ng | TRANSCRIPT OF PROCEEDINGS DEPARTMENT OF HEALTH EDUCATION AND WELPARS ee DIVISION OF REGIONAL MEDICAL PROGRAMS = we AD HOC REVIEW COMMITTEE -_— se le le PANAL A Rockville, Maryland May 23, 1974 Pages 229 thru 489 HOOVER REPORTING COMPANY, INC, Official Reporters Waeshbiagtoa, D.C, 546-6666 7 OO ~~) 10 - 12 -13 14 - 16 ‘17 18 19 20 21 25 HOOVER REPORTING €0.,{NC. 320 Massachusetts Avenue, NE. ; REGION IOWA MEMPHIS MISSOURI NEBRASKA NEW MEXICO NORTH CAROLINA NORTH DAKOTA - NORTHLANDS TEXAS OHIO VALLEY OKLAHOMA SOUTH CAROLINA SOUTH DAKOTA TENNEESSEE MID/SO. CONTENTS 237 267 288 299 313 323 343. 357 404 423 440 457 475 MOTION » 235 251 278: 297 312 321 339 356 401 421 436 455 466 482 228A APPROVED 236 266 280 297% 312 322 341 356 402 422 | 437 455 475 485 1 DEPARTMENT OF HEALTH, EDUCATION AND 2 WELFARE ~~ AD HOC CONSULTANTS MEETING FOR REVIEW OF 10 RMP APPLICATIONS | “hi 12 13 ‘ 44 16 17 18 Conference Room H Parklawn Building i . 5600 ‘Fishers Lane 20 , co Rockville, Maryland 8:30 A.M. 21 Thursday ( May 23, 1974 ‘ 22 23 . . 24 25 HOOVER REPORTING CO, INC. a aa. Bee ME 228 5/23 am . >/em * PROCEEDINGS 8:40 am . ! 2 MR. CHAMBLISS: © I would like to say, ai of all, 3 good morning to the members of this panel. I indeed commend 4 you again for the diligence and the zeal that you tackled thi 5 most difficult task we had yesterday. 6 I would like also to welcome to the panel) Dr. ] ~~ Scherlis. Good morning, Dr. Scherlis. 8 - DR. SCHERLIS: The expression is "the late Dr. 9 . -§cherlis". 10 || MR. CHAMBLISS: © And say we are glad to see you, 4 and we are still waiting on Mrs. Wyckoff and Dr. Mijler; wii. but, if the committee so chooses, I think we oan proceed. -13 | We're halfway through with our task and today we 44 have fourteen regions yet to be reviewed. The order that I 15 would suggest, and certainly this can be changed, would be 16 along the following lines: Lowa, Memphis, Missouri, Nebraska un New Mexico, North Carolina, North Dakota, Northlands, Ohio 18 Valley, Oklahoma, South Carolina, South Dakota, Tennessee 19 and Mid South, and finally Texas. | | 20 .DR. SLATER: Sir, I have to catch a 5:10 train at : n the Capital Beltway, so I have to leave here about 4:15 or. 9 maybe a little later, if it's not raining; and I'm on Texas. 23 i can tell you Texas won't take more than five minutes. oA Jesse Salazar is the primary reviewer, it will take ten 95 minutes. ‘COVER REPORTING CO, INC. 20: Massachusetts Avenus, NE. mA AANAN OF em2 ~] 10 cl 42 13 | 44 16 av 18 19 20 ( 21 ( ; 22 23. 2A 25 HOOVER REPORTING CO. INC. 320 Massachusetts Avenus, NE. nA aAnnin 229 MR, CHAMBLISS: It will take ten minutes. DR. SLATER: We should be able to finish. _ MR, CHAMBLIS : I could make the suggestion that we take Texas now. It's too hot in Texas to start with Texas DR. SLATER: We're anxious to talk with each other, because this requires some preliminary review by us ‘ to be able to make a sensible presentation. - So if you could do it after lunch, we'd appreciate it. . | MR. CHAMBLISS: After lunch? All right, we will start out with Texas immediately after the lunch hour. DR. WHITE: Bob, where do we stand in terms of relationship with the other panel? MR. CHAMBLIS : The other panel, as of last night, had completed nine out of 23, and we had completed 14 out of 28. , | . vo. DR. WHITE: Some of us have suggested a target of this afternoon's. joint meeting. Is there some way they can be reinforced in their efforts? | | MR, VAN WINKLE: “We talked with Dr. Pahl just a minute ago ana he's over reinforcing that right now. MR. CHAMBLISS: A suggestion has been riade that the first panel that completes its work would go over and join the other and help them speed. up. | DR. CARPENTER: I also have to leave about four, and Northlands is therefore a bit of a problem, maybe, except . em3 ~~ 10 U 42 . 13 17 18 19 20 eo, ‘OOVER REPORTING CO, INC. 20 Massachusetts Avene s, NE. -- & A AKA if we finish on schedule it won't be. MR. CHAMBLISS: I think we'll get to Northlands about near the lunch hour, just before or just after. DR. CARPENTER: Thank you, sir. | MR. CHAMBLIS: Then, shall we begin with Iowa, and welcome Mrs. Wy ckof£. | MRS. WYCKOFF: Sorry to be late; r coulda't get a | cab. | em4 ~ - 10 n 12 2 14 a 18 19 20 21 Can, 22 23 of: 25 HOOVER REPORTING CO, INC. ‘good Regional Medical Program. 16 ‘as though the Regional Advisory Group, for example, had 320 Massachusetts Avenue, N.C. | 231 REGIONAL MEDICAL PROGRAM REVIEW IOWA MR. CHAMBLISS: In the caseof Iowa, Dr. McPhedran and Mrs. Salazar are the reviewers and Mr. Zivlavsky is the staff support, will provide staff support. | DR. McPHEDRAN : “I am recommending that we give Towa the amount that they are asking for. I think this is a And to go through the categories that were suggeste on the review sheet, first of all, a little background from me: I site visited Iowa in the past, it was several years ago, but a lot of the direction of the program that was there at the time is still there, and I've had occasion to meet with Charles caldwell on one or two times since then, and he continues to impress,me as an imaginative coordinator. yo, . From what is presented in the application, it sound great stength then and continues to be a strength, anticipat-— ing the form of the review sheet. To return to that, the program leadership t classify as at least satisfactory, and the staff’ as generally good in the Regional Advisory Group; a good group there. The kinds of meetings they have held in the past to develop programs and to monitor it as ‘it goes along, seemed imaginati and very much to the point. em5 ~) 10 - 11 12 . 4i4 16 -17 18 19 20 a1 HOOVER REPORTING CO, INC. 370 Massachusetts Avenue. NE. | “conduct. 232 Past performance and accomplishments as satisfactoy also. Satisfactory in all of the other categories.) I guess that the program staff and the Regional Advisory Group principally were the factors that make me feel that the over-all assessment of the region is above average. It is a well-administered staff of generalists. . It's a ‘ stated policy, that is, that persons on the staff retain some general competency in various activities that they There's a good deal of. emphasis on joint decision making on the staff members. This is gone over in the current application. I think that they have, as I say, a good Regional Advisory Group support. | The only sour-note, I guess, for me, was that the relationships with comprehensive Health Planning, which I thought previously were quite good, seemed to be somewhat less than satisfactory, as judged from some letters that I think are included in our notebook here, which were not in the original application. But, on the whole, I think that the general program purposes and their past accomplishments simply weren't what they have been asking for. And, according to this master financial sheet, which perhaps I found more helpful than I should, what they are asking for constitutes only 80 percent 233 em6 1 of what it was thought they could have in targeted available 2 funds. | 3 7 And even if they are expecting to request in July, 4 it would only come to about 95 percent. 5 I really think with the management and direction of 6 this program, it has been good enough in the past that it ‘ 7 certainly warrants that kind of support, without going into 8 ‘further detail. | of]. . a MR. CHAMBLISS: Thank you, Dr. McPhedran. ~. 10 . - Mrs. Salazar. 11 MRS. SALAZAR: I subscribe to Dr. McPhedran's 12 views, and this is the impression that I gleaned from the 13 application. i” . . However, there are some concerns which I had an 15 || occasion to discuss with Prank briefly about the CHP involve- -4ag|| ment and some other comments. But the timing seemed to be 49 bad, that they just couldn't get to them. I would like to 18 hear from Frank. 9 MR. CHAMBLISS: Mr. Zivlavsky, would you -- a6 MR. ZIVLAVSKY: Iowa, from the beginning, had a ot very close working relationship with CHP, They have maintained ( “ap that relationship throughout their program history. - Ko 03 What they have in the application is actually one of non-official B Agency comment, that there are 15 CHP agencies 95 in the State, five of the 15 are actually approved B agencies. CE ee nena Nt em? wo =~ 10 il 12 13 - 14) - 16 “i 18 19 20 21 25 234 The comment you have here is a comment from one of the non-CHP B agencies. They telephoned them in to Division RMP and requested a three-day delay in their application, This was approved, and they submitted it on the 3rd of May instead of May lst. They just admit it's a breakdown in their machinery for the CHP to be processed, because they have always taken into account the CHP comments, have been able to negotiate their differences with CHP.- They have submitted five | additional letters here, but basically two CHP agencies have delayed their review. One has favorable comments. One has a recommendation for disapproval. And the last line, I just state that the Iowa CHP has not yet responded to negative comments or questions due to the short timeframe. We received these on the 20th of May, and inserted these into the books of the reviewers and the coordinator, and we have: not had an official chance to sit down and negotiate on a one-to-one basis with each of the differences of the CHP agencies. And L, usually they have a comment in there that it's a breakdown in their machinery. The staff is on top of it. I will be watching this closely, and that's really about where it is. ‘ MRS. SALAZAR: One of the things that I noted in reading the application is the resiliency of this staff to ems 3 =? - 10 11 12 13 14 - 16 17 18 19 20 21 22 23 oA 25 HOOVER REPORTING CO, INC. TON Mhacese hucatte Avonne NF -a very flexible manner. And I think that's very good. 235 react and turn around and react to all kinds of crises, in MR. CHAMBLISS: Someone has said that's based on their youth, because they all are very go-go types, young, aggressive, they move quite fast. I simply throw that in as an observation. DR. McPHEDRAN: So I would move that they be funded in the. amount requested, which, to reiterate, is $1,061,349. “or. CHAMBLIS: We have a motion on the floor that Iowa be funded, recommended for funding at a level of $1,061,349. Is that seconded? DR. MILLER: Well, the yellow sheet says 249; but maybe there's a mistake here. DR. WHITE: What is Mr. Caldwell's background? MR. CHAMBLISS: I believe his background is either in hospital administration or public administration. DR. WHITE: He's about the third coordinator they have had, isn't he? MR. CHAMBLISS: To my knowledge he is the second. DR. McPHEDRAN: Second. DR. WHITE: Willard Prell was first. MR. VAN WINKLE: That is 249, DR. McPHEDRAN: Okay. Amend that, MR. CHAMBLISS: Do you amend the motion? Is there a second to the motion? 236 em9 Ty MRS. SALAZAR: I second it. Zi oO MR. PULLEN: It adds up to 349. 3 MR. CHAMBLISS: It has been properly moved and 4 seconded that Iowa be recommended for the level of 5 $1,061,349. 6 | It has been seconded, so we now may have discussion a DR. SCHERLIS: I note that one of the projects is 8 for emergency medical systems. I thought that was specifi- 9 cally exempted unless there were continuing projects. Is” 10 this a continuing project? It's for $74,500. 11 MR. CHAMBLISS: It is a continuing project. 12 DR. McPHEDRAN: Yes, I think it is a continuing 18 project. 14 MR. CHAMBLISS: Continuation of a previously 15 funded project. Sy. 16 || : Is there further discussion? 17 . If not, the Chair calls the question. 18 _ Those in favor? 19 [Chorus of "ayes".] 20 . MR. CHAMBLISS: Those opposed? ( 91° [No response,] ( . 99 MR. CHAMBLISS: The “ayes" have it, and the motion | 93 passes. . | oA ~--+ 25 pote REPORTING. eml1o0 ~) 10 li “a2 “18 i4 16 17 18 19 20 tt, _—— to nN 25 HOOVER REPORTING CO, INC. 9901 Massachusetts Avenu>. NE. 21 237 REGIONAL MEDICAL PROGRAM REVIEW MEMPHIS MR. CHAMBLISS: So we will now turn our attention to the Memphis Regional Medical Program. | The reviews there are Dr. Carpenter and Mrs. Wyckoff, with Mrs. Lorraine Kyttle providing staff support. DR. CARPENTER: This is a region that r've had an opportunity to visit. As many of you may know, it is an interesting Regional Medical Program involving part of five States and growing out of an existing health planning body in the Memphis area. That body later became a Comprehensive Health Planning agency for the area, and that growth of the regional program made a great series of State and local RMP's, naturally, and probably it would have been an impossible situation-without that beginning. But it really has worked well, and given the Memphis Regional Program, I think, a particular characteristi of its own, In some ways it seems to me to behave like a very broad planning agency. The nature of the Comprehensive Health Planning agency, as much as it behaves like a Regional Health Program. But I don't think it's all bad. This is a data analysis that attempts to get into ‘ health care problems in the region. It is the latest in a series of publications based on data that was,demographic 7 emll a 10 11 “42 ‘ 138 14 16 17 18 19 20 25 IOOVER REPORTING CO, INC. 20 Massachusetts Avenu>, NE. data that was available and re-analyzed to meet the region's . region. 233 needs. Also surveys of health in various places in the As usual, in the world, it's very difficult to determine that the program has been guided in direct ways by this kind of data analysis, but I believe the ability of the: region to generate that kind of data and to ‘reinforce and talk about the health care needs of Memphis has provided them with a kind of credibility leverage that has been important in the development of the program. ) The region has a relatively stable staff. The coordinator has been there, Culbertson, for a long time. And they have a stable -- well, they have had some changes in their varying structure because we had legal questions about the original arrangements. ‘They are now settled down into a standard RAG arrangement, and that was not terribly adversely affected by the regional catastrophes. They are not terribly explicit in the way they write their application. They list, I guess, four goals and 13 objectives; and, as I tried to analyze then, I come. up with what I really think are seven ideas. And these are related nicely to the usual medical goals of the Regional Program, and I don't see any problem there, , é They discuss priorities as though they were separate from their goals and objectives, which is a little discon- eml2 a 10 | il 12 13 14 16 17 18 i9 20 ( 21 25 HOOVER REPORTING CO. INC. 320 Massachusetts Avenu>, NE. Wacshinotan Df. 20002 solved the fact that they were really paraphrases, and one 239 certing, but by the time one o'clock came around I had can in fact group their goals and objectives into some range of priorities. | The request is for about $700,000 in core support, a million six for 28 continuing applications and a million for nine new applications; $300,000 for developmental awards. The projects from the beginning of this region have not had very specific goals. ‘They have been very: general: Let's get together, sometimes plan; let's get together for general action kinds of goals. And they've not been evaluated particularly well. I have great difficulty in this application in understanding in some ways what they have accomplished. On the other hand, they have brought in an enormous number of dollars from other sources to the region, or at least have contributed to it, and because of this very close working relationship between Comprehensive Health Planning, experimental health care delivery systems, and Regional Medical Programs in the area, it is very difficult to give credit for what happens. Which is certainly not.a complaint at all, but it does make evaluation very difficult. I believe that the Regional Program in that area had a significant role in bringing something like a half million dollars to the region in other support in each of the eml 2 10 — U 12 13 14 16 17 18 i9 20 21 25 {OOVER REPORTING CO. INC. 320 Massachusetts Avenu>, NE. Vashington, D.C. 20002 240 last three years. They estimate that they have served 200 ,000 patient : | in the last year, and about 2,000 professionals have been trained. So there are some kinds of program evaluation that are available; but, again, the project evaluation is a problem. And one almost gets the feeling that the projects were ancillary to the main issue. Which, again, I think is more an interesting _ different approach, perhaps; but there are some difficulties, I think. There is, for instance, $60,000 invested ina project to improve death certificates. Which really turns out to be an experiment by one of the pathologists who does one and a half autopsies a week, and tries to see whether Merays and gastric analysis would add anything to his ability to perform as a pathologist. That was hard for me to see aS a Regional Program. MR. THOMPSON: It's interesting, though. DR. CARPENTER: It's very interesting. Of the million dollars, roughly, for the nine new projects, half of it goes for area education centers in ten hospitals, and really, this project, half a million dollar project buys an organizer, a librarian, and provides space rental to the hospital, provides a secretary and some books, journals, and audio-visual material for the area. a ee eT eml4 “10 on 12 13 i4 16 17 18 19 20 ro nN N 25 IOOVER REPORTING CO, INC. 20 Massachusetts Avenu’, NE. Yashineton. D.C. 20002 21 241 Ana the outputs of that project are said to be to list the educational and clinical resources in the area of these ten hospitals, to relate the leadership of} the clinical and educational resources to determine the need for new educational programs, and to develop an over-all manpower plan. Now, I just believe that that's the work of the Advisory Committees, not $500,000 worth of staff. And I ¥ also -- I don't know, at a time when this program is going to be phasing out, I wonder what the meaning of a developmental award is. Now, let me stop at that point and see what my cohort would say. t ‘MRS, WYCKOFF: Well, I think Memphis has the most beautiful case of euphora about RMP than any of the RMP's., They have chronié optimism about how this thing is going to go on, and they are just going to conquer all the problems in the world. And it's partly due to Dr. Culbertson's personality. He carries the thing on his back. pretty well. They also operate ae a very peculiar animal. They are different from any other RMP, because they're like a family. They seem to telephone each other and keep in touch with each other across State lines and across all the terrible amount of paperwork and rules and regulations that 242 eml5 1 exist. They rise above it all and do it in an informal 2 fashion, and they seem to get together after hours and keep 3 the wheels very well oiled, and do the things that have to 4 be done. ° It's an incredible thing, and they cannot believe 6 that they are going to be phased out. They just don't 7 believe it. 8 Instead, as you can see from this report, they 9 “make all kinds of alternative plans, so they're going to 10 survive no matter what. -il And I really have a little faith in them., I 12 honestly think they may be able to do it. They have put it { “13 together, they have got this experimental health systems | 14 management agency, and of course their Comprehensive Health 15 Planning Groups, and the RMP, and they are planning to get 16 ready to jump in any direction when the legislation comes 17 through, They are going to be ready for anything. So I 18 think their development funds will be used to launch 19 whatever needs to be launchea at that time. 20 They show more faith in survival, when the crunch { 21 went on, they went right ahead with their plans, and they ( 92 are all ready to get their maximum amount of money with new 23 projects and everything whem the funds came through. 2A They have only seven -- I think it was out of, 25 was it 18? They had only seven approved and unfunded requests HOOVER REPORTING CO, INC. 320 Massachusetts Avenus, N.E. eml6 ~) “10 iu 12 18 14 16 17 18 19 20 c 21 24 25 {OOVER REPORTING CO, INC. 20 Massachusetts Avenu>, N.E. Vashinoton. D.C. 20002 putting through at the worst possible moment. - comment on this phrase “escrow accounts", Is that a 243 at the end, and I think they had li that way, succeeded in So I really think that they may be able to make a go of this. I would like to hear a little from staff on what they know about the new plans they have for this new trustee-. ship board. If there is anything in there. DR. WHITE: I wonder if Mrs. Kyttle might) also substitute for keeping money after the thing is over? DR. CARPENTER: That's a catalysm. MRS. RKYTTLE: Well, you asked about the organiza- tion that is forming, and you are quite right. It's almost incestuous, because NMCC's spawned RMP, .and RMP's spawned HSM. RMP responded to the RFP that R&D issued for experiment health systems, wrote the application, pulled the people together, set it under a corporative kind of stance, because that's what the RFP requires, and Voila, there's Health Systems Management, Inc., which is right across the hall from RMP. DR. McPHEDRAN: I'm on the ropes, Mrs. nyttle. RFP, R&D sent out a request for contract proposals across the country. That's a request for contract proposals, for proposals onexperimental health délivery systems. Regional Medical Programs in Memphis sat down and wrote one, but did em17 ~l 10 | di 12 13 14 16 17 18 19 20 25 JOOVER REPORTING CO, INC. 320 Massachusetts Avenu, NE. Vashington, D.C. 20002 244 not send it in under their name, because they were not at that time a proper applicant, They spawned HSM, RMP and the local B, which is one of the most active B's in the State of Tennessee, not just west Tennessee but in the State of Tennessee, had formed an umbrella trusteeship -- and that's not a catalysm; that's theirs. They call it an umbrella trusteeship. It proposes the merger of the executive committee of each of these agencies, and it is a straight-forward, unabashed move to present the three of them. This is not an area where one is more interested in surving over the other. The three of them want to survive. They did an intersting thing. They agreed that each of these three entities, if their full boards ratified it, and since this paper was prepared all of the boards have ratified it, the full boards. The body bringing the largest turf to this umbrella trusteeship, and without doubt that's RMP with parts of five States, would bring the turf or cognizance of this new group, should the turf want that. And so there is, then, the possibility that there would be an 80-county five-State Health Service Agency or whatever might come out of the new legislation. They thought that that would be the experiment, and that's the purpose of that organization you asked about. MRS. WYCKOFF: They believe in survival. em18 10 | ; ll 12 . 