.4EOOI3'723* FAR k ee N @@WELF@ EP RTMEN F@ HEALTH. EDI ATIO @EGIONAL 'I-IEDICAT4 PROC-PWL SE,::.VICE. COUNCI Rocl-,ville,.I--Iar land y Tuetday,- 9 Noveinbet 1971 ACE - FEDERAL IIEPORTERS, INC. Official Reporters 415 Second Street,. N. E. Telephone: Washington, D. C. 20002, (Code 202) 547-6222 NATION.WIDE COVERAGE 2 C O:N T E@ N T S em PA @3 e sby'Dr, Wils@on by@@ Mr. RiSo . . . . . . ma s . . . . . . . . 27,@ 77 t y g,argulies . . . . @6 ity Discustsion. 49 @Kidn 72 81 7 a s Dr. Hi'@n 102 8 obv@ Pahl r..Aaum s 110 @io sby, peterson@@ . . . . . . . . . . . idera :@of 'Applications,.@ izona@. 9 2 Arkansas . . . . olorado/.Wyomi;ng conne cu 134 8 Ohio@ Y. 19 St te@ r @,North ak D CR-4157 GIBSON Cs DEPARTMI OF HEALTH, EDUCATION, AND WELFARE 2 3 6 7: 9 10 REGIONAL @LEDICAL,PROGRAM SERVICE COUNCIL MEETING@,@ 12 14 1 5 16 conference Room GH Parklawn; B'Uild3'.ng 17 5600 Fis,hers Lane Rockville,, Marylan Tuesday, November 9 :1971 19 20 @'21 IL 2,2 23 @24 25 I I I I I I1@@4 r 3 P R 0 C E t D I N G S - - - - - - - - - - - 11/9/71 CR @415 DR. MARGULIES: May I have your attention, please. Gibson/ mith Dr. Wilson is on his way down here and since he 41 is,g ing to open the meeting I thought we could prepare for 5' his coming by having me remind you of the conflict of interest 6 n the and the confidentiality of the meeting, the statement 7 front of the books, to remind you of it, and to,take the opportunity while he is on his way here to introduce@two new 9@ members of the Council who are here for the first time today, 10 although one of them has been a ointed for quite some time, pp drey Mars of The Plains, Virginia, who is here on my Mrs. Au 12 right. Mrs. Mars has had a long experience with RMP in -2 13 Virg2.nia and has been closely Associated with dahcer activities 14 and@other kinds of volun r 0 tary effo tb f r a number of years; ancl 15@ Mr. Robert Ogden, who is President and GenerAl Counsel of the 16 North Coast Life Insurance Company of@Sookane, and:@has served 1 7 in a very distin ui4hed manner as Chairm6.n of the Regional 18 Advisory Group. 19 Now, since the introductions are complete, Dr. 20 Wilson, would you care to take over. DRIO WILSON: Thank you Harold, and weic @to the @22 new:,;nembero of the Council. 23, I don't have any long messag6 for this morning. I 2 two or three hbusekeeoin types of thingoi .4 do want to do 9 Wumber one, although I haven't had word from 4 1 cture has downtown yet, I think our new organizational stru 2 been approved* I talked to you, I t-hiak, about this at the .3 nd it cleared the last Council.rtieo-ting, at least briefly, a 4 last hurdle: d was to have hit the Secretary's desk the last 5 part of last wee%.@, Things never stay on his desk verv long. 6 I Irish the same could be,said for a number of other desks in 7 HEW North. But so far as I know, we are now functioning under 8 the new HSMHA organizati6@nal oattern. That, of course, br gs 9 me then to the direct introduction of someone with whom you 10 may have had previous dohtact. Did you introduce Jerry 11 earlier before,! got here.@ 12 DR. MARGULIES: No, just to a few peopl@. DR. WILSON4 I just did. Jerry Riso, many of you 14 have known, was the Deputy Assistant secretary for Health and 15 Scientific Affairs with Roger E4eberg, and has been willing 16 to come out to serve with us wearing one hat here And then 17 another hat:,within the Department as A whole. The hat he wea3S 18 for us is De uty Administrator for Development. This is the p 19, org nizational pattern I.an now saying I think is cleared owr- 20 town and in@that role Jerry has the coordinating resp6nsibilJ- 21 ties for@ of fi,ce ,for Reqi@onal 14edical Programs, for Compre- 22 hensivo q6a@lth:Plannin4@'which is now a separate program from 23 C itv liealth@-Services and the other 314 programs it hat; ommun 24 been moved'over and is now under this general direction for 25 rch and D National Center for Health Services Resea evelopm6nt, 5 1 for Hill-Burton, the Federal Hospital Services or whatever 2 Hill-Burton is always easier -- and finally for the Health., 3 maintonance Organization activity. 4 Now, these grouped together in our terms were calleil 5 development but the Secretary has another term which seems to 6 be in use now pretty heavily in the Department, and that is', 7 what is called institutional reform or change agent type pro- 8 grams. You can call it either you like, but nevertheless these 9 are the programs where we pay for very little in the way of 10 direct health care but spend:most of our energy and resources 11 trying to see if we can work with the providers or with the 12 community in changing the way health care is given. 13 Jack Brown I don't see Jack around anywhere 14 is the AssociAte Deputy Administrator. Jack has be6n.8-0edial 15 Assistant to me'and will be working directly with Jerry. Thdy 16 are officed up oh the 17th floor and will be carrying a major 17 b share of the reso6hsibilities in those programs. You will e '8 hearing a little more from Jerry in a little bit. 19 The other hat which Jerry wears is Director 6f.the 20 Health Maittenance Orga". zation Program for the Department,.,-,,,, 21@ been worki with@wit 'thO@ This is the technique that we have 49 22 Department, for instance Burt BrcA4n,, who is Director of 23 and is now the Deputy Administrator for Mental Health, foi'the agency as a whole, which spreads across several Pro rams. g@ 25 Also A special assistant to the Secretary fok,@.'drug,a)Duse,,,,4nd 1 we are doing this same thing with the Health Maintenance Or- 2 ganization where we have got a highly mobile program, one 3 fairly rapid rate We find that we can get that's moving At a 4 the attention of other agencies, and indeed other departments, 5 if the individual has a direct assignment of responsibility in 6 AssistA this special area from either the Secretary or the nt 7 Secretary. We are not really particularly proud about titles 8 but we'd like a,little action, and this seems to be one of the 9 ways you can get action. 10 so Jerry has a substantial get of responsibilities. 11 YOU Will be seeing more of him within the RMP programs as we 12 @get his office sort of staffed out. Did We@get the re ly on p Jordan's -papers? 14 MR. Rlso-. NO. 15 DR4 WILSON: Well, we have had one appointment we 16 have been working on since last April which also was supposed 17 to have@been announced yesterday, and we will check 6n_thAt today, the directorship of the Health Maintenance OrqAhizAtib@ 19 Program within,HSMHA. 20 In any dvent, I kind of wanted to update this 21! council because you will be seeing and working with@Je-rr'y a 22 good bit as a part of the @overview approach that he has@for 23" our development programs. 24 Now let me go back and refresh your memories on 25 something where.part of you will recall clearly. For some@of 7 weren It at the meeting in 1 you it will be news because you 2 Chicago. We did discuss at the Chicago meeting the fact that 3 we,would be looking to RMP to provide advice and counsel on 4 issues that fell within its domain that extended beyond the 5 monies that were assigned to RMP. This organizational change 6 is@.th&t same approach, and so you As a Council will continue 7 to get more and more requests looking at the role of the pro- 8 viddr in maintaining quality in the health care system,,. and 9 looking at the role of the provider in responding to found 10 need, and that@assignme nt you will hear more and more about as we get further and further along with our delineation of job 12. d6a6tip @o orr orkin ti oles for the program. We ate w g very 13 intensively. It takes longer than I guess I had anticipated 14 when I talked to.you in Chicago-to get a Federal program sort 15 'of reoriented,but You can reorient them it just takes 16 4F i 9 longer we e ;st 11 movin in that same direction. It 17 is taking a bit of time but we will be coming back to you and 18@ askingr for a i66 and counsel on issues that fall within the 19 domain of RW that do affect all of the HSt4HA ptograms and in 20 turn at times affect all of the HEW program$. 21,, that's a We still have 15 diff6rent.proqrams, an-- 22 lot. We still ate struggling with the other issues t t we 23 have discussed qh y in@previous,meetings of how one can go 24 ining of the talents of several councils for ut the comb, 25 5 ific issues where you still time is' an element, because 1 don't et involved when a new issue comes up. We are strug- 9 2 gling with two.right- now that have implications for national policy and we don't h.ave a good way of getting councils in- 4 volved in time--lirn'ted issues. We think that there must be 5 cutive committee arrangement a better way, whether it's an exe 6 or whether there is some kind of a small task force kind of 7 group. 8 However that may be we will be asking Jerry to 9 work with that and come up with ways so that his office,as t 10 provides extraordinary coordination for me, will have your 11 advice and counsel not Only at regular Council meetings but 12 in interim periods as well. 13 I repeat one statistic that always sort of amazes 14 about 2 rough me. I-le do have 01000 people who give us advice th 15 - councils, committe6si or consultant appointments. We have not. 16 at all learned how to use that advice well, either from the 17 point of view of the use of your time,, or from the point of 18 view of s6lvih4@@@the problems in which we have a mutual inter- 19 est, but we haven't given up and we solicit your suggestions 20, and counsel. We do,have now about completed a paper on 21 what do we call that talent banks, skills banks? 22 MRI*@RISQ-, Skills inventory. 23 DR4 WILSON: Skills inventory. We have used all 24 kinds of titles. Nevertheless, we are working with our own 25 staff to try@out a@sort of a brief questionnaire. If it 9 1 ill get it before too long, which is an attempt works out you w 2 to see if one way or another we can kind of catalogue what 3 people would like to do, a little bit of what their availa- 4 bi,lity is, and then when we have one of these,6rash programs 5 perhaps we can get urposely engaged@ift the conver- you more p 6 sation than just sheer memory allows. 7 The only other thing that is quite different that 8 I would like to,bring to you, there are a number of -- the 9 Washington scene calls it new initiatives running around. I 10 am not sure'any of them are new, but the emphasis certainly -2 has changed in the last period of time. 12 The one to which this Council will ne d to rather 13 carefully address its thought and purposes over the next year 14 at least, and perhaps longer, is the issue of the extension 15 of the physicians' energies or the professionals' energies. 16 Now,, that in the past has had a very heavy tendency to lean 1 7 on auxiliary,, allied professions, you know, physician assis- 18 tant type of approach of one sort or another, and I see no 19 evidence that the interest in that kind of activity is going 20 to wane. I think it's beginning to crystaliz!p,,,albng certain 21 @lines. and will be a little more focused.,, 22 The one that is picking up and which needs very 3 careful watching is one which Bland and Ispent.a lot of time 24 talking about as long as four or five years ago, and'th at's 25 the role of technolo in the health care field,, and it turns gy 10 :L out that with the appointment of Mr. MaGruder, whom some of 2 you know in science and technology in the White House -- he 3 is the gentleman who worked with SST for a period of time and 4 they didn't get the SST off the ground so now he is taking his 5 talents to something else. we are now undergoing a great 6 deal of review that I think is exploratory at the momentt but which should be in our minds as we look at our limited re@- 8 sources and@attempt to decide how we can best get our job 9 done. 10 The basic issue is one in which there are about 11 six different panel groups under the general guidance of the 12 Federal Council oh Stience@and Technology, each of which is dealing with a service area, a service oriented area, personal 14 services oriented area, like the building of houses, for in- 15 stance, which uses an awful lot of manpower and a relatively 16 low degree of automation or like the health care field, 17 As they are looking at theses what really is being 18 said is that the economists feel that for a nation to continue 19 to prosper from the point of view of economics, any field must 201, have a certain degree of te6hhology in it, that if,it's to_ 21 tally personal services otieht6d it tends to level off@and be- 22 come self-de@@feati--ng. You lose the growth potential and that 23 becomes not an advantageous part of the program of building 94 the economics of the country, 25 Now, what is ing on in these sev etal grouos go 1 for health services what's going on in thes4 I chair the one role for -oroT3riate @2 groups is a very vigorous search for an ap 3@ technology in the personal services oriented field. These are 4@ peo le of national stature who serve on the panels. The re- p 51 p6rt will go through the Federal Council on science and Tech- 6i This is not an HEW report. It's a general governmen- hdloly. 7 tal report. And my guess is that as each of the personal set- 8 vices oriented fields make their own case for the advantages 9 for investment in technology in their field, that will finally 10 be waived from the point of view of where would it be best to 11 invest in technology from the point of view of economics, not 12 from the point of view of the health field or the building of 13 buildings or something else, but who can make the best use of 14 an investment in technology. 15 1 never was one to feel that we ought to sit aroun 16 and wait to see what happens. It seems to me that the signals 17 are in the newspapers and several panels and they are around. It's very clear, to me at least.- and I hope to you, that if yc'u '19 look at the cost of providing health care in its present mode P@ 0 and you look at the number of people who cannot ge he lt -21 care, then you@try to think about giving what we agree we must have in its present form that you can't get there from 23, tcent of our nation are under-served, and if here, that 20 pe @24' you take our present manpower and its:increments then you tall 25 in the system, that we jtst can't.live up to about investment 12 1 the promises we've made. And I think it's equally, c ear that 2 there are a great many places where, without at all inter- 3 fering with the physician or the professional patient inter- 4 face, we still could do things a lot more effectively, and use 5 the extender of our energy a lot better than we are at the 6 ill current time. I won't debate that@point at the moment. '@l w 7 be glad to, but I am making I think just the general overview 8 statements at the moment. @9 So as you look at the various kinds of opportuni- 10 ties for sponsoring new activities with RMP, I think you need 11 @to keep this issue very much in the back of your mind from a 12 tactical point of view, since 1 have some considerable feeling 13 are goin a tment in the field, that we ,g to see a substantial inves 14 and I do think it will be substantial when the decision is 15 made. 16, Harold, that's about all I'd want to make as an 17 opening statement. I'd be happy to try to clarify any con- fusion I've invoked. 19 MR. OODEN: Could I ask a question.> 20 DR. WILSON: Yes. 21 will your@@office MR. OGT)EN: what input, if any, 22 have in this studv being done by the@office of Science and 23@ Technology? 24 DR. WILSON: Well, I chair,the oommittee. There is 25 a group of the panel itself is a panel of twe@lve@,@ Palmer 13 1 sits on it, who is on the Board of,Trustees for instance, of 2 the A14A. Max Berry, who is a practitioner in Kansas City, who 3 has had a substantial interest in the Wbtd probldm-oriented 4 system, is on it. Ralph Berry, the economist from Harva 5 who teaches medical economics, is on it. I can't give you tl.@ 6 whole list. Wendel Musser is on it from the VA. There is 7 someone on it from DOT, as I recall it, And from DOD. There i; a wide variety of people picked basically by the Council on 9 Science and Technology. There are some physicians among them 10 and of course people from the other fields as well. We will 11 have pretty good input. We are staffing it. 12 MR. OGDEN: Pihe. 13 DR. WILSON: And 1 think it would be perfectly 14 appropriate to address anything through Harold or through Je rry 15 that you want to that you think ought to be contemplated by 16 the panel. 17 Well, Harold, they all look either Ioverwhelmed, 18 not yet awake,, or totally satisfied and I dan't tell which. 19 (Laughter.) 20 MRS. MARS: Let's say totally satisfied. 21 DR# WILSON: Okay, then, I will turn it to Jerry, 22 and I will be here for a little bit although, of all things, 23 even the Administrator dissipates once in awhile, I have 24 two meetings out in the Middle West in the next two days, and 25 I looked that schedule over and decided this weekend wag a 14 ving this good weekend to go goose hunting, so I will be lea 2 afternoon, and I am in the process of attempting to get stuff 3 cleared off the desk, so you will have to pardon me if I sneaki 4 out. it really is a dissipated life of an administrator. 5 MR. RI80: Thank you, Vern. I am delighted to have joined HSMHA. Several months ago whet Vern asked me to con- 7 sider coming to HSMHA and wearing two hats, he promoted the 8 idea on the basis of it being a very significant professional 9 challenge and a job that needed to be done, all the kinds of 10 things Vern tells you when he is trying to promote an idea. 11 But he never did tell me that part of the challenge would be 12 to hold a position that has not yet been created, to head an 13 organization that has not yet been established, and to coordi- 14 6 who have not yet been appointed. But we nate subordinat s 15 have been operating this way for about six or seven weeks and 16 it has been all of the challenge that,Vern indicated to me 17 that it would be, and I will cover some of that. 18 There are some visible signs of progress, however, 19 despite my having been here six or seven weeks. I found my 20 way to this room without any helpi and that I can tell you is 21 progress in this building. 22 I have spent the last six or seven weeks becoming 23 acquainted with some of the programs and some of the n- dividualt within the programs. I really can't give to you a direction in which we will go because I am still finding the just give to 1 directions in which we are currently heading- I 2 you some of the questi 6ns that I am asking with respect to the 3 programs I am working with, and from these questions and the 4 mentz of our agenda answers,I think you,will find the ele 5 during the next several months. 6 I am basically raising questions on how can we im- 7 prove our ability, our being for people within HSMHA, people 8 who participate with HSMHA and other people within the health 9 field -- our ability to recognize and define our health needs. 10 How may we better relate our research activities within HSMHA 11 to these needs? How may we better identify early in the game those concepts and practices which we consider at least to be 13 of si nificant value, at least we think they will be of sig- 14 nificant value, and therefore ought to be introduced to the 15 field? How may we promote the introduction of these concepts 16 to the field@under appropriate kinds of safeguards, appro- 17 priate testing? And finally, how can we improve the working 18 relationships and the communications among our programs? And 19 finally, to the extent that all of this results in two kinds 20 of things: Qne, clearly identified areas in which change 21 ought to be ade and, sec 6ndly, rather comprehensive agreement 22 on the@natureof the changes and the way in which we would do 23 it, how. may we, imp nt it. It's a rather tall order, I 24 k t, and if @success will be measured in terms of now Our, 25 two ththgs,,Ilone,theltime,,and energies of people around here, then I am reasonably confident we will achieve some measure of 2 success. 3 The other hat that I wear might be of va ue to you 4 because we have moved, I think, far,,ahead with respect to the 5 HMO's as in comparison to where we were several months ago, 6 and 1 do wear these two hats at this point in time. 7 I'd like to describe to you some of the fundamen- 8 tals upon which,we are building our HMO program and give to 9 you some indication as to the kinds of activities we are 10 going to be engaged in during the balance of this year, and it 11 will help set the tone, I think, and the momentum for subse- 12 quent activities. 1 hope we are taking a fairly practical and prag- 14 otsibility is to matic view of HMO'S, and part of our resp 15 cor t some misconceptions that are held by many people about rec 16 imois, and it might,be valuable to start with just that. 17 We are not suggesting, and we will not be party to 18 suggesting, that there should be any element of cor..,Inulsion within the HMO program. We will not participate in programs 20 that appear to have this element of compulsion. 21 Secondly, we recognize many,,virtues are saigned t(o 22 t wa inted@"'I do not HMO's which in our@judgment are no ,rr 23, regard the HMO as a substitute for health insurance. Secondllp,, 24 alth maintenance may be a broader phrase to many people 25 than is implied within the kind of activity that an HMO will it fact become involved in. I think we are taking pains to 17 ith re- make that clear to people who are reaching for us w 2 6pect to requests for information, and in some instances re- 3 quests for specific guidance on next steps. There is an as- 4@ :tounding degree of interest in HMO's today. I think we have 5 had in the last six weeks something like 300 inquiries. They 6@ range from casual interest on the part of a group to a specif c 7 request for information and assistance on steps that a group 8 of people might take to develop an HMO. 9 our program has essentially three or four elements 10 to it, and I will Just touch upon that. We are engaged in,atd 11 will continue to be engaged in during the course of this year, 12 assistance t a rather comprehensive program for technical 0 13 prospectivo:Hmo developer6r and this will be assistance from 14 y it will be lirrtited.by our resources,, of courses but it will 15 be a wide range of technical assistance services that will 16 cover, among other things, problems with respect to organizing 17 an HMO, prob s@with respect to the kinds of management 18 systems necessary to manage the HMO, technical assistance in 19 the area Of conducting actuarial studies. There have been 20 requests for Assis anc6 with respect to marketing the HMO 21 concept with respect to a specific developer, and there will 22 probabl be re uests for services which we have not yet an- y q 23 ticipated. All I-can say to you at this point in time is 24 that the demand for this kind of assistance is going to far 25 outstriolanything we could reasonably and practically offer, 18 1 iand that will introduce into our thinking somelconstraints as 2 to not which group or what kinds of groups ought to be dis- 3 couraged, but it will limit curability to serve a ecruatelv 4 and at some point in time we will have to focus upoIn a number 5 being in a as contrasted to a reaching out to e ryone.or 6 position to respond to everyone who conceiva ly might have 7 this interest. A second area that we are operating in is we will 9 conduct and are in the process of conducting a be t r e uca- 10 educational in the sense of providing to tional program, MO people who want information about H at least some reliab e 12 informations.