NEW © FILE BEGINS Doc | /AK B&B INFORMATION & IMAGE MANAGEMENT 300 Pence Grveuer's RRuULeVvVARD UPPCR MARLEORG, MARYLAND 20772 ° UBA © (3D) 249-3110 Teneo. 8 Near gpd eran & t f » senna EP stern STENOGRAPHIC TRANSCRIPT DEPARTMENT OF HEALTH, EDUCATION, AND WELFARE MEETING ON AREAWIDE PLANNING ‘ Official Reporters : 26), Covetton Avenves N W. ‘ Telephone: 393-6011 Craft/Renzi 1 DEPARTMENT OF HEALTH, EDUCATION, AND WELFARE 2 - - -~ 3 MEETING ON AREAWIDE PLANNING 4 ae 5 6 t 7 ; . Room 921, 9 7915 Eastern Avenue Silver Spring, Maryland 10 Monday, July 8, 1963 1] The meeting convened at 9:20 o'clock a.m., Dr. 12 Jack Haldeman presiding. 13 FR 4 15 16 17 18 19 20 al 22 23 24 20 ACE-FEDERAL REPORTERS, INC. 261 CONSTITUTION AVE N.W Washinctan OD C, aS sia aaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaasasacaaaaamaasaaaaaaaccccccs SA lA ACCT TC CC: Tc ails mmm 2 Agenda Item Page 3 || Discussion on implementation - Dr. C. Rufus Rorem.. . 8 4 | Discussion on implementation in Southern New York - Mr. Joseph Peters ....... 2.4.46 .246 4042. 48 10 il 12 13 FR 14 15 16 17 18 19 20 2l 22 23 24 25 ACE-FEDERAL REPORTERS, INC. 261 CONSTITUTION AVE,, NW. WASHINGTON, 0. C, 1 PROCEEDINGS 2 DR. HALDEMAN: I wonder if we could get on with our 3 | hog killing. I guess everybody is here except somebody from 4 || Blue Cross. veEraee told me either he would be here or someone 5 | £rom his office would be here. 6 I don't know whether we need any introductions. I 7 | think we might go around and just rapidly call off. 8 | (Introductions were made.) 9 I think the purpose of this is probably three-fold. 10 The first purpose, I think, is to get a discussion 11 || O£ methods of implementation of areawide planning. George | 12 | and I argued over this term "implementation" throughout the 13 || deliberations on the so-called Bugbee Committee, and I don't FR i4 | think we ever found, really, a better word. 15 MR. BUGBEE: The argument was on the semantics, an 16 || idiosyncrasy of mine. I don't like the word "implementation", 17 | but I have given up. 18 DR. HALDEMAN: In the Bugbee Committee there was a 19 | Lot of difference of opinion, and the report as it came out 20 || contains very little in terms of specifics in terms of various 21 || methods that might be used for implementing areawide planning. 22 Part of it was deliberate, I think, because we didn't 23 || feel we were wise enough to make recommendations in a document a4 || Such as this that would be applicable universally. 25 And secondly, I think there might be some real ACE-FEDERAL REPORTERS, INC. 261 CONSTITUTION AVE., N.W. WaseiIncton, 0. ¢, 0 1 | minority opinions if we had taken one side or another. There 2 || were those on the committee that felt very strongly that there 3 || should be franchising or the equivalent. There were others 4 | that felt equally strongly in the opposite direction. And I 5 | think both the Public Health Service and the American Hospital g | Association that were sponsoring the committee had not taken 7 || any particular position in regard to this. g | It seems to me like the time has come for setting g || down and at least discussing various methods that are being used io | throughout the country to implement areawide planning, what has 11 | worked, what hasn't worked, and get a general discussion of the 12 || Subject. 13 I myself have mixed feelings on this subject because FR 14 | it seems to me like it is an essentially negative approach and 15 || @ lot of our hospital planning agencies, a great deal of their ig || Gime is taken up in stopping construction of one kind or 17 || @nother. 18 It seems to me like in the course of our discussions, ig || We might want to discuss what are some of the positive elementg 29 || in planning. I was right impressed with the recent article by gq) || Bob Sigmond of Detroit in which he took off in depth on the 22 || positive elements of planning. 23 The second general subject is one of priorities. 24 || L would like to make an assumption in this part of the discussion 25 || that the areawide planning agency is responsible for the ACE-FEDERAL REPORTERS, INC. 261 CONSTITUTION AVE .N W. WastinstTos OC 1 | distribution of capital construction funds, whether they be 2 || Hill-Burton or a modernization program, Federal funds, or 3 | whether they be capital construction funds raised in the 4 || community such as in Columbus, 5 | I think this problem of priority is one which in the gs | future years the Hill-Burton program is going to be faced with] muc te be 7 || more than they are now because the current priority system und g || Hill-Burton which is largely a matter of relative need is g || fairly simple, and it works relatively well in rural areas, 19 || but when you get into a metropolitan area, it obviously breaks 11 || down. 12 And if we get a modernization program, every State 13 || Hill-Burton agency and every local areawide planning agency FR 14 | 18 going to have a problem of priority, not only in the general 15 || hospital category, but among categories. And so I would hope ‘ig || that we would take a hypothetical situation, perhaps, ina 17 | COmmunity and see what we can develop in the way of priority 1g || Principles. 19 I have always felt that if we get a modernization 20 || Program -~ Well, first, our specifications for a modernization 21 |Program do require the areawide planning agency be consulted, a2 ||but secondly, will not spell out in any detail priority principles, 93 leaving that to the State Hill-Burton agency as well as local og |Hill-Burton agencies. 29 I thought probably that the process would be locally ACE-FEDERAL REPORTERS, INC. 261 CONSTITUTION AVE .N W WAtHisGTon OF. 10 il 12 13 FR 4 15 16 17 18 19 20 21 22 23 24 29 ACE-FEDERAL REPORTERS, INC. 261 Sone tation AVE .N.W. WASAINGTON 0, C, a good deal like an NIH study section would be, pooled profes- sional judgment based against certain general guidelines which are developed. Now, the third thing I would like for us to take up is whether it would be desirable to have what might amount to a national meeting of personnel of local areawide planning agencies. The American Hospital Association, Hi Sibley, and Public Health Service have just completed a series of seven regional meetings which were intended originally to be sort of a field testing for a cookbook that we had developed, based ‘largely on these committee reports, but going into more detail some detail as to the data needed for planning, the analysis of the data and what not. I don't think any of these meetings really served that purpose. And the reason it didn't serve the purpose was that the groups that participated were, not only people from areawide planning agencies, but were a lot of people that were broadly interested. And they served a useful purpose, I think, in that it stimulated interest in areawide planning. As I was saying, I think those sessions served a very useful | purpose, but it was not as useful in terms of people in areawide planning agencies who are actually doing the work in areawide planning agencies, having an opportunity to get down and discuss more or less detailed questions and to discuss the things that the staffs of areawide planning agencies are FR 10 ll 12 13 14 15 16 17 18 19 20 21 22 23 24 25 ACE-FEDERAL REPORTERS, INC. 261 CONSTITUTION AVE |N.W. WtSHINGTON OC. | what we will do with the proceedings, but we are having them interested in. So we wondered if there wasn't a need for a meeting that would be pretty well confined to the individuals in working on the staff areawide planning agencies and, if so, how should such a meeting be structured, when it should be and what not. And I would like to take some time in this area. As far“as I am concerned, the meeting these two days is quite unstructured, and if you want to take off and consider other things, that is quite appropriate. I am not quite sure taken down so that we can develop some sort of a report if it appears that many pearls of wisdom are being dropped. George, do you want to discuss this from the standpo of the background as chairman of the Committee on Areawide Planning? MR. BUGBEE: I think you have covered it very well, Jack. I think we are all conscious of some worry about how far you go with legal sanctions, but I don't know that anybody feels terribly strongly. It is kind of an academic argument and probably not the most important method of. implementation anyway. So I suppose you go through the whole range. Even ir the informal conversation of last evening, it seems to me peop! are developing quite a little experience in how to put these int 10 ll 12 13 FR i4 13 18 17 18 19 20 2l 22 23 24 25 ACE-FEDERAL REPORTERS, INC. 261 CONSTITUTION AVE .N.W. WASHINGTON GC. 9:00 o'clock plane tonight so I won't be here tomorrow. things in motion. I like your idea of positive as well as negative, too. DR. HALDEMAN: I think when we talk about implementation we might try to bring in this element of positive action. Suppose I just go around the table and comment what you are © doing in this area and what you would like to do, what has worked and what has seemed not to work. Rufus, do you want to lead off? DR. ROREM: Yes, I would be glad to be first to speak because I am going to be the first to leave. I have a Well, I think that we like to characterize our effort as primarily being interested in stimulation of individual hospitals to do planning on their own account and then stress in that the fact that the self-interest of an individual hospital means that they must be familiar with and aware of what the other institutions are doing. And we have urged every hospital to appoint a long-range planning committee for its own institution, composed of representatives of the manage- ment, of the trustees, and of the attending staff and, if they wish to cooperate, community members -- it is all to the good -- as well. | Conversely, we work with community groups particularly in areas where there is no hospital to study the characteristics of their own area to see whether and what kind of a health 10 1} 12 13 FR id 15 16 17 18 19 20 al 22 23 24 25 ACE-FEDERAL REPORTERS, INC. 261 CONSTITUTION AVE., N.W. WASHINGTON OG, facility may be needed. Now, one of the things that you will have to take away with you is our work document or guide for the use of long-range planning committees of individual hospitals. — And in this, there is a tabulation of the results of our resident survey applicable to the year 1960 which shows in tabulations of 29 districts where the people of that area with hospitals go as inpatients of each of the 29 districts. In other words, when a person wants to say: Where do the people who live around me go? -=- the tabulation shows where each of the 29 districts that are classified here were hospitalized and, conversely, the planning committee of a hospital can see where its patients come from. We will find, for example, that they might get 40 per cent of their patients or some other figure from a particu] geographic area. Yet, they may only serve 10 per cent of the people from that geographic area. our idea is that this would serve as the basis for th hospital to plan ahead and as to what areas it wants to be more active in, the areas where it will encounter already entrenched position on the part of other institutions. This is strictly superficial. It does not devise the services in terms of medical, obstetrics, pediatrics, and in this particular guide does not deal with outpatient service or nursing homes or many of the other important facts. LAT e FR 10 li 12 13 14 15 16 17 18 19 20 2i 22 23 24 25 ACE-FEDERAL REPORTERS, INC. 261 CONSTITUTION AVE .N,W. WeseingrTar, DL. 10 I mention this as a method because we use this as a backdrop for appraisal of any projects for expansion or for new institutions strictly as a guide and as a backdrop and try to keep this interest going. I might say that all of our general hospitals have now established long-range planning committees and four of our eight nongeneral hospitals, nursing homes, and things of that | kind and rehabilitation centers and homes for crippled childre have also done so. Just as far as implementation is concerned, we use “no implementation except that of persuasion and the announceme of an official position which our organization takes after going through a series of hearings which we call nonlegal hearings. If a hospital has a program on which they would like to have our opinion, it goes through four steps. They first have a conference I call a conference of the hospitals most likely to be affected. Now, after three and one-half years, those are very lively discussions and the insttitutions now are getting so their representatives -- these are administrators -- speak up frankly in their own self-interest which for a while they were very self-conscious. It was a log-rolling affair. Then, it is brought formally between a committee of the administration and hospitals involved. The institutions are n, nc Ll 1 | always there, and that second group actually take a vote as to 2 || whether they think it is a good idea. | 3 DR. HALDEMAN: What is the difference between the 4 || composition of the two groups? 5 DR. ROREM: The first group is the hospitals most | g || Likely to be affected, which means those are probably contiguous 7 | areas. The second is a representative group of all the 8 hospitals in the’area elected by them -- seven people. Then, g | that recommendation goes to all the hospitals in the area. 10 Euphemistically, I guess I would say that every 1, || hospital administration is a member of an advisory committee to 12 | us whether he likes it or not. He just is. And that group i3 | hear a statement description of it, and they take a vote. FR 4 MR. BUGBEE: In a meeting? is DR. ROREM: In a meeting. 18 DR. HALDEMAN: Open meeting? 17 DR. ROREM: Open meeting. And they take open votes ig | UP to now. We are talking about making it private, but it ig || isn't now. 20 MR. SIBLEY: How often do you meet? 21 DR. ROREM: About twice. We meet in between times tb 92 || hear committee -- 23 MR. SIBLEY: This group meets twice a year? 24 ODR, ROREM: We have met twice this year because of 25 || Special things that have come up. ACE-FEDERAL REPORTERS, INC. 261 CONSTITUTION AVE., N W. WasHinston O. Co. 10 il 12 13 FR 14 15 16 17 18 19 20 21 22 23 24 25 ACE-FEDERAL REPORTERS, INC. 261 CONSTITUTION AVE ,.N.W Waewingran Bo. 12 DR. KLICKA: May I interrupt you? Is this meeting structured in such a way that you or your organization makes its recommendations on the basis of your guidelines to this group? DR, ROREM: That's right.. | DR. KLICKA: Before they start their discussion? DR. ROREM: Not at these points. DR. KLICKA: What do they base their consideration on? DR. ROREM: Well, on the merits of the case. DR. KLICKA: This is what I mean. Who presents the merits of the case in a so-called scientific way? Do you do this or do you permit the hospital that wants to do somethi to present its case alone? DR. ROREM: The hospital is present. The hospital really takes over and questions are asked in terms of the standards. DR. KLICKA: But you don't evaluate this first for the group on the basis of your studies as to whether you think this is good or bad. DR. ROREM: In the sense of in writing? DR. KLICKA; No, it wouldn't make any difference, bu it would seem to me that the group who were to be affected would first like to have the opinion of the Planning Committee relevant to how this would fit in the scheme of things. 13 - l DR. ROREM: By the time it gets there, they know 2 || how or staff understands. 3 DR. KLICKA: How do you do this? 4 DR. ROREM: The first meeting, I introduce. The 5 | first meeting is really a go-around, just a general talk. | g || The second meeting, by that time, I have an opinion which I give 7 || 4 tentative -- no, it doesn't crystallize until after the third g | meeting. Then, ft crystallizes definitely. And it still is g || @ wandering discussion the first three times around. 10 DR, HALDEMAN: What is the third one? ut DR, ROREM: Then, the third one is with the entire 12 | Sroup of hospital administrators. 13 And then, the fourth is with the Planning Committee FR 14 of our Board of Directors. is MR. BUGBEE: But each of the three groups has an yg || official vote they pass on to the next one for examination. 17 . DR. ROREM: The very first one has no vote at all, ig || but the representative committee, the advisory committee as ig || @ Whole, and the Planning Committee, and it goes to the Board a9 | With a specific recommendation that is very short. And as it 2 || 80es along, I make summaries of these which are acceptable 92 || to the institution, one-page statement of which they might have 93 had 20 pages. And they accept it as to whether or not it is 7 factual, but not analytical at that time. But after it goes 25 || through the third one, we take a very definite position. The ACE-FEDERAL REPORTERS, INC. 261 CONSTITUTION AVE .N.W. WASHINGTON, OF O. 10 il 12 13 FR 14 15 16 17 18 19 20 2i 22 23 24 25 ACE-FEDERAL REPORTERS, INC. 261 CONSTITUTION AVE .N.W,. Wassingran @¢, nearer tara saa aaa aaa saat samme smaaaaaaaaaaaaaaaaaaaaaaamaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaiaaaaaiaaiastaa mamas amsaasaaaaaaaaaaaaaacaaaaaaaaascaaaaaasaaaaaaiaaaiaiail 14 recommendation goes to our Planning Committee. And this is consistent with sound public policy and coordinated planning in our area. DR, HALDEMAN: What is the composition of your Planning Committee? | DR. ROREM: The Planning Committee is selected strict ly from the Board of Directors. It happens to be seven members ; it could be eight. DR. HALDEMAN: What is the composition of your Board of Directors? DR. ROREM: Our composition of our Board of Directors is all laymen, some of whom may be hospital trustees. They are the presidents of large corporations -- that is, financial i. industrial, and mercantile -- plus several clergy and plus some educators. We have an advisory committee, this representative committee that I spoke of, of hospital administrators. The chairman meets with our Executive Committee and Board of Directors the Advisory Committee of Hospital Administrators and an advisory committee of the medical society, the profession, but it is appointed by the president of the medical society, six people, with the president always ex-officio. And we have quite a few meetings on the side. A; far as priorities are concerned, I might say that ri priorities are found on page 11 of this report when we get to 15 1 || it, and these are the ones we have used. They are a little 2 || bit generalized if you want to call it that, but the highest 3 || priority with almost no quibbling at all is to any programs 4 || which will contribute to greater coordination of patient care 5 | within the community rather than mere sanction of existing 6 || types of facilities and services. . 4 The second program goes to those which will achieve _ g || more effective uie of existing plant and personnel. Moderniza+ g || tion, of course, would be a part of that. 10 The third is something like the second, those which 11 || WL11 prolong the useful lives of existing facilities without 12 | jeopardizing the standards and efficiency. 1B At the bottom of our list are programs which will FR 14 || increase bed capacity because we are caught up. We are dealing ws 15 || from a position of surplus rather than of scarcity. 16 We all know it is easier to plan for scarcity than i7 | it is for surplus. It is like the sailor says with the rope. ig | He was really in a terrible jam because he had a rope that was ig || too long. He didn't know what to do. He said, "If it was too 29 | Short, I could splice it, but it is too long. I don't know 21 || What to do. I don't know where to start, 22 So for what it is worth, that's what we do. I didn't 93 mean to take so much time. oA DR. HALDEMAN: I think we ought to ask questions so 25 |we thoroughly understand how it works. ACE-FEDERAL REPORTERS, INC. 261 CONSTITUTION AVE .N.W., Wase'ncron O C, aL zc: casa; état amaasaaaaaamaaaaaa aa saaaamamaaaasasesaasassa amass tasea sata seaman etae a tareeaaatcreaaeee 16 1 Does your Planning Committee ever override your 2 committee of administration? 3 DR. ROREM: It has not yet; it might. 4 They have approved ten projects up till now expressly 5 || and disapproved one. And all of those up till now were 6 recommendations of the advisory group. 7 But I might say that we haven't been brought into g || court as one of the people last night mentioned they have. g || We have been brought into the court of criticism and public 19 || dissatisfaction on the part of the client that wasn't happy, 11 || and they have used up till now their response and method of 12 || expressing dissatisfaction as being what the lawyers would 13 || call "ad hominum, " FR 4 They put it, not on my Board of Directors, but on 15 || the staff as being unreasonable and intransient. 6B MR. COUSIN: Jack, may I ask a question? 17 oo DR. HALDEMAN: Yes, 18 MR. COUSIN: Rufus, what does it mean to a hospital 19 | in your area if your group gives its approval or turns 20 || thumbs down? 21 DR. RUREM: It means they can quote wherever they see oo || fit the fact it has been approved by the Hospital Planning 23 Association. 24 MR. COUSIN: Does this have any real impact? 25 DR. ROREM: Yes, for both small and large contributions, ACE-FEDERAL REPORTERS, INC. 261 CONSTITUTION AVE., N.W. WASHINGTON OS 17 1 | particularly for large and somewhat small. 2 MRS. COLEMAN: Has any hospital elected to not ask 3 | your opinion? 4 DR. ROREM: Up to the present time, we haven't moved 5 | in and given it anyway, but we are thinking of doing that. / 5 If they don't ask our opinion, we are very likely to adopt the 7 | position of giving it anyway. 3 MRS. COLEMAN: How big a project? For small things, 9 I suppose they have no obligation to consult you at all. 10 DR. ROREM: No, but the Hospital Council of Western 1) || Pennsylvania which works very closely with us has expressly 12 | and by resolution suggested and admonished the hospitals to 13 | report and ask for approval whether or not the public campaign FR 14 || ¥4S contemplated and whether or not the amount was large. 15 We are not defining the word "large." 16 MRS. COLEMAN: Suppose they just wanted to put in an 17 || intensive care unit or something like that. Would that be ig || Something they should bring to you? 7 DR. ROREM: As a matter of fact, one hospital did go || exactly that about $125,000 they wanted to spend. They did Pl bring it to us. And in the condition like that, it doesn't 92 || 8° through all the channels. It goes straight from the staff oS to the representative committee and Planning Committee. The oA Board never hears about it. 25 MRS. COLEMAN: Suppose it was something that didn't ACE-FEDERAL REPORTERS, INC. 261 CONSTITUTION AVE .N.W. WasHincron, F.C. a SAAS tease atasaaaaaaaaaaammaaamaaaaamasacaes eases atau emmsssaseaacasmea mmm nmanannmmmcmmmmannannaeaias 18 1 | cost very much money, but was a vital change in scope of the 2 || hospital like they wanted to take out pediatrics or put in 3 || pediatrics or something like that, but they weren't increasing 4 || the beds. | 5 DR. ROREM: The hospitals that want to do anything 5 | Like that generally take the initiative and want to get some 7 || approval because they know they will, probably. And so there_ g || 1s no special problem. And in a few cases, they have done so. 9 We have a hospital which this week on Friday will lo || @mnounce that it is closing its obstetrical department and that 11 | @ll obstetrical services will be going to a hospital two blocks 12 || away as of next Monday. It is a 300-bed hospital with a 36-bed 3 obstetrical unit. And the hospital that is going to pick it FR 14 | Up is a 550 bed, mainly maternity hospital. And the doctors have 15 || been on both staffs all the time. 16 They are going to close it. And on that, we worked i7 | with them all through this. I can't say we were more than an ig || influence. That hasn't gone through two channels at all. It ig | WaS applauded from the beginning, and it is now a reality. 20 MRS. COLEMAN: So whether it goes through channels 21 || Or not depends pretty much on the amount of money involved. 22 | Is that more or less true? 23 DR. ROREM: I would say so pretty much and whether 94 || OF not there is to be a public campaign, the two combinations. 25 One hospital has announced by 1970 it plans to build ACE-FEDERAL REPORTERS, INC. 261 CONSTITUTION AVE .N W. ac. WaAsHINGTIAN 10 11 12 13 FR 14 15 16 17 18 13 20 21 22 23 24 29 ACE-FEDERAL REPORTERS, INC. 261 CONSTITUTION AVE ,.N.W, WASHINGTON, OFC, 19 a doctors' office and interns and residents home and expand and improve its emergency and outpatient department which obviously would be improved. They have got the money. But they can't spend it until the urban redevelopment association has declared an area that is blighted. So they had to make this statement of this policy in order to help the urban redevelopment. There is a case where the facts have been known to us, but no formal application. We are just a little bit embarrassed that it broke in the papers, and I have told peopl I think in their self-interest they ought to have their program on record with us as it develops. All isn't perfect with us. DR. HALDEMAN: You say that in ten instances, they approved the contemplated action of the hospital and in one instance they did not, is that right? DR, ROREM: That's right. DR. HALDEMAN: So usually, they go along. DR. ROREM: Usually, the institution goes along. As 4 matter of fact, we turned down two. But before it came to a vote of our board, the hospital said, ‘Would you mind if we just withdrew the application completely which they did. They came back a second time six months later and it was approved. DR. HALDEMAN: If you had it to do over again, e " 10 ll 12 13 FR 4 15 16 17 18 19 20 21 22 23 24 29 ACE-FEDERAL REPORTERS, INC. 261 CONSTITUTION AVE..N.W. WaeriasTon, Oo. 20 would you use the same mechanism or a different one? It seems to me it has the element of a little bit of back scratching if the decisions are pretty well made by administrators. MR, BUGBEE: Does it? Or if you have 26 of them or 25 always supercritical of the 26. | DR. ROREM: I might say that this last one, the one that is now coming through a second time, is one that decided — to ignore -- This is one that was turned down, went right ahead anyway. It happened they got Hill-Burton money and had that to go on. And they went ahead anyway. And, incidentally, the two we turned down both received Hill-Burton money because of the particular gerrymande ing at that time of the area. And the one that recast its program, we approved. The other one, we haven't approved, and it is well along. Off the record. (Discussion off the record.) MR. BUGBEE: Rufus, to this point Jack raised, though would you find the 26 administrators when you get to that stage or as they filter up from representatives, are they fairly judicious, or do they log-roll? DR, ROREM: Let me tell you what happened this last time. Usually they are unanimous. This last one is going through the channels a second time. And of 18 out of 26 that could have been present, 11 reo > 21 1 || voted to let the old disapproval stand. Four decided that it 2 || ought to be changed. One of those votes was the institution 3 | itself. And four decided they didn't want to take a position 4 and abstained. So it is not always unanimous. | 5 DR. KLICKA: As you evaluate this kind of a situation, 6 | what is their reasoning based on -- a pretty sound analysis of 7 | the material that you presented to them? 8 . DR. ROREM: I would be willing to say yes. 9 DR. KLICKA: You agreed with it, didn't you? 10 DR. ROREM: - Yes. u |p Mr. Willis was present at all of these. 12 Dave, why don't you get into any points as long as we 13 || Aare discussing this? You are at a distance now where you can FR 14 | think back where we could have done something different. Is 15 | what I have been saying somewhat similar to what you might have 16 || said? 17 MR. WILLIS: Yes. 18 DR. ROREM: Up to now? 19 DR. HALDEMAN: First, I think Jack Cousin had a question. 20 MR. COUSIN: I wanted to know, do you work with ostea- 21 ||pathic hospitals and, secondly, how does Government react to 22 || this? 23 In other words, if there is a city, State or a county 24 institution, or even if there is a health problem involving the % icity, State, and county, Federal Government. We don't have ACE-FEDERAL REPORTERS, INC. 261 CONSTITUTION AVE sNW. WasHincroa, 2. ¢. 22 1 || much luck except with Hill-Burton, but the city, State and County, 2 | for example, if it is a city hospital and they want to cut out 3 || pediatrics, does this get to you either from the hospital or 4 | from the city council or the Board of Health? 5 DR. ROREM: ‘Let me say first of all, and this makes g || us unique, this happens to be a trading area in which there is 7 7 || no local government hospital, the largest one in America by far. wy 8 Secondly, there is one 25-bed osteopathic hospital ij g || this whole area. 10 And the third is that there is no proprietary 11 || hospital in the whole area, It makes the issues a little 12 || sharper. 13 Another fact is that at the present time we don't FR 14 || Know of any M.D.s who want a staff appointment that don'e have 15 || One. 16 Now, the osteopaths, however, they have a nice 17 || hospital, and you go 25 miles out or 30, osteopath hospitals ig || Start up again. But in Pittsburgh, they haven't up to now. 19 MR, COUSIN: What would you do if you had a request 99 || for an osteopathic hospital and you could pretty well develop gq) || that the osteopathic physicians had much fewer beds available gq || to them than the M.D. hospitals, and they wanted to put a 93 || hospital up where there was a surplus of beds, but not of o4 || OSteopathic beds? 95 DR. ROREM: 1[ know. I don't know what we would do ACE-FEDERAL REPORTERS, INC. 261 CONSTITUTION AVE .N W. : Waste nagran 2. e. 23 1 || at this point. I suppose after we got over the faint, the 2 || faint of the first time, we would see what could be done about 3 | taking care of these people because our State is very similar 4 | to Michigan except that here the M.D.s have the lily-white 5 | Concept which is pretty well accepted in the general community). s | That is strictly M.D. t 7 I don't know of any institutions in the immediate g | area that have any M.D. hospitals that have osteopaths only; g | not a single one. tJ 10 MR. COUSIN: We have something like 2,000 osteopathi 11 || beds out of 17,000. We have one county where something like 12 || 15 per cent of the people in the county are being cared for b 13 || Osteopaths, FR 14 | DR. ROREM: We have less than 50 out of 8,000. 15 MR, COUSIN: And you are not going to change that; ig || We are not, 17 | MR. BUGBEE: I don't want to stop at the osteopath, ig || but I want to ask you, you have been a little elusive about ig | Who presents the brief for the hospital. 20 In fact, as you are describing it, the hospital 21 | Presents its data and you and all the rest question the data, 22 || but it is really the applicant's responsibility to present all 24 DR, ROREM: Yes. 25 You understand that this has all reached them before ACE-FEDERAL REPORTERS, INC. 261 CONSTITUTION AVE .N.W. Wasyinara, 8 10 ll 12 13 14 1S 16 17 18 1g 20 21 22 23 24 25 ACE-FEDERAL REPORTERS, INC. 6 | CONSTITUTION AVE .N.W, WASHINGTON, B.C. _do you change? 24 they come to the meeting. MR. BUGBEE: That's right, but still, it is their presentation rather than the planning staff. DR. ROREM: Up until it reaches our Planning Committ then I am in there giving my opinion pretty strongly. - | MR. BUGBEE: Or you might question them or ask then for new data or bring in your own data. DR. ROREM: That's right. MRS. COLEMAN: Do you tailor their program somewhat? Do you modify it? In addition to approving or disapproving, DR. ROREM: I would say it is fair to say that most of the programs by the time they even reach the representative committee have been changed materially. Wouldn't you? MR. WILLIS: Yes. I think it is part in answer to your question and Mr. Bugbee's to note that there is a working schedule set up. Ever hospital must have its long-range planning committee, which committee must announce long in advance of the time it comes to these official committees what its tentative plans and programs are. And then the staff works with them. And most of the modification and SO on occurs there in the early planning stages before it ever comes to the committee. DR. ROREM: JI might say we have postponed I would say & @ iy 25 1] at least a dozen projects, not disapproved, just postponed. 2 || And just they were out of this world and weren't to be considered 3] at all. One project was for complete rebuilding of a mental 4 | hospital. They were going to spend money for renovating first 5 | and $5 million for a nonprofit unit of about 300 beds, and it 6 looks now as if they are going to just drop it completely and 7 || §° out of the nurses home business and set these people up over g || in their big nurges home. And this is an illustration. 9 DR. KLICKA: In these meetings, Rufus, is there a 19 || Complete agreement on the accepted bed need for an area betweeh 11 | your organization and the State organization that is responsiblle i2 || for the administration? 13 DR, ROREM: And the Hill-Burton. There is now. FR 14 DR. KLICKA: Do they accept your figures or you 15 || accept theirs? 18 DR. ROREM: They are the same figures. 7 DR. KLICKA: You are not answering my questions. ig || Ave they yours or their figures? 19 DR. ROREM: We gather the figures for them. There a9 || £8 no conflict as to what the mathematics is, 21 DR. KLICKA: Who computes the beds? Do you do it 92 || OF the State do it? 93 DR, ROREM: For the State plan? Py DR. KLICKA: No, for these regions that you are 25 talking about where a hospital comes in and says, 'We want to ACE-FEDERAL REPORTERS, INC. 261 CONSTITUTION AVE . NW, WasHincTon, OC. FR 10 ll 12 13 14 15 16 17 18 19 20 al 22 23 24 25 ACE-FEDERAL REPORTERS, INC. 261 CONSTITUTION AVE .N.W Wasuingron, Oo. C, State would regard as nonacceptable. 26 develop a program that will add 200 beds. Does that 200-bed figure come within your purview or is it the State plan? DR. ROREM: It isn't cut that fine, really. We typi cally would accept as available beds some that might have been thrown out as non-fire-proof which are in use. The State uses a strictly mathematical formula for engineering for | acceptable and nonacceptable beds. So we would be inclined to have on balance included in the list of beds some that we know to be closed down, for example, which the State wouldn't know because they don't go behind that, and some which the DR. KLICKA: All right. There is a problem there, but I am talking about the overall bed need for a region. Who compiles that bed need? Do you do it or the State do it to start with? This is a fundamental thing. MR. WILLIS: The State does it. MR, BUGBEE: Who said you are flush’in beds? You started out a while ago saying you have more beds than you need, Who said that? DR, ROREM: We assert that on the basis the beds are not used to capacity and on the assumption we keep current records of bed use. And on this Simple principle, if beds arer used to reasonable capacity, there isn't a need for more in the totality. And this isn't just a single figure. The bed vacancy is a composite. 27 l Whatever the bed vacancy, maybe more than half of 2 || those are maternity and pediatric and something else, less 3 || than half are medical and surgical. And one of the things that 4 | we work toward and are trying to bring about is the transfer 5 || O£ medical, obstetrical, and pediatric facilities for use for 6 | general beds. And if that were done, it would relieve the 7 || need completely even in periods in the winter peaks. 8 MISS JENKINS: You mean for medical-surgical, diverting g || O.B. and pediatrics to medical-surgical? 10 DR. ROREM: Yes, and we are trying to get more 11 | hospitals to drop this obstetrical entirely. 12 I hasten to say the hospital that is doing this isn't 13 || doing this as a matter of abstract theory. It is a very FR 14 | Practical administrative decision on their part. We don't 15 | hope for anything more than enlightened self-interest, at least ig || don't. I hope every hospital would be guided by what it 17 | thinks is best for itself, but would also know what is going on ig || @round it so it would be an enlightened self-interest and ig || Mot a short-sighted one. 20 MRS. COLEMAN: Do you have very much difference in a1 | quality between your hospitals? I mean, do you have very good 92 | Ones and very poor ones? 23 DR. ROREM: Yes. 24 MRS. COLEMAN: This presents a real problem. If a 25 good hospital wants to add beds, but there are enough beds if ACE-FEDERAL REPORTERS, INC. 261 CONSTITUTION AVE., NW. WrcHINGTON. 0. C ait Atacama atm Aaa camammasaaeacmasaeacmmmenenem a eee maaeneeman 28 1 || you count all these raggedy beds around, what do you do in 2 those instances? You say you can't build any more beds 3 | because we have enough beds in this area? 4 DR, ROREM: You asked what do we do. We do the best 5 | we can. But what do we think or what do we say? § MRS. COLEMAN: Yes. 7 DR. ROREM: We try to take a look at the particular | g || need. ~ 9 For example, one hospital adding beds for research 10 | Work in metabolism, we don't consider that as having to compete 11 || with the medical-surgical cases. 12 Likewise, another hospital has added which we approved 13 |} just recently a building program which is going to add eleven FR 44 | intensive care beds and a few more for rehabilitation. They 15 don't have to scramble for our office's priority concept. 16 | And another one is going to put up, which we approved, 17 || @ 78-bed chronic care unit right on the grounds of the ig || institution. We don't regard that as being competitive with 19 || the addition of general care beds. 20 MISS JENKINS: Rufus, do you examine those parts such 21 || 48 the chronic and long-term care units and go on on the basis 22 || O£ the hospital's justification, will it be financially sound 23 || 4£ they want to do a certain type of research? Do you discuss gq || With them are they going to utilize this facility? It is going 29 to be a charge to the general patients to underwrite it, or dd ACE-FEDERAL REPORTERS, INC. 261 Const (TUTION Ave iNW WeHINGTAN DO, 10 11 12 13 FR i 15 16 17 18 19 20 2l 22 23 24 29 ACE-FEDERAL REPORTERS, INC. 26 1 CONSTITUTION AVE . NW. WsHINGTON DLC 29 you go into this at all? DR. ROREM: The only place that research has come up has been in connection with the university medical school and affiliated institutions. MISS JENKINS: That's enough said right there. DR. KLICKA: Do you think that's the role of the Planning Council? MISS JENKINS: To some extent. DR. ROREM: We get into the Operations, if you mean by that -- DR. KLICKA: I wonder if we could put this on the agenda. I think it is a very important question. MISS JENKINS: Do you think it is basically wrong, Carl, if they are going to put a particular special service in which they have not well programmed? DR. KLICKA: We are talking about research? MISS JENKINS: Oh, no. I am talking about research where it involved beds and what the financing of that research will be. I am thinking only in terms of beds -- that is, beds that would Support research. DR. KLICKA: This wouldn't be very many beds. You are talking about a small 7- or 8-bed ward to support a specific research, MISS JENKINS: [I would not be involved in that. I thought Rufus was talking about something a little bigger than FR 10 i] 12 13 i4 15 16 17 18 19 20 21 22 23 24 25 AGE-FEDERAL REPORTERS, INC. 261 CONSTITUTION AVE .N.W, WASH NGTON 0. C. 30 that. DR. ROREM: We do have one 24 beds. MR. WILLIS: I would like to add something to Dr. Rorem's last three comments, first, to Dr. Klicka. | When Dr. Rorem was just getting started, the State agency computed bed needs simply on bed population ratio. And all of their ratios were much higher than locally was believed to be necessary.” And this created, you can well imagine, some problems. Money was dangling there and plenty of empty beds around. Two things occurred to change that situation. First and most important was that the state Hill-Burton began to modify the bed population ratios by direct inclusion of utilization data in their concept of need. The second was the Hill-Burton areas themselves were redefined so that the city boundary was broken. Now, in Pittsburgh, as in most cities, there was an excess of beds to population. Once you broke down the city boundaries as arbitrary limits of an area, you throw those excess beds into the suburb calculation and you immediately watered down that need, too. So both these things happened at the same time. And interestingly, the local hospital when presented with the idea of changing the Hill-Burton areas this way, knowing in advance that this was going to virtually wipe out any Hill-Burton FR ~ 10 I] 12 13 14 15 16 17 18 19 20 al 22 23 24 25 ACE-FEDERAL REPORTERS, INC. 261 CONSTITUTION AVE ,N.W. Wasntncton D.C, ‘hospital. So the good hospital begins to protect the interests 31 priorities for general beds, still went along and voted for it. And the express comment was, "We better learn how to use what we have before we ask for more," which was pretty good. I am not sure all of them really knew what they were voting for, but they did. And the Hill-Burton agency adopted the same areas. . Then the matter of quality. When these areas were redefined, a big teaching hospital and a good hospital was put at the core of each area. So every area has got at least one good hospital and every area has got at least one bad of that area, and it will always be given a higher priority to try to protect that way. On the matter of getting involved in program and financing, I would like to point out a difference that has impressed me between the way this is happening in New York and the way it happened in Pennsylvania. In New York, statistically, there is a great unmet need for long-term care beds and virtually every hospital in the Rochester region is putting in an application for nursing home beds and chronic disease beds and so on. This was quite a marked contrast to the situation in Pittsburgh where C. Rorem' group had gotten so involved with each institution pointing out the difficulties in financing and in staffing and in programming and how this will relate to the short-term care and so on. 8 32 1 || There were very few tears because they anticipated the 2 || problem, whereas in New York they were doing it simply on the 3 || basis of beds and available money and nobody is really terribly 4 || concerned about how this is going to be financed or what the 5 | program is going to be. 6 One, you have a plethora, and the other one a dearth. 