13 14 16 17 18 19 20 as 21 25 4OOVER REPORTING CO, INC. 320 Massachusetts Avenu>, NE. Machinatas AE FANN? a complication in that frame. The possible complication is - that Memphis RMP has assisted, and that is from beginning to 245 MRS. KYTTLE: The three of them, not just RMP, MR. THOMPSON : It does offer complications, however. We're used to, you know, the one-on-one business, who's on, who's off, between CIIP and RMP. Now, they have substituted a menage a trois kind of thing, to complicate it even nore. . MRS. KYTTLE: I don't know if they look at it as where they are now, all other B's in west Tennessee, all of then, But the one that is operating in southeast Kentucky is a Memphis RMP, funded not any longer, but it was, MRS. WYCKOFF: And Mississippi. MRS. KYTTLE: Northern Mississippi “and the boot- heel of Missouri and eastern Arkansas. The five operating B's are all B's that have been funded and initiated by Memphis RMP, Now, if Memphis RMP pomes into this umbrella trusteeship with the greatest territory, it will encompass the territory of those Bis, and they know that, and they realize that that will be the option. If those local B's. and indeed the legislation permits that type of arrangement, they thought that that would be the interesting experiment to form a new Health Service Agency for that terrain, wit- subcontracts with existing B's, that they have already funded, eml9 10 11 "412 | 13 i4 16 17 18 “19 20 25 JOOVER REPORTING CO, INC. 320 Massachusetts Avenu?, N.E. Nachinstan NC 20007 246 MRS. WYCKOFF: I guess you have to give Dr. Cannon a little credit for also holding this organization together. MRS. KYTTLE: Yes, ma'am, DR. SCHERLIS: Yow much of the funding actually ' would be directed toward the setting up of such a group? | How much of it is seed money? MRS. KYTTLE: They seek no funds for that. The I arrangement they have made is that they are rotating for the first period of operation, the executive director of HMS serves as the chairman of this new board, The staff is provided by RMP, and the leg work is done by CHP. and for the next ninety days, they first started thinking of a year and they realized that that would be too long a time, the next ninety days the coordinator of RMP . serves as chairman; the staff of HSM has to fund the money to get the staff work done, and the CHP organization does the regional communicating. DR. SCHERLIS: You°told us about that $400,000 in escrow, DR. WHITE: There's actually 800,000. ‘There are actually two different escrow accounts. MRS, KYTTLEs This application seeks no money for € that organization. DR. SCHERLIS: Yes. But where does the money come em20 ~~ 10 se 12 14 16 17 18 19 20 ( 21 25 HOOVER REPORTING CO.,1NC. 320 Massachusetts Avenu, NE. Washinotan. D.C. 20002 247 from? Two things: how is it: labeled, and how can a sum of money be available? MRS. KYTTLE: All right, that's the first question you asked about. The $800,000, when you total the two, it's a combination of five and three. Let's speak to the 500 first, and that is the creation of local consortia to ‘develop health manpower needs and relate them to identified health service needs, and relate them to health manpower resources. MR. CHAMBLISS: Is that to which the funds are going to be used? MRS, KYTTLE?: Five hundred thousand, DR. CARPENTER: That's for ten hospital librarians, ten secretaries, and ten planners, community . organizers. MRS. KYTTLE: You asked if that should not be the work of the local advisory committee, because so many of these groups were formed from such advisory committes; but they have no local advisory committees. These are predomin- antly in ares where there are not B's, and this is how Memphis starts B's. DR. CARPENTER: No, they have B agencies now except in -- organized in every area, but not -- MRS. KYTTLE: They are not funded. em21 ers, on ~ 10 ll 12 14 16 17 18 19 20 21 aoe, 22 23 2A 20 JOOVER REPORTING CO, INC. 320 Massachusetts Avenu>, NE. Nachinetan AC 20002 248 DR. CARPENTER: Two of them are not funded. But ‘they are two out of ten at most.. No, these are not B agencies, these are -~- MRS. WYCKOFF: Health Centers. DR. CARPENTER: These are hospital libraries. MRS, WYCKOFF: ‘There's the seed money to start) things. MRS. KYTTLE: I said they have no local advisory committee in these areas, save Jackson. There is one in’ 4 Jackson, and there's one ongoing there. j DR. CARPENTER: But they showed us a map of the B 1 agencies, right, and they cover the whole area except maybe a few outlying counties. ‘MRS. KYTTLE: These are areas that have no health manpower committees working in them. DR. CARPENTER: “oh, okay. No manpower committees. MRS. KYTTLE: And that's how they have Spawned, they have first developed some health manpower committees for B's. These are areas whee the B's have formed without health manpower committees, DR. CARPENTER: That's the point I'm making. If they had the manpower committees, they wouldn't have to spend a half a million dollars. | MRS. KYTTLE: Well,‘for some reason, and I have tried to research it and I don't understand it, the philosophy em22 ~ 10 11 ' 412 13 44 16 17 18 19 20 23 24 25 HOOVER REPORTING CO, INC. 320 Massachusetts Avenu3, N.E. Witte... AM INAS 249 the Memphis Regional Program thinks local consortia to address health manpower needs should be seated in a hospital, They feel the hospital setting is the setting for an HSEA, and they have felt that way from the very beginning. And that's where these are, ten sites. MR. CHAMBLISS: Dr. Scherlis. DR. SCHERLIS: Now we've gotten through the first gear, what happens to the second ten libraries, secretaries, et cetera, for the second year? They are being funded? MRS, KYTTLE: The same thing that will happen for all the others. Some of them will make application under the new legislation as health service agencies. r mean, that's going to happen across the country. Most of then feel that they are ready to make application. MR. THOMPSON: Ten libraries are going to be certified as health agencies, as r understand you? MRS. KYTTLE: One of the first things the local area is going to have to do is to create its own manpower committee. The librarian wiPl not be -- even she's a part of the system, but she is not the pivot. DR. WHITE: I'm suffering from an inability to recall Webster's definition of “escrow". But it seems to me it has to do with putting money aside for future use. MRS. KYTTLE: They want to impound their own money. They want to put $500,000 aside now so that they feel em2z3 10 i i “13 14 1G 17 18 19 20 25 JOQVER REPORTING CO, INC. 250 by July they will have gotten these things ready to ga to contracts, or in the writing stage now of when, I think one is in Kentucky and the other is in Crittenden County in Arkansas. Rather than coming in in July with this proposal of ten sites all worked up, they want to escrow the, money out of the total package now, so that it can begin in July rather than make application to us in July. MR. THOMPSON: So, in other words, they want to use “the escrow business as a substitute for a specific| proposal. MRS. KYTTLE: Yes, and they want to tell you now what they want 7 put it aside for. MR. THOMPSON: Has this proposal been matched up through the whole internal review process as a proposal? MRS. KYTTLE: As a concept. DR. CARPENTER: I think there are a series of small proposals. Isn't that the way it got through the RAG as small proposals? But it did in part, in $25,000 hunks it went through RAG, : MR, THOMPSON:: $25,000 hunks up to $500,000? That's a nice piece of business. | DR. WHITE: They have got $800,000 there. MRS. KYTTLE: And it all went through at once. DR. CARPENTER: They didn't hide any of it. MRS. KYTTLE: It did not bleed through, it went through as a concept, and $25,000 apiece for ten sites. em24 ~1 10 11 12 18 14 16 17 18 19 20 25 HOOVER REPORTING CO, INC. 320 Massachusetts Avenu?, N.E. nA aanan 251 DR. CARPENTER: Can I, at this point, break into the conversation and make a funding recommendation? MR. CHAMBLISS: You may, indeed, Dr. Carpenter.. DR. CARPENTER: I would, just to get the discussion going, move a certain funding level. Their annualized rate now is a million and a half. Their targeted rate is about two million three, and they request three million four now . and predict that they will ask for a million two later, | and that will get them at two times target. I think that the region is pretty good, but not in a position to go from a million and a half to four million seven at the time of phase-down. I would suggest a funding level a little above the target level, of $2,600,000. | MR. CHAMBLISS: Will you place that in the form of a motion? - ”. oo DR. CARPENTER: Yes, I do. MRS. WYCKOFF: I'11 second that. MR. CHAMBLISS: It has been moved and seconded that the level be established for -- be recommended for. - Memphis at $2,600,000, | Is there discussion? DR. WHITE: I would like to pursue this further, and I am going to. We've talked about the 500,000. There's another 300,000 in escrow dollars, which I interpret as this, Mrs, Kyttle, as underwriting the survival of these three in em25 ~1 10 ll "12 13 i4 16 7 18 i9 20 21 25 DOVER REPORTING CO. INC. 20 Massachusetts Avenw2, NLE. fashington. B.C: 20002 252 whatever form they're going to take. It says that, I think.. MRS. KYTTLE: It says that high priority out of this developmental will be given to those agencies, you know, in the total region. That's the RMP region that I'm. pursuing, the logical kinds of things that the new legisla- tion proposes, ! There again that falls within the umbrella purview, but the umbrella -- the organization that is the umbrella is not seeking funds, but it seeks to fortify its philosophy that it's a good umbrella, it hopes that the legislation will speak to a State, you know, whichever one a out firs and it wants to have agencies funded within it, that it can contract with, That's what the high priority is for those agencies DR. WHITE: Now, is that $300,000 the same as the developmental fund? MRS. KYTTLE: Some of those are B's. Yes, that's out of that. ° a MR. THOMPSON: I think what we see here is probably the bald statement of the problem that you are finding more or less in the same degree in all of these, most of the proposals, and this is an attempt to second-guess what the legislation is going to be as far as, you know, whether this is regional health authority or State health authority, em26 ~) 10 ll 12 14 16 li 18 19 20 21 Pubeett ( 92 23 2A 25 HOOVER REPORTING CO, INC. 320 Massachusetts Avenu, NE. and it's floating around in all these crazy bills. 253 Now, I think we have a policy problem here, whether our RMP funds should be used to relate an agency, a proposed agency for nonexistent legislation. And I think that's true here, I think that's true in a subsequent thing that I'll review to you. In other words, when you, from RMPS sent the message down: Fellows, get on the ball with your. CHP and no kidding this time. “We've seen a lot of getting into bed with CHP, and it's -=- in fact it now looks like a plot by the two of them to survive, whatever happens. Now, I don't know what's going to happen if this legislation setting up this envisioned Regional Health Authority is delayed by two years. You know, all this money that we're pouring jn here to build these various elaborate umbrella agencies, the consortia -- they have about six names for it -- it's going right down the old tube. MR. VAN WINKLE: I would like to.point out that they have been encouraged to start various programs with CHP. MR. THOMPSON: That's what I'd like to know: who has the crystal-ball authority that they can tell me that the Regional Health Authority is going to be established by the end of RMP's life, and take over RMP's staff or skills and start in business. Who the hell has got that informatior I don't have it. a4 em27 1 MRS. KYTTLE: Mr. Thompson, you know it would be 2 ‘beautiful if that were the case, but no region has had that \ 3 word, and they are all trying to take the most logical and 4 flexible stance that they can, trying to provide for the possibility of State structure as well as providing for the 6 local structures, until they .see what the legislation is. 7 MR. THOMPSON: When you cover all the bets! on a 8 racehorse it costs a lot of money, and that's what these 31} - people are doing. They're putting two bucks on every horse 10 _ in the race, hoping that somebody will come in and they will 11]| be on it! As long as it's not their money, that's okay. 12 MR, CHAMBLISS: This is one of the policy questions 13 that we alluded to earlier on when the committee was convened| 1 14 and this is one of the issues that will be dealt with as the 15 review goes forward. . 16 I would like ee the presence of Dr. 17 Margolis here, our former Director. And since this is a 18 policy issue, I'm wondering if he would say a few words on 19 this point. 20 DR. SCHERLIS: I was just going to make one ( 21 suggestion. I think that Memphis really shows some good ( 99 judgment with the idea of an escrow account for $800,000 and 93 I would think that some of the wisest judgment that this ‘ . @ Review Committee could make is to have an escrow account of 25 HOOVER REPORTING CO, INC. 320 Massachusetts Avenu>, NE. Washinoton. 0.0. 20002 a hundred, a hundred and twenty to forty thousand dollars © em28 os ~ 10 - 11 12 13 14 16 17 18 19 20 nN N 25 JOOVER REPORTING CO, INC. 320 Massachusetts Avenus, NE. Nashington, D.C. 20002 42929 that we would have available, and say, let's save that for “some decent health planning as of July Ist, 1975. While ‘I wasn't here yesterday, which is a calendar error that I apologize for, I spent, really, as all of you did, a very difficult time reviewing these, because we're doing it on promise and hope and faith and, frankly, charity. | And all the old judgments that we have used have had to go down the drain completely in reviewing these; and _ I think that if Memphis gets approved for an escrow account, that my next suggestion will be that we vote an escrow account of a hundred or eighty million dollars for July lst, to be used if there will be health planning then. I don't think that putting this into some thirty, | forty, fifty little different projects, that we're begged for and scrounged for by Going out and saying, Come on in, we have this last chance to get it. A lot of them read that way. That that is really the equitable way for us to use government funds, I have the serious questions that all of you have had, and we're operating within a very difficult framework, to reach equitable decisions. I am all for escrow accounts, particularly of most of that one hundred and twenty or hundred and forty million dollars. em29 ~ 10 11 12 13 i4 16 17 18 19 20 21 ee 25 HOOVER REPORTING CO, INC. 320 Massachusetts Avenus, NE. An AAAnn 256 I didn't mean to pre-empt you, but I wanted that stated somewhere along the line. | DR. MARGOLIS: Well, my most positive word is that I am delighted to see my good friends here again. I am delighted to see that you are tearing at things as usual, | I don't understand your concern, John, in not knowing how to spend money on nonexistent legislation. After all, money was appropriated, impounded in '73 to be° spent in '76; when the authorization would expire by June 30th, anyway. | | So it's a perfectly clearcut situation! I would like to address this question, because I think the points you raise are important, and rather than matters (of policy, although they certainly involve policy, there are also senses of ‘ining in judgment, which will have to replace, as they often have in this program, some kind of policy base. In all of the discussions on planning, legislation, developed both some kind of unified health planning proposal, there has been more dissatisfaction -- and not very well hidden -- than gatisfaction with everybody's proposal, as you implied. The administration is not wildly enthusiastic about what it has proposed. The Rogers Committee feels about the same about its own proposals, . There is great uneasiness +, “em30 ~ 10 i 412 14 16 17 18 19 20 f 21 ( 22 23 2A 25 HOOVER REPORTING CO, INC. 320 Massachusetts Avenu>, NE. Wachinotan NL 9NNN? 257 about what would occur. Time is running out. And some of the basic problems remain. The problem which everyone has looked at, usually defined so poorly, that it is looked at plainly, is the meaning of planning, the relationship between planning and implementation; and the relationships between planning and management. ‘ | 7 : | Traditional questions which have been up for consideration time and time again. “The difficulty involved in all the pieces of legislation and in the debates which really don't get around to this is that ‘no one is ready to | say what that relationship ought to be. Nobody is willing to come down hard, although there are indications that a position has. been developed. For example, tas now felt that whatever these health service agencies will be, or whatever name they a out under, they will be private, nonprofit structures within the State. There will be an uncertain kind of support for State structures. The planning process will be kept from State implementation, however, there will be some small amount of money for implementation, a larger amount of money for implementation based on whose bill you're looking at. What is missing in the process is something which can produce, in the health delivery system, a cooperative em31 208 1 structure which allows people to operate in the private and 2 in the nonprivate systems in such a way that they are able 3 to do together more effectively those things which they wish 4 to do than they can do them separately. Which is an early f 5 description of Regional Medical Programs. 6 It creates a real problem. And in many ways what a our reviews are attempting to do is being approached under 8 ‘other names, with different kinds of understanding, and with 9 a variety of methods. 10 _ But the debate has not been joined. I don't think u it will be joined. And when you're through with this 12 session and we're through with the review session which is f 13||' coming up after that, there is still going to be great 14 difficulty in making a judgment about what is RMP going to 15 do in relationship to CHP, what will the planning function 16 |] - actually be, what will the relationships be between planning 17 and implementation; and, furthermore, what is going to be 18 the role of the State government in this? 19 Because, in general, the role of State goverment 20 has been downgraded,;almost lost sight of, there have been - 9] serious objections to it from outside and from within. And ( 90 we're going to be entering the fall season whether using an 93 escrow account or not, with no more certainty about what oA that relationship is than exists at the present time. 95 What we have been saying is a’ consequence, and it's HOOVER REPORTING CO, INC. 320 Massachusetts Avenu, NE. Washington, D.C. 20002 em32 ~~) 10 n 12 13 14 16 17 18 19 20 25 HOOVER REPORTING CO, INC. 320 Massachusetts Avenu>, N.E. Washington, D.C. 20002 259 about the only way out, maybe not too bad a one, is that the most proved factor beyond a Regional Medical Program, and it's now my job in addressing all these programs, it applies to others as well, certainly the CHP; but beyond the CHP, the other kinds of federal programs which are in the States which have sort of opted out of this activity, 4 the most judicious: thing for them to do is to get together ‘with one another as rapidly and as fully and as enthusiastic _ ally as possible, and decide what they're going to do togethe regardless of what the legislation is going to look like. And between the passage or nonpassage, which is a good likelihood, of the legislation, its approval, its appropriation, its regulations and its administration, so many things will occur that if the people who are out there quit trying to decide who is going to be in charge and v. decide how they are going to run the thing together, they are going to move rapidly ahead, Now, sometimes this is interpretative on the part of RMP people, if I'm talking to them, as some of the RMP's are, is that they should quickly move to take over. | Now, that wouldn't work. CHP takes the same response when they are listening to their own partisans; it's for you to take over. | And if they will get just a little smarter, they will move together; but they are going to have to move with cr, em33 ~} 10 | u 12 “18 i4 16 17 18 19 20 21 25 IGOVER REPORTING CG, INC. 20 Massachusetts Avenu>, N.E. Yashington. D.C. 20002 ‘rather minor actors. 260 other programs. Maternal and Child Health Service, Community Mental Health Service, which, for some reseon, along with others, have never been considered a part of the general concept of comprehensive planning. Migrant programs, all of them have each been looked at separately, and all the conversations have been RFP and CHP as if those were the only actors in the game; when, in fact, they are some of the actors, and in many instances Now, I think the additional thing which is) going to make a difference, about the time we get started with it, is the growing concern with the regulatory function within the State which will produce an entirely different environ- ment for the total relationship between planning and. implementation. Because, the regulatory function will throw in a new responsibility which must be a State responsibility, almost by definition. That regulatory function already applies to institutional development. It's going to, in all likelihood, involve cost control, because we get national health insurance and there is freer and freer conversation now about a complement to certificate-of-need legislation for construction and that will be some kind of certificate~of-need for man- ée power, Now, when these kinds of things occur, people who v y em34 ~~ 10 u "12 ( 18 44 16 17 18 19 20 ( | 21 25 HOOVER REPORTING CO, INC. 320 Massachusetts Avenu2, NE. Woehinatas HWE ANNI 261 have been vying for responsibility may find themselves vying for getting out of sight; because it's going to be no ‘child's game. And yet by looking at the total structure, as it will be much faster than many of us have expected, the relationships between the planning, the implementation, the operational and the regulatory functions can become clearer, and the responsibilities for the various parts will begin to fall into place. | But to try to assume full management or full authority for any one of them is injudicious, it won't work, and I don't think anyone would really want it when they get all through with it. The real struggle, in all sincerity, will be on the part of those who aaa that the regulatory function, particularly control of rates and fees, be placed anywhere but where I am. Nobody is going to want that. And yet it is going to be the part of the system which is going to have the greatest power, and from which most of. the strength is going to flow within the States. I think it will go in the States gradually. The other big debate is whether the National Health Insurance is to be more federal or State directed; but that's a very fundamental issue. Now, I know that's not a policy thing, but at least 262 em35 } it's a statement ofsome kind of dynamics which will work 7 well some place and not others. The concept: of escrow, I 3 would certainly agree with you, is certainly -- if you're 4 going to consider the setting aside of funds for an uncertain 7 but realizable goal in the immediate future, that should be 6 a programmatic kind of action across the board, rather ‘ ‘ than ‘limited to any one program, to come up with that kind 8 of an idea 9 And even then, it is a risky kind of thing to do, 10// because you don't know what the situation will be when those iy funds are released, | 12 I don't know if that helps or not. _ 13 MR. CHAMBLISS: Well, thank you, Dr. Margolis. i4 There may be some questions that the panel would like to 15 raise, in addition to 77 Dr. Vaun? 16 DR. VAUN: Getting back to this, not with regard 17 to Dr. Margolis' comments , the only thing that concerns me 18 about the escrow is that, does this place any of the 19 other RMP's that have seen fit to come back in July, ata 20 disadvantage? 21 In other words, are these people gambling that all 99 money is going to be doled out on the first round, and, really 23 what you've been saying is not so there won't be any money 2A left for the second round, so they're putting their little 25 nest-egg in an . : JOOVER REPORTING CO, INC. 120 Massachusetts Avent, NE. Nachinetan AL INN em36 ~~ 10 ‘Ul ' 12 13° i4 16 17 18 19 20 25 HOOVER REPORTING CO, INC. 320 Massachusetts Avenu>, NE. Wachinotan NC 200K? 263/264 Has that thought occurred to anybody? Is this what they are trying to do? MR. CHAMBLISS: There will be a sum of moneys remaining for the second round. DR. VAUN: So as you envisage it, this would be not placing anybody at a disadvantage? The other RMP's. MR. CHAMBLISS: Well, the total amount is limited so therefore what is ultimately awarded to Memphis comes out | of the entire amount available. DR. MILLER: Isn't it true that previously, except for developmental fund awards, which has not been mentioned in the current directions, no region was allowed to just apply for escrow funds, by lump of escrow money. You got it another way. But you couldn't apply for escrow funds. o v. . And now you do not have an authorization or direction for regions to apply for a development award, either; do you? MR, CHAMBLISS: We do not. DR.MILLER: Well, isn't it appropriate that this review committee specifically record in the record that we do not recommend funding for that activity or that kind of an award, that part? MR. CHAMBLISS: That would be a problem, and we are looking to this committee for its judgment on that. Sa “i ~ ¢ ¥ em37 ~~ 10 i "12 13 14 16 17 18 19 20 25 {DOVER REPORTING CO, INC. 320 Massachusetts Avent, KLE. Yachinetan AL 20? 