# and secondly, at least identify@for them sources 13 other than ourselves which might be helpful to them in think- 14 ing about HMO development. We are conducting, it's not a@modest grar*program, but we have no intentions of a massive grant program, Of fi- 1 7 nancial support and technical assistahce to a number of HMO 18 developers. We concede openly that some of the bes advice 19 we wi o pec'tive HMO developers is that their 11 give to some pr s 20- thinking is not sufficiently mature about the plan@s6 that 21 they ought to pullback a bit., 22 of th best advice'@l',4e@ will give to I think some 23 some prospective HMO deVelon4i4 is,that their plan is hot 24: t hot to otoceed,@.fti@ther, and that viable and that@they ough 25 for others,, that we will, or at least we hope to describe 1 19 1 for them some@of the problems they may Anticipate, and so in- 2 troduce into their thinking a degree of realism that could 3 be lacking. 4 As I say, there is a great deal of interest. The 5 interest ranges from large numbers of physicians, substantial 6 numbers of consumer groups, some business organizations, some 7 labor unions, and how many Of these will go from the point of 8 general interest to a specific application for a grant is 9 extremely difficult to predict, but 1 quess,within the last 10 four months we have had on the order of 150 grant applications 11 for assistance. $ome are very good and some are very poor, and 12 some of the poor ones are the ones we'd like to@see sta,rtedi 13 so that is part of our problem, 14 We ate also concerned with the HMO programs of 15 making available to individuals the option within their own 16 health insurance@programs, the HMO option4 There has been 17 some interes' on the part of business organizations some in- 18 terest on the part of labor unions, in knowing more about 19 HMO'si because they might in their own thinking elect to in- 20, troduce into@ their own health insurance programs the HMO 21 option for@ their employees, and we propose to stand ready 22 to provide them with what we hope is objective advice and 23 what we hope is,qqod advice. 24 By June of this year this one last comment with 25, respect to HMOIS. 'With respect to the current activity in., 20 1 HMO's,, most of the activity is planning and development. T at 2 is, groups which either in June or before that or even now are 3 interested in knowing more about it, and having reached that 4 point of decision and saying to themselves, "Are we suffi- 5 ciently interested in proceeding further, and therefore, we 6 will enq-aoe in the feasibility planning and the administra- 7 tive planning necessary to become operational." 8@ At this point in time, almost all of the groups we 9 are dealing with are in various stages of planning and de- 10 volopment. It is our guess, and it is a reasonably informed 11 guess that a number of these will reach within the next six 12 months a go@or no- decision with respect to onqoing opera- tion and at that ;)oint the nature of our activities may 13 14 change, and at that point in time I think I will be better 15 prepared to discuss that. 16 in summary I am delighted to be out here. I am 17 tonishdd how few things I can get done in given days but a 18 then I realize there are just so many things to be done. It's 19 a long work day out here, and Vern, coming,out of the Midwest 20 6tarts it earlier than most. We check each other by@our cars 21 in the parkitq lot, and sometimes I hide behind a pillar until @22 after he,leaves so I itapress him by having my car there. ltl!l 23 a long day. @it's a fascinating thing for me, and maybe, 24 just maybe, we will have many th ncrs done within the next couple Of months, and even before our organization s 21 established. Thank you. 2 DR. MILLIKEN: In this development of HMO, is there 3 any emphasis being given to the establishment of criteria for 4 'Control,mechanisms? 5 MR, RISO: Yes, I have asked Harold to take the 6 lead. I have@a-sked the RMP program to take the lead in devel- 7 oping -- I don't mean it in this sense, but standards of 8 performance for HMO's and what criteria ought we to apply to 9 the performance of HMO'S, and at what point in time will we 10 be in a position, or anybod be in a position, to say this HMO y 11 has or has not performed. We are going to do this from a pro- 12 fdssl6nal basis because the rate at which you increase enroll- 13 ment is no si, of anything, and the fact that you have in 14 fact kept your dxpenses below your income doesn't prove any- 15 thing if you have not provided care. 16 I am delighted that Harold has seized this initia 17 e HMO g oup, b .ive and is workincj@with th r ut the definition of 18 the qtaiity of care within the confines of the HMO's is the 19 responsibility of the RMP program. 20 MR. MILLIKEN: I think this is very necessary be- 21 cause a lot of applicants that I have seen have no concept of 22 the :e act th re mu ls. at@the st be contro 23 MR- RISO: That is true, absolutely. 24 MR.@"MILLTKEN: And this is ve evident in the 25 lidation app 22 1 MR. RISO: As I say, the interesting thing about 2 this and yet you have to expect this --'you have to expect 3 that when you actively promote, as@we have and others haver 4 the concept of HMO's or of anything,else, there are going to 5 be all sorts of people and groups@interested in pursuing it 6 further. Ile cannot control that. On the other hand, recog- 7 nizing that, it's our view that we can through mature and 8 objective advice, siphon off, if you will, those people who 9 really ought not to be encouraged. 10 Secondly, then having hopefully confined ourselves 11 to a number of groups, that have at least some hope of succ6st, 12 expose them to some fairly sophisticated management analysis 13 in terms of the viability of the plans, economic viability, 14 the:standards, ill they enroll people how will they work, how w 15 how will they,in fact provide resources for people who today 16 n't have financial resources, and then at that point in time 17 we -ple might discourage those T)eo- or those groups that really rve to be discouraged because there are elements in their 19 'plan that@simply make@it a marginal HMOO 20 I'think we have to face tbe,fact, though, that de ite efforts we are going to'bave some"HMO's that for pp 22@ any number of reasons, either po6ri@ conceived, poorly mahaq6d, f o6 thi b 6' marginal. We Id like to :hold or,any o ngs e ome that number down, and it is highly likely ou will have some 95 HMO,s fail, and we are actively concerned'abo'ut the pron-Lem of I I I i 23 1 the HMO that fails and as a principle -- I am speaking personal 2 now -- your obligation is to the person who enrolled i'@ .,Lat 3 ntrasted to, as a matter of principle, sustain:in HMO as co 4@ operation everv HMO that gets started. I don't think we will 5 have to live with the prospects of some HMO's failing, and that in some instances where that HMO is a drain upon a parent institution, I think it would be quite valuable to have 8, that HMO fail. 9 Now, in other instances there may be some that we 10 do not want to see fail and would actively support;as a matter 11 of Principle at this time we do not contemplate assuring every 12 HMO that 'gets started continued operation. I think Id 13 defeat the purposes of the program. 14 DR. WATKINS: I am wondering if we need an A, Bi C 15 of eligibil tv.: Be,&ause@in New York I feel that Colu@ia PNS, 16 Mount Sinai and Einstein are going to be the prototypes of 17 @HMO's when there are churches and other small groups that 18 would@like to be involved, and they feel they are not eligible 10 because they@@ on@-It have aunion background or a $,20,000 group 20, census to work with. So perhaps if we,had an A,,BC eligibility 21 it would avo d people putting in months of work and spadework 22 and then being turned down. 23@ MR RISO: That's probably a good idea. The'ohly 2 e number f contacts being 4 su rise 1have:is that given th 0 rp -25 made with us, and iven the variety of sponsorship, I am 9 24 somewhat surprised to hear that there are some groups not 21 fully cognizant of the fact that they have the same option of ,3 negotiating an.HMO development as any other, but if there is a .4@ question with respect to a specific group you have in mind I'd 5 ur-. e'@them-@to reach for the HMO program director within the ;g 6 regional office and receive whatever reassurance they need 7 both with respect to their eligibility and, secondly, with 8 respect to the specific steps that they should take to At 91 least bring the issues to whether or not they should proceed 10 @or not to a head. I'd urge any group in any part of the 11 country with that kind of question in mind to reach for the 12 regional office and then if you don't get an answer a good 13 answer or one you like, but an answer, theft please call@our 14 HMO program@hereo We'd be happy to do that4 15 DR* KOMAROPIF-. Some of us are b6in4 asked tome, 16 specific questions by people interested in HKO's in our 17 regions. Can you give us ah,idea as to how much grant money 18 to supplement the initiation of AMO's might be@@availsible, 19 after July lgt or sooner, when the deadline for submitting 20 applicationt is, and in what form, dk,with what degre-e,of de- 21 velopment an application has to present itself here.@ 22 MR.@,iRlSo@.- There is in process right now a review P,3@@ ofli"'an of grant applications that were generated over the period of ly to about two or three weeks ago. In.fact, the review process in the rpgiont is going on today. Those awards 25 iare likely to be made before the end of this calendar year. 2 The objective we have in mind with respect to 3 those very candidly, we know are going to,,make some peo-ole 4 unhappy, but that's a fact of,life both here and downtown and 5 everywhere else. What we will be doing is taking a look at 6 the original contracts that were made back in Mayi look at 71 what has been Accomplished both with respect to the type of 8 sponsor and geographic dispersion of these particular HMO 9 grants and contracts, evaluate the current roundf and look at 10 those and tee whether the pattern that evolves out of two 11@ roundt gives us an adequate spread both with respect to qeo- 12 phi6&11 of spohsorthi There is gra_ y and with respect to type p 13 a plan for another round in around February and another one 14 e fiscal yea three in All. by the end of th r 15 Now,,the,levels at which we propose to fund we 16, have identified at this point in time a sum of money. we 17@ don't have as yet legislation As you may know. The magnitude ill be dete f our i ty,in February and July or June w r- 0 19@ @mined by legislation, and the Novdmber level will be modest zo: time enough to@encoldra those HMO s@ that, but at the same g,e 21 should be encouraged, and not enough tc( encourage ose@ that 22 should not be.6 23 Th@ you. DR. KOMAROFF. 24 MRS. WYCKOFF: Are you discouraging the rural type ol 25 HMO which has@ very limi d resources? i I I I - I 26 MA. RISO: Not at this point. What we Are not 2 doing is establishing as a rule of thumb that we are going to 3 discourage them right off the bat. But what we are doin"g't 4 and we will do for the first time in the November cycle, we 5 will consider that for some HMO's -- and the average planning 6 grant is estimated to run at about $100,000 to $150,000. It's 7 my view it's much too much, to come to a conclusion you ought 8 not do it. And to we will entertain a notion of modest fundiny 9 in the order,of about $20,1000 or $25,000 to some prospective 10 HMO developers, to allow them to pursue, with some assistance, the question of whether they should go into an HMO or whether there are some factors that are clearly identifiable that woull 13 really mitigate against further encouragement. 14 So.it's quite possible that some groups in rural 15 areas wanting to go into HMO'S, which on the surface might 16 appear to be viable but after spending some time and effort 17 -and providing professional resources to them to explore,, come 18 to the conclusion that you really can't because you've got a 19 different kind of problem that an HMO was never designed to 20 solve. MRS. WYCKOFF: At thatp6iht are you giving them 22 any help or alternatives for them.> 23 MR. RISO:@ I would hope So,, because you Start th 24 a needi and the HMO is just a vehicle for meeting that need, .25 and whether or not some -oeor)le q inq,to be get that answer is 27 1 dependent on the quality of assistance we provide them, and 2 I suspect that will be spotty. It depends on who you draw. 3 But we are indicating clearly, however, to people 4 who will work on these, that in the process of coming to a de- 5 termination that an HMO in a given area is not viable, their 61 responsibility as professionals ought to go beyond that in 7 terms of at least telling people what the next steps might be 8 to resolve the problem. But part of the value will be in at 9 lease increasing the awareness of the problem. 10 Thank you. 11@ DR, MARGULIES: Thank you, Jerry. 12 I also have some housekeeping things to announce 13 but mine are less oly ian than Vern's. They have to do with MP 14 things like coffee and doughnuts And so forth. It's my 15 nature. 16 We will have a coffee break at 10:15 and@2:30, and 17 to show you how,non-Olympian I am, the coffee@is 15 cents and 18 'the doughnuts are 10 cents each and we ask you all to pay 19, according to that amount, no more, no less. 20 (Announcements.) 21 bRo MARGULIES4. We have introduced some of the new 22,@ d like to add to that the fact members of the Council. I' 23 that we ome memb rs of this Council. I think are also losing s e 24 Our losses are severe you are al @well,aware of the fact. 25 ity this evening to placate ones, and we@will have an opportun 28 1 ourselves for those-losses depending on how much cash you take 2 to the bar. 3 But just to remind you, Dr. Crosby's term ends this 4 time. He is unable,to attend. Dr. Everist, who is here with 5 us, also has his last tour@of duty ending today at this Counci_ 6 medtihq. And Dr. Hunt,, whose tour was relatively brief, but A 7 very vigorous one -- he was serving out an unexpired term, and 8 as a consequence his period of duration with the Council is a 9 little less than some of the others. 10 I'd like to also announce or introduce to you:-- ,-i I think most of you know -- that we have been most fortunate 12 in obtaining a new Director for the Professional And TechnicAl 13 Division. Dr4 td Hinman, who we. pursued for a period'of many,, 14 nths, has had a ve distinguished daroer,.moat strikingly MO ry 15 as the Director of the Public Health Service Hospital in 16 Baltimore, which he was able to use as a mechanism for ex- @17 tending his interest in improving community health services'. 18 He has bd6n here for upwards of three months, I think it is. 19 td, would you card to stand? He will be discussing 20 with you later on during the morning some of the activities 'for which he.is assuming responsibility. That particular 22 division I think will be highly productive and in some very 23 specific a., as ich this Council has addregs6d frequently at 24 levels of concert for program development and,f6r clarifida- 25 lieve A the @tate. of development of ti,oh for what we be s a 29 number of soecific activities with which tie are concerned. 2 For example our responsibility for dealing with the issue of monitoring the quality of medical care which has already been referred to, lies in that division. Our concern 5' with developing ideas about what is meant by an Area,,Healt-h 6 Education Center lies within that division, et cetera. And I 7 think by maintaining a consistent base of knowledge we will 8 be able to do more for this Council and consequently for the 9 RMP's than we have in the past. 10 I'm hot sure how many of you know that we also have 11 suffered a loss it the death of Dr. Philip Klieger, who has 12 for many years been a part of the Regional medical Programs 13 and who was extremely Active in the whole area of r6habilita- 14 tion He had surgery, returned homej and apparently had a 15 .myocardial infaiction and 6xpired quite suddenly. His loss 16 is a very severe one. His contributions to the RMP have been 17 consistent, And we all have expressed, through the Regi6nA! 18 Medical Pro and I ho e it was understood it represented 'gram 19 the interest of the Council, our sindere@concern,to his widow 20 ,and to members of his family. 21@ one other change which I would like to bring to ',22 your attention which is Already in operation/ which is again 23@ housekeeping but somewhere closer to the Olympian level$ is (/M the fact that Mr. Ken -is going to be responsible, and 95 is working out already is, for the Council affairs. This 30 1 extremely well. It's a matter of not only pulling these 2 Council activities together but keeping you informed, sending 3 out quick reports on Council activities, developing m.nutes, 4@ and in general maintaining the staff intelligence on Council -5 affairs. If you don't know him, I wish he would stand so you 6 know who he is. 7 We need to talk for a moment about a confirmation 8 of meeting dates. We have set them up at the present time, 9 u, for February And I want to recheck them with yo 8 to 9 for 10 th6 next meeting. I think you have them before you: May 9 11 and 10; August 15 and 16. 12- I am,not going to discuss at this moment something 13@ which we have considered, however, because it requires a 14 little more planning, but there is some thought going into the 15 idea of reducing the number of meetings to three a year rather than four. As we are getting into the triennium, And As we 17 are able, to handle these triennial applications more effec- 18 tivdly And in consideration of staff responsibilities, this 19 may turn out to be hot only desirable but quite practical. @PO But for the time being we would like to confirm with you those 21 they meeting dates and to check with you to see if in any Way 212 prove to be@a serious conflict with other activities,. 23 If not, we will consider them confirmed., and I 24@ would like at the present time to have a motion, if one is 25 st 1-4, 1971 appropriate, regarding the minutes of the Augu 31 mail. meeting which were distributed to you by DR. ROTH: I move they be ap .proved. Second. DR. SCHREINER: 4 DR. MARGULIES: Is there any further discussion? All-in favor say aye. 6 (Chorus of ayes.) 7 Opposed? 6 (No response.) 9 The minutes are approved. t3 10, I have a series of very quick reports,which I 11 would like to,bring to you to bring you up to date onla 12 number of activit s@;,-most of which are continuation of prior 13 interests. Some of them will elicit interest on-yolur part? 14 for your specific and some Of them will raise some questions 15 action, I do believe. 16 We have agreed to have a meeting of the coordina- 17 it tors, a national meeting of the coordinators in January. 18 will be January 18 through 20 in St. Louis. This was Act done 19 because,a meetingiof the coordinators is,a good thing to 20 ha bcdasion, but.rather because this appears to be the ve on time for the@coordinators to MOV6 together in a common way. '22 3: on@t really believe there is much sense in simply having @20 meetings because At periodic intervals that is a desirable @24 thing to d-0.@ We meet very freq e uehtly with th coordinators. ble amount of time with the coordinators We spend A Considera 32 1 where they work and we meet with them in groups, but what we 2 have felt is important at this time in the history of RMP is 3 to change the pattern from prior meetings of coordinators 4 and I think it's of great interest to the Council.as well and 5 we hope that as many of you can attend will the@time has 6 come to recognize the fact that RMP has had enough experience and has obtained enough maturity to begin to talk about some things which represent rof6ssionalism in the Regional Medical p 9 Program. It is A special kind of profession. It is a special 10 erent kind effort towards institutional development of a diff 11 and one which has become increasingly important. 12 Consequently, it was out decision, and the steer3.nc '13 as in Sip af firma- committee representing the coordinators w py Zt 14 tiorll that-this should be an expression of what the coordina- 15 tor6 are doing and think and need to know by their own efforti 16 and as ills. We will, we hop a product of their own sk e, have 17 present also people like Jerry Riso, Verh Wilson, Dr.@D all, 18 to keep ourselves in touch with HEW RSMHA interests. 19. But what we are planting to do is to center the 20 meeting around an input on the part of the coordinators, 21 around the central theme of increasing access and availability 22 ubi6cts tohich-the to medical care, with some specific sub-s y 23 will develop. 24 Now this is going to be done', has alteaidy beef% done by asking them to meet, the coordinatots,,o iona@ :,25 na sect 33 1 basis and begin their deliberations before they reach St. 2 Louis. This will allow them to utilize their time effectively, 3 will obviate the usual need to get together, form ideas re- 4 form them, and go-home again over a very short period of time. 5 So that in a sense this conference has started. it has 6 started under the aegis of the separate members of the steer- 7 ing committee who represent on a sectional basis the codtdina- 8 tors. 9 ill be competent, therefore, to come into They w 10 St. Louis with a representation of ideas which have been 11 generated by the interaction of Coordinators and staff At the 12 sectional level. They will be talking there, in the form of panels abo t@such hioh level interest subjects as area health u 14 aduc tion centers, health maintenance organizations, improved 15 ich is utilization of health manpower, et cetera, all of wh 16 related in a ot6lrarmatic sense,, rather than a theoretical 17 sense, to the improvement of access@to medical care,and as an 18 expression of RMP competence. These panels, then, Will e 19 so desi ned that there can@be smaller meetings in which each 9 20 0f the oanelists acts as a chairman of a section deal w 21 a sub'ect, and there will be a final plenar session on the y 22 last dayiat which time we hope to reach some working conclu- 23 n need still to be resolved, sionsi decide whit qqestio s 24 perhaps raise issues for further R&D within HSMHA, and perhaps i what programmatic so some gu give people like Jerry Ri idance n 34 emphasis we think is necessary or needs to be generated. You 2 will get further information about that as time goes on and 3 you will all be officially invited to attend. 4 In your book is a description of the reorganization ,5 of the Operations Division. It' s under Tabs X, C and D and E 6 as information items in the agenda book. 7 We announced to you earlier that we have set up a 8 method of dealing through the operations desk on a geographic 9 basis. That in fact hag been put into action, and when you 10 have the time to do so you will be able to look it over an see how it has been worked out4 It has already produced ev 12 dence of a higher level of coherence in the management of 13 RMP from.the RMPS point of view, by allowing each desk to deal 14 with a Regional Medical Program in toto rather than in the 15 fragmented fashion which seemed to characterize our managemen 16 in the past. 17 T'd like to just stop for a second and say that 18- these kinds of changes, which I think is becoming more and 19 more obvious in the Regional Medical Programs, is due not 20 only to a larqe staff effort but one which Herb Pahl has led 21 in a very striking wa hate to $ay anything complirq6ntarv y 22 about him when he is so nearby me, but his ability to see 23 issues, to organize peonlei to bring them along, and to accept 24 ays difficult; is extraordinary change, which is alw ,,and I would be unforgiving of myself if I didn't I'll never sav 35 s Particular point I anything good about him again but at thi 2 feel required to do so. The next item I would like to.mention -- andI this 4 is going to become an issue which is going to be of real con- cern to you -- I don't know whether we want to get into it at 6 ntil 1 the present time, but we can, or we can delay itu ate 71 in the day when I think we may have an executive session on 8 two or three issues which will require that kind of attention. We have over some tine been develo an updating ping 10 of bur regulations. These regulations in turn have gone to 11 general counsel for their validation and for preparation for 12 publication within the Pederal Register, making them thereby 13 official. This is an essential part of our activities. Since 14 we operate in the public interest we should be viewed'nublicl). 