7 | I don't know which is better. 8 MR. COUSIN: Rufus, if I understood you correctly, g | before a project comes to your attention, each hospital has 19 || to have a long-range planning committee and a long-range plan. un | DR. ROREM: That's right. 12 MR. COUSIN: Now, has your Planning Council okayed ig; @ll of these long-range plans because it is conceivable -- FR 14 DR. ROREM: We haven't even received them all. 15 MR. COUSIN: It is conceivable to me a hospital could 16 || Come to you with a short-term project that fits in very nicely 17 | with a hospital's long-term planning, but the long-term planning ig || doesn't tie in at all with the long-term community planning. 19 DR. ROREM: Right, it could be. We do the best we 20 can. 21 For one thing, we just continually repeat in variations a2 | On this theme that it isn't the first cost, it is the upkeep 93 || that causes the most of the problems for the institution and 24 || the community. A $4 million hospital is going to cost $60 25 million before it is discarded. Somebody is going to have to ACE-FEDERAL REPORTERS, INC. | 261 CONSTITUTION AVE , NW, Weeninsvman OC ir a Sis: aaaaaaaaacacasaaaaaasaaaaaaaaaaaaaaaaaaaaaaaaaaaaaas aaa sasaaaacaaaacaaaaaaccacacaaaaccssccc a 33 1 || pay that, divided by three for the annual operating budget for 2 || rough-and-ready purposes and figure the length of life. 3 | And so you aren't just committing yourself to $4 million; you 4 || ave committing yourself to $64 million, assuming no change in 5 | the price level. 6 MR. SIBLEY: It sounds like marriage. 7 (Laughter .) 8 MR. COUSIN: Do you intend to eventually 0.K. all of g | their long-range plans? 10 DR. ROREM: We aspire to that, yes. I don't want 11 || to give the impression that this is -- You know, a guy always 12 || can talk more freely away from home. I imagine the rest of you 13 || ave doing the same thing. FR i4 (Laughter.) 15 DR. HALDEMAN: Rufus, behind your whole discussion 16 and the effectiveness of what you have done, isn't this the fadt 17 || that there are relatively few major sources of capital construq- ig || tion funds, a few industrialists provide a fairly large bulk? 19 DR. ROREM: I would like to answer that. That's what g9 || £ thought when I came there. 21 DR. HALDEMAN: But it isn't true? 22 DR. ROREM: It is not true. Big industry provides 93 |in the gross Something less than -- I thought in the aggregate o4 |@bout a third of all capital funds, corporate contributions. 25 jit isn't true. It is not more than 20 per cent, and it is ACE-FEDERAL REPORTERS, INC. 261 CONSTITUTION AVE . NW. Wt wineroa 0. C, SS SSS AGA FR 10 11 12 13 14 15 16 17 18 19 20 2l 22 23 24 20 ACE-FEDERAL REPORTERS, INC. 261 CONSTITUTION AVE . NW, ac SSHINSTON, 34 concentrated in the areas up till now where the big industries have their concentrations of employees. And suburban hospital just for general purposes and convenience of travel, have a very hard time getting big corporate support. I mean the new residential suburban hospitals. | Now, a town like Homestead or McKeesport or Sewickle where there are heavy concentrations of employees, they continue to give very, very good support once a thing has gone through. DR. HALDEMAN: Conversely, if your organization did “not recommend that there be an addition to a hospital, would i be very difficult for them to raise the capital construction funds? DR. ROREM: Yes, it would -- has been. DR. HALDEMAN: In other words, in the last analysis - _ DR. ROREM: Even if they weren't going to give an awful lot anyway, it still throws a pall over the campaign, no doubt about it. DR, HALDEMAN: But you do in a situation where your real implementing force is the influence on the givers of capital construction funds. DR. ROREM: Especially big givers. MR. BUGBEE: The thing you brought out last night that is important, too, you say 20 per cent big givers and 20 per cent small givers, your small earners and bank loans and wD 35 1 || bank loans are affected by sanctions, too, you see. 2 DR. ROREM: That's right. 3 MR. BUGBEE: I don't know as much as they should be 4 || but didn't you and Jack both say that the loaners are beginning 5 || to talk about what the recommendation is? : 6 DR. ROREM: That's right. 7 I might say also that we haven't had a general hospital 8 || even give any thought to a big program unless they got Hill- 9 || Burton money. 10 MR. BUGBEE: Unless it got? nfl DR. ROREM: Yes. And up to now, some are starting 12 | to talk about it, but it is all for expansion or for non-bed 13 | activities and no bed expansion has even been thought of FR 14 | except in terms of Hill-Burton support. 15 And up to the present time, there is no difference 16 || of judgment between the Harrisburg office and ours. 17 MR. BUGBEE: You mean from the present on, not up to ig || the present time. 19 DR. ROREM: No, actually, the very first six months we 20 | were there, we disapproved two plans. Both of them a month 21 || after we disapproved them were approved by Hill-Burton, both 22 || O£ them. And we are still wrestling with that fact. 23 We later approved one, and we still haven't approved o4 || the other, 25 DR. HALDEMAN: Off the record. ACE-FEDERAL REPORTERS, INC. 261 CONSTITUTION AVE .N.W. Wiewnaras Of FR 10 1] 12 13 i4 15 16 17 18 19 20 al 22 23 24 20 ACE-FEDERAL REPORTERS, INC. 261 CONSTITUTION AVE .N.W. WastncTran OC ' funds until they ask our organization whether it is consistent (Discussion off the record.) DR. KLICKA: I hope we can come back to this. This question is beginning to be a real problem in Illinois. DR. HALDEMAN; Well, I don't mind opening discussion. Well, we will put it on the agenda to discuss. MR. BUGBEE: Let me ask, Rufus, has Hill-Burton | designated you? Do they before they grant money now ask your. recommendation? “Is there any official or unofficial agreement DR. ROREM: Yes, in writing, and I have to quote it. They will make no final decision on a request for Hill-Burton with the broad plan for Allegheny County. MR. BUGBEE: It hasn't gone long enough for you to tell except those recommendations. DR. ROREM: After those first two went through, the: has been no difference of opinion. MR. BURLEIGH: What kind of a time interval elapses, Dr. Rorem, the time you first have a project until the time th Council -- DR. ROREM: First brings it to our attention, put it that way. We don't always live by, but we have set an eight months time lag, eight months lead time. And we have spent that particularly with respect to Hill-Burton recommendations. But sometimes it is two years. Sometimes it igs quite a while. Ww re 37 1 I know I am taking up a lot of the time, but I am 2 || getting my money's worth in here because I can't be here 3 || tomorrow. But I might say that we had two hospitals that were 4 | all ready to go. They were going to apply for Hill-Burton. 5 ; It was pretty clear they weren't going to get it, so they g | relaxed. So they are now getting down to the merits. They 7 | can get it now. 8 They wére four miles from each other. They had g || 4lmost identical short-range and long-range problems. The short- io || range problems, they both had unsuitable facilities being used} nu | One happened to be the obstetrical department which 12 | Was in the prime location and was too big and the medical and 13 | Surgical facilities needed to be replaced. FR 14 The other had exactly the opposite. The obstetrical 15 || department was in bad space in old buildings and medical and ig | Surgical was running high. So they both had to do something 17 | Quick within five years, also in three years, but also something ig | quick. : 19 So we focused their attention, each one, upon what a9 || they could do without -- using the expression -- doing anything “~ p> 21 what administrative decisions could be made. 92 And in cooperation with the Hospital Council and a 93 physician on their staff, we made administrative and space o4 || Utilizations of what they now got. As a result of the 25 inspection, we turned up the equivalent of about 25 beds in ACE-FEDERAL REPORTERS, INC. 261 CONSTITUTION AVE .N.W. WASHINGTON, oc Ai zc. Aik; aaa etaaa ma at FR 10 11 12 13 14 15 16. 17 18 19 20 al 22 23 24 29 ACE-FEDERAL REPORTERS, INC. 261 CONSTITUTION AVE . NW. Waseingron, BD. Lf. “doctors and had the equivalent of opening up another eight 38 one institution that could be had just for administrative decisions. For example, a certain segment of pediatrics could be used for medical and surgical. That's one illustration. The director of nurses had herself and her assistant} right in the middle of the patient care area with empty space in the nursing home 50 feet away. All she had to do was move out and there were eight beds. Another was an introduction of a discharge timing which by announcement curiously enough was accepted by the or ten beds as far as this total was concerned, So they are back to normal again, but still need to do something. And the other hospital wasn't full except in the medical and surgical. The point I am coming to is this simple that at Several meetings, I finally got the representatives of the boards of both hospitals together, Willis with me. We had a long session and I talked freely. When I wrote up the minutes, I called it a Summary. I even gave it a title -- "Challenge and Opportunity." And the challenge and the opportunity was to work together. And I recommended that they have a list of about 20 things in which the hospitals were alone and seven things that they could do together and recommended they have a 39 1 | joint consultant on a program. 2 And they have agreed to this and are going to pay 3 | out cash for a joint consultant. And it will be a physician 4 || in our area, They have agreed on someone. It looks now as tr 5 || 4£ it is going to be one of the members of the school of publi 6 health, Dean Clark, you all know him. 7 So we get neck keep into operation and into operating g || finances. And wé have the advantage that there is nothing g || €xcept sympathy and understanding from the Hospital Council. 1¢ || And Mr. Sigmond's -- who is so interested in this -- main 1 || criticism of us is we don't do enough, we don't get deep 12 || enough into operations. We should be doing more; we should i3 || be pressing harder. FR 14 So the criticism we get isn't that we are interfering 15 f| €Oo much, but we aren't interfering enough, which as a short 1g || round is a good criticism to have. 17 MR. PETERS: I am inclined to say -- you mentioned ig || eight months and as high as two years for a proposed study -- i9 || in New York there is a proposed bill which hasn't got a committee 20 || yet, but it will probably have a committee this year which says 21 | that the regional council should make comments on establishment 22 || O£ mew construction in 45 days and 60 days on expansion of 93 || facilities. And this has bothered a lot of us because we won- 24 || dered how with our particular committee structure we could get 25 |) 4n opinion out in 45 days that represented anything than an ACE-FEDERAL REPORTERS, INC. 261 CONSTITUTION AVE .N.W. Wassingran D.C FR 10 1] 12 13 14 16 17 18 19 20 al 22 23 24 25 ACE-FEDERAL REPORTERS, INC, TITUTION AVE . NW. AWINGTOR 2 SS. 261 CONS Was “now, and we are taking a beating over it. And we are not 40 off-the-cuff opinion. George can comment on that because George was chairman of one of our committees for years and knows how difficult it is to extract an opinion in 45 days. MR. BUGBEE: He is probably right. Eight months is about what it takes. ; MR. PETERS: That's pretty much our experience, about eight months. MISS JENKINS: This is consoling, Joe. We had one demanding an opinion next week, and it has been four months about to render an opinion yet. I will go back and quote you. DR. ROREM: As it goes forward and the other describe their procedures, I would be very much interested to know what reactions you folks have to getting the administrators and representatives of other hospitals involved because as far as I know, we are the only ones that get the other hospitals involved with anything like this depth. And I might say this was written into our bylaws, this advisory committee of hospitals, before I came and at the insistence of the hospitals at that time. I say "hospitals," the presidents and management. MRS. COLEMAN: What is the range in size among the hospitals? FR 10 ll 12 13 14 15 i6 17 18 19 20 al 22 23 24 29 ACE-FEDERAL REPORTERS, INC. 261 CONSTITUTION AVE... N.W. Wasningron, 0. C. ‘problems to tackle. 41 DR. ROREM: Our smallest hospital, general hospital, short-term hospital, is 119 beds. MRS. COLEMAN: And the largest? DR. ROREM: About 650. We have four of those. DR. HALDEMAN: I don't want to prolong this. There is one other area, though, I think we ought to get into in relation to each of the communities we are going to talk about] And that is the Central city versus suburban problem and what the problems are and how you are meeting it because it seems to me like an areawide planning group, this is one of the hard + ber You may have a surplus of beds in a central city, but you have suburban areas growing up which are going to, in many instances, get proprietary beds if you don't let them have thei own beds. You might speak to that point. DR. ROREM: We take the position that suburban, through statistical facts which are true which we point out, a number of statistical facts, one is that at the present time there are not many specialists living in suburban areas having offices in suburban areas. They haven't come out there in part because there haven't been hospitals. - But we have suggested that the principle of the satellite hospital be used and even if it is a bed facility that it be an offshoot or be sponsored by one of the larger 10 ll 12 13 FR 4 15 16 17 18 1g 20 21 22 23 24 25 ACE-FEDERAL REPORTERS, INC. 261 CONSTITUTION AVE .N.W. W4sHINGron, GC. | of one of the other larger hospitals, but it is an old institut 42 institutions in order to reduce overhead costs and duplication of facilities. There is an emotional appeal in the new areas, of course, for an institution that will be identified and be a part of it. But when the chips are down for money, they don't come forward with the money. And even this institution, this $4 million institution, that is going forward, after three years, they have raised and have got $1 million in pledges, cagh some portion of it. And it is not identified. We tried to get them to identify it whether it be an offshoot or branch with a good name, and they wanted to continue it. They are moving away from an area of great need, but also an area quite uninteresting to the institution because it is a blighted area. MR.BUGBEE: You know, Jack, on this issue you raise, it is like the question of the administrators conference, I think. One of our major problems is trying to establish procedures and principles that apply to different sized metro~ politan areas. I suspect New York, Chicago, probably Detroit, Pittsburgh, is probably the size where you can do it, Cleveland Rochester, Columbus. DR. ROREM: That's right. MR. BUGBEE: For the administrators council, but I tion 10 ll 12 13 14 15 16 17 18 19 20 21 22 23 24 25 ACE-FEDERAL REPORTERS, INC, 26 1 CONSTITUTION AVE |. NW. WéSHINGTON, DLC, one half-hour from a hospital. 43 think the questions of suburban versus central city are almost equally separated. And we talked last night, and Rufus got this page where he has five regions. Well, you could make an argument about central city serving the entire area much more validly than you could in Detroit, I would guess. I think your issue is: Do you want your beds spread that way? The old Hill-Burton geography points towards spreading, but I don't know that the travel anywhere here is prohibitive, DR. ROREM: There isn't anybody who is more than MR. BUGBEE: You at least by travel have the option of having the hospital in the center or outlying. Then, the question comes where it should be and that's the part I don't ¢- DR. ROREM: I used statistics that I am sure I call attention to in one item of the travel, One, I point out that after all, these fine roads that cause people to move out to the suburbs run both directions. SO, you see, it is just as easy to get back as it was to go out. And the other is that as far as bed care is concerned on the average, a person is bedded down at the advice of a doctor about once every eight years. But on the average, he wijll See a doctor about five times a year. So only one out of 40 that see a doctor. So the important thing is to have doctors in the Community that are handy and quick. 44 1 We had a situation in our area where a man, a 2 || department head of one of our large corporations, worked his 3 | heart out on a drive for a hospital that was only going to be 4 | a half-mile from his house. He thought, "How wonderful when 5 || you wake up in the night and the kid has a cramp and rush him 6 || to the hospital." And just before the ribbon cutting, he waa 7 | transferred to Milwaukee and had to start all over again. 8 (Laughter.) 9 So this idea of convenience to a hospital. 10 . And another case, one of the fellows working on this} 11 || his wife got sick while up in Butler County and had to come ig || back 20 miles. 13 MR. BUGBEE: Rufus, you are talking about the five FR 14 || Visits versus once in eight years. 15 Jack, even that little research you did or your 1B department did pointed out that parking was the crucial thing. 17 | See, even for the five visits a year, if you had your doctors ig || Where there was ample parking, probably the half-hour isn't ig | prohibitive to take the child, leave out the emergencies. 20 DR. ROREM: In the study of emergencies, we found that qi | the people that are medical emergencies or psychological 22 || emergencies where they travel fast to get somewhere, they waitdd a3 || longer before they were seen than they did the time traveling a4 || €O get there, 25 MR. SIBLEY: 1 Want to follow Rufus' point a little ACE-FEDERAL REPORTERS, !NC. 261 CONSTITUTION Ave ,N W. WASHINGTON OC 45 1 || more because it leads into a broader subject perhaps which you 2 || just ended by saying you are planning for the location of 3 || physicians and you are not using physicians at all in your 4 || procedure by which you review hospital plans or patient care 5 | facility plans. You are using only hospital administrators. 6 And at this point, the question comes, is the hospital 7 | administrator capable of speaking for his medical staff, or g || are medical staffs willing to abide by the speaking of the g | administrator when the review takes place? 10 DR. ROREM: . It is up to the institution to have 11 || Cleared all of this before it comes to us. And some of these 12 || bring physicians along to these meetings. 13 I might say further that we propose from now on because FR 14 |, Of the interests of this committee of six doctors to use then. is | They have even said they would be willing to go on record as ig || taking a position on plans. 17 MR. SIBLEY: So this would be another planning ig || Procedural step, 19 DR, ROREM: It would be a parallel one or participating. 20 MR. SIBLEY: You gave us four steps. Would you put 21 | it in here some place in the four steps? 22 DR. ROREM: It would be a parallel one. The six 23 doctors are invited to all these meetings. A couple of times, oA they have come. 25 MR. SIBLEY: So up to now, your physicians, the ACE-FEDERAL REPORTERS, INC. 261 CONSTITUTION AVE . N.W. WASHINGTON. 2. 0. 46 1 representatives of organized medicine, because I presume this 2 is what they are, have not felt threatened, so they have not 3 || begun to appear. 4 DR. ROREM: That's right, but they say now they are 5 || willing to and would like to. There is no provision for them to 6 || take an official position, but the chairman has said they 7 || would be willing to take an official position. And I have got 8 | to bring that to my board and see if we want them to. 9 DR. HALDEMAN: Jack, “10 MR. COUSIN: I was going to ask something else, but 11 | this physician discussim changed it a little bit. 12 When we did a patient distribution Study, the same 13 |} @8 you did, we also did Physicians. FR 14 DR. ROREM: We did, too, but we can't analyze it 15 | Statistically. It tg too vague. 16 MR. COUSIN: We are going to do this over again about 17 yevery five years, But meanwhile, we have done it_from time to ig time in certain Study areas for certain specific purposes. 19 DR. ROREM: You mean just the facts where the doctors 20 have their offices? 21 MR, COUSIN: Yes. 22 DR. ROREM: We have done that, 23 MR. COUSIN: We have discovered a great many more 24 ¥Pecialists out in suburbia than you seem to indicate, 25 DR. ROREM: We are getting more, too, The last three ACE-FEDERAL REPORTERS, INC. 261 CONSTITUTION AVE., N.W, WASHINGTON, DO. C FR 10 il 12 13 14 1 16 17 18 1g 20 2l 22 23 24 25 ACE-FEDERAL REPORTERS, INC. 261 CONSTITUTION AVE., N.W, WASHINGTON Oc. years made a difference. MR. COUSIN: Getting back to the central city versus the suburbia and probably the size of the city metropolitan not wanting to come downtown because of the parking, and not only because there is this terrific emotional play in having a hospital in x, Y, 2 suburb, many of the patients and perhaps even a higher percentage of physicians do not like some of the social changes that are taking place in the metropolitan hospitals. You could give them the world's best parking lot and you could have all these beautiful highways running back and forth, but they just don't like going to some of these former ly still well-known top-flight institutions where the complexion of the patient load is changing rather drastically. MR. BUGBEE: Be sick with other nice people. MR. COUSIN: And some of these hospitals out in the country are having a higher percentage of specialists than they had previously. And some of the top-flight men at the Harpers and Graces and Mt. Carmels and so forth -- well, Mt. Carmel is semi-suburban -- but some of these top-flight downtown hospitals are losing some of their better men, particularly the fellows 50 years and under who are moving their offices out into the Birmingham's and the Grosse Points and so forth. MR. COUSIN: The nice people want to be in the country. area has a lot to do with it, but besides, what about suburbanites anc 10 12 13 FR 14 15 16 17 18 19 20 al 22 23 24 29 ACE-FEDERAL REPORTERS, INC. 261 CONSTITUTION AVE... N.W. WASHINGTON, &. C, 11 got to think in terms of two distinct organizational structures First is the 24 years continuous existence of the Hospital Council of Greater New York. So that I am not so sure that the roads and the parking are all the answers. DR. ROREM: Oh, no. DR. HALDEMAN: I think we perhaps ought to move on to Southern New York. I do this with a bit of anxiety, you might say. ‘ During the Bugbee Committee deliberations, we had four representatives of this metropolitan area on the committee, and we finally had to pass a rule that New York City couldn't be mentioned in this committee -- (laughter) -- that we would never come up with a report on areawide planning. | In recent weeks, I have had a chance to talk to a number of the people in New York interested in this metropolitan planning group. And that is to the coaching by Dov Coleman. I think I was assured that something could be done in this area. So, Joe, I wondered if you would lead off, and. George might like to speak, anyway you want to present it. MR. PETERS: Again, we seem to be outnumbering the rest of you three to one, although George is a Chicagoan now. MR. BUGBEE: Alumni. MR. PETERS: But a very important alumni. % Actually, as far as New York is concerned, you have And then, more recently, during 10 ll 12 13 FR 14 15 16 17 18 19 20 21 22 23 24 25 ACE-FEDERAL REPORTERS, INC. 2614 CONSTITUTION AVE _N W, Washinston. GC, 49 the past year and a half or so, the Hospital Review and Planning Council of Southern New York. Even though there is a tie between the two, they are structured somewhat differently, although a good deal of the history of the former has been inherited so far by the latter. Let me talk first about the Hospital Council of | Greater New York which I said had 24 years of existence and which was the first planning council which purported to represent the community and which had a community-based board of directors. We devised a master plan when Dr. Pastore was there in the middle '40's. This master plan, as you all know, and I won't go into it in detail, is based on the bed-death ratio and established a certain number of beds and made some arrange; ments for distributing these beds primarily by teaching functions. Over the years, we found that it was of little use to us. And during Dr. Nickelson's regime, we pretty much discarded it, although we have still continued to use a modified figure based on the bed-death ratio. And I say, "modified", we modif “T it pretty much the same as you all do on the experience of demand, use. If we find facilities aren't being used, quite obviously, we have a sufficient number of beds. In New York City in general, I am talking about the five boroughs of New York City, we have a sufficient number of beds, although as is true of probably all of your areas, they 50 1 | are very poorly distributed. Manhattan has many, many more 2 | beds than it needs and roughly about 60 per cent of all the 3 || patient care rendered in Manhattan hospitals is rendered to 4 || Manhattan patients. The other 40 per cent of the patients 5 | come from all over the city and all over the region and even .. 6 | from all over the country. | 7 So our big problem in New York which parallels g || pretty much what Dr. Rorem talked about here, we have an area g | where we have enough beds. We found out that the population 10 | o£ New York City. has gone down since 1950 and little change is 11 | expected in the next 20 years. 12 In fact, we have just published, and I am sure all 13 || o£ you have a copy of it, a monograph dealing with the future FR 14 || population of our region. We find that in New York City, as I 15 || said, we expect little or no change in numbers of people, ig || although we expect at least a 2 million growth in the other 17 counties outside of New York City, primarily Nassau, Suffolk ig || and a few of the ones up north of the city. So this presents ig || @ new problem for the new Council. 20 First of all, what do you do with New York City? 21 || And secondly, what do you do to meet the growing needs in the 22 || suburban counties? 23 We haven't done much about the latter, and one of the o4 || big things we have done during this first year of our new 25 ||existence has been to spend as much time as our small staff ACE-FEDERAL REPORTERS, INC. [61 CONSTITUTION AVE . NW. WASHINGTON, O C. a1 1 || would allow to get familiar with the problems and the character- 2 || istics and the hospitals of the other nine counties outside of 3 | New York City. And this is a tremendous job. We are talking 4 || about now outside of New York City more hospitals than probably 5 | any of you have except Dr. Klicka. We are talking about 100. g || hospitals outside of the five boroughs of New York City and 7 || 140 general hospitals in the five boroughs of New York City, g || @ total of 240 héspitals with roughly 115,000 beds, I believe. g | We are talking about a huge complex, 10 | I dreadito think what would happen if our present 11 || 8taf£ got the long-range plans of every one of these 240 12 | hospitals. | 13 (Laughter. ) FR i4 I wouldn't know how to file them, much less how to 15 | imterpret them. It isn't a problem. 18 Ours is a problem of dimension to a@ great extent. 17 | So let me talk about how the old Council Operated and then go ig || into very briefly how the new one hopes to operate. 19 The old hospital council did not get involved -- 29 || Correct me if I am wrong, George, because you were on the 21 || Policy end, I was really on the staff end -- the old hospital 2 || Council did not get involved in studying hospitals or giving 93 || @dvice unless it was formally asked. This is pretty much like o4 || You said your early days were. We did not do any studies. We 25 | did not render any opinions. We did not make any recommendat ipns ACE-FEDERAL REPORTERS, INC. 261 CONSTITUTION AVE . NAW, WasHinacror 0 °C, FR 10 ll 12 13 14 15 16 17 18 19 20 al 22 23 24 29 ACE-FEDERAL REPORTERS, INC. 261 CONSTITUTION AVE ,N.W WiswHingran 2 52 unless the group or the hospital or the agency wrote to our Board of Directors and our Board of Directors took this up at its next meeting and passed a resolution that the staff should or should not work on the problem. This was the pattern for at least during my stay the and I am sure it was a pattern for all the 24 years of the old ‘ council. This meant and still means that a lot of institution a lot of agencies, do what they darn well please because unles they ask us, we have never given our advice. And, unfortunate an awful lot of hospitals haven't asked us. In fact, some of the greatest institutions have neve asked us about our opinion. And until very recently, none of the proprietary hospitals of which we have about 40 in New York City and another 20 outside to make a total of 60 have never asked our opinion, although in the past year this has changed drastically. But this is not because of any action which our Board has taken, bat the action which Dr. Trussel and Doug Coleman of the Blue Cross have taken. That is, they now ask us to give our advice on these institutions. SO we are now advising on the need for proprietary hospitals, but as many people say, it is closing the barn door after the horse has left. We have 60 now. The problem now is to keep those 60 at that number. I say we did studies. Actually, we did three ma jor types of studies over the years. We studied individual tT 53 1 | hospitals at their own requests and I would Suspect we have 2 |, done about 100 of those in the past 24 years. Our batting 3 | average has been very good, I think, on the individual hospita Fe 4 || Studies, 5 We have had our failures, but we have had some 6 || reat successes, particularly in recent years. 7 Now, individual hospitals ask us questions. A usua 1 g | Question, of coufse, is: Should we add more beds, inaugurate g || 4 new service or new program and so forth. 10 We study those and write a written report which in 11 || the old Hospital Council was sent to a committee which we 12 | Called the Master Plan Committee. 13 Now, the Master Plan Committee was structured as a FR 14 || Combined committee of the Board of Directors and a group 15 | Of outstanding, for want of a better word, technicians. We had ig | About a dozen people on that committee and about half of them 7 were board men. George Bugbee was the last chairman of the ig ||Master Planning Committee. We don't have it any more as such. 19 And we had men such as the Commissioner of Hospitals 29 | Of New York City. That is the man responsible for the operation qi ||O£ the city's municipal hospital system. We had some know ledgekb le a2 |Physicians who were engaged in research. We had Blue Cross -- 23 Who is on it at this time -- Doug Coleman. Even before he was o4 |0 the Board, I think. But we had that type of person plus 25 Board people, know ledgeable people, who could give us technicall ACE-FEDERAL REPORTERS, INC. 261 CONSTITUTION AVE NW. Wis4inctan oO ¢ 34 1 | advice and Board people who could give us the reaction of the 2 | community. 3 DR. ROREM: Any voluntary hospital administrators 4 | on that? | | 5 MR. PETERS: Yes, we usually had one who came usually 6 | @€s a representative of the Greater New York Hospital Associatibn, 7 which is the trade association. In the past few years, it has 8 || been Martin Steinberg who, as you ean well imagine, brings a g | much broader approach than that of a hospital administrator. 10 The hospital administrators we have had on it have 11 | been selected, not primarily because they were hospital 12 | administrators, but because they could give us a broad picturel 13 || They were not there because they served one hospital or one FR 14 || group of hospitals. 15 ; The Master Plan Committee reviewed the staff's 16 || recommendation. The staff would write a report and bring it 17 || directly to the Master Planning Committee at which time the Master ig || Planning Committee would discuss it at great length, And ig | George can tell you what great length means. They would ask 20 || All sorts of questions because you had very knowledgeable people 21 || On this committee who could ask very specific questions and give 22 || very specific reactions to the report. 23 In some instances, it was necessary to bring the 24 || report back on a second or third occasion until it met the 25 || Approval of the Master Planning Committee. ACE-FEDERAL REPORTERS, INC, 261 CONSTITUTION AVE . NW. WasHington OF. ¢. 35 l MR. BUGBEE: I never was sure whether it was the 2 || function of the council, but I would say they were as detailed 3 | and probably better than most consultants would do on a 4 || community plan. They might have 100 pages in great detail. 5 MR. PETERS: The average report ran about 30 pages, bome g | went to 100, some reports even went into more than that. 7 When the Master Plan Committee approved the report, | g || and I might add fhat they rarely approved the report without g || putting some sort of word change or something. They always 19 || put their hand on the report. It never came out precisely 1, | @8 it went in. There was always some change, either a word i2 || Change or policy change or adding a recommendation or taking 13 || OU€ a recommendation, although in general, the sense of the FR 14 | Feport always was the same as it went in. I don't know of 15 || @ny time when the staff was completely overruled. 16 When the report was approved by the Master Plan 17 || Committee, it went to the Board of Directors. The Board of 1g || Directors, of course, then did the same thing to it, but with 1g | Mot quite the elaborate discussion that you would get in the 99 || Master Plan Committee. And this is the report that was sent q1 || tO the hospital. 99 Now, the biggest problem we faced then and still 23 face to some extent is how do you assure that the hospital o4 || OF the group to which you are addressing the report will do what a5 | YOU want them to do. And this was the great problem that ACE-FEDERAL REPORTERS, INC. -61 CONSTITUTION AVE , NW. | WasHtnGron, OC. ff FR 10 il 12 13 14 15 16 17 18 19 20 21 22 23 24 29 ACE-FEDERAL REPORTERS, INC. ONAVE .NW soc 261 CONSTITUTI Waser erg 56 plagued the old Hospital Council. We did have one great instrument and one which was very helpful over the years. And that is, we with the Hill- Burton agencies were working with the State of New York on a contractual basis to administer Hill-Burton funds locally.. So a great deal of our leverage we had during the last days of the old Council was based on this Hill-Burton leverage. We could actually make specific recommendations on where the Hill-Burton money in the five boroughs of New York City should go and this gave us, as I said, a great deal of leverage. And there are many people who believe that many hospitals asked us for studies merely to get on our good side so they could get Hill-Burton money. I suspect this is true. It is certainly not a bad thing. It is certainly better to have a hospital come to us for Hill-Burton money after we have made recommendations than have them come to us cold. So we didn't look upon this as such a terrible thing. We used it, and I think we used it to good advantage in many instances. For that, I would say some of our best Hill-Burton grants came out of the fact we did do a study and some of our worst came out of the fact we didn't know too much of the hospital because we haven't had a chance to study them | depth. We had our failures, and let me tell you something 57 1 || about the failures. You learn a lot by the failures. 2 One of our most persistent group of failures over 3 || the recent years has been what do we do with the specialty 4 || hospital of New York City. New York City still has a number 5 | Of specialty institutions. It has, I believe, four or five - g || well-known institutions which provide care for eye, ear, nose, 7 || and throat patients. At least two of these are among the g | greatest institutions of their kind in the world. 9 - MR. BUGBEE: With the first physical plant. io MR. PETERS: Both of them have old physical plants. 11 || One goes back to the 1890's, the other goes back to the early ig || 1900's. Both of these institutions have looked to the Hospital 13 | Council for advice. FR r One of them has come to us from, I think, the first 15 || Study the Council did in 1939. It was the New York Eye and ig || 2ax Infirmary. And one of the last studies we did prior to 17 ‘taking on the new Council was New York Eye and Ear Infirmary. ig || We did three studies, and in all three institutions we urged 19 them to close down their present plant because it was inadequate 99 || and to merge with another institution. The hospital still 9) || exists independently, so you can see how successful we have 22 been. 29 Another hospital, Manhattan Eye and Ear, was a little og || Smarter. They never officially asked our opinion, but they c 25 Constantly worked with us. They never wrote that all-important ACE-FEDERAL REPORTERS, INC, 261 CONSTITUTION AVE .N Ww. Wase'neran OC 10 1] 12 13 FR 14 15 16 17 18 19 20 al 22 23 24 25 ACE-FEDERAL REPORTERS, NC. 261 CONSTITUTION Ave ,N.W. WisHIngTon O CC. have been the knottiest problems because I say we are not 58 letter to the Board requesting a survey. But their President has worked very closely with us over the years. And again, it has been a failure even though they have had the best of instructions. They have taken every step possible to merge with institutions, but have never been able to work out a program of mutual satisfaction of both institutions. And the hospital now with the advice of one of the outstanding consultants in America is planning to rebuild next door to its present location. Those have been two of our great failures. These dealing here with the kind of hospital which we so frequently deal with in New York City -- that is, the inferior hospital. Here, you are talking about great institutions, institutions of world leadership. And I don't think I am exaggerating to say these are world leadership institutions. And this has been the problem. What do you do with the specialty hospital. We have argued about this. We have Long lived with this concept that there is no need for a specialty hospital. Yet, when you get down to a particular institution, particularly a great institution, you begin to wonder what do you do with then. DR. KLICKA: You succeeded with one, Women's Hospital MR. PETERS: Yes. Well, we succeeded, but it is still occupying its 59 1 present plant. Its plan is to merge, but until it actually 2 || closes down, we haven't succeeded. 3 MRS. COLEMAN: It is being merged administratively. 4 DR. KLICKA: They are building a new building. 5 MR. PETERS: Yes. 5 We have succeeded with others, New York Orthopedic 7 || and one or two others. It hasn't been all failures by any g || means, but these two have been the knottiest ones. 9 MR. SIBLEY: You regard this as a problem because io | this is criteria you are talking against. You set up a criteria 1, || there shouldn't be specialty hospitals. 12 MR. PETERS: Yes, our Board says we shouldn't have 13 || Specialty hospitals. FR 14 DR. KLICKA: What if you had a children's hospital? 15 || Do you think that Board would be against this? 16 MR. PETERS: Yes. 7 MRS. COLEMAN: Not adamantly so, Even though they ig | take a position, they are not married to it to such an extent ig || they want to see good care stopped in order to prove something, 20 DR. KLICKA: Wouldn't you consider a children's 21 | hospital a specialty hospital, but being a little different, o2 || really, than an ear, nose, and throat hospital? 