265 DR. MILLER: Do you want that in the form of a motion? MR. CHAMBLISS: A motion is not in order at the present time. There is a motion on the floor, and that motion is that the level of funding for Memphis be recommendell at $2,684,000. | MRS. WYCKOFF: Well, why don't we do it? a, MR. CHAMBLISS: You may so indicate that, and the staff people will take due notice of it. | MRS. WYCKOFF: Should we amend the motion that the escrow funds be taken out of this? DR. WHITE: All of the escrow ‘funds are.on the yellow sheet, they are not on the application. The awards, What you see on the application is a developmental award and a project, and I believe we are not supposed to get so deeply into the region's management as to reject a specific ”. project, I guess I have the feeling that if we reduce the requested funds by an appropriate amount, the region will probably behave fairly well. *And I would be satisfied just to reduce the funding amount and then proceed. | Does that make sense to anybody? DR. McPHEDRAN: Then how about, as a separate piece of business that does not have anything to do with this é particular consideration of this program, that we could have this motion that Dr. Miller suggests. Could we do that? em38 =~] 10 il 12 ( 13 14 16 17 18 ‘19 20 25 HOOVER REPORTING CO, INC. 320 Massachusetts Aven, N.E. RA AAAAA 266 Just as a general part of the proceedings of this committee. If we could do it that way. MR. VAN WINKLE: But the staff can also express your concern about these two items. MR. CHAMBLISS: Then I call the question. Those in favor please indicate by the usual sign in voting. | [Chorus of “ayes".] “MR. CHAMBLISS: Those opposed? [No response. ] MR. .CHAMBLIS: The motion is carried. At two million six, with the concerns of this panel being conveyed to the region in the advice letter and by staff. I must say that the privilege that we've had of having Dr. Margolis, the Deputy Administrator of the Health Resources Administration, come in just at this key moment, when we were discussing a very critical issue having to do with Memphis, was most timely. I would endeavor to ask the staff to set the whole question in some type of framework, and then we would like to have Dr. Margolis comment on those issues, be conveyed to the staff and to perhaps some of the regions. I think this is very timely, what he has done. em39 m=] 10 ul 12 13 id 16 17 18 19 20 i 21 ( 22 23 2A 25 LOOVER REPORTING CO, INC. 20 Massachusetts Avenu>, NLE. _ Ao Annan 267 REGIONAL MEDICAL PROGRAM REVIEW MISSOURI MR. CHAMBLISS: . We shall now then turn our attention to a review of the application from the Missouri Regional Medical Program. The reviewers here will be Dr. McPhedran and Dr. Miller, and staff support will be provided. by Mrs. Resnik. Thank you, Dr. Margolis. DR. MCPHEDRAN: Yesterday Dr. Miller and I got * some additional material on the Missouri application, and I cite this now not to beg off, because I have read it, in fact, but it was interesting because it was. a staff visit to Missouri and it was suggested to me that maybe I ought to change my views to some extent. In fact, the value of this program and the. merit of the application, specificall But I must say I think it hasn't changed my views a whole lot, and, while I've got more to say about it than I did, it really remains about the same. To go through the review sheet: program leadership I was unable to classify one of the categories, and have checked "satisfactory to poor" because I think that it is variable, without mentioning particular persons. I think that it really is uneven, and I'm basing this on the fact é that the leadership seems to me very much the same as I recal it from at least two -- because I've been there twice -- ™ i em40 ~~ . 10 il 12 . 13 14 16 17 18 19 20 21 es 25 {OOVER REPORTING CO, INC. 320 Massachusetts Avenu?, NE. Vashington, D.C. 20002 -they postpone the marking of that enlargement, it is 268 two previous site visits, and a lot of discussion at various National Advisory Council meetings. . | I really think that what has happened in this application reflects this leadership to a considerable extent. I have no criticism to make of the program staff, and never did, except that I think it used to be very large, and the proposal suggests enlargement. I can't -- unless currently 30 with a proposed addition of 45 staff. The program staff in the past we used to criticize, maybe this should have been more a criticism of the leadershit for its lack of initiative in helping people in the region to develop parts of the program, develop projects and develop other component parts of the program. According to the moet tecent visit, that is nota problem now, but it certainly used to be. I am persuaded by the recent visit, I have said that at least it's satisfactory, but I really wonder whether, if it's satisfactory now, it is justified to consider all the additional staff to such an enormous ly large staff that is proposed. The Regional Advisory Group which, until a couple of years ago, numered only twelve, has been increaseg, I thin by two stages toa total of 55 members, and it appears that em41 ~ 10 11 12 13 i4 16 17 18 19 20 21 22 23 24 25 HOOVER REPORTING CO, INC. 320 Massachusetts Avenu>, NE. Washington, D.C. 20002 269 it is satisfactorily supervising the activities of the program, In the fourteen months before this application there were four Regional Advisory Group meatings , I think eight of the Executive Committee, and several of the various technical and standing committees. | So the committee structure has continued to functio and the Regional Advisory Group also said that there is a ‘fifty percent attendance rate at these several RAG meetings. Past performance and accomplishments, I think are mediocre for the most part. I found it difficult to either say satisfactory or poor or inadequate. Considering the amount of money that this program has gotten in the past, it is difficult for me to be more generous in my assessment of this. In the past there was a very large investment made in a lot of computer centered activities, and I guess that this still remains with me, although it's all gone from the present application. | We thought, ‘those of us who visited it, that there was bad judgment and even, perhaps, appropriate for the State of Missouri. , mulishness about following the direction and guidance that we attempted to give. | The objectives and priorities seemed to be satis- é factorily stated. I think that the proposed activities, and I can em42 ~) 10 asl 12 18 14 16 17 18 19 20 21 25 HOOVER REPORTING CO, INC. 320 Massachusetts Avenu:, NE. Washington, D.C. 20002 . is a question pertinent to the one Dr. Scherlis raised 270 summarize briefly the categories are satisfactory but not imaginative. The feasibility, that is, the likelihood that the activities proposed can be accomplished in the time that they anticipate the program will continue is, by their own statement, likely in some and unlikely that they can manage in others. t For example, they state that all the EMS activities that they have proposed, and I will come back to this, there earlier, whether or not these are new EMS activities; but they say that they feel these activities can be upgraded in the next year. I really wonder whether that is so. The cooperation with CHP seems to be quite satisfactory. My over-all assessment of the region is that it 2 /. is only average. I am afraid I have more comments and remarks to make, In this Regional Medical Program there appears to be no serious problem in the relationship of the grantee, which is the University of Missouri, and there never has been and that continues to be,°I gather, a satisfactory relation- ship. MR. THOMPSON: | You‘don't shoot Santa Claus.. DR. McPHEDRAN: No, not intentially. em43 ~ "10 i 12 13 14 16 17 18 19 20 f 21 25 {OOVER REPORTING CO, INC. 20 Massachusetts Avent, N.E. Vashington, 0.C. 20002 207) 546-6666 271 The major thrust that they have stated for them- selves are five: emergency medical systems; health; Manpower; education, and under that category especially training people to deal with the problem of high blood pressure, and training seminars to be conducted for, many categories of hospital personnel. Third is listed as integrated health care delivery systems, with especially heavy emphasis, as I see it, on -Supporting hospitals in. developing JCAH type criteria, and also a problem of oriented records for local practitioners. Ambulatory care systems, particularly concerned about availability and of care. The purposes, the major thrusts are as general -- I'm quoting from the application there; just general, as I'm stating them to be -- systems for end-State = kidney manage- ”. ment. Their fiscal year '75 suggests that their EMS role will be completed, and the local communities will be able to take the developed programs and projects and handle them on their own, although I don't think that my reading of the application particularly supports that. Then I went through the request for funding, including changes in core staff. I spent less time, I must say, on the continuing projects, but a good deal of time on the new projects, and tried to dig out for my own em44 mY 10 dU "2 _ 13 14 18 19 20 25 HOOVER REPORTING CO, INC. 320 Massachusetts Avenu>, NE. Washington, 0.0. 20062 272 purposes what I thought was a necessary expansion of core staff. And what I questioned might be new EMS projects, and I realize the staff might have gone through this and may want to, perhaps, dispute my judgment. The excisions that I performed enabled me to cut their proposal from $3,010,113 down to $2,295,113, I felt, that there was $713,000 that could and in my. view should be removed from the proposal; and it happens to coincide with ] what staff, in the person of Mrs. Resnik, has recommended; and I guess it also coincides to some extent with the | targeted amount. , But I think it is worthwhile to suggest what specific things there were, There were, for example, requests for what amounted, I think, to increases in core staff, They have six district consultants, and the recent staff site visit suggests that they should be continued. I have no quarrewl with that. But there is a suggested sum of $31,000 by sub region to increase staff support for tHe distrist liaison to $186,000; and I will quote from the application what the ultimate justification is. It is said that the specific outputs would be a plan and method of implementing the plan to operate under : the new legislative athority. If no legislative authority is forthcoming by fiscal year '76, this year's effort will em45 ~~ 10 1 "42 433 14 16 17 18 19 20 25 HOOVER REPORTING CO, INC. 320 Massachusetts Avenu>, NE. Washington, B.C. 20002 me that that money ought to have been spent. -273 have been one of which the Missouri Regional Medical Program can well be proud. We will have brought together at the working level members of principal federal and State health agencies, to work toward a common cause of improving the Statewide health care system, and I think that I would really have felt that even in a Form 15 something more specific than that could have been given me as a peroration to convince | There are other things in there that I feel a similarly if not worthier of support. I won't bother you with the details, but I do want to mention that I thought that there were about around twelve, as I see it, new projects, no EMS, twelve, roughly, totaling around $245,000, that I | just don't think are in the guidelines, are they? MRS. RESNIK: iba treating them as gub~compenents of already existing and ongoing EMS projects, which is essentially what they are. They are dealing with training, but in different locations. And they tell us that they © understand that that is within their authority under the. present guidelines. They are applying to the EMS bureau, but they don't foresee any grants, DR. McPHEDRAN: This looks to me like new EMS, 7 . and so that's 245,000, and then going through some other projects, I noticed this, but I did it anyway, I thought there em46 ~! 10 11 "12 13° i4 18 19 20 25 HOOVER REPORTING CO. INC. 320 Massachusetts Avenu>, NE. Washington, D.C. 20002 274 were several things, like there's a quality criteria project in a hospital in Jefferson City, and it looks to me as if that really is PSR activity, and I wonder if that similarly should be excluded. And several other things that also seem to me une suitable. , So that, in summary, what I did was I felt that at least $715,000 could come out of it, and I came out with a recommendation, as I say, of $2,295,113, which is obvious ly unreasonably precise, but it is approximately where the 1 targeted sum is. I would have no quarrel if we said the | targeted sum would be satisfactory; and I would like to know what Dr. Miller thought about it. | MR. CHAMBLISS: Dr. Miller. MR. MILLER: , This is an interesting experience we all go through, I pursued a rather different and more devious route of arriving at the same conclusion. I have known the Missouri Regional Medical Program for a long time and many of the staff people on it, and. perhaps it is worthwhile to mention a little of the backgroun on this. When RMP got started, Missouri was really ready, because Missouri was more regionalized . in the medical ¢ establishment than most any State in the’ union, having their medical school in Columbia, which is a small, a relatively em47 ~] 10 11 12 13 14 16 17 18 19 20 ate, { | 92 23 oA 25 HOOVER REPORTING CO, INC. 320 Massachusetts Avenus, NE. Washington, D.C. 20002 21 275 small city, and therefore, having had to farm out clinical ‘medicine for a long time into other communities, which is almost never done in most of the other medical centers in the United States, and which was extremely repugnant to then, as you may all remember. So Missouri was, its time had come, and the mule characteristics recognized this, and they proceeded with vigor. ‘They also had some people in the leadership posi'tio who have considerable skill in recognizing political expediency, and when it is popular at the national level to spend money on electronic computer equipment and remote control things, they were in there for millions and get then. When it is politically expedient to turn thém off, they turn them off like it was a water faucet. Which they have 7. a now done, because something else is politically expedient. I have four applications that are mine that are coming up today, all of them are somewhat similar. And Dr. Schleris' comments previously have bothered me, yesterday and today and last night, and even lose a little sleep over it. Because the principles formally ascribed to Regional Medical Programs of quality programs, well evaluated demonstrations that are woth the money, seem to be all gone, and I suppose it seems a matter of political expedience, but " am48 “1 10 11 "312 138 14 16 | 17 18 19 20 oN Nn ror 25 HOOVER REPORTING CO. INC. 320 Massachusetts Avenu>, NE. Washington, D.C. 20002 sR en FOR 276 it looks like we're stuck anyway. But it is bothersome. And in these four programs that are coming up, they all have applications, they are going gung ho for election, it's politically expedient to get the money and they're out to get it. And by whatever most clever mechanisms they felt could be used to get it, regardless of whether it is cost > effective or will be continued really, or what the ultimate goal is. a | Now, Missouri has done it to a rather great degree. It has -- it doesn't have an escrow item in here,'a develop- mental fund item, but its method will give it a nice big one, There are separately described staff component projects, 26 of them in this application, either with a dollar amount, none of which is excessive by itself; but together is nice. | . There are six district liaison systems with a total budget of $186,000. They went all out on EMS without having a general State EMS plan, which is forbidden, so there are five continuations and eleven new EMS projects, for a total of $518,000, It would be some Little job to keep them coordinated Maybe they will need those district guys to keep all those different outfits working in any kind of a rational coordinati way. i I could go on in more details, but I think I will ng em49 ~] 10 11 12 14 “16 17 18 19 20 21 i 25 HOOVER REPORTING CO, INC. 320 Massachusetts Avenu2, NE. Washington, D.C. 20002 277 say, first, however, that a little bit in contrast to Dr. McPhedran's view, I feel that the basic questions that we're supposed to answer on this review sheet, most of them relative to other RMP's, you'd have to grade Missouri as good to excellent. The program leadership, you may not like them, but. they've done a good job in Missouri. The program staff is ‘equally so. The Regional Advisory Group, they get along with very well. | It's a little funny, but it works. their past performance and accomplishments, they have been a leader in Missouri without any question. They have lead regionalization in Missouri to a phenomenal degree, and they have more general acceptance than many other regions. eo . i . Their objectives and priorities I would interpret as political expediency, and they have done it extremely well. 7 The feasibility, of course, is. very low, because we are theoretically supposed to grade these things on whethe they can do this in one year, and they obviously ‘can't possibly do what they've got in this application. They get along fine with CHP, they, support them in many ways. So they will get good acceptancte by them, The total picture, 26 staff component projects and em50 ~] 10 me 12 14 16 17 18 19 20 21 tong, 2A 25 HOOVER REPORTING CO, INC. 320 Massachusetts Avenu2, NE. Washinoton. 0.C. 20002 278 27 continuation projects and 19 new projects. Much of this is over-ambitious for one-year concept and it looks like it cannot be accomplished. My conclusion: I recommend funding, however, at the targeted level, which I think it is a way out af the dilemma ef coming up with a dollar figure. ‘ MRS. RESNIK: They are coming in with a $500 request July 1, they indicate. DR. MILLER: We will address that thio months Erom now. | MR. CHAMBLISS: All right, each of the [reviewers has come up with a different amount here, DR. McPHEDRAN: Well, I really didn't make that in the form of a motion, I have no quarrel with -- "2. =. Jeok. ts DR, BILLER? — Ohi I wouldn't. mind if he wanted to” figure out how you can justify eéming out with $2,295,113. I'll go along with it. DR. McPHEDRAN: I will move the target amount, which is $2,364,333. MR. CHAMBLISS: Is there a second? DR. MILLER: I will second. MR. CHAMBLISS: , It is moved and seconded that a recommendation for Missouri be the. targeted amount of ; . $2,341,490. DR. McPHEDRAN: I know you were probably senmi-— em51 ~~ | 12 _ 13 i4 18 19 20 { 21 25 HOOVER REPORTING CO, INC. 320 Massachusetts Avenu, NE. Washington, 0.0. 20002 279 facetious, Dr. Miller, in saying that the changing in the computer or the electronic program direction which had developed so many electronic aids to care that was turned: off like a water faucet. In fact, that really wasn't so. It was damn hard to turn them off. I mean it really was hard. It took a great deal of effort and persuasion, and determination, and repeated visits, and Bob ‘Toomey -- DR. SCHERLIS: It has not been turned off, the output has been changed. | | | DR. MILLER: Excuse me, I should make a comment. I have been through this with several other RMP'S some of which I made site visits on also as a coordinator. I agree with you. The electronic fanaticism in our society is extremely difficult to turn off. We had it in many others. Georgia was a good example, when I was down there. | . But it has been turned off now in almost all RMP's,. @ MR, CHAMBLISS: May I restate the +ecommended- amount for Missouri as being $2,364,333.. Is there further discussion? I call the question. Those in favor of the motion, please indicate by ‘ the usual sign of voting. [Chorus of "ayes".] em52 "1 =~] 10 ‘Qi . 12 38 14 16 17 18 19 20 25 HOOVER REPORTING €0,, INC. 320 Massachusetts Avenu?, NLE. Washington, D.C. 20002 (202) 546-6666 ‘no EMS funds if they are to be used in disparate programs, 280 MR. CHAMBLISS: Those opposed? [No response. ] MR. CHAMBLISS: ‘The motion is carried. DR. SCHERLIS: I ask one question now that you've voted on it, This relates to the fact you said they had a great many different types of EMS activities, and you questioned coordination. Is that correct? - DR. MILLER: Very difficult to do this with this many separate components. | DR. SCHERLIS: You mean they are making no effort to coordinate it? Is there any umbrella EMS for the region? | ‘DR. MILLER: No, no. They would hope to get one, But in the meantime they are going to have all of these ar : “. . various sub-components which are allowable, MR. THOMPSON: Mr. Chairman, would you transmit our unease about the EMS situation in Missouri to the EMS people? MR. CHAMBLISS: We will, indeed, We are much aware of the discussion here, and we will be in touch with the EMS people, . DR. SCHERLIS: I would almost suggest that we give In the State of Mary land we have had examples of what is now a large State support of some $2.4 million throud em5 3 “I 10 ny 12 18 14 16 17 18 25 HOOVER REPORTING CO. INC. 320 Massachusetts Avenu, N.E. Washinoton. D.C. 20002 281 the Governor. In the face of what are already small EMS activities and some not so small, and you will spend endless dollars trying to coordinate what are programs that begin: with noncompatible equipment, noncompatible standards, noncompatible operations. And I would think that if we perpetuate such support, that we will be causing an excessive amount of funds | to have to be spent later on. Some training programs will differ, criteria for State certification will differ because you will be training at a different level. . I think part of the insistence that we should have would indeed be that these he coordinated, regardless of what the ground rules are. Otherwise, we should not support any EMS activity whatsoever. I feel very strongly about that, having spent a good part of my energies in Maryland, because of the very reasons that we have had different types of funding, different community structures and different involvements. We would be undoing a great deal of what has been done in the past. MR. CHAMBLISS: The EMS people are moving towards State plans and State systems, Statewide systems. ; ; DR. SCHERLIS: But if you give money to that group, they will do their thing. The history of our society is 282 em54 1 that everyone does his thing if he has the wherewithal to 2 do it, and I would assume that by making separate structures 3 administratively, with our own means of support, they will ( 4 do their own thing. i 5 I hope this won't be true of Missouri. 6 MR. VAN WINKLE: We did that in kidney, you know, ~] Len, If that did meet with within the State plan itself, 8 nothing was approved here. 9 DR. SCHERLIS: But we have this leverage over - 10 these programs, I gather from some of the feeling that we ‘Al don't. - 12 MR. THOMPSON: You see, the problem is that many i | Aa of the States do not have State management. 44 , MR. CHAMBLISS: A good amount of our previous 15 funding for EMS has resulted in the development of State 16 plans. I can assure you’ of that. 17 DR. MILLER: Can I make some comments? I have “18 been connected with this at the local level. Although I 19 don't pretend to know it alley I know quite a bit. 20 EMS systems started out with an Office of i 21 Transportation funding, which is very large and many have ( 92 _ them ~- there are many of them in the United States. We 93 happen to have a very large onein Minnesota. And they're oA buying ambulances. They are héaded by ambulance drivers, 95 by and large; they're buying ambulances and training ambulange . HOOVER REPORTING CO, INC. 320 Massachusetts Avenu, NE. Washington, D.C.20002 O07 GAL BEER em55 . 