15 Some of the questions which ate going to be looked 16 at thorek and some Of the decisions which ate going to@be 17 made in those regulations, refer to@such long-term sticky 18 issues as the proper relationship between grantee agency, 19 Regional Advisory Group, coordinator and core staff.- These htve 20 been defined, and 1 think with some clarify,lbut as with all 21 regulations there will remain room for interpretation which 22 of the Council.. is going to be a responsibility over time@ 23 ifnen these have been moved from the early draft stacTe -@to a y will become something-for 0 24 point of finality, the y 85@ liberations and certain sections of them.will certainly be 36 1 familiar territory. 2 Back again to the Council And I am not bouncing 3 around; this is all part of the pattern Council functions @4 are clearly spelled out in the regulations whiph,are being de- 5 veloped as are the Regional Advisory Group functions And their 6 interrelationships. 7 The make-up of the Council, however, a not a part 8 of regulation-but a part of practice or a part of Administra- 9 tiv-e preference. This Administration has a strong preference 10 f or the ladies, and that I must assume we all join. As a 11 consequence, the two ladies who are here will over a period of 12 time have company, and it is our hope that by the time we have 13@ filled vacancies which are occurring -- Bruce, this will@be 14 heartwarming to you -- you will be replaced I'm sure, in a 15 manner which will be inadequate in one sense, but fully adequate 16 in another. We don't think we can replace you. The best we 17 th ught we could do is to seek for someone of the opposite 0 18 sex who could do through her special skills something which will comp6hta te us for what we lose with the loss of your 20 special skills, 1 don't know what I just said. 21 (Laughter.) 22 But in general, we are going increase e female 23 complement on this Council. 24 0 11 think you will also see some reflecti n o @our 25 hope to create a better balance both in @erms,of a mic rity 37 1 membership and in terms of a balance between the sexes by the 2 present make-up of the review committee. It is now at full 3 strength, and the new members, who are not here, of course, bul: 4 whose names I would like to give to you, include Miss Dorothy 5 Anderson, who is an assistant coordinator in Area 5 in Cali- 6 fornia; Dr. Gladys Ancrum, who is Executive Director of the 7 Community Health Board in Seattle; Mr. William Hilton from the 8 Illinois State Scholarship Commission in Chicago; Mr. Jenus 9 B. Parks, who was with the United Planning Organization in 10 Washington; Dr. William Thurmon from the University of Virgi 1; 11 Mr. Robert Toomey, who is the Director of the Greenv lle 12 Hospital System in Greenville, South Carolina. 13 These are all pretty much in the nature of announce- 14 and I think now we will move into some issues-which are ments, 15 going to remain of some concern to you. 16 one of them has already come up for some brief dis- 17 cussion, and that is the current status of area health oduca- 18 tion centers, We have had under discussion the q6neral@concept 20 AHEC for some months, and in fact when we reviewed the,activi 21 ties of P14P since its origin, we found that we have been in 22 the AHEC business for quite awhile. You will recall that at 23 the last meeting of the Council there was a presentation of tte 2411 Willowbrook, which represents many elements activity in Wat 9 of what we are talking about in the AHEC. As with the HMO, no legislation has been passed to make the Area Health Education Center a newly defined legis- 3 lative program. The Regional Medical Program legislation, @4 however contains all of the necessary substrates for AHEC 5@ development. Regardless of how the legislation comes out and 61 'marily three -- one of them is that it the alternatives are pri 7 won't come out,, which is one alternative. The second is that 8 it will be passed in the form that was introduced originally 9 giving the -primary responsibility to the Bureau of Education 10 we and Health Manpo r Training at NIHO and the other one is that :Ll the primary responsibility would be under Title 9 and R egional 12@ Medical Programs, 13 ted, and of course Those issues are still being deba 14 the outcome is unpredictable. In any case, it is quitd clear 15 that the RMP will be involved in AHEC'S, working Closely 16 with the Bureau regardless of where primary responsibility ist 17 closely with the Veterans Administration under any and working 18 of these circumstances. It is also clear that whether we 19 call it AREC or something else, the RMP's are moving strongly 20 in that direction, and the kind of ferment, Jerryi which you 21 have described in the HMO area, is closely paralleled by@that @22 is in the AHEC area. There are some interesting differences, however, in perspective, Iand from my own parochial point of view,, 1, think then at the,RMP@does represent an absolutely essential ingre th 39 1 in the development of at-least one kind of AHEC. There may be 2 several. Because one can regard the Area Health Education 3 Center as an extension and an expansion of the educational 4 activities in the,University Health Science Center and else- 5 where, or it cah@@iepresent it as a kind of community-bas6d 6 activity, designed around, service needs, which is so olanned 7 that the educational activities specifically serve those 8 service requirements, which is the way I interpret it. 9 Nowi as a matter of experience and practicality, thin 10 likelihood of developing a strong community base for an Area 11 Health Education Center, by proceeding through the Regional 12 Medical Program? with a balance between University Health 13 Science Center and community, the possibility of doing that 14 effectively I think is high. 15 The possibility of going through the University 16 Health Science Center as the primary Agent to the community to 17 develop that relationship exists, but I think it is lower, be- cause the University Health Science Center has its own@re- 19 sponsibilittes. It has grave financial problems. it has 20 prior concepts of curriculum. And it is in fact bound to 21 academic requirements which@have been long developed. I have 22@ made no se 7f the fact i moving round the country that cret o n a 23 f AHEC is to I think that one of the,,potential virtues o 24 challenge the institutional practices of University Health 25 h i'r Science Centers, And t6@in some ways assist them in t e 40 efforts to move out of their accustomed resting place and into 2 the community. I think many of them wish to make that move. 3 They find it very difficult. And I think that RMP, And 4 specifically RMP with the AHEC under the Veterans Adniinistra- ti6n collaborating, can make that move which-I think will 6 occur, move more rapidly and mote effectively. 7 Now, we are not in the position in RMP to put out a paper which describes what we think the AHEC ought to be. Ii-. would be inappropriate at a time when the whole subject is 10 being debated and the resting place for lead responsibility is 11 still uncertain., But we have shared these views with the 12 Bureau, and the Bureau has been generally in accord with them. @3 Certainly Ken Enditott does not believe that the AHEC should 14 be an extension of the University Ilealth science Center and a satellite thereof. On the contrary, he believes that there i6 has to be devised a method of producin within the community 9 17 real competence for relating education particularly education 18 at the middle level, with service requirements, with the re- 19 sults determined, evaluated, measured by the manner in which 20 they improve the ddlive of servIices. ry 21 Now, this jumps over the accustomed measurement of 22 educational Activities which is the completion of curriculum 23 and the acquisition of a diploma, ce if d gree And icate or e 24 if it is done effectively enough, thatcertificatef,,@@diplbma or 25 degree wi 11, @c@ome@s6condary, and th f fectivene@ ss of the 41 1 services being provided will become primary, and since I pre- 2 sume that is our goal, I hope that we can be effective. n 3 pursuing that kind of an activity. 4 This Council will, I am sure, begin to receive, 5 either in partial or in complete form, applications for what 6 represents that kind of an AHEC activity. We will also in 7 RMPS be working very closely and in a more formal fashion with 8 the Bureau to expand our Activities 66 that we. can do with the 91 Bureau of Education and Manpower Training those dom)ined in- 10 vestments which up to the present time have been found diffi- 11 cult to locate. The climate for it is good. There is little 12 or no difference in our views of what needs to be done. So 13 that I think, Jerry, we feel safe in sayin that we are going 9 14 to get on with the AREC. To what degree we will assume Ste- 15 wardship for it, and to what degree,we will be cooperating wi 16 someone else is,as yet uncertain, but it will be an active 17 program within the RMP. 18 Would,you like to add anything to that? 19 MR. RISO: No, I would hope that I get that paper 20 today. 21 @DR. MARGULTES: it was there last evening. 22 MR. RISO: Cood. This thing ought-to come to a 23@ head in rather short order. I am confident that it will come 24 out, too, one, that it will come out in way that we can work a 25 @with it; secondly, it will come out in a way in which RMP 42 1 will take a significant leadership role in the development of 2 these, I am delighted with both. 3 THE CHAIRMAN: Bland. 4 DR. CANNON: Maybe you and Jerry will clarify Paul 5 Sanazarols department. I can't quite relate this@now in TIMO's 6 and AliEC's and sort of get the feel of where our Council 7 stands. 8 MA. RISO: That's one of the questions I'm raising. 9 The proposed plan of organization of HSMHA places upon t-le 10 National Center.,a distinct, and not necessarily new but a much 11 clearer role in terms of being part of a leadership activity 12 here to bring about change in health care delivery. 13 The question -- and I don't have an answer; let me 14 jump to that one and tell you that at the outset -- the ques- 15 tions I am raising are essentially Ithreefold: One, in looking 16 at the Center, And in looking at the kinds of activities where 17 it spends its money, looking at the amounts of money it spends, the questions that I do propose to raise are: Are these the 19 areas where monev ought to be spent,, is the program in which 2 0 the programs that we support through the National Center, pro- 21 grams that deserve the level of support that we ate curron 1-Y 22 providing -- that is, with respect to piioritieg@a@nd suoh.@@ @23 Secondl , from an operating point of view,,,,@ can,we be s tisfied y 24 that the res It# being developed by the National Center re u (1) clearly known, (2) are adequately reacted to by th6@,.RMP 43 1 and other programs, and (3) do we have the management system 2 for putting those particular findings, those particular pro- 3 jects that we think are valuable,into ongoing programs? 4 Intuitively I'd say that those systems do not exist 5 and that there are major improvements necessary in wo ing re- 6 lationships and communications, and so the fact that you ra se 7 the question is perfectly understandable.- because I work here 8 and 1 can't answer those questions and 1 am raising them4 9 MRS. WYCKOFF: We do need to know more about what 10 they are in terms of HMO'S. 11 MR. RISO: You are absolutely tight. We all do. 12 And it is an item, not for concern in a negative 13 sense, but particularly with respect to the hew plan of or- 14 ganization.- and particularly with respect to clustering five 15 p s which t working both independently rogram 64ether, and then 16 and with other programs within HSMHA, Are supposed to have a 17 significant role in "institutional change." 18 We@ll, it is obvious and necessary that your re- 19- search arm has lot to be an integral part of this activ ty, 20 and this means that there have to be consistency between their 21 objectives and the objectives of the group, and some --I 22 don't mean:duplication now but some consist6hcy between the 23 Priorities in Areas they spend money,, areas in terms of pro- 24: grammatic at6As,,,Iand the areas we are interested in. And effective working rdiati ships which allow 25@@ then finally some on 44 11 communication in terms of where we stand, and think of it as a 2 series in terms of moving from research to field testing to 3 evaluation to full-scale production, to go back into the world @41-I come out of, and those relationships really -- I am not confident -- I couldn't assure you those relationships, one, 6@ exist today, and that the current relationships will remain 7 the same five months from now or less. 8 DR. MARGULIES-. Let me now bring you up to date on 9 what we are doin with the Section 907 activity. For those of 9 10 you who donit recall, Section 907 is that part of our legis- 11 latioh which@requires us to provide through the Secretarv a 12 list of those hospitals which represent the most advanced 13 skills for heart disease, cancer, stroke and kidney disease. 14 we have made qood progress, and we have reached a level of 15 understanding by bringina together a very competent group 16 people from around the country who can accept the idea that 17 we can do this effectiv6l and usefully by defending heavily y 18 on the contracts which we have had in the past for developing 119 guidelines, and modifying those in such a manner that we can 0 set up inst tutional criteria. I believe,even the cancer 21 tract _con produced enough data for institutional criteria so that we are going to be able to find it useful for that pur- pose The heart guidelines and the stroke guidelines, of 24,@ 6 urse, are effective for that purpose, and then we have, in 25,;@ ts for addition to that, put together a group of consultan 45 kidney disease which is simpler because it is dealing pri- 2 transplants so that we can establish marily with dialysis and@ 3 some criteria. 4 We will probably be working through contract with 5 the Joint Commiss@ion on Accreditation of Hospitals, and we 6 Will try over a period of@'time to move through this process so 7 that the level of skills which are identified and kept current 8 will apply hot only to the hospitals with the most advanced, but also those which are of necessity related to such insti- 10 tutions, so that we have a series of reports which will allow 11 the profession and the public to make wide choices in how they 12 seek help. 13 I think it is moving along well, and since there 14 are no more details than those, I think that we probably needn t 15 pursue it further. We will want your assistance,,however, as 16 we move into the final statement of criteria, and as the Joint 17 Comission converts these into a method of inquiry which fits 18 techniqu with their es, because you have to establish criteria 19 first and then convert them into a useful form. 20 t further on it Clark, unless you'd like to commen 21 I think that's -robably as@much as we need to do with it now. 22 pecifics about the RMP#s and Now to@@some more s. 23 the last several meetings your prior@;recommendations. Over 24 there have been@sev@eral Regional Medical Programs which have 25 sually because been the subject of particular attention u 46 1 there are problems. We have met with all of them in depth 2 and there have been some results which may be of interest to 3 you. I don't know that what has occurred ca@t be analyzed in 4 full, but there are some symptoms which I think are-worth 5 noting. 6 In Central New York, Dr. Lyons has resigned_ as of 7 November lst. 8 e s In Rochester, Dr. Park r i resigning January lst. 9 In Susquehanna Valley, a coordinator who resigned, 10 as I think you already knew, and a new one is being soucjht.@ He will be an M.D. and they Are close to a resolution and a 12 selection there. 13 In New Mexico, Reginald Fitz has been replaced by 14 Dr. Jim Gay. He is a neurosurgeon. We will live with that fact, but he appears to be all right anyway' Bland. 16@ We had An extremely direct meeting with Oklahoma, 17 with Dale Groom and with Dr. lielio, The discussion was frank. We have no formal announcements of further alterations but 19 they understand what kind of directions would be more appro- 20 priate for them, and there may be further specific changes 21 there in the very near future. 22 Greater Delaware Valley also has@a new coordinator. 23, Dr. Wollmah has been confirmed as he was@acting@@,and he is 24 now the regular coordinator of the Greater Del aware program. Nebraska, which was in issue'. has anew oordinator 47 Dr. Marcie has replaced Dr. Morgan. 2 South Dakota has also a new coordinator named Dr. 3 Low, 4 In Albany we had a meeting in depth, and I had the 5 feeling that we left with both of us relatively unaltered. 6 There was a possibility of some change, however, because among 7 those who came down were some people who had some real fire in 8 them, and Ilthink we will have to pursue that one with a 9 little more vigor. 10 We dlc5n't play games in this Council so we have to discuss things pretty,openly, Jerry, so that one remains of 12@ some concern. :However, Stu Bonderant, who is on the Regional 13 Advisory Group up there,, understands what needs to be done. 14 We have put a very definite tim e limit on the pr,)gramt which has 15 most characterized the Albanv,program, and there is no question 16 that it will be phased out before the end of the year. So 17 that they will perforce be seeking new directions. 18 ill be having a site v*sit with the metropolitan We w 19 D.C. RMP in the very near future, and that also may be an ex- 20 tremely difficult one for a number of reasons because there is 21 not only the issue of the D.C. RMP, but there is also a ques- 22 tion of a kidney proposal which Dr Schreiner I think has some 23 faint knowledge of. 24 brnia, in Area 3, Dr. John Wilson, was In Calif 25 replaced by a full ti'me acting as coordinator has been 48 coordinator, Dr,. Faulks, who I think you are all familiar with 2 who is an extremely good choice also. 3 There are three RMP's where new coordinators are 4 either being sought_or have been selected and not announced. 5 higan. It's no As you know,@Al Eustice did resign from Mic 6 secret by now they tried very hard to get Bob Chambliss to go 7 out there as coordinator, and we gave him a very long rope 8 which extehded@as far as 56 miles short of Michigan so that he 9 could go as close,to it as he wished,, but we pulled him back 10 and he's remained here as the Director of the ODerations Divi- 11 sion, And that set them back a little bit because they thought 12 they could snatch him. They don't have a coordinators but they are seeking one., 14 Pete Doan is resigning from the Colorado/,',Iyoming. 15 Both of these resignations were tim6-based. They Are both at 16 the age of mandatory retirement. And I believe Al Hoffman 17 will stay. So these are replacements which Are based upon in- 18 stitutional regulations on resignation. 19 We have, as I indicated, met in depth with All of 2 0 the programs@which have difficulties. I have not discussed 21 ohio. I-,have@lnpt discussed Delaware. Both of these are 22 special issues which@I think we will preserve for the period 23 of time when@we go into executive session. We will also be 24 talkin,9"at that time'about the new construction for a cancer 25 center in the Seattle area. 49 1 Now, before coffee break I'd like to bring up one 2 other issue, which is not a perennial one, but rather one whicli 3 has emerged in new form as we have created a different kind of 4 PJ4P review structure, and that has to do with the relati sh D; 5 between kidney activities and the PMP activities otherwise. 6 We have been accused by the review committee, by 7 people outside and inside RMPS, of being very inconsistent in 8 the way we handle the kidney activities relative to the way we 9 handle the Regional Medical Program review. That accusation 10 is absolutely accurate. We are inconsistent, and we are de- 11 liberately i@h consistent, and we will probably perform better 12 if we understand the reason for the inconsistency. 13 The kidney activities, which are essentially, as we 14 review them, concerned with end-stage tre@atmeant, with dialysis@ 15 la t, and with all the necessary requirements for dialy- transp n 16 sis and tran- lant, is categorical, unblinkingly, plainly 17 categorical in its approach. And as a consequence, and be- 18 cause we wish to go about the management of,that categorical 19 activity through the,er6atibn of a national network with a 20 minimum of unnecessary duplication, we do have to perform two 21 kinds of acts which we hope we can perform with effectiveness. 22 one of theta i§ a review as we in the past reviewed Droie ots @-@23 technical review. That technical review has to take place in a special form. what we propose to do for technical review are going to will be tied in with the way in which we 1 reorganize the kidney activities, about which I will speak in 2 a moment. The nature of the technical review Dr. Hinman will 3 describe to you either before coffee or innediately after. 4 But the essence of the process is this: That we will under- 15 stand that a technical review is necessary, that that technical 6 review will be brought to the review committee as a project 7 type of deliberation. It will also be brought to the Council 8 where we now have kidney competence -- well, we have always 9 had kidney competence, but we have supplemented Mt. Wyc%off 10 by having two more kidney experts on the Council, and they 11 will be in a position better than they were this time to re- 12 c-eivd at an,early date the technical review and consider it on 13 th e merits of its technical competence. 14 Now, that does hot separate us from the responsi" 15 bility to consider this with two other issues in mind. One is 16 how this relates to a Regional Medical Program, and the other 17, is what it rep.resents in the otay of funding. So far as the 18 RMP mechanism is concerned, it is necessary that we recognize 19 the fact that a technically effective kidney activity may be 20 proposed b a Regional Medical Program which has so many -orob- y 21 lems and is having so much difficulty functioning as an RMP that a serious question is raised about whether it is ap 22 pro- 23 sp6nsibility. priate that they take on this re 24 This can be true for two very broad reasons. one 25 of them, because it will divert their energies into something 1 which is less meaningful than it should be for total regionali- 2 zation. The other is because it will make them believe that 3 they are achieving something by having been awarded a fairly 4 sizable grant when in fact they are achieving too little. 