93 MR. PETERS: A children's hospital is really nothing 94 more than a general hospital for little people. We are not 25 ja gainst all Specialty hospitals. We have certainly not ACE-FEDERAL REPORTERS. INC. , 261 CONSTITUTION AVE .N.W. Te ATIN AS cca; ea a FR 10 1] 12 13 14 15 16 17 18 19 20 2l 22 23 24 25 ACE-FEDERAL REPORTERS, INC. 261 CONSTITUTION AVE .N W. WasHingstan, OC. 60 resisted the movement of the hospital for special surgery. Of course, they are affiliated with somebody else and are working closely with New York Hospital, New York-Cornell Complex. What we are trying to do with each of the specialty hospitals is to get them to affiliate with another institution and if and when the time comes to replace their plants to get . some sort of geographical proximity. And here is where your problem comes in Nw York City, Manhattan particularly, where land becomes a very expensive commodity. Well, that's the type of hospital we have had failures with. One of the big problems is everybody hasn't asked our opinion. Unfortunately, some of the greatest instit tions haven't asked our opinion, but these are great instituti and they have tended pretty much to do what is in the best interests of the community . Now, let's go into the new planning agency, the Hospital Unit Plarming Council of Southern New York. DR. HALDEMAN: Joe, I hate to interrupt, but one or two people have indicated that a break might be in order. MR. SIBLEY: Jack, I don't think everybody knows Jim Ensign from the Blue Cross Association who has come in. (Whereupon, a recess was taken.) DR. HALDEMAN: I wonder if we can get on with our hog killing. ons , 10 1] 12 13 FR uu 15 16 17 18 19 20 21 22 23 24 25 ACE-FEDERAL REPORTERS, INC. 261 CONSTITUTION AVE . NW, WASHINGTON, D.C, meeting with a Hamburg 61 MISS JENKINS: Jack, that typifies you as coming from Ok lahoma . DR. HALDEMAN: Five years from now I won't say that, probably, after being exposed to New York. DR. ROREM: You will move up the animal kingdom and be sacrificed at some other level. . DR. HALDEMAN: I might even be seen with an umbre 1lla| Where I came from, a man who walked down the street with an umbrella would get laughed off the street. MR. BUGBEE: I suppose you will appear at the last DR. HALDEMAN: 0.K., gentlemen. MR. PETERS: Let me run down very briefly the organiza- tion structure of the new Council and then let me give you some background on the criteria that was distributed to you today in this material because I think you might find it of some interes in your work. The new Hospital Planning Council of Southern New York is a successor agency to the old Hospital Council. It officially came into being last spring which makes it over a year old now. It covers 14 counties, the five counties or boroughs of New York City, and the nine outlying counties which take it out as far as Montauk Point on Long Island and a little bit north of Poughkeepsie in New York. It is the southern tier of counties in New York. t FR 10 Il 12 13 14 1S 46 17 18 19 20 al 22 23 24 25 ACE-FEDERAL REPORTERS, INC, 261 CONSTITUTION AVE .N.W, WasHIngtan., 2. ¢, own, saying they would like to plan for the 2 million people 62 There were many problems in structuring this, and there is nobody more qualfied to tell you about the problems that were faced in this than George Bugbee because he was the chairman of the group that brought this about. For your information, George, there are still some unresolved problems. MR. BUGBEE: I know. MR. PETERS: Particularly with relationships of one of the subgroups in the area which is constantly giving indication they would like to break loose and go out on their in their area which makes a pretty good sized planning area, by the way, 2 million people. But they originally consented to join us, and one of the big problems in the immediate futurl Ww is going to be how can you work with these people, still giving them some degree of autonomy in their local affairs and still bringing them into the whole regional complexion. This is going to be perhaps one of the most difficult organizational problems that the Council is going to face in the coming months. But the new Council, as I said, covers 14 counties, and it was structured so we would get representation from the entire region. We have a Board of Directors of 43 people, 36 of whoo are elected and seven are so-called ex-officio members who represent county commissioners of health, county commissioners 10 11 12 13 14 15 16 17 18 19 20 al 22 23 24 25 ACE-FEDERAL REPORTERS, INC. ‘61 CONSTITUTION A Washinaran oo vVE.NW. c “very diligent in attending, and we certainly have no problems 63 of welfare, and the various commissioners in New York City. It is much larger than the old Council. The old Council Board, as I recall, was about 30. This is 43. Although it is very encouraging to say that the attendance even though some of these men come from 150 miles | away, has been remarkably good. I certainly can't say that the Board is too big in terms of attendance... We certainly are getting 30, 31, people at every meeting, more‘than that. And some of the ones who don't come are the ones Locally. In fact,-the ones from out ‘of the city have been . in that.) 2 0 7 oe Bam OT TN ak dae Poe tee gy . As to whether the Board is too big to manage,,.go. far it .has been no problem, but it. ds conceivedthat it.might be.a problem in the future. :We had a master. plan, committee before Ww which acted as sort .of an Executive Committee in, that it ‘reviewed all .the studies and made recommendations prior to giving it.to the Board, That_ committee has officially been abandoned, but in its place, we have set up. one of a proposed: four committees the Facilities Planning Committee, which will represent one of the major functions of the Council,..and this-will be the... Committee that will. be dealing with prob tems-.of-.expansion, -.. affiliation. and. so. forth.s ing: ay. recs toe Lg, et : ie es Ae Uk, SM Bee oe ovr ocuec We plan to set: up three other. committees:.and three otheroperating: divisions’ -2° financtal Yiahtindk e nedidal’ sents a“? 10 il 12 13 FR 14 15 16 17 18 19 20 21 22 23 24 25 ACE-FEDERAL REPORTERS, INC. 261 CONSTITUTION AVE., NW. WASHINGTON, ac, services. Here, we are thinking in terms of the problem that greatest institutions side by side with some hospitals which 64 and administrative services. MR. SIBLEY: Would you define each one a little more? MR, PETERS: Sure. Facilities planning will deal with the problems of construction, expansion, location of hospitals in accordance . with measures the committee needs. They will probably be prett much in the entire area te old Council stressed. That is, resources, physical resources, how you distribute them and so forth. This is nothing more than an expansion of our old role} We are hoping to get into the whole area of medical Ann Coleman raised, the problem of quality, quality of medical care, which is a bit of a problem in New York City because in New York City, you have, I won't call it unique, but certainly its: dimensions are greater. You have some of the world's wouldn't pass muster in some of your rural areas, even. You have got a lot of small hospitals. Rufus said the smallest hospital was 119 beds. I wish we could say that in New York City. We can't say that. We have a lot of them 80, 90, 75 beds. A lot of these are proprietary hospitals. Particularly in Brooklyn, there are a good number of small voluntary hospitals. Some of these are good institutions, some of them are not so good. A large number of the proprietary hospitals have not 65 1 || even met the standards of the Joint Commission on Accreditation 2 of Hospitals. And even though they have passed those standards, 3 || it still leaves much to be desired as far as good hospital 4 || care to the community is concerned. 5 We are concerned about this, and we are also concerned 6 || about another problem which Rufus doesn't seem to have. And 7 | that is the problem of medical staff appointments. I wish we - g || could say that every doctor in New York had the appointment he g || Wanted or has an appointment. 10 DR. ROREM: Not the one he wanted. They have got 1, | some, 12 | MR, PETERS: Some appointment. 13 We found on the studies we have done that 70 per FR 14 | cent of all the doctors in New York City do not have a voluntary 15 | Or municipal hospital appointment. 16 I mean, 70 per cent have and 30 per cent do not have. 17 || Seventy per cent have a municipal or voluntary appointment and ig |30 per cent do not have. 19 This does not say that 30 per cent do not have | 20 ||Proprietary appointments or do not have courtesy appointments. 21 We have no way other than contacting each doctor individually a2 |Of knowing this. 93 At the present time, the medical directories in New a4 |XOrk State do not give courtesy appointments or proprietary 25 hospital appointments, 41lthough we have been led to believe that ACE-FEDERAL REPORTERS, INC. 261 CONSTITUTION AVE., N.W. WASHINGTON, 0. C, 10 11 12 13 FR 4 15 16 17 18 19 20 2l 22 23 24 25 ACE-FEDERAL REPORTERS, INC. ‘61 CONSTITUTION AVE .N.W. WASHINGTON, D.C. tion, under utilization, overutilization. 66 the new directory which comes out this year will give proprietaty hospital appointments. So we will get a little better picture this year when we get the new directory in. So we have the problem of what do you do with these 30 per cent of the doctors who do not have voluntary or municipal hospital appointments. This is another problem whic! we hope the medical services division will be dealing with, and the whole problem of medical education and so forth would be part of the function of this medical services division, together with the problem of utilization, studying of utiliza- We also hope to set up a Division of Financial Planning, and this will entail bringing together, coordinating many of the activities of other agencies which are presently doing some work in this field. With the exception of Blue Cross which is responsible for 17 counties, 14 of the 17 count; there is nobody in the area, in the region, that collects data, financial data, or autopsy data from all the hospitals in the region because we have three major groups of hospitals. We have proprietary hospitals which pretty much act on their own. We have a whole complex of governmental institutions of which the largest is 18 or 20 hospitals operated by the New York City Department of Hospitals. And then, we have five State hospitals which are all mental in New York Cityand a couple more in the region. And then, we have a large number of ee Les, 67 1 | government institutions which are beyond this that we have no 2 || relationship to speak of at the present time. 3 MR. BURLEIGH: To what extent are the proprietary 4 || hospitals a relatively regional -- 5 MR. PETERS: The proprietary hospitals have been 6 | with us in New York City since the 19th century. And prior to 7 || the onset of the Depression, there were more proprietary g | hospitals than there are now in terms of number of hospitals. g | There are less hospitals now, but more beds. A good many of io || these have come about since World War II and even a great i. | £lurry in the past three or four years. 12 Part of the flurry of proprietary hospitals in New 13 | York Citytook place because of changes in the zoning laws in FR 14 | New York City And the date was set up ahead. So in order to 15 | get under the wire, a great many of these plans were filed to 16 |) get under the deadline so they could make best use of the 17 | Space prior to these requirements. 18 So you have had, I would expect, around 1,000 built ig | in the past few years, but around 1,000 proprietary beds in 20 || New York City. 21 MRS. COLEMAN: But the point is really what caused 92 || it, not the zones -- that was just the timing -- but what 23 || Caused it, we had & growth of population in one particular 24 || borough without a corresponding increase in voluntary hospital 25 | beds. ACE-FEDERAL REPORTERS, INC. 261 CONSTITUTION Ave . NW. WASHINGTON. D, C, a C21. ccc hia: teat 68 1 DR. KLICKA: This is Queens? 2 MR. PETERS: The Borough of Queens, yes. This is thi WwW 3 | most rapidly growing borough of the five in New York City. 4 | And there were a small number of voluntary hospitals, none of 5 | which were very strong economically. | 6 MRS. COLEMAN: Only one of which was very good 7 || medically. 8 MR. BURLEIGH: I was wondering about the absence g || of staff privileges in voluntary hospitals. 10 MR, PETERS: There is no question but this has something 11 | to do with it. How you measure it, I don't know. This has a 12 || great deal of bearing, but I find in many institutions, the 13 | Ones in private are also on voluntary staffs in the same area. FR 14 MR. BUGBEE; It could also be with a lot of foreign 15 || Professionals and this is sort of the European pattern with the 18 big teaching hospitals. The big hospitals in Manhattan have 17 | 50 per cent in wards and free care. There isn't much room for ig | Private patients {in them. It is the sort of nursing time thing 1g | that they have on the Continent and England where I guess it 20 || goes back to that part. 21 DR. HALDEMAN: How much of it is due to the fact that 22 | in the suburbs, the voluntary effort just hasn't caught up? 23 MRS. COLEMAN; That's certainly true in Queens. 24 . MR. PETERS: Queens up until recently was a suburban 8 | Fype of borough of New York City, and that's where you have had ACE-FEDERAL REPORTERS, INC. ZEEE CONSTIT!TION AVE NW Wetwiycrox DO 69 1 | your growth because your population has grown spectacularly 2 || with the small number of voluntary hospitals, but poor financial 3 || condition, couldn't move fast enough. 4 And in this respect, the proprietary hospitals, 5 | for all we have said against them, have had one great virtue, g || and that is they have met a need and met a need very rapidly 7 || because you can get a proprietary hospital built and occupied - g || in two years. You can't even get the committee of a voluntary g | formed and working in that time. 10 DR. KLICKA: Yes,you can. u | MR. PETERS: But it Queens it wasn't very easy to do. 12 | Queens is a peculiar borough. It is a middle-class borough. i3 || You go through the entire borough, you see very little wealth. FR 14 | It is a low middle-class borough. Some areas have high middle 15 | class, but there is no real money in the borough of Queens lik Ww ig || there is in some of the older sections of New York City such 17 | @S parts of Brooklyn and Manhattan. 18 MRS. COLEMAN; And it was probably overbedded with 1g || municipal beds so that the poor population could be taken care a9 || O£ in municipal hospitals. 21 MR. SIBLEY: I am going to lead you back to financial 92 || Planning because I am interested in what you people see as 93 || your role in financial planning in New York City. 24 The Commissioner of Insurance has required you to 25 || review Blue Cross, hasn't he? ACE-FEDERAL REPORTERS, INC. 261 CONSTITUTION Ave., NW. Waseingron, O. c, 70 7 1 MR. PETERS: Yes. We will get into the whole problem. 2 One of the major things we see ourselves doing 3 || immediately is capital financing which is pretty much akin to 4 || our present role of planning, but we are hoping to get involveil 5 || a8 all regional councils are expected to get involved in New g || York State in judging the adequacy of Blue Cross rates, Blue 7 || Cross payments to the hospitals and all the other things that | g || so-called studies of efficiency, studies of the cost of g | hospital care and so forth which we have been instructed to io | get into by the governor's administrative order. wu MR. SIBLEY: Are you going to do this for the State 12 || Welfare Department as well? 13 MR. PETERS: We ‘haven't worked anything out in this FR i4 | 4vea at all. This is one area we have merely set down as a ig || potential division. The relationships are extremely complex. 16 || You have United Hospital Fund which represents 80-some voluntary 17 | hospitals in the five boroughs of New York City, but does not ig || Yepresent voluntary hospitals in the other nine counties. 19 | You have the Department of Soéial Welfare which collects finandial 29 || data on all hospitals for which the government pays for care, 2) | Which in this instance is voluntary hospitals and also municipal 22 || hospitals. They don't collect any material from proprietary 23 | hospitals so far as I know with maybe one exception which 24 || does take care of some government indigent patients. 25 DR. ROREM: You say, "proprietary hospitals can ACE-FEDERAL REPORTERS, INC. 261 CONSTITUTION AVE., NW WASEINGTON, oc, FR 10 li 12 13 14 15 16 17 18 Ig 20 21 22 23 24 29 ACE-FEDERAL REPORTERS, INC. 261 CONSTITUTION AVE , WASHINGTON, D.C. Nw. Hospital Fund for voluntary hospitals in five counties, and 71 accept indigents." MR. PETERS: It so happens Manhattan General does. DR. ROREM: Nothing in the statute of limitations that avoids it? MR. PETERS: This was raised at the last Board meeting, this very question. There is nothing that prevents them from taking care of indigent patients if they are given to them. We have to get the approval of the Commissioner of Hospitals and so forth. We have financial data collected by the United not all the voluntary hospitals, only those that are members of the Fund. You have the Department of Social Welfare collecting financial statistical data for all the voluntary hospitals which accept city charges and mental institutions. But then, you have got Blue Cross which collects financial data from all the hospitals. So that is the only source at the present time of financial data from all the hospitals in the 14 counties. The big problem of the new Council would be when it sets up its division, how much are we going to do and how much are we going to have to take from somebody else. Obviously , you have got people doing it. Blue Cross has got a legal responsibility. They collect data anyway for their own operat So you are going to have to work with Blue Cross. You are goi 72 1 || to have to work with the Department of Social Welfare and with 2 | the United Hospital Fund which, again, has a chartered 3 | responsibility to do certain work in this field. 4 They would have to change their whole role if they 5 || didn't do this. So it is going to be a very delicate arrangement . 6 Fortunately, we have very good working arrangements 7 | with all these groups, particularly Blue Cross, which finances. 8 | us to a tune of one-third of our annual operating expenses. 9 | United Hospital Fund finances us to the tune of about one-sixth “10 of our operating expenses. So you have a working relationship 11 | there. It is a matter of who is going to do what and how. 12 Certainly, we are going to have to do substantially 13 | what we have done in the past,but how far we are going to go on a 14 | this is a matter of development and evolution. It is going to 15 | be a slow process. 16 The medical service division, on the other hand, is 17 || one that our Board has given the highest priority other than 1g | Our present activities, getting involved in that area, quality, 1g || Standards of care, medical staff appointments. 20 And the other would be administrative services. This 21 one has been tabled. This one is the area where so far as the a2 Official position of our Board of Directors igs concerned will 23 await further discussion. And this is not anticipated this would 24 be started for some time. 25 MR. SIBLEY: How did that one get included? What ACE-FEDERAL REPORTERS, INC. 261 CONSTITUTION AVE .N.W. WASHINGTON. 0. C, ea i cacacac état tte 10 li 12 13 FR u 18 16 17 13 1g 20 21 22 23 24 25 ACE-FEDERAL REPORTERS, INC. 261 CONSTITUTION AVE .N.W. WASHINGTON, @. C, 73 was the thinking behind it? of operation. Also, I think under there is concern with teaching, nursing, and all kinds of educational projects and the hope for a general drive on economy or, at least, a medium for use by the hospital. t MR. PETERS: It gets in the whole area of nonprofes-| sional staffing and professional staffing other than doctors. Certainly, you have to take into consideration your planning procedures. MR. SIBLEY: I want to get on this because it is for a purpose. These are all considered in your agency to be planning, you see. This is a very broad definition of planning MR. BUGBEE: It is Trussel's definition. You may recall it is his planning and review council. And the review assumes operations and quality. here and that is the Blue Cross is planning, not only to Support it, but probably to contract with this agency. And I would guess that probably they are patterning it to some degree after what you are doing, Jack, in Detroit, but with the thought that enforcement of economic sanctions against construc tion and various other things could better be handled by Blue Cross contracting through this agency than Blue Cross trying to do it itself, MR. BUGBEE: I think the whole question of the economics wy e I think there is one other thing that has some interdst FR 10 ll 12 13 15 16 17 18 19 20 2l 22 23 24 25 ACE-FEDERAL REPORTERS, INC. 261 CONSTITUTION Ave .N.W, WASHINGTON D.C. an interim contribution. It is not for all time, we hope. 74 They have talked about contracting in Support up to half a million dollars. I don't know whether it will, but it would make possible the staffing of some of these other ventures if they do. MR. PETERS: At the present time, Blue Cross has | guaranteed us $100,000, but not to exceed one-third of the total of our contributions from all sources, including themsel} So last year we got $95,000 or some such figure, $94,000. So we are pretty close to getting the 100 per cent contribution from Blue Cross as they presently see it, but this is only MR. BUGBEE: I think the other unique thing is you get about $30,000 from the State as your function at the Hill- Burton agency. DR. HALDEMAN: Jack, did you want to speak? MR. COUSIN: Yes. I have a question. Because what you are planning to do there in some ways is what we are planning to do except you formalize it a little more than we have and you are apparently going into it a little deeper than we have. | MR. PETERS: We are only formalized in our paper, Jack, so far, MR. COUSIN: This may be an embarrassing question, but -- MR. PETERS: If it is so embarrassing, I won't answ ves. 75 1 MR. COUSIN: What does this do to your other Hospital 2 || Council in New York? 3 The reason why I am asking it is because my organiza+ 4 || tion does planning, but it is also the trade association. 5 | And while some of our administrators feel that we should have 6 | planning in the trade association separate, our public representa- 7 | tives who are the ones that pretty much control us feel that we 8 || are better off in the long run in doing planning and all the g trade association work because you can't divorce the two. 10 They tell me what we are really doing is health ll ‘economics, not planning. 12 MR. PETERS: First of all, I am on the board of the 13 | Greater New York Hospital Council. The Executive Director of FR 14 | the Council is automatically ex-officio member of the board 15 | 4nd the association. 16 We don't see any real conflict. First of all, they i7 | 4re admittedly the spokesman for che voluntary hospital system. ig | It is their job to see that the interests of the voluntary ig | hospitals as a group are promulgated. Our job is to look at 20 |jthe thing from a different point of view, the point of view 21 ||Of the community. 22 This may not be the same as the interests of the 93 ||voluntary hospital either collectively or individually. Fortunate- o4 lly, it has been, but it is not necessarily the same thing. 25 We look at things differently. We don't go down to ACE-FEDERAL REPORTERS, INC. 261 CONSTITUTION AVE NW. Washington, @. C. 76 1 the city hall nor to the State chambers to lobby for passage 2 || of a certain bill or lobby against the passage of a certain 3 || bill like the association does. We are not involved in the 4 || whole problem of unionization of hospital employees, which they 5 | are. We are not involved in seeing at the present time the | 6 || voluntary hospitals get the most advantageous raise for 7 | Blue Cross when the third party pays. 3 We will be involved in rates, but from the point of g || view of whether the community is getting the best value for 19 || its money, not in terms of whether the hospitals are getting 11 | the most they can from the agencies. It is a different point 12 | Of view, and I think there is room for both. 13 MR. BUGBEE: There is another thing, Jack. This is FR 14 | 48 touchy as anything, and the Greater New York was very 15 || concerned with this development, but the fact remains they ig || have never done anything but representation. They have never 17 || done economic activities or joint purchasing or any of the 1g | things that are conceived to be a Council function except ig || representation. And maybe there is a role for them in representa- 20 || tion in relationship to Council, but they were worried to 21 | @ degree it pre-empts part of the assignment that should have 22 || been theirs. 23 MR. PETERS: George, since you left, the Greater o4 || New York Hospital Association was studied. Like most hospitals a5 || they got their study, too. so they brought in an outside ACE-FEDERAL REPORTERS, INC. 261 CONSTITUTION AVE .N.W. Waseington GO. C 77 1 | consultant to look at what the role of the Greater New York 2 || Hospital Association would be. And even though they are 3 | structured in a very complex way, the consultant recommended 4 || @ very complex structure. Actually, there wasn't quite as much 5 | conflict as one would think would arise. | 6 Sure, they would have a Division of Financial Planning. 7 | But this is purely from the point of view of representation to. g || gather material from the hospitals to present a brief to the 9 | city or to Blue Cross or to any other third party for 10 | getting better reimbursement patterns for the voluntary 11 ‘hospitals which they represent. 12 They are talking about studying personnel, but their ro Co study of personnel is going to be a little different than ours, FR 14 || They are talking about salary, salary and wage procedures, 15 | policies regarding employment, collectivization so they can 16 || work with unions because as of July Ist, the hospitals of 17 || New: York City are no longer exempt. So they have to live with ig || unions and like it as of seven or eight days ago. So there is 19 |4 different type of thing. 20 Even though they are expanding just as we are expanding, 21 1 still see very little conflict except in this one area of 22 || administration. 23 MR. COUSIN: Which you have taken, 24 MR. PETERS: Which we have taken, but partly because 25 jO£ this because this is a very, very delicate area, and this ACE-FEDERAL REPORTERS, INC, 261 CONSTITUTION AVE ,.N.W WasninGTon OC, FR 10 11 12 13 44 1 16 17 18 19 20 al 22 23 24 29 ACE-FEDERAL REPORTERS, INC. 261 CONSTITUTION AVE NW. W4SHINGTON, O,C, -in how we look at the images of our job, which is really what 78 is the area where we are going to have to, over a period of time, our committee has recommended we have joint conferences with the Greater New York Hospital Association and United Hospital Fund which also does work on administrative research. For example, on methods of improvement and things like that which Charlie Roswell has done with Government aid. There is where your great area of conflict may be. This is th area where it is“conceivab le we may never be operate. MR. SIBLEY: Joe, we are already into this area of administration, and this is why I am particularly interested you are describing, how you compare your image with the image of the association. And we got caught into it. I think for a number of reasons, but the one that ca out was when Frank Gromer was president, he insisted there mus be a code of conduct of hospitals which was in the organizatio management end of things. And we have developed now what we call organization and management standards which are going to our House of Delegates in New York in August. We realize that they are going to be revised many times and worked over many times, but they are now in very definitive form, very specific. There are about five general headings and about seven to ten under each one. But we don't know how to administer them, and we have been discussing this. Our Board discussed it at considerable length. You 79 1 | see, this was a promise that Frank Gromer made to the 2 || Blue Cross Association that the quid pro quo was between 3 || hospitals and Blue Cross. And I think it is probably the 4 || same with the insurance commissioners and welfare departments 5 || around the country that the hospitals have to demonstrate, or 6 || there has to be some mechanics of demonstrating, that they are 7 | doing the things, they are being well organized and well g || managed. That is, if they then proceed to say that good g || patient care gets some good organization and good management, io | Which I think we accept as a basic premise, although we are 11 | not sure that this is correct. 12 So we have moved into this field rather gingerly i3 || Ourselves because we are not sure, but we felt we couldn't wait FR 14 | Any longer and with the Trussel report kind of activity -- that i5 | £s, 1£ you follow out the concept of that report. And as far 16 as I am concerned, in my thinking, these are all facets of the 17 | More general problem that hospitals, not being in the profit- ig || making activity, have to find mechanisms for demonstrating they ng 19 || 4re using the money which comes to them which is, in a sense, 20 || in trust, in trust for Blue Cross or in trust through taxes, 21 | Or in trust through insurance or in trust whatever the mechanism 22 is. 23 We answer that question we are taking the necessary 24 | Steps to use this money wisely, and this is basically, I suppose, 25 |what you are set up to do. ACE-FEDERAL REPORTERS, INC. 261 CONSTITUTION AVE _N.W Wedhineron OF C¢ FR 10 1l- 12 13 14 15 16 17 18 19 20 al 22 23 24 25 ACE-FEDERAL REPORTERS, INC. 261 set heeh i bel AVE JNLW, C. Wasrine “We had to talk in terms of organization, administration, 80 MR, PETERS: By the way, this is not to say that the Hospital Council has had blinders insofar as these other aspects of hospital planning are concerned. I think if you look at the study which we prepared a few years ago -- about a year or two ago -- on the so-called municipal: voluntary . | hospital relationship study where we analyzed the role of the voluntary and municipal hospitals in New York City, which came out as a 600-page book in the beginning of this year, you see, we at that point had come to the awareness that we just could no longer think in terms of facilities and services|, availability of personnel, standards of care, all these things finances, In fact, if you look at that book, you find that more than one-third of that book deals with finances. The role of government money, voluntary money, philanthropic sources and private payment goes to one-third of that book over and over again. We also talked about the ability of the municipal hospital system to administer itself properly, the organization of municipal hospital system, and how it should relate to the organization in voluntary hospitals. And we talked about all these things, and this was the first time where we official] really got way beyond our previous limited scope. Do you think $0, George, when we got into this . Ly FR 10 1] 12 13 14 15 16 17 18 19 20 2i 22 23 24 25 ACE-FEDERAL REPORTERS, INC, 261 CONSTITUTION AVE ,.N W WasH waron @. C. ‘at the Board of Directors of the Greater New York Hospital 81 municipal voluntary, maybe not to live with it, but maybe accidentally. We got into all the areas. DR. ROREM: I would like to ask a question, technical question. Did I understand you to say the municipal hospitals do not have membership in or are not represented by the | Greater New York Hospital Association? MR. PETERS: Yes, they are. MR. BUGBEE: Proprietary are not. MR. PETERS: Municipal are, but actually, if you Look Association, you see that the Commissioner of Hospitals is like I am, an ex-officio member of the Board, and he is the only administrative hospital person that is on that Board. So even though there are 18 hospitals, 18 hospital Superintendents, they play a very negligible role in the policy- making of the association. So even though they are members, they come to all the general meetings, but as far as the Board of Directors, as far as holding office is concerned, historically the municipal hospital executive had played no role. DR. ROREM: Except their primary concern is with the voluntary hospital. MR. PETERS: No question. The other ones don't even pay the same dues. For want of a better word, they would be an associate 82 1 type of membership because the problems that the Greater New 2 || York Hospital Association deals with are primarily the problens 3 | in the voluntary hospitals. 4 DR. HALDEMAN: Is there an association of proprietary 5 | hospitals? 6 MR. PETERS: Yes, there is at least one. There is 7 | One, anyway, Association of Brivate Hospitals, Inc. 8 MR. SIBLEY: Are you on their Board, Joe? 9 MR. PETERS: No, but they are on our Board. And 10 | George can tell you about all the travail that went through 1 || on that one. They are on our Board, and I may say that I feel 12 || sorry for Dr. Berson who represents it because when the vote 13 | comes 40 to 1, he has long since now just stopped and sits FR 14 and listens. 15 All it does, really, in many respects, is assure ig | that they will know what we are doing, not that we know what 17 || they are doing. In other words, any time we prepare a document , ig || you can be sure that the Executive Director of the proprietary 19 || hospitals has a copy of it on his desk the minute it is off 20 || Our press because we send it to our Boardman, He probably 21 || gives it to him. So it is a one-way communication at the 22 || present time, 23 But certainly, I would say that it was a wise move 24 || to bring him on. If you are going to try to get them to upgarde 25 || their standards, you ought to at least let them have some voice ACE-FEDERAL REPORTERS, INC. 261 CONSTITUTION AVE , NW, WSS5H-NGTON OF. C 10 il 12 13 FR 14 15 16 17 18 19 20 2l 22 23 24 25 ACE-FECERAL REPORTERS, INC. 261 CONSTITUTION AVE , NW. Waseiagton Fo 83 in it because one man can't dominate the group. Hopefully, we try to let him see the broad picture and are hopeful he will bring this back to his members. Let me get to the criteria because this is a good point. | DR. KLICKA: One question before you do that. Either I missed it or you didn't make it clear. I think I missed it. . In all“of this structure, are you talking about planning as it relates to hospitals, or as it relates to total health facilities which include nursing homes? MR. PETERS: Total health facilities. DR. KLICKA: And long-term care facilities, all of these things? MR. PETERS: We have done a little bit of work in nursing homes, and we occasionally have some relationship with other types of institutions, but this has been more accidental than deliberate in the past. Dr. Coleman, who was our Association Director prior to going to Johns Hopkins was farmed out for a period of time, working with the Department of Mental Health Council which represents the Department of Hospitals, Health, Welfare, and Mental Hygiene, in New York City. And he did some work on nursing home facilities. And he came out with a figure that in New York City we need approximately 15,000 more nursing home beds by 1970. FR 10 11 12 14 1S 16 17 18 19 20 2l 22 23 24 25 ACE-FEDERAL REPORTERS, INC. 261 CONSTITUTION AVE... NW. WaswingtTon @. C. “We have to get involved in this. We certainly can't limit 84 So we have some guideposts in this area to work with. This was done, not by the Council as a council, but one of the staff members loaned out. As I recall, that wasn't even approved, didn't even go to our Board of Directors, his report. It went directly to the group, but we have used it, and it does represent a landmark which we can work under. We need more nursing home type facilities in New York City, and we have been working a great deal with hospitals on this trying to get individual hospitals to expand their scope. And I suspect we are going to get involved in other things. ourselves to the general hospital. If we did, we would be limiting ourselves to only just one segment. It is hoped we can get more involved in the whole problem of care for the mental disease patients, care of the aged. We find ourselves getting working time with homes for the aged, Mrs. Coleman worked with some last year, as I recall DR. KLICKA: I am going to ask you a ridiculous question. Does anyone have the opinion you are extending yourselves too far and trying to do too much in your organiza- tional structure? MR. PETERS: I would suspect there are. _ DR. KLICKA: I am asking a serious question. MR.PETERS: Seriously, first of all, I told you about th¢ 10 il 12 13 FR 14 15 16 17 18 19 20 al 22 23 24 25 ACE-FEDERAL REPORTERS, INC. 261 CONSTITUTION AVE., NW. WASHINGTON, D.C, therefore, what right do we have to make pronouncements about 85 fact many believe we are trying to extend ourselves too far geographically. DR. KLICKA: No, I am talking about -- MR. PETERS: That's one area. I am sure that I could think of at least one member of our Board of Directors - who must think we are out of our mind getting involved in this medical services concept. He has very often spoken up that the problems of tiedical care are the domain of the medical society and doctors that practice medicine. And since we have very few doctors on our Board that even touch a patient, quality of medical care? This is a medical problem, and you laymen, no matter how well intentioned you are, should get away from this. And he has spoken this out at every single Board meeting he has been at. | I would suspect there are one or two other members of our Board who are also physicians, and I might even say One or two of our lay members, who would say he is perfectly right. This is one area where we know there is some controvergy, at least some’ doubts, in the members of our own Board of Directors. I know that there is at least one member of our Board of Directors who thinks -- at least one, maybe more than one -- the idea of the whole new Council, its structure, its organiza- tion, its Concepts, its Seographic responsibilities, is all wet FR 10 11 12 13 14 15 16 17 18 19 20 ai 22 23 24 25 ACE-FEDERAL REPORTERS, INC. 261 CONSTITUTION AVE .N.W, WASHINGTON, O.C, 86 And he will not come, he doesn't come, to any Board meetings. I would say one of our best Boardmen, one of the men who could make some real substantial contributions. So I would suspect there are many individual hospital administrators who would say that we are out of our minds. Particularly ones we leave the area of facilities and get into anything beyond facilities, there are a lot of people I am sure who aré going to resist us. We haven't met that resistance officially because we haven't gotten into these areas as yet, but I suspect we will get it. And I don't think the committee, when they formed this Council, ever thought it was going to be an easy job. They realize the problems, and it is going to be difficult. DR. KLICKA: 0.K., you answered it. DR. HALDEMAN: Could we go on to the principles? MR, PETERS: We got involved in this criteria. As I say, we know quite a bit about New York City. After all, we have been working in New York City for 24 years, but to be completely frank, there are a lot of things we don't know. But we know quite a bit about it. As of a year ago, we knew nothing about the eight counties outside of New York City. So one of our first jobs, as I said earlier, was to broaden our knowledge of the 100-odd hospitals outside of New York City to get some idea of all the things that were happening that affect medical care and 87 1 | hospital care outside New York City. 2 Quite apparently while you are getting this information, 3 || you still have got to make decisions. If an agency is going t¢ Nd 4 | wait until it gets all the facts and is not going to make any s || decisions until all the facts are in, he is not going to do g || anything. We have got to plan regardless even with our t 7 | Limited knowledge. ' 8 Once we were organized, people started asking us g || questions, and we had to give answers to these questions. So io || £t was quite obvious that we had to have some broad outline 11 || criteria to guide the Facility Planning Committee and the 12 || Council as a whole in making decisions both for New York City 13 || and for the other nine counties outside the city. FR uu So we had criteria, one-page criteria on New York 15 || City which we assembled about two years ago. And this, we 1g | Were operating under for the past two years. When we became 17 || @ new regional council, it became quite obvious that we had ig || tO broaden our principles to take into account the other nine 19 counties and the differences between the other nine counties 20 || and New York City. 21 As I said, the other nine counties have an expected 22 || Population growth. New York City is expected to remain static] 93 || 50 We were told to expand our principles for New York City to 24 || Cover nine counties. “= ‘There was some thought that perhaps we would have to | ACE-FEDERAL REPORTERS, INC. | 261 CONSTITUTION AVE .N.W, WasHincran. D.C, Aaa aaa ataataaaasaaacamasasaaaaaaaaaaaaaa casas mmmmammamaaaaaaaaammmmmmsm ammeter can aetna east 261 CONSTITUTION A Washing 10 1] 12 13 14 15 “46 17 18 19 20 al 22 23 24 25 ACE-FEDERAL REPORTERS, INC, VE.NW. c | wags taken on the fact that every hospital should attempt to se 88 have two sets of principles, one for New York City and one for the expanding nine counties. We thought that it would be possible to develop a set of principles which would apply to the region as a whole, it was no longer feasible to try to make distinctions. We ought to start thinking as an integrated region rather than as three separate groups within the region. So staff devised these criteria, And as you will notice, they are very general. I suspect there is nothing in here which is new with perhaps one exception, and that is the very strong position th —5— all income groups within the population. This is quite a dramatic jump in New York City because, as I say, ,we have municipal hospitals to serve the indigent. We have proprietary hospitals which serve the pay patient or Blue Cross patients. And we have voluntary hospitals which serve all patients, but as George pointed out, they carry a large share of the indigent patient load in the city. This is not true outside the city because there are no local government hospitals outside New York City. There are one or two, but they are a very small group compared to New York City. The problem was we felt that to perpetuate hospitals with such limited functions in serving limited Segments of the community made our planning a great deal more difficult and reve FR 10 il 12 13 14 15 16 17 18 19 20 21 22 23 24 25 ACE-FEDERAL REPORTERS, INC. 261 CONSTITUTION AVE . NW. WashinGron DOC - £rom now could be a blighted area or slum. It could have 89 probably resulted in a need for more beds if you are going to start splitting the community up into small groups because you have lost one element of flexibility automatically by having hospitals which take care of the pay patient and hospitals which take care of the poor and hospitals which do both because these populations are not static, they change. As the economy changes, the number of people who Yequire care in municipal hospitals, at least theoretically, changes. And what happens in New York City is we find, particularly as areas change, an area could be a middle-class area today, ten years enough hospital beds, but supposing all these hospital beds were proprietary hospital beds? Who is going to take care of the needs of these changed areas? Or, conversely, suppose the area was a slum and through redevelopment became a g0od area and you had a municipal hospital servicing it. Who is going to take care of the needs of the private patients in that area because, by law, the municipal hospitals are Limited primarily to care for the indigent, although they can take emergency cases for pay patients, So we wanted to recognize two problems, the problem of changing economic conditions and changing community conditions, the dec lining neighborhood or area that was changing for better or for worse. So we felt in our future planning, we should 90 1] || attempt to have hospitals that would service whatever type of 2 || Patients were there at the time. 3 In other words, hospitals that would take care of 4 || the indigent and the pay patient in various proportions, depend- s || ing on the need at the time. 5 So this, in essence, really meant that we were going 7 || On record as being against private hospitals. 