10 11 12 13 i4 16 17 18 19 20 25 HOOVER REPORTING CO, INC. 320 Massachusetts Avenus, NE. Washington, D.C. 20002 rang Caf £200 283 attendants, and setting up standards for their performance, and that funding is precluded from doing anything with the patient except delivering him to the door of the nearest hospital. It cannot go any further. When EMS incentives started with RMP here'a couple of years ago, why, the focus was to try to get comprehensive | planning for comprehensive care of emergency cases,,and to face the issue about what happened to the patient after they -got inside the hospital. door. And so many RMP's undertook to do this, and many of us supported planning for comprehensi} emergency system development in the States. Then EMS bill came through, and it seemed like that this was going to take over, the over-all coordination; but this, as usual, has not happened. And the leadership there doesn't seem to have the capacity yet for attacking the whole problem. So at the local level the possibilities of local B agencies or regions or districts within the State of getting funding through the new EMS bill was really quite remote and they came back to RMP in most of the local levels to do this. | So there are three separate fragmented kind of programs for EMS in this country right now, and they're not coordinated at the national level, and the attempt of RMP's is to try to get coordination at the local level, which we em56 a ~1 10 4 12 13 14 16 17° 18 19 20 25 HOOVER REPORTING CO, INC. 320 Massachusetts Avenu3, NE. Washington, D.C. 20002 ENARL ED BERD - plan. 284 have always been challenged to do in the RMP management system, | MRS. WYCKOFF: But if you offer them money and say, If you will make a State plan and you have this money, would this create a climate? DR. MILLER: That's exactly what we did two years ago. Many of us did it two years ago. We paid for the deve lopment of some kind pf a State DR. SCHERLIS: Not necessarily. I was chairman of the EMS Committee nationally that reviewed all the projects that came in, and these weren't, except in| rare instances, State plans. And I'd say if you look at the whole United States now, there are very few States that have any | semblance of a State plan. Maybe two or three. DR. MILLER: Now, there's a good difference between a good State plan and a State plan, so I'm not saying they're good; I'm just saying -- DR. SCHERLIS: My only concern here is that I hope in whatever letter goes out indicating funding that one proviso of that letter states that each of these.areas have set up compatible systems, that there has to be a plan utilizing all their forces. I don't think that this State is large enough to have individual areas designated as they have, unless there is some over-all State compatible plan of em57 =~} 10 l 42 13 14 16 17 18 19 20 21 wnttiine, 2A 25 HOOVER REPORTING CO, INC. 320 Massachusetts Avenu>, NE. Washington, D.C. 20062 smn ae en 285 communications and everyhing else that goes into it. I would think that unless we put that into whatever support letter we send out, this will be something that will have to be dismantled later on and will have to he fragmented. That's the only point of my observation. MR. CHAMBLISS: We do appreciate these observation i that the panel has made. We have at the table Mr. Mike Posta, who coordinate the EMS activities for the RMP's, and he indicates to me that of the 23 site visits that were made by staff over the last year, that the majority of them had, as an effect of the RMP | support, the development of State plans. And we will keep in mind your admonitions for lessening fragmentation and more coordination between the three federal agencies that are supporting EMS activities. I want to assure you that RMP has already been in contact with the Emergency Medical Service Program here, and agreements have been reached as to what we probably might ° fund and what their area of responsibility is. And I assure you these discussions will continue before these funds are awarded. “I would call to youx attention -- MRS. RESNIK: May I add one word about the Missouy ¢ EMS program and the thrust in this application? It was stimulated, by and large, by the passage of a i em58 ~~ 10 11 12 13 id 16 17 18 19 20 at oe, 25 HOOVER REPORTING CO, INC. 320 Massachusetts Avenu, N.E. Washington, D.C. 20002 PARAL OEP POLE 286 State Law 57, which set forth standards and requirements for equipment on ambulances at various training levels, to the extent that these programs involve programs with little training, and that is the majority of the new activities, it is not new in the sense that they are treating a new aspect of EMS. They are training at various levels to conform, or their existing training to conform to the State requirements as described in the law. And that is why it looks fragmented, but it is part of eventually a total training system. I raised the question with them about equipment and various items of that sort, and there was still a considerable number of dollars that has to be looked into. But there was a major point in establishing these as separate activities to conform to the State law. MR, CHAMBENSS: I think have already had a vote| on Missouri, and the discussions we have been having is an add-on. | I would simply suggest to the committee that it may wish to take a coffee break at this time; and, if so, maybe we could return at 10:30, 10:33 with our coffee and resume. [Short recess.] MR, CHAMBLISS: May I call the panel to order again, please, and indicate to you’ that I gather that the em59 10 : 11 12 13 i4 16 17 18 19 20 mn, 21 25 HOOVER REPORTING CO. INC. 320 Massachusetts Avenu2, NE. Washington, D.C. 20062 (202) 546-6666 287 other panel is moving quite well -- and so are we -- and suggest that we might take a look at the application from Nebraska Regional Medical Program. Yes, Dr. Thompson? em60 10 | 11 12 13 14 16 17 18 19 20 { 21 ( 22 | 23 2A 25 HOOVER REPORTING CO. INC. 320 Massachusetts Avenu2, NE. Washington, D.C. 20002 288 REGIONAL MEDICAL PROGRAM REVIEW NEBRASKA - MR. THOMPSON: I guess I am the only one. MR. CHAMBLISS: Yes, you are the reviewer, and the staff support will be provided by Zivliavsky. Will you proceed? . ‘ MR. THOMPSON: t will. Nebraska has not been the most flaming RMP among the 53. It's relatively small in amounts of money granted. It never achieved triennial review. Its status has always been on an annual basis, although there were indications, I understand from staff, that they were going to apply for triennial review one month before the famous letter zipped down to tell them to phase out. They have a new man there who has only been there, I think, a couple of months , about half time. I expected with his history a far less professional job on that proposal than the one I find before me. Actually it indicates to me far more strength in the region than has ever existed before. I don't know exactly what happened to cause it. | I wish that every report we ever had did what Nebraska did very early in their proposal. There is Exhibit 1 goals/objectives, and they are fairly well spelled out, Both the goals and objectives. em61 .289 1 What happened was that when they got the letter, 2 the original RAG began to fall off and they then reappointed 3 ‘a. committee for the phraseout, which consisted of selected 4 people within RAG, and they began the phaseout operations, ° and then when the breath of life came back into the program 6 they selected from this committee, the phaseout committee, ‘ thirteen people from RAG, so. they only have thirteen people 8 in their RAG at the present time. § ; + However, when you look at the makeup of this. . 10 committee it is very widely represented, They have a lot u of public representatives, and they do have a Indian 12 representative among the twelve, so there was an attempt ( 1311 to retain at least a Statewide representative RAG in this i4 small group. 15 I think what we have to think, to regard this, we 16{|- have to remember the Pen and the goals are not all that 17 ||. innovative, but they are good solid goals, and I think they 18 | are within their reasonable capacity of Nebraska to carry 19 out. 20 One of them is kind of unusual, in that their i 9] Goal No. 3 has the specific objective to stimulate the ( 92 development of comprehensive home health care systems. 23 In other words, they have really gone all out for home health Oy care systems. ‘ 95 Their goals, roughly, in broad terms, there is a HOOVER REPORTING CO, INC. 320 Massachusetts Avenu>, NE. Washington, D.C. 20002 eam62 ~ 10 U 12 ( 18 14 16 7 18 19 20 21 a, 25 HOOVER REPORTING CO. INC. 320 Massachusetts Avenu:, NE. Washington, D.C. 20002 290 planning goal, there is manpower training goal, there is this goal of home health care systems. - There's the data reporting analyzie kind of goal. And then the last goal is the facilitator, coordinator, gathering people together kind of goals. | But in each one of these broad goals there are ‘ specific program type objectives. And one must say that there is a very close relationship between these goals and the kinds of programs that we see coming up in the proposal, Now, at the present time, they have been operating at a level of 502,000. I said they are one of the smaller programs, I think they are one of the four smallest programs, as far aS money is concerned. Their target would be some 868,000. This package v. - here is 962,000 with an indication that they will be coming request in with an additional/of $150,000. So we then have a program that is kind of climbing up beyond their original base level support. the program that probably would have gotten triennial approval, if the funding thing hadn't changed, Now, in general, they -- the most recent change in this program, as it has been with most of the other programs we've seen today, was their relationship with CHP, They decided to start working with the various CHP agencies within em63 «1 10 11 12 i 138 14 16 17 18 19 20 21 ate, Posten to NS 25 HOOVER REPORTING CO, INC. 320 Massachusetts Avenu, N.E. Washington, D.C. 20002 291 the State, and they have more or less redefined their mission within -- still retain their goals, Therefore, on Nebraska Regional Medical Program, it mission is toward cooperative work with A and B agencies in Nebraska State Department of Health, in an attempt to match those health care providers who have a need for service ‘ with those resources capable of responding with services with the ultimate purpose of improving the health care, for all Nebraska citizens. So that this is kind of a redefinition of its own mission, vis-a-vis the CHP agencies. It is not all too clear from the proposal how weil this is progressing. Several other projects that we will be talking about actually came from B agencies, and in one B agency right off they said it vould be unfair for us to write off on this, because actually we were involved in gathering the proposal and designing the proposal. There are other sections where there is an absence of a writeoff or a signoff by B agencies or A agencies, and others where the A agencies and B agencies in particular indicate a very positive view toward the projects. So it's kind of spotty. I will try to have the staff elaborate on this, because, although it's evident they ‘ are trying to cooperate, how successful they are is a whole nother question. em64 wl 10 ret 12 _18 14 16 17 18 19 20 25 4OOVER REPORTING CO, INC. 320 Massachusetts Avenu>, NE. Nashington, D.C. 20002 ea Ree 292 Now, when you look at the proposal, and it's probab the thickest one in this go-around, it seems rather awesome until you realize that it is a fairly simple proposal. They put their money on two things, an A hex kind of a busine which they believe should be, like Memphis, to cover a fairly small region, and if you were concerned over the fact that some of these area community health-education consortia, as they call them here, or hospitals in Memphis, you will _find some of them are nursing homes in Nebraska, betause: their primary concern is with that level of training. So, of all the projects we're talking about, there' these two main thrusts, the A hex type thrust, with] a nationalized learning ~- I mean .a Statewide learning resource center, and then some one, two, three, four, five, six specific regional agent type outfits. Surprisingly in this proposal, there are eleven different home health proposals, home care proposals, some of them defined in one way, home health satellite or the day-care service for elderly and disabled; and they have these scattered throughout the State, mostly based in nursing home type places. They are trying: to get nursing homes for whatever few little bits and pieces of visiting nurses' associations they can find, and beginning to design a global home health hackup program, for the elderly in various parts of the community. hy -em65 ~1 10 ll 12 13 id 16 17 18 19 20 24 25 HOOVER REPORTING CO, INC. 320 Massachusetts Avenuy, NE. Washington, D.C. 20002 293 And of course this is, as I said, these two thrusts are in line with their Goals No. 2 and No. 3; and the rest of this rather large list of variety of programs, nurse- physician programs in the cities, shared hospital resources, which are not unusual, they are all small. They run from 12 to 33 thousand dollars. It's obvious they're shoving this money into programs that are in existing institutions. There is this problem of their renal program, which is the largest of all these non _--A hex non-home health related outfits. Which I will allow Staff to respond to, because it looks like a fairly shaky business, all in all. I'd like to hear from staff. I'm going to use him, if you don't mind, as kind of a secondary reviewer, because my secondary reviewer isn't here. And let him particularly elaborate on the problems of the interface with CHP's and with the kidney problens, and any other comments he may have on Nebraska. MR. CHAMBLISS: Mr. Zivlavsky, will you comment, please? MR. ZIVLAVSKY: The Nebraska application is 576 pages. Dr. Hess, three years ago, made a site visit out there, followed up by a site visit approximately a year and a half ago. There was .a major shakeup out there. They followed up on many of the concerns from the first site visit. They em66 & ~1 10 11 42 . 13 ae, 14 16 17 18 19 20 i 21 25 HOOVER REPORTING CO, INC. 320 Massachusetts Avenut, -N.E. Washington. D.C. 20002 good job in this relationship. They receive a few stars for -294 increased their program viability and they were just as any upsweep to come in for a triennial anniversary application when our phaseout letter hit them right between the eyes. . Some of the good things that they have been able to do have been their efforts in indirect costs, for example, have been less than five percent of their total costs. over the past two years they have really been able to do a that, at least. In the area of minorities, the State has approxi- mately 2.7 percent. They have worked in the area of sickle cell screening for the entire black community of Lancaster County, which is in the Lincoln area. They have worked with a mobile cancer bus in terms of screening the Indian population. ” ”. The program staff has provided assistance to the Panhandle community action, which involves the migrants and Indians out in western Nebraska. In their phasein they have hired an additional minority -- I should say they lost one minority person in their program staff. ' They were able to hire another minority person on their program staff. I am not sure -~ they come in with an application requesting no people. Prese@tly they have 11.5 full-time 2 equivalence, I think they can use a couple of people to help them in the monitoring area. em67 ~1 10 ‘Ul 12 13 14 16 17 18 19 20 f 21 20 HOOVER REPORTING CO.,1NC. 320 Massachusetts Avenu, N.E. Washington, D.C. 20002 anAn eee ener 295 I don't know. That's up for discussion or grabs, I guess. I like the comment on the negative CHP comments , and on page 345 of the application, specifically commenting on Mr. Thompson's CHPA comment, the reason the CHPA agency withheld comment was because they developed the proposal ‘ and they were actively involved, and I believe they felt it was a conflict of interest. So they backed off, and this was one of the reasons that they dia not comment. The second negative comment is on project No. 47, and again the CHP agency has commented that this project lacks specificity. The program staff is following up on this particular project, and it involves the Omaha and Winnebago tribes, and basically there's a misunderstanding that the outreach from the community health representative in the community population, the CHR's, they assume that you have much more time than really is available; she has a half a day a week for outreach activities, and they didn't really get this clarified before they submitted the proposal to the RAG, The RAG again is following this up with’ program staff and I think they can negotiate this. difference, The renal project, DRMPS,. Dr. Mathis, the present coordinator, if he would not seek out-of-State technical consultants, and he agreed to do this because all the people em68 ~T 10 ou 12 14 16 17 18 19 20 ( 21 25 HOOVER REPORTING CO, INC. 320 Massachusetts Avenu, NE. Washington, D.C. 20002 ‘regional advisory group, however. ‘The Regional Advisory (296 within the State of Nebraska have been involved in their project. Yesterday we received a letter from the associate coordinator for program services, attached to three: comments basically from the technical reviewers. All three had. negative technical comments, reducing the budget from approximately $51,920 down to 15 or 20 thousand dollars. These comments have not been submitted to/ their Group will be meeting this following Friday, reacting to these negative comments. Basically what you have is a questionable; stance. We are trying to ask the community for some suggestions or recommendations on what to do with this particular project} I think I have answered, v. : MR. THOMPSON: My funding recommendation, they ar: WwW now 502, the target is 868. This comes in at 962. There's a possibility of another 150,000, because there is really no slush fund or escrow, however, designed in this program. All the money is carefully identified in this, these little small programs. It is very difficult to cut much of this, but I would make the recommendation they be funded at $912,000, which is $50,000 less than they now have, which reflects their cost of that kidney program, which'I have some doubts about. em69 or ~~ 10 uu "42 38 14 16 i7 18 19 20 ote 25 HOOVER REPORTING CO. INC. 320 Massachusetts Avenus, NE. Washington, 0.C. 20002 297 I am not going to tell them that this is against the kidney program, but they've got to read. The kidney program has cost 50,000, we're cut 50,000, And they still will be the third smallest program in the country if they get all this. DR. WHITE: Well, in the past we could say these technical experts cane out. If you go ahead and insist on each of these, inspite of our advice and their advice, next time around;they can thumb their nose at us this time, because -- | | | MR. CHAMBLISS: Would you speak just a little louder, please? , | MR. THOMPSON: I think the technical comments on this -- I can't see how the RAG can step around them. It was unanimous, and I think the RAG will just drop that. a think we .can put a little hint in the advice letter. | I move, then, $912,000 for the Nebraska proposal. MR. TOOMEY: Second it. | MR. CHAMBLISS: The motion has been proverly moved and seconded. Is there discussion, please? Question. Those in favor? [Chorus of "ayes",.] MR. CHAMBLISS: Those opposed? ~em70 ~I] 10 ll 412 13 i4 16 17 18 19 20 21 nt, 25 HOOVER REPORTING CO, INC. 320 Massachusetts Avenu3, N.E. Washington, D.C. 20002 298 [No response. ] MR. CUAMBLISS: The "ayes" have it, and the motion carries, at a recommended level for Nebraska of $912,000. : em71 a, ee =~] 10 4 12 13 i4 16 17 £48 19 20 ( 21 25 HOOVER REPORTING CO. INC. 320 Massachusetts Avenu>, N.E. Wacshinotan DC 2007 herself from the room. 299 REGIONAL MEDICAL PROGRAM REVIEW NEW MEXICO MR. CHAMBLISS: Shall we then move to New Mexico? The reviewers here are Dr. Miller, and Dr. White, with Mr. Zivlavski as staff support. | | Will the record so indicate that Mrs. Jesse— ‘ Salazar is not a part of these proceedings, and has absented DR. MILLER: The New Mexico application is another of the umbrella type RMP applications. | It is an extremely ambitious one, and has an application for $2.77 million, when the current level of funding is $1.2. However it does not plan to come in with another application in July, so-this is its total application for the next year. | The New Mexico RMP had ~~ has a new coordinator, and who starts, let's see, May Ist. Dr. Gaye, who has been, in my opinion, an able coordinator in the past, is resigning as of the 30th of June, but will remain.as a consultant to Dr. Walsh, the new coordinator. Otherwise, the program leadership seems to he good, and I presume that this arrangement looks like it will still provide a continuity and a fairly stable ._program leadership. The program staff seems. to be adequate, and capable em72 =~ 10 un 12 . 13 14 16 17 18 19 20 25 HOOVER REPORTING CO, INC. 320 Massachusetts Aveny2, N.E. Washington, D.C. 20002 300 in general. The original Advisory Group, I don't quite know what they did -~- why they did what it did. I couldn't find it in there, but they recently padded the Regional Advisory Group, increasing its membership to 120 people. And we've seen that in reverse a number of times in the last few years. I don't know what will motivate it doing this. | But, of course, it forced the deve lopment of sub- committees to then run the program, and at least it seems to be reasonably satisfactory. The past performance and accomplishments have some bright spots, and some that maybe aren't quite so bright. But in general they seento be satisfactory. | As I felt their objectives and pylorities were, also. And the proposal is congruent with the explicit objectives and priorities as given. The feasbility is another one of these where, with the tremendous proposal for a year, it doesn't seem very likely that it can carry out well the projects that it proposes, | CHP relationships apparently are quite good. So, over-all, I felt the program is above average. And I felt that the -- that if RMP was going to be continued for another three years, this region, like two or three -em73 ~T 10 U "12 i4 16 17 18 19 20 25 HOOVER REPORTING CO, INC. 320 Massachusetts Avenu3, NE Washington, D.C. 20002 301 others we've had yesterday and today, would be really well- established for going gung ho ahead on a three-year program, Most of the projects in this application are really projects for the staff. There's some confusion in my mind as to what constitutes a staff program in New Mexico and what constitutes an extramural provect, Since, in most of the. projects, why, the RMP is the, apparently the sponsoring organization, and many of the staff that are going to be working on the project are staff people of the Regional Medical Program. So I interpreted all except two of these projects to actually be essentially staff activities. Which, in this case, would mean, then, that almost the whole program in New Mexico is a program staff management system of staff and projects run by the same people. vy. There are two projects that are extramural, which they list as the lowest priority, in which it received some unfavorable comments. So that _- which are for a neonatal regional program and -- I forget what the other one was. Genetics. Oh, yes, genetics regional program. There's one huge emergency medical service that is an expansion staff project, continuing -- it's a continuation project, but it's a huge expansion, with a budget of $911,000 Same kind of problem we had before, I don't know what it was last year. Does the staff em7 4 4 10 n 12 13 14 16 17 18 19 20 { 21 ( 22 23 2A 25 HOOVER REPORTING CO, INC. 320 Massachusetts Avenu>, N.E. Washington, 0.0. 20002 302 know? DR. WHITE: : We're trying to determine that right now. That kind of information is not in any of our research. I think since the program is funded to July '72 for $520,000. | DR. MILLER: $528,000? Well, it isn't such a huge expansion. | DR. WHITE: Well, that was for two years. DR. MILLER: That was a two-year program. DR. WHITE: That was two years? DR. MILLER: That was two years of funding? DR, WHITE: Yes. Oh, this is one year, $911,000+ and another one of their projects, health education for the public, was expanded 7. . to $303,000, and I don't know what the previous level of that was. HMR. VAN WINKLE: Project 25. DR. MILLER: No. 25, health education for the public. MR. ZIVLAVSKI: There is another substantial increase. They had $175,000 in there, and then about 70,000 for the past six months. And they put approximately 225,000 in there, DR. MILLER: I have some philosophical feelings em75 an 10 | . 1 12 “13 14 16 V7 18 19 20 25 HOOVER REPORTING CO, INC. 320 Massachusetts Avenu2, NE. Washington, D.C. 20002 303 about health education for the public beamed through every possible communication mechanism for one year for $300,000, as to what are the cost-benefits, and how would you ever know? And if you can't know, what the devil do you, do it for? MR. CHAMBLISS : Dr. Miller, I think in all candor, with the reviewers, it should be noted that we had a staff presentation of that project, health education to the public, ‘during the last year. We were not overly impressed with what came out of it. I say that just so the committee may know, that that presentation had been made to the staff. DR. MILLER: I think I can complete my statements now with the feeling that this is an over-ambitious, largely staff programs in an RY¥P that is fairly good, and therefore ”. my feeling is that we ought to hold our funding to the - targeted level. MR. CHAMLISS : Dr. White. DR. WHITE: Well, I noted that Dr. Gaye was retiring. I don't know Dr. Walsh. I know nothing about New Mexico. This is the first time I've had anything to do with New Mexico, other than the site visits as a reviewer. Dr. Walsh is an unknown quantity, to me at least. The staff seem to have the credentials. | My interpretation of the Regional Advisory Group is em76 on 10 1 42 33 i4 19 20 25 HOOVER REPORTING CO, INC. 320 Massachusetts Avene s, NE. Wt AK AANA 304 that it was ex panded to 120 people in 1971, at whose behest I don't know, but possibly to get the minority group in, or one thing or another. But, in any event, when the phaseout cane out, they then began reducing by’ attrition, and beyond that they also began not meeting, to my interpretation, in delegating their authority to an executive committee and I think this is reflected in the fact that the proposals, as I read them, are enormously impossible. | If they had trouble spending -- I think it says in here the number of people they trained in two years in the EMS program for approximately $250,000 a a they have no earthly hope of spending 900-some thousand in a year's time and getting their money's worth out of it. I think also that health education to the public is a hopeless proposition by the avenues that they propose. I don't why we can convince people to take aspirin by using mass media, but we can't convince them not to take it. MR. THOMPSON: Well, you know, Bayer's advertising budget is far beyond any thing we put out. DR. WHITE: In any event, beyond that, I would agree with Dr. Miller. I would consider this an average, neither bad nor good; and I think it's entitled to its fair share of whatever money is portioned out, and I would agree to the targeted fund minus whatever is reserved for July, aNLE THD 46 WD fls ~) 10 i - 12 1 14 16 17 18 | 19 20 25 HOOVER REPORTING CO, INC. 320 Massachusetts Avents, NE. Washington, 0.0. 