5 But the underlying element is the fact that we are insisting 6 that if we do approve something which is technically sound, 7 that it be managed with regionalization, and that it serve 8 the maximum public interest within that region, If the RMP has not achieved effective regionalization of provider ser- 10@ vices, then there is a very great likelihood that it will have 11 a sound kind of an activity with little or no regionalizati6n. 12 That issue will regularly come up and it will require delibera- 13 tion by this Council to resolve the differences. 14 When the kidney project is technically unsound 15 there is no issue. When it is technically sound and the RMP 16 is sound, there is no issue. when the two are out of phase 17 there is an issue* 18 'The other question has to do with the way we look 19 at the fundin of a kidney activity, vis-a-vis the basic 9 20 funding of the Regional Medical Program. That is si ler@thar 21 any of the other issues, I believe., It becomes self-evident 22 when you look at the basic commitment which we may have to 23 r an RMP, that a large kidney activity cannot be app oved for 24 support if we@@limit the funds available to that activity to 25 at Regional Medical that which as Already been awarded to th 52 Program. Sometimes,.an RMP may be operati q at a level, say, n. 2 approval for a kidney activity in the of $650,000, and'it gets lyt this would be an award of an range, of $,,2,00,000. Clear 4 actiOity tch is@maningless because it couldn't possibly 5 support it. o so and when we So we.do,,, when we are able to d 7 know enouah about our budget, anticipate a level of funding, 8 since this is still a categorical project type activity, wh c 9 sets aside when we can do it, as I say, an amount of money 10 which will go into kidney programs, and we operate, as we understand our budget, within the constraints of the funds 12 which are available. When you approve a kidney activity at 13 whatever level it may be, we look separately at the total 14@ funds which we hope will be available for kidney activities 15 and make at least some of our determination for final award 16 oh the basis of that total resource. Since this vari6s accor- 17 ding to the allocation of funds to RMP And the other demands 18 for funds within RMPT we are never sure until a little later 19 in the year, and we are not sure at this moment what that 20, total allocation@is. 21 In the past fiscal year, through contracts and 22 ap $5 milli ,grants, we were investing proximately on per year 23 in the kidney activities through RMPS. We hoT>e, if we get a 24 t of funds in the RMPS, to ihe that larger, final allotmen rease 25 in Accordance with the total amount available, and in acdordance 53 1 with what project activities come in.@ So that,we have to also 2 operate on a separate fiscal review, as well as on a separate 3 programmatic review basis. 4 Now, I think that that'is a reasona le enough ex- 5 placation of our inconsistency and I-hope that we can live 6 with it. I also hope that we can confine that kind of incon- 7 sistency to the kidney activity and not acquire new categorical 8 programs which tend to move in the same direction, because all 9 else that I can see which represents new interests, either 10 n n, ca through Congress, or through the Afti istratio h be devel- oped most effectively by having a sound delivery system rather 12 than by having an isolated kind of project-related effort4 13 DR. MERRILL- 1 wonder if I could ask you or Mr. 14 Riso t o respond to the following question: If.kidney,is,to 15 be treated as.A technical review, and perhaps correctly so, 16 would this erhaos have any bearing on the discussion that you 17 told us of new negotiations, the role of technology in the 18 health field.7 Certainly a good many of the kidney activities depend for that efficacy upon advances in technology, and I 20 @think the new apparatus for dialysis,, the production of anti- 21 0 r lymphocyte globulin, and a good many@ the a. Will this have 22@ an input into the technical review in a@way,in which kidney 23 funding i considered by the RMP?, 24 DR. MARGULIES: I think I@d have to,,angwtr no to PI 5 ink;@what Vern was thAtl John, from what I understand. I th 54 talking about might be related to this, but he is essentially 2 emphasizing new technology of the automated kind, the,.type of 3 thing which was produced by space explorations -out of NASA 4 interests, the types of communication networks w-hich@'can be 5 established in rural health care delivery systems, s of the 6 remarkable things that ilashington/Alaska is doing with the use 7 of the satellite, that kind of thinqp rather than scientific 8 technical development. 9' DR. MERRILL: Perhaps the commuter would fit better in in this. DR. MARGULIES: Perhaps. 12 DR. SCHREINER: Well, while I agree;with your cau- 1 3 tions, I'd just like to raise one additional as,?edt to what 1 4 ng,kidney programs you mention. T think the problem of stro 15, and weak P14P's is going to.be with us for allofig time. While 16 it is true you@have to be cautious, I would ask that you think 17@ in another direction, namely, that where there has beena@prob- 18 lem in coordination in P14P that has been difficult to solve 19 over a period of.time,' it's just possible that becau@@se,of the 20 tight organized definitive way that kidney care is delivered 21 that it might@be the means by which you,iniecf!@'the starter 22 fuel into that particular program and get it:piovin4.'@",l can 23 remember several institutions where no@surgeon.talkea to an 24 internist until they had to do a transplant@'togethe@.@@@'And I don't think we should keep saying theylv c e T6t to talk,,to each 55 other first in order to do that. It may be that the doing of 2 it@ my be the means by which you get them to talk to each 3 other. 4 DR. MARGULIES: 1 think you're quite right. There 5 are no absolutes @in this and we have also considered that 6 possibility, bi4t;tbese are the general kinds of ground ru es. 7 I do think it's time for a coffee breaki I'd like to say that 8 when we come back I will bring to your att6ntioh some ques- :9 tions which the review committee raised about kidney programs. 10 I think that I have at least brought you up to-date oh our thinkin , but you,will want)to respond and you will want to go 9 12 a little farther on the reorIganization of the kidney activi- 13 ties within the RMPS, 14 Let's see if we can be back in, say, twelve minutes. 15 @(W 'hereupon, a short recess was taken.) 16 DR. MARGULIES,: May we reconvene., -please. We are 17 still not@:through with the kidney issue. t wonder if-:we could get backlon to the agenda, please. There are two issues which we wish to discuss 20 further req ding kidney. One of them is broader than the 21 kidne issue aloni6,.lthat has to do with section 910,and its y 22 ten@ia@l use lndss. But first, I would like to have the 23@ @C'u ci@1'recei,,ve for their consideration the expressions of o n 24 interest from the review committee during their last cycle, 25 specifically related to kidney disease. They asked four 56 1 questions, and it seemed to me that some of them were of 2 doubtful relevance to Council deliberations, but you can form 3 your own judgments about that. 4 1 will give you all four of them, an ien we can 5 go back and consider them one at a time. 6 following consideration of the individual ap plica 7 ti6ns, the committee passed the following motion regarding 8 guidance from the Council: 9 l.' Whether Council recommends that@money appor- 10 tioned for renal disease be considered in a proportional ratio 11 to the total amount@of money of the RMPS budget. 12 2. Vlhether the total amount of money spent in a 13 given region for renal disease should be in proportion to the 14 total amount of dollars being spent in that@r6gion. Ipresume 15 they mean by that RMP dollars. 3. Whether renal programs funded by the regions 17 Will come out o their total budget or out of a sepa a budget. 18 4.' lihether renal programs should be considered 19 outside of the total regional activities or not. 20 Now,;I, attempted to address these issues in general 21 in what I said before@ the'coffee break, and I wonder if we 22' might not go back with any kinds of comments you-care to make 23 on those particular questions. 24: Theifirst one was whether the Council recommends 25 that money apportioned for renal disease be considered in a 57 proportional ratio to the total amount of money in the -RMPS 2 budget. 3@ DR. MILLIKAIZ- How was the dollars arrived at? Did that just sort of happen? You mentioned in your initial com- nents about $5 million. 6- DR. 14ARGULIES: Actually, the final decision on 7 budgetary dispersal;is an administrative decision in which w- 8 only participate partially. If we let any suri of money, aslit 9 appears we will, above the level of last yearts funding, this 10 will be associated with a considerable amount of administra- 11 tive negotiation. We will say what we want. HSMIHA will say 12 what it wants. 99W will participate, the OMB will, and there ip 2 13 is a round-robin of:activities. 14 The figure of $5 million or any other level for 15 @@:kidney cannot be arrived at on any basis of need, because it 16' clearly is inadequate for the needs. it's@ttkictly.an inter- 17 nal budgetary issue, and one decides that that's how much you 18 can afford re ative to RMP sup ort relative to area-health ,p 19 education development or manpower utilization, or whatever may 20- the competing elements within the program. 21 DA. 1.4ILLIKAII: Then the answer to that question is 2-2 reallyi as farras the review committee is concerned just the 23 ave given. explanation you h DR. MARGULIES: They felt a little uneasy with it. 25 he lt maybe the Council should decide it. T y fe DR. @ROTH: This is prol@ably askitg the sane questio 58 1 in a little different format, but when RMP assumed the mantle 2 of guidance in the kidney effort, did it accumulate any speci- 3 fic additional funds to do the job? 4 DR. MARGULIES-. In the very initial stages it 5 carried some contract activities from aprior time but in fac: 6 there have been no additional funds made available for kidney. 7 DR. MILLIKAN: No earmarked funds? 8 DR. MARGULIES No earmarked funds. The legislation 9 says you may spend up to $15 million, And then they immediately 10 reduced the total amount available well below what it had been 11 previously, so that regardless of what was recommended bv l@2 Congress or by the@appropriations process, we had even less 13, for kidney than we had before the legislation was passed, if 14 at it that way. you want to look 15 DR. SCHREINERO. I wouldhl.t want to look at it that 16 w a what hap ay, bedaus pened, they reduced the appropriation first, and after we want to the Appropriations committee they 18 Added earmarked funds for kidney, and then the Bureau of the 19 Budcret froze it. And then in the conferences, since actually 20 the kidney people who are working on this appropriation were not particularly pushing for earmarked funds, realizing the 22@ problem there is in administering ea rke'd funds,'but were 23@ usi it to try to@iddhtifv the interests of;Congress and the 24 interests of the C6ngres. onal committee. 25 So the earmarking was taken off when the money was 59 1 But I think the intentions -- and this was by agree- thawed. 2 ment -- the intentions of the AppropriAtions Committee were 3 to increase the total appropriation. Of course we'd like to see it increased more, obviously, because it isn't meeting,.the 5 need. 6 DR. MARGULIES: I think there is no question about 7 it being the intent of Congress to increase the investment in 8@ kidney disease activities, and there is no question about our 9 to do so. I really think what the review committee is intent 10 asking the Council to do is to assume an administrative re- 11 sponsibility which it's in a -poor position to carry out. We 12 are not in a very good position ourselves because we only, as 13 ntet into this discussion. You mic I say, e Tht ask the same 14@ question I hope you won't about.the money for pulmonary 15 .@@@'-,pediAtric centers. One could just as easily say that the 16 amount of money should be equivalent to what you give for 17 v kidney disease. 'The needs exceed the funds a ailable for i8 both, so the decision is actually a fiscal decision, which is 19 not related to total needs, but actually related to relative 20 competition for funds. If we could do so, we would like to 21 @increase the,kidney investment in the range of 50 percent over 22@@ what it has been in the past, which would be in fact out@@of 23 proportion to:the increase in funds potentially ava iAbiee.'! 24 But it isn't on'that kind of a basis @p,'-decision 25 determined by wha"t'@ he has been made. It's really also 6 1 potentialities are for good projects which can be supported ahil 2 maintained over time, et cetera. 3 DR. SCHREINER: I'd like to just comment so it's 4 not misunderstood. It's so easy, I think, to keep kidney 5 categorical, but the official position of the-legislative 6 committee in the National Kidney Poundation was against ear- marked funds. They simply were trying to point out that if 8 you add a job to an already 6xistihg job, that you need to 9 provide additional money, so on the one hand we are talking 10 about additional appropriations for the added job. On the 11 other hand, they were not in favor of putting bridles on the 12 money in terms of the way it should be spent administratively. 13 So I think they are not thinking cate4oridally,ih 14,@ the implementation, but I think when you go and ask for a new 15 task that there ought to be something to go with i an no 16 take xigting ap away from the e proptiations. 17 DR. MA LIES-. Perhaps I can clarify this first 18@ question by recounting to you the kind of logic which was 19 generated for asking it. It went like this: 20 an $15 The appropriations said that not more th 21 million should be spent on kidney disease. This meant $15 22 -million. $15 million is such and such a percent of the total 23 appropriation. Therefore, the percentage which shou o intc 24, kidney activities should be whatever percentage that presumed 2.5 $15 million is of the total appropriation. 61 1 Now unfortunately, there are a few flaws in that 2 logic, one of which is no more than $15 million does not mean 3 A minimum of $15 million, and it simoly breaks down at that 4 point; nor is in fact the budgetary process ever subject to that kind of percentage logic. 6 DR. EVERIST: It seems to me we can give a mono- 7 syllabic answer to the last two questions, and the first two 8 are not appropriate to the Council* 9 DR. MARGULIES- would you care to do so? 10 DR. EVERIST: I w on. 11 'DR. MARGULIES: What is the monosyllable that you 12 wish to use? 13 DR. MILLIKAN: No, yes, no, and so forth. He's 14 proposed we tan answer the first two. I would suggest we say 15 no, no, yes, and no, in the following sequence. 16 MR. OGDEN: I agree. 17 DR MARGULIES: You would have the renal or6grams funded-by@the regions@come out of their total budget? That's 19 a sort of meaningless question because it will have to be 20 their totalibudqet if you give them the money. 21 DR, EVFIRIST: Right. 22 DR@. MARGULIES: Rather than a separate budget. 23 So what you are proposing is that the answer be no 24 no, yes, and no. 25 DR. 80HREINER: The only provision I would like to 6 2 1 introduce on No. 4, it's conceivable that in the areas where 2 there is little or no regional activity at the present time, 3 that this could be,the opening wedge. In that sense it could 4 be outside of existing regional activities, because there 5 even are regions that haven't formed yet in some of those 6 areas and this may be a way of doing it. 7 DR. MARGULIES: I wonder if we could have a secon 8 to this and then a discussion of it. The motion was that the 9 answers in numerical order are no. no,, yes, and no. 10 DR. ROTH: I'll second it. 11 DR. MARGULIES: Okay, it has been moved and seconded. 12 John, do you want to say anything? 13 DR. MERRILL: Well, only to comment again on ques- 14 ti on No. 4. Philosophically, at least, it might well be pos- 15 6ible that a renal program in and of itself might subserve 16 exactly the purposes for which RMP was Created, and in so 17 doing I should think we should fund it as any portion of RMP 18 and not necessarily as a renal Program.in itself. 19 Secondly, if we consider, as you have stated we 20 will -- and I think it is probably true at least@at present -- 21 that this is a technical activity@related to dialysis trans- 22 plantation* there are a limited number of people which can be 23 served by this, And insofar as that is true, I would th nk 24 that renal rograms should not be a major drain on the P.5 ctiv, er the purposes in a it* as a whole. But where they do s ve 6 3 many instances they have actually led the field in showing 2 the way in serving these purposes, I would think that they 3@ should be considered on their own merits. DR. McPHEDRAN: Dr. Margulies, do we really have 5 to@answer these questions? I mean if we really don't agree 6 with the premises from which the questions were derived in 7 the first place, I mean that they are really significant ques- 8 tions which I think many people on the Council perhaps don't, 9 since we don't have much regard for that percentage calcula- 10 tion of the budget, and since that is the premise from which 11 this is derived, maybe we don't have to answer the question4 12 Maybe, Dr. Everi6t will correct me, but I think to some extent 13 his answers are a little bit facetious because you can't just 14 no, no, yes, and no these things. There are obvi6ts@qual.ifi- 15 cations to each one. 16 DR. MARGULIES: I welcome your thought, Alex, be- 17 cause what is lying under this -- and it comes up 'regularly on 18 the review committee -- is a desire to move from review at 19 their level and review and policy formation at your level, 20 into administrative activities which 1 can fully understand, but some members of the review committee would like to'believe 22@ that there is a way in which the review process can actually 23 determine budgetary allocations in a very specific sense and -24 carry out the whole fiscal management function, which@in the 25 days when joe murtog was on the review committee would usually 6 4 1 get set down in short order because he had plenty of NIH ex- 2 perience proving that that do6sn'It work very well. 3 So if you want- to sa that you think at least those 4 questions which relate,to,,budgetary determination are in- 5 appropriate for-the Council, that also is your prerogative. 6 MRS. MARS: I think they@,are asking just for a 7 guideline, really aren't they, so to speak? I know th s 8 came up in the site visit that I madd, and I can well under- 9 stand the review councils or6blem, but I think that we should 10 try and set some sort of a guideline rather than just saying i'l yes and no, to to speak, because each sO6cific renal 3ect 12 does have to be considered and treated individually, as Dr. d the necessity for Merrill said, according to its mdrits. An 14 the money and the ratio of total amount of money being appor- tion6d, must be granted accordingly. So 1think in all fair 16 ness to them,that we.should try and set some sort of a guide- 17 line And not@just answer that way. 18 DR. MARGULIES,: If you pursue that thought, which L9 I think is reasonable, it comes around again to the question 20 which they struggled with, and that is: Should we,review in@ 21 accordance with@the funds available-@.@or review in Accordance 22@ with the technical or, in the case of the RMP, total,program- 23 matic comp6teftce@of the program? And we have felt very 24 strongly that an thing'which is tied to a presumed budgetary 25 umed level of competence is an level rather than@@a pr4Ws 65 undesirable review mechanism. Not only that, it is_impract4- 2 cal because we don't know what money we are -ta lking about. We 3 don't today. 4 DR. MERRILL: I think in essence,lthen, what you 5 are saying is what Mrs. Mars and I are saying, is that they 6 should be considered on their own merit regardless of budgetary 7 considerations. 8 DR. KOMAROFF: I hate to introduce a complication, 9 but do you ever conceive of 910 Authority being used to fund 10 renal projects across several regions, and does that compli 11 cate our answer to No. 4? 12, DR. MARGULIES: I don't think it complicates tle 13 answer but I had intended to talk About 910 in this connection 14 and I will as soon as we are through with this discussion,, be 15 cause there is no reason why the 910 mechanism should not be 16 used for this and for other activities, 17 Well, let's talk about it for a minute and bring 18 some of you up-to-date on what it is vie are talking about. 19 The 910 section,iii the RMP legislAtioho among other things, 20 allows for the award of a grant or,& contract on a multi- basis so that if there is somethin which is of@, regional 9 22 i ich 'they concern to more than one region, there is a way h wh 23 can join@t,6gether, make application and get funds hich serve 24 @a common purpose. Sometimes this can be a@single'activity 25 which serves multiple RMP'S. In other cases'@it may be an'@ 66 1 interrelated RMP activity which is located in several areas. 2 We have not utilized it during the past year for 3 the very simple reason that we were down to bedrock on funding 4 and there was no possibility. On the assumption that the 5 funds will be reater, and also on the assumption that we will 9 6 put more money into kidney disease, the utilization of Section 7 910, particularly for some of the projects which are being 8 promoted in the kidney area, is perfectly reasonable, and 9 there is no reason why we shouldn't utilize it. But it would 10 still leave the question of review on the basis of merit 11 review on the basis of funds available one to be versus 12 answered. 13 DR. EVERIST: I don't think we can change our 114 philosophy for one disease. 15 MR. OGDEN: Harold, perhaps what you are saying in 16 answer to Dr. Komaroff, that perhaps the answer to Question 4, 17 when you are talking about total regional activities, may in- 18 clude Section 910 for purposes of regional concepts. 19 DR. MARGULIES: Right. 20 MR. MXLLIKEN-. I#hat's the time phasing on this? 21 Would this be a policy forever, or would this be reassessed 22 by the Council,) 23 DR, MARGULIES: Well, I don't think we have any 24 forever policies. The issues can be broken down'here., now 25 mp6r that we've gotten into it, and I think it's mote i tant 6 7 1 than just the questions that are being asked: One of them is 2 whether the Council feels that it is in a position to advise 3 or to make policy on the way in which the various portions of 4 the RMPS budget are to be subdivided and allocated over time, 5 or whether it should confine its activities to policy and to 6 the review of programs and projects in this case on the basis 7 of their merit. 8 Now, quite frankly, if you were to advise us in 9 HS14HA and HEW that you would determine what our budgetary dis- 10 ttibution would be, the advice would be received but nothing 11 would happen. It would be nice for you to say it if you want 12 to but it isn't going to occur because there is another Pro- 13 cess known as the Executive Branch of the Government which takes 14 care of that. 15 DR, McPHEDRAN: Well, I'd like to be in the positio 16 of complaining to the Executive Branch when I think that their- 17 budgetary limitations frustrate our professional purposes, and @18 I wouldn't hesitate to do that. It's just that Ilthink that 19 these questions ate really too precise or they require answers 20 in too great precision about budgetary management for me to 21 want really to vote on it. I guess that's what I was trying 22 to suggest before. 23 DR4 MARGULIES: So we're hung up. We do have a 24 motion. The motion is no, no, yes, no. 25 DR@.MILLIKAN: With explanation. 