8 MRS. COLEMAN: And municipal, 9 MR. PETERS: And municipal, but you notice on page 1 io | Under "flexibility", we put a little out on municipal hospitals 11 || bY saying, "It is recognized that, because of local traditions 12 | and statutory policies, there are often marked differences in 13 || the roles of government institutions in servicing various FR 14 | SFOups within the population." iB | We left a little loophole there, although I might 7 say we have been pretty much in the past few years discouraging, 7 and in this, Dr. Trussel shares our views »completely, the 12 addition of more municipal hospital beds in New York City. 13 DR. HALDEMAN: Is there any move to open up 20 municipal hospitals to paying patients? 21 MR. PETERS: There has been talk about it as far back a2 ||#8 the hospital survey of New York which was in the ear ly 93 "30's. One hospital in New York City, Sydnum Hospital., which a4 "8 & voluntary hospital in the Harlem area which face d great 2 if inancy a} difficulties, and in the late -40's became a ACE-FEDERAL REPORTERS, INC, 261 CONSTITUTION AVE | N.W. WASHINGTON O.C 91 - 1 || municipal hospital with the stimulation that probably 100 per 2 | cent of its 200 beds would be for private patients, but this was 3] a recognition of the peculiar problem facing the Negro doctor 4 | in the Harlem area. | 5 DR. HALDEMAN: I am thinking of the situation in- | 6 | Kansas City where the municipal hospital is now opening its 7 | doors to pay patients. 8 MR, PETERS: There has been talk about it, but the 3 | Council has resisted it pretty much officially, and there has 10 | been very little talk about it in recent years. | ni DR. ROREM: In New York States, as I understand it, 12 || upstate, a number of these so-called county hospitals are 13 | open to the general public. M4 MR. PETERS: Herkimer. is ft: DR. ROREM: Are any of those in the lower tier like 16 that? 17 MRS. COLEMAN: There is one in Westchester that will 18 | take special types of patients. 19 MR. PETERS: Alcoholic, mental disease. 20 MRS. COLEMAN; It was used when we had polio. 21 DR. ROREM: Nothing like the one in Utica, for example. 22 DR. HALDEMAN: Joe, I wonder if we could go on and 23 | get some of the various methods that are being used to try and 24 | implement because, as I understand it, there are a number of % forces, not all within the Council, but within cooperating ACE-FEDERAL REPORTERS, INC. 261 CONSTITUTION AVE .N.W. Wasedinctan, O. C, 92 l groups such as Ray Trussel's authority in relation to licensure 2 of proprietary hospitals that are having an impact on it -- 3 | the use of the 5 per cent funds in the Blue Cross and other 4 | things that amount to trying to implement good planning that 5 || are bringing forces to bear from a variety of directions. | - 6 MR. PETERS: The Hospital Council has traditional 7 || authority in terms of there were three ways in which we could. g || influence hospital planning. 9 And first of all, that was moral suasion. The other 190 || Was through financial controls, contributions and so forth. ull And a third was legal sanctions and government authority. 12 || We have used all three, but have relied primarily on the first 13 || moral suasion. FR 14 So far as government is concerned, it is a very com- 15 || plicated pattern in New York City area on government controls, 7 and there is a document available which summarizes all the 17 | Various ways government gets into the picture, 18 But the one way which I think you would be interested ig | 18 most, in New York City, the Commissioner of Hospitals, a0 || Ray Trussel in this instance, licenses proprietary institutions a1 || 4t his discretion. And he has interpreted this to mean he 22 ||can withhold a license to a proprietary hospital and discourage 93 || their expansion or even discourage their opening in the first 94 Place. And he has relied on Council to assist him in giving 25 jadvice under which hospitals should be approved and should not ACE-FEDERAL REPORTERS, INC. 26! CONSTITUTION AVE..N W. WASH NGTON D.C. 10 il 12 13 FR 4 15 18 17 18 19 20 2l 22 23 24 25 ACE-FEDERAL REPORTERS, INC. 261 CONSTITUTION AVE .N.W. WASHINGTON O.C ! 93 be approved so far as opening, so far as new construction or expansion is concerned. And we have in the past year in particular -- two years, actually -- been advising him on a number of proprietary hospitals. All we do is advise him. He has not been able to make all of these stick. He has had to give in. DR. KLICKA: Why? How does he give in? Is he sued. or how does he give in? MR. PETERS: He hasn't been sued, but apparently all kinds of pressures have been placed upon him. MR. BUGBEE: He moved in when some of these were already in construction. That was a little hard to stop. MR. PETERS: He came in too late in some instances. Others, a little give and take. Some others, he let adda small number of beds. Here is the problem they face. We talk about efficiency of operations. Some of them were small and wanted to become a little bigger, wanted to add 50 beds, and also wanted to add ancillary services. But to add the ancillary services, economically, they couldn't do it unless they had the beds. So he would have to give in and say, "0.K., 20 beds , but make sure you build up your X-ray department and modernize your obstetrical department or modernize your operating room suite," or such things as that. He realizes in some instances asking the man merely 94 - 1 | to do one without doing the other was economically impossible 2 | for them. So he had to face the problem if you want a second- 3 || vate hospital with inferior ancillary services that continue 4 || to exist, or do you want to upgrade them a little bit, let 5 them expand their ancillary service, but also expand their 5 || beds to some limited extent. And he gave in there to some 7 || extent. 8 But, on the other hand, I think we have done a great g || deal to discourage, I think the day of explosive expansion 10 | Of proprietary hospitals is past so far as New York City is 11 || concerned so long as you have a Commissioner of Hospitals who 2 || £8 willing to put his neck out. If and when you get a Commis- 13 || Sloner of Hospitals who is not willing to take drastic action, FR 14 || NO one can tell. But I think the day is -- but you have anoth Ww 4H 15 | Control, you have Blue Cross. 16 DR. KLICKA: He has just made one of the most important 17 || Statements that have been made today, though, and I would like ig || to emphasize this. He talked about courage. And believe me, ig | don't ever discount this in this field. 20 Go ahead. 21 MR. PETERS: Courage? 22 DR. KLICKA: That's right. 23 MR. PETERS: I think Ray Trussel is an outstanding o4 || example of courageous action. 25 DR. KLICKA. That's right. That's why I wanted to ACE-FEDERAL REPORTERS, INC. 261 CONSTITUTION AVE., N.W. WasHingron, O C, 95 1 || give it emphasis. 2 DR. HALDEMAN: What other methods are being used in 3 || the area? 4 MR. PETERS: Then, of course, these are legal. 5 | Theoretically, on the books, according to the administrative 6 || procedures of the Department of Social Welfare, the Department 7 || Of Social Welfare -- this is administrative now, on its g || administrative code -- in considering an application for the g | granting of a charter to a new hospital should take into 10 || consideration need, the need for the hospital. This is not in i1 || the law; it is in their working arrangements. And in the past 12 | two years, the Department of Social Welfare has come to us and 13 | asked us our opinion. FR 14 But I might also add that they have disregarded our i5 || opinion after we gave it to them. | 18 MR. BUGBEE: Licensure is a jungle. It is between 17 | the municipal, delegated to the Commissioners of Hospitals, or ig | the State. You would have to read the book because for 19 || proprietary and voluntary in the five boroughs and out, the 20 || rules are all different, aren't they? 21 MR. PETERS: It is a very complicated structure. 22 || But suffice it to say that the Department of Social Welfare 23 | has within its rights the ability to withhold a charter to an 24 || institution that is not needed, a voluntary institution which 25 | is not needed, ACE-FEDERAL REPORTERS, INC. 261 CONSTITUTION AVE .N.W, WASHINGTON. D.C, 96 1 DR. ROREM: I might say in Pennsylvania the law now 2 || States that a voluntary hospital has to have a certificate 3 | of need and a proprietary does not. 4 MR. PETERS: Proprietary in New York does not either 5 || except in New York State, the Department of Social Welfare can) 6 | withhold the charter to a new voluntary membership corporation 7 || which wants to start a hospital. 8 They have not for some reasmor another in our g | region. We have on three or four occasions in the past two 10 || years told them this hospital is not needed, and they have 11 | chosen to go ahead anyway and give the charter out. So that 12 || Means we do have some legal control, but the Department of 13 || Social Welfare for some reason or another does not choose to FR ia || follow it. 15 MR. BUGBEE: You have some other idiosyncrasies. ig || The Department of Social Welfare is a board, nonpolitical and 17 || Ronapproachable through administrative controls or anything elge. ig | So they have done pretty much as they want. 19 MR. PETERS: As far as the proprietary hospitals are 20 || concerned and municipal hospitals, we have the Commissioner 21 | Of Trusts of Municipal Hospitals, Department of Hospitals. 22 Take the municipal hospitals. We have worked with all 93 || the commissioners over the past years very closely, and they ga || have come to us asking our advice about the building of 25 municipal hospitals. We have a lot of municipal hospitals that ACE-FEDERAL REPORTERS, INC. 261 CONSTITUTION AVE .N W., WASHINGTON OC. 10 il 12 13 FR 14 15 16 17 18 19 20 val 22 23 24 25 ACE-FEDERAL REPORTERS, INC. 261 CONSTITUTION AVE., N.W. WASHINGTON, O, C, 97 are in inadequate facilities, and there has been some discussion whether they should be closed or replaced. We rendered our own opinion on a number of these. Dr. Trussel has agreed completely with us that we were right, but here again, we got into the whole area of polit cal forces and both Dr. Trussel and we have been defeated. I think that Fordham Hospital, which was a hospital | we said should be closed, Trussel said it should be closed, all the knowledgeable people said it should be closed, but local political pressures have kept it open. I think of Gouverneur Hospital which we said many years ago should be closed, Trussel said should be closed, he closed it. But as of a week ago, we have reversed our decision It is now going to be built. . MR. BUGBEE: Who has reversed this decision? MR, PETERS: The hospital council because of the fact we were going to make Bellevue Hospital smaller. MRS. COLEMAN: Don't try to understand it. MR. BUGBEE: Ninety million isn't enough for Bellevue Hospital? MR. PETERS: The problem with some of these things here, you mentioned before about location of the hospital -- I think it was Dr. Rorem mentioned -- this is a problem we faced, The planner can say, "Thirty minutes traveling time,' i- 98 l and Gouverneur-Bellevue is a good example. Gouverneur Hospital 2 || was a small hospital which lost accreditation, small municipal 3 || hospital, with 200 beds in the tip of lower Manhattan. Within 4 15 or 20 minutes travel time by bus, you came to Bellevue 5 Hospital which is the same type of. hospital except ten times s | as big, staffed by three great universities -- Cornell, | 7 Columbia, and New York University medical schools -- one of 8 the great hospitals of the world that was actually servicing 9 this area anyway in unsuitable facilities, going to be rebuilt. 10 The question was should you rebuild an X-sized 11 | Bellevue Hospital or an X-minus 200-bed Bellevue Hospital i2 | With 200 new beds down in lower Manhattan? 13 We said, "No, build the X-sized Bellevue Hospital FR 14 and forget about the 200-bed satellite down in the southern 15 part of Manhattan which, don't forget, had lost its accreditation, ag lost its approval, all its residency approvals, a poor institu 17 || tion. But the Mayor had promised in his first campaign they ig || Would get a new Gouverneur Hospital. And despite what you ig | S4y about the Mayor, in this instance, he was tenacious. He a9 || kept to his promises. He never gave in. And Trussel advised gq} || him to close it, and he closed it, but nobody could make it 99 stick, 23 Here, you have the local community very vocal, oA demanding something and the planning agency and all the 25 || knowledgeable people saying, "No, you don't need this, it is ACE-FEDERAL REPORTERS, INC. 261 CONSTITUTION AVE .N.W. WasHinGTaN. GO. Cc S11: 2..ccaseasaaaasaaaaaacamaaasaaaaaaaaasaaaaaaaaaaaasaaaamaaaasaseaaaaaasaaaataaaaaaamamaeaaeaeammmmmmnnmmmmnnmmmmaas 99 1 || not for your best interests." How do you reconcile this problem? 2 || We are a community agency. We purportedly speak for the 3 || community, but are we speaking for the community when the on 4 | community says they want this and we say no, you don't need it 5 DR. ROREM: If this had been a voluntary hospital, 6 || you could have made it stick. 7 MR. PETERS: How? 8 DR.ROREM: They have to get the money from somewhere. 9 MR. BUGBEE: They wouldn't have raised it down there io || either. un | DR. KLICKA: You didn't change your position? 12 MR, PETERS: We changed it the last meeting because 13 | O£ the rearrangement of cutting down, if they cut down Bellevub. FR 14 DR. ROREM: You saved face by cutting Bellevue back 15 200 beds? "16 MR. PETERS: Yes. 17 DR. HALDEMAN: Is there affiliation with Bellevue? 18 MR. PETERS: No, they are going to affiliate with ig || Beth-Israel, which is in the area. It is a peculiar thing. 20 || We are going to get a Department of Health, Welfare, Hospitals 21 || @nd Mental Hygiene to work together. It is very unique. 92 || They are planning on an interdepartmental complex to make certein 23 || Ploneer efforts in providing care locally. 24 MR. BUGBEE: They are rationalizing the Mayor's 25 || COmmitment. ACE-FEDERAL REPORTERS, INC. 261 CONSTITUTION AVE . NW. WASHINGTON O.C. 100 1 DR. HALDEMAN: I think their batting average may be 2 | pretty good. There are at least two or three municipal units 3 | that are being built around and will be operated by a voluntary 4 || nonprofit hospital. And it does always seem to me like in the 5 | last analysis, you usually have to compromise some things in g || order to get the major things you want. 7 MR. PETERS: Let me get into the idea of how we g || work with voluntary hospitals. This is the area where we have g | done a great deal of our work in the past. And here is where ig || we probably have had the greatest success, partly because, as [ 11 || said, people ask us to study them. So the mere fact they ask 12 || us indicates they may abide by our recommendation. They 13 | don't have to ask us under the present circumstances. FR 14 They ask us for our recommendation. We do a study. is | We come up with an answer. 4g In this instance, I think the greatest tool we have 17 || had to use has been Hill-Burton money, being the local agent ig || for Hill-Burton for the State and five boroughs of New York ig || City which has given us a tremendous weapon, actually a weapon a9 || far beyond the actual amount of money involved. You are talking gi || OF an average of $1.5 million or $2 million a year, most of 2 || the grants being made half a-million dollars, $300,000, $200,000, 23 relatively small grants in terms of the total amount of money oA which is being expended for capital construction. a Here is where we have influenced hospitals a great ACE-FEDERAL REPORTERS, INC. 261 CONSTITUTION AVE., N.W. W4sH'ncron O.C, ae A a cama aaa aca er FR 10 11 12 13 14 15 16 17 18 19 20 2l 22 23 24 25 ACE-FEDERAL REPORTERS, INC. ‘6 1 CONSTITUTION AVE .N.W., WASHINGTON, o.c. ‘Trussel was coming to us asking about specific proprietary 101 deal and gotten hospitals to do largely what we would like to see them do. Here we have gotten beyond merely the approval of a grant. We have told them to add outpatient departments, hew services. We have attempted in many ways to get them to do substantially more than they intended to do originally, and I think they have been very successful here. DR. ROREM: I would like to ask a question. You said originally that no approval or disapproval was expressed unless requested by the institution. Is ‘that still the case? MR. PETERS: Yes, with the exception now that Dr. hospitals. DR. ROREM: Somebody asks you, though. MR. PETERS: And Blue Cross is coming to us, so somebody is asking us at the present time. DR. ROREM: You don't move in on the basis of sound public policy,you feel you ought to move in on a situation? MR. PETERS: I think in time, it is the intent we will move in. DR. ROREM: I have a reason for asking. I am import don't wait until they ask you. Tell them first. As the day goes on, I want to hear more about that. MR. PETERS: Actually, if you look at the new structure of the Council, what it stands for, there is no question about it. It was the intent that we move in before we are asked. ined 10 il 12 13 14 15 r 17 18 19 20 21 22 23 24 25 ACE-FEDERAL REPORTERS, INC, 261 CONSTITUTION AVE _N.W. Washington, 0. C. 25 or 30 in the past four years. We do about.seven a year. 102 DR. HALDEMAN: Staffwise, you really wouldn't be able to. MR. PETERS: Right now, we have got a small staff. We have got a backlog of requests. We have so much work to do just to keep abreast of all the official requests. We have got half a dozen we are working on right now , and our staff has not grown since the Council has expanded. DR. KLICKA: How many studies have you done of this type in the last three or four years? MR. PETERS: Last three or four years? I guess abou wT DR. ROREM: Special studies, specific institutions. MR. PETERS: And also special studies of specific problems or community problems. For example, we are still studying the hospital needg of a certain area. It is the converse a of going at it because a local group says, "Study the area." And we Look and evaluate the area needs and the hospital's role in meeting these, and we do special problems, particularly voluntary relationship, which is a very complicated one in New York. Several years ago, we studied problems of providing ambulance service to New York City residents. Things like that We get involved in all types of Studies, but as I said, the bulk of them are studying an individual hospital's program for the future, whether they should affiliate, close, merge, FR 10 il 12 13 14 15 16 17 18 19 20 2i 22 23 24 25 ACE-FEDERAL REPORTERS, INC. 261 CONSTITUTION AVE .N.W. WASHINGTON, 0,6. 103 expand, relocate. We have relocated several hospitals in New York. There are two that were relocated very successfully, both of which have expanded upon relocation -- Misericordia Hospital and Booth Memorial in Queens. Here, we took existing hospita tk in Manhattan, which is substantially overbedded, and told them the plants were inadequate, not to build where they were, go somewhere else where they are needed more. We did this on two occasions in recent years so successfully these hospitals were expanded, but they were too small when they moved. We have kept one hospital from moving away from a deteriorated neighborhood, and this, I think, has been one of our greatest successes. Here is an area that went bad. Here was a hospital that was doing a service. They wanted to go out to the suburbs where the nice people are, and we said, "No, stay where you are because this is an area of great need, impoverished." DR. ROREM: In Manhattan? MR. PETERS: In Brooklyn. We have areas of Brooklyn that are just as bad as some of the areas of Manhattan. DR. HALDEMAN; You have had several instances where hospitals have consolidated, haven't you, two or three hospitals together to build a new hospital? MR. PETERS: We have one recently, Prospect Heights, which was a hospital in Brooklyn, a bad plant, one of the 10 il 12 13 FR 14 15 16 17 18 1g 20 ai 22 23 24 25 ACE-FEDERAL REPORTERS, INC. 261 CONSTITUTION AVE . NW. WASHINGTON. O C. 104 kind of hospitals that was mentioned give us concern about the quality of care rendered. The hospital was old, almost 100 years old. We got them to close and merge with another hospital. The other hospital is still operating as a satellite, but in time they will close the building. The building is no good. . We have done this on other occasions. Ann is working on one right now which gives every hope of maybe three hospitals merging. MRS. COLEMAN: Three hospitals and an old-age. MR. PETERS: A related facility. We have done this thing that Dr. Rorem mentioned, instead of replacing a municipal hospital on its present site which has problems in staffing, problems in getting doctors, good doctors to give sufficient amount of time because they can't bring their patients there anyway, we have got these inferior plants to get these hospitals rebuilt on the grounds of voluntary hospitals or else to get voluntary hospitals to aid these institutions in staffing. And we have been very successful in that. We have one hospital in the Bronx that is going to move with a great voluntary hospital, and we set the pattern. I think this is one of the best contributions we have made so far as relations between the two types of hospitals are concerned in the past years. I think probably Hay Nickelson's greatest 105 1 contribution to the Council was in getting this concept across}. 2 It was essentially his concept. 3 DR. HALDEMAN; To get back to implementation, what 4 about the Blue Cross, the 5 per cent fund, the Blue Cross 5 || collection? 8 MR, PETERS: We have done nothing on that. 7 DR. ROREM: What is that? 8 MR. PETERS: In the recent Blue Cross formula, the g | hospitals can put away 5 per cent, but this cannot be expended io || without approval. It can only be expended for replacement or 11 || expansion. It cannot be used to underwrite deficits. And 12 || this is, as you can well imagine in a city which has so much 13 || Money expended for medical care as New York City or the 17 FR 14 | Counties of the New York area which Blue Cross is responsible is || for, a tremendous amount of money. It has been going on now 1g | for about two years accumulating. And within a few years, you 17 || 4re going to be talking about millions and millions of dollars} 18 DR. ROREM: Is this 5 per cent paid over to the 19 || hospital or given -- 20 MR. PETERS: Given to the hospital, but they have a1 | t0 set it aside. They have to fund it or they may. 22 MR. PETERS: They ‘have to. 23 DR. HALDEMAN: And isn't it also true the purposes o4, || for which it can be funded have got to meet approval of Blue 95 || Cross? ACE-FEDERAL REPORTERS, INC. 261 CONSTITUTION AVE .N.W. WASHINGTON O GC. A aia SSSA SS aaah amma mummies aaaacaaaASAa aaa mma racmmmmma Oni mmm asaanasaaaaaaaataamaas ts sssaaaaec racemes scmmmmmmmasmsmmmmastasamaats 10 11 12 13 14 15 16 17 18 19 20 2i 22 23 24 25 ACE-FEDERAL REPORTERS, INC. 61 CONSTITUTION AVE, NW, WAasHineron, D.C. ccs isc sé casa. aaa aatacesasaaaaaaasamaamaaaaaaaamasmmammmmaassesmsmasaaaaaa test taaeasamamaasaaaaaaaamamamasaaaassaamaaaaaamaasasscaasaatataenastasacammasmamassmmaaamaamaamsamasamasammammmmmamaaa 106 MR, PETERS: Blue Cross, DR. KLICKA: Blue Cross or the Council? Please repeat. Blue Cross, not the Council yet. DR. HALDEMAN: The feeling, as I understand it, is they may ask the Council's advice, but I think there is a legal question which Jim might raise later on as to whether they could turn over the responsibility to the Council. I think there is a question whether that would be legal. MR. PETERS: One of the problems they face is the fact how much autonomy these other agencies can give up. Blue Cross can ask our opinion. DR. ROREM: Is this actually a 5 per cent plus over and above depreciation allowance? MR. PETERS: No, this is the equivalent. DR. HALDEMAN: Jim, would you want to touch on this? MR. ENSIGN: I want to say Doug Coleman's concern has been all along with some parallel action on the Blue Cross Board, advice given it by the planning agency. And the opinion that has been given them by the legal counsel is if they merely accept as their ruling the opinion of the planning agencies, they might be in trouble with restraint of trade or collusion. And so, therefore, I guess the approach is they ask the advice and then act upon that advice. MR. PETERS: Trussel faces the same problem as Commissioner of Hospitals, precisely the same problem. FR 10 il 12 13 14 15 16 17 18 19 20 al 22 23 24 25 ACE-FEDERAL REPORTERS, INC. 261 CONSTITUTION AVE., N.W. WASHINGTON, 0. C, “menting devices that there are available to the Council or in ‘United Hospital Fund at the present time doesn't get involved 107 MR. BUGBEE: And the welfare,too. MR. PETERS: Welfare does, too. MR. ENSIGN: And I think in Michigan, Jack can probably comment on this, Blue Cross gets advice from the Detroit area Hospital Council or Hill-Burton authority, other State areas, and acts accordingly and may use other evidence that they gather themselves to reach the decision they finally reach. But usually, it is in line with recommendations of the planning unit. DR. HALDEMAN: Are those pretty well all the imp le- New York? MR. PETERS: Of course, there is also the fact that groups like United Hospital Fund and so forth can use certain sanctions, depending, to implement our recommendations, but in construction, merely giving contributions for free care. But if United Hospital Fund gets involved ina capital fund drive, which they have been seriously considering for years and which officially they are going to probably get involved in next year, it is their intent that in distributing the monies raised, they will turn to the Council again as Doug Coleman turned to us for advice, Whether they will take our recommendations 100 per cent is the same problem that was raised before, but they will 10 li 12 13 FR rv 15 16 17 18 19 20 21 22 23 24 25 ACE-FEDERAL REPORTERS, INC. 261 CONSTITUTION AVE... N.W, Wasningran, 2. ¢. “allowances might very well be made in a central fund to be 108 turn to us because we have the mechanism to determine need, and they haven't got it. They have got the money. They have got to give it vut according to some rational basis. They will turn to us, seeing they will support us anyway to the tune of $80,000 a year, turn to us for advice on how to distribute this money. They are talking about tremendous sums of money. DR. ROREM: I would like to ask just so I get it straight, I have suggested from time to time on my own as I am concerned with a broad problem that Blue Cross depreciation used for general hospital construction as an institution need may appear instead of paid out to the individual hospital. Has that been picked up and laid down or not picked up? MR. ENSIGN; There has been a lot of discussion on it MR, PETERS: I can say you wouldn't be elected man of the year by the voluntary hospital boards. MR. ENSIGN: We discussed this and did some legal research on the question, and it was found you run into some problems like with withholding money ostensibly which belonged to and was the right of the hospital to receive as a proper reimbursement, diverting it into a central pool. I don't know that it has ever been tested. 1 don't think it has. It is something people talk about, but they are all afraid of. 109 1 DR. ROREM: There are things, too, whether or not a 2 || big responsible agency like that does not have an obligation 3 | to see that the total properties are kept in balance rather 4 || than the individual's. | 5, DR. HALDEMAN: How about priority and principles? g | What have you other than these basic principles? 7 MR. PETERS: We haven't enunciated anything in writing, g || but we operate pretty much with priorities, and the Board g || Operates. 10 Obviously, we are always interested, for example, 11 || in replacing unsafe facilities. This is one of the priorities 12 || Which has been given. We have always given a great deal of 13 || emphasis to this both in administration of our Hill-Burton FR 14 | Program locally and in our studies. We have always given a 15 | Sreat deal of stress to hospitals which exercise a great ig | influence on the region. WV For example, the great university teaching institutions. ig | We try to strengthen them as much as possible because when you ig | build up a Columbia-Presbyterian or New York-Cornell Medical 20 || Center, you are not talking about a hospital now which is 21 || Servicing a local community. You are talking about a hospital 22 || Which services the entire region, both in terms of patient 93 || Care insofar as many of the very difficult cases are sent thera. a4 || tt 1s leadership in terms. of medical education and research, a5 || And these institutions, there is no question you get a great ACE-FEDERAL REPORTERS, INC. 261 CONSTITUTION AVE., NW. WASHINGTON, D.C, 10 11 12 13 14 15 16 17 18 19 20 al 22 23 24 25 ACE-FEDERAL REPORTERS, INC. 61 Constitut WasHinato ON AVE , NW. N. 0.6, 110 deal of support from the Council. In other words, what we are trying to do if we could do it, we would like to build up the strong and starve out the weak because it is awfully difficult, we find in the past, to try to build up the weak, particularly if they are occupying some poor plants. . MR. COUSIN: Mr. Chairman, I would like to ask a question. We, I think, tend to have a little bit of that philosophy except that you can then be accused, you know, of backscratching, and we are occasionally. What do you do when you have a suburb where they have all the dough in the world and they have an awful lot of the good medical staff that are in these so-called great institutions. And you know darn well that this new hospital is starting out, it may be 200 or 300 beds, but that eventually, in the future, it probably, teo, will become a great institution. Now, do you encourage it to g° up to 400, 500, 600, 700? There is need out there. Or when a great institution in downtown New York where there is a surplus of beds wants to go from 1,000 beds to 1,300, you just give them your papal blessing because they are so-called great hospitals? You tell them, 0.K., automatically, go an extra 300 beds where actually those 300 beds you could put up a good argument they should be in Bronxville or Queens or some other place? DR. HALDEMAN: In other words, you are entering another 10 il 12 13 14 15 16 17 18 19 20 ai 22 23 24 25 ACE-FEDERAL REPORTERS, INC. 261 CONSTITUTION AVE.,N W. WASHINGTON. O C there are decisions you have to make. 111 dimension, the suburban and central city. MR. PETERS: I have been talking primarily in terms of what I know about the most, New York City. Getting into the suburban area, you have an entirely different problem, no question about it. You certainly don't expect them to come from Poughkeepsie to go to downtown Manhattan togt their medical care. You have to provide a lot locally and no questions about it. You are going to have to strengthen the suburban hospitals the best you can. But when you come to the other problem you mentioned], MR.. COUSIN: The decision we have in our area, Ford Hospital came to us and wanted to put up 300 or 400 beds. We have to admit it is a great hospital, but on the other hand, it is in an area where we have got -- I can't remember offhand -- 2,00 or 3,000 surplus beds. MR. PETERS: I would tell them not to do it, then, if you can get away with it. DR. KLICKA: If we can ask Mr. Peters to summarize the points of strength of implementation and the points of frustration, areas that he wished they had greater support thai ea frustration, see if he can put them into a concrete ball of wax for us here, MR. PETERS: I would say one of the things we wish we knew about the most is we could know the plans earlier, FR 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 ACE-FEDERAL REPORTERS, INC. 61 CONSTITUTION AVE., N.W. WasHingron, OC, ‘But if we could get a mechanism where we could get that for al 112 the plans of all the hospitals, what they intend to do, because I think this is one of the things we are weakest on. We don't find out about things until it is too late to do any- thing about them. And if we could have a mechanism whereby we would be assured that -- I am not talking about after the plans have been approved by the Board; I am talking about when the first seed comes in somebody's mind -- we would like to do something that we would know about it and we would be able to give our reaction to it. I said, "our reaction", either our approval, disapproval, caution, or whatever we want to'do. the hospitals, I think we would be a great step forward. It wouldn't solve all our problems by any means, but it would certainly be a great deal better than what we are doing now because now we find it is half done sometimes. MR. SIBLEY: You must have that for a very high per- centage of your hospitals already, don't you? MR. PETERS: Yes, but we don't have all of them. MR. SIBLEY: What you mean is you don't have every one. You have a lot. You sounded as if you didn't know. MR. PETERS: We don't have them for all of them. MR, SIBLEY: You have got to find ways of cultivating the hospitals that so far haven't cooperated. MR. PETERS: I am talking about at the present time we get a great deal of it through our inventory. Once a year 113 1 | we take an inventory of all hospitals, and we ask them, "What 2 || are you planning to do?" A great deal of the information we 3 || get has already been approved by their Board. They have 4 || hired an architect or they have got a consultant working. 5 | We would like to get down even before that. 6 MR. SIBLEY: I agree, but once a hospital sets up 7 || 4 master plan for itself, you are pretty much aware of what 8 || direction it is going. g MR. PETERS: Yes, but it maybe would not be what 10 || we would like to see them do. | MR, SIBLEY: You do on a master plan. 12 MRS. COLEMAN: We don't get that. 13 MR. SIBLEY: I realize this is one of the techniques FR 14) we are talking about, certainly. One Hill-Burton agency I 15 | know of will not consider a hospital proposal until they have 16 | seen the master plan of that hospital. 17 MR. PETERS: There are darn few hospitals in New ig || York that have master plans in that sense. 19 MR. SIBLEY: This is long-range. 20 MR, PETERS: Very few of them do have. 21 MRS. COLEMAN; When they apply for Hill-Burton, that's 22 || narrow. 23 MR. PETERS: It is much more the immediate program. 24 MR, BUGBEE: I think there is one point to be made 25 here ’ though, about reviewing. And I think Rufus is beginning ACE-FEDERAL REPORTERS, INC. 261 CONSTITUTION AVE .N.W. WASHINGTON. D.C. Sic tae amaaaaaaaaaaamataaaaaaaaaaaeaaa daca tai amma taeda naman FR 10 11 12 i3 14 15 16 17 18 19 20 21 22 23 24 25 ACE-FEDERAL REPORTERS, INC. 6 1 CONSTITUTION AVE .N.W. WASHINGTON. OL C, 114 to get individual plans. The New York area exaggerates it, but everyone of them, you can't just read a plan and say yes or no and add any depth to it. If you are going to go out and really look into it, you are talking about a lot of staff time as well as a good deal of wisdom. | So if they all came at you, I don't know what you would do because you can't hardly cope with those that do come to you as a staffing job. MR. PETERS: Certainly, if they gave me all the plans tomorrow, we would probably put them all in the file cas¢ Ww ‘because we don't have the staff to analyze through and pick up as we need it. But as we grow and develop, I would hope we could get this type, being advised as early as possible as to the planning of each individual hospital. DR, ROREM: I would like to make one observation there. I wouldn't think you would have to be completely frustrated if you got a flock of plans. Just an arithemtic. alignment of what they added up to would probably show you it was impossible and just to let the other hospitals know that the one up the street is planning the same thing you are has a tremendous chilling effect. The very first thing we did when we got in Pittsburgh we did this. We asked for the plans, It added up to a tremendous amount of money, in this case, a small area, $90 million and 2,000 additional beds. We just added them up. We didn't 10 ll 12 13 FR 14 15 16 17 18 19 20 al 22 23 24 29 ACE-FEDERAL REPORTERS, INC, 261 CONSTITUTION AVE ,N.W. WASHINGTON, D.C, 115 evaluate them at all. And we reported them to the group, this advisory committee as a whole. You would have thought, goody, goody, think of all that money. They said, "My god, we will all go broke togethen. That was the reaction. | MR. BUGBEE: It sounds like to you are answering’ "I am not right in this." You may be able to make such an answer, but when you come to work with them as alternatives, then you are just not talking about an office procedure by a long shot. MR. COUSIN: Another problem you get into, because we did this very samé thing. We did just add them all up, and we came out with a $125 million. What did this do? This had a chilling effect on the voluntary, the truly voluntary System, particularly the corporate givers. But it had a blow- torch effect on the hospitals that didn't intend to ever hit the corporate givers anyhow. We didn't do this, but what happened was that the better hospitals had to suffer about a six-year moratorium before they could get any money while the Hospital Council studied the situation. But approximate ly an equal amount of unsatisfactory beds of a quasi-proprietary nature were built. MR. BUGBEE: What conclusion do you draw from that, Jack? What do you mean? Yatwould be opposed to announcing the $125 million until you had your study or -- " 116 1 MR. COUSIN: No. I think we finally resolved the 2 || situation, but it was after the horse was stolen. And that is| 3 | we got the Blue Cross eventually put through its standards 4 || that they wouldn't take anybody on as a participating hospital 5 || until they had been approved. So now, if we were to announce g | $125 million worth of construction, any of these Per who do 7 || not intend to hit the community for philanthropic funds or even g || hit Hill-Burton, they would still be faced with the fact that g | if they built their hospital, they would eventually have to 10 || go to Blue Cross for participation and Blue Cross would turn 11 | to us, and we would say we never heard of this hospital. 12 DR. HALDEMAN: What type of hospital? 13 DR. KLICKA: I would answer that more specifically FR 14 | because we have the data, and we wouldn't publish it for this 15 | Yeason. The very worst thing that we have in Chicago is the 16 State survey and planning as an example of this because we 17 || think it exaggerates the need for beds in our whole metropolitan ig || @rea. And the people who shouldn't be building beds are ig || continually pointing to this State survey and plan as their 20 || Justification for doing it. 21 MR. PETERS: I can tell the New York City experience g2 || With the same thing. They had a meeting just the other day on 93 || this very subject. 9A | MRS. COLEMAN: The problem is we have a high figure 2 | on bed requirement on the State plan, and we know it is high. ACE-FEDERAL REPORTERS, INC. 261 CONSTITUTION AVE .N.W. Wacuivaton DC t 117 1 || I am quite sure that if our beds were properly distributed, 2 || we could lower the bed requirement figure by as much as perhaps 3 || 4,000 beds. But the point is we do not operate under these 4 circumstances. | 5 We have too many maternity beds. We have too many 6 | specialized beds in specialized hospitals. We have too many 7 || beds in small hospitals. And under these circumstances, we g || do need approximately what is called for in the State plan. 9 Doug Coleman raised the point that the people are 19 | Quoting this figure to him, this bed requirement figure. So 11 || we sort of compromised on disclaiming the figure by a footnotel, 12 || Actually, it shouldn't be used as a planning figure. It is 13 | what we need now. oJ FR 14 MR. BUGBEE: Are these Hill-Burton figures, the beds 15 || per thousand ratio without adjustment for use, or what are they? 16 DR. HALDEMAN: No, even with adjustment -- 7 — MR. BUGBEE: Still high. 18 DR, HALDEMAN: -- they are still high. 19 I don't think the purpose of this meeting is to go 20 || into Hill-Burton planning, but we are working very hard, as you 21 || know, George, revising our procedures and policies. We want 22 || CO get away completely from ratios. We want bed need determined 23 || On the basis of projected population, taking into consideration a4 || Utilization by major service. 25 The main problem is the small one, even in New York ACE-FEDERAL REPORTERS, INC, 261 CONSTITUTION AVE., N.W. WachHInGray DC 118 1 || City, lack of manpower. The tendency on the part of Hill- 2 | Burton agencies is to go in and study areas that they know 3 | they are going to have to project in the next two or three 4 || years, and they are kind of treading water with this thing. 5 As a result, here in Washington, D. C., for example, g | Hill-Burton plans for Maryland and Virginia greatly overstate 7 || the need in the suburban areas which are growing rapidly g || and can take additional beds. But at the same time, you can g | go to the plan, and it is very unrealistic planning. 