20002 SOFT RRR EEL -looks at what is the easy side of the Emergency Medical ambulances together, then’to create a crisis center to inte- 305 and let it go at that. MR. CHAMBLISS: Dr. Scherlis. DR. SCHERLIS: I looked at the Emergency Medical Services, which constitute a great part of their budget, and in reviewing it, I asked some serious questions about it. It Service, the trainee and the vehicle end of it, but in terms of looking at a system of care, there are some serious I questions. Maybe I could just spend a minute or two on this. Under objectives, it looks at training and communi- cations, which really consisted of developing a statewide emergency communications system linking all hospitals and grate all communication links. ira . . I guess the question I have is something that maybe they have not included in this, dthough they have about 40 or 50 pages devoted to it, and I would rather see that than all the individual sources, amd that is, are they are talking about characterization of care? I see the reference that this is an important aspect but if you are going to have people talking to people, they should talk to them about something aside from the fact: "We're coming in ‘in a hurry; we've got some sick people aboard." WHD47 1 ~ 10 ‘i 12 13 14 16 1? 18 19 20 21 22 23 24 25 HOOVER REPORTING CO, INC. 320 Massachusetts Avenue, NE. ¢ Washington, 0.C. 20002 -one or twenty burn centers, one or twenty trauma centers, and Communication Evaluation," and I would have to review . included, if they are going to get some answers in terms of 306 I don't know if they provide in there, and perhaps Staff can comment, whether they have provided medical communi- cation at one end or whether this is administrative communi- cation. Also, if they are under all of these funds proposed for centers in the state for treating more. specifically cer- ‘ tain types of catastrophic events, if they are talking about one or twenty cardiovascular centers -- so what is "Training tnis carefully, but I would think one would like a great deal more in the way of evaluation than what they have what they want to do. Continuity -- they are going to ask the Governor for money, which seems to he the best way to continue all forms of care, at least by going through the appropriate motions. But I don't see adequate emphasis in here on what I would think seem to be the real problems despite the fact they are putting in an awful lot of money. They are talking about basically new and better ambulances, about communications, about training, and I think the other end of-it, in terms of what happens when these people get to a center? I don't: know if they are talking about by-passing certain areas, or if they are talking about 307 WHD48 1 really having hierarchy type of care and really a regional 2 type of emergency system. It does not seem to come out of, 3 at least, the document that we have, and I question Whether 4 or not this is really an adequate presentation or whether 5 |] you know more about their plans. 6 Maybe this does not do justice to the plan they “1 have. I don't think that this warrants the price-tag placed 8 on it, at least from the minimal review r have given it. 9 Perhaps you can comment? 10 || MR.- CHAMBLISS: Are there Staff comments in response 11{| to Doctor Scherlis's query about New Mexico? 12 MR. ZIVLAVSKI: Why don't I just start from the 13 || TOP and make a few comments? 14 In terms of the RAG and the number of the RAG, when Doctor Gaye became Coordinator, it was his decision to involve v iw || more people in the decision-making process. He increased the > RAG 220 members, broadly representative and including minori- 17 18 ties and parts of the state, and the whole thing. 19 In this application it seems like a conflict of os information, but in the RAG report it’ mentions 120 still being o1 there, but actually they have decreased it to 73 members. 99 There is a litfe confusion in interpretation; it . depends on which page you look at. The -- in terms of the -- ; of Doctor Miller's comments on whether there is confusion over staff projects, and are they essentially control projects, 25 - HOOVER REPORTING CO, iNC. 320 Massachusetts Avenue, N.C. Wachinatan 1 9NNN? WHD49 1 ~] 10 11 12 ( 13 i4 “16 17 18 19 20 21 25 HOOVER REPORTING CO, INC. 320 Massachusetts Avenue, NLD. Wianhinetd an NP IAN 308 four or five of these activities were out originally with CO numbers. The last review we had, in a site visit we had down there, we indicated to them that what they needed to do was to place these projects in independent status, provide them with a project number and make sure you give them the -- the information to the Project Directors that these are unlimited activities and they can't crawl back into the wings of the university once the project phases out. Just in the last six months, they have typed these: co type numbers and have been: able to communicate these to the people. | These are free-standing, they are centrally located - in the headquarters of the RMP, physically right in the same area. However, they are operating as project directors, 100° percent type of activities; when the project ceases, they Pa : . ”. . . are going to have to find new employment, whenever that happens. DOCTOR MILLER: But they are staff of the RMP; they are listed under the personnel lists for each one of those things as the New Mexico RMP staff. MR. ZIVLAVSKI: | There is no duplication in terms of salaries on the Form 6, which is the core staff salary budget, as well as the Project Directors' salaries. There is no duplication of funding; each of the moneys are coming out of different types of activities. WHD50 1 ~ 10 11 12 14 16 17 18 19 20 21 23 24 25 HOOVER REPORTING CO, INC. - 320 Massachusetts Avenue, NE. | : 8 309 You can look at Project 32, the community health resource development, Project 33,:the health resources registry, and Project 34, regional health resource plan and, development; each of these three projects are leaning toward the future of health vesouree planning. These are not in escrow, there is not -- these are defined moneys and they tell you exactly what. they hope to do in these areas. i Staff did -- there was a presentation by Project No. 25, which is the health education for the public; ‘it has substantially increased their requests. This is a statewide project; the former project director of this is now a Deputy Director of the RMP. | It presents a problem; maybe the alternate sugges~ tion is to have a technical review committee, site visit from /. out of state consultants to come in, people that don't have a bias, and maybe we could send this message back and then write an advice letter to the program to have somebody from out of state come in, let the °RMP pay for it with their own funds, then give the report to the Director of the program —~ -not to Walsh, not the Deputy Director, who is thé previous Project Director. Project Number 18, EMS, there is a heavy emphasis -- they have done a lot of things in here; I don't know how to tackle some of your questions, but you mentioned the fact of WHD51 10 11 "12 1B 14 16 ‘47 18 19 20 21 22 23 24 25 HOOVER REPORTING CO, INC. 320 Massachusetts Avenue, N.C: Wachinatan DE 2A? 31LU categorization; the Deputy Director, Doctor Hanratty, has been working on a computerized system for it. Their position is that they are not happy with any of the national plans for categorization, AMA or any of these. They would like a modification of each of these plans, and they would like to have a computerized categorization of the hospitals. And they are working on that right now; they started out slightly on their surveys, ‘the form has been pre- . . \ pared. I can't tell you what modifications have been made in the categorizations of all the hospitals, but there is an obvious gap, because one or two hospitals in Albuquerque, one in Santa Fe, and then you have the rest of the state, and they haven't complded this. They have the survey form developed. It is a modified form, and what the results will ” be have not appeared yet. In area medical communications they work closely _ with the State Department of Communications. Everything they do there is pretty well basedeon a total effort, because there are a lot of scant resources. They have done quite a job in terms of- training. No RMP funds have gone into the purchase of vehicles; the RMP ~- Doctor Walsh, by the way, the Bresent Director of this Program, is also the Director of the EMS project. If he is finally selected as the final Coordinator on July lst, his WHD52 1 ~ ‘. 10 11 12 13 14 16 17 18 19 20 2) HOOVER REPORTING CO, INC.” ON Macone hucatte Avenue NE 311 Deputy Director, Doctor Hanratty, will -- it looks likely that he will take over as Project’ Director. He has been Deputy Director on the project for one year. MR. CHAMBLISS: I wonder if that sufficiently covers the query about the categorization and so on? DOCTOR eee I might point out that if you take the targeted fund -- I was a little more charitable in approaching their EMS; I think they do have some compatibility) in terms of their training prograns, and by legislation théy are going. to be uniform. Communication as I read it was between am bulances and hospitals, where there are enormous distances to get to. ’ DOCTOR SCHERLIS: The average .run can be 50 to 100. miles. » . yoo, . . DOCTOR WHITE: They need to communicate with the interim stations along the way just in case something happens. DOCTOR SCHERLIS: This is why I asked about the categorizations, because I don't know how they are going to react to passing certain ones if they have to, and this is a key feature to a state that large, with a long haul. DOCTOR WHITE: But regardless of the quality _ MR. THOMPSON: This is rather ironic. Unless I am mistaken, the first proposal that -ever came in from New Mexico, altogether in the old, old, old, days was on emergency WHD53 1 ~l 10 rr 12 fo 4138 14 16 17 18 19 20 21 22 23 24 25 HOOVER REPORTING CO, INC. 320 Massachusetts Avenue, NE. appraisal of educational efforts, won't they? 312 medical services. They did a rather large study and they found out that the primary cause of death downthere was not heart, stroke and cancer; it was Indians spread out over the highway in these old cars. We did not give them any money because they did not fit into the categories of heart, stroke and cancer. DOCTOR WHITE: It still doesn't solve the problem of the Indians, because they point out in here, there are no areas in which the Indians are terribly keen about participat- ing in. MR. CHAMBLISS : Is there a motion and a recommended level of funding here? DOCTOR MILLER: I move that they be funded at the target level: $1.64 million. DOCTOR WHITE: Second. MR. CHAMBLISS : tt has been moved and seconded that New Mexico be recommended for funding at a level of $1,644,0001 Is there discussion on the motion? All in favor? (Chorus of "Aye") Opposed? ‘The level is recommended at $1,644,754. DOCTOR WHITE: They will get the message hout staff MR. CHAMBLISS: Your concerns will be passed along, indeed, regarding EMS and..education for the public. HD=1 1 ~~] 10 | ou 12 13 i4 16 17 18 19 20 al 25 HOOVER REPORTING CO, INC. 320 Massachusetts Avenue, N.C) | Washington, D.C. 20002 North Carolina has a current funding level of $1.67 million, ILS REGIONAL MEDICAL PROGRAM REVIEW NORTH CAROLINA REGION | | MR, CHAMBLISS: Shall we go on then to North © Carolina? Doctor Miller, Doctor McPhedran, and Staff will be represented by Mrs. Parks. | | DR. SCHERLIS: We should have Mrs. Salazar. come back, shouldn't we? | DOCTOR MILLER: This is another large application. it puts in an application for $3.26 million, and plans to sub- mit another application in July for $400,000. Targeted level is $2.78 million, and the composite of the present application with the proposed additions in July will be 132 percent of the target, or $880,000 over the target amount. a The Region is a good Region, in general, has done a lot of things in the past that are quite outstanding. They have a change in the Project Director and Coordinator, which I can not assess. Perhaps the Staff can help us with that. The new Executive Director, Ben Weaver., was pepaty Director for five years, so it is presumed that his leadership should probably be adequate. The program staff approach looks all right; they plan to increase it quite a lot during this next year, but WHD-2 1 mS) 10 ou 12 . 13 i4 16 17 18 19 20 21 ( 22 - 23 24 25 HOOVER REPORTING CO, INC. 320 Massachusetts Avenue, N.C: | Washineton. D.C. 20002 that would not help, because their needs are so great, and they are really deprived of health care. There are many 314 they have a fairlygood nucleus anyway. The Regional Advisory Group assessment is all right. The past performance, as I mentioned , is good; their objectives and priorities are good, and the proposal fits in with their objectives and priorities. Their CHP relationships are good. This, in my opinion, is one of the extremely needy areas in this country, where you can hardly design anything areas of health care deprivation in services, and they have been working toward these and have made some outstanding achievements, I think, in this area. So I think they deserve a recognition of those things. They have, in this application, 45 projects. A lot of them are not very good in principles of feasibility or per- formance, and are not in my opinion, justification for the costs. One continuation, one which bothers me terribly, but I guess it's just one of those things, is a medical air operations, which is $50,000, which is a continuation, so I suppose they have been doing it, which is solely for the -- the money is spent solely for the purpose of flying faculty, students and staff around the state in private planes in 1HD-3 1 ~ 10 i 12 13 14 - 16 17 18 19 20 21 ( 22 23 24 25 HOOVER REPORTING CO., INC. 320 Massachusetts Avenue, N.E. | 315 support of the area health education center project. . Of course, all kinds of. faculty -- as well as students and staff -- would like to fly in private airplanes almost anywhere if you give them that luxury. Another one, they have a project in here for the medical foundation they have in the state for a PSRO develop-, ment for $125,000. I think this is inappropriate; PSRO's are going to be funded, and as near as I can tell from that application, it is a pure PSRO project development. __ Then there are multiple rural health clinic supports There are supplementary support to state clinics or state rural health clinics, which undoubtedly are needed, and are , supported by the state. But the. amount of this support amount ‘ to $243,000 altogether. And then another supportive project for supporting vy. . : . the area health education center activities in the state which is funded outside of RMP, to develop a Library network for $363,000 in community hospitals throughout the state. Although I don't question their statement that community hospitals have no library facilities that amount to anything, and when you want to educate health-care professionals in rural communities, why, one of the things you need is a library, but it seems like an overly ambitious approach with- out any guarantee that it will be continued. Another of the fundamental things, of course, ina Ui WHD-4 1 3 ~I 10 ul 12 13 i4 16 17 18 19 20 2] 20 HOOVER REPORTING CO, INC. 320 Massachusetts Avenue, NC. Washington, D.C. 20002 place like North Carolina, which I think is probably in some of the other similar types of states, there is very little guarantee that these -~- any of these activities will be continued after RMP funding, probably because, however, that their potential for funding things is so poor that tey are quite dependent upon Federal funding programs. In general, I regard this as a superior program, and it is a terrifically needy area, where they -- a application which is over-ambitious, and some of it 4 inappropriate, and my recommendation would, again, be ing at the target level. MR. CHAMBLISS: Doctor McPhedran? DOCTOR MC PHEDRAN: I agree. I really have to add. DOCTOR MILLER: I'11 make the motion, then. ’ v . . DOCTOR MC PHEDRAN: I'll second that. MR. CHAMBLISS: It has been moved and seconded that North Carolina be recommended for funding at the targeted level of $2,775,522. Is there discussion on the motion? DOCTOR MILLER: Their present funding for the current year is $1,175,000, so they will get -- MR. VAN WINKLE: About $1.1. DOCTOR MILLER: They will get $1,100, 000 more money; they probably can't spend that either. true composite s a fund- nothing THD-5 1 ~ 10 i "(42 13 14 16 17 18 19 20 21 25 HOOVER REPORTING CO, INC. 320 Massachusetts Avenue, H.C. Washington, D.C. 20002 4 I: DOCTOR WHITE : Well, I guess that is what bothers me, in terms of losing out on a million dollars. Even though you said it was a superior Region, yet I look at -- what? 45 new projects, which -- DOCTOR MILLER: Very needy. How do you really -@ecide on deprived areas? There is no way to solve those problems without pouring money into them. ! MR. THOMPSON: They are going to come in with | another $400,000. I | DOCTOR WHITE: Let's not get people used to some- thing -- why get the poor people out in the hills used to something they are going to lose next year? : DOCTOR MILLER: . Reminds me of a site visit I went ona couple of years ago to West Virginia. Have any of you been to West Virginia? We were questioning a lot of these things, and one of the physicians said: "We depend on Federal money for a living; we will do anything -- whatever the Federal money resource requires, because we are totally dependent upon Federal money." | | | DOCTOR SLATER: They are not the only group that says that. MR. CHAMBLISS: Doctor Miller, may I just ask a point here, about the PSRO? Did yau say that was out and out WHD-6 1 ee ~~ 10 il -12 13 || i4 16 2” 18 19 20 21 25 QOVER REPORTING CO, INC. 7) Massachusetts Avenue, N.C, ! ashingtes, D.C. 20002 023 546-6665 PSRO? DOCTOR MILLER: Nearly as I can tell. Does the Staff have any other interpretation? MRS. PARKS: We thought the same way. DOCTOR MC PHEDRAN: I agree. DOCTOR MILLER: I think it is totally inappropriate at this time. DOCTOR SCHERLIS: I have some concern, because I think in your description of the various projects, programs ang 50 on, I was detecting a certain note of lack of enthusiasm, and then I had your conclusions, which reflected, in a way, a disparate approach. | You know, the need is there, I think we would agree; the RM has a pretty good track record, and again I would assume that, given an area that is impoverished in many ways, these funds might eventually do some good. I do have a significant concern, though, in terms of all that money, in view of what I think were very apt eri- ticisms of the ability to really spend this wisely, and I would think, particularly in view of the fact that they are coming back for at least additional funds at $400,000, and in view of the fact that we doubt very much that all of this can be -- not just efficiently spent, but let's say inadequately spent, that you might then entertain some reduction from the target figure, understanding that they are going to come back WHD7 1 ~ "10 11 12 13 14 16 17 18 19 20 21 25 HOOVER REPORTING CO, INC. 320 Massachusetts Avenue, N.C. | Washington, D.C. 20002 (900) SAR-RABA 4 for more, although I know that is not a constraint, but I just have some difficulty, as I view the large array of pro- jects, particularly the one for, say ~- well, I guess it would be $362,000 for a statewide network of hospital librar-~ ies. I wonder if you might not entertain the possibility of reducing that some, because I don't think they could really effectively utilize this support level. DOCTOR MILLER: I judge on that library business they are going to staff those libraries? I could not tell in the application, but they are probably going to set up libraries in every one of these hospitals, which has jnothing now. : Is that true? MRS. PARKS: Right. They will be tied into the nine area health-education centérs, but I don't think that the | supportive personnel will solely be funded through the North Carolina RMP. DOCTOR MILLER: Well, it costs a lot of money to set up nine libraries. DOCTOR WHITE:- Doesn't it cost a fair amount to keep them going, in terms ad personnel? DOCTOR MILLER: It is a terrible problem. She says they are going to keep them going; will the hospital undertake the responsibility, or the AHEC, or solely someb ody else, for ~7T 10 W “12 13 i4 16 17 18 19 20 21 HOOVER REPORTING CO, INC. 320 Massachusetts Avenue, NC. Washington, 0.C. 20002 ranma ces crest 4 the operation, of these libraries after one year, after the RMP is gone? DOCTOR WHITE: If nothing else, somebody has to dust the books. MRS. PARKS: I am not really sure. The only infor- mation I have is what is in the Form 15, and it was not clear 4 as to how many would. i | DOCTOR MILLER: It does not say; there are a lot of unanswered things as you read these. . DOCTOR WHITE: Did you find contributions from the Appalachian Regional Commission? Matching funds and things of that sort that look as though they might be substantial? DOCTOR MILLER: I don't think they have that ‘in here ,do they? MRS. PARKS: No. MR. THOMPSON: What I can't understand; they have been working specifically with hospital libraries, hospitals and quality control for all these years. What the hell have . they been doing? All those small hospitals; that was the main thrust of the project -- quality control and libraries. | DOCTOR VAUN: The objectives of the National Library of Medicine is not to perpetuate the old concept of libraries. It does not cost a lot to build a library that can function through the National Library of Medicine network, and if we pour this amount of money into creating a lot of old-fashioned THD-9 1 3 ~T 10 11 12 13 i4 16 1” 18 19 20 2] ( 22 25 HOOVER REPORTING CO, INC. 320 Massachusetts Avenue, N.C. 4 Washington. D.C. 20002 321 libraries, you might just as well flush it down thedrain. MR. VAN WINKLE: Staff had flagged that for that consideration. | DOCTOR MILLER: Well, I think cutting the budget, even to the target level, will put the pressure on them for some of this kind of stuff. | MR. CHAMBLISS: That is the motion, to recommend funding at the target level. | Is there further discussion? . DOCTOR SCHERLIS: May I move an amendment to the motion? | | | | MR. CHAMBLISS: | You may indeed. DOCTOR SCHERLIS: I withdraw my motion. . MR. CHAMBLISS: Those in favor of the motion, let it be known by the usual sign of voting. (Chorus of "ayet) Those opposed? (No response) May we have a show of hands on that vote, please? (Show of hands.) '- (hree in favor, and the "Nay's" have it and the motion is not carried. The Chair will entertain a new motion. DOCTOR SCHERLIS: I would move that the target figure be reduced by $400,000, as the level of funding for the coming fiscal year. fHD11 1 ~ 10 11 12 13 i4 16 17 18 19 20 21 ( 92 23 24 . 25 HOOVER REPORTING CO, INC. 320 Massachusetts Avenue, N.C. ! Washington, D.C. 20002 asking fora significant sum more -- I'd like to give them ' think that I tried to express myself rationally, but, I ‘didn't you? $22-A the vast array of projects, particularly that one, and to think in terms of what will happen to a statewide systems when you have libraries in individual hospitals, and what will occur-at that time. I think there is a lot of fat in this budget. I don't think this is going to affect their overall program one iota, and I think to fund them at their target level now, when they will be coming back for additional funds, they aren't bound to ask for only $400,000; I'm sure they will he that latitude. Now, if you asked me if I reached a rational feeling would suggest to you that the input to that was about 95 per- cent gut reaction. Po v7. Is that a fair appraisal? That's what you thought, pocTor MC PHEDRAN: That is what I thought. MR. CHAMBLISS: Shall I call the question again? Those in favor? (Chorus of "Aye" ) Opposed? | (No response) The motion is carried, to recommend a level of fund- ing at $2,375,522. ~ 'HD10 1 +e ~l 10 - 11 12 13 i4 16 Vi 18 19 20 at ( 92 23 24 25 HOOVER REPORTING CO, INC. 320 Massachusetts Avenue, N.C. Washington, D.C. 20002 (202) 546-6666 DOCTOR WHITE: I'11 second that. MR. CHAMBLISS: The motion is now that the recom- mended level be set at $2,375,522. It has been properly moved and seconded. Is there discussion? DOCTOR MC PHEDRAN: I supported the previous motion, and I really feel it is important for me to say that this is another arbitrary choice -- so was the previous one. I don't really know how you decide, and it is obviously arbitrary and I don't know how it can ever be intelligently decided. In fact, it can't be without a more detailed review of the projects. So I think that I would like to know whether Doctor Scherlis would acknowledge that this is a really arbitrary amount? DOCTOR SCHERLISY’ . Let me tell you the rational way inwhich I reached my decision. I sit here and listen to the reviewer with a great deal of care, because he is going © -- has gone through the document more than any of us have, and must really have some expertise. And I get a certain flavor which I file away, I assume, somewhere in my brain. Really, it is a gut reaction, and then as the dis- cussion goes on and I try to relate what I have heard at previous meetings, to a particular state, what I did in this instance was to look at the sum they have asked for, look at « WHD12 1 REGIONAL MEDICAL PROGRAM REVIEW 2 : NORTH DAKOTA REGION ai MR. CHAMBLISS: Now we will move to North Dakota. 