1 DR. MARGULIES: it is the sense of the Cou4cil 2 that you wish to continue to review on the basis of the merit 3 of the proposal, that you are not in the position to determine 4 year by year budgetary-allocations, that you would like to be 5 in a position, howe 6ri to-criticize the budgetary deci ions 6 which are made and have some accounting of how those budgetary 7 decisions were made, and that you mean by regionalization of 8 being associated with reqionalization of kidney activities, 9 that this can be either through an RMP or through a Section 10 910, but that it should be designed in such a way that it 11 services the broadest possible public interest, I can add 12 those kinds of comments back for the review committee along 13 with however this vote comes out, which we haven't yet taken. 14 Is that, without complicating the issue too much, 15 > what you are saying? Nlay we have a vote now on the motion. 16 DR. MERRILL: Could I ask a point of semantics first. 17 No. 4 reads, "Whether renal programs should be considered out- 18 side of the total regional activities or not." Does the 11 no 19 mean they should or the "no not. 20 DR. MARGULIES: I think thev are saying we should 21 not be that's a'little difficult, isn't@it? I think what 22 you are saying is that the Regional medical Program should hot 23 be@considered outside of total regional activities. 24 DR. EVERIST: That's the way I read it. 25 DR."MERRILL: i'@hought Section 910 did authorize that. 69 1 DR. MARGULIES: It's still regional, but@rea 2 with a different kind of distribution. 3 DR. SCHREINER: Point of order. Could I@ ask,the 4 proposerof the motion to change it to no, no,,, yes, maybe'@> 5 DR. MILLIKA14; May I comment on this as'far as No. 4 6 is concerned I join Alex, in a sense, I guess. I am just 7 amazed that they asked this question. I won It editorialize on 8 that any further. Looking at it literally, it says, "@ere 9 renal programs should be donsidbred." Well, I think they 10 should always be considered in the context, if we are a Re- 1-1@ giaonal Medical Advisory Council, they should be considered in 12 the context of the regional activity in which they are being 13 developed -- in which each regional program is beincj--@dev6loped. 14 1 heartily agree with George's earlier comments that a renal 15 program may be a vehicle for accomplishing some kind of M4P 16 activity which has not been accomplished through any other 17 vehicle. Well, my.answer does not exclude that answer at a 18 am simply giving a forthright answer that should they be 19 considered outside of the total regional activities or not, 20 my answer to that is no. They should always belconsider-eld in 21 the context of the regional activities, but the.depision may 22 va widely depending upon the wisdom of the review Committee ry 23 and the Council. 24 DR. ROTH: I have a very simplistic view of 25 these questions have been asked. I think the review committee 70 is saying, "If we make a recommendation based on each one of these four, is this going to be countermanded on account of an 3 established Council position?" And to me it seems very clear 4 that is not ap that if they recommend money portioned for renal 5 disease, proportional to the total money in RMPS, we are not going to rule it out on a policy base. And the answer to 7 question 2 is that we are not going to rule it out on an es- 8 tablished policy base. We are taking the position Oragm4tic, 9 that whatever money that goes in is part of their total budget 10 -so thIe answer is yes, And the final answer is no, they sh6ul 11 not be considered but of the total regional activities. They 12 are an integral art of it. p 13 DR. MARGULIES: I think you might get a little 14 sense of the lack of solemnity s r or at least analy is in th6i 15 question, if you look at No. 2. The implications there are 16 th at,the region receives a lot of money, gets more money for 17 hey for kidneyi@which reallv makes no.pro- kidney, a little MO 18 grammatic sense whatsoever. 19 MR. OGDEN: Move the question. @20 DR. MARGULIES: The question has been moved. All 21 in favor say aye. -2 Chorus 2 of ayes.) DR.,MARGULIES: Opposed? 24@ DR4 KOMAROFF: Are we voting on the no or maybe? DR. MARGULIES: The maybe was not accepted by the 71 1 primary mover. 2 DR. P4ERRILt: Are-we including in the answ to 3 No. 4 your comments about Section'910? 4 DR. 14ARGULII,;S: Right. 5 Now, I would like to continue with the kidney dis- 6 cussion because it's an extremely important area and one that 7 has been a little confusing. 6 We have completed plans to change internally the 9 way in which we manage the kidney activities. one of the 10 changes has been to try to integrate the competence of the 11 people in the Division of Kidney Disease with those in the 12 Professional Division and in the operations Division, so that 13 w ith very little delay there will be an opportunity for the 14 professional people to move into a total professional environ- 15 ment the operations people into a total operational environ- 16 ment, and this will allow us to have greater continuity with 17 the management of kidney activities will expand the poten- 18 tialities not only of those divisions but also of the indiv d- 19 uals in those divisions who ate otherwise restricted in their 20 own career activities to alsingle portion of a single disease. 21 That will have been,completed in the very near future. @it 22 will enhance out ability to deal with an e=andihg program 23 and will allow us to maintain the competence which'we already 24 hid. That is,an int6rnal@,mechani'sm 'which will place the pro- 25 3.d ctivities under fessional responsibility for the X. ney a 72 1 Dr. Hinman's direction, and I would like to have him now 2 speak to you about the kind of functional directions which he 3 anticipates in that kidney activity after which I th nk we can 4@, consider the discussion of the kidney activities closed unless 5 further issues come up. 6 DR. HINMAN-. I was asking Harold if I should just cover kidney to begin with because T am going to have the 8 opportunity to discuss some of our other areas of interest 9 with you a little later on. 10 We looked at this issue of how we would be able to identify and,review appropriately the applications that would 12 the 'in4,fr6m the regions in support of a national pro- be for Om 13 gram that would attempt to alleviate the shortage of resources 14 to treat patients with chronic renal disease. 15 If you will recall, you all issued a policy state- 16 mnt'in November of 1970 to the effect that there should be a 17 national network, and it went into greater detail. 18 :It appeared to us that we should make an effort to 19 try to get it back into the regional review,process and 20: w.3. in'the regional activities as much as possible but still 21 t los ain.special emphasis upon i so it would,not t no acert 22 get lost because of the nature of the problem. 23 So that the plan is as follows: 24@'@ Pffective very shortly, when we get the various, 25,, oieces--@of paper ready to go out to the regions, Wtt Will notify 73 1 the regions that there will no longer be a central ad hoc 2 technical review of renal projects. However, we are going to 3 ask that they handle them somewhat specially. As soon as 4 someone in the region identifies that they are interested in 5 sending An application to the Regional Medical Programs, 6 through their local region, they will be asked to contact 7 RMPS here in Washington to discuss with someone on the staff 8 as to whether the activities proposed will fit within the 9 priorities that have been established for funding activities. 10 We see that it would be most unfortunate to encourage a group 11 to actively pursue planning for a renal endeavor if it were 12 totall outside of the scope of RMPS funding. This would not an application in,, but@theylwould not 13 mean they could not send 14 be encouraged by us. 15 Secondlyt as soon as they were proceeding along to 16 develop the project, they would be required to establish a 17 local technical review committee. We will prepare a-@list of consultants who they may select from if they wish. They would 19 have the opportunity to use other individuals. Th s would 20 be their option. But they must show evidence of 'using experts 21 in the renal ateas@ili their review of the project before it 22 went to the Regional Advisory Group. 23 We would hope to have close enough contact that 24 we would know that the technical review, was an adequate te6h- 25 hical review.to be able to advise the coordinator of the 74 1 region when it was presented to the R gional AdVis e Croup 2 Obviously we cannot stop the process but we can give them 3 advice as to how we see the review process going oh in t e 4 local area. 5 Assuming that it gets through the Regional Advisory 6 Group, when@it comes here, it would be our responsibility to 7 certify to you, to'the review committee and to vou the NationaL 8 Advisory Coundil, that appropriate technical review by c6rLi-pe- 9 tent individuals who did not have a vested interested in the 10 project, had indeed been carried out, And to indicate to you 11 our estimate of where this,fit in the total national priorities 12 as established. 13 At that point in time it would be up to,you to mace 14 the decision of whether it would be funded and the funding 15 level. 16 Now, in this context it is our plan to update the 17@ N vetnber 1970 policy. It's a very br ad policy and implies .0 0 18 that we,might be willing to fund essentially any type of 19 activity. obviously those of you familiar with the problem 20 realize that we cannot.ttnd All activities, And if we are 21 t the greatest utilization out of our dollars, going to ge 22 are,qoing@to have to be selective in the areas in ich hey 23 are invested. 24, We are hoping with this new emphasis idney to 25 th ivision get together with the various institutes at N:tH, e D 75 I of Biologic Standards, and the Food and Drug Administration, 2 to develop some method of ap uch issues as anti- ,preaching s 3 lymphocyte globulin, so that funded activities will result in 4 information that at the end of'a period of time, a year or 5 two years, would allow a decision as to whether this should be 6 a licensed drug or not. Because if we go at it strictly by 7 individual project bases, like HLA typing or ALG or any other 8 type of immunosup'-pressing activity, we are going to end up@ two years from now without knowing the 9 whether we really have 10' ty e of information to license a provider, license a f irm,, to 11 manufacture the drug. 12 So it's our proposal to call together k6presentA- 13 tives of these various Federal agencies and try to develop a @14 coordinated Federal strategy on certain igsue§; hopefully 15, especially on ALGO so that at some time we will know where 16 we will go. 17 The National Institute of Arthritis and Infectious Diseases had a conference in TeXas just a few weeks ag lookinj 19 at some of the issues about typing, We hope that we can 20 coordinate these activities because we,,,Iall have limited dollars, 21, and -what we are really after is-accei§s:to services for 22 patients with end-stage tenal,disease, And continuity of ser- 23 vices, and we are going to have to usd'--a very tight cootdi 24 nated method to make our' bucks go to spread this direction. 25 xt of our method of,ooerations in our In the Conte 76 I division, we will be task-oriented in our activities. We. 2 will keep a task group together on the issue of chronic renal 3 disease. And those of you who heard Dr. Scribner's presenta- tion in New York a couple of months ago in which he spoke o 5 a life plan approach, I think is a very excellent summary of 6 the method'@ should think about, that our endeavors should 7 be to see that all groups k from a life plan ap ach wor pro 8 rather than suppor t of home dialvais by itself or support of, 9' institutional dialysis or support of transplantation. 10 This is not a retroactive change, as Harold was 11@@reminding me; this is prospective. There are ap lications 12 before you today that are not in this context. They were 13 reviewed bv the ad hoc technical renal review committee and 14 went through that process. There are a couple that'@are n t e 15 hopper right now which will be handled on An individual protest review basis so that no one will get hurt, we hope, in this 17 conversion to the decentralization. 18 'As. Dr. Margulies has said, we wish to be consistent in our approach, and you all have decided to decentralize as 2Q al review process. We are following mu as pos , sible the tot 21, @'t with kidne but putting in some additional check marks be'c'ause othe magnitude of the problem. 2,3 ]OR. SCHREINER: May I compliment you. That was verr 24@, succinct. 'I think almost everyone of those represents a very substantial improvement. I . I- - I I - I 77 1 DR. 14ARGTJLIES: Why don't you just stay here because 2 I want you to get back to your divisional activities. 3 There is one other item of action which came up 4 e which I think i of real importance with the review committe s 5 and should not be considered without an expression of Council 6 attitude. 7 this had to do with the distribution and use of tho 8 letter which is written to the Regional Medical ProIgram after 9 the review process has been completed. As you will recall, @io what happens in the total review _process -- let me just say a-, 11 an aside, that the RMP's to a surprising degree look on the 12 site visit as the beginning and end of all.of the review 13 process that they undergo, and we must somehow disabuse,@th-em 14 of this idea, because it's one incident in what@is I think an increasingly painstaking review cycle. 16 But they are concerted not with the summa of the ry 17 site visit, and not with the material which goes to the re 18 view committee and to the Council,, but rather with the@,letter 19 which then goes to the RMP. Thes4 have increased in@@@their 20 qual' markedly over the last several months. We are 1 ty ve 21 not satisfied with them but they are improved and they are 22 pleased with the level of improvement. it is the proposal 23 of the steering committee rather than the review committee 24 v 0 no, this was both that the site isit ra teceiv6a copy 25 of the letter which finally goes to the RMP after the process 78 1 has been corwleted. 2 Now, this has been regarded in the past as@a 3 rather special communication which goes to the coordinator 4 or goes to the chairman of the Regional visorv Group or the 5 grantee, whatever the arrangement may be, for them to utili'.ze 6 as they wish. It is also understandable that site visitors, 7 particuiarl those that are going to continue to be site y 8 visitors and going to go to the tame or other regions, would 9 feel a sense of continuity and would ain information out of 9 10 receiving that advice letter which cannot otherwise be o 11 tained. I have no objection to it. We think that there 12 might be,some real value served. 13 On the other hand, the question of whether this 14 represents confidentiality is an issue at stake. 15 What we have done is asked the steering committee, 16 which represents all the coordinators, for their View of it4 17 They thought it was a good idea. We have also said 'we L8 wouldn't proceed with it unless we gave an o ortunity pp to the 19 coordinators, which we have, to exprest their concerns or any 20 reservations they may have about it. But I really,think it's,., 21 the kind of an issue which the Council should act on b*caut6 22 it does repres degrees some very forthright eht in varying P@3 statements which go after your review to the Regionai'Medidal 24 program. 25 MRS.MARS: Have the coordinators proferredlany 79 objection to this letter going out? 2 DR. MARGULIES: we have had no, objection to date 3 but they have actually had too little time for a reaction. 4 They had it a few days ago@ 5 DR. MILLIXM Could we discuss it in January at 6 the coordinators meeting? 7 DR. MARGULIES: we could discuss it at the co- 8 ordinators meeting, but I think that probably the individual would rather@readt to it in his home base than he would in a 10 larger group. He may have misgivings that he would be un- 11 willing to express in public. But the steering committee re- 12 sponded with no evidence of hesitation. 13 mRS. WYCKOFF: I think it would certainly heln 14@ those of us having to make a second site visit knowing what 1:5 came out of the first site visit. The confidentiality@@ 's the other way. They don't get A copy of the site visit@repdrt. :17 DR. MILLIKAN: You are not discussing the site 18 visit report. 19 MRS.,@WYCKOFF: No. That's where the confidential- 20 ity is. 21- DR. KOMAROFF: As the advice le ters have become, 22 more candid, which they clearly have in the last few months 23@ in fact, the.latest one I saw was almost verbatim Copy of 24 the te visit report I see no @t @'I problem at all. If si hica 25 the site visitors have received a@copy of,t-he site visit report, which is the most candid document of all, I see no problem with their receiving a document that was probably watered down to some degree. Furthermore, the process of ton- 4 ing down the language is a verv sophisticated one that I think the site visitors can some-times assist staff in doing. In 6 fact, I-,have participated in two such languar the perfect and 18 remaining totally inconsistent. I think we will have to reach 19 that kind of conclusion 20 Jim 1 donllt know whether@you want to comment on 21 what the VA is thinking about in this area of medical records 22 or not. Do you feel free to? 23 DR@* MUSSER: Well, we have groups in 50 of our 24 hospitals working with substantially the ileid s st6m, and I y 25 think at this particular time our people think this is the 92 1 direction we should be going. Now, the extent to which we 2 might find in our system certain modifications of the Weid 3 are in order that we don't know, but we'd be hap program py to 4 work together with your group in this regard. And I think *5 we have the advantage, because of site, of getting answers to 6 a number of questions, particularly as they involve f irly 7 large groups of patients, both in atient and outpatients, p @8 getting these answers quite quickly. 9 DR. HlNfLAN: I had forgotten to mention that 10 Dr. Everist. The VA efforts are ones we are watching with a 11 great deal of interest because this is an attempt by a system 1P- to make a conversion. 13 DR. MUSSER: We also have moved a bit toward the 14 Automation of the record. We have several other projects,. 15 for instance one in Boston that is working on an automated 16 history, and we have tried several others. We tried the Duke system and found that not to be suitable, but we will have 18 some information on these several projects within the next 19 month or so. 20 DR. 14ARGULIES: Good. 21 Dr. Watkins. 22 DR. WATKINS-. It would seem to me,@whether you 23 like it or not, A good surveillance or a pure revi @system, 24 might be requisite. 25 DR4 HINMAN: Well, medical audit, pure iew is 9 3 1 the cornerstone of our Methodology on qualitl, care monitoring 2 But in a nutshell, what we were @lanning to do is to identify 3 the elements that the individual HMO would have to eD 4 surveillance of, specify some of,the things that would have 5 to be included in each, lement, let them work out the par- 6 tioular method of review. For instance, in clinical evalua- 7 tion it would be basically around the medical audit. There 8 are several types of medical audit of clinical evaluation that 9 might occur. One would be the retrospective format in which 10 a diagnosis was selected, certain standardsIestablished, and tively a sequence of 50 charts or something lik3 then retrospec 12 this could be reviewed. 13 Another o ne that appeals to me Personally ne, o 14 the e one in which the physicians Mott, would be a prospectiv 15 on the staff of the individual group practice would agree 16 that in, for instance, urinary tract infections, that-certain 17 things would have to occur if that diagnosis were made. 18 Certain diagnostic oints should occur, certain therapeutics p 19 types of activities, and certain follow-up activities. I 20 would hot propose that the medical staff would necessarily 21, say that the dose should be thus-and so, but then that the 22 .Individual T)hysici-ans w eview their performance4on the quld r 23 standards that they had helped set. 24 It is'a very4interestinq exercise, because the Pj,5 expectations that @an individual physician has of his 94 nd his actual performances ate not always the performance a "same.. So we think that prospective review audit is appro- priaiee as well. 4 Random sampling is appropriate because no nat r 5 what format you set up for selecting diagnoses or prospec- 6 tively,setting things, you are going to miss some, so we are 7 recommending some random sampling occur. 8 Another thing we are concerned About is particu- 9 larl those HMO's that have pharmacies, that they should have y 10 a method of@identifying abnormal drug profiles and reviewing 11 those cases, or they might say that they would review a 12 s le of all the cages that ate on tranquilizers or all the amp 13 on antibiotics beyond 14 days, or some other type of cases 14 drug activation of the audit process. Again, it would be a 15 pure medical audit, but it would be activated by something 16@ but of the pharmacy. Another area is one out of the laboratory. it 18 would seem Appropriate at some point in time to sequentially review what happens to abnormal blood sugars, how many of 20 e out it them Went on to charts, and nothing was ver done ab s a-,for instance. a 22 or the one that is even more frightening, if vou 23@ go into alaboratory and you ask for the record chart numbers the last six months, @24 on positive acid fast cultures over 21. and.theh You go And pull those records and see how many of 95 them have been,missed, this'can be frightening in some in- 2 stitutions, particularly when it's an ambulatory collection 3 of the sputum specimen. 4 So we think the laboratory should be a method of 5 activating an audit process. By the same token the X-ray 6 department should be as well. It might be appropriate to 7 review sequentially a certain sample of GI series or some- 8 thing like this. The issue being that there is continuity 9 of care, that when a physician has identified that some !pro- 10 cedure should be done to attempt to make a diagnosis or to 11 support a therapeutic decision,, does this procedure that is 12 ordered then feed back and either support his initial decision 13 or change it, or does it get wasted? 14 DR. MARGULIES: I jtst want to say that this 15 emphasizes again the need for a good record systemi because 16 none of it can be@achieved unless you can derive this ihforma- 17 tion in a consistent fashion. 18 Mrs. Wyckoff. 19 MRS. WYCKOFF: I am concerned about the fact that 20 have at least 50 million Americans that move every we year, 21 and that we live in such a,,fluid societv that you@will have 22 to develop the kind of thing that can follow the 50 million 23 wherever they go and be of some use wherever they Are. 24 Otherwise, it's wasted.. There was an attemDt over the last 25 ten or fifteen years to do someth.Ing I -,,like th's in that small 96 program@@lcovering migrant workers. There is a record that 2 was developed at that time which is used very successfully 3 in some places and not used at all in others, simply because 4 nobody'asks for it. This is something that might be looked 5 into. 6@ DR. SCHREINER: I would just point out that I 7 think part of'the at least beginnings can be simply to make 8 people aware of what has been done to exchange records, be- 9 cause a lot of the physician expectation can be done by sdlf- 10 selection. At least we have changed our records three or 11 four times when we thought they were great because we saw 12 another one that was better, and if you don't see the other 13 one then you are never going to make that potential compari- 14 son. But there ate two activities along Mrs. Wyckoff's 15 line. one is Dr. Falkner, I believe, is the one who initiated 16 the medical@passport concept which is a Private group, and 17 then there's one that's carried by State Department people 18 here. I have a few of them as patients, and the carry a y 19 very succinct record because it's an absolute necessity. 