10 Getting this thing over onto a more realistic basis 1 || is a more complicated thing than we had originally anticipated| 12 || We have had a committee meeting almost monthly now for about 13 || @ year and a half particularly considering such things as, FR 14 | first, what is the definition of a bed capacity because Hill- 15 || Burton agencies have agreed to develop a uniform bed capacity ig || $9 One State's plan can be realistic in terms of another State!s i7 || Plan. 18 oo For instance, if you just change a minor definition 1g || ON State plan, you may overnight change the bed need factor by 99 || Several thousand beds. | 2 Secondly, the definition of suitable or unsuitable 92 || has varied all over the place. California until this year a hasn't admitted there is an unsuitable bed in the State from g4 || the standpoint of fire safety. If they license it, it is suitapie. 45 Whereas in New England, about 20 per cent of the beds in the ACE-FEDERAL REPORTERS, INC, 261 CONSTITUTION AVE ._N.W. WASHINGTON O,C, af EEE EE EEE ee 119 1 || State agencies are declared unsuitable. And this is an 2 || extremely complicated subject which we are moving on as 3 || rapidly as we can, but which with the present state Hill-Burtoh 4 || agencies staffs is going to take time to develop in each 5 || community because there is no substitute for detailed study 6 || o£ the individual community. . 7 Now, our hope is that the areawide planning agencies| g || are springing up all over the country literally. Today, we g || invited purposely representatives from areawide planning 10 || @gencies that have been in existence and had some experience, 11 || but we have got, as you know, a large number of agencies that 12 | are coming into being. 13 DR. ROREM: Did you count the list that Hi sent us, FR 14 || 21 full-time and 19 part-time? 15 DR. HALDEMAN; What will happen five or ten years ig || from now, I think will be much different, and I think in most 17 || imstances, the State Hill-Burton agency will utilize the plans ig || 48 developed within a State. 19 I think the State agency is faced with deve loping 20 || 4reawide planning agencies that will approach a problem somewhat 21 || consistently. 22 You take Ohio, Columbus, Cleveland, Akron, Cincinnati, 23 || all use different definitions of what is beds or different o4 || Principles in evaluating projects, not that every community hag 25 || to do the same. ACE-FEDERAL REPORTERS, INC. 26 1 CONSTITUTION AVE., N.W. WAsHIANGTON O ¢ 120 1 And I think what has been said today illustrates 2 the fact your approach in areawide planning has got to be 3 | different according to the characteristics of your community. 4 | But there are certain overall principles, at least. These 5 | certainly are going to be tremendous when they start handing 6 || out the money for a modernization program because Cincinnati 7 | might get twice as much per capita merely on the basis of your g || criteria for evaluating obsolescence being different in one g || community than in another. But this is a hard pull. 10 Now, we have not given any demonstration grants in i || areawide planning where there hasn't been a cooperative 12 || 4¥rangement worked out between the State Hill-Burton agency 13 || and the local areawide planning group. I don't think they can FR 14 | Completely give up their responsibility, the State can't, but 15 | I think in almost all instances, they will take the recommendat 7 tion of the local areawide planning agencies. 17 MR, DRENNAN: This past year, we worked very closely ig || with the boys in that. The weekly utilization, we turned up 1g | Occupancy rates and utilization they used in formulating the 20 || @reawide State planning as far as our particular area was gq] || concerned. 22 MR. BUGBEE: Did it change the bed requirement? 23 MR. DRENNAN; Slightly. It reduced it because we o4 || Learned a lot about occupancy rates of small hospitals and so a5 ||forth during the past year. ACE-FEDERAL REPORTERS, INC, 261 CONSTITUTION AVE |. NW. WASHINGTON, 0. C. 10 ll 12 13 14 i) 18 17 18 19 20 al 22 23 24 25 ACE-FEDERAL REPORTERS, INC. 261 CONSTITUTION AVE .N.W. WASHINGTON, O. 6 121 DR. HALDEMAN: I think we have got a lot more to learn about what constitutes bed need. We have had two national conferences on this subject which at least from ay point of view -~ I don't know how you felt -- it showed up the problem areas more than any solution because I can't for the life of me understand why Indiana should only have 2.7 beds per thousand and Missouri have 4.5 beds per thousand. There is the same disparity between Idaho and Montana, for instance. And it isn't all in connection with the way they de mine what is a hospital bed. There are some factors we simply don't know about. That's why I feel so strongly that bed need should be determined based on a local study, using utilization, but using judgment factors that can't be derived from figures. Because if you get a new highway going out in an area, it is going to have an impact, ox, you know, a big industry is coming in. Those things aren't derived from statistics. In the last analysis, bed need, I think, in the light of our present knowledge has to be the analysis of available data plus pooled professional judgment. I think perhaps we should break for lunch. Let's try to be back at quarter of two. (Whereupon, at 12:40 o'clock p.m., the meeting recessed, to reconvene at 1:45 p.m. the same day.) cer- SHORT HEW July 8 fls Ace SR 10 ll 12 13 14 15 16 17 18 19 20 al 22 23 24 25 ACE-FEDERAL REPORTERS, INC. 261 CONSTITUTION AVE., N.W. Waseinaran, 2. o. 122 AFTERNOON SESSION 1:45 p.m. DR. HALDEMAN: The meeting will convene again. Are there any further questions any of you want to ask Joe Peters about the New York program? Anything further, Joe, that you or Ann would like to add? ‘ If not, I think we ought to go on to Sue Jenkins and see still another distinct variety of planning activity. MISS JENKINS: I will try to make this brief because we are dealing with a much smaller area and problems that look big to us, but I can see them shrinking in size. This is a consoling thought. I will briefly describe the characteristics of the area, the hospital and nursing home situation of the planning agency, the methods of implementation, and share with you some of my apprehensions about some of the points of establishing priorities and in the possible light of coming Federal funds for modernization I should like to share them with you, too, if I may. Our area is one of 1,200,000 people involving five counties in two states; three counties in Missouri, two coun- ties in Kansas. In that area there are twenty-two hospitals if we include our Veterans Administration Hospital and our United States Air Force Base Hospital which are not involved 123 2 1 || in planning except the USAF hospital was and wanted to add 2 i twenty OB beds and we stymied it through contacts of the 3 | Bureau of the Budget in Washington, they did not think they 4 had the OB beds. Ur et 5 These twenty hospitals range in size from the smalles 6 | of forty-five beds to the largest of 500 beds. There is one 7 | medical school hospital there at the present time, the tniver- 8 | sity of Kansas, which draws its patient load from all over thé 9 State of Kansas as well as the metropolitan area and Missouri. 10 A new and illuminating factor which Dr. Haldeman is ll very familiar with and has served as consultant to is our 12 | municipal hospital system which has gone under a private volun 13 tary board operated under contractural relationship with the SR 14 | city which now is affiliated with the University of Missouri 15 | School of Medicine presently located in Columbia but extending 16 || post graduate work and looking ultimately, Jack, in the last 17 || few weeks even towards the faster coordination of a medical 18 school in Kansas City. . 19 We have no proprietary hospitals with the exception . 20 of one little twenty bed osteopathic proprietary hospital. We 21 | have succeeded in killing three proprietary projects. We do 22 || not anticipate that we will always have such a good batting 23 || average. 24 DR. HALDEMAN: How did you kill them? 25 |) MISS JENKINS: Two of them through the planning ACE-FEDERAL REPORTERS, INC. 261 CONSTITUTION AVE ,N.W. Wasninagron, D. &. 124 3 1 |agency. One of them in the suburban areas simply by communica- 2 tions with and about a twenty-page report to a couple of the 3 | medical leaders simply scared the pants off of them about the 4 | possibility of their ever being able to operate at a financial 5 || level that would permit it to pay itself out. The other two 6 | through simply conferences with the planning group which we 7 || were able to persuade them not to go ahead'with it. We do have 8 | the two Federal hospitals, the USAF Base and of course the 9 | Veterans Administration hospital. 10 This five county area contains the four city and all 1l | suburban areas. The suburbs do not yet go beyond the periphery 12 | of the five counties. We do have a very close relationship 13 | with the two state Hill-Burton agencies; an excellent one with SR 14 || Kansas, not too good with Missouri, but at least a working 15 | relationship. We have been dealing very heavily in the past 16 | six months in the nursing home picture where we are ceding, as 17 || most urban areas are, a tremendous surge of the building of 18 || the proprietary nursing home, many of them with_FHA secured 19 | loans or reaching through the Small Business Administration, 20 | some with private financing. 21 The planning agency itself was established by the 22 || hospital organization. 23 DR. KLICKA: You do not get into the control of that 24 |} at all? 25 MISS JENKINS: The what? ACE-FEDERAL REPORTERS, (NC, 261 CONSTITUTION AVE.. NW. Wasnincrow, O. Cc. ean rare aaa eee ACE-FEDERAL REPORTERS, INC. 10 11 12 18 14 15 16 17 18 19 20 21 22 23 24 25 261 CONSTITUTION AVE., N.W. Waswineron, D. fC. 125 DR. KLICKA: The nursing home field, MISS JENKINS: Yes, indeed. We are working almost exclusively. DR. KLICKA: You have approved them? MISS JENKINS: In Kansas we have a relationship with the State of Kansas that they will not approve any.-nursing home project in the two county urban area on the. Kansas side that does not have our approval first. DR. HALDEMAN: What is that? MISS JENKINS: They try to make it for licensing. If private finance comes in and wants to build in that area, they check first with the Kansas State Board of Health, their Facilities Division, for what they will require for life insurance and so on. They are referred to us before the Kansas agency will even talk with them practically. Whether we could stop them has not come to a test yet of those that are totally privately financed so we have not had any built yet. - For FHA they have to have our approval on the Missouri side. We could not get the state to say they would not issue a certificate of need unless a need could be demon- strated, They blanket issue a certificate of need in Missouri Simply, if their quota says there is a need, they issue it. We got around this by establishing really a very fine working relationship with the FHA people who have decided that they 10 1] 12 13 14 SR 15 16 17 18 19 20 ' 2) 22 23 24 25 ACE-FEDERAL REPORTERS, INC. 261 CONSTITUTION AVE.,N W WesHinaron OC 126 will not talk with them until they have come and talked with us and had a report on it. MR. BUGBEE: Have you said no to anybody? MISS JENKINS: Yes, to I expect a half dozen. MR. BUGBEE: Not on need but on sponsorship? urIss JENKINS: Actually we are right up at what we may consider the top area of need insomuch‘as the market demand indicates this because most of these big promoters are coming in with a high priced home up in the four, five, six hundred dollars a month bracket. We have a report we will be sending to you hopefully within the next week to ten days of a research study in which we cooperated with community studies on the market demand for nursing homes which gives a pretty fair picture of the existing licensed homes, all of those that are projected and those that are in the process of construction and those that are in the dreaming stage and have just barely contacted us about them. We have gone into, I think, a pretty fair analysis of demographic data, income brackets, those on old age assis— tance, what the Blue Cross plan does, what the insurance pro- grams do and so on. We have been dealing then with a planning agency that is involved in facilities and services in the hospital and nursing home area. We have not gone beyond that, The planning agency itself, the planning committee, the basic committee, is a fifteen man committee which has beer SR 10 11 12 13 14 15 16 17 18 i9 20 al 22 23 24 25 ACE-FEDERAL REPORTERS, INC. 2613 CONSTITUTION AVE .N W, WasHincron, 0, C. 127 functioning since 1957. It is required that a majority, actually I think nine of the fifteen, are now totally non- hospital related individuals. We are most inadequately staffed. The staffing is a little different than it looks on paper in that we do have a very able and very highly recognized non-profit research organization in the area of community studies incorporated with whom we collabordte in research and who produce some research for us. We also have a relationship with the Blue Cross plan which provides us mimeograph, address, ograph, photocopying, handling of all mail and all this type of thing which we do not have to staff for. Blue Cross does all of our IBM work, all of our statistical work. We do have a continuous reporting program which is now in its seventh year, and this is all on IBM and is maintained for us by Blue Cross, The planning committee functions in a relationship to the hospital organization in, I think, a very comparable way with Jacques Cousins in Detroit. He has complete economy; it is not controlled by vested interests, it is not a corpor- ate structure, it shares staff and it is inadequately staffed. MR. BUGBEE: You are going too fast. I thought ther was one structure that did both. MISS JENKINS: Yes. MR, BUGBEE: You are doing both? MISS JENKINS: Yes. wo 128 7 ] MR. BUGBEE: I see. But in spite of that 50 per cent 2} Of yow board is public members rather than hospital members? 3 | MISS JENKINS: No, the planning committee must be 4 || maintained at over 50 per cent non—hospital related. 5 MR. BUGBEE: I see, 6 MISS JENKINS: The over-all board of directors of thy 7 | hospital organization is a public trustee medical staff and 8 | administrative, . g DR. HALDEMAN; Does your planning committee report 10 || directly to the public? ll MISS JENKINS: Directly to the public, never to the 12 || board. It makes no report to the board, it has no strings to 13 || the board at all. Its principal relationship to the board is SR 14} that the board has to see that it is provided with staffing. 15 || The board appoints the chairman, no others of the planning 16 agency. 17 MR. BUGBEE: Who does appoint him? 18 | MISS JENKINS: Actually, the nucleous of the planning 19 || committee was first named by the board. Beyond that it is a 20 | self~appointive body. 21 ' MRS, COLEMAN: Responsible to whom? 22 MISS JENKINS: Responsible to itself and the commun- 23 || ity I should say. It is no different than if it were separately 24 | incorporated actually in this respect. Represented on it are 25 | trustees and physicians but it is dominated by your industrial ACE-FEDERAL REPORTERS, INC. 261 CONSTITUTION AVE ONLW. WASHINGTON, 2. C. 129 8 ] and your civic representatives, 2 It was possible to get at least all of the major 3 hospitals to develop their long range planning committees, 4 | The first couple of years actually the function. of this 5 | planning committee was conferences, not only one but several, 6 || with each individual hospital regarding the development of the 7 || planning committee in an effort to determihe to the extent the 8 planning group could the desires and aspirations of this par— § | ticular hospital; the direction it hoped to go, the type of 10 || service in which it was interested, whether it was in expansion 11 of its teaching programs, development of research and the 12 || chronic long term care or what it might be, 13 We have certain peculiar problems, the osteopathic 14 | thing is one of them. Jack, I did not realize you have this 15 | to the extent you apparently have. We have in Kansas City one 16 || of the osteopathic colleges, of which I believe there are still 17 | five in the country, are there not? 18 DR. HALDEMAN: Michigan is trying to establish 19 || another one, 20 MISS JENKINS: Are they really? al MR. COUSINS: Yes. 22 MISS JENKINS: Where? 23 MR. COUSINS: in Michigan. 24 MISS JENKINS: Goodness, 25 DR. HALDEMAN: Of course it is quote possible that in Kansas City that this osteopathy school will become the ACE-FEDERAL REPORTERS, INC, 261 CONSTITUTION AVE., N.W. WasHinartan, 2. oC. a acc ccc sama tattle tata isaeia.dameaaama sass samme saa amass ta amma mmm ia a a asarene 10 ll 12 13 14 SR 15 16 17 18 19 20 al 22 23 24 25 ACE-FEDERAL REPORTERS, INC. 261 CONSTITUTION Ave, N.W, Wasninsran, D.C. medical school at the Kansas City Medical Center, MR. BUGBEE: Kansas City? DR. HALDEMAN: Yes. There is talk of it. MISS JENKINS: We have encouraged it. We have had the municipal system actually have four hospitals, now have three, They did have General No. 1 for white and General No. 2 for Negro. It has been integrated for several years now. MR, BUGBEE: Which state is that? MISS JENKINS: Missouri. Actually, we have in the area four major municipali- ties. There are some eighty lesser incorporated municipalities that make up the urban comples in this area, MR, BUGBEE: Does Kansas City, Kansas, have a munis cipal? MISS JENKINS: No, Kansas City, Kansas, has a long pad conditional relationship between the hospitals and the care pf the patients, also the University of Kansas City. The University of Kansas has done a great deal of this werk for the Kansas side. The Missouri side has had the General Hospital Which is now the General Hospital Medical Center. The osteopathic situation is one of the problems of Planning. We have fewer than one one bed fey osteopath and five or the MDts. There is no crossover at the present time except put in the region. Not within the planning area but within the region we have some of the small county hospitals with both the 10 ] 10 11 12 13 14 SR 15 16 17 18 19 20 21 22 23 24 25 ACE-FEDERAL REPORTERS, INC. 261 CONSTITUTION AVE., N.W. Wasninaron, BD. £. era ana a EL. accel cca 131 MD and osteopathic on the staff. As Dr. Haldeman mentioned there has been some talk, and we have been doing some talking, about the Kansas City College of Osteopathy and Surgery forming a nuclear of a new medical school. Whether this can come to fruition, Jack, within the time necessary is the factor there. There does not appear to be the major resistance of the organized medical profession against it that there was, say, even five years ago Another problem relates to three very small Negro hospitals in an area that has made very forward steps toward integration within the past ten years. Each of these Negro hospitals wants the community to build a new hospital, each three times the size that it presently has, when they are running two of the smallest ones, only about 40 per cent occupancy at the present time. This is a difficult one to deal with, not in size but in all of the sociological aspects of the thing. We are hopeful, Jack, that we can help resolve the Negro thing throug! the General Hospitals taking pay patients. Many of the Negro group that are in the largest of the small Negro hospitals, 100 bed, are very marginal cases, This hospital is operating at four dollars per day below its cost structure and its charge at the present time without any means of supporting it finan- cially except the Catholic Diocese. We are hopeful that the small segment of the Negroes who do not have a place to —_ 8 SR 10 1] 12 13 14 15 16 17 18 19 20 al 22 23 24 25 ACE-FEDERAL REPORTERS, INC, 261 CONSTITUTION AVE., N.W. WasHINGioN, 8. C. 132 practice may be accepted by the General and thereby manage to close. Somebody here commented how difficult it is to close a hospital that has ever had existence, If anybody knows any easy way to go about taking out an entity that is in miserable financial condition, that is carrying a far below optimum patient load and all and still take them out of existence, I don't know. . Of this group of hospitals there were only two specialty haspitals, one a children's hospital and the other a 75 bed psychiatric hospital. The children's hospital situa- tion has been reasonably resolved again through the really very good work of the planning agency in that it will affiliate: with the General as a part of this Missouri University complex now. DR. HALDEMAN: Not only affiliate, they are going to replace the two hospitals with a single physical structure, | MISS JENKINS: What are you referring to as the two hospitals? DR. HALDEMAN: The children's hospital and —~ MISS JENKINS: You mean Mercy? DR. HALDEMAN: Yes. MISS JENKINS: That will provide the facility. It will gaintain separate operation, however. DR, HALDEMAN; But there will not be a duplication 133 12 1 | of kitchen or X-ray laboratory or whatnot. At least, that is 2 ithe hope. I thought that was nailed down. 3 MISS JENKINS: I thought it was nailed down, too, 41 but it is not nailed down at all. They are even saying they 5 || are going to build their own labs, X-ray, kitchen and every- 6 | thing else, 7 DR. HALDEMAN: It is very interesting experience 8 | where we talk for a day and a half, a half dozen foreigners 9 | sitting down with the planning group and the board trustees of 10 | these two hospitals, and at the end of it I thought they had ll | agreed to build only one new structure and maintain the iden- 12 | tity of Children's Hospital. 18 MISS JENKINS: But to share, not to put in laundry, SR 14 | not to put in power plant. They are still abiding by these 15 | two. They are not abiding by the fact they are not going to 16 | have their own X-ray and their own laboratory and their own 17 || kitchen and all that, except a factor coming to light within 18 | the past two to three weeks may reinstate your hopeful prog- 139 | nostications on this. 20 This hospital first was talking about 200 beds and 21 the planning committee kept pushing them back and pushing them 22! back on it. They decided to build 115 beds. They have 103 23 | beds at the present time and the General Hospital and Medical 24 | Center has 40, They agreed upon 115 finally. It was not easy 25 | to get it to that but they came out that this 115 bed hospital ACE-FEDERAL REPORTERS, INC. 261 CONSTITUTION AVE., N.W. WasHingtTon, OC. 134 13 1 || was going to cost $5 million. They started on a fund drive 2 | for three and a quarter million dollars saying that the balance 3 | would come out of their endowments and what they could recover 4 || from some of their properties at the old site. The fund drive 5 | has been going on for many weeks now and instead of just pour- 6 ing money into it, Jack, as they felt the community would do, 7 || they have about $700,000 on the three and a quarter million. 8 i It is not likely, perhaps, that they may be able to Bo beyond § |} a million on the fund drive. 10 MR. BUGBEE: Did your agency endorse their fund ll | drive? 12 MISS JENKINS: Yes. Not for that amount of money, I 13 | am sorry. I should not have said that, George. They endorsed SR 14 | the project because they had over a period of three years a 15 | very strong hand in the location of this hospital, It had 16 | intended first in locating in a relationship with the University 17 | of Kansas Medical Center. We very strongly opposed this for 18 || some very good reasons, 19 Missouri will not pay any welfare payments outside 20 || the State of Missouri at all. They would have lost their 21 | whole welfare picture out of Missouri, they would have lost 22 much of their properties in Missouri. They have some very 23 fine acreage in Missouri but a good portion of this would have 24 reverted to the heirs who gave it to the hospital had they 25 moved the hospital outside the state. ACE-FEDERAL REPORTERS, INC. 261 CONSTITUTION AVE., N.W. WASHINGTON, 0. C. Aa ai aa a tain 10 11 12 13 14 SR 15 16 17 18 ig 20 al 22 23 24 25 ACE-FEDERAL REPORTERS, INC. 261 CONSTITUTION AVE., N.W. WASHINGTON, O.C. 135 MR, ROREM: Did you give the area and number of hospitals before I came in? MISS JENKINS: Our area is one of 1,200,000 people involving five counties in two states. In that area there are 22 hospitals representing approximately 5,000 beds. un. ROREM: Thank you. MISS JENKINS: The 22 hospitals include the United States Air Force Base hospital and the Veterans Administration hospital. MR. ROREM: Are they big? MISS JENKINS: The Veterans Administration hospital is a 500 bed hospital, it is a very little hospital, and the Air Force Base 50. MR. ROREM: How many? MISS JENKINS: Fifty, somewhere around there. It may even be fewer than that. All we know about them, as I mentioned, Rufus, they wanted to add 15 or 20 beds to the OB departments and all the OB departments on the south side of the city were running a low occupancy. We could not get any- where with them so we went to the Bureau of the Budget and the never got the appropriation for it. That was a sneaky thing to do and I do not know yet whether the USAF hospital knows we did it or not. All they know is that they did not get their money. It would have been rather pointless, really, because most of these people on the base live in the city anyway. 136 15 i DR. KLICKA: I take it you did not send it to the 2 hospital. 3 MISS JENKINS: We did not. The hospital is our ‘ member and one of our dues paying members and one of the most ° cooperative in the Hospital Association that we would hope to 6 have, We felt like heels about it. They were very fine to work with. We felt like heels about the little sneaky deal. 8 MR. BURLEIGH: Don't feel you have it licked yet. ° MISS JENKINS: This is so little I cannot imagine 0 Congress concerning itself with it, frankly. 0 The osteopathic problem and the Negro problem and 2 the problem of how you develop in harmony and in coordination 8 with a private voluntary hospital system a new medical center SR i“ and potentially a new medical school is a very difficult thing, 8 We have had very little cooperation and planning from the 6 University of Kansas Medical Center because it serves the 7 whole statewide area. We had our first request from them here ° within the last six months when they felt that the planning : committee could be of help to them. " The Shriners were going to build four burn centers 2 over the country, and one of them they were thinking about a building in Kansas City, Kansas. K. U. came right straight s to us to exert what pressures we could on getting this insti- “ tution in connection with theirs. It is a small number of * beds which would deal with out of area patients entirely. eget Aa a AAA Sa eases tataaaaaatas tases aaa aman a a a ra 137 16 1 i The planning agency approved it and K. U. thought it was 2 | wonderful. The next time they want something they may be back, 3 1 I don't know. 4 With the General Hospital and Medical Center their 5 || cooperation with planning has been excellent and I think it 6 | will continue to be so. It represents problems which frankly: 7 | we do not know how to cope with and which the private voluntary 8 | hospitals of the area are extremely apprehensive about, Jack, 8 | as you could well imagine, in the taking of pay patients, part 10 || pay patients and so on in this big facility. ll MR. BUGBEE: Is your area over—bedded? 12 MISS JENKINS: It is over-bedded on general beds. 13 We have never had a problem with Hill-Burton regarding general SR 14 || beds because we have not had a priority for a general bed in 15 || the area since 1949 except that we did work with the two state’ 16 Hill-Burton agencies in the redistricting where Missouri had 17 | a base area line that cut right through the corporate munici- 18 pality-of Kansas City, Missouri, and in the Kansas side the 18 || the two counties of Johnson and Wyandotte. Johnson County, 20 | the suburban county, where the population shoves right up 21 against the line, that was a base area line and we got them 22 || to revise their base areas to include the five county, two 23 state area as a single area for planning. That was good 24 | cooperation. 2s Jack, didn't you sit with the planning committee ACE-FEDERAL REPORTERS, INC. 261 CONSTITUTION AVE ,N.W. WASHINGTON, O. C, aa A eam racemase ta aacammmmmacumacaeasasstaae sams aise 10 ll 12 13 14 SR 15 16 y 18 19 20 2l 22 23 24 25 ACE-FEDERAL REPORTERS, INC. 261 CONSTITUTION AVE.. NW. WASHINGTON. 0. C. 138 when they heard Shawnee Mission of the suburban area in Johnson County that already had a Hill-Burton grant approved and they went ahead and built a 65 bed hospital in the suburbay area to which we were Opposed not only in conference but pub- licly and through public disclosure they built it anyway? It is interesting to note it will probably be the best example of what not to do in suburban areas that we have. They built a 65 bed hospital and a nursing home. They cannot get the occupancy of 80 per cent of the nursing home. The occupancy of the 65 bed hospital has been running 40 to 50 per cent. Their financial problem is simply incred- ible. They have been open a year and they have not even paid for the roof that went on the nursing home which was the first unit that was built three years ago. They are operating at $43 a day on the short-term hospital where the hospitals with a full array of service are $35 to $36 a day. THeyare going to add 75 to 150 more beds, they say, if they could get anybody to finance them. I would say their costs would-shoot to at least $50 a day on the thing. MR. BUGBEE: How did they get the Hill~Burton grant? MISS JENKINS: They got the Hill-Burton grant before this redistricting was done when the line was still one county and one district and another. The grant was secured about 1958 before we got the redistricting taken care of, so they went ahead and built. I don't know, we now are probably going 10 1] 12 13 14 SR 15 16 17 18 19 20 al 22 23 24 25 ACE-FEDERAL REPORTERS, INC. 261 CONSTITUTION AVE., N.W. Wasninaton. £. C. eg 0000 are 139 to get them back before the planning agency with, What do we do now? There are two or three hospitals that would have some willingness to attempt to operate a satellite operation on this but taking this indebtedness would be a horrible factor. 1 don't know how they would live with it. I dontt know how they are going to live with it. ‘| MR. BUGBEE: Who loaned them the money, insurance or banks? MISS JENKINS: George, I don't know. I don't know. They have put out a brochure now to any financing house who will even consider this on a basis of refinancing. I do not see really how anybody can refinance it. Actually the factor is an implementation which is used or persuasion, public dis- closure, where one has to. It is unpleasant and has not been done in two instances. DR. KLICKA: How do you do this, newspaper? MISS JENKINS: Newspaper. DR. KLICKA;: Do you send out a release? MISS JENKINS: Actually, one of the officials of the Kansas City Star, which is our only newspaper, is a member of the planning agency, one of the non-hospital related individua on the planning agency. DR. KLICKA: So he sends a reporter out to see you? MISS JENKINS: In fact, he writes the story. He and 10 1] 12 13 14 SR 15 16 17 18 19 20 2l 22 23 24 25 ACE-FEDERAL REPORTERS, INC. 261 CONSTITUTION AVE., N.W. WASHINGTON, D.C. 140 I sit down and write the story with a reporter. MR. BUGBEE: And I suppose you dramatize it on a television program, MISS JENKINS: No. The largest voluntary hospital in the area was actually done by the reporter on this except it was the planning agency's decision to and this was not over any major thing. It was a hospital that desired to add in its modernization program 100 beds when it had been approved to add only 27 beds in a part of the reshuffle of the moderniza- tion program, They went out for $2 million, hopefully going to get about $3 million. Their fund drive was completed over a year ago. They have not got the $2 million yet because we have a little control, That is your next factor in the implementa— tion, indirect control over funds. Our areas, you probably al know, attempted to put on a united campaign three years ago and it fell through primarily because of one or two hospitals that felt they could get more money on their own, including this one big one really, but major industry is pretty well represented on the planning agency. For example, Ford and General Motors are represented with top executives of both and the corporate giver will not give unless the project has been approved by the planning agency. The report is tssued to the hospital and condensed into a letter, and also a letter given to them which they 1. 10 il 12 13 14 SR 15 16 17 18 19 20 al 23 24 25 ACE-FEDERAL REPORTERS, INC. 261 CONSTITUTION AVE., NW. Waseingrow, 9. C. 141 quote from, use, One hospital in fact blew the letter up into a one page ad and bought advertising space in the Kansas City Star. This was research, Jack, on the big hospital. So you have some element of help and implementation there, We have a great deal of help, we feel, through the Hil1-Burton agencies, In Missouri if anybody files an application that we have not seen, we try to know what these are before they go in. The state Hill-Burton agency advises us and furnishes us with a copy of the project. We may then call the hospital in and talk about it. We give a report to the state on every project which is before them, and up to this point neither state has ever approved one that we said not to approve. I think again this is possibly luck in good part but they have . never approved one over our state disapproval. | | MRS. COLEMAN: How do you state your disapproval? Committee action? MISS JENKINS: Committee action, - MRS. COLEMAN: A letter to the Hill-Burton agency? MISS JENKINS: A report, yes. We write a report on each project, MRS. COLEMAN: At the Hill-Burton request? MISS JENKINS: Yes. The nursing home situation, as I say, is one that is creating a great deal of problems. Many hospitals have desire 5 21 I 10 ll 12 13 14 SR 15 16 17 18 19 20 21 22 23 24 25 ACE-FEDERAL REPORTERS, INC. 261 CONSTITUTION AVE , NW. Wasnincron, D.C. 142 to move in the direction of chronic and long-term care in the nursing home and so on. It takes a hospital so very much longer to plan a project than for Holiday Inn to come in and say we are going to build three of these now, United Convales-— cent Hospitals in California say we are going to come in and build a big one, | MR. BUGBEE: Is that proprietary? MISS JENKINS: These are all proprietary. I think we have heard from most of them but the real problem is if you approve very many of these you do satellite your area with nursing home beds. Then when a hospital comes along probably we have one hospital that has been working for five years in cooperation with the planning agency on the development of long-term beds and it is a hospital that is adjacent to another big hospital and we started them on the road toward an urban redevelopment project which would clear a big area right in the center of Kansas City and let them share parking lots and laundry and various things and let this one hospital build a sizable number of nursing home type beds. It has taken them five years to get their Plans in shape prac-— tically for this, and by the time they get around to asking for Hill-~Burton money we may have filled the area with pro- prietary nursing home beds. DR. HALDEMAN: Sue, isn't it really skimming the cream off the crop; they have filled up the demand for those 10 1] 12 13 14 SR 15 16 17 18 19 20 21 22 23 24 25 ACE-FEDERAL REPORTERS, INC, 261 CONSTITUTION AVE .N.W. Waseinaron, £1. o. 143 that can pay three or four hundred dollars but you still have this group of public assistance and others that cannot afford three or four hundred dollars that have a real need? MISS JENKINS: That is right. This is what our report will show. However, we are getting some proprietaries. We had a staff conference with one just a couple of days ago that wants to move into the urban area operators that operate two homes in small towns in Kansas, very good homes. I mean we checked their operation, checked them out with the Kansas State Board of Health. They are going to build facilities that will price $130 to $200, possibly $250 at the top. MR, ROREM: What is that? MISS JENKINS: Nursing home care. These are the ones that we want to encourage and do encourage. The ones that are asking four, five and six hundred dollars a month are going to lose their shirts, I don’t think there is any questio about it. They still make your area look as if you have an adequate supply of nursing home beds under Hill-Burton when it comes to approving hospitals, do they not? MR. ROREM: I have a theory that the nursing home problem is going to be solved not at all by voluntary philan- throphic services but by actions of the two extremes, straight commercial investment for profit at one end and governmental institutions at the other end. I think we can make some passes maybe here and there where it can be done reasonably iS 144 _ 23 1 | well. A general hospital might have a unit. 2 MISS JENKINS: I think it is a limited number prob- 3 || ably. 4 MR. ROREM: I bet that is not going to be the 5 || problem, 6 DR. HALDEMAN: Apropos of that, Rufus, I was very 7 | surprised at our recent survey of homes in‘the nation. It has 8 | not been published yet except for the summary that showed the > 2 || number of nursing home beds has almost doubled since 1954 when 10 || we did our last survey but the ratio between non~profit, gov- | ll | ernment and proprietary has remained almost constant. I thought 12 || the trend would be a higher percentage. Still about 7 out of 13 || 10 beds are proprietary and about 9 out of 10 homes are pro- 14 | prietary. So you cannot analyze them that way, you do not SR 15 | detect the trend. 16 MISS JENKINS: Yes. VW MR. ROREM: You do not detect it towards non-profit? 7 DR, HALDEMAN: Either way. Se 19 MR. PETERS: They are keeping pace with each other. 20 MR, ROREM: It varies. 2h DR. HALDEMAN: Take Minnesota, for instance; 70 per 22 cent of the beds are voluntary. 23 MISS JENKINS: I don't know what the answer is going 241 to be. I am surprised at the naivete and lack of sophistica- * tion of some of these big promoters on nursing homes who really ACE-FEDERAL REPORTERS, INC. 261 CONSTITUTION AVE., N.W. Wasrinsran, Oc. 24 SR 10 1] 12 13 14 15 16 17 18 19 20 ai 22 23 24 25 ACE-FEDERAL REPORTERS, INC. 261 CONSTITUTION AVE , NW, WASHINGTON, 0, C. 145 have not the slightest concept when you sit down and talk with them of what it is to provide care. They think of it in terms of another motel and you hire an RN to be around once in a while and that is the limit. At lunch time I asked if they have a recreational program and they said yes, they have a swimming pool. | I don't know, These are all in anticipation that there will be a Federal program that will pay nursing home care for the aged and they simply want to be in there and on the bandwagon, We really feel if we can provide enough infor- mation showing what the market demand is in the area that they may quiet down a little bit in the building of this more expen sive type of facility; at least they are reasonable to talk with. We are spending an immense amount of staff time in talking with them, I never saw so many people in my life. They apparently want to start building nursing homes. In Chicage I had seen a tremendous surge of building. Carl, you no doubt wish to comment on that. I talked to Miss Nickelson in Chicago a week or two ago and she bore this out, the low occupancy in these beautiful big new. homes and how they are going out and building back to back and in areas that could not possibly sustain then, DR, KLICKA: There are 2,000 empty beds and the trend is to convert them into hospitals, SR ACE-FEDERAL REPORTERS, INC. 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 261 CONSTITUTION AVE., NW. WaseincTon, D. £. 