4 The presenters here will be Doctor Slater and Doctor 5 Scherlis; Miss Resnik will represent the Staff. 6 DOCTOR SCHERLIS: North Dakota, Mr. Chambliss, is ~~ the smallest budget RMP in the nation, of $367,746, and are 8 coming back in with a request for $774,057, which is 132 per- 9 cent of the anticipated target. 10 | I would like to make a comment that there must be WW some kind of a leak in this agency, because despite your pro- 12 testations that they don't know what the targeted figures are, -North Dakota is so honest that they said: 13 14 "There has resulted a grant application figure 15 that exceeds the target figure." 16 Which doesn't bother me very much. 17 DOCTOR SLATER: North Dakota also makes a point 18 which I think will rectify that -- and I am abstracting here: 19 | "We have considerable difficulty attracting 50 physicians to North Dakota. Our image is ridiculous in 1 view of the. national situation." oo aoe, ( 99 I think they’ have some problems in this proposal NL. 95 which reflect that self-image. Quite honestly, I am concerned oA about their priorities, and there is not a thing, I believe, 05 that we can perhaps do about this. | HOOVER REPORTING CO., INC. 320 Massachusetts Avenue, N.C. | . Washington, D.C. 20002 i fOAAN Cae oeee WHD13 1 ~~ 10 11 “42 13 i4 18 19 20 21 HOOVER REPORTING CO. INC. 320 Massachusetts Avenue, N.C. * Washington, 0.0. 20002 (702) 546-6056 f t 324 Their. image, in fact, is based on the fact that they have about 146 primary care physicians per 100,000 population, which is the lowest on the national scene, and their concern is that they need to upgrade their medical care system, primarily going in the direction of producing more ‘manpower and increasing the education of those individuals,. both professional and lay, who are already there in North : i Dakota. | As you know, there has been a major press to develop a four-year medical school, and I had the opportunity to visit North Dakota after the original feasibility study, to determine whether they would become a Region, and recommended to you -- what? In '67, I guess; Doctor Scherlis has been there ‘more recently, so his information is better than mine -- but they now have been accredited for a four-year school, and . . are searching for ways to 4amplement this. Well, to get back to what they have been doing, they have, from what. I can make out, a small, reasonably well- organized, active staff, and I will have to rely entirely upon other people's inputs to determine how effective they are. | | ; Their program thrust, as I said, was in education and manpower. Past accomplishments include Emergency Medical Care System; they have been able to produce 1,000 Emergency WHD14 1 ~~ 10 “i 12 -13 14 - 16 17 18 19 20 21 ( 22 23 24 25 HOOVER REPORTING CO, INC. 320 Massachusetts Avenue, NE. | Washington, D.C. 20002 - education -- continuing education programs. 325 . Medical Technicians, which has produced a number of one per 600 population, which is the highest ratio on the national scene. They are proud of that; they feel it makes a very effective dent, at least on attending to accidents and emer- gency problems. In the second area of activity, the University of North Dakota, working their EXtension Service through the Medical School, and working in conjunction with the Public Health Department, and the RMP , have really been able to get engaged in a great deal of data collection and professional There are four AHEC areas which are actively involved in the arrangement of local..teaching programs for lay and allied health professional teaching people, and associated with this have been the arrangements for a great deal of travel by nurse educators as well as the bringing in of local physicians to become engaged as teachers in their own special areas of capability, for not only lay but allied health professional people. So that by and Jarge, I think they have concentrated a great deal on blanketing the state with a great variety of types of continuing education and special types of therapy for coronary care, renal, chronic renal disease, problems requiring rehabilitation of the “handicapped and the like. Now, where are they going, against this kind of a WHD-15 1 ~ -. 10 11 12 13 14 - 16 17 18 19 20 2] 25 HOOVER REPORTING CO, INC. 320 Massachusetts Avenue, N.C. | Wachinotan AL INNA 320 background? They have presented a series of activities here which -- in which I would like to indicate to you where they - see their priorities, on page 16. Their RAG is made up of 47 people, with nine repre- sentatives from Comprehensive Health Planning. I believe they work very closely with CHP, but I don't have any direct evidence of it from this proposal, except in the sense that the CHP people are involved in reviewing and helping set priorities on the proposals that go through. They are asking for a series of projects, and I will just run through them and give you the commentary on them. First of all, they are intereseted in feasibility study to look into the development of a residency program in internal medicine. This of course is oriented to getting the y -medical school off the ground. $13,775; this will put togethe committees, consultants and site visits. They are particularly anxious in looking at Pittsfield, Mass., Rutgers University, Muncie, Indiana, I. believe it is, who have been able to develop residency program at community hospitals. They would like to develop a consor- tium of hospitals for the residency programs that emanate from the University of North Dakota. The second project, small -- $9,620 -- a feasibility study to look into the potential for graduate programs of UT VHD16 “1 al 10 11 | 12 13 14 16 17 18 19 20 21 f rad é HOOVER REPORTING CO, INC. 320 Massachusetts Avenue, NE. | Washinetdn. 8.0. 20002 3 327 behavioral science related to family practice, and they are looking to the possibility of developing a Master's degree in behavioral. technology as a graduate program, and. also set up resources for marital counseling, child-rearing, sex counseling, addiction, dying, and trey will do this through statewide meetings and consultations and this kind | of activity trough AHEC. . ! The third type of program is $400,000, a biomedical comunications system connecting the four AHEC's, phase A and B are to go on during this fiscal year, first of all to study the feasibility and costs, and mechanics of this, and secondly to purchase the equipment. : After they purchase the equipment, by the end of Fiscal Year '75, they will then present a fiscal study to see whether or not it is possible to continue to fund this, /. “and that will go to the legislature, later to be in fact picked up and operated by the University of North Dakota. There is really no mention of the -- apart from microwave connections and a few general words -- there is no mention of the kinds of equipment, how the terminals will operate, what the details are, how the people will fit into this -- now many specific types of programs will be function- ing through the learning centers that will be located in these four places. By and large, I don't understand this and am very WHD17 1 ~? 10 ou 12 _13 i4 16 17 18 19 20 21 ( 8 23 24 25 HOOVER REPORTING CO, INC. 320 Massachusetts Avenue, N.C. : Washington, D.C. 20602 concerned about this type of expenditure of money. I bring this up now because it is a tremendous ‘chunk of money to spend when one could put this into; the pro- duction of personnel who will go out and improve the/ home care treatment, and so on. Fourth, they want a computer lab. “ghey really are anxious to be able to program the health data that they are pulling together and improve their computer laboratory capa- bility. That is $36,000. Satellite hemadialysis unit they want -- they have _one five-bed unit presently, operating at Fargo; tey! want a three-bed unit put together at the United Hospital| in Grand Forks, which would give them two in the state. A project review program for North Dakota certifica- tion and need law and the Federal capability expenditures; $25,000. They want to bring in a consulting firm, John, to tell them what the capability of a certification of need law is. You will have to comment on that for us. | They are talking about a human services center, for $41,700. They have developed a medical park, with two new . hospitals going up; I believe it -is in Grand Forks, and they would like to put up a separate facility in which all of the other health and human services agencies are placed, so that everything is placed in one area there, and they can inter- HD18 1 ~l] 10 | il 12 18 i4 16 ‘17 18 19 20 21 22 23 24 25 HOOVER REPORTING CO, INC. 320 Massachusetts Avenue, N.C. Washington, B.C. 20002 i ' 329 digitate more effectively For the coverage of people being serviced by that area. | It sounds like a good idea; they put it on the bottom of their priorities list. Number 8 is a data analysis -- two of these have been withdrawn. The last one is development and teaching health data collection forms, to be done by the Department of Health in Sieneeens $25,000. iI am very concerned, personally, about the | amount of time that is spent up there collecting data and analyzing it. I don't quite understand what they are doing with all this data; they were talking about this back in 1967, It seems to me they should have been able to get some kind of an operational base on what can be done in North Dakota, with all these years of RMP activity, so someone from Staff or e “poctor Scherlis will have ‘to fill us in on that. I would like to suspend further commentary on this at the moment. I can't decide whether or not to suggest that we hold them to the targeted funds, or to wack out the $400,000 entirely, as we just did on that project. MR. CHAMBLISS: Thank you, Doctor Slater. Mr. --. Doctor Scherlis? DOCTOR SCHERLIS: I don't know if I can be helpful in this. When I was in North pakota, I guess I share the concerns that other site visitors have had previously; this «4 WHD19 =~] 10 il 12 “13 14 16 li 18 19 20 21 22 23 2A 25 HOOVER REPORTING CO, INC. 320 Massachusetts Avenue, N.C. Wachinatan WE INNA? 330 has been a state which, at least in my experience, has been rather unresponsive to suggestions from out of state. I remember as I was leaving, going to the airport, a finger was thrust at my chest and I was told that: "you people from Washington just don't know what we people out here really need and should do." ‘ And I only resented it because I wasn't from Washington. Their Executive Director makes this a 25 percent ‘effort as far as his time allotment, and there is no} Deputy Director, so that is a blank. And I think this is indicated "in a way by the type of projects that we see, because these do not really indicate any homogenous presentation in terms of addressing what many people who come to that state feel the real health needs are. | - When I was there the thrust was more toward v7. ao Physicians' Assistants and Emergency Medical Technicians, on the bais of what has been there described as faras the ratio of physicians to the population of the state, and it concerns me that they are going at the computer approach rather than through the people approach. | Two of the projects have beenwithdrawn, two which were given very unfavorable ratings by their local CHP agency, so this reduced their overall request by, I think $28,000. ¢ DOCTOR SLATER: Both of those were data collection, again. WHD20 1 ~] 10 u 12 -13 i4 16 17 18 19 20 21 23 24 25 HOOVER REPORTING CO. ENC. 320 Massachusetts Avenue, N.C. | Washington, D.C. 20002 DOCTOR SCHERLIS: Their staff is small; they have a 25 percent Executive Director, an Assistant birector for Administration -- that's another -- that is a eui1-tlme person and they have two individuals in Program Evaluation, which is a person and a third, and a full-time person in Health Education, who is a nurse involved in health education, so they do suffer from lack of staff, as a great many of these projects appear to derive from the university. When we were there there were some hopes of having areas outside of the larger population centers, and et's -face it -- North Dakota does not have many large population centers by our criteria, but these do not seem to have been implemented, and I think -- and are affected in the present report. | As you look at the individual programs, you can fault them. I think in terms of ‘using RMP funds for reside ry programs at a medical school, you know, if you can't get your money anywhere else, RMP a be approached, and yet you could say that in North Dakota, if they can attract physicians that come to their state under any guise, this is a wholly worth- while way of improving health care. - “ I am impressed with the fact that this has a little different flavor than it used to have; at least they are interested in more ways, in health care delivery, and the North Dakota project, at least in my experience before, was ~ (HDQ.21 1 gs a | - 10 il 12 13 44 - 16 1 18 ‘q9 20 21 22 23 24 20 HOOVER REPORTING CO, INC. 320 Massachusetts Avenue, NC. ante ak taa.. AP AANNS _And the way they would do this would be to have the physicians care, and as I read this, I don't quite know what they say. - siderable investigation of computer systems now in. operation, grams that will help physicians improve the level of health 332 very much from the top and not totally physician and provider oriented. I am concerned, as Doctor Slater was, about that biomedical communications system for $400,000, and also irko the application of computer technology, which was another $36,000, and this was to have health care professionals in . the state -~- as they said it: | "affect an evaluation of the application of computer technology in health care fields." apparently located in different communities to have access to the computers, in order to improve the delivery of health - The speak of the “selection and implementation of process for computer programs or software will require con- . v.. and therefore considerable travel, study and collaboration with other investigators throughout the united States will be necessary." And I guess what they will be looking for are pro- care. This is how it comes out, and I would think that, Number 1, the funds that they ask for won't be helpful in that regard, and Number 2, a lot of these programs are readily accessible by getting in touch with other areas and utilizing WHD22 ~T 10 sl 12 13 14 16 17 18 19 20 21 HOOVER REPORTING CO, INC. 320 Massachusetts Avenue, N.C. Washington, D.C. 20002 ! ed the mail, and I wonder how much acceptance there will be by North Dakota physicians in this, and I don't sense Erom this that the homework has been done. If you talk about a state that asks for three and a half million dollars , and you cut it down to two and a half million, I don't feel very badly. But when you take a state that is asking for a relative pittance -- it is already the lowest-funded| -- and then you begin carving out big chunks, you leave it with - very, very little, if anything, to move on. So one rational approach that I also should have mentioned in my discussion before is inconsistency, which is again, one of my chief virtues. | | So I don't feel constrained to be consistent in any recommendation that I make, and one thing that this Review Comittee has always impressed me’ with is its great ability to be consistent. This has been, if anything, the most con- sistent feature about it, including the directions that we get on top, about what RMP means this year, at this meeting and this has been true of every meeting I have ever attended, and I think that I won't have to defend cosistency any longer in tat regard. So I would support your general comments; I guess it is a question of coming up with a sum of money to recommend and perhaps you could have some discussion before we offer IHD23 ~] 10 -i1 12 “13 14 16 Vi 18 19 20 21 22 23 24 25 HOOVER REPORTING CO, ENC. 320 Massachusetts Avenue, N.C. i Wachinotan HC 720007 with all of the facilities as originally planned. The letter _which I guess I just haven't had a chance to duplicate, is ‘from the project Director, Doctor Christopherson, who suggested 334 that motion, if that is within the purview of the reviewer. MR. THOMPSON: Has there been any Staff input on this $450,000 thing? | | MISS RESNIK: Yes, there is one letter in response to a question which I asked a Doctor ~- did he need/|to do all of this at this time? It is tied to the four AHEC's at the four big cities -- Grand Forks, Minor, Bismark and Fargo. He suggested yes, they probably would not tie in that he could reduce the equipment by about $80,000, and man~ power by $24,000, leaving a total of a little over $300,000 for the project. | “That still is very large, and I believe what may v7. have happened is that they approached the AHEC's and = they couldn't get additional funding. They are funded for five years out of the old Manpower grant, and so they are just. trying to do something with this, although tey are justifying it on the basis of the educational programs in the medical schools. | MR. CHAMBLISS: Doctor Miller? DOCTOR MILLER: I don't think I have a vested interest, so I think it is all right for me to make some com- ments. THD24 1 ~] 10 11 12 13 14 16 17 18 19 20 21 25 HOOVER REPORTING CO, INC. 320 Massachusetts Avenue, NE. | Washington, 0.0. 20002 -the population is 500,00 I have been a big brother to the North Dakota RMP's for a long time, and we really need to understand the Dakotas in the center of the country, in a program like this; you know, the Dakota Territory was a territory and when they finally became a state, which was a long time ago, but it was one of the latter ones, and North and South Dakota € are typically pioneer American -- rugged, independent indivi- ‘dualists, everybody doing his own thing now in his own way, and to heck with his neighbor, and they never could get together. They still can't; they are divided between North and South Dakota, as different as though they were arch- - enemies, though it has modified somewhat lately. North Dakota medically of course is very small; 0, MInnesota's is one million. They ? /. _have 50 hospitals in North Dakota, whereas Minnesota has 286. They have 500 physicians; Minnesota has 5,000. They are arch-conservatives, rural. America, independent; they have some justifications for it, incidentally. They have very small amounts of medical personnel and hospitals, by population ratio, but do you know where the longest length of life is in the United States? Northern North Dakota. They have the fewest number of health care facilites] in the United States, by population -~ Northern North Dakota. ‘So maybe there is something about health that is WHD25 1 ~ 10 . . i 12 18 44 16 17 18 19 20 21 25 HOOVER REPORTING CO, INC. 320 Massachusetts Avenue, N.C; | Washington, DE. 20002 have a big AHEC grant, and have these four units whi more important than medical care. Now, they are beginning to change, and the is motivated by the very great need for them to have plete medical school. incidentally was a superb one -- their graduates cou almost any othe medical school they wanted to go to United States and get admitted, because they were ve! well-trained two-year men. But that is not an option now, and they re desperately need to develop their own medical school the potential of developing a clinical tie-in, multif / change a com- Nowadays, their two year school, which ld choose in the ry, very Ally . They ch have ble small places, with the medical school and still maintain quality in medical education at the clinical level. Now, they need support in every way they can get ” it in order to carry out this rather ambitious plan. They also pioneered in the training of medics, and were one of the first ones, along with Duke -- but a different approach, of trainig Physicians’ in North Dakota. Assistants, which has gone very well So they are moving into a cooperative approach, they are cooperating with each other in their viciously com- petitive adjacent towns better than they have before, would put in a plug for --- letts give them a little ‘DOCTOR CARPENTER: and I push. Is it really true that people in WHD26 1 oe ~ 10 11 “12 13 14 16 17 18 19 20 21 HOOVER REPORTING CO, INC. 320 Massachusetts Avenue, NC. ; Washington, D.C. 20002 337 North Dakota live longer, or does it just seem longer? (Discussion off the record) DOCTOR SCHERLIS: Anecdotally, North Dakota is the only place I have ever been to where the home that we went to, which is one of a series of apartments, instead -- (purther discussion off the record) We do have a number we have arrived at. MR. CHAMBLISS: All right. We would like to have the recommendation of the presenters. | DOCTOR SCHERLIS: I would not be prepared to defend it, but that is for a number of $500,000, which is midway between, actually, what they have asked and what is targeted, and the rationale that we have used, which is not offered as a means of defense, is that they now have a level of $367,000, they requested $774,000, and actually reducing that by what v. : ‘they have indicated they can, which is $104,000, plus eliminatr- ing two projects -- which is not a significant decrease -- it comes to a total of $100,000. I would think at this particular time, with the medical school coming in, that within the constraints that they have during the coming year, this would be -- I would assume the values of the programs they are looking at, and certainly they can come back in July for more. The major reduction is what they have indicated they can take. WHD 27 1 ~] 10 u “1 "13 i4 16 17 18 19 20 21 25 HOOVER REPORTING CO, INC. 320 Massachusetts Avenue, N.C. | Washinston. D.C. 2000? MISS RESNIK: They are not coming back in July, according to their suggestion. MRS. WYCKOFF: Can they come in now, or is it too late? DOCTOR SCHERLIS: Well, even if they are not coming back, this reduction, $104,000 -- what they have indicated ‘ they can make by dropping two projects, again this is not a significant reduction but I think it reflects on some of their -- well, computer services, that the other additional reductions have made, so this is $500,000, which is over their present level of funding. | | | DOCTOR SLATER: It effectively takes oat. the bio- medical program. Since the $360,000 was put. into microwave sending and receiving equipment, it makes it possible for them, though, still to spend somewhere between $20,000 and $40,000 to put in four sudzouvaeuel learning packages in the AHEC centers, which could be used locally to improve teaching techniques for various types of personnel. | By suggesting this, *we have taken $224,000 out of the request, so we have effectively killed off the biomedical system. MISS RESNIK: Yes, they still have a start, and now we can go ahead, if it is agreeable, to suggesting limiting ¢ the locations where they are going to try out this " Medline" microwave. WHD28 al 10 il 12 13 id 16 1 18 19 20 21 25 HOOVER REPORTING CO, INC. 320 Massachusetts Avenue, N.C. Washington, D.C. 20002 “ficate of need legislation. legislation in a state that is -- that has only two dialysis © ‘e MR. CHAMBLISS: Would the Committee so recommend? Did we have a motion to. that effect, or was that a recommendation? May we have a motion, please? DOCTOR SLATER: Motion by Doctor Scherlis, seconded by me. MR. CHAMBLISS: It has been moved and seconded that the level of funding for North Dakota be at the level of $500,000. | | Is there discussion? DOCTOR SLATER: I would like Mr. Thompson to refer briefly to that question before we go on. | | | MR. THOMPSON: where are 24 states that have certi- "DOCTOR SLATER: To spend $25,000? - pocTor VAUN: The importance of certificate of need v units escapes me, but what I wanted to make was the observa- tion that the knife seems to be getting sharper: as the day wears on, and I am especially sensitive of this when we have been dealing with other Regions whose requests are in the millions. oO, | “ We have arbitrarily landed on the target figure, and when we are dealing with a small state like this, that has a very small -- $80,000 makes a lot of difference, and in light of Doctor Miller's comments, I really would like to see us THD29 ~ 10 ‘u “412 _ 13 i4 16 17 18 19 HOOVER REPORTING CO, INC. 320 Massachusetts Avenue, N.C. < Washington, D.C. 26002 i! 349 give them at least the target figure. MRS. SALAZAR: Mister Chairman, I endorse that. Is discussion still in order? . MR. CHAMBLISS: Certainly. MRS. SALAZAR: I used to have some administrative responsibility for the state of North Dakota, am of all the Regions I have ever dealt with -- and I have dealt with quite | . a few -- the state of North Dakota has a-long history of being very penurious in their applications. They spend money wisely and they spend it well, and they are very fiscal, . “| they are very accountable to every dime.. I am looking «down the list of the RAG and I see a lot of old familiar names, and I also see some on the staff, and I also note that they are trying to recruit a Deputy Director, which is one of the things that I recall is an old problem, and I am wondering how much we would damage the program if we reduce it by a relatively small figure? How attractive this would be to somebody they are trying to recruit for leadership, whicheis very much needed in this area. DOCTOR SCHERLIS: “We would like to withdraw our motion and sugget that it be the. targeted figure. MR. CHAMBLISS: The amount mentioned in the motion is withdrawn and the target figure is substituted, and that figure is $582,217. WHD30 HOOVER REPORTING CO,INC. : 320 Massachusetts Avenue, NE. | Washinsion. DC 20002 ~~ 10 11 12 "13 14 16 17 18 19 20 25 and so on? 341 DOCTOR SCHERLIS: I would also like to just note for the record -- it is interesting to note, and we should have mentioned this in what I think is a very active motion on appeal -- they never ask money for overhead. Isn't this true? They are the only state in the Union that refuses to ask for overhead of RMP, ‘and maybe this is a way of refunding some of that overhead. : MR. CHAMBLISS: Question? Those in favor of the motion? | | (Chorus of "“Aye") of Those opposed? (No response) The "aye's" have it; the motion carries. DOCTOR SLATER: Will the Staff advice going back on this indicate the concern over the priorities of communication /. MR. CHAMBLISS: Yes. MR. THOMPSON: And the certificate of need thing? _ MR. CHAMBLISS: And“the certificate of need thing. DOCTOR SLATER: This concern is coming from people who have spent time in the rural areas. | | MR. CHAMBLISS: Will the Staff note that? I would now like to ask the Committee to make a decision as to how we could proceed during the lunch hour here. We have completed the review of eight regions this 4 THD31 1 morning, we have eight left; we could, if you wish, complete 2 one more and then -- Northlands, and that would free Doctor 3 Carpenter, and then after that immediately start in on Texas, 4 and that would clear Doctor Slater. I stand open for suggestions from the Committee as g || to how we should proceed. =] MR. THOMPSON: Let's get going on Northlands. | | 10 dV 42 18 14 16 17 18 19 20 21 HOOVER REPORTING CO, INC. 320 Massachusetts Avenue, NT. | Washington, B.C. 20002 enn tac £ect WHD32 ~ 10 11 12 13 14 16 li 18 19 20 al HOOVER REPORTING CO, INC. 320 Massachusetts Avenue, N.C. | Washingten, 0.0. 