20 They go to Africa or India or somewhere and they have to 2 have.-@fundamental data on drug sensitivity and intoculations 22@ and major procedures. 23' So there are some very very brief record forms that have been developed. one is the medical passport,, whic@. 2.5 was ori inally developed at Cornell, and the other one is 9 7 1 the State Department form$ and you have a third, the migra- 2 tory workers. So there are some systems that have started, 3 and a lot of people don't know about these. 4 DR. HIN14M: The Department of Defense has had 5 experience in this for years because the active duty military 6 individual when he is transferred from one place to another, 7 his personnel records, his 201 folder, and his medical record. 8 This has been extended in some situations to dependents also 9 when their sponsors are transferred from one area to another4 10 So@ there is some precedent in it. Of course, this is still 11 just pieces of paper. It does not include the X-rays or 12 electrocardiograms necessarily. And there are radiologists 13 and others who are going to Push that when an individual moves 14 from one area to another they should take their X kays with them. This gets@them out of dead storage, be-cause as you 16 know, most X-ray departments, every three to iv6 years, 17 burn all old records thaIt are not in their teaching files. 18 This would assure, if the individual didn't lose them, that 19- there would be the continuity of all his chest films an w at- 20 tot over a period of-, time. But there has got to be a better 21 system, as you say, Mrs. I,,Iyckoff, with patients moving@from 22 one area to atother. 23 DR. SCHREINER: could we get the help from Mr. 24 Riso on this kind of thitg? It would seem to me within the 25 feasibility of existing technology, for example, to devise a 98 1 uniform system to reduce X-rays to a microfish kind of thing, 2 and then devise a standard machine that would blow,them back 3 uccinet up again so that the person could carry these in al,s passport, because nobody is going to carry around folders 5 of X-rAys like this, 6 DR. 14ARGULIES: Especially if he's a doctor shopper. George, this is exactly the kind of thing which we were ta k- 8 ing about at the beginning of the morning. There is no ques- 9 tion that we have the technical competence to do that kind of 10 thin it's very simple to reduc information to a manage- 9 e 11 able size.@@It's also perfectly possible -- and I wish we 12 could move more in this direction particularly in some of the 13 rural areas to maintain these kinds of information in a central computer bank. I rather suspect that we will reach 15 the point at sometime in the future there's point in 16 waiting for it -- where there is a central repository. It 17 would be much simpler then to siMly be able to pull out of a central bank all the pertinent information which the patient L9 has control over. He can maintain confidentiality with no 20, difficulty. But it's that kind of advanced technical skills 21 using what we already know how to do, that we have to er on 22 with. -ter ba 23 MRS. WYCKOFF: There is a central compu iik 24 for migrant school children now operating. PI 5 DR. SCHREINER: The computer is probably, not 99 1 technically good for visual material. 2 MR. MILLIKEN: I was just going to say some cities 3 have developed some uniformity of medical records between out- 4 patient clinics, public health clinics, and school health pro- 5 grams, and to avoid this problem of moving and loss of records 6 and duplication of medical work-ups, and these cou e 7 studied. I mean these ate available. This is more on the preventive, early detection angle. 9 DR. MARGULIES: I was struck on a visit to Seattle 10 not long ago with the fact that they have a patient way up 11 in Alaska who has a pacemaker, and instead of requiring him 12 to travel tremendous distances from there down to Seattle, 13 they are monitoring it off a satellite and getting radio 14 communication 90 percent of the time., keeping him under con- 15 trol, reducing costs. These are simple things to,do. They 16 seem wav beyond ordinary events, but they are really not, 17 and it's that kind of thinking that 1 believe we were talking 18 about today that we have to start moving with more formidably 19 MRS. MARS: Most hospitals, though are very reluc- 20 tant about wanting to release any records? How do you get 21 over that? They'd rather burn them than give them to 22 patients. 23 DR. MAAGULIES-. They are very reluctant to release 24 records, except.at the same time it's amazing how,many people 25 can get at them. 100 MRS. MARS: I mean to the patients. 2 DR. 14ARGULIES: The patient has a right to informa- .31 tion, and if it is Xept under the@contt6l of the iaatient, 4 which it can be by the -,Proper kind of keying method, then there isn't any question of having control. MRS. MARS: But I think"it-'is a problem and it has 7 to be considered. 8 DR. SCHREINER: In general the input systems are-, 9 better developed than the retrieval systems, It's not hard 10 to put An X-ra on microfish but itts hard to get it back y 1 in A cheap fashion where you can blow it back up again so 12 you can read it. 13 DR. MARGULIES: I think this discussion. I'm 14 sorry,, Bob, you wanted to say something. 15 MR. OGDEN: I was going to say that 1 think, Mrs. 16 Mars, in the forthcoming programs of national health lecris- 17 lation, which are obviously going to come, that nerhaps something ought to be included about the patients tight to 19 his k6c6rds, 20@ MRS. MARS: Exactly, because otherwise I say just 21@ v and get your records.- You just can't. tr- 22 DR. MERRILL: ,.There is one small point about that 23 which is perhaps a littl"e" too tech ical for, this discussion, 24 but there are patients' records which include notes by 25 ther physicians can interpret, and physicians which only o 101 which the Patient does not have the ability to interpret correctly and which cat frighten him to death in many in- stances, so that would have to be controlled. -4 @'@t)R. HINMAN: As Dr. Margulies mentioned when he wa.4'introdulcing me, I have been involved in getting a h6s- 6 pital working with a community group on some of its health 7 care problems, and we attempted to get a decision from three 8 hospitals running ambulatory care areas and inpatient Areas 9 And patient groups concerning the ability4of the patient to 10 carry some part of the record with them between each institu- 11 tion. B6cause the plan was to be able to cover all the hours 12 that different institutions which sponsor the night clinic at different times and the question 13 and the weekend clinic 14 came up about the record. And some of,the community T,)arti- 15 c- q ite concern d About whether ipants were u e they could con- 16 vince their peers, their associates, to bring the records 17 with them. So@@it's not a simple problem. 18 DRO MARGULIES: Well, I think we have reco ized 7 19 the fact up to this oint that Dr. Hinman will not be worry p in(,l 20 what to do with his free time, if that question ever arose. 21 @We are moving along quite well through the morning 22,@ agenda And be able to get to the review activities 2a' this af n with no difficulty. There are some additional 0 kinds of @,rtinOht iftforma ion which I want to bring to the 1 before that occurs. One of the more important ones Counci 102 1 is the current procedure for reviewing anniversary applica- 2 tions. We had a discussion of that at the last Counc 1 3 meeting and promised to Come back to you with some more crisp 4 information, and I'd like Herb Pahl to pick un at this point 5 on that subject. 6 DR. PAHL: I would like to just take a few minutes 7 to give you what our current position is with respect to the 8 review of the Anniversary applications because there Are two 9 other reports which are of importance to you prior to@lunch 10 time. 11 I believe that the best starting point is the letter 12 that nt out to you dated November 1, from Mrs. Lorraine 13 Xyttle, who is the acting chief of our office of grants 14 review, and which contained a statement about the staff Anni 15 versary review panel, contained an overall chart showing the 16 procedures by which the various ty-pes,@of anniversary applica- tions are now reviewed, and also a membership list of the 18, staff panel. 19 So ra et than try to review all of that, which 20 you have had an opportunity to look at, I would merely try to 21 @give you a,bit of,a conceptual framework. As you will recall 22@ at the last Council meeting, there was a statement concerning 23 the review responsibilities under the triennial review 24 system which@you endorsed and which delegated to the office 25 of the Dit6dtor a set of responsibilities relative to our 103@ 1 management of those applications within the triennial review 2 period, and the implementation of that delegation of respon- 3 sibility has resulted in the establishment of this staff anni- 4 versary review panel. 5 The review panel basically is charged with re- 6 viewing those applications for the 02 and 03 years of support 7 within a triennial period, and making recommendations to the 8, director as to whether further technical review by the review 9 committee, orlby other outside,consultants, is necessary, 10 and what, if any, kinds of action should be brought before 11 this council, and what should be brought merely to your atten- 12 tion :for information purposes. 13 In the present book of ap Plicati6ns, I'm sure you 14 e on pi aries under have seen that there ar nk sheets the4summ 15 the anniversary applications of the statements bv the staff 16 anniversary review panel. 17 We have presented the conceptual framework and l@8 the'mode of operation of this panel to the review committee 19 at its meeting in Odtober, and I'm pleased to say that it 20 was very graciously received in the manner in which it was 21 presented to them, namelyi we would like to have that group, 22 as well as Council, devote more time to the review of thre6-y6ar programs and advice to us as deemed necessary, 24 rather than@devote so much time to those aspects of matters 95 staff is quite capable of handl ing.: which we feel bur own 10 4 S o the review committee did feel that it was an 2 improvement in the review process in thatl"6nly a portion of 3 those types of matters which formerly had been presented to 4 them would now be coming to them in the future. 5 Now, concomitant with'-the establishment of this 6 new review panel by internal staff personnel, is the require- 7 ment on us to bring both to the review committee and to you 8 that kind of information over the triennial period oarticu-;' 9 larly which will keep you in touch with the regions-and the r 10 activities. in other words, we are asking neither@the review committee nor you to review the entire program year o year 2 1 as you have heretofore. Consequently, we are interested in trying to disp ay information for you as we go throu s 14 th will feel comf6r- ree-yoar period, in such a way that you 1 15 and table with what is developing, the changes of s 16 activities in the re4i6hl to that when you do dome to that 17 point in time where you have occasion to review the region i8 again for A subsequent three-year period, you will not feel 19 that it is a stranger to you because there has been this time 20 int6tval where you have not reviewed it it such detail as you 21 have before4 22 in addition to @reviewiiig,the applications within 23, the triennial period, we Ate asking our staff anniversary 24 e_ review Panel to look at those applications which are r 25 questi ar of supnot-t before a triennial period. ng one ye These,always include new projects, so these applications for 2 @one-year support automatically will go from the staff review 3 panel,to the review committee, but with a somewhat different 4 perspective than they have before. 5 The,.review committee this time, I believe in the 6 case of North-DakotA, received the application and,come,nts 7 from the staff panel and endorsed the staff panells recommen- 8 dation completely, which in a sense was a vote of confidence 9 in the new procedure. io I don't believe I will go into the mechanics Of it except to say that the panel has met once. It ac ts as a L2 minor council, if you will. There are people on it as you have seen from the membership list who are not in the qppra- 14 tions Division, so that we do believe we have objectivity; '15 impartiality, and a real sense of trying to review the 16 region s application. 17 Prior to coming to the staff anniversary review 18 panel,, there'is a thorough staff analysis, as has been done 19 atio by operational desk heretofore,, and an actual present n 20 staff to the@ review panel, and then there is a formal voting 21 procedure and a rating procedure, such as is conducted in 22 the RMPS rev-1w cb=ittee. 23 we.believe that this is an improvement in the 24 review@proce.PS, primarily because it better utilizes the ?15 talents of our professional staff who are knowledgeable and 1 in daily contact with the regions. @le also believe that it 2 better utilizes the time of our advisers and consultants, and 3 we would hope that as we go through this new process both 4 ou and the review committee would advise us as to how best y 5 to keep you in touch with the activities that you now will be 6 somewhat more remote from except for these three-year periods 7 would ap I riticis@ and we preciate some constructive advce and c 8 in this regard and in other matters that you may see. 9 Now, 1 think with the time available that probably 10 constitutes sufficient information, but I will be very glad is, and we will keep you to try to answer questions About th 12 advised of procedures if you have any specific concerns. 13 DR. EVERIST: I think this is beautiful.' It would 14 actually cut down on the amount of time necessary for tl-i s 15 one by one-third, you use one-third of the time you have always had to use before. I think it's great. 17 DR. PAHL: Thank you. 18, DR. MARGULIES-. Well, if you think of anything 19, bad about it later, let us %now. 20 Two other items to bring you up to date before 21 the lunch break so that you will be ready for the@reviews 22 themselves: I'd like to have Ken B&um give us a status 23 t'vities report on e, resent local 104P review Process ac 1 24, which we h @beeh carrying out. Ken. 25 DR. BAUM-. They always put me on ,,ihen@lunch is I!l 7 approaching. I guess that's to keep me from';,being too long- 2 winded. 3 My n job is to bring you up to date o what we are 4 doing with respect to verifying whether the actual review 5 process that the 56 RMP's go through in reviewing individual 6 operational activities in fact meets the review process re- 7 quirements and standards that have been set by MIPS.- 8 You will recall that in the transition from in- 9 dividual project types of review that this Council and the 10 review co ittee formerly conducted to the type of program 11 review which is going on now have as a quid pro quo for we 12 iving the individual Regional Medidal Programs authority to 9 LIU review their own projects from a technical standpoint set a 14@@ series of review process requirements And standards. 15 'These have been sent out to All the Regional 14edi- 16 cal Programs three or four months ago, and they have been t6- 17 viewed and cleared by the various kinds of internal Processes 18 that are required. 19 Essentially, the review process requirements and 20 standards cover such things as the fact that there will be A Regi et up in accordance with the law, onal,Advisory Group s that there will in fact that they do in fact review rojec 23 be technic 1 eview groups that 106@ over the projects before 4,t r 24 the@ get to the Regional Advisory Gr up, that there will be a y 25 set of regional objectives and@prio ities.. a@-d,,that these 108 1 will be made known to applicants and project sponsors, that 2 there will be feedback of comments to applicants and project 3 sponsors, that conditions of funding will be made known to 4 them, thatI.there will be an appeal process in the event that 5 an advisory group ther than the Regional Advisory Group can 0 6 turn down an individual application. So these are the kinds 7 of things that are covered in our requirements and standards. 8 What we are doing now is going through a process 9 of verifying the fact that the review process in the 56 10 Regional Medical Programs do se requiremen es in fact meet tho T' 11 At this stage, two site visits have been conducted, one in 12@ western Pennsylvania late in September, the other in Tennessee 'td one has been 13 Midsouth on the 4th of October. A thi 14 scheduled for Washington/Alaska sometime in becember, but I 15 don't believe that an actual date has yet been -get. 16 As a result of the first two visits, we have done 17 quite a bit of soul-searching. The two regions that were 18 initially selected were selected because they were thought tc 19 be easy ones that we wouldn't run into any problems with, and 20 it turns out that perhaps none of them are going to be easy, 21, nticipated in developing a so we have@taken longer than we a 22 res ons'@ to the regions, but in both cases now an advice 23 letter is ei he@r,-completed and on its way up the line or it 24 in f inal draf t,, sg!e.. E5 I.t @,e ected that the fou operational branches is XP r 109 that have been set up on a geographical basis will take over 2 the bulk of the site visiting that will go on. It is also hoped that in order to minimize the number of site visits we 4 will be able to develon a Procedure that will enable us to 5 piggyback perhaps a review process verification visit with 6 the normal three-year site visit procedure, perhaps with the 7 regional office man filling in later on the types of informa- 8 tion that can't be obtained in the normal site visit process. 9 Then, too, we have a series of management assess- 10 ment visits that are conducted by the grants management staff 11 and look into organization and management of Regional Medical 7 12 Programs. believe eight or nine of those are scheduled for 13 t xperimenting with combining he year, and we are Also now e 14 the management asse sament visit with the review process veri- 15 fication. 16 So we will try to do this in the most expeditious 17 manner@and@cut down on the number of duplicative site visits 18 or repedt contacts that we will have to have with the 19 Regional Medical Programs in order to do this. 20 we@hove that as a result of this process that we 21 will not only find that most Regional Medical Programs will 22 confo f hand, and that we will be able to easily rm out 0 23, rectify th t do not co form to the standards fairly 'any n 24 uickly4 But the outcome of this ghould be a local review q 25 process in,which the review committee and this Coun ii can 1 have confidence in terms of their carrying out capable, tech- 2 nical reviews of individual operational activities, and one 3 in which the applicants themselves can have some comfort in 4 feeling that their applications are being looked at on the 5 local level in a manner that is both fair, reasonable and 6 technically competent. 7 DR. MARGULIES: Any questions, elaborations? 8 Well, that's a status report, and 1 th n t at as 9 indicated -- I suppose in retrospect, unsurpriainlly the 10 first ones did bring up some issues which have taken addi- 11 tiohal time4 but which, as in many such experiences, will 12 ease the rest of the process considerably because it helped 13 to settle some issues that heeded to@be settled. 14 Finally before lunch I would like to have Mr. 15 Peterson bring us up to date on the modification of the re- 16 view criteria in the rating system since the last meeting 17 so that as,you enter into a review you Iwill know whatever 18 slight changes have been carried out. You will find them 19 relatively moderate and so is he. 20 MR. PETERSON:' I did report, Dr. Pahl and 1, to the 21 Council last time on the fact that we had developed and tested 22 with the review committee a rating system in the course of 23 the July-Au ust,cycle, and we reported on that to the qroupf'. 9 24 so I'm not goin to spend any great deal of time except to, 25 note as I did to the group last time some modifications were made in the review criteria and the scoring system itself as 2 a result of our initial trial. They were, i think, specifi- 3 cally enumerated for you. 4 Let me simpl say that the review criteria in y 5 their modified form and the scoring system were used again 6 in connection with this review cycle, the October-Novem:)er 7 review cycle. I think the level of acceptance by the review 8 committee was significantly high. our analysis of this 9 second go-around did not point up,with one singular'exception 10 which I would like to make reference to in a minute, anyth ng 11 considerably different than what 1 discussed with the group 12 u have in front of you are the ast time in Aujust. Mat y6 13 modified@critetia and the modified weights that we discussed 14 with you last time. I pointed out at that time the kind of 15 changes we had made from the initial one which essentially 16 revolved around such things as breaking minority interests out 17 as a specifiIc singular criterion as opposed to having it in 18 a number of placesi the feeling on the part of the review 19 committee that thev were uncomfortable with some conglomerate 20 types of criterion such as organizational viability and 21 and we've broken those down, as I'mehti6ned ef fectiveness, 22 last time, into several components, the coordin'Atot., core 23 staff, RAG, gran e organization. 24 cond trial with the revieNr Ithink based upon the se 25 e wav@'of ted committee, we had very little in th sugges: 112 1 modifications. One @of the few specific suggestions that came 2 up did r'elate.,to the weight which we had given to the co- 3 ordinato@r of eight. I think there was some feeling, at.least 4 on the part of,,seveia@l review committee members, that time 5 and time again the coordinator is a singularly important cri 6 tical element in an RMP, and perhaps we ought to reconsider 7 that weight in an upward way. 8 We, as staff, will be looking at that based upon 9 what other outcomes we see from our more detailed analysis, 10 but I would not think that any major modifications would be made in this now as a result of a second use, and if there 12 are any slight or minor modifications that they would be verv, 13 very :few in number. 14 Now, let me mention a second aspect of this' and 15 you will be seeing that in the course of the meeting. You wilL 16 recall that as a result of the first use of these criteria 17 in the scoring system, the review committee came up with ratings which were grouped for our benefit -- legions were y 19 grouped in three groups with a range of ratings indicated. 20 I would note that in their first go-around, the average score given,to a region was 244. This was,back in 22 July. we find the second time around, I think not an un- 23 expected phenomena,.:that as they have greater familiarity with 24 the s tem,,@@and.ali%q@ s they look back and saw all kinds of ya E5 scores, and,we disciigsed this with them in much the 8ame 113 1 manner as we had with you last time, that there has been a 2 significant increase in their average score, so that as a 3 result of the October scores the average was 297. 