146 MISS JENKINS: This would be the most alarming thing we might run into in this. MR. BUGBEE: Portable X-ray. MISS JENKINS: We do not have the support of Blue Cross that Jack has in Detroit. We hopefully are moving in this direction. If we can get our Blue Cross board to have the courage and the guts to go ahead with something on this, this is what it certainly is going to require. All that we are doing now, Jack, is a bit of a cutback on this Shawnee Mission. They are taking a cutback under a special contract at Blue Cross which causes them to lose more money as they go along. I think when Jack reports to you his story on the decision in Michigan on this maybe it will persuade more Blue Cross plans to do this. However, when we move into the era for funds for modernization in the urban areas and priorities, I can see this develop as one of the finest dog fights we could ever expect to have, and I am sure this will occur in any metro- politan area. Surely there will not be enough money to do any more than a drop in the bucket job at the start on a program such as this. MR, BUGBEE: Such as what now? MISS JENKINS: Federal funds for modernization and renovation of aging hospitals or plants. MR. BUGBEE; You have plenty of them? 10 1] 12 13 14 SR 15 16 17 18 19 20 21 22 23 24 29 ACE-FEDERAL REPORTERS, INC. 261 CONSTITUTION Ave NW, Wasuineron, 0. Co 147 MISS JENKINS: Yes, we have plenty of them. How you will decide who is up for grabs on this money is going to be an extremely difficult thing. In our area we have a big new General Hospital and Medical Center going up with a replacemen building and medical school. Undoubtedly they are going to feel they ought to get these funds; they are already saying this when they come through. ‘ You have some hospitals that are going to have trouble getting matching funds for money. Maybe their need is very great, maybe you cannot do very much towards seeing that they get matching funds for it. David Willis posed a question over a good hot sand- wich during lunch, at a delicatessen incidentally, Should this money become available, do you spread it through your area giving a little piece here and here and here, er do you try naturally to determine priorities and try to do a full and complete job with one of them if your money is limited? The determination of priority such as this concerns -us very much. Hopefully I thought some of the great brains around this table would have some very enlightening ideas about it. MR. ROREM: You came too late, Three years ago we could all have told you. MISS JENKINS: Really, it is I think a very serious problem. If Uncle Sam were going to cut loose with enough money to do a complete job with all urban areas in the country 10 ll 12 13 14 SR 15 16 17 18 19 20 21 22 23 24 25 ACE-FEDERAL REPORTERS, INC. 261 CONSTITUTION AVE,,N.W. Wasningeron, 2. f. 148 this would not pose any problem realizing that it will be an infinitesimal fraction of the job to be done. If you do get such funds, then the determination of these guide lines for priorities become very important. If you don't get them estab-+ lished and reasonably accepted, you could break up some very good planning agencies over this type of thing. | DR. HALDEMAN: You have several communities that have had to face up to that and have faced up to it. We have one here, Columbus, Ohio. You may not agree with their solu- tion but at least they faced up to it. Rochester, New York, is another one that has. MR. BUGBEE: I think you are a little pessimistic, Sue. I think a little money might be able to cope with it better a little at a time than it might all at one shot. MISS JENKINS: Frankly I would like to cope with it a little at a time, even in an area no larger than ours. We are not very apprehensive about it. MR. BUGBEE: I did not mean to indicate you were not entitled to that. DR, HALDEMAN: Any questions? MR. BUGBEE: For the minutes, I think the long range planning committees in each hospital --— I do not know that Rufus' Appendix B answers all the problems but it is an awfully nice outline of how to constitute such a committee, If they ever write this up and want to look at it, it is in his 10 ll 12 13 14 SR 15 16 17 18 19 20 21 22 23 24 25 ACE-FEDERAL REPORTERS, INC. 261 CONSTITUTION Ave., NW. Wasninaraw, Do. 149 Alleghany County book, Appendix B. MR. BAUM:.:On your fund raising campaign that you are talking about, was this not conducted at the same time in Kansas City, Kansas, or Kansas City, Missouri? MISS JENKINS: On a united effort that did not get off the ground, is that the one you are referring to? MR. BAUM: It did not get off the ground? MISS JENKINS: No. MR. BAUM: That answers my question. MR. BUGBEE: You mean by that you never got to the money raising part? MISS JENKINS: It was a totally separate organizatio It was a community organization, you see. It was not either our hospital organization or the planning agency, it was a community organization set up to hopefully get the capital funds necessary to implement the recommendations of the plan- ning agency. The planning agency did not put price tags upon these projects. The community organization left much to be desired in its structuring. The planning agency in the area hospital association certainly endorsed it wholeheartedly. It did not get any job done, however. As a consequence each individual hospital. went out on its own -- not each, several of them did. Out of the several that did and are still planning to go out on their own, only one of these broke the line with the recommendations 150 29 1 | of the planning agency. This was the one that went to the 2 || public disclosure and did not get all of its money. 3 DR. HALDEMAN: Any further questions? 4 If not, Dave, you may proceed to talk about the '§ || Rochester regional planning board or about Monroe County if 6 you prefer, 7 MISS JENKINS: What is Monroe County? 8 MR. WILLIS: It is the home county for New York. 9 It is a trade association made up of hospitals and related 10 |} facilities, all of a voluntary nature and governmental, not 11 | private, covering eleven counties. It includes Rochester, no 12 | other very large cities, and some sizable towns scattered 13 || around Elmira and Corning. SR 14 For some years the Council has had a relationship 15 | similar to the Hill-Burton which Mr. Peters had in New York. 16 | In Rochester though, unlike New York City, there was a trade 17 | association that had a planning function as a delegated repre- 18 | sentative of the state Hill~Burton agency. - 19 Starting now the regional hospital council has set 20 | up a separate review and planning committee within the struc- 21 | ture of the hospital council with membership of about forty 22 || people on this committee with a smaller steering committee of 23 || twenty people. The size of the committee structure I think 24 | is important as an asset and a limitation at the same time. 25 I think rather than tell you specifically about the ACE-FEDERAL REPORTERS, INC. 261 CONSTITUTION AVE NW. WASHINGTON, D.C a a 151 30 1 || projects that have been undertaken I would like to discuss 2 | some of the problems that I see in here and I think may be 3 || related to some other areas as well. 4 First as to the matter of whether or not an eleven 5 | county area wherein the central core of the area is about 120 6 || miles away from its farthest point constitutes significantly a 7 i single service area, I think it is questiohable. A three hour 8 || drive from one end to the other, especially when your medical | 9 | center is that far distant, I question whether or not this can 10 | really be done to the fullest extent. The old concept of 1] regionalization, if it is to get beyond just a matter of 12 || grading the size of facilities as you proceed out from the 13 || core and if it is to get on into a functional differentiation SR 14 | and rational utilization of these, has got to obviously depend 15 | upon medical organizations and medical staffing. 16 All of the specialists in this eleven county area, 17 | or virtually all of them, are concentrated 120 miles away from 18 the more rural areas. In the Rochester area it-is a rather 19 | stable population. There are some developing suburbs, none 20 | of them mushrooming. It is largely a clearcut distinction 21 | between urban areas and rural areas. The rural areas jealously 22 | guard their differences from the urban areas and the county 23 boundary is a very important social, political and economic 24 | unit to those areas. 25 Every time you have a committees, or at least the ACE-FEDERAL REPORTERS, INC. 261 CONSTITUTION AVE... N.W. WASHINGTON, OC, 31 SR 10 ll 12 13 14 15 16 17 18 19 20 al 22 23 24 25 ACE-FEDERAL REPORTERS, INC. 261 CONSTITUTION AVE.,.N.W Waseingron, 0. c. 152 feeling so far is you cannot constitute committees based upon problems or proposed solutions to problems but you must estab- lish committees based on geographical representation. With eleven counties you start off having at least eleven people on every committee. You then have within the urban area such a wide gulf between the medical school and the hospital and the other hospitals that you have a twelfth representative on every committee, Then you must bear in mind that in New York State the Department of Social Welfare and the Department of Health have been battling for some time and the battle as assumed recently is a rather heated debate in the press and in any public meeting, so you have got to have in each of these counties someone from Health and someone from Welfare. So you are now up to twenty-four members on any committee. The matter of supervision of hospitals, some of the facilities are supervised by Welfare, some are supervised by the Health Department. I don't know, in New York City we may have been able to overcome some of this. In Upstate New York it has been rather difficult to date. Therefore, I wonder whether such a broad area necessitating such large committee structure for any action has not got in itself some built-in needs of its own making, but be that as it may I don't know yet. We have the forty member review and planning 153 32 1 || committee which now acts as the Council's screening and 2 || approving body for all of Hill-Burton applications. The 3 | steering committee reports back to the reviewing committee 4 | which reports to the executive committee which reports to the 5 | entire board of the Rochester Council and then in turn to the 6 | state Hill-~Burton agency. The Hill-Burton agency has really 7 || been quite wonderful. I just had my first+‘experience in 8 || sitting with Jack Burke and seeing how they determine bed 9 || need. It is a weird and wonderful thing that defies descrip- 10 | tion but I have not yet seen a formula which approaches it 11 for good soundness of the end result. 12 DR. KLICKA: Those are inconsistent statements. 13 MR. WILLIS: We will argue later. 14 The approach to date is that before they had a full SR ; 15 || blown planning function the Rochester area has been largely a ™ 16 | numerical legalistic sort of planning, largely a determination 17 | as to the size and location of facilities with very little 18 | inquiring except into the content of medical care programs. 13 | Recently the major part of the retention has been developed 20 to two essential problems, nursing home and related long term al care facilities and psychiatric facilities, 22 Quite interestingly in the Rochester region these 23 || two problems have been brought to focus largely because of the 24 || presumed threat of proprietary facilities going into the area. 25 | Aside from a single psychiatric unit of Strong Memorial Hospital, ACE-FEDERAL REPORTERS, INC. 261 CONSTITUTION AVE .N W. WASHINGTON. D.C 33 SR ACE-FEDERAL REPORTERS, iNC. 10 1] 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26! CONSTITUTION AVE .N W WasHinctTon, B.C, ‘with whether or not it is voluntary, non-profit or proprietary 154 which is the teaching hospital in Rochester, there is not one hospital in the entire eleven county area which will overtly admit patients requiring psychiatric care aside from the state te institution. A proprietary group wanted to build a psychiatri¢ facility and this caused a re-evaluation of the entire program} VW Now everyone wants psychiatric facilities, anything to keep thy proprietary people up. t MR. SIBLEY: Did you put this group up to this? MR. WILLIS: No, but I bless them for it. I cannot say that in Rochester but I say it here. The same thing with nursing homes. I do not think this is unrelated to what Sue Jenkins mentioned there. MR, ROREM: With respect to what? Who is concerned over sponsorship rather than service? MR, WILLIS: I think the Regional Hospital Council and the civil leaders have been taught to be more concerned rather than is the service needed or do we have_a better alternative now or in the foreseeable future, [I think in Rochester we come up with the same answer that was implied in Sue Jenkins’ comment, we would rather do without services than wait for non-profit. MISS JENKINS: No, I did not mean to imply that. We have no objection at all to the good proprietary or com- mercial nursing homes, they are very helpful. 10 il 12 13 14 SR 15 16 17 18 1g 20 2l 22 23 24 25 ACE-FEDERAL REPORTERS, INC. 26! CONSTITUTION AVE NW. WasHincton, 0. C. 155 MR. WILLIS: My charter does not admit proprietary facilities to its membership, which does not put it in a very good position to work with proprietary groups to encourage them to amend. their programs and so on to fit in with some overall planning. The Regional Hospital Council has also taken sides in this fight between Welfare and Health. MR. BUGBEE: Which side, the Health? MR, WILLIS: Yes. They have publicly cast their lot with the Department of Health which means that they are on the outs with the Department of Welfare and get very little cooper ation from that department which is the department overseeing most of the proprietary facilities. This is a kind of unfortu nate situation. I do not know how you have handled this thing in New York City. MR. PETERS: We have not taken sides at the moment although if the vote were taken I think probably Health because of the composition of our board -- probably, I am not sure -- the state hospital association of New York. MR. SIBLEY: So your association does not agree with your state association? MRS. COLEMAN: Our group is not quite clear in its mind, MR. PETERS: They might go for Health, I think. DR. HALDEMAN: I was interested in the concept which I have never heard you enunciate, Hi, in implying that an axed 156 35 1 | wide planning agency was a local arm of a state hospital 2 || association. You didn't mean that, did you? If we are con- 3 | sistent with our concepts, it seems to me we have to say it 4] is an independent entity. 5 MR. ROREM: Are you pulling his leg or do you think 6 || he said this? I did not hear him _ it. | 7 _ MR, WILLIS: He took the position. 8 MR. PETERS: He said we are in New York State so 8 therefore we have a New York State association. 10 DR. HALDEMAN: I think this is an important concept 1] because I do not think an areawide planning agency should look 12 upon itself as a sister organization, as another hat for the 13 | hospital association. It seems to me they have to maintain SR 14 that relationship with the state hospital association. 15 MR, PETERS: It is partly when you have the dual 16 role like Jack has and Sue and so forth that you come in 17 contact with the state association. We have no contact at 18 || all with the state association. ; 19 DR. HALDEMAN: I say it was in that context that 20 you made your romark. al MR. SIBLEY: As long as it is in your state, that 22) is all. 23 MR. BUGBEE: Since you are at a dead end, let me 24 add one thing that has been on my mind for months. I wish 25 we would stop talking about the trade associations when what ACE-FEDERAL REPORTERS, INC. 261 CONSTITUTION AVE ,NW WASHINGTON, 0, C. a SR 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 ACE-FEDERAL REPORTERS, INC. 261 CONSTITUTION AVE | N.W. WASHINGTON DC 157 we mean are the traditional functions of hospitals. MISS JENKINS: Three cheers. I do not like to call them trade associations. MR. BUGBEE: I don't know who started that. I do not like trade associations used for hospital associations. I trust they are not trade associations. MISS JENKINS: We are not a tradd association. MR. BUGBEE: Member association. MR. WILLIS: I agree with you, it would be nice if most of them were. MR. BUGBEE: All right. Do you want to take over on another argument? MR. WILLIS: Touche’. MR. BUGBEE: That is a dangerous viewpoint for planning. MR, WILLIS: I would just like to add a few more points, To go back for a moment to the size of an area encompassed by one planning activity, we run into the problem that we span three different Blue Cross plans, four different medical society organizations in addition to eleven county organizations, three different Welfare Department districts, four different Health Department districts and so on. Whether or not this naturally forms a single area I do not know but it is difficult to margine all four. This will be true in any very large region I think. 10 11 12 18 14 SR 15 16 17 - 18 19 20 21 22 23 24 25 ACE-FEDERAL REPORTERS, INC. 261 CONSTITUTION AvE .N.W. WASHINGTON. 0. C., 158 So far as the role of the hospital and planning goes, we are going to be aiming at much the same sort of thing that Dr. Rorem outlined, to get the hospital outlined in its own planning. Further, the idea is to get each logical group- ing of counties to set up their own areawide planning council or conference which will be unofficially an arm of the regiona planning group but can keep a greater contact with local prob- lems, local needs and relate better both ways. MRS, COLEMAN: Excuse me. How many people are in your area? MR, WILLIS; About 1,300,000 in the eleven counties. 5 . ROREM: How many short term hospitals, Dave? MR. WILLIS: About thirty-five. MR. BUGBEE: You say how many, 1,300,000? MR, WILLIS: Yes. About 600,000 in Monroe County. It is rural area with a few little towns. DR, HALDEMAN: I think you have to use one more statistic on that. How many beds? . MR. WILLIS: I don't know. DR. HALDEMAN: One thing that I think is in their minds in that area is the manner in which capital constructioy funds are raised and are distributed. I can say that if the planning council is going to have a force in the distribution of locally raised capital construction funds, the overall eleven county council, the local group will not accept the 159 38 1] || dictates for the total final decision on that. Even though 2 || Meriam Folsom is chairman of both the planning council for the 3 || region and the planning council for Monroe County, I heard him 4 || Say more than once that the determination of how that money is 5 | spent has got to be largely in the hands of Monroe County. 6 Now what would have happened historically if the 7 || regional council had gotten off the ground'prior to the Monroe g | County, I don't know. Inasmuch as Monroe County came first and g | was a strong organization from the standpoint of planning when 10 | the regional council came along, it posed a real problem for 11 the regional thing. 12 MR. ROREM: You mean to say there are two hospital 13 || councils there now? 14 DR. HALDEMAN: There was a regional council which * 15 | had a membership function and has a long tradition of very 16 || excellent service to the member hospitals. Then Monroe County 17 || prior to the time the regional councils were given review and 18 || planning functions had a very strong patient care planning 19 || agency which in effect was a hospital planning ~- 20 MR. PETERS: In New York City, isn't it, pretty 21 || much? 22 DR. HALDEMAN: Yes. It does not have a long history 23 | but they had control of all capital construction funds and 24 || were able to implement what they did, and I think that has 25 | had an impact on the Rochester region. I think it is probably ACE-FEDERAL REPORTERS, INC. 261 CONSTITUTION AVE _N W WaseincTon, 0. C eae aaa saaammmaaasaaaaaaammmammaa aaa aeaa acacia SR 10 1 12 13 14 15 16 17 18 1g 20 2l 22 23 24 25 ACE-FEDERAL REPORTERS, INC. 261 CONSTITUTION AVE..N W. WASHINGTON, O. C. 160 a sound provision, Where you have a large regional area, if your funds are going to be raised locally there has to be a relationship developed locally with the region, What that is I am not so sure. I think it will follow some pattern, but the local people will not hold still for every decision being made in Rochester, Rochester being a hundred miles away. - MR. WILLIS: You have the fund raising in Monroe County which is the patient care planning committee. We hope™ to set up in other areas, too, which may report to their local communities so far as the local needs of the programs go but which report to the program councils as far as the Hill-Burton goes because that is not the official designee. DR. HALDEMAN: But you hope to provide the staff services for these local planning groups, the data collection and analysis? MR, WILLIS: Yes, that is right. MR. PETERS: You are facing exactly the same problem where we had three local Hill-Burton councils, one which was in New York and the others in Long Island, which had a hospita administrator working X number of hours a year on a per diem basis part time, which still exists in Long Island. That was a Hill-Burton council with a part time executive secretary an hour or two a week. These two still continues to exist. They are theoretically part of us but have their own stationery. The one in Long Island has recently incorporated, 1 40 1 10 11 12 13 14 SR 15 16 17 18 19 20 2l 22 23 24 25 ACE-FEDERAL REPORTERS, INC. 261 CONSTITUTION AVE., N.W, Wasningran, 2. o. 161 become a membership corporation of the State of New York, continues to exercise the Hill-Burton functioning with our blessing. But how do you keep them from breaking away and exercising the total function without our blessing? In other words, we are talking about in Long Island, for example, two million people more in population than Dave has, and Dave has a problem. I can see right now you can imagine what the problem is with Long Island with two million people and possibly double within the next twenty years. DR. HALDEMAN: I think we are going to hear from the Columbus regional area. They perhaps have not had their local committees organized long enough to evaluate but at least they are the only area in the country that I know of where there are local committees established in relationship to a region wide planning body that is in operation. I think it will be interesting to hear that, MR. PETERS: It depends on which comes first. The sequence of events I suppose is very important in this whole thing. DR. HALDEMAN: They fortunately did not have to contend with a previously established group. Do you have anything further, Dave? MR. WILLIS: No. MISS JENKINS: May I ask what is your relation to decision making out in these areas removed from Monroe County? 10 ll 12 13 14 SR 15 16 17 18 19 20 21 22 23 24 25 ACE-FEDERAL REPORTERS, INC. 261 CONSTITUTION AVE .N W Wasdinston, QS. 162 Are you going to allow them a degree of autonomy in making their own local decisions or do they have to be approved by your group in Rochester? MR. WILLIS: If we are going to have any concept of a regional group, at some point it should have some approval from Rochester. I think the greatest responsibility and a good deal of autonomy shoiild go to the local areas. [I am convinced myself that you cannot go on indefinitely sticking td wT counties as meaningful areas, the people just don't live their lives accordingly. DR. KLICKA: Is this the way the state plan is set up? | MR. WILLIS: On counties. At best they are willing to accept individual areas, groups of counties. MR. BUGBEE: Yes, but your whole area is a region for the state plan, MR, WILLIS: It is a region, and the areas within the region are counties. - DR. KLICKA: In other words, your planning would show specific bed needs for each one of these counties? MR. WILLIS: That is right, by county. MR. PETERS: That is right. If you get the state plan which is published each year, you will see it is a tabu- lation of all the counties of New York State listed according to need with the ones of the greatest need being on top county SR 10 | 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 ACE-FEDERAL REPORTERS, INC. 261 CONSTITUTION AVE .N W WASHINGTON, 3. C, 163 by county; number of beds, percentage of bed needs and so forth. MRS. COLEMAN: Except in New York City where five counties are treated as one, MR. WILLIS: Yes. MR, BUGBEE: There is no simple way to do it. There might be wiser and more acceptable ways but I do not think anyone had any data. MRS. COLEMAN: No. MR. WILLIS: I think the best thing that can be done now is work towards perhaps groupings of counties, but on the county boundaries sticking to county boundaries, All the data is only available by the county basis. DR. KLICKA: You use, of course, state lead figures in your planning, do you not? MR, WILLIS: Yes, they are worked out with the state DR. KLICKA: So there is complete agreement here. - MR. WILLIS: We just sat around the table and went back and forth and in a couple of hours had all the problems solved, DR, KLICKA: Shows what people with good will can dol DR. HALDEMAN: Go ahead, Dave, MR. WILLIS: It looks like, to summarize, what I think are in the operation of one agency the major problems we have got to :reckon. with the first few years. I don't know 10 ll 12 13 14 SR 15 16 17 18 19 20 21 22 23 24 25 ACE-FEDERAL REPORTERS, INC, 261 CONSTITUTION AVE., NW. WASHINGTON, 0.0 164 what the answers are. One is what do you do in the interim? Until you have got your principles and priorities and some concept of a plan laid out, how are you going to handle the backlog of requests for projects? How large can the area effectively be? What is the role of the medigal school and teaching center? Aside from saying this is the place where _ you send your special cases, what influencé is this really going to have on the operation of the individual hospitals? I think in most areas the medical school is a little bit diffident of anything that smacks of community service in an effort to preserva our teaching and research functions. I don't think we can go on indefinitely holding back some of the other areas because of feed back. MR. BUGBEE: North Carolina has some research but I don't know if they can get out beyond it, can they? MR. WILLIS: The thing I have in mind is a hospital that is a 200 bed hospital half a mile from a medical school. Any kind of logical finding should be different -from a- hospita which is 200 miles from the medical school, yet I dare say it is the rare exception where the proximity to a medical school is really affecting the nature of the hospital, its program and so on. Unless there be a very real and close affiliation, which I think is going to be the exception, what should the role of medical schools be. aside from just saying that their 165 44 1 || roles are going to preserve the selectivity of what they want 2 to take in and what feed back they are going to have? 3 DR. HALDEMAN: Again in North Carolina there has now 4 | been set up an office so the university teaching hospital is 5 | playing what I think will be an increasing role in community § | hospitals outside the state. They are working on etandardiza- 7 || tion of laboratory techniques and a great many things and I 8 | think it is possible but you have to set up an independent 9} activity. It can't be integrated very well. I think there in 10 || Rochester you have several examples that are coming about as a ll | part of the patient planning care council that is markedly 12 || expanding the role of the medical school within the Rochester 13 || area. SR 14 MR, THEWLIS: Dave, you mentioned the medical school 15 | itself. I was thinking throughout the country, and this 16 | thought has occurred to some of us in the larger teaching 17 |. hospitals, whether they are associated with the medical school 1g | or not, what impact can they have or do they have with the 13 | hospitals? 20 MR, WILLIS: Yes, I mentioned the considerations. 21 || This is not just an academic question. When you get out into 22 || an area such as the Rochester area you get into rural areas 23 | and the smaller towns. There becomes a very real question as 24 || to how much and how far you can expect these smaller groups to 25 | go towards limiting their medical care programs and referring ACE-FEDERAL REPORTERS, INC, 261 CONSTITUTION AVE, NW. Waseingran, &. €. eae 166 45 1 | things in because in every case the referring doctor is going 2 || to lose the case, 3 Now much of this is going to ultimately have to 4 |} involve our planning not just facilities but I dare say going 5 || to have to involve some planning on medical staffing and the | 8 | use doctors are making of the respective facilities to which 7 | they are entitled to practice. We find in‘some areas, for 8 example, right in the City of Rochester that the hospitals 3] that have some affiliation with the medical school are the 10 | very ones that are endeavoring to duplicato everything that is 11 | in the medical school. Their medical staffs have a taste of 12 | some of the things which are available, yet they cannot make 13 || full use of all of those things in the medical school setting SR 14 | because of the restrictions on privileges, so they go back to 15 their other hospital and that is where they are agitated. 16 I think it is where they are closest with the medi- 17 cal school they use the greatest energy to duplicate. Where 18 the hospital is far removed from any kind of affiliation it is 19 as if it is less interested and less duplicated in expensive *0 | facilities and services. a With that I will quit. 22 DR. HALDEMAN: Any questions? 23 MRS, COLEMAN: This is not a question but I think “ distance has really no part of this, we see the same picture 0 2 in New York City right within one borough. The little hospitd} ACE-FEDERAL REPORTERS, INC. 26 1 CONSTITUTION AVE ,.N.W WASHINGTON, D.C. 167 46 1 || is not very ambitious, the one that needs an affiliation the 2 || most is the least interested in it. 3 MR. PETERS: It can be a four or five blocks walk 4) away. 5 DR. HALDEMAN: I think the activities of the. 6 || Rochester phase in planning their council is an excellent | 7 | example of a situation where the planning council does control 8 || the distribution of funds for capital construction and it has 9 || a tremendous impact on the area. Initially the hospitals 10 added up the total bill and it came to something like forty- ll | five or fifty million dollars short range needs of the Rochester 12 || hospital, 13 The planning committee knew that they could probably SR 14 only raise at this phase of the construction program about 15 | $13 million, The projections, based on utilization and popu- 16 | lation growth, indicated a need in the next three or four or 17 | five years of some 500 additional short term beds. In addi- 18 | tion, they had one hospital that was quite obsolete and needed 19 | to be replaced. i The significant step they took, I think, is the at study of the in-patient population, a review by both inside 22 physicians and physicians from outside of Rochester of the 23 patient population characteristics. In other words, how many 24 | patients were in the hospital that did not need to be there 2s by virtue of the medical needs of the patient, and if not what ACE-FEDERAL REPORTERS, INC. 261 CONSTITUTION AVE .N W. WasHington, OC. 10 1] 12 13 14 SR 1S 16 17 18 19 20 21 22 23 24 25 ACE-FEDERAL REPORTERS, IMC. 26 | CONSTITUTION AVE .NW Waswincron O=.¢ 168 type of institution should there be? In some cases it was perfectly evident they could be in their own home, others a home care program, others on a long term care program and whatnot. The upshot of it was that they decided to change the method in which they were going to cut the pie. They got three of the hospitals to agree to establish what I believe they are balling continuation care, you might say, for patients that do not need the services of Short term hospital but do need active medical care, with the thought they would go ultimately to nursing homes, | | They have instituted a home care Program which has srown very rapidly. Last week I was ina meeting with the Visiting Nursing Association. She Said there are about 200 patients on their own care program, a large percentage of which would be using beds, They are only expanding about 125 beds as contrasted to 500 beds. They have done a lot of Other things that go into patient care, They have developed with the community college An associate degree nursing program which all the major hospi- tals are associated with, They are establishing a common laundry. They have considered the possibility of centralizing pertain expensive laboratory tests, and I think that is still nder study although I think there is an agreement in Rochester here they have had a long history of cooperation where certain SR 10 ll 12 13 14 15 16 17 18 1g 20 21 22 23 24 25 ACE-FEDERAL REPORTERS, IMC. 261 CONSTITUTION AVE . NW. WasxHingran 0. ¢, 169 hospitals would do a given test and other hospitals would send samples in to them. They have worked out a program for eliminating the tuberculosis hospital and transferring the residual hospitals to a county infirmary. They have worked out an affiliation between the university teaching hospital and the county infirm ary to upgrade the medical care, They ard in the process of transferring the municipal hospital which was a part of the university teaching hospital to the university so that they would be operated as a single unit. These are just some of the activities that the patient planning care council, and I must admit I think it is the top lay leadership because in talking to the health offi- cer and some of the physicians I doubt if the physicians would really have gone along, because they wanted more beds, if it had not been for the caliber of the lay leadership in the community. Do you want.to add anything to this? - MR. WILLIS: I think there are some interesting differences between what goes on in Monroe County and what we are doing in the western region because the Monroe County planning commission is largely community representation and it has not a label locally nor is it in fact an arm of the hospitals, which means that many of these accomplishments you Speak of have been accomplished in spite of the hospital. The 10 ll 12 13 14 SR 15 16 17 18 19 20 21 22 23 24 25 ACE-FEDERAL REPORTERS, INC. 261 CONSTITUTION AVE., N.W. WASHINGTON, D.C, 170 governmental people have an intereating rezction, They said, Isn't it wonderful to see what can be done when you get the good lay leadership to back up the government, which has been their reaction because many of these things are things they wanted to accomplish. When the planning is more Closely related to the hospitals it takes on a slightly different‘ coloration. They are trying to bring the government in to face the purveyors of health care rather than the other way around. I do not know which one is going to have the pattern for the future but it is quite different. DR. HALDEMAN: Well, we might go on to Columbus then}. Grant, do you want to proceed. MR. DRENNAN: I think the previous speakers have all outlined the problems we have and are contending with in Columbus. I think Dave's situation is probably closest to our own. The types of organization regional planning is a depart-— ment of the federation which is a triple headed-monster and community oriented and a non-profit organization. Our board is composed 25 per cent of hospital administrators, 25 per cenit hospital trustees and 50 per cent members at large which repre- sent manufacturers, religion, medicin, purveyors of insurance, both Blue Cross and private insurance companiss. Our Blue Cross coverage is less than 30 per cent in the general area, The population is somewhere around a milliaqn 171 1 | and a half in the regional area, 700,000 of it in Franklin 2 | County which is our base county ‘in which the federation has 3 || been operating for eighteen years in the Planning, financing 4 |} and council services field. We have a regional planning 5 committees which operates with the federation and under the 6 | federation's board of trustees. 7 I should say here that what I am’ saying now is outlihed 8 in our guide lines and is being tested. We have three years _ 8 to make up our mind what sort of structure we are actually going 10 to use when we get through with the demonstration grant and the Il | study. Thus far most everything that we have set out in the 12 | guide lines was found to be workable, 13 The regional committee was not started first. We SR 14 have gone down to the grass roots, so to speak, the same as 15 | in Pittsburgh. We have asked each hospital to set up a plan-~ 16 ning committee or building committee, In some places they caljl 17 | it a building committee, in others a hospital planning committee 18 for the individual hospital. That is for each hospital within 19 a community. 20 Then we have gone to the county level and asked that ai each hospital have a representative of its board of trustees, 22 representative of its medical staff and its administrator to 23 serve on the county committee. Along with that we ask the 24 County Health Commissioner, in some cases we have District as Health Commissioners which serve two or three of the smaller ACE-FEDERAL REPORTERS, INC. 261 CONSTITUTION AVE .N.W. WASHINGTON, D.C. SR 10 ll 12 13 4 15 16 17 18 13 20 21 22 23 24 25 ACE-FEDERAL REPORTERS, INC. 261 CONSTITUTION AVE ,N.W. WASHINGTON. 0. C. 172 counties, a reprasentative of the County Medical Society, one representative representing all the nursing home operators in the county, and members at large which may be named from industry and others. DR. HALDEMAN: How many counties? MR. DRENNAN: Thirty-six. . Six of those counties have no hospitals and most of them are too small probably to have a hospital, at least we are trying to convince them of that fact. We are going to do some special studies in that area, MR. ROREM: How many short term hospitals? MR. DRENNAN: Fifty-five. I think there are 200 some nursing homes; probably 50 are nervous, mental, tuberculosis and so forth. These are all listed in the guide lines. MR. BUGBEE: Have most of them got county homes? MR. DRENNAN: Yes, but not all of them have county hospitals. We have a couple that have a combination in geriatrics, or it may be somewhat acute in its function for the presence of the home, We got to the county committee. These county committees are already functioning in almost all of the 36 counties. They discuss problems, shoot us requests for infor- mation and also send us some of their difficult problems. The osteopathic problem is the one we mentioned. In rural areas 173 } we are operating joint staffs, newly built hospitals. In one 2 case the other day the Administrator said it was just working 3 | wonderful. 4 MR. ROREM: You mean a general hospital? 5 MR. DRENNAN: These are two general hospitals that / 6 have osteopaths on their staff. The osteopaths are probably 7 in a minority. In each case it will be an‘ M.D. and be accep~ 8 table for accreditation by the joint commission. 9 One case is working out well and another is the suit 10 being filed now to break the lease I think on the hospital 11 because they are not admitting osteopaths in their hospital. 12 So we have all kinds of problems there. 13 In the county committee all the hospital voluntary : 14 non-profit administrators or governmental administrators are SR 15 in at the county level. 16 MR. BUGBEE: How often do those county committees 17 || meet? 18 MR. DRENNAN: As often as they can. We do not staff 19 the county committee meetings at all. We provide data and 20 information. 21 MR. BUGBEE: Do you have difficulty having them 22 || meet? 23 MR. DRENNAN: Probably one-third of them are metting 24 || pretty regularly now. Others, it depends on how serious thein 25 | problems are. If there is more than one hospital in the ACE-FEDERAL REPORTERS, INC. 261 CONSTITUTION AVE., N.W. Waseincton, 2. ¢. 10 il 12 13 14 SR 15 16 17 18 ig 20 21 22 23 24 25 ACE-FEDERAL REPORTERS, INC, 261 CONSTITUTION AVE,,N W. WasHIncron, D. f. 174 county, they are probably meeting more often to discuss their problems. Then we come to a zone committee which is a combina- tion of three, four or five counties which we thought were geographically located. Six months study indicated we better reorient some of our zones because the hospital patients are going more to another zone than the one that we had in mind. DR, HALDEMAN: You set them up before you did your ~ study on patient origin? MR. DRENNAN: Yes. We took the 36 county area which is the central Aistriet of the Ohio Hospital Association and actually the same counties. MR. BUGBEE: Hill-Burton region, too? MR, DRENNAN: No, sir, the Hill-Burton region extends all over the map. There are three Blue Cross plans within the region. I don't know how many Health districts, a great number of them. At the zone committee we have the chairman and each vice chairman so at most you have at least ten officially designated representatives that come to the zone committee plus members at large, primarily from industry or from the community power structure. MR. BUGBEE: Do you staff those zone committees? MR. DRENNAN: Yes, sir, every one of them. MRS. COLEMAN: Regular meetings? SR 10 11 12 13 14 15 16 17 | ‘18 19 20 al 22 23 24 25 ACE-FEDERAL REPORTERS, INC, 261 CONSTITUTION AVE., NW WasHInGrow. DC. 175 MR. DRENNAN: Regular meetings every two months or SO. Dr. Volpe is a roving ambassador, our organizer in our meeting with zone committee people. Ed Lentz does a great deal of the writing. While [wear two hats, I am very much — interested in what goes on in regional planning, MR. ROREM: Full time for each zone committee? MR. DRENNAN: Full time staff members, yes, sir. They go out to the meetings. We have ten zones. Right now we have two staff members. Their time is divided. We are in an advisory capacity. They do not meet without Dr. Volpe or Ed Lentz. DR. HALDEMAN: We did have an application that would provide for three positions in this area. MR. DRENNAN: Four. We are hiring on that basis. DR. HALDEMAN: I did not include the statistician. There were some wonderful opportunities to do some Special studies but we had another purpose in this. With the shortage of personnel with experience in this field we would like for some of the areawide planning agencies that have on- going programs to have some young people that are doing a good job but actually looking towards increasing the manpower in this area. The greatest problem we are facing is getting trained personnel for areawide planning agencies. MR. ROREM: Could I just quiz you a little further 176 1 | on that. Do you mean there are provisions by which, assuming 2 there is work to be done, people can be engaged for jobs for 3 some sort of pay without going through the regular routine of 41 a grant? 5 DR. HALDEMAN: No, it has to go through the regular 6 routine of a grant but it is a special demonstration sort of 7 a grant and is the criteria which we evaluate it as ditterent. 8 || You have to write up a study of some kind or a service program 9 of some kind. On the other hand it is with the thought of 10 | having two objectives, one to strengthen the agency but 1l || secondly to provide a training ground for some bright young 12 | people in areawide planning. 