20002 1 343 ’ REGIONAL MEDICAL PROGRAM REVIEW NORTHLANDS REGION > MR. CHAMBLISS: All right, let's move forward to Northlands, and let the record show that Doctor Miller, the former Coordinator of Northlands, has absented himself from the room. | The reviewers here are -- is Doctor. Carpenter. Staff support will be provided by Mr. Jewell, on Northlands. . i DOCTOR CARPENTER: Well, this is a -- sort of the same problem. The Coordinator, as is perfectly obvious to everyone here, has left, and I think he left quite a hole. The Region has given up its own priorities, or if it hasn't, at least it doesn't mention them in the applica- tion. The staf is -- it simply lists the Federal words and then says what it might do after that. The staff is tiny; there are four people, with three professionals. They have in mind enlarging to five, I believe] But I see no evaluation of any significance, and again, the | projects don't seem to me to have any specific goals. They are talking about area health education centers but it is not clear that there is local support for these, and it seems more a question of bringing in Mayo-produced software to be displayed to hospitals and staffs who undoubted] will be busy elsewhere. Y THD33 1 ~l ©. 10 11 12 13 14 16 17 18 19 20 21 23 24 25 HOOVER REPORTING CO, INC. 320 Massachusetts Avenue, N.C. ilaohinatan AL INOAD 344 They don't have any activity in primary care, and I was pretty concerned at that point. That was my first time through, and I -- after I went back through it again, it is a triennial application; this is the third year. Their mechanism, except for the staff, I guess -- teir mechanism is intact. The RAG was inactive for a while, but it seems to be back again. The man who took over was the Deputy Director for a.number of years, and he puts together a very mechanical application. It is beautiful, you know? All the -- every- thing is color-coded, and you can find your way through it very nicely, but I just don't find any substance there. The contracts through CHP and the state agencies 1 “will apparently lead to the designation of Emergency Room facilities by classification and a better communications /. ' system between the various agencies providing emergency care in the state, and this will be something which I believe the original Coordinator started, and it is going to leave a legacy that I suspect will be useful. | | The definition of levels of training for various kinds of emergency personnel and per formance standards have been elaborated, and: for the continuation and development of this emergency project, they are asking for $140,000 for local plans, and $120,000 for the state coordinating mechanism. Then there is this network of community-based health WHD34 1 ~ 10 uu “12 - 138 14 - 16 17 18 19 20 21 23 24 25 HOOVER REPORTING CO, INC. 320 Massachusetts Avenue, N.E. | Washineton. D.C. 20002 545 education centers; they do have local councils, and at least a part-time staff now, in each of. the areas. Continuing education was _- has always been, I guess of importance to them, and they have continued that. They are -- they have a series of these AHEC's; they have a standard description on each of the projects, which is goals that I think were set sometime ago, and then on some of the projects, there is typed in with a different typewriter some additional ideas. - | Oo | For instance, some of the -- they have a management 4 training program, and some of the AHEC's, but not all of them, | will take advantage of that. One of them is going to get involved in public educa tion, but no particular information about exactly what that means. “Y. oo Altogether, this program for the community based health-education centers will cost about $636,000-$640,000.. Then there are -- they are interested in the PSRO, _ business, and they are not confing at it in a way which I would think -- or, I would think they probably should have not started this way; they are interested in quality evalua- tion, and they know that they are laying the groundwork for a PSRO, but I am not sure that they are going to -~- I am not sure how you look at it. They are going to set criteria, but they are going WHD35 3 ~~“ 10 11 12 13 i4 16 17 18 19 20 21 22 23 24 25 HOOVER REPORTING CO, INC. 320 Massachusetts Avenue, NC. Washington, D.C. 20002 | 3940 to develop nine pilot programs, too. And all in all, they will invest $190,000 in something. called the "Foundation for Health Care Evaluation," and I hope -- MR. THOMPSON: It sounds like a PSRO to me. DOCTOR CARPENTER: I hope we can have some descrip- tion of what that organization is. They have managed to pull together some people who don't ordinarily work together in quality care; they got the Medical Society and the hospital group together, and that | must have been a challenge, and then they got the Mayo Clinic to go along, too, so there has to be something good going on there. | Well, we have a state -- they want to coordinate a state hypertension control program, and that will cost $133,000 for clinics -- for a clinic in one hospital, and yo _then $87,000 for software for public education programs. There is $120,000 to sell the idea of organ procure- ment to both the public and the professionals, and a part of that program is to find out why heptatitis is a problem in transplantation. There is $69,000 to start the last two CHP's that the state thinks they need. Some of the projects are so vaguely described that the state A agency expressed coricern in regard to two of the projects, involving the specificity of the plans, and I guess, “ WHD36 ~1 10 11 42 . 13 i4 16 17 18 19 20 HOOVER REPORTING CO. INC. 320 Massachusetts Avenue, N.C. | Washington, D.C. 20002 question him on this. 347 that I am on CHP's side. Can we hear particularly from Staft about the nature of that foundation for health care evaluation? | MR. JEWELL:. Doctor Carpenter, I questioned Mr. Wilkins when he was in here, on this, and it is a fund-holding ‘company. No, not a fund-holding company; I am trying to think of the words he used. , 7 I really can't answer your question; I could not get . ; a satisfactory answer at the time he was in there, and I did DOCTOR CARPENTER: All right. | The number of that project -- well, it is hard to find the projects because they are under several categories. MR. CHAMBLISS: Is that 1075S? DOCTOR CARPENTER: We can find it by the dollar A. value. MR. CHAMBLISS: 107S and 107? Would that be the activity? . DOCTOR CARPENTER: ‘That is, probably. MR. JEWELL: That is the hospital association. (Discussion off the record) MR. THOMPSON: They say there is $326,676 in quality assurance; how did that number get arrived at by Staff? DOCTOR CARPENTER: Well, it is hard, I'll tell you. WHD37 1 | 10 ii 12 “13 414 16 17 18 19 20 21 22 23 24 25 HOOVER REPORTING CO, INC. 320 Massachusetts Avenue, N.C. Washington, B.C. 20002 It is on the purple sheet in the front. 545 I spent a long time last night trying to do that, but you . | can add up the various projects in that area. | MR. THOMPSON: Well, there is 17S, which Lh $158,000; then there is 107, which is another $73,00 have combined those projects that had something to do with evidently Staff, or whoever made up this briefing ss Must quality assurance, to come up with the fact that 20 ercent of the budget is on quality assurance. MR. JEWELL: That is from their words, Mr.| Thompson. MR. THOMPSON: I only got the yellow sheet, DOCTOR CARPENTER: ‘There is some blurring,| too, because there is a hypertension program that was -= well,.. there are several of them. One of them is a quality assurance program in hypertension. e So some of this quality assurance business, I think, has a little bit of pizzaz to it. There is a guy from the Mayo Clinic who is working pretty hard at it, and he started with a single disease and worked out criteria and applied them, and now wants to expand it to a couple of others. MR. THOMPSON: Beverly Payne did that a couple of: years ago in Michigan. You know, and he started out with more than one disease. You know, it is awfully difficult; these guys are just rediscovering the wheel. WHD38 ~_ 10 il 12 ' 13 14 16 17 18 19 20 21 22 23 24 25 HOOVER REPORTING CO, INC. 320 Massachusetts Avenue, NLC. Washinton. D.C. 20002 wits DOCTOR CARPENTER: It is awfully difficult to match and meet these. He is matching the relationship between the ability to meet the criteria and the outcome, or trying to in a hypertenson project. And I think that -- you know, that is a significant ‘area that requires more innovation. Let me -- you want a funding level, or do you want | to talk a while? | | MR. THOMPSON: Go right ahead. What about the kidney thing? Is that going to be legit? | : | DOCTOR CARPENTER: I don't think, very; Lo. MR. THOMPSON: I'd like to pursue legitimate pro- jects here; I've got 20 percent wrapped up in quality posure ance and I'm not sure that is not a PSRO basis. I have $149,000 or 9 percent of the total budget wrapped up in kidney disease. Then I have the payoff to CHP, which I'll roll by. ° MR. CHAMBLISS: Let me speak to the CHP issue. MR. THOMPSON: I didn't include the CHP. DOCTOR CARPENTER: ‘The quality assessment, there is about 190, 000 going into what might be a PSRO, and if it is not it is so vaguely described it would be impossible for me to support it. 350 WHD39 1 The rest of that $326,000 -- you know, I think it 2 is not unreasonable to suggest something will come of that, 3 | and it certainly will not be a complete PSRO; it will be, 4 you know, an opportunity to try to lead people beyond Beverly 5 Payne's criteria, which I believe is terribly important. él]. The renal project, I don't think, is very good. a, i Are you suggesting though, John, that we are not supposed to ~~ 8 fund renal projects at all? And I guess the issue then is oe g|| this is not a catinuation. | 10 MR. VAN WINKLE: That is not a fact. W The only thing we need to do is flag the kidney so 12 it can be discussed with Doctor Goodman in the end-stage 43 renal program. We have to make sure that they are in compli- i ance, and this sort of thing is not something you fund without checking. » 15 y. | 1b | DOCTOR CARPENTER: The main thing with that kidney " program is that they are talking about procuring organs, and 7 they don't tell you for what. - 7 I assume they don't “plan to bank them indefinitely, but I don't know. 20 . MR. VAN WINKLE: Could I speak to that? > 21 Doctor Fred Shapiro is the Director of the Renal 22 Program in Minnesota and probably one of the leading nephrol- 23 ogists in the country in terms of setting up what we con- 24 sider to be one of the better programs that we have seen. 25 , HOOVER REPORTING CO, INC. 2 320 Massachusetts Avenue, H.C. “| AR ANAS I WHD40 ~ 10 il 12 13 14 16 17 18 19 20 21 ‘22 23 24 25 HOOVER REPORTING CO, INC. 320 Massachusetts Avenue, N.C. ' Washington, D.C. 20002 - state. ainda HE does have true regionalization; he has been taking care of the Dakotas, too, as well as Minnesota, and those satellite units you see basically are coming ott of Shapiro's units. DOCTOR CARPENTER: “Does he do enough transplants to have an impact on things? | MR. VAN WINKLE: Absolutely. MR. THOMPSON: I guess my concern is the kind of field you have for the project which is not matched with at _ least my idea of the - resources that are available in| the DOCTOR CARPENTER: you mean you think Bhey could do more with what they have? | | MR. THOMPSON: I am talking about ~- you know, there are some very good people in that state. | DOCTOR CARPENTER: Well, you know, I can't argue with you there. MR. VAN WINKLE: Mr. Thompson, I don't think there is any! question that after Doctor Miller left, most of the other staff left also, and at one time all we had was Mr. Wilkins, his Deputy, and I believe one other person. Is that correct? And one part-time individual, and I -- Mr. Wilkins is excellent; I am not questioning that whatsoever. It is ¢ just so thine ~~~ MR. THOMPSON: Inthe old days, we used to get some HD41 1 ~l 10 on 12 .13 i4 16 17 18 19 20 21 23 24 25 HOOVER REPORTING CO, INC. 320 Massachusetts Avenue, N.C. Washington, D.C. 26002 IIADN EAL LOC didn't have any at that time. - happening. ad od he real flaming projects out of there. MR. VAN WINKLE: That is right. Their RAG and their Executive Board are excellent. They are very good, but they went into -- as I heard somebody mention earlier -- ito neutral, and they informed us at that time that they were making no moves or any decisions or moving forward in any way until they got some answers from us, and we informed them back: "You may have a considerable wait," because we So there was a period of time there was very little DOCTOR CARPENTER: Our idea now, at a $1,250,000; the target is $2,170,000, the request will, by July, amount to $2,500,000, and I would think we might start now at some- where around $1,600,000. | DOCTOR WHITE: Ean I interject a comment? According to the yellow sheet, at least, all but $226,000 is for on-going activities. They only ask $226,150 for new projects. I don't know what percentage of continua- tion projects are being augmented, financially, but if you cut them too drastically you may not wen allow them to con- tinue what has already been started. DOCTOR CARPENTER: Well, it is not too clear. YR. THOMPSON: They may be supporting them, but their annualization funds now -- 1HD42 1 ~1 10 UW 12 18 14 16 17 18 19 20 21 22 23 24 25 HOOVER REPORTING CO, INC. 320 Massachusetts Avenue, N.C. < | Washington, 0.0, 20002 MR. CHAMBLISS: Did you have a comment on that, Mr. Jewell? | | MR. JEWELL: Well, Doctor White, I don't know if. it is unusual but it is probably unique. For example, on EMS they will set a limit of perhaps $25,000, which are funded through the CHP B agencies. You don't -- it isn't grab-bag here; tey set a fund and if you can comply-- they set a fund for a certain amount, and if you can comply with what they . i set out as their goals and objectives, then that. set amount ! 4 is all you get. | “MR. THOMPSON: I think it is too drastic. DOCTOR CARPENTER: Do you? All right; I had $1,700,0 -- I was anywhere, all over the map. If you were to say -- well, give them what -~ there is no way that those three guys are going to bring home the bacon and a $1,700,000 worth of projects, even if some of chem are a under way, I don't think. But I don't know; what do you want to do? Give them half of their new projects, anc what they had before? DOCTOR WHITE: Does anybody know at what percentage their old projects have been inflated? | MR. CHAMBLISS: Do you have any idea? MR. JEWELL: It is not a great amount. I am sorry, I don't have that figure, but augmentation of $10,000 would be a lot. HD43 al 10 au 12 -13 14 16 17 18 19 20 21 22 23 24 25 HOOVER REPORTING CO, INC. 320 Massachusetts Avenue, N.C. Washington, D.C. 20002 that. | DOCTOR CARPENTER: It has to be augmented in a bunch | I doesn't it, because they went from -- MR. JEWELL: Well, I meant on the individual. There are some of them, Doctor Carpenter, that are larger. DOCTOR CARPENTER: $600,000 increase; their request is $600,000 larger now than what their annualized amount is, and they are reduced in staff, and they have $200,000 worth of new projects, so there must be a $400,000 increase in their continuation -- $300,000 or $400,000 or something like MR. CHAMBLISS: All right. Are you prepared to make a new recommendation, or does your former recommendation hold? DOCTOR MC PHEDRAN: I have an observation to make that may be beside the point; it is on a matter of detail. I think that this matter of developing standards for care of common problems in different hospitals and office prac- tices and so forth, that it is to me an argument of no effect that somebody else has done it in the past, Beverly Payne or anybody else. I really think that people's behavior in the ere ment of these things will never be changed until they are doing it themselves on a local level. I think that it is worthwhile to avoid the duplication of efforts in various parts of the | state. I don't think it is an inapproprzte expenditure of WHD44 1 ~) 10 a 12 -18 14 16 17 18 19 20 21 23 24 25 HOOVER REPORTING CO. INC. 320 Massachusetts Avenue, N.C. ' Washington. B.C. 20002 - in the past. 3D) money. Now, I don't know whether it is within RMP guide- lines; I haven't really gotten that far in thinking about it. But I really think, from what I have seen since I have moved to Augusta, it makes me feel that the efforts which are being made the staff of this community hospital to develop, -- they are doing GCAH types of preparation for audit purposes, is probably going to be of more value to us than almost any- thing else you may have done, and it really did not help them a lot to know that somebody else had made some recommendations I know it sounds like God and Motherhood, but I really think it is true; I don't think there is any point in bringing anybody else's recommendation in except as it guides you in making your own. . | MR. VAN WINKLE: ” Well, that is certainly something that can be checked out by staff. ‘DOCTOR CARPENTER: I don't think if that is the start-up project that that is a problem. It is this non- specific ~~ whatever it is -- $190,000 for the foundation for health care evaluation, that we just know nothing.about. L don't think that is the problem. The other half of that money is for quality assur- ance, and I agree with you. I think it is the best thing they are doing, and ought to be supported. 530 THD45 1 So -- would you believe $1,700,000? That is a 2 motion. | | 3 DOCTOR VAUN: Seconded. 4 MR. CHAMBLISS: It is moved and seconded that the 5 level be set for Northlands at $1,700,000. 6 i} Is there discussion on the motion? Those in favor? ~] 8 — (Chorus of "Aye") | | . 9 ; Opposed? | io |} . (No response) ! u The motion carries. | , 49 The Committee has done all its work assigned for asl the morning, and I would say we can have lunch and come back 14 and start with Texas. 1b (Whereupon, at 12:45 P.M., the Committee recessed ub for luncheon, to 1:30 P.M.) 1? ae --- 19 ° 20 21 . 22 | 23 24 25 *e HOOVER REPORTING CO, INC. 320 Massachusetts Avenue, N.C. ' Washington, 0.6. 20002 Y ~ 10 ll 12 13 14 16 17 18 19 20 21 23 2A 25 HOOVER REPORTING CO, INC. 320 Massachusetts Avenue, N.C. | Washington, D.C. 20002 of the other panel and they are moving along with speed. ' leave today -- Dr. McPhedran. TEXAS REGION . 357 MR, CHAMBLISS: May I call the panel to order and indicate that first, I have been-in contact with the Chairman We are Looking forward to the joint meeting of the two panels so that we can have a view cf what they have been doing and they in turn can see where we stand and we are not , at the moment certain as to whether this group can meet eithey this afternoon or tomorrow. ‘Iam more or less inclined to believe that it may be in the morning. i would then suggest to the reviewers that you may begin to consider amending your plans with that in mind. I do know that doctor -- let's see, who has to | DR. SLATER: I am sorry, I am irreversibly committed to leave. ” /. SS MR. CHAMBLISS: Dr. Slater has already indicated previously. Will you leave today, Mr. Thompson? MR. THOMPSON: Yes, I have an important meeting to make. . MR. CHAMBLISS: Dr. Vaun? DR. VAUN: I have an appointment tomorrow after- noon. MR. CHAMBLISS: I think that will not be a problem} DR. SCHERLIS: Would it be advisable that we meet ~) 10 11 12 “13 i4 HOOVER REPORTING CO, INC. 320 Massachusetts Avenue, M.D. | Wachinetan AT 70007 . enforced by the entire review committee. | "358 at 8:00 o'clock instead of 8:30? MR. CHAMBLISS: I will get that to the other parties. | MR. TOOMEY : What is the purpose of the other meeting? MR. CHAMBLISS: Since we have been split in two groups to coordinate the work of both of them, so that we can have the joint recommendation covering all of the -- all of the funding levels opposed by the two panels known to and | DR. McPHEDRAN: Is that something that you need as a pro forma matter? MR. CHAMBLISS: It is a pro forma thing. DR. McPHEDRAN: We can't just give you a blank check? . vy. MR. CHAMBLISS: Since Dr. Indicart has said that this should be a quality review, I think whatever semblance we can maintain of making sure that all of the requirements are met for such, I would hope that as many as can stay over would do so. I would call to your attention also the fact that we have a new Reporter present. Shall we then begin with a review of the appli-. cation from Texas and the reviewers -- DR. WHITE: I hope you all will know I am excused. ~ 10 uw 12 13 i4 16 17 “18 19 20 21 25 HOOVER REPORTING CO. INC. 320 Massachusetts Avenue, N.C. Washington, D.C. 20002 CONN BAG AEE - discriminatory towards sexes. I thought it would be helpful ‘had the same difficulty. .a co-staff of 7 professionals, 5 commercial. ¢ has served his capacity since November 1973. However, he has MR. CHAMBLISS: Mrs. Salazar and Dr. Slater and, for the record, we note that Dr. White has absented himself from the room. | Miss Murphy, Miss Mary Murphy, one of our operations people will be the staff person on this region. MRS. SALAZAR: At the outset, I must say at the time of the New Mexico deliberations were 19 minutes, so I am making a push for equal time and a little beyond that, I hope you will bear with me. I am eager not to be to go into a little more detail because I found the application extremely hard to understand and perhaps some of you have Texas is rounding out its first year of triennium status, funded at $775,832, which covers 14 project activities|, / This request continued funding for six on going programs and five new areas of health education, health economics and systems demonstration, health manpower, health care quality, and management of major diseases, amounting to $3,239,000. There is also a staff development component requested in the amount of $287,000. The present director had RMP experience since 1970, having served as a deputy ~ 10 | 11 12 13 14 16 7 18 19 20 21 25 HOOVER REPORTING CO. INC. 320 Massachusetts Avenue, N.C. Washington, D.C. 20002 . by physicians or more immediately related professions. ‘ propose in the application with a delegation of authority -very highly sensible position, access, utilization, organi- to as RAG has added two minority members, one of rural and one director from June 1971 until August of last year when he became acting director. The remainder of the corps staff has wide experience from 1-1/2 to 4-1/2 years. The total number of staff was reduced from the time of phaseout from 32 to the present 14, And the various disciplines are impressive. t But, I do have some concern about the region's ability to mount the very ambitious program that they now propose without active day to day surveillance and participati I have other misgivings about the region's ability to deal with the broad State-wide medical programs as they and responsibility through the project's contract conditions, - Especially since these issues are addressed in the proposed wv. zation, manpower and so on. The regional advisor group and the board of trustees of the Texas RMP, Inc., which is the grantee, appear to have excellent lines of communication. Although it is the same time noted that the executive committee met only once in 1973. This committee of RAG which I will hereafter refer é urban base. on 3 ~ 10 / 11 12 “13 14 16 17 18 19 20 21 25 HOOVER REPORTING CO., INC. 320 Massachusetts Avenue, N.C. ' Washinotan NC 2NNN . of 1973 and it met subsequently three times to address interna and external health influences and significant legislative 361. It is interesting to note that although the program committees were only reactivated in early April of this year, meetings are already scheduled in June with only three replacements out of the 70 members requiring space. I think this is a test to the continuing interest in the State and especially in the RAG-RMP affairs. The RAG has obviously been very participative in the program development which evolved into this present ‘application. It had a special planning committee in November | thrust. The RAG is also moved into the direction of strengthening relationships with the health planning agencies and has met with medical.agencies as well as other Federal and other related associations. “Several of the projects seem to emanate from these sources. As a result of the joint Arkansas Council, a proposed rate for high new born death rate is under the Texas RMP for joint funding. This is I think a real break- through for Texas in view of the fact that they seem to be responding better to local needs and demands which cross f traditional State lines. ¢ With the CHP involvement in the application, there is some very familiar names with longstanding experience in ~1 10 il 12 .13 14 16 17 18 19 20 21 HOOVER REPORTING CO. INC. 320 Massachusetts Avenue, N.C. | Washington, D.C. 20002 health planning, are rather obviously alert and informed to ! the new thrust of Texas RMP. a, I notice that Sister Marian Strohmeyer is actively involved. She has been involved in the ned th planning in the lower Rio Grande Valley, which is one of the depressed and under-served medical areas of the State. However, the time frame for the preparation and submission-of this application imposed very serious -limitations in my view on community involvement and review. And to me it at least created a vacuum in the application in order to review the CHP report. It appears planned. It is so planned that it is almost meaningless to me. There were four letters of endorsement with two to follow and there was some expressed reluctance from local groups to comment. on State-wide programs. They felt they didn't have a bearing, that they’ were not capable of that. There is also an element of inconsistency in this vacuum. In February of this year, the second annual meeting. of health planners of 22 councils of government was sponsored by the Texas RMP. The purpose of this meeting was to solicit assistance in information about successful projects funded by the Texas RMP since 1968. Another such meeting is planned for next month. I think that perhaps it is time to inquire about present status and cooperative efforts in view of this, as ~ 10 _il 12 -13 14 - 16 17 18 19 20 20 HOOVER REPORTING CO. INC. 320 Massachusetts Avenue, NLC. Washinston. 