4 I might just add also, because Dr. Pahl has alluded 5 to this, the staff anniversary panel is using the same criteria 6. and doing the same kind of scoring. That Dan6l came up with 7 an average score of 306, which is fairly comparable, and 300 8 would sort of be the median conceptually. 9 lie have, and you will see this, because of the 10 significant difference between the average score in July and 11 the one in 06toberi applied a weighted mean to in effect 12 equalize the earlier scores with the subsequent round. This application of a weighted mean does not in anv way alter that 14 initial series of groupings in terms of A, B, and C, upon 115, which certain selected funding decisions were made by Dr. 16 Margulies subsequent to that. 17 I think our own feeling as staff is now that we 18 probably are in a position, with some possible slight modifi- 19 cations stilllr to sort of freeze the system and let's see how 20 it works for two or three more cycles before we do any more tinkering with@it. I think quite apart from that, however, we 22@ do look forward-as staff to being more helpful to the review 23@ committee and anniversary panels Darticularly, but certainly 24 the Council also, in that to a far greater extent we would 25- ay inform tion hope that we could be able to target and dis-ol a 114 I that,is relevant to some of the criterion where that an be done in a fashion that will add to the judgmental as oD 2 ,posed 3 to the intuitive process that is involved. 4 The final thing I'd like to say.- again -- I think 5 it can't be repeated too often -- is that the rating system, 6 including the criteria and the scoring system,@represehts only 7 a tool, and it's one device which the dirdetot and the Council 8 needs to take into account in looking at regions, but it is 9 not the answer, or the only answer, but it is an assist or a 10 tool. 11 DR@. MILLIKEN: In out last review meeting s6vetal 11 of the applications indicated that there was a great need for 13 the coordinator to have a high level and very competent assis- 14 tant codrdinatdr@to be visible and to carry some of the'loadl that some of the problem was; a lack of such a,person. 16 I have been thinking since that meeting that this i; 17 such a common thing, that it would not be well in the future is to consider adding in the rating system some visibility for 19 this position so that it does get attention. 20 @DR. MARGULIES: i.think that"s a good point. -The 21 nators who ap issue c with ref to dobrdi peaked ame, up@,more erence 22 to begetting along feebly and needed some propping up. The in regions in wh'ch there 23 same thing is@true, however, s 24 strong leaderohip.,but in which there is obviously heed for @25 some back-up for that strong leadership, and I think it would 115 I be a wise thing to identify, particularly --,Nqell, this is 2 true in nearly all circumstances. I have had some@of the 3 better coordinators talk to me about t his with great concern 4 saying this is just fine, but I need to haye,someote who can 5 take over at some point when I am not here and we need to be 6 grooming him. I think it's a good idea. 7 DR. KOMAROFF: Have the coordinators or their staff.4 8 looked at this rating scheme and given their opinion to the 9 steering committee or otherwise? 10 DR. MARGULIES: They have had afull opportunity to 11 :go over it, and unless we hear some evidence of a general 12 dislike for it, which we have not up to the present,time, we will consider this the process that we will continue to work 14 with. we will not at any time reach the conclusion that it 15 has to be just like this, but it has reached the point of a 16 remarkable consensus as a working method, and unless we hear 17 something which represents serious objection of a widespread 18 kind, and unless you find that during the course of the de- 19 liberations today and tomorrow in some way ineffective, we 20 will use,it as'Pete has indicated over a long period@of time. 21 T MR. PETERSON: I failed to mention that ony. 22, After we did discuss this matter with,the Counci@@,4 ast'@,,-time, 23 i ator @cv@'t the- review we then made@,a mailing to the coordh 24 criteria with an explanation of how the 6V m was being 25 applied, and I think there was some or -le feedback from rdinators' steering committee that we are giving then 'the coo 2 an opportunity in a sense to comment and take exception. 3 DR. MARGULIES: In fact, the steering committee, 4 when we discussed it with them, was enthusiastic. It was not 5 just grudging ap proval. They thought it was a darned good 6 idea.' So !-,-think we are on a very positive level. 7 I'd like to do just two more things before we break 8 for lunch. One of them is to again draw your attention to the 9 items which have been included under X. Ile have covered some 10 of them under the information only, but you will find under 11 some pink sheets a list of members of RMPS review committees, 12 some information on the experimental health services delivery 13 system, the selected vignettes which are going to be Up e dat d 14 and kept current and general# and something about the evaluation 15 of earmarked funds. Now, these, if they require further di;s- 16 cussion, we will provide time for. 17 The 'other thing I want to mention is that we-Will 18 schedule a meeting in executive session at the end of the 19 afternoon. 1 The main things we want to talk about at that 20-@ time are the status of activities regarding the Ohio program, 21 ,:,.some is,s es'involvinq the Delaware desire to be a separate 2@ 'Re stions involving the gi ,al@m6dical Program, and some que If there ,,ettabli@ent of a cancer center in the Northwest. 24 are other issues that need to be discussed At that time,, we 25 them to the agenda which is fairly unstructured* -can add 117 1 hlesz there are further quest ons Let's plan now,,u 30 wh @2. to re t en we can get on with the reviews. convene a @3 (Whereupot, a luncheon recess was taken, to 4 reconvene at 1:30 p.m.) 5 6 7 8 lo 12 13 14 16 17 18 19 20 21 22 23 24 25 AFTERNOON SESSION 2 DR. PAHL: May we come to order now. 3 Now that we have finished the business of the 4 mornin I think we might appropriately turn to the review 9 5 of the applications. Ile are aware of the fact that Dr. Roth 6 and Mr. Hines have departure schedules, so that we will have 7 to make sure that we get Dr. Roth's in this afternoon and 8 Mr. Hines first thing tomorrow morning, if not this afternoon, 9- If there are others who have to depart prematurely, please 10 let me know so that we can schedule the discussions on Itheses, 11 but we would hope that the rest of you would be able to stayr 12 through the rest of the proceedings, and we would presume 13 since we have the major part of this afternoon to devote to 14 applications that we could finish up our business before 15 early afternoon tomorrow, unless we get into some 6xtensiv6 16 discussions on the ao lications. -P 17 I might also add that because of lack of effici6nd7 18 in communicating all of the necessary papers to Dr. Schreiner 19@ 'Merrill, unl 6s there is a indicat ise we and Dr. e n ion otherw' 20 da the discussion and formal review and voting of the Will 1 ve 21 kidney aspects of the proposals,and those few applications 22@ which are devoted solely to the kidney activities, until 23 tomorrow morning, so that Drs. Merrill and Schreiner will haNe 24 the opportunity to read and consider these a little bit more 25 at lenqth this evening. 119 1 With those few remarks, and welcoming Dr. Brennan 2 to our meeting, I think we might turn to bur first at>plica- 3 ti on, which is Arizona, where Dr. Cannon is the Drincipal re- 4 viewer, Dr.@Ochsner is the back-up reviewer, and Mr. Smith 5 is our primary staff person. 6 Dr.@Cannon. 7 DR. CANNON: Well,_I would. li@e to' recommend that we accept the review committees. recommendations, although the 9 review committee did not support entirely the site visit 10 recommend tions so far as the amou t of fu dinct. a n n In looking At this objectively with their comments, 12 it seems ap riz' na deserves a propriate that although A 0 dditional 13 funding, that maybe the site team went a little bit far in the amounts, and.I believe that the review commit tee recommenda- 15 tion is more realistic. 16 One of their recommendations is for a revisit 17 before 04. That means if they can expand the core activitv 18 with the amount of additional funds given, that some don- 19@ fu ther fundih ight be reconsidered. Is sideration for r g m 20 that the way you interpret the site visit, before 041 21 DR. P Let me ask Mr. Smith, Mr. Russell or 22 Mr. Smith. 23 MR. RUSSELL: T think this was the intent,-Dr. 24 Cannon. that the review committee felt that since Ait a @in 25 Arizona has many P34P's and really are on another exciting 1 20 threshold, and with this no-m@7 look thev should have a vear to 2 trv to revamT3 their -,.)ro,7ram ilorrl their new directions, and 3 that bv going back with the site visit, that if the chanaes 4 ,iad occurred that we do anticipate will occur, t-'nat nerhans additional money could be recommended at that tiT-,,@c-. DR. CAT-INON: So the recommendation is for, as the review committee has suggested, @1,211,000, 03, 04, 05. The 8 developmental component is $71,000-Dlus. 9 If vou want to go into a further discussion about 10 I the program, I would be happy to do it, but I don't think it's 11 necessary. 12 DR. PAIIL: Dr. Ochsner, do you have anything to 13 auu? 14 DR. OCIISNER: I don't believe I have. I would second the motion. DR. PAHL: It has been moved and seconded to accept the review commiittee's report and recommendations. Is there further discussion b-,7 Council? 19 DTZ. LoCl-IRI@;INER: are you oroposircT? 20 DR. CAL7NON: That's e.-.cludinq the renal cor-,inonen@,. 21 will have to take that un separately, as I understand it. 22 DR. PAHL: Yes, sir. The motion does not includei 23 the renal nroT)osal. Is there further discussion by Council? 24 Does staff have any further conrient to aO,.d? 25 1 All in favor of the notion to accept the review I I I i 121 1 comrqittee's recommendation, please signify bv saying aye. 2 (Chorus of ayes.) 3 Opposed? 4 (No response.) 5 The motion is carried. 6 May we next turn to the triennial application from 7 Arkansas. i@ Mrs. Mars is the princi al reviewer Dr. DeBakey, p 8 who is not hereo is backup reviewer, and Mr. Says is our 9 staff person. 10 mRs. 14ARS: I made a site visit on the 16th -and 11 17th of September to Arkansas. Dr. Mitchell Spellman, the 12 dean of the new postgraduate medical school of Los Angeles, 13 California, was the chairman, and out major concerns were 14 with the leadershi review program pro!6ct review, the region's 15 developmental component request, and we did give considerable 16 attention to the interrelationships of the projects, their 17 correlations to regional Dlanning, and their contribution to 18 regional goals. 19 We spent quite a lot of time examining the achieve- 20 ment6 of'the ongoing programs, the priorities and the program 21 goals, and their relevance to the @IP goals, and objectives 22 to the recri6n's critical health needs. 23 We also gave intense scrutiny to the region's 24 evaluation mechanism. This w s e St v a th fir site@ isit by a 25 nal one. team since July 1969. ours was the third operatio I 122 have ha And during that time they d new leadership, and I 2 thin]-. the new leadership must be given some recognition be- cause Dr. Silverblatt, who replaced Dr. Bost, is an exceptional 4 man. He is an extremely dynamic person, and a very capable 5 coordinator wi. the most overwhelming enthusiasm and con- 6 sciousness for his work that I think I've ever -met in anyone. 7 He has a very deep perception of his own program and feel$ P 8 ver gtrohql s to the direction it takes. y y a One of the things, of course, that we were very 10 concerned about was the fact that with so strong a leader, 11 just how much did he dominate the core and the RAG, but it 12 was very interesting to find that he himself hag surrounded' 13 0 himself with an entirely new core staff which is extremely 14 capable and are not yes men at all in@any way. Ile is 50 years 15 61di and the core staff that he has surrounded himself with 16 are mostly in the early 40's, and he has a great deal of 17 youth as well. All these people seemed extremely loyal to 18 him, and they respect and admire him tremendously. 19 They are asking for a very substantial increase in 20 funding to support ten additional People, and these are verv 21 much needea4 @They asked for $595,673 to o@@ core, and 22 the site visit committee recommended $595,6734, 1 think that 23 we can certainly approve of that. 24 The e criticisms not very many of the re are son, 25 program. I think that with any funding we should add a 123 directive that more minor ty groups be included in RAG as 2 well as on the staff, and Dr. Silv'erbiatt is very aware of 3 this problem, and he is not remiss to change it in any way, 4 but he felt that by doing so that there would be too-manv 5 people in Little.Rock,and he just simply Oi,dn't seem to know 6 quite how to ac uire re minori leaders,, but we did give @mo 7 him several suggestions. 8 we felt that RAG was not being' 6 nsidered early p 9 e q n by the time. the programs enough in the project plannin a,@c 10 came to RAG, that they had been t finished, so that there was very little original thinking" the p-art of RAG. Also, 12 another concern of.ours was that,'jces-oonsibtlity had been 13 G for the ap al abrbaated to the executive committee of RA _,prov 14 of monies and funding for orojects@witho'ut-@an@@@'limitation'; 15 and this we@highly recommended, and Dr. Silv6rblatt and all 16 the core and RAG agreed that this would be corrected, and we 17 hope that RAG will,be more involved in the origination of 18 programs. 19 The identification of needs of the region on the PI 0 basis of health data has been very difficult, as their 21 @facilities,:for such collection have been extremely poor. 22 r6at deal to accomplish in this area. Thev certainly have a q 23 We were pleased, however, to note that in the face@6f diffi- 24@ cuities of 'getting@the dat including the lack of coopera- a 25 tion from other institutions, that RMP has become a source 124 in sharing the data it has collected from the various community 2 agenc ies. It's purchased computer tapes for census data and 3 is working with the medical school, the state health depart- 4 ment, and CHP to deVe lo-,o a health data base. The establishment .5 of a better base and meaningful goal and objectives I think ro should-,.overcome much of the weaknesses in their evaluation 7 As you know, there are ten projects being terminated. 9 of@@'these@@@@.it@',s much to their credit to say that they termi- 10 iiated @then of their own accord since they were not meeting 11@ the goals. 12 Also I thought an admirable fact is that six of 13 the programs that are being terminated, they have found con- 14 tinuing local funds for, and I think this is hig hly iml.oortant4 15 The ARMP and their RAC, have Very definitely recog- 16 nized that their chief impact is in the area of influence of 17 health dare delivery servic8i and this is illustrated, I think, 18 by their training program for the care of coro ary n patients. 19 They have had a dramatic success in shaping influence and im- 20 proving care. Actually, from the initial base of eight CC 21 units, the program has expanded to 45, and 20 more are in the@ 22 planning process. They have over 200 nurses and 160 physicians 23 that have al'eady been trained. The kdhAl orogram,@headed by Dr. Flanagan, has ma e 2 remarkable headway, as a year ago there wasn't a single 12 hemodialysis unit in the State, and now iere are ,-wen 2 The program has certainly brought expertise to all the sub- 3 regions of the State. Dr. FlanagAn, of cotrs6,'is a@very 4 outstanding'@urologist nephrologist, I'm sorry and he has 5 worked, 1 know,, under Dri HuThe. I hadimet him,there pre- 6 viously, because as you all kno'%%7 Dr. Hume is in Richmond, so 7 he has certainly worked to make@thi@,s program a success. As to the c anp er program, this@has fallen down, but there is a new woman doctor,who has,,taken this overl,'@a 10. outstandihg;person, and sh presented all her plans to us 11 for the development and reactivation of dAnd6r prolgr si And @12 I think that under her diribcti n some Retrogress wil -be@made 13- 'in that field. 14 They have very definite programming for th ir de- 15 ir@coopera- veloprnental component, and they are increasing the 16 -tic>n with the State Health Department, and developing neigh- 17 borhood centers in the two model cities, which are Little Rock 18 clinics in various Otark And Texarkana They are develonih 9 19 and delta regions of the State. They are going to bring 20 ral pockets and lead t established quality care into the ru 0 21@ centers and clinics throughout the State. I@feel that the 22 core must:have great flexibility to take@advantage of unseen 23 opportunities that do offer the Possibility of significant 24 achievement for minimum expenditure of resources. Arkansas 25 has certainly some very unique problems inasmuch,as its 126 tomography is very queer. The mountains run east and west 2 rather than north and south, and there literally are no roads 3 going north and south except two, which border on the edges 4 of the State,, so that everything goes east and west which 5 makes it@ve difficult for transo6ttatioh and communication. ry 6 urmount. So this has been something that they have had to s 7 other than that, I think it's an oxceptional@,pro- 8 @gram. I@think the leadership is exceptional, and I c'e@@rtaitiv 9 recommend the acceptance, of the review committee. 10 If there are any questions I'll be c -@@@answer jlad to them. @12 Thank you, Mrs Mars DR. PAHL: Dr. Roth? 14 DR. ROTH:, @First, thank you for trying to get 15 that plug in for the urologist. I appreciate the try. 16 But you mentioned that there was a reluctance or 17 an inability to get background resource information from 18 certain agencies, and I got the irqpli6ation,that thete,were 19 outfits in the area that had information, and that so far 20 nobodv was letting it out of them very well, and since'one 21 of the roles of RMP@tIiat I think most of us agree on is its 22 catalytic effect of trying to get reluctant peolple in, I 23, was just wondering if you would want to comment. 24 MRS. MARS: This they art--,doina:, and they have 25 had trouble with the agency, actually with some of the 127 comprehensive health planning Agencies. However, the VA, 2 Vet6tAns Administration hospitals, are working very closely -3 with them, and there, is very good rapport there, and -I think 4 that this is going to be overcome. Now agencies are turning .5 to W4P for4@the information and beginning to appreciate what it, can do. !)R. PAHL: Thank you. Is there further discussion 8 from the Co @@ncil--> DR. MERRILL: I have just a correction for the 10 record. I hate to appear chauvinistic. But Dr. William ]Flanagan 3.S a nepht6logist who took his training with Dr. Merrill in@@Bdston. (Laughter.) 3 MRS. MARS: I said he worked under Dr. Hume. Did 15 I say traininq? I'm gotry. I meant to say he worked with 16 Dr. HIume. 17 DR, PAHL: Thank you, Mrs, Mars, for a very pxcel- lent.re ort-a'nonetheless. p 19 The motion has b en made Is there a second,to e 20 the motion? 21 DR* OCESNER: I second it. 22 DR. PAHL: The motion has been made and seconde 2,3 Further discussion by Council or staff? 24 If not,@all in favor of th6 motion, please sig if@ 25 by, saying aye. 128 1 (C tus of aye,8i) 2 opposed? 3 (No response.) 4 The motion is carried. 5 1-tay we now turn to the Colorado/wyoninq triennial 6 application. Mrs. Wyckoff is the principal,reviewer. Dr. 7 Watkins is back-up reviewer. Mr. Clanton is staff resource 8 person. 9 Mrs. Wyckoff. 10 Briefly,,this is a triennial appli MRS. WYCKOFIF: cation for a@total of $3,384,030 for the fourth, fifth, and 12 sixth year of operation, including a request for a develop- 13 mental component of, $288,000,total for all three years. 14 th the site visit The review committee agreed wi 15 committee and recommended apor6val of the total request, a 16 Adjusted the amount to conform to the advice of the snecial 17 team of site visitors who studied Project No. 29, pediatric i8 hemodial s.is, for the Rocky Mountain Region, at the request 19@ of the Ad Hoc Renal Disease Panel. This panel allowed 20 $102,000 for the first year of the protect $91igOO for the 21 the renal 'Project. second, and@$71,400 for the third Year of 22 Thev,-@also recommended $57,831 for one year@only for 23 Project No 7 training program in radiation therap Y@@and 24 nuclear medicine-technology, to allow time for local resource 25.@ to assumeltotal support of this project which'3'.s,now assured 129 :L by the Denver Community College. 2 As a member of the site visit team which has made 3 visits to this region each year for the past two years, I 4 must say we were favorably impressed by the considerable prog- ress made under Dr. Doan as coordinator and under the un- 6 usally gifted leadership of Dr. Nicholas as chairman of, 7 Colorado/Ilvoming RAG. 8 Dr. Doan is leaving, by the way, and a@se rch,com- 9 mittee is now working on a successor for him, and I believe 10 they have several Pretty good candidates in mind for him The RAG has moved vigorously in the direction of 12 total program concept. It has developed goals and obi6ctives 13 relevant to regional needs and resources, acceptable to@healt@, 14 agencies and providers,, and has established ad,hoc",task forces 15 which have worked out authority arrangements based upon 16 regional data collection. 17 A consumer health care data has been used to iden- 18 a to quality tify a number of@h6Alth problems rel ted q antity 19 and accessibility. It is interesting to note that of the 13 20 projects supported during the 03 year, all but three ate to 21 be continued with funding assistance from other sources 22 Staff is an extremely important catalyst for A 23 broad range of activities in this, and has good relationship 24 with all existing health agencies, providers, schoolsp And lay organizations. 130 1 Since there is no strong CHP activity in the 2 region, core staff has stimulated consumer interest groups 3 which might serve as nuclei for CHP 8 agencies, but if the 4 B agencies fail to materialize these groups can become part !5 of the local advisory bodies for P14P, which it essential for 6 any outreach activity in this thinly populated mountain 7 country. 8 There was a genuine concern for strengthening 9 services to.rural areas outside of Denver, deprived county, 10 migrant workers, and remote subregions, strengthened by th6'@ 11 hard data recently developed. There are a great number of 12 specialists in Denver who are sort of underused,@and:there'. 13 are general practitioners in the country who are terribly 14 overworked, and this is one of their principal problems. 15 Core staff is working closely with community 16 colleges on programs necessary to develop health manpower 17 services outside of Denver. New approaches are being de- 18 signed-such as the planned utilization of returning medical 19 dorpgmen as ward managers, and possibly as assistant hospital 20 administrators.:, 21 Other plans call for expanded role for nurses in 22 various settings. Icounty extension agents, for example, were 23 found useful in deriving information about health needs and 24 in initiating action immediately in remote rural areas. 