.) : DR. PAHL: If not, then I'd like to ask Dr. Vaun and other members of the committee to either comment or make a statement or have us clarify on any of the matters raised or overlooked during this morning's proceedings. DR. VAUN: Just as the regions' request came very close to the money that was available by coincidence, for the ~ 10 1 12 13 18. 19 20 te te 24 (COVER REPORTING CO, INC. 20 Massachusetts Avenue, NE. /ashington, D.C. 20002 7. record, I'd like it to be known that we did not see this in the event that our recommended reduction coincidentally. happens to jibe with their overage. | “DR. PAHL: Absolutely. We have been amazed by the number of ‘coincidences in this program throughout, so nothing surprises us,| but we feel we have to give you the framework in which you're work- ing. Now, on procedure, I think if we could now break and reconvene at 11 o'clock or no later than 11:05 -- if - necessarv, bring vour coffee back. We'll rearrange the room and then you can have Panel "A" and Panel "B" and we| can get down to the business at hand. 8 Thank you very much. (Whereupon, at 10:40 a.m., a brief recess was taken. ”.