0.C. 20002 | personal non-human approach to fulfilling the provisions of 363 well as other pending proposals and the RAG reports. That they are under consideration like the arkansas~-Texas joint council, As to feasibility, the contract approach to these proposals seems to have some advantage of concise language and subject presentation, the goals and objectives are clearly defined, easy to read. However, the same economies of language do impose ‘specificity and detail. I have no criticism of contracts per se as a mechanism but I have some problems with the the contracts. There is a quality throughout here of saneness of the language. | It is common, to all the projects and it is difficult to determine the inter phases and the -- the network in other words, of the relationships of one project to the other. The language is good and it is lofty and it is worthy and it sounds like they can do it. But once again, the impression that these views that you are looking at, all of these throw a thin layer of professional systems who are unquestionably skilled in such presentation and I have trouble ¢ with the understanding of it. I have trouble with understanding the programs commitment to address themselves to these ~1 10 - il 12 “13 14 16 17 18 19 20 21 22 24 25 HOOVER REPORTING CO, INC. 320 Massachusetts Avenue, N.C. i “364 problems. They don't come through in these little descriptions of the request for contracts. vhat is nv own bias. There is an intangibility about it that I find is very difficult to deal with. Let me just quote one little paragraph. Description of one of the programs. To develop and demonstrate educational approaches for barriers to health care, | ‘So much of the contracts and the effectiveness of the contracts, I believe depends on the language, that I find it impossible to get an understanding from what! I read in this application of what Texas is going to do with these contracts. I have some concerns about giving contracts to profit organizations and who will monitor them and I will spell those out later. a, I would not at this time like to make a recommenda tion until we hear from Dr. Slater about that. MR. CHAMBLISS: Thank you, Mrs. Salazar. Dr. Slater? DR. SLATER: I thought you were going to be going for 19 minutes? . | I would like to say, Mrs. Salazar and I met just briefly at lunch, is the first time: we communicated on Texas. é .And I will simply reiterate for you what my statement was for her. T ~~ 10 1 12 _ 13 14 16 17 18 19 20 21 HOOVER REPORTING CO, INC. 320 Massachusetts Avenue, NL. Yeashington, D.C. 20002 365 I was deeply impressed with the objectives as she has quoted them of the Texas ‘program and felt that as long as looking at health education, quality State-wide disease projects, health manpower concerns, that clearly there is plenty of room to move. 7 And that one cannot fault under any circumstances’! this kind of -~ the set of objectives. jo What I simply cannot get a handle on, reading Texas, was what was really coming out of it and I came prepared to say that I am impressed with the range of activities that are going on and feel that, from what I read, that they apparently do have very good review by an involve- ment of the comprehensive planning group. ‘But I still could not understand it because there is too much, there is too broad a range of activity explained into few words, which I “7. believe you say lack any color whatsoever. I think that perhaps Mrs. Salazar put a figure on it by saying there doesn't seem to be any medical pro- fessional input into this that gives the sense of the priority within the framework of the humanity aspect of it and I am not saying that that comes through that strongly in the other proposals but this is a little too perfect in some ways. What I am saying is that I am impressed with what 2 they are attempting to do and if one takes a look at page 24, the project status report, contract No. 73-1, continuing 3 ~ 10 ‘i 2 _ AS id 16 17 18 19 20 21 HOOVER REPORTING CO, INC. 320 Massachusetts Avenue, NC. * Washinston. D.C. 20002 366 education for registered nurses providing community health services, is on schedule. Comments: Extended 60 days for additional effort; Progress excellent. That is fine. And there is two pages of this tyne, or 2-1/2 pages of this activity and we simply have to. accept the fact that everything except the two projects is on target and doing well. On the basis of that, there is a request for continued activity of, I can't get here, I would say some- thing like, maybe $300,000, $400,000 extension. : Now, when one goes beyond that one gets into the matter of what do they plan to do in the future? As Mrs. Salazar pointed out, because they are in a tight time frame, they have decided to follow the general guidelines of their thrust, their objectives and sent out proposals for, send out requests for proposals. Do you want me to ‘go on with this? Mrs. Salazar. Yes. DR. SLATER: And let me, if I can find my way in again, let me give some sense of what they are doing here. They have an access committee of their RAG, é * e oriented, an access committee concerned about getting into the health program. It is asking for $286,400 for what is ~) 10 ll 12 13 14 16 17 18 19 20 21 25 HOOVER REPORTING CO, INC. 320 Massachusetts Avenue, NE. | Wachinatan AL 2HNN? sent out, widely distributed throughout the State. They ‘barriers through education at $48,000; Work Activity B, 367 called the Texas health education project. Within that there are a whole series of objectives which are fine. Objective 1 is develop and demonstrate a coordinated approach to individual health education in a selected area. Then there are Work Activity A. Apply those guidelines developed in RMPT Contract No. 74-14 through a. | coordinated approach to individual health education in a specific community, town, county, multi-county region. $45,000 is available for that. Two, determine health education requirements and develop effective means of meeting those needs. There are four work activity suggestions here range from Work Activity A, analyze cultural barriers to adequate health care and’ develop methods for overcoming the develop an outline form that can be used in rural poor communities to assess health status and informational needs at $40,000. | | Work Activity C, study the legal barriers to health care as perceived by the consumer and provider and recommend educational approaches to overcoming those barriers at $63,400. é And Work Activity D, demonstrate and evaluate the use of upper division nursing and medical students as remote R ~~ 10 ou 12 - 13 14 16 17 18 19 20 2] HOOVER REPORTING CO, INC. 320 Massachusetts Avenue, NE. ' Wachinstan AL ANN? tion community, the Texas Health Economics and Systems in Texas for $160,000, and a very laudable group of objectives wy area community health educators during non-school periods at $35,000. | Objective 3 is improve health care and reduce overall cost through education. Work Activity A, analyze areas of greatest consumer abuse in the health care system and suggest) education programs aimed at overcoming same at $55,000. | ' All of those activities add up to something like $286,400. | | Then, under the general rule book of the) utiliza- Demonstration Project are indicated. That is a figure of $636,340, and I think I would lose you if I read over all- the objectives and work activities. Needless to Bay -- MR. THOMPSON: That is a five-year project conservatively speaking. I just reviewed it just for you, Bob. DR. SLATER: Thank you. I didn't even speak to you about it. Health Manpower Committee of the RAG is to assist, coordinate and cooperate with those who wish to perpetuate, expand and improve the quality and output of health manpower ¢ laid out here. I don't think anyone is finding any fault al (2) ~~ 10 i 12 -13 14 16 oy 18 19 20 21 23 24 25 HOOVER REPORTING CO, INC. 320 Massachusetts Avenue, N.C. (Machinatan AL IAN? 309 with this. The report on current distribution and trends in Texas is -- work activity, none is required at this time. They were satisfied at a -- excuse me, that appears ito be in here under what they were going to fund and I have been misled. | But they have a series of objectives under attempting to define better health manpower . Here is a very ‘specific one. ; | | Encourage the development of a responsive and timely State-wide health manpower Gata base for use by health educators, policy-makers and others. Work Activity A, a six-month study for this purpose, with Governor's Office of Information Services, is nearing mid-point. This, is already under way. Continuing Education Committee is wanting to identify, encourage and assist those health care professionals interested in finding new and more effective methods for providing continuing education in the region, and they require $308,700 for that. MRS. WYCKOFF: Is that PSRO? DR. SLATER: I don't think so. MR. THOMPSON: There is.a quality that is laying é the base for that. DR. SLATER: Can you identify that? HOOVER REPORTING CO, INC. | 320 Massachusetts Avenue, NLC. i! Washington. 0.0. 20002 ~ 10 l "12 18 14 16 17 18 19 20 21 24 25 care in response to identified needs of the professional atv MR, THOMPSON: Project No, 111. You mention PSRO specifically in the project, but although it doesn't make it directly -- | DR. SLATER: Objective 1 is assist in the development of new approaches to upgrading quality health community. : | . | Work Activity A, establish a quality review task group comprised of physicians and other health professionals to provide leadership and decision-making functions for the project. - | Work Activity B, select a technically qualified, unbiased organization capable of providing research, analysis, evaluation and other work support to the task group. The analysis evaluation, in other words. MR. THOMPSON: I was’ on the PSRO task force and I can take this and lay it out and say to the PSRO, here you are, go. . DR. SLATER: The final one is just for $6500 -~ I don't think I dropped a zero -- I did, $65,000, excuse me, regional disease management program. | | | That is oriented to the management of major categorical disease awareness and treatment program in Texas. And the goal is to design and tést effective mechanisms for developing and managing State-wide disease programs. ~ 10 i 12 13 14 16 17 18 19 20 21 24 20 HOOVER REPORTING CO, INC. 320 Massachusetts Avenue, N.C. ! Wachinotan 1 C PNAN? brief description as it appears here or of the more extensive Sft Now, they have several objectives, To document the methodology in Texas for a coordinated State-wide response to major disease awareness and treatment programs. Work Activity A, to evaluate the major disease programs supported by RMPT since 1960, heart, cancer, stroke,-. hypertension, renal, to identify successful and unsuccessful features. | Now, that is evaluating the major disease prodran- supported by RMP since 1960. That is a lot of work. Develop a methodology for a comprehensive, coordinated State-wide approach to major disease programs. That is to be sublet to somebody or maybe multiple people- for $65,000, There are some other objectives here. Monitor the major disease programs currently being /. funded through RMPT. Objective 3, recommend to the regional advisory group concerning the efficiency of participating, or continuin to participate, in major disease programs. I am saying that I support this type of activity. I think it is very necessary and we have to move increasingly to it in this country. What I don't get a feel. for, either from this ¢ write-ups that appear in the book and they are not that much 3 ~ 10 | ou 12 3B 14 16 u 18 19 20 21 24 25 HOOVER REPORTING CO, INC. 320 Massachusetts Avenue, NI. ! Washington, 0.0. 20902 - expect many, many proposals to come in and in fact having 372 more extensive, they are simply almost the same thing laid out on the dollar street activities, required pages required by RMP, I can't get a feel how long it takes to do these, Whether there are groups in Texas to do them and what is the quality of the work that is going to be done. I can't seem to get a professional sense of this. ‘ I am concerned that they are asking for ja great deal to be done in a very short period of time. Now, I gather against this background that. they _ something in the range of 90 or 100 from which they wish to choose about 25, and I am anticipating obviously that their staff and RAG group are going to screen out those that are technically capable of being done in one year) I come back to the concerns that Mrs. Salazar /. had, which I believe should be reviewed here and that is the matter of what kind of assurance do we have of the monitoring that can be done by essentially nonprofessionals, non- physician professional staff and it may be that they need other kinds of professionals on activities that are essentially contracts. | The question I have is when one puts contracts out, are they all to profit-making organizations? ¢ Does the contract carry any concern for the conflict of interest between those who are on a profit-making “Gy oo ~l 10 au 12 13 i4 16 17 18 19 20 21 20 HOOVER REPORTING CO, INC. 320 Massachusetts Avenue, NLC. Ulachinetan RE IAA? If basis in providing the kinds that we want in comoared to the usual grant system? I think that -- I don't want to go any further at this point. Do you have any follow up? MRS. SALAZAR: No, except for this letter. MR. CHAMBLISS: Yes, let me introduce the letter. There has come to the attention of Dr. Pahl what is marked as an urgent’ piece of correspondence from: - Texas. It arrived during the break and the reviewers have had a chance to read it. I would simply submit that the panel may wish to ‘know of its contents. DR. SLATER: Yes, I think the Texas people were concerned that they had put a proposal into us in which they /. ‘were really asking us to take on faith the fact that they were going, following the program thrust that you have described and had submitted a request for proposals to be submitted to > them and that these proposals are now just coming in and that they are planning to have their RAG staff group act finally on those proposals on June 28 or something like that, which is something more than a month after we would have funded them to do it. é So that we are in fact funding them in advance of the time that they actually make a decision for the proposals. ~ 10 oa 12 . 13 14 16 17 18 19 20 21 25 HOOVER REPORTING CO, INC. 320 Massachusetts Avenue, N.C. ' Washinotan NE PNf02 374 What they are suggesting is that their proposal as submitted to us, be modified to the extent that they take their 25 top priority proposals and submit them to the RUP staff here who would review them and make a decision on whether or not these satisfy, in essence, the goals of RMP and the thinking of this Committee is the staff could interpret that. Is that a fair display of what they say? MR, POSTA: -Yes, sir. - DR. SLATER: They are concerned that -- DR. SCHERLIS: Could you translate that? MR. POSTA: What their picture is, that by going the contract route they would like to have as long a period ' as possible, meaning 12 months. If they had zoars until July 1 to get their 15's and 16's in more specificity, by the time it got through all counsel, they would have a maximum 10 months to do the activities proposed and their whole concern is, on the contracts that they had funded in the past, through their evaluation process according to Texas representatives, the ones that have been funded in the least amount of time, have not been as successful as those that were given a full year's duration. ¢ MR. THOMPSON: Do we have any idea to whom these contracts are going to be let? 375 1 MR. CHAMBLISS: Miss Murphy, can you comment on 2 that? 3 MISS MURPHY: I think in the primary and 4 secondary review, a summary of contracts funded from 1972 5 through 1974, and just reading down to the peovle that they 6 were contracted to: | 7 Texas Hospital Association -~- these are the past 8 ones and probably some of these same will be included in this | : 9 round. 10 Texas Hospital Association. : ‘| i Texas Medical Foundation. 42 Chamber of Commerce, Tyler. 13 Coordinating Board, Texas College and University 14 System, Austin. 15 Scott and White Memorial Hospital and Scott, . y. 16 . Sherwood and Brindley Foundation-Temple. 7 Human Resources Development Foundation-Houston. 18 Bexar County Medical Foundation-San Antonio. 19 Cameron County Board of Health-Harlingen. 20 Texas Hospital Association, Austin. 21 Texas State Department of Health, Austin. 99 St. Paul Hospital-Dallas. 25 Texas Medical Foundation, Austin. oA The University of Texas Health Science Center at San Antonio. 25 | HOOVER REPORTING CO, (KC. 320 Massachusetts Avenue, N.C. ‘ -- fh aanan =~! 10 11 12 13 14 16 17 18 19 20 25 HOOVER REPORTING CO, INC. 320 Massachusetts Avenue, N.C. _ Na nanan Southwest Research Institute, San Antonio. And I could go on. I have another page and a half. Those are the types of people that they were contracted to. They sent them to a very select group. I have the sheets where they are checked off, ‘ how they had selected them and according to their expertise. Five hundred. . MR. THOMPSON: ‘I am concerned myself, only fairly knowledgeable in the area of health care economics, that this project that they have laid out here is very well done, but the problem is that work, the way it is laia out, ‘work activity A has to be completed before work activity B can 1 be begun and C. When I said .it would take five years, I was being yo - slightly facetious. It would take three years. But, I don't know where they are going to find the people down in the hospital association, because I know the people down there who are going to be able to do this. This is a fantastic -- it is a well laid out, fantastic idea. MISS MURPHY: They are only going to let 30 to 35 contracts out of this whole group. DR. SLATER: I assume they are going to operate e in the future on the basis as they operated in the past. If one takes project status reports and accepts their very brief / 377 1 indication of how they are proceeding, one says they are 2 satisfactory, I just don't have a feeling for this and all 3 we can do is assume on how they are going to operate in the 4 future as they have in the past. | 5 MRS. SALAZAR: They seem to be convinced that 6]} the contract mechanism is the way they are going. | 1 ~ MISS MURPHY: That is the only way they feel they 8 can go. . ; 3 . MRS. SALAZAR: They feel that their experience 10||. with the contract is very good. | i DR. SLATER: I will accept that.. | 12 MR. VAN WINKLE: They have 130 letters of intent . 43 | out. | i4 DR. CARPENTER: Did the regional advisory group 15 approve this? my wll MISS MURPHY: Yes. V7 DR. SLATER: I think it is difficult to have done 18 more than this, because of the reporting that will be 19 necessary to get a grasp of the reports. Either that or. 20 they might have been able to give us an appendix of their 21 status reports which would give us some indication of what 29 was coming out of the projects that are already funded and 23 the implications. ¢ o4 MISS MURPHY: This is what the form I referred , \ 25 to do -- summary of contracts funded. Very small print. HOOVER REPORTING CO, INC. 320 Massachusetts Avenue, NLC. ; Uinahinwtan PL ONAAD 378 1 MR. CHAMBLISS: There have been some concerns 2 on the part of staff expressed about the 16's and the fact 3 that they have not gone into any detail. 4 We would certainly want the views of the committee 5 on that aspect of the application. 6 MRS. WYCKOFF: Does this mean that they are going. ~ to reach out beyond the walls of the great elite establishment 8 in Texas and try to get into the uncovered areas that really i 4 9 been touched? 10 || - MR. THOMPSON: These are the same old boys. WW These are the same old boys. | +49 DR. SLATER: I would like to take exception to 43 Mr, Thompson. 14 They really are making an effort to look at the i mortality rate in the area. v. 16 . MRS. WYCKOFF: I think the physicians are really 17 on the job. 18 MRS. SALAZAR: It is very difficult to say, Mrs. - i9|| Wyckoff, from the reading, the kind of thing Dr. Slater has 20 indicated, it is very aifficult’ from the reading. | 21 This is why I have proplems with the application 7 being completed that it will indeed begin to cover these 93 areas. oA Mary, maybe you can tell us at the time of phase- | out, where did Texas go? How Fax down the road did it go HOOVER REPORTING CO, INC. 320 Massachusetts Avenue, NE. feabtnaten MO SALAD ~1 10 Bel "42 18 14 16 17 18 19 ~ 20 i] bo 23 24 | | t o t 25 |, HOOVER REPORTING CO. INC. | 320 Massachusetts Avenue, WO. “ Washington. D.C. 20242 P 379 back? Maybe I can get some meaning from it. MISS MURPHY: ‘They went from 35 people and now they have 7 professionals, 8-1/2 -- | MRS. SALAZAR: I am not speaking so much of staff. MISS MURPHY : They closed all of the sub-regional | offices. No more sub-regional offices. : Like these RMP's were sent to El Paso, sO many of their old staff that they had, that they knew were distri- buted throughout the State to try to get a good coverage -- | MR. THOMPSON: I don't think ‘seven people can monitor these. ! MISS MURPHY: Say that you pick a good project director, why would some person have to go out and do it? MRS. SALAZAR: How can you monitor yourself? DR. SLATER: T think what needs to be clarified is whether or not there is functionally any difference between a contract and the traditional form of grant mechanism that the RMP follows in the sense @f professional quality and monitoring and judgments that are made. I think if the committee can satisfy itself, that contracting is just as good functionally. MR. VAN WINKLE: Dr. Miller has had some experience é with that methodology. MR. THOMPSON: Before you go, because you are goin vy