13 MR, DRENNAN: I have one from Cornell but little 14 experience in the health and hospital planning field, and his SR 15 | primary subject will be investigation of what to do with 16 counties that have no hospitals. He will be going out and 17 meeting with the county and zone committees under Pete Volpe's 18 guidance but all the time his major concentration will be on 19 providing services for counties without hospitals. He will 20 acquire all the techniques in the planning field and the 21 | other studies that go along with it. 22 DR. HALDEMAN: One of the interesting things thetr 23 initial study showed was that the counties that did not have 24 a hospital, the utilization of hospitals by the residents of 25 those counties was 120, ACE-FEDERAL REPORTERS, INC. 261 CONSTITUTION AVE., N.W. WASHINGTON, D.C, a iA C3 cas ecacaé ee aaaaaaacataécaaataateatasa seaman eee aaa 10 11 12 13 14 SR 15 16 17 18 19 20 al 22 23 24 25 ACE-FEDERAL REPORTERS, INC. 261 CONSTITUTION AVE..N W. WASHINGTON. D.C. ‘nothing outside the region to compare it with, but tn these 177 MR. BUGBEE: Comparable counties or compared with -- MR. DRENNAN: These are all rural counties that have no hospitals. MR. BUGBEE: Is that typical of a rural county, that it has 120? MR. DRENNAN: There is no typical one in our region, George, actually because we have some down' on the border line of Ohio and West Virginia where 65 per cent of their admission come across the border. So when you link that to the county population figures, you are all out. They have over six beds per thousand down there and it is not enough when you base it on county population alone. Their occupancy rate is still only in the nei ghbor- hood of 75 to 80 per cent of the roll. That is not typical but these admissions, it just happens that we have some that are surrounded by territory on which we have reports. We haved counties that have no hospitals they are all in-the 80 per cent admissions that were admitted to hospitals within our region. This much we know. We do not know how many are outside but the captive ones, I am sure ‘this is accurate, MR. ROREM: Have you said in other similar rural counties, similar in every respect but having a hospital, how much higher was the annual admission fee? s 10 1] 12 13 14 SR 15 16 az | 18 19 20 21 22 23 24 25 ACE-FEDERAL REPORTERS, INC. 261 CONSTITUTION AVE. N.W. Waseinaron, 0. C. 178 MR. DRENNAN: We had admission rates of ninety. MR. ROREM: Ninety? MR. DRENNAN: Yes. MR. ROREM: That is what I am saying. MR. DRENNAN: Others, 105 or 135. DR. HALDEMAN: It was the average that he was talk— ing about. ‘. MR, DRENNAN: One hundred twenty. MR. ROREM: I wanted to ask, do you have any theory as to why these particular ones? MR. DRENNAN: I don't know. We hope to find out within the next year. MR. ROREM: I mean are they a different kind of people, older or younger, or richer or poorer? MR, DRENNAN: Over 65 or 75 had no relationship in the hospitalization except we know that the over 65 patients stay twice as long. MR. ROREM: What is the ratio of docters? MR. DRENNAN: We are in the process of finding that out, too. Some of these counties are coal mining, strip mining areas, others are just forest areas and they vary from about 12,000 in population, MR. ROREM: Are these counties of that general nature? MR. DRENNAN; Twelve and twenty thousand, 179 1 MR, ROREM: The reason I ask that, in suburban areas a 2} district of ten to twenty thousand, a medium sized district, 3 | which is a very small district as far as we are concerned, 4 || there seems to be no correlation at all between districts, from 5 || the hospital and number of admissions per thousand. If we 6 | probe that a little we might see a difference in the character 7 || as far as the number of admissions does not seem to affect it. 8 || I dontt know why. 3 Where there are variations there are two kinds of 10 | explanations; there are different kinds of people, older or 1l | younger, and we do not have other data. They go elsewhere. 12 MR. DRENNAN: We know from what county every patient 13 || came and for our purposes at the moment we think this is SR 14 | enough. We have a big work sheet map of the counties showing 15 | the number in a six month period that went into each county 16 || from another county, and it is amazing. They travel 120 or 17 | 140 miles to come for neurosurgery or open heart surgery or 18 | things of this kind. We are only getting into this. We have 18 || some data now, we can begin to investigate a little more 20 | thoroughly. a1 We are back at the zone committee level. Then from 22 1 the zone just the chairman of the zone committee is represented 23 ||on the regional committee from each one of these zones, ten 24 | members there. So we have screened it out. This may be a 25 hospital administrator. He is the best man in his zone. We ACE-FEDERAL REPORTERS, INC. 261 CONSTITUTION AVE... N.W, Wasningron, D.C. 180 1 | have no objection to his being on the regional committee, or 2 |) it may be a health commission, or it may be the owner of a 3 || pottery or an Ohio power company is very influential in our 4 || rural areas. ‘We have representatives on some committees in 5 |} the Ohio Power Company. 6 MR. BUGBEE: How many administrators are there among f 7 || the ten on your present committee? 8 MR. DRENNAN: I think there is one actually. 8 MR, ROREM: Big city man? 10 MR. DRENNAN: Yes, as a matter of fact, and he ll ||represents all the administrators in Franklin County. 12 Then we get into the other state power structures or 13 |} the branches of the state in the region. The United States SR 14 ||Medical Association has a doctor in the academy of general 15 | practice. We have one labor representative in that group. 16 The Ohio Hospital Association has a representative in that 17 group. 18 MR. BUGBEE; These are the ten zone representatives 18 | that you have mentioned and you are mentioning the others? 20 MR. DRENNAN: Yes. We hope the ten we have from the 21 |zones are going to be tentacles of the power structure of the 22 |zone that they represent. 23 DR. KLICKA: What is your score plus or minus? Have 24 you encouraged successfully or discouraged? 25 MR. DRENNAN: I could not enumerate, We have gotten ACE-FEDERAL REPORTERS, INC. 261 CONSTITUTION AVE..N.W, WASHINGTON, 0. C, 12s cca tacts 10 1] 12 13 14 SR 15 16 17 18 19 20 21 22 23 24 25 ACE-FEDERAL REPORTERS, INC. 261 CONSTITUTION AVE., NW. Waseningron, 2. C. 181 rid of a burn center that was tried to be brought in, two hospitals. The newspaper story created quite a sensation; the university wanted it and Children's wanted it and so forth. It ended up I think neither one of them will get it. We discouraged the cancer hospital. DR. HALDEMAN: You have a differentiation between Columbus and the other counties. He has not mentioned it but that Columbus community supervised the distribution of $70 million in the Columbus area since the war and there has been literally no construction in general héspitals in the Columbus area that has not been recommended by that council. Also, you have handied the actual distribution of funds. MR. DRENNAN: That is right. DR, HALDEMAN: You are awarding the distribution of funds out of that office. MR. DRENNAN: But the choice of architects and whether they want a yellow brick or red brick or whatever. DR. HALDEMAN: It is unique in the country in this regard to the control, really. The only other place that comes close to it is Rochester, New York. MR. DRENNAN: He asked some of the failures. We did have 66 beds that were built there by a group of doctors who were not welcome on the other hospital staffs. Started out as a proprietary until they got the loan and got it built and then they took advantage of Blue Cross and other things. 182 i MR. BUGBEE: In processing applications from the 36 2 | counties now? 3 MR. DRENNAN: Yes, sir. 4 MR. BUGBEE: Are they tuning in? 5 MR. DRENNAN: Yes, sir. We were designated before 6 | as an approval. We did not hand out funds for Hill-Burton. 7 || That was Dr. Dubois' provision. He did a ‘fine job. We were 8 | designated by the Ohio Hilli-Burton authority as the approval 9 | agency for Franklin County. This has been back two or three 10 | years now and we had reasonably good success with that. For 1l || the 36 counties at least nothing happens down there within our 12 | area that Bill Worp or a. DuBois or some of our staff are not 13 || conversant with or getting argument for or against. It has sh 14 | been wonderful cooperation. 15 MRS. COLEMAN: What do you do about Franklin County 16 | and the rest of the counties? How do you get these two groups 17 | into it? 18 MR. DRENNAN: Well, we have not really brought them 18 | together and yet we have not kept them apart. We have brought 20 representatives together but we would not try to get 55 admin- 21 | istrators together. The representatives, we tried to stimulate¢ 22 | these local communities and counties to do a job. 23 MRS. COLEMAN: The counties have some form of organi-4 24 || zation that meets once in a while? 25 MR, DRENNAN: Yes. ACE-FEDERAL REPORTERS, INC. 261 CONSTITUTION AvE., N.W. WasuwingTan, 2. f. 183 1 MRS, COLEMAN: Then the zones? 2 MR. DRENNAN: Yes, four or five counties. One person 3 from each zone. 4 MRS. COLEMAN: Who comes from Franklin County? How 5 ldo you get Franklin County into this scheme? 6 MR. DRENNAN: Franklin County is part of Zone 1. 7 There are five or six counties that surround Fragklin County 8 plus one that is somewhat remote and still very much related 9 |to Franklin County. We were originally going to carve Columbus 10 jout as a separate zone. We decided against that before we went ll into the organization. So Franklin County is part of Zone 1 12 and when they meet one representative comes to Franklin County 13 |representing the administrator's council. SR 14 MRS, COLEMAN: You have two-thirds of your population 15 |represented by one person and the other one~third represented 16 Iiby ten? 17 MR. DRENNAN: No, less than half. Less than half of 18 lpranklin County compared to about a million and a half. 1g MRS, COLEMAN: But Franklin County is not the whole 20 jiof Zone 1? 21 MR. DRENNAN: No. That is right. 22 MRS. COLEMAN: How many people are represented by 23 |vone 1 population? 24 MR. DRENNAN: Oh, boy. 2 MRS, COLEMAN: It does not matter really but the ACE-FEDERAL REPORTERS, INC. 261 CONSTITUTION AVE .N.W. WASHINGTON. OF. C. 184 ] | point is -- 2 MR. DRENNAN: There are other representatives from 3 || Franklin County who come to Zone 1. They have representatives 4 ||from city planning, 5 MRS. COLEMAN: From city planning only one person 6 || comes, 7 MR. DRENNAN: We make an exception in this case. 8 MRS. COLEMAN: Yes. 9 MR. DRENNAN: In this one zone we do have members at 10 |} large primarily from Franklin County. If we find people of the li || caliber and experience in planning groups and civic groups 12 | outside of Franklin County, they will be brought into the zone 13 || committee. Since the zone committee is not a determining polidy SR 14 | committee level you are not too worried actually except keeping 15 | it a reasonable size. We are not bothered about the balance of 16 | power. Regionally we are, very definitely. 17 ' Now where did we get to? We got the regional commit+ 18 | tee representing medical, labor, Blue Cross, insurance compan- 19 |} ies, manufacturing and so forth. All of the zones are repre~ 20 | sented and this committee meets about every three months, al MRS. COLEMAN: That must be a pretty large committee} 22 MR. DRENNAN: About thirty-five. 23 MR. BUGBEE: When you say they are representing all 24 | those zones, they are large but they may come from Franklin or 25 || down south or anywhere, ACE-FEDERAL REPORTERS, INC. 61 CONSTITUTION AVE., N W, WASHINGTON, D.C. SR 10 ll 12 13 14 15 16 17 18 19 20 21 22 23 24 25 ACE-FEDERAL REPORTERS, INC. 261 CONSTITUTION AVE... N.W. WASHINGTON, O.C. 185 MR. DRENNAN: Yes. Ten zone chairmen are there representing the zones. Then the others are people like Margaret Dubois who are there from Hill-Burton in an advisory capacity. There is one labor representative. DR. HALDEMAN: In relation to Franklin County you do really control the distribution of capital construction funds. What is going to be the relationship in some of these other counties? . MR, DRENNAN: We are probably going to be an advisor to hospitals and other groups outside of Franklin. When I say "advisor," you have heard very much about the Hoffman Act which permits counties to hold bond issues to construct hospitals which can be leased back to non-profit organizations. Right now we are advising Cleveland County on that implementation. We will do the same thing for the counties within our region in advising Margaret Dubois or Bill Worp or whoever is going to be in Ohio of the amounts of money that are avail- able from Hill-Burton, from the bond issues which the county might put on, plus any other sources of funds, plus the canm- paign council if they do not have that information to advise them as to two or three companies that we know that are in the business of fund raising and might assist -—-- not one, but we will do the same as architects, we will name three good ones and approved and' lat them make their choice. We do not collect information at this time on 186 1 | Operating funds, expenses, or sources of revenue. The Ohio 2 || Hospital Association does this with the Ohio Health Department} 3 || They are taking their data such as needed for planning purposes. 4 You. ask what the county committees do at the meetings, 5 || We have sent out about three planning requirements memoranda, 6 || The first one was on what are their plans for the next five 7 | years. It was informal but still stated ix writing as to how 8 || many pediatric beds, how many medical-surgical beds and so 9 || forth do they anticipate they will need by 1970. Also, how 10 | many private, semi-private, ward accommodations? What is their 1] || anticipated cost? What are their anticipated sources of revenue? 12 || Does the hospital hand down funds from which this is obtained? 13 I don‘t know what we have now. Probably thirty of 14 | them are in. At each one of the zone meetings Pete Volpe is * 15 |} collecting from the representative. County~wide nursing homes 16 |} and health care centers @f all kinds are included in this mem— 17 |lorandum, That is one form. 18 The other is a manpower needs requirement memoranda 19 |} which has to do with medical Staff and per medical personnel. 20 | If they are going to have 500 beds in 1970, how many X-ray 21 |} technicians, how many nurses, how many doctors and so forth do 22 || they anticipate they will need? We are backing this up with a 23 |print out from a company in Chicago from all the medical peopid 24 |in the 36 counties which we now have and which we are going 25 over and checking against staff affiliations. So we have them ACE-FEDERAL REPORTERS, INC, 261 CONSTITUTION AVE .N.W. WASHINGTON, D.C. 187 1 ||by specialty and we have them by age and so on and so forth. 2 Someone mentioned the importance of planning for 3 || medical but we want to know where they are. The communities 4 || know to some extent where they are. The county in Athens tells 5 | us now that they have three or four that are up to age 70, they 6 | are going to retire, and where are they going to get some more’ 7 |The Ohio State Medical Association has given their cooperation 8 | to a very full extent in this study and they are also working - 9 || with us on determination of medical levels, regional center 10 || and so forth. If we have a regional medical center in ll | Columbus and Zanesville and Springfield and so forth, what is 12 | given there and on down to Marietta or Cambridge or some of 13 | the outlying communities. SR 14 MR, BUGBEE: Do you discuss what they should do or 15 || what surgery should not be done there? 16 MR. DRENNAN: I do not know what is going to come out 17 | of that but I would say something like open heart surgery, 18 neurosurgery, some of the other procedures they would recommend 18 || to keep in Columbus. Once again we are not doing this, the 20 | medical profession is doing it. They are giving us the advice 21 | and all we are doing is putting it down and talking it, over 22 || with various counties. It may be theoretical or idealistic 23 | but we think it is fundamental in the staffing of beds and so 24 || forth and the kind of beds you need. 25 MR. BUGBEE: Remarkable. ACE-FEDERAL REPORTERS, INC. 261 CONSTITUTION AVE .N W. Wasuingron, GC. Snr i ne 10 11 12 13 14 SR 15 16 17 18 19 20 al 22 23 24 25 ACE-FEDERAL REPORTERS, INC. 261 CONSTITUTION Ave , NW. Waseincron, 0. €. 188 MR. DRENNAN: We are trying lots of things, let's put it that way. We are not doing anything in the disease field now because the City Health Department has a grant from the State Health Department and the facilities for care of both by voluntary health agencies and the hospitals are cooperating and the state institutions are cooperating.' When we know something more about their methodology and the success of it -—— Ed Lentz happens to be the Project Administrator on that study -- then we may try and apply the 36 county area, Wa have unfortunately stayed out of the nursing home area because we have been besieged with Holiday Inns and Nursing Inns of America and so on, We did I think block a 300 bed nursing home right opposite Riverside Methodist Hospital by the Nursing Inns of America. I think it was twelve stories high and had provisions in it for surgery. Our architect discovered this for us. It could have been very easily con- verted to a 300 bed hospital with general care. -They were doing it entirely under the guise of a nursing home. General beds were tight, medical-surgical beds are running about 90 per cent in Franklin County and about 85 per cent outside. Like some of the others we are trying to dis- courage any building of maternity beds and converting wherever possible. One hospital in Columbus has given up its ten bed maternity section and another one of the rural counties we hope 10 1] 12 1 14 SR 15 16 17 18 19 20 21 22 23 24 25 ACE-FEDERAL REPORTERS, INC. 261 CONSTITUTION AVE.. NW. WASHINGTON, D. C. appear in his final total. He wanted to call it multiple unit 189 is going to shortly. Twenty miles to the next nearest maternit section. Now Columbus, we have been collecting data there for eighteen years. We are pretty well certain as to what the trends are there. We will need about 500 general beds by 1970, Some of them are already in the stages of construction, — One satellite hospital is coming up with about ‘125 beds. We expect to build another 200 bed hospital in the far eastern part of the county. MRS. COLEMAN: How do these satellite hospitals work’ MR. DRENNAN: I don't know, ask Rufus . Ours won't be open until October 1. It will have no maternity, no pediatrics, no medical-surgical. The laundry will be at the main plant. Mostly administration will be at the main plant. MR. ROREM: I might say I had quite a time getting a project director or the hospitals to allow that name to hospital. I said that is all right for a scientific document but put satellite hospital first and then submit it because satellite means one of several hospitals under the same mana ge- ment. Sometimes the satellite becomes bigger than the home office, but the main thing is the joint management. Sometimes their specialization of patients is quite common, let us say obstetrics can be done at the one, MRS. COLEMAN: Do you arrange this by mergers or by y 10 11 12 13 14 SR 15 16 17 18 19 20 21 22 23 24 25 ACE-FEDERAL REPORTERS, INC. 261 CONSTITUTION AVE .N.W. Washincron, D.C. 190 hospital? MR. DRENNAN: You are talking about satellites we have treated? MR, ROREM: Except one is under construction now. That is strictly an outpost of an existing institution. DR. HALDEMAN: They have had a grant to study exist- ing satellite institutions and have a publication out if you are interested. MR. ROREM: Just out within the last month. MR. DRENNAN: This satellite that is going into operation is osteopathic. They have 225 beds now and their present site will not lend itself to expansion. They have a concentration of the staff members in the far western part of the county so it seemed like an ideal situation to experiment on it. MR. BUGBEE: Are you going to give medical staff appointments, one staff? MR. DRENNAN: As far as the osteopaths are concerned, I am not sure. We are coming very close in some circles in Franklin County of excellent cooperation between the osteopa ths and the others but there was no need for it because we had a very, very fine osteopathic hospital in Columbus which took care up to the present time of all the staff needs of the osteopath. As they continue to grow there may be more and more pressure. Throughout the Ohio area where the hospitals are BO 191 1 | developing there is more and more willingness to accept these 2 kinds of positions on their staff. 3 MRS. COLEMAN: I was not aware of that. Are they? 4 DR. HALDEMAN: The number of graduates has remained 5 || fairly constant up to last year when the school in California 6 | was converted to a medical school, so the numeric drop in them 7 | was by virtue of that. This will be offset by the new school 8 || in Michigan if they go through, but I think the trend is going 9 || to be towards conversion of osteopathic schools to medical 10 | schools, ll MR. DRENNAN: I think our choice has been the indivi- 12 || dual patient's choice, and once we buy that premise then the 13 || community has a responsibility to provide hospitals for osteo- 14 | paths as well as M.D.s. SR 15 MRS. COLEMAN: I was a little surprised because we 16 | have them in New York City but they are not important. 17 . DR. HALDEMAN; I have very mixed opinions and feel- 18 | ings on this. As I know some of you know, I have been working 139 | in terms of planning for medical facilities for the last three 20 | years. I have mixed feelings. Today post graduate training 21 | in medical residency is more and more important in the training 22 | of a physician. If you look at even the university teaching 23 | hospitals for osteopathic schools there are institutions of 24 | 100 beds, and you look at the residency >. training opportun- 25 | ities and they are relatively nil. ACE-FEDERAL REPORTERS, INC, 26 1 CONSTITUTION AVE., N.W WASHINGTON, D.C. 10 ll 12 13 14 SR 15 16 17. 18 19 20 21 22 23 24 2s ACE-FEDERAL REPORTERS, INC. 261 CONSTITUTION AVE NW. Wasningron, 2. C. 192 I think we should aim in the long range for upgrading the school of osteopathy. On the other hand, I think I agree with Grant that with the present shortage of physicians that there should be places for them to practice. I would much rather it would be done through opening the existing hospitals to osteopaths rather than continue the osteopath hospital. . It is just like the problem of your small Negro hospital. In Kansas City I think that it would be much better for them to be given staff privileges at Kansas City General in spite of the fact that some of their practice would have to be limited rather than perpetuating a specialized hospital. MR. DRENNAN: This is one good reason for having M.D.s on your planning committees. As you notice we have one from each hospital, a representative from the County Medical Society, plus the County Health Commissioner, all on this level where staff privileges may be discussed, We have a number of communities that are refusing them in their hospitals so the M.D.s want to build another hospital with in-patient beds. It is a problem that we are continually facing. If you do not have the cooperation, I do not know how you are going to solve the problem. MISS JENKINS: Do you have any osteopaths on your operating group? MR. DRENNAN: Yes. DR. HALDEMAN: How late do you want to go this 10 11 12 13 14 SR 4S 16 17 18 19 20 Zi 22 23 pk fls 24 25 ACE-FEDERAL REPORTERS, INC. 261 CONSTITUTION AVE,, NW WASHINGTON OO, C, 193 afternoon? I am taking count as to where we stand. I would like to complete the circuit this afternoon if we could and maybe work until five thirty, because in the morning I would like for us to approach this question of imple-+ mentation from a more theoretical standpoint rather than what you are actually doing, what are the areas that have promise, and sort of list them. ‘ | I do not think we need to perhaps talk about priorities to any extent because it is evident that our mind has not crystalized far enough on this. I would like ® then have a chance to talk about whether there is a need for a type of meeting of individuals from staffs of area-wide planning agencies sometime this fall, and if so, I would like for us to have enough time to maybe just structure such a meeting. I was hoping we could work through in the morning until say one o'clock and get away. Does that seem like a reasonable arrangement? All right. ; In view of the fact we are going to five thirty, we will take a five minute break. (Whereupon, a short recess was taken.) NE eee ee 194 pk/Short 1 DR. HALDEMAN: Dave, do yau want to proceed? flg Short 2 Hi, I don't want to pass you up. 7-8-63 HEW 3 MR. SIBLEY: Go ahead. 4 DR.. HALDEMAN: You don't represent a planning 5 council. 6 Jacques, do you want to tell us about Detroit? 7 MR. COUSINS: Yes. In sitting here and listening 8 to the other side of the table I feel like the President of 9 || Dogpatch Airlines comparing his operations with Pan Am or 10 TWA or American Airlines. We don't do a lot of these things. 11 || I guess we ought to and maybe we will but right now we don't. 12 We have about 4 million people. We do the tradi- 13 || tional assosication type work and then the hospital planning. 14 || The hospital planning is conducted by a planning committee * 15 | which is made up of about two dozen or more people, somewhat 16 || over half of whom are public representatves and the others 17 || are distributed among other hospital trustees and hospital 18 || administrators and we have the county health officer, the Dean 19 of the Medical School, and the President of the Hill-Burton 20 || Advisory Commission on our Planning Committee, all with votes. 21 The staff of the Hill-Burton Agency is invited to 22 | attend all of our meetings, and-unless there is snow on the 23 || ground they do attend all of our meetings. 24 Likewise, I seem to have an invitation to attend any 25 || of their meetings whenever they discuss Detroit. ACE-FEDERAL REPORTERS, INC. 26! CONSTITUTION AVE... NW. Wasningron, B.C. in re | 195 pk 2 i We started out by doing population studies and by 2 || doing engineering studies of all of our physical plants and 3 || then while we were doing this we developed you might say, 4 some criteriaa@ general policies, 5 One has to do with the size of the hospitals. We 6 like 200 beds of a minimum in the metropolitan area although 7 || we will make exceptions in certain circumstances. ’ 8 DR. HALDEMAN: What are the circumstances? 9 MR. COUSINS:: Primarily if it is out in the more 10 | mral parts of the area or if it is in a situation where we are ll | faced with being able to put up a 125-or 150-bed hospital, well, 12 || we cannot put up any more but if we don't put that one up or 13 || encourage it, some fly-by-night or 50-bed institution will get SR 14 || in there, so we kind of bend over backwards. 15 Usually we try to merge the two groups together and 16 || we have been successful in a few instances in doing this. 17 We have been doing patient distribution study since 18 | about four or five years ago so we know where our physicians 19 | are and where our patients are, and I hope we will be doing it 20 next year again. 21 MR, SIBLEY: Do you have any relation of those? : 22 MR. COUSINS:: No, we just counted noses, where the 23 | patients come from and where the physicians have their i 24 MR, SIBLEY: But you have not drawn any critera fro 25 | that? ACE-FEDERAL REPORTERS, INC. 261 CONSTITUTION AVE., N.W. Wasarnaran, QC. pk 3 1 10 11 12 13 14 SR 15 16 17 18 19 20 21 22 23 24 25 ACE-FEDERAL REPORTERS, INC. 261 CONSTITUTION AVE .N W. Wasningran, B.C. 196 MR. COUSINS: No, we really have not. We have broken it down so that, for instance, we know how patients pay their bills, you know, length of stay, what kind of Specialist they go to and so on and so forth. We have never written anything up on these statistics We use them almost daily. MISS JENKINS: On your doctors did you get their age and specialty? MR. COUSINS: The age of the physician? MISS JENKINS: Yes. MR, COUSINS : We can get that. We don't have it on the IBM card. In other words, you can name any physician in Detroit and we can tell you where he has his patients in six months, MISS JENKINS: We maintain an IBM card on that. MR. COUSINS: We discovered that some hospitals that we thought they were getting the bulk of the man's work were not getting nearly as much and we were able to predict with considerable accuracy what happened to your. hospital, and by physician we can tell yau what happened. MR. PETERS: Contact the doctor himself? How did you get the information, contact each doctor individually? MR. COUSINS: No, we told the hospitals we were going to do this and we did it. MR, PETERS: You got it from the hospitals? pk 4 1 10 ll 12 13 14 SR 15 16 17 18 19 20 2 22 23 24 25 ACE-FEDERAL REPORTERS, IMC. 261 CONSTITUTION AVE ,.N.W Waskingran O 197 MR. COUSINS: Yes, we had bushels of mail coming in every night showing all the discharges. MR, ROREM: You mean you do this currently? MR. COUSINS: We did it during the six-month period. MR. ROREM: 225,000 discharges? How many? MR. COUSINS: 225,000 discharges, all on IRM cards. It is very helpful. ‘ Well, on a quarterly basis the staff gives to this Planning Committee, which incidentally over the past seven years has not changed very much, continuity on that Committee now, we give them on a quarterly basis an analysis of need based on population and this does not change very much. Then we show them the number of acceptable beds, the total number of beds in the 10 study areas that we have in our six counties, the number of beds under construction, the number of beds that we have approved for construction -- this differs sometimes -- the number of projects that they have approved for future construction, the number of projects and the number of beds that the Committee has approved for future construction, the number of beds that are being tabled or undex study by name of hospital, and then we have another column :: which is all the projects that have come to the attention of the staff, We have about two projects a month; that is about the average comming to our attention. I would say about 20 percent pk 5 SR 10 il 12 13 14 15 16 17 18 19 20 al 22 23 24 25 ACE-FEDERAL REPORTERS, IMC. 261 CONSTITUTION AVE ._N.W WASHINGTON, O C 198 of them never get beyond the staff because we usually are able to say to these people, ‘Well, you want an area where they are over-bedded," or we point out some of the financial problems involved. So about 20 percent of the projects never get beyond us, although any project coming to our attention and they write us a letter and insist on meeting with our Planning Committee, they do meet with our Planning Committee. Now our Planning Committee meets, oh, anywheres from Six to 30 times a year, it depends on the volume of work involved. Sometimes they have various projects to consider and sometimes it is strictly housekeeping work that they perform, Now I think probably the area in which we have been most successful has been in the implementation of this and I think the reason for it is because of the power structure in Michigan or Detroit. We are somewhat like in Pittsburgh. You get a few corporations and a labor union to agree on something and it is wetty difficult to buck it, at least for any major project. This creates other problems. For example, when we were first set up to do planning these same corporations and the union set up a capital funds corporation called the Metropolitan Detroit Building Fund and these people took about five years to raise $15 million which was then spent pretty largely on our recommendations after we had spent five years studying the needs in the area. pk 6 SR 10 1] 12 13 14 15 16 17 18 19 20 val 22 23 24 25 ACE-FEDERAL REPORTERS, IMC, 261 CONSTITUTION AVE ,NW WASHINGTON, OC, 199 They didn't take our recommendations in toto and they double-checked us by hiring Jim Hamilton and Associates to come in and do a double survey. They didn't follow Hamilton's recommendations 100 percent either. Hamilton's recommendations and ours were almost identical. our number two choice might have been his number five choice. ‘ MR, BUGBEE : Why didn't they follow it? MR, COUSINS: Well, there were a couple of reasons. There were one or two instances of honest differences of opinion where Hamilton thought our recommendation was wrong and we thought his was wrong. Then there were a couple ofcther problems. The capital funds corporation covered only three counties in our six-county area. Hamilton, of course, studied only the three counties, we studied six. So in our recommendations to the Building Fund we told them if the corporations in their budgets set up "X" amount of money contributions to hospitals they should ... donate to the Building Fund "X" minus a certain amount becausa there were three counties outside of this area that have legitimate needs. So you have some responsibilities to these other counties and this is another place where we have a difference; but by and large, I think you have to say that Hamilton used 10 11 12 13 14 SR 15 16 17 18 19 20 21 22 23 24 25 ACE-FEDERAL REPORTERS, INC, 261 CONSTITUTION AvE .N.W. WASHINGTON, 0, C. 200 our figures so its really a matter of judgment more than anything else. The other area in which we have been able to implement things has been excellent cooperation with our State Hill-Burton program. I cannot think of any project that we turned down that Hill-Burton gave any monies to. I can think of a few projects that we approved that Hill-Burton didn't giv Money to but not, the other way around. The other thing is that we have had a very good working relationship with Blue Cross. The first document that we ever published had a list of about 11 philosophical expressions of the new hospital planning. One of them was that we should work closely with Blue Cross, one with the size business that I mentioned, and another one was that hospitals should be truly community oriented and not corporate setups,that we have so many hospital where a proprietary type corporation operates a voluntary non- profit corporation, We also said that we should give priority to com- pleting hospitals that had been recommended for expansion befor we build new hospitals if everything else happens to be equal. We also said that we didn't like to see any expansion of hospitals that had not been built originally for hospitals and that we would turn down automatically any hotel conversion job or motel or private home. Ww 10 11 12 13 14 SR 18 16 17 18 19 20 21 22 23 24 25 ACE-FEDERAL REPORTERS, IMC. 261 CONSTITUTION AVE ,N.W Wasringtonw 2.6. 201 Then Blue Cross came along a few years later, about three years ago, and set up standards for newly participating hospitals. In these standards for newly participating hospitals one of the standards says that the hospital has to be built in response to demonstrated community need. So when a new hospital applies for participation in | Blue Cross, Blue Cross writes us a letter and says, "Is this hospital needed?." I guess we have had about 18 of these letters in the past three years. I guess we have said probably "yes" to about 10 or 12 and we said "no" to the rest of then. Blue Cross has backed us up on every single one of them except one and that is one where the hospital had started construction just about the time these new standards cane in. Now it has reached the point where anybody who wants to start a hospital and addition -- MR, BUGBEE: Either a new hospital or an addition? MR, COUSINS: Well, within the past three weeks . unless Michigan Blue CrossIms adopted new standards, the standards for existing participating hospitals and the additions to existing hospitals are going to have to be approved by us or approved by Blue Cross. Blue Cross will turn to us and Hill-Burton for advice. DR, HALDEMAN: Could you get those criteria and send SR 10 1] 12 13 14 15 16 17 18 19 20 val 22 23 24 29 ACE-FEDERAL REPORTERS, IC. 261! CONSTITUTION AVE .N W Waewneron BOC 202 it to us? I got a copy from McCarthy a couple weeks ago but I don't know what happened to it. Have they been formally adopted by Blue Cross in Michigan or was it just a draft we were looking at? MR, COUSINS: No, they have been adopted now. MISS JENKINS: Have they been adopted as that draft t indicated? MR. COUSINS: Yes. MR. ROREM: I don't remember having received any. MISS JENKINS: I received one. DR, HALDEMAN; I might say that I hope that all of you perhaps weculd take the mailing list ~~ do we have a mailing list of this group? -- and send to us copies of any written material that you have about what you have been talking about. I know in a number of instances yau do have it written up in one form or another. Is there a mechanism for getting information around? MR, ROREM: None that has been formalized that we know of. MR. SIBLEY: Since I left Chicago or since I left theoffice, which is practically two weeks, we have made out a list of the 40 Planning Councils which have executives that we know of and asked them to do the thing that we require, we ask our State hospital associations and Metropolitan hospital membership councils to do, which is to put each other on their pk 10 1 10 11 12 13 14 SR 15 -16 17 18 1g 20 21 22 23 24 25 ACE-FEDERAL REPORTERS, ISIC. 261 CONSTITUTION Ave .N W Wachingras @ 7 203 mailing list so that anything they have to mail goes auto- matically without coming through our office. That has now just been initiated and we will send this revised list out, I guess, semi-annually. DR. HALDEMAN: Is there some way we can get on that Mailing list? I don't know. Ken, do we get it? | MR. BAUM: No, we don't. t MR. SIBLEY; I have already written it down, it is ~ in my pocket, | DR, HALDEMAN: All right. MR, DRENNAN: I think everybody in New York gets our Mailing list. We send it rputinely and I think we send you several copies. DR. HALDEMAN: We get lots from Columbus. MR, DRENNAN: Nonprofit mailing franking. DR. HALDEMAN: Well, pardon me for the interruption. MR. COUSINS: Now it has gotten to the point where it is almost impossible for anyone to think about starting a hospital in southeastern Michigan without getting tangled up with the State Health Department, Blue Cross or the Hospital Council, because whenever any..one of these three agencies ever hears about a project -- when I say "hear" I mean I was in Chicago the other day speaking to a group of the House of Delegates of the Osteopathic Association, and I heard about a project, 204 ll 1 Well, copies of this have already gone to our State 2 || Health Department and to Blue Cross. Now nothing may come of 3 || this but we alert one another immediately and we always tell 4 || anybody that contacts us that we have to contact the other two 5 || people, 6 So the net is pretty well drawn and it is almost 7 || impossible to get around this. ‘ 8 Now we have problems. Our problems are osteopaths, 9 || small hospitals that do not ever intend to receive philanthropic 10 || funds or even Hill-Burton funds, and who in the past have ll | always been able to secure adequate financing. 12 Now this is beginning to tighten up a little bit 13 || because as a result of what I guess the community thinks is i 14 a reasonably objective job I would say, that every major bank 15 |} in town, many of the national insurance companies, the larger 18 | ones, particularly those that have some sort of a group office 17 | or district office in Detroit, contact us whenever they are 18 asked for a mortgage. - 19 This has bean remarkably effective judging by the 20 | number of times we get called by different banks as we keep 21 | saying we either never heard of this project or we disapprove 22 | of it. 23 The hospitals apparently have to hunt a little longenx 24 Ito get this money. So this is helpful. 2s DR. KLICKA: Did this just grow or did you do ACE-FEDERAL REPORTERS, IMC. 261 CONSTITUTION AVE .N W WESHIRGTINN AC a aaa a aT 5113S c amma ammmmmammmammmmmmasmemmmaacaataaaacmmsacmmastasasacm causes sama 12 SR 10 1] 12 13 14 15 16 17 18 19 20 2l 22 23 24 25 ACE-FEDERAL REPORTERS, IMC. 261 CONSTITUTION AVE .N W Wasnincton, 0. C. 205 something? MR, COUSINS: This grew. We talked about doing some thing but our attorneys told us we would get into serious difficulties if we ever called a meeting of the banks and insurance companies to talk about it. But through our service association type work and our relationship with the Health Insurance Couhcil and other groups such as that, this is how it has spread. We are having nursing home problems now. We hope to get into this. We have Negro problems, that is one of our real big ones. We have a problem in timing. As you may recall a few moments ago, I said that we send out these quarterly reports for a Planning Committee showing what the need is in the different sub-areas and how close we are to meeting that need. Well, a hospital will appear before us in 1959 and it wants to build something. Well, we don't like what they want to build or we don't like the corporate setup and we don't tell them "no". In some instances we do tell them. Let's say in one instance we don't tell them "no"/ We tell them that if they revise their project, the corporate structure, we will then consider them. We have a few of these that over the past couple of 13 SR 10 ll 12 13 14 15 16 17 18 19 20 2] 22 23 24 25 ACE-FEDERAL REPORTERS, IC, 261 CONSTITUTION AVE .NW Wesrincron, 0 206 years because of our prodding, because of Blue Cross' prodding, because of some work done by the McNearny group in Ann Arbor, they have revised their Corporate setup and they have revised their projects. They are now coming back to us but the need has changed in this area, In fact, from here I am going back to al meeting where we have to decide what to do‘with one of these which is now as clean as a hound's tooth but there is no need and he owns the land. I don't know what we are going to do. Another problem that we have, although I think it is beginning to change a little bit, is with governmental officials, originally they paid no attention to us, the city and county level. Now they are beginning to pay a little more attention to us. Certainly the City of Detroit is now asking us to sit in as members of various committees appointed by the State Council or by the Board of Health to decide what to do with the Board of Financing of indiginent care, providing psychiatric facilities in the city hospital, in relationship of the city hospital to the Medical School and other things, but we earned this, I think, over the past six or seven years, Suburban officials are still extremely leery of a "Detroit group" telling them what they should do, but I think there are some improvements made along that line. Another problem that we face is in relationship with 14 1 10 11 12 13 14 SR 15 16 17 18 19 20 21 22 23 24 25 ACE-FEDERAL REPORTERS, INC. 261 CONSTITUTION AVE., N.W, Wasninaran, 2. &. ' somebody else has sneaked in and filled up the vacuum. 207 county medical societies. We have one big one, the Wayne Medical Society, and while our relationship and service association is excellent with them, in the planning work the relationship is very good with some of the members but the County Medical Society is a very difficult animal to work with. They will never commit :‘themselves, at least ours wont. They change their leadership evety year and this can mean a 100 percent change in the philosophy of the County Medical Society. Sometimes the guys that are in leadership positions don't represent really what the membership feels. So we have some problems there. By and large, I guess you would have to say that as far as implementing things were concerned we have as tight control, I think, as any other area which had hospital council and this bothers me, frankly, because I am not so sure that we are that right all the time. One paradox, as a result of our work we have probably delayed the construction of needed good facilities because everybody says we have to study this thing, and meanwhile, I think this is changing a little bit, particularly due to Blue Cross' standards and the fact we won our lawsuit. This means that these fly-by-night operators, I think, are going to have to think twice before they think to build hospitals in Michigan: 208 15 : I must say that when the corporation set up this United Fund drive, capital financing, then we had a recession 3] in 1958, I kept telling the chairmen of Ford and Chrysler that 4 || they were crazy to let a minor recession delay this fund drive 5 | for about two years for the very simple reason that if they 6 | didn't kick in the Money in capital fund-raising they were 7 going to pay for facilities anyway, because somebody would 8 | build these additional facilities. 8 Since Blue Cross in Michigan is financed largely by 10 | the big-3 and since Blue Cross in Michigan allows for a depreciation, the corporations are in a peculiar position. If 12 they don't give the money, they bargain for it over the bargain- 18 ing table with the UAW and they wind up paying for it anyway. SR 14 | So this $15 million drive which was supposed to produce about 15 | g00 new beds, I think in modernization about 500 or 600 other as beds, this thing was delayed for a couple of years and mean- 7 while, we saw almost an equal number of beds put up in 7 situations that we didn't think particularly desirable. 18 MR, BUGBEE: What sort of situations, small 20 hospitals that had an accumulation? al MR: COUSINS: Yes, 50-bed hospitals that decided to 22 | become 125-bed or 150 that decided to become 210 or a new out- 23 and-out construction project. 24 An osteopathic hospital in Pontiac, a new hospital 25 just 10 miles from Ann Arbor and a few other hospitals of thig ACE-FEDERAL REPORTERS, INC. 261 CONSTITUTION AVE., N.W. WassineTon, D. £. CO Ci eee, 16 SR 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 ACE-FEDERAL REPORTERS, INC. 61 CONSTITUTION AVE., N.W, WASHINGTON, D.C. 209 nature, but none of these people are going to the corporations for funds and most of them are not even going to the Hill- Burton for funds, I don't know whether in the future we are going to be able to control this any more. I know that our United Foundation has recently set up a capital gifts provision which intends to set up a blueprint to study and'then to provide the financing for 20 years worth of needs in health, welfare and recreational activities in the greater Detroit area. Now how effective this is going to be I don't know. MR, SIBLEY ; This being a part of the giving scheme on the part of corporations? MR. COUSINS: Yes, five years and they fill up the pot and the pot would be empty. MR. SIBLEY: But it is regular giving each year? MR. COUSINS: Yes, and they would hope by doing this they could then control things even more than they do now, See, we are faced with a developing medical center that is going to hit the community somewhere for $180 million. Some of this will be Government money but a lot of it will not be Government money. This has to be tied in. The last two capital fund drives have been largely in suburbia. Now we are beginning to pay attention to what hais to be done downtown. MR. SIBLEY: Do you :«:call this positive planning, 17 J 10 ll 12 13 14 SR 15 16 17 18 19 20 21 22 23 24 25 ACE-FEDERAL REPORTERS, INC. 26 1 CONSTITUTION AVE., N.W. Wasnincron, D.C. 210 Jack? DR. HALDEMAN: Yes. MR. SIBLEY: I certainly agree with you. Now we have to face large amounts of Money that are going to be needed and not just let it slide along. MR, COUSINS: Ina nutshell, Jack, I have pretty wel] covered what we do. ‘ DR. HALDEMAN: I am interested a little more about the implications of the court decision. TI don't know, Jim, whether you were going to talk about that. Is it going to be appealed or is this just the first bout, the first round of a fight that will go on? MR. COUSINS: Well, the court decision was rendered now I think about two weeks ago, and the losers had 20 days in “ which to appeal either for a new trial -- boy, I sure hope the} don't -- or to appeal to the Supreme Court. This court decision was the situation wherein an existing downtown hospital that had been a group. participating hospital for 30 years eet up a new corporation and created a satellite hospital in a building that was 35 years old and in the eyes of our Planning Committee and Hill-Burton did not Warrant having any money put into it in an area where neither Hill-Burton nor our area Council thought there was need, The hospital finally came to our Planning Committee in order to secure our advice but the first thing they told us 211 _ 18 1 || was that they had already bought the land, hired the architect, 2 it cost them $700,000 and regardless of our decision they 3] were going to go ahead and do it. 4 We told them they were nuts, that it would cost 5 || them more than $700,000, probably close to a million. We | 6 || were wrong, they have spent a million and a half already and 7 || the hospital is not open yet. 8 They then went to Blue Cross to get the Pparticipatioh, 8 | and based largely on our findings and on the findings of the 10 Hill-Burton Agency, Blue Cross turned them down. 1 The hospital then sued Blue Cross and we were in 12 court, I think, for the better part of five weeks. Carl was ah 13 expert witness on behalf of Blue Cross and Charlie Laturno SR . 14 | was an expert witness on behalf of the hsopital. iS Charlie set it up beautifully for Carl and for me 16 || because our attorneys asked him how did he know that this '7 | hospital needed to be built and he said, "Well," he had driven 18 around the neighborhood for an hour and the kind of houses that 19 | were going up were very similar to those in Chicago where they 20 needed new hospitals. 21 So then they asked him had he ever done any area-wide a planning and he said, "Yeah, hundreds of times," 23 We then asked him how he did it and he told us how hd 24 did it. We asked if he did it for this particular project anda 25 he said, "No," he had not. 261 ConerituTion Ave. NW. Wasvington, D.C. 212 19 1 Then Carl came along and said how he did it and we 2 || told how we did it. Charlie gave a textbook approach to the 3 thing although he had not done it for this particular hospitall. 4 Interestingly enough, an important decision which wals 5 || favorable to Blue Cross was favorable on the point of law and 6 | that is that the Blue Cross Enabiing Act may contract hospital. 7 The judge said that it was not within his province tb 8 || stipulate that they must contract but then he tore into -- I 3 |} don't think you are named in the findings by name, I am. 10 The judge disagreed on our determination completely ll || and said we were all wrong and he arrived at his own deter- 12 || mination. He just took the population from Macomb County and 13 | multiplied by 3.5 or 4.0 and he came up with a figure. SR 14 MISS JENKINS: The judge did? 15 . MR, COUSINS: Yes. What the judge ignored was that 16 | Macomb's population is all along the southern border of the 17 || county and there is a whole string of hospitals anywhere from 18 | a quarter of a mile to three miles just south of that line and 19 | this is where most of those people go. 20 Personally, as far as we are concerned, there is no 21 | reason why they should not go. 22 MR, BUGBEE: When is the 20 days up? 23 MR, COUSINS: I think the end of this week. I think 24 | Friday or Monday. 2s MISS JENKINS: Do you think they have the money to ACE-FEDERAL REPORTERS, INC. 261 CONSTITUTION AVE., N.W. WASHINGTON, O. C. 213 pk 20 1 |} continue the litigation on it? 2 DR. HALDEMAN: They have in the Detroit area a very 3 | difficult time of filling many beds without the assistance of 4 | Blue Cross. 5 MR. COUSINS: Yes, but they get only $15 a day from 6 || Blue Cross. Now this has some very serious implications 7 || because we have a couple of other projects’ that are under con-+ 8 | struction right now. 9 MISS JENKINS: But you were not sustained on the 10 | basis of the plan, you were sustained only that Blue Cross ll || does not require? 12 MR, COUSINS: We have another court decision 13] involving that. Now this is the reverse. This is a situation SR 14 | of where we approved of a hospital and the Community Planning 15 | Commission of this particular community also approved the 16 hospital and the Zoning Board approved the hospital but the 17 | City Council turned it down, so there the hospital is taking 18 || the City Council to court to force the City Council to give 18 | them a permit to build. 20 MR, BUGBEE: Why did the City Council object? 21 MR, COUSINS: The City Council objected because they 22 got something like 10 square miles and they have just had three 23 | new hospitals under construction there and they don't want any 24 | more nonprofit organizations in the community. 25 When we testified in court it was interesting to hear ACE-FEDERAL REPORTERS, INC. 261 CONSTITUTION AVE., N.W. Wasnincron, D.C. A A LC AC: cz; ama ammeter 21 1 10 1] 12 13 14 SR 15 16 17 18 19 20 21 22 23 24 25 ACE-FEDERAL REPORTERS, INC. 261 CONSTITUTION AVE , NW. WASHINGTON, D.C, 214 the judge in his opening remarks Say that he didn't want any- body from Hill-Burton testifying because he was sick and tired of Government intervention in the county and he didn't want any- body from the Hospital Council and he didn't want any outside experts, this was a matter for citizens, It is still in litigation. MR. ROREM: You know they say you have not arrived until you have been sued a couple of times so that will be next. Have you been hauled into court yet, yourself? MR. COUSINS: No, the Hospital Council has not. It has always been Blue Cross or the hospital or a unit of Government hauled into court but we are always asked to testify Iwas in three different courts in two consecutive days and I had to get my stories straight because I had to reverse it in court hearings. DR. HALDEMAN: off the record. (Discussion off the record.) DR. HALDEMAN: My theory on the record is that the way you win these cases you just worry about them enough. It seems to me we had something on Hill-Burton every month it comes up, just felt like we were never going to get solved and I worried about it enough. MR, SIBLEY: I thought you made John and Bill do you worrying for you? Bn 215 22 I DR. HALDEMAN: I do, but we worry. 2 Further comments? 3 Questions? 4 MR. ENSIGN: Jack, the judge's discussion on the 5 need for the hospital was based on cutting up the area-wide 6 pie in terme which seemed to fit the plaintiff's pattern, 7 the plaintiff gerrymandered this thing to make it work for 8 || himself, . 8 MR. COUSINS: Yes. 10 DR. HALDEMAN: What is the implication of this ruling, 1l | Jim? 12 MR. ENSIGN: It is difficult to Say because it was 13 || decided only on a point of law which happens to be in Michigan, or 14 || enabling legislation. It means different things for different 15 || plants, some of which have no control whatsoever in the contratt 16 || with them and some Plans laid down in the statute with the 17 contract, all licensed institutions and others. The language 18 | is different. ° 19 T would say that we would be very happy about it had 20 | the judge Supported the concept of area-wide planning. We hope 21 i that the case would come up where that ruling takes place but 22 af it comes up the point of law is not present. 23 This one would have been turned down and this would 24 have had serious implications. 25 DR, HALDEMAN: There are other Blue Cross groups that ACE-FEDERAL REPORTERS, INC. 6! CONSTITUTION AVE. NOW. WASHINGTON, D.C. Bn 216 23 I are planning on taking need and consideration? 2 MR. COUSINS; There are, indeed. 3 MR. ENSIGN: In Arizona, the Arizona plan adopted 4 the same exact language that the Michigan plan has in Spelling 5 out what a participating hospital must pay which states that 6 the hospital must have been planned and built in response to 7 a clearly evident need for additional beds‘in its community 8 and so forth. ad 9 Just because you didn't know that this was the rule 10 does not let you off the hook, so there are a number of plants 11 | that are picking up this kind of thing. 12 In Arizona, it would help to head off the eight per- 13 | centers, In fact, it has caused a lot of bondholders heart- 14 | ache. SR 15 MR. COUSINS: Trying to be objective, I sat through 16 || most of this trial. If I had been the judge, I don't know 17 | which way I would have gone because Dr. Klicka confused me , 18 Hill-Burton confused me, the expert on the other side confused 19 || me. 20 My own County Health officer was adamant that it was 21 | wrong and immoral. Macomb County mothers had to go to another 22 || county to be delivered of babies. 23 The president of my County Medical Society said that 24 | there was a need for beds, and by applying the formulas used a by myself and Dr. Klicka and forgetting about all the hospita lp ACE-FEDERAL REPORTERS, INC. 26 | CONSTITUTION AVE .N.W., WASHINGTON, D.C. 24 1 10 1] 12 13 14 SR 15 16 17 18 19 20 al 22 23 24 25 ACE-FEDERAL REPORTERS, INC. 261 CONSTITUTION AVE... N.W. Wasningron, 0. C, 217 that were a quarter of a mile to three miles outside the area I would very easily arrive at a very fantastic need for Macomy County. That judge must have been bored Silly or thoroughly confused because I think I know what I am doing, I will tell you after having been cross-examined and after having to say why did we use this formula, what formula Gid they use in Pittsburgh? what did they use elsewhere? why were they dif- ferent? how did I arrive at 175 population for these particula sub-areas of the county when Hilli-Burton arrived at 192,000? why was there a difference? You know, you get a lot of experts together and a guy who just depands on ordinary common sense just says the hell with all the experts. | MR. BUGBEE: That is what he said, I guess. MR, COUSINS: That is what he said, took several pages to say it. | So we have a lot of work to do in the selling and the public relations end of this thing. DR. HALDEMAN: Well, I think we better get on. Any other questions? I will go to carl. DR, KLICKA: I will kind of make mine brief, I will have to. MR, SIBLEY: Ten minutes, Carl. DR, KLICKA; Ten minutes, 218 - 25 ] I think it is of some interest to tell you that the fact that we had no committee organization at all. We had 5 a Board of Directors and that was it. So everything was flush 8 || with the hospital field knowing what they did in New york. 7 I proposed a number of special area committees that 8 included on the Membership a number of professional experts 3} and laymen who were active in the health field. 10 There were, I think, five or six of these committees 11 | and I was very proud of them, I thought I had structured them 12 | very well. 13 Well, this recommendation went over like the pro- _ 14 | verbial lead balloon and fr can still remember mr. Ryerson 15 accepting my recommendation graciously but Saying, "Carl, we 1 | are not going to run this Council this way. We want you and 17 | your staff to do the work, you make your recommendations to this 18 Board or to the Executive Committee which we will form," which 1g they Subsequently formed an Executive Committee, this smaller 20 group made up primarily of the officers, Let's see what al happens, 22 Well, since that time we have reviewed 161 hospital 23 proposals. Now of this 161, 78 were oposals for brand-new 24 hospitals. of the 80 Proposals that were for revisions of 25 programs of existing hospitals, whether they would be expansions ACE-FEDERAL REPORTERS, INC. 261 CONSTITUTION AVE... N.W. Wasningron, 0. C, 26 1 10 ll 12 13 14 SR 15 46 17 18 1g 20 21 22 23 24 25 ACE-FEDERAL REPORTERS, INC. 26 1 CONSTITUTION AVE... NW. WASHINGTON, D.C. 219 or contractions or relocations, all but three followed the recommendations that were finally made by the staff and endorsed by the Executive Committee. I want you to know that the key here in being able to do this and to have such a turnover has to do with the fact that we do not do studies in depth as they do in New York| We have been the greatest thing that ever happe ned to Chicago, I guess, as far as professional consultants are concerned, because in most of these instances we have urged them to have thorough Surveys done. In the early days this got us into trouble because we found ourselves getting into more and more disagreement with the phase of the study that related to bed need and this is because these consultants used the only material that they could and this was the State survey and plan. | The more our research staff came up with data the more we began to appredate that the State survey and plan was much too generous and inconsisten, 7 We began telling consultants as they came into the area that we would providethem with the bed need recommend - ations and rely on them to do everything else in the hospital which had to do with detailing of the long-range program, internal organizational studies, in relationship to various relationships that they might establish for other agencies in the community and so forth. 220 _ 27 1 Then what we have done is to have taken these 2 studies, to have reviewed them and then to have discussed 3 them with our Executive Committee. We have worked very 4 closely with the professional consultants that have come into 5 | the area and as far as I can tell, they have been just as 8 happy as we have been and we have been very happy with the 7 || relationship that has been evolved. 8 Now with the new hospital proposals we have had a 8 little different set of circumstances. Of the 78 proposals, 10 | about 60 of them were proprietary in hature,. Every single 11 | one of these were proposed by people who had had vast 12 experience in establishment of discount houses and shopping 13 | centers. SR 14 Without exception they wanted to place them in areas 15 || where we thought the need was already well met or was to be 16! met by programs that are already jelled and moving along. ” Sponsorship was not only by the real estate developers 1S but in most instances there were a few doctors who were part i and parcel of these organizations. 20 ‘Tt was difficult to get the details of the organ- 7 izations but most of them were the small corporations of 10 a people or less. This is the same kind of a partnership arrange - 23 ment you know that permits the owners to take advantage of a depreciation on their income tax ‘venture and which is really 25 the big appeal in this whole thing. ACE-FEDERAL REPORTERS, INC. 261 CONSTITUTION AVE , NW. WASHINGTON, 0. C, 28 1 10 11 12 13 14 SR 15 16 17 18 19 20 21 _ 22 23 24 25 ACE-FEDERAL REPORTERS, INC. 261 CONSTITUTION AVE., N.W, WASHINGTON, B.C. 221 Well, of the 18 voluntary efforts for new hospitals we encouraged 90 and most of these are already under con- struction or have been built and are in operation. One of them is postponed to a later date, one of them is going to end up being a satellite hospital to another one and it is under planning. The remaining ones we dis-~ couraged primarily through what we call logical persuasion and they bought the persuasion. Sixty proprietary instituations got actively dis- couraged. Of this 60 that we actively discouraged one was built, and this one I don't think would have been built had it not been for the fact that it was financed pretty largely by crime Syndicate money. That hospital is still in operation; however, it is really on the ropes and having a very difficult time. There again, although it is not known, it presumably is being perfused by crime Syndicate money. MR. BUGBEE: What does that mean? DR, KLICKA: This means it is being fed. Pardon me for using a little medical jargon. Now 59 therefor have been discouraged and I think most of them successfully discouraged. Now I would like to tell you a little bit about how we did it because this is the implementation. I would like to use the blackboard for this. One of the things that we have discovered is that 222 29 1} the local officials in the community can be extraordinarily 2} helpful. I won't go through the historical development of this 3] but I will bring you up to one that we worked with in the last 4 | six months that we think is most interesting and this was one 5 | that was a hospital that was proposed in Northbrook, a real 6 || nice northern suburb. 7 We learn about these and we learned about this one 8 || through our scouts. Our scouts throughout the metropolitan 9 || area are primarily hospital administrators. They pick up 10 | facts relating to the establishment of these hospitals in ll | various ways. This one was picked up by -- I think this 12 | particular scout happened to be Dave Kinzer who was Director 13 | of the Illinois Hospital Association. He saw a small squib in SR 14 | the newspaper up there where a group had gone to the Zoning 15 | Board and had asked for a zoning variation to permit them to 16 || build a hospital. 17 Dave called our office and said, "Carl, do you know 18 about this?" I said, "No, thank you very much." The next 19 | move was to write a letter to the Mayor of Northbrook telling 20 || him that we had heard about this and asking him if he knew 21 | about the services of the Hospital Planning Council for 22 | metropolitan Chicago, and if he didn't we would be very happy 23 | to work with them in determining whether or not the establish- 24 || ment of a hospital in Northbrook would be in the best interest 25 of the community. ACE-FEDERAL REPORTERS, INC. 261 CONSTITUTION AVE..N W. WASHINGTON, D.C, ccc. acaaasaaamaaaaaaaaaaaaaaaacaaaaaaaatatasaasaaaaamaasammamasasmmaamaamaaaaaaaammaaaaamaamacammmass sa scaumasmmmmmmmmmmmsss ar pk 30 1 10 ll 12 13 14 SR 15 16 17 18 19 20 21 22 23 24 25 ACE-FEDERAL REPORTERS, INC. 26 | CONSTITUTION AVE.. N.W, WASHINGTON, D.C. 223 We subsequently heard from the attorney of the village Saying, "Thank you very much, this is going to come up in the Village Council meeting where the Zoning Board is going to submit their opinion regarding the advisability of giving a zoning variation to this group and you will be permitted to come up and talk to us at the same time." In the meantime, we did a little bit of scouting of Our own. We found out what the Physicians in the area thought about this and we learned, fortunately, that they knew nothing about it, which was good because you see, this indicated that these people had not even bothered to talk with the doctors in the area, We found that they were not at all in favor of this, ‘they all had staff positions in their hospitals. They knew Some things about the man who was primarily the sponsor here and they didn't think that he would be a fit sponsor, actually, for a hospital in their area, So when it came to the Council meeting we talked first on the basis of our studies indicating that there was a lack of need, we thought, and that if a hospital were established it would definitely cause a hardship to the hospitals that were already Supporting this area for reasons well-known to this group. We also felt that the Sponsorship of the hospital left something to be desired and we reviewed this, Finally, we 31 SR 10 1] 12 13 14 15 16 17 18 19 20 21 22 23 24 25 ACE-FEDERAL REPORTERS, INC. 261 CONSTITUTION AVE ,|N.W. Wasnincran, O. C. 224 pointed out that the plans, and we had seen the plans, were minimum and although they could be approved by the State because they met their minimum requirements, they were vastly undersized, That is, the hospital was vastly undersized, fotally, it: only provided for something like 450 square feet per bed, and for a 150-bed hospital we thought they would end up with a kind of hospital that would not be consistent with the other facilities in Northbrook. Anyway, we developed a case. The doctors Spoke from the audience and they made some objections. They felt that if there was to be a hospital certainly they should have been advised of it. They had not been asked whether there was a need and they also didn't like the idea of someone coming in and establishing a hospital and possibly bringing doctors up from the City of Chicago, doctors who already were not there, This is vested interest but this is all right because this is all part of the pattern. Finally, Dave Kinzer got up and he spoke against this hospital from the point of view of just good general principles of community hospital planning and the fact that this did not fit into it at all. The attorney for the defense did get up and he talked up and pointed up that in this particular area there 32 1 10 ll 12 13 14 SR 15 16 17 18 19 20 21 22 23 24 25 ACE-FEDERAL REPORTERS, INC. 261 CONSTITUTION AVE., NW. WasHincron, D.C. 225 Was a need for some 300 beds and this was in contradiction to our recommendations indicating that there was a lack of need of new beds and that the area was already well supplied. This was unfortunate but he was able to do this. I don't want to prolong this, but the Village Council took a vote and voted eight-to-nothing against the establish- ment of this hospital. They were subsequently sued by the Sponsors and we had to go through all of our testimony again before the judge, it was a District Court proceedings. The judge has not yet announced his decision but we are hoping that it will be in favor, of course, of Northbrook. Now this technique of using village councils has been extremely effective and we have used it Many, many times, The whole case, of course, is that we try through education to get the village to make a decision relevant to whether or not they wish a hospital in their area. After they have had an opportunity to review the total picture we think they are in a better position to do this than they would be if they had not had this exposure. Actually, the Mayor raised this question: In the course of our discussion he said, "Dr. Klicka, why do we need to worry about this, why not let Dr. Yoder in Springfield make the decision whether we need a hospital or not up here?" I said, "That is your privilege, but it seems to me you make quite a thing about local government, that you should retain 226 33 1 the decision whether you want a hospital in your community of 2 any type." 3 DR. HALDEMAN: Carl, what authority would the State 4 Health officer have? Could the licenser program take con- 5 sideration in Illinois? 6 DR. KLICKA: That is right. If we were not in this 7 picture, if we had not projected ourselves in this picture, 8 the next step wouid have been for assuming the variation had 9 been given for this group to subnit their plans to Spring- 10 field. il If Springfield would approve their plans on the 12 basis of the physical nature of the plans, then they would 13 proceed to build. SR 14 DR. HALDEMAN: Do you have authority to disapproveuthe 15 application based on lack of need for the facility? 16 DR, KLICKA: No, This is right but they could dis- 17 approve it on the basis of it being an inadequate facility 18 and this would be the only way they could do it. I am going 1g to come to that example right now. 20 MR, SIBLEY: Could they not do it also on the ai inadequate financing or not? 22 DR. KLICKA: It is possible that they could now. 23 MR, ROREM: Nonprofit corporation? Proprietary? 24 DR. KLICKA: No, no; this is the new model, this ig 25 the pseudo-voluntary group. This had two corporations. This ACE-FEDERAL REPORTERS, INC. 261 CONSTITUTION AVE., N.W, WASHINGTON, O. C, 227 _ 34 1 was to be owned by a small group of seven or eight men and 2 then they were going to lease this on a long-term lease arrande- 3 ment to a nonprofit corporation who would pay rent to this 4 group, but there was an interlocking board, All these members were also on the board of this 6 || corporation. MR. COUSINS: That is the Detroit picture? 8 DR. KLICKA: I thought this was the Chicago pattern. Most of them are coming up this way now, this is the fashion. 10 DR. HALDEMAN: They have not any trouble at all with 11 | tnternal Revneue with this? 12 DR. KLICKA: No, not yet. 13 MR. COUSINS: Not so far. SR 14 MR, BUGBEE: The owners must pay tax on the property|. 15 DR, KLICKA: These people pay property tax. They 16 pay property tax, of course, on this hospital but that is the V7 only tax they pay. 18 One of the biggest things they want this for, though|, 3 | is to fool the public into thinking they have themselves not a only something for nothing but they have themselves a good none a profit hospital and they are naive enough to think this is so. ae and it maybe, I don't know. 23 Now this has worked out very well until recently and 7 we are having a serious problem. I want to jump to this 25 because down here at a little place called Lyle, it is in ACE-FEDERAL REPORTERS, INC. 261 CONSTITUTION AVE... NW. WASHINGTON, O. C. a a aac tia ca aca sc ai CT CT AACR ia Amara cea 10 ll 12 13 14 SR 15 16 17 18 1g 20 21 22 23 24 25 ACE-FEDERAL REPORTERS, INC. 261 CONSTITUTION AVE., N.W. WaseingtTon, 0. c. 228 Gladwin County, there is a doctor who was unable to get staff privileges at the Hinesdale Hospital, he had a residency there but they didn't consider him good enough to have staff privileges, Another hospital here, he is on the staff of this hospital but he is always on probation because he never has his records up-to-date and also when it comes his turn to take call for the emergency room he is never available. So he is always on probation but he wishes to establish a 150-bed hospital. Now he started this program about two years ago and we were working very nicely with the State on this and I thought the thing was well scotched. The reason it was scotched is because he was making some serious mistakes. He was putting it in the wrong kind of a structure. For instance, he was trying to attach this to his Medical Arts Building and his plan was terribly inadequate, so it was primarily on the plan that he just was not getting anywhere at all. We thought it was abandoned but all of a sudden here in the last few months we find he is very active. I called the State and talked with Dr. Yoder. After I had talked with his two lieutenants, George Lindsly and Roge Sondag, more or less trying to get a progress report on where this thing stood, I got a total clamming up. He said, "What " 229 36 ] has happened? I found that Dr. Yoder is having very severe 2 pressure brought on him by both Republican representatives and 3 || Democrat representatives to permit this fellow to go ahead and 4 |) develop his hospital and the argument that they are using is 5 | free enterprise, 6 "We cannot interfere with free enterprise in this 7 |) country, this man should be permitted to build this hospital." 8 Now, unfortunately, the State plan shows that 9 || presumed need for about 300 beds in this area. This hospital 10 || in Hinesdale was a 200-bed hospital and just added 150 beds 11 |) and now has 350. 12 Neighborville has 150 beds and are ready to add as 13 || many beds as needed when needed. They are running very 14 | confortably. SR 15 Up here there is another hospital, Winfield Hospital 16 which is one we have been working very closely with, tuber- 17 | culosis, in the process of Converting it. It will be open in 18 Ta year adding 125 beds. This is quite a ways out from Chicago 19 As you talk with these three groups it is obvious 20 | to them that the State survey and plan is way, way off and 21 || they are very concerned about this. Dr. Yoder said, "Carl, if 22 || you are going to do anything about this you better do it real 23 | fast because they are moving along with a new set of plans that 24 |/I am going to have trouble starting." 2s So a new form of implementation, ACE-FEDERAL REPORTERS, INC. 261 CONSTITUTION AVE., NW. Waseingtan, &. C. iS i1iS iscsi. ji; aaaaaaaasaasaasaaamaamamaaaaaaaaaaaaamaaaamaaaaaaaaaaaaaaaaaaaaaaa aaa‘; i; amass 37 1 10 ll 12 13 14 SR 15 16 17 18 19 20 al 22 23 24 25 ACE-FEDERAL REPORTERS, INC. 261 CONSTITUTION AVE., N.W. Wasnincron, D. of. 230 I met with the Joint Conference Committee of this hospital and I have met with the Administrator of this hospita who is carrying the message to his Board of Directors. This hospital is taking an action and they have written a letter to Yoder protesting the development of this hospital. The doctors on the staff individually are now writing. This hospital, the Board of Directors are sticking with Yoder, 1f don't know whether we are going to get any of the doctors to write. [It is a very interesting story. There is confusion here as far as the medical staff is concerned, because there are three general practitioners on the staff of that hospital who are using lies and all other forms of defamatory statements against community hospital planning, some of it in protesting against the medical staff taking any position oncthis,. These doctors are suspect of being part of the financial picture of this hospital. We don't know what they will do but we believe that they will also take an action protesting the construction of this hospital. DR. HALDEMAN: The only fly in the ointment, Carl, is that the State Hill-Burton Agency administering a licensure act is pretty well obligated to approve a plan which meets their minimum standards of Construction and equipment. DR. KLICKA: That is right. DR. HALDEMAN: I recognize there is a little gray lL 231 38 1 area in there where they may have a little latitude but they 2 || have got to act with a fair degree of consistency. This thing 3] has worried me in the administration of the Hill-Burton Act 4 | because our act says you shall approve the hospital if it is 5 || in accordance with the State plan. 6 DR. KLICKA: There is something even worse than 7 || that. ‘ 8 DR. HALDEMAN: I am not saying that is necessarily 9 | bad, it is bad that we don't have our State plans in better 10 || order. ll DR, KLICKA : Let's recognize and not say it is good 12 | or bad, just say it exists. Let's assume we can be the people 13 || who take the brunt of any -~ SR 14 DR. HALDEMAN: I was wondering why you didn't aim them 15 | at the local officials the way you did at Northbrook. 16 DR. KLICKA: Because Dr. Sinovitz(?) here controls 17 | the City Council. 18 MR. ROREM: If you had said that earlier we would 19 || have understood. 20 DR. KLICKA: Always leave a question for dramatic 21 | effect. 22 DR. HALDEMAN: Have you not been hitting pretty hard 23 | at the people who have the money for these types of enter- 24 | prises? 25 DR, KLICKA: I want to make one point and I will ACE-FEDERAL REPORTERS, INC. 261 CONSTITUTION AVE., N.W. WasHincron, DB. o. ia SC icc 1 / Saat aaaasmmaaamamaaammaaaa saa daaaiamsaaaaamasamatas aman ammmaaa eam a 232 39 1] answer. 2 One of the big problems that we are having here in 3 |} trying to help Yoder, recognizing the fact that he has some 4 limitations, is that he has not kept us informed about this 5 || particular program. 6 They usually have talked to us about other programs 7 || that have gone on but this one he has not. Now tf recognize 8 | that he has been under such great pressure down there regarding Ut 9 this. 10 When I pressured him as to why he didn't keep us in- 11 || formed he astounied me by saying on that they have to maintain 12 | confidentiality on some of these cases. 13 They refer to the Hospital Licensing Act, and I am SR 14 going to quote: "The Department shall make or cause to be 15 || made such inspections and investigations. as it deems necessary} 16 “Information received by the Department through filed 17 reports, inspection or otherwise authorized under this Act shall 18 | not be disclosed publicly in such manner as to identify 19 individuals or hospitals except ina proceeding involving the a question of licensure or revocation or in other circumstances 41 that may be approved by the Mospital Licensing Board." aa This is something I think we will want to get into 23 tomorrow, The only reason I am m&king this point is that in 7 trying to implement you have to use all kinds of methods, even 25 | to the point of trying to get around, if you will, legal ere pk 40 ] 10 11 12 13 14 SR 15 16 17 18 19 29 21 22 23 24 25 ACE-FEDERAL REPORTERS, INC, 261 CONSTITUTION AVE. NW. Wasvingron, D. ©. 233 obstacles to what I Sincerely say are probably good attempts at Regional Hospital Planning. Now in our monthly report we make a Point which I keep referring to relevant to the relationship with the State agencies, This is another reason, George, that I am going inte this in some detail, only to Point out to you the obstacle that we have here in trying to implement something which we believe is proper. MR. BUGBEE: Haven't you got any Democrats or Republicans on your own Board? MR. SIBLEY: This is the next step. I think what we have to do if we cannot get this changed is not on our own Board but to get people down in the legislature whom we can use to c6linter pressure the Director of the Health Department, push this where necessary. DR. HALDEMAN: I must be defensive of the State Hill Burton Agency, Mr. Sibley, because tr have to administer a Hill Burton Act presently. There is lots in it I don't like and believe me, we get a lot of pressure on certain projects in which we are powerless to act. I think the answer is to change the legislation and not to require the Hill-Burton Act or try to get the Hill-Burton Agency to do something which is contrary to Dr. Yoder, 41 1 10 11 12 13 14 SR 15 16 17 18 19 20 21 22 23 24 25 ACE-FEDERAL REPORTERS, INC. 261 CONSTITUTION AVE. NW. WasHIneron, D.C. 234 MR, SIBLEY: I am all for that. MR, BUGBEE: I don't think the pressure is an adhesive member of the Administration. I am assuming that if this fellow has pressure it is the Governor or somebody like that. DR. HALDEMAN: I happen to feel that Frank Yoder tries to do what his best. t Off the record. (Discussion off the record.) DR. KLICKA: I want to make just one last point. I am really mixed up at the moment with four years of experience now with regard to voluntary license, voluntary planning relevant to franchise planning. I think if I am on one side or the other I am stronger for the voluntary side now than I ever have been before, particularly with my recent experience with this. MR. ROREM: What do you mean on the voluntary side? DR. KLICKA: I am talking about the system we use. MR. ROREM: I don"t quite know. As opposed to what? | DR, KLICKA: As opposed to having the decision as to whether a hospital can be built or not in a manner that can be determined by law by some State agency. One of the things that we are not is that we are not subject to pressures. 42 1 10 ll 12 13 14 SR 15 16 17 18 19 20 21 22 23 24 25 ACE-FEDERAL REPORTERS, INC. 261 CONSTITUTION AVE... NW. Wasningran, &. C. 235 MR. ROREM: Do you mean, though, that the State agency now has too much power or too little or which? DR. KLICKA: I am saying this: that with the powers they have they must administratively be subject to the types of pressures that a political politician can bring against any politic party. | MR. ROREM: But you leave it that way, you get your pressure in there too, is that it? I am serious, Carl. f am not trying to be funny. DR. KLICKA: I know you are. I say this: this is, I think, the way it has to be done. DR. FALDEMAN: Well, I would like to paraphrase what Mr. Sibley has said, that I don't think implementation can be either public or private, I think it has to be a combination. We have got to use all means, and some of those are Government and some of those are not. I would not want it in either one hand or the other, but I would want it in an effective combination of private and public. DR. KLICKA: This is precisely why I am not unhappy with the situation as it exists at the moment. In other words I am saying that now what we do have is a combination of both and I think we have to be very careful before we throw more authority for implementation into the law because of the dange} of political pressure in this field. I think this is a very, 236 43 1 very dangerous area. 2 For many, Many, many years people have pointed to 3 the Savings and Loan Act in Illinois as being an example of 4 the way this could be done. I realize now that the Savings 5 and Loan Act is running into great problems -- that is, the g || Administration in Illinois -- and the people who are running 7 savings and loan organizations in Illinois:are saying that 8 the law is not effective because when the chips are down the 9 director who has the ability to determine whether or not the 10 Savings and loan institution will be built on the basis of 11 |i need finds himself subject to such political pressure that 12 unfrotunately, he goes in the direction of the greatest need. 13 DR. HALDEMAN: I think we are going to have to 14 adjourn, SR 15 Do you want to reconvene at 8:30 in the morning? 16 | (Whereupon, at 5:30 o'clock p.m., a recess was taken 17 until Tuesday, July 9, 1963, at 8:30 o'clock a.m.) 18 19 20 al 23 pk/Short 24 29 ACE-FEDERAL REPORTERS, INC. 261 CONSTITUTION AVE., N.W. Waswingraw, D.C.