25 The site visitors decision to recomend the total amount requested was largely based upon the realization that 2@, @-the re ion has 20 RAG approved Projects which,@@were not included 9 3 that the RAG in the application packa4e. This indicated to us 4 had established sound priorities and realistically faced'its 5 This total r6quest is only slightly more funding problems. 6 than its 03 year. 7 In recommending the developmental component, the 8 site visitors felt that, first, the RAG was capable of mature 9 decisions, two, that health resources@@.of thd,,@:region are:very e new directions the,,reg-ion;@-is taking showing scarce, three, th the ability to respond to the needs of the peripheral areas. -the re iew al of. r=enA t'oh of, v Therefore, I move appr -,the reco 13 enil Disease, and I would committee and the Ad Hoe Panel oh 14 like to ask Dr. Schreiner or someone to comment on the renal 15 recom- disease budget And say whatever they'd like about that 16 mend.ation. 17 DR. SCHREINER: Fine, if you want to w ap this up I 18 did get a chance to go over this one, 19 DR. PAHL: Please proceed. 20 DR. SCHREINER: I think the comments of the site 21 visitors and ad hoc panel are all verv Pertinent and I agree 22@ with them in general. 23 @both by the no it. am ered tion of a two bed n 24, using the same nurse technician ratiof,are we, for egample 25 @abid to staff a four-bed home dialysis training program. I 13 2 1 think that there are optimal sizes for these kinds of things 2 in terms of the relationship. You do have to@ have two nurses 3 in the room if ou have a number of people, but the two y 4 nurses can really operate with four beds most of the time, 5 except when you are dealing with a very extremely III patient, 6 and I wonder if they shouldn't be encouraged either to share 7 their facility by having it contiguous with an adult unit or 8 nearby or else ask them why not go to a fout-bed unit, because 9 I don't think the personnel cost would be very much greater. 10 This is an inefficient size for a chronic dialysis unit. st this in the form of a DR. PAIIL: You would Ca 12 recommendation to them however. 13 DR. SCHREINER: Yes. Otherwise I think it's fine. 14 DR. PAHL: Thank you. 15 CY@OFF: That cpuld.be a MRS. WY 16 to negotiate with them. 17 PAHL: Dr. Watkins, as backup. 18 DR. TIATKINS: I concur with Mrs. @lyckoff's discus- L9 sion. 20 DR. MERRILL: Mrs. Wyckoff, is@this ne hrology p 21 unit only pediattid.1 22 MRS. WYCKOFF: Yes. 3 DR. MERRILL: And this is for transplantation and 24 dialysis. 25 133 MRS. WYCKOFF: Yes. 2 DR. SCHREINER: They are proposing to go into a 3 transplant program and have a peel"off by the fourth year. 4 MRS. WYCKOFF: It's covering a riuch larger area 5 than just that one region, Col6rado/Ilyoming, but they are not 6 getting any funds from the other regions exdept through oay- 7 ment by the patients. 8 DR. 14ERRILL: I notice representatives from the 9 University of Colorado Medical School here do not include any 10 surgical people. 11 DR. PAIM: Dr. Schreiner, with vour Permission 12 perhaps we could defer this Also until tomorrow until Dr. 13 Merrill has had a chance to review this, and perhaps the 14 Counci re could consider the ap Ithetef6 placation with the de- 15 fetral of the kidney proposal until tomorrow. 16 It has been moved and seconded, if I understand the 17: principal and backup reviewers' comments, to Accept the com- mitteels recommendation,, with however, deferral of c@6nsidera- 19 tibh of the kidney project until tomorrow. 20 Is there'further Council discussion? 21 Is there discussion from any of the staff? 22 If not, all those in favor of the motion p ease say 23 aye. 24 (Chorus of ayes.) 25 opposed? 134 1 (No response.) 2 The motion is carried. 3 The next application is the triennial application f(w 4 from Connecticut, ith Dr. Millikan as principal reviewer, Dr. 5 Cannon as backup reviewer, and Mr. Colburn as our staff 6 representative. 7 Dr. Millikan. 8 DR. MILLIKAN: When I received the blue sheets, my 9 first reaction, I guess, was amazement, and,then when I re- 10 read a paragraph on page 3, it says, "In the discussion, committee endorsed the concept of CRMP but expressed skepticism 12 as reflected through these qudstions.that were ask6d: 18 13 it real? is it unique?" and there are a'series of questions, 14 there. 15 1 had to conclude that somewhere in the process 16 of overall review the,project site visit participants had 17 somehow failed to communicate adequately to the review com- 18 On Se tembet 23 and 24 there was a project: site visit p 19 and 1 happened to be on that visit. 20, This failure of comunicati6n is So significant that I feel I need to review a bit some of the design and 22 sone of the issues at stake in this application, because the. @23 review cor,='ttee has recommended a, ver significant decrease y 24@ i budgetary@allocations f@r that recommended by the site P.5 visitors. 135 1 one question asked- Is this@unique?,,As far as I 2 am concerned, the answer to that is yes it's extraordinarily 3 unique. 4 As one reconstructs the coftceptualization of this 5 particular RMP, you get to the opinion reading between the 6 lines and looking at the action that there was a s rting 7 point with the original legislation for cooperative arrange- 8 ments between institutions of excellence and the providers of 9 medical care, but that the design was so skillfully put to- 10 gether, that there was a potential in the very design itself 11 for producing ultimately a fundamental change in the delivery 12 system by a series of steps, and these steps were o esighed 13 that they would hopefully be palatable and logical to,,the 141 physicians of the State, so that they not only would be 15 accepted but would actually gradually be generated by the 16 physicians of the State. And as the designers of the scheme 17 looked at what they had in the way of basic building blooksi 18 they,of-course saw Yale University and they saw the developing 19 school of the@State of Connecticut I-ledical School, they saw a 20 variety of agencies around the State,,@they saw several thou- 21 sand physicians; 95 percent of whom are staff members of 33 22 community hos er6ed in on the possibility of 'pitals, and they z 2,3 maki al fundamental contact Point with@the physicians ng the re 24 of Connecticut via these hospitals; then went,almost immedi- 25 ately to the idea of, well, should we try to let these 136 1 physicians to come from their hospitals to Hartford and to 2 New Haven, to @Yale,'@,or wouldn't it be viisek to get them sort -31 of womped up:'in their enthusiasm by doing something locally 4 by assisting them i@n@the design of a changing svstem in their 5 own locale. 6 So starting with the entry point of these 33 7 community hospitals, there evolved the concept of developing 8 physicians of full-time chiefs of service. 9: Now., at the time when all this business got started 10 there were four such chiefs in the State of Conhectidut, and 11 of this date, there are approximately 42 and so me 16 now, as 1P- other appointments are available. The concept of the full term chief included three 13 14 subdivisions of responsibility,, First was an inhouse retpoft" 15 sibility to education, organizatioh,@and quality of care. in @16- three of the hot'ital§ how, where there are full-time chiefs, p 17 there is a local internal medical audit going on. The concept of education was much more than the idea of simple refresher or review courses, but it had to do 20 with the interrelationships between what we call formal educa tion and h@,i@t mi@ t impact on patient care. 22 For instance, in one of these hospitals a full-tin@e 23@ chief@ was designed t6@study it involves the records there 24 of patient!i,4-inply Xn6wn to be hypertensive because high blood 25 pressures arO!@"recbrded in the records. Then there was a 137 follow-Up on these records to see whether anything had been 2 done about high blood pressure, and in 40 percent of them 3 there was no evidence that anything had been done. So then 4 there was an intensive series of interrelated education ac- 5 tivities between the staff of that hospital and personnel from 6 Yale, and now they are in the process of doing another aud t 7 to see whether that educational experience about high blood pressure has made any impact on the behavior of the physicians 9 in that area. 10 The third responsibility of the full-time chief is 11 called an outIreach responsibility. Now, it's oretty obvious 12 that if you look at his beginnings in a hospital he must make 13 his way there oh the basis of how he can get on@with the 14 staff and what alterations he can convince them to make, and 15 so forth. But then comes the point in time when he begins to 16 look out into the community. This is part of the design4 17r Well, an interesting example of how this has 18 worked is in Danbury. The full-tim6 chief of medicine there 19 convinced the staff that they should really inspect their 20 emergency room service. So they looked at their emergency 21 room service over a period of three months with a team of @22 tion including people from the University their own solec 23 Cdnt6ki but $elected by folk at the local level, and they 24 fou nd that two percent of the people going through that @25-@ emergency room were categorized as emergency problems, 46 1 38 1 percent were categorized as urgent, and 52 percent we-re cate- 2 gorized as non-urgent, that is, could be handled any time fromi 3 three weeks to three months hence without hurting the health 4 of the individual. This was their own judgment. 5 Now, the point of that was that when the staff 6 there saw these figures, they were convinced that some altera- 7 tions in the pattern of practice of that emergency room as a 8 portion of that hospital was indicated. so they then began 9 to develop the idea of an outpatient facility which would be 10 available at the hours of the day appropriate to siphon off a 11 large n@, et of the 52 percent who were categorized as non- 12 urgent patient problems. 13, Well, I just cite that as an example of the continu- 14 ing kind of activity of the full-time@chief. Now the question 15 has been brought up,about how responsive CCRMP is to the heeds 16 of A variety,-of kinds of people. 17 W611, one of the things that they have built into 18 their systems 1 think, is,an unusual deqree of flexibility 19 and elasticity, hot only in searching out the or6blems but in 20 responding to the ptobl6ms. For instance, in Hartford, 21 there is an area of some@19,1000 underprivileged, low income 22 individuals, so@a series of three organizations were put to- 23@ gether by RMP to get@going a clinic in that area, and this was 24 e ooened July-1, 1970,-@ done. with $30@,000 of IKMP money. The plac 25 and in its first year became responsible for the health care 139 needs of 6 000 of the 19,000 people. Well,'thev imnediatelv 2 identified that that isn't by far enough, but what I am talk- 3 ing about is the response to need. There is some 170,000 4 Puerto Ricans collected in one nortion of the State,@ and the handle here, or the vehicle, George, was diabetes,, and they 6 found that 3506 of these people had diabetes. So some dia- betic clinics were put into operation with Spanish transla- 8 tions of'the literature, Spanish-speaking people making the 9 contacts, et cetera, to try to get these folk into a better 10 health care system, in this instahcd the vehicle being that of diabetes. 12 There have been queries raised about the small 13 size of the core staff. TIelli this depends on how you define 14 core staff. There are very, ver few peop the Conne y _le in cti- 15 cut Regional DIedical Program sitting behind desks making no 16 contact with anybody outside of their offices. And the reason 17 I.put it in that frame of reference is that in a sense the 18 full-time chief and the "university-based facility" and 19 lic relat ohs are that probably is a poor term as far as pub 20 concerned constitute a real basic p6ttion,of core staff 21 energy and Activity. 22 The question has been raised by"@@several-. well, how 23 do you monitor somebody who is on the.staff of Ya f you 24 are sitting in an RMP program office,@across town? 25 Amnle of an individual at Yal6 well, they had an ex 140 who, according -to,the RMP, literal core staff, was not sub- 2 serving t @fun ion that he was supposed to be doing, and #3 they went.to the@dean and a couple of other people at Yale. and 4 they got that ineumbent@@changed. So there was evidence at 5 that level that they could impact on the staff at Yale. 6 The query has been raised abou th@fuadi of 7 these full-time chiefs. Well, they start with the,idea that 8 they will provide a maximum of $15,060 per annurn to a hospital 9 for a full-time chief for a period of three years. Now, in 10 actuality, they've got several ftll-time chiefs short of that figure, the rest of that money to be contributed by the hos" 12 physi I activi- pital and the facilities and all the badkup ca 13 ties and other@personnel, to be put in the hopper bv the Os- 14 pital. There are a couple of full-time chiefs that are 15 letting $11,,OOO per annum through the Regional Medical Progran. The query has been raised about the a of 17 the- ased staff. W6 had an opportunity to interview 18 some of these eople. Ote of them was a pediatrician who had p L9 replaced another individual because the other individual 20 hadn't apparently,'-been imch interested in the Pj4P concept. The man we-@"talk dilito gets 40 percent of his salary from RMP. 22@ 0 it was estimated@by him and by others that he spends about 23 percent of@'his 'time on RMP activities. Now, titime" is not 24 further defined' 25 an @s that Well, what I@ trying to display hereli 141 many, it seems to me, of the fundamental things that we have 2 been talking about for a long time have been achieved. Re- 3 gionalization is beautifully displayed the ability to ferret 4 out local problems and interact to them. For instance, there 5 is an estuary area along.the doast that has a summer popula- 6 tion of 120,000 and a winter-time population of about 30,000, 7 and the Middlesex Hospital adjacent to this, through its full- time chief, was spending $20,000 of PJ4P money, has got a clini< 9 going in the estuary area which last summer took care of 13,00( 10 people, subse-rving the heeds of, in this instance, a transient 11 population. And that was done with a relatively small amount 12 of money. 13 I neglected to say that the Hattford@e orim6nt, XP 14 where the 6iOOD of the 19,000 were taken dare of last year by 15 this local clinic group, is how self-supporting. It's getting 16 no RMP money at Iall. But I-m using it as an example of what 17 can be generated by proper planning.@ So regionalization I 18 think has been adequately taken care of. 19 The query comes about the position of the Cdhnecti- 20 cut State medical Society and the intera@dtion and the reaction 21 of formal medicine to CCRMP. 22 I suppose that the simplest way to display what 23 hag happened, and is continuing to happen, is to point out 24 that at the'last review of this CCRMP "problem," there wa6 a 25@ necticut formal request to this Council from@@@the State of Con 142 1 Medical Society, that we disapprove the application. Thisi 2 time you have seen no such request. 3 Now, that's one way of identifying progress, and 4 I know it creates kind of a smile, but I am displaying it as 5 an indication of a gradual chan ing attitude. 6 Now the interesting thing about that Connect cut 7 Medical Society business is that we heard all kinds of testi- 8 money from individuals who are members of that society attest- 9 CC-RmP4 Tle had one ing to the validity of the concept of the 10 man get up from the audience and identify himself by name as the President of a county medical society and said that their 12 compendium of opinion in that county disagreed 100 percent with the unexpresse d statement of the Connecticut Medical 14@ society, and Russ can tell you about the Presentation made at 1 5 the recent AMA House of Delegates meeting, once again re.nre- 16 senting the Connecticut Medical Society as firmly opposed to 17 the CCRMP. Is that'too strong a statement? 18 DR@ ROTII: Yes, that's too strong. This was in 19 reference committee hearings, a couple of resolutions intro- 20 duced'from other States in support of the RMPL wishing to re- 21 affirm official Policy position of the AMA, backing the M4P 22 concept, and this obviously occasioned considerable 4is ssi6n.,-, 23 'One of the most vocal memberparticipants 'in the @24 discussion was a physician from Connecticut. He did noti make 25 the mistake of representing himself As the spokesman for the 143 State Medical 8ociety;@ however, he attempted to take RMP 2 apart. Other people from Connecticut, however, stood up and 3 said nay, and I'm happy to report that the upshot was that in- 4 deed the Ameri'c 'Medical Association sup ,port goes for it. 5 But when Clark came in with his glowing renort, a ter recover- 6@ ing from the initial surprise, I think it's a beautiful niani- 7 festation of Accomplishment in an area which is one of P,@4P's 8 most important roles in my opinion. 91 DR. MILLIKAN: Incidentally, the gentleman that 10 we've been talking about is not anonymous at all. Ile happens 11 to be -- and he's not been excluded from the deliberations of 12 the CCRMP on the'execttive committee of the Regional Advis- 13 cry Group. So that his opinion is a part of the mix, but 14 he's outvoted when it comes to certain action items@, but it's 15 not as though he had been deliberately excluded because of his 16 adverse opinions concerning 17 One of the fascinating things about what I think 18 of as the uniqueness of the total design is the way it's now 19 beginning to accommodate itself to such items as Area Health 20@ E ducatioh Centers, because they could come close to writing 21 the defihitioh,of this iri_a'variety of settings, whether it 22 were to be in@Hartford,6;r at Yale or at Stanford or wherever; 23 they have the concept in mind of the Area Health Educa- 24 tion Center and are really moving in this direction, 25 Now', as far a's.,,.the HMO business is concerned, once 144 1 again'they are so flexible in their design and their ability 2'@ to get into these hospitals and make contact with the doctors 3 has been so significant that the HMO business is now very, 4 very much.on their agenda, And there ate four of these in the 5 design process right in the New Haven area itself. So the 6 totality of,the design for this Regional liedical Program has 7 been so well put together and so well-worked-out that they are 8 able to alter, if you will, or maybe lead, if you will, in 9 the construct of new ideas and the implementation of those 10 ideas, It says: Is the Core staff large enough to monitor 12 the university's activities ilell, I mentioned a few moments 13 ago two examles, where the university had changed the nersbn- nel involved in R?4P activity As a request of the PMP centr 15 office staff. 16 I think the word "monitor" is in a sense unfortunate 17 because the University of Connecticut medical School and Yale really represent in this R?4P local arrangements, and they are@ 19, all working together with a whole host of other agents rather than one literally monitoring the other, or one boino directly su MP b rvient, tp (another. it really is an exa 16 of inter- 2@2@ relationships. Z3 u Now, the qu6stion here is raised: Are the nivet, 2 sit3.es reallv committed to the concept and what is their real 25 interest. 145 Well, if you go back to the history of the Yale 2 participation, you find that the Yale interest in going outsid@ 3 its own walls antedates the RMP original legislation. They 4 were beginning to get interested in community medicine, were assigning medical students and graduate students in economics 6 and sociology and political philosophy to looking at the 7 nature of the provider-consumer interrelationship in health affairs as early as the early '60's. 9 I think that there is good evidence that the Yale 10 and University.ofIConnecticut commitment to this concept is a 11; irm one and a permanent one. 12 Well, you can get the qist, I think@ of my comments. 13 I think this is a unique program. I think it has fine leac r- 14 ship. I think the cooperative arrangements between a whole group of agencies I didn't mention the blood bank program, 16 for instance. This has been a beauty. They have got some 17 real evaluation data, for instance. They have ch nge@ the 18 lost of blood, that is from outdatinqi et cetera, from 50 19 percent in the State of Connecticut to 12 percent in the last 20 18 months via the computerization, and changed the availability 21 scheme as far As getting the blood out in the State where it's 22@ needed. This has been done with RMP leadership. 23 So there is a host of@bits of evidence about the 24 wide ranging nature of the activity, and with these verv brief 25 c ominehts I am going to move that we fund this program at the 146 level identified by the project site visit group which, inci- 2 dentally is considerably under the original request fror6't-he 3 Connecticut Regional Medical Program, that we do concur w th 4 certain of the questions about Dossibly enlarging the core 5 staff. The question was asked of personnel: Whv don't you @@6 have a larger core staff.> They have some oositions en, t I p y 7 think one of the things we came away with is that they have 8 tried to develop a, core staff as well as inhouse chiefs and 9 cut University -Dersonnel who really believe Yale and Connecti ts 10 illing to work in in the total program and they are w a dedi- dated fashion for it, and they are reluctant simply to fill 1?- positions just for the sake of filling them until they can get 13 the personnel they really want. 14 But I move that o e Rev 1 reconT!Inlded 15 by the project site,visitor6 with these ideas about some addi- 16 ti6ns to the Recrional Advisorv Group, some additions to the 17 Board staff, and so forth. 18 DR. PAHL: Thank you, Dr. Millikan. 19 Dr@, Cannon. 20 DR, CANNON: You don't think I'll add anything to" 21 that, do you? 22 (Laughter.) 23 DR. PAIIL: No, sir, I was just asking. 24 DR. CANNON: No icing On that@cake. 25 I think that Dr. Millikan was there, and I think 147 y good rundown. I believe the review he has given you a prett committee should hear his entire rebuttal. We've got it re- corded. 4 DR. MILLINXTI: It's really just a part of it. DR. PAHL: Dr. Schreiner. @6 DR SCHREINER: I don't know whether you want a 7 completely total comment here or not. 8 DR. PAHL: On the kidney proo6sal aspect? 9 DR. SCHREINER: Yes. 10 DR. 14ERRILL: I have looked at that so I can corq- meht on that, too. 12 DR. PAHL: Fine, let's do the kidney one on this 13 then. 14 s to what Dr. Milli- DR. SCHREINER4. I was curious a 15 kan's response was. 1 looked these over and I don't know all 16 of the people who are on the Ad Hoc Panel on Renal Disease. 17 There is a lot of expertise on surgery and organ profusion, 18 and I think their critique of the organ and tissu6 transfer 19 program is generally correct, but I don't see anv sign of 20 very much expertise in the realm of irmunofl6rescent and 21 electronmicroscody, because there are some statements made it 2 @e criticism here@that are just plain not true, such as ten 23 -percent of kidney Ipatient cases require EZI or FDA biopsy 24 ataly8is. There is no such data in existende. It depends on whether vou do prospective or retrospective analysis, and it 148 1 depends on what kind of Patient material you are dealing with, 2 if you -are dealing with a loaded pediatric census with lym-pho- -3 nephrosis, then maybe you don't need it in a large percentage 4 of cases. But if you are dealing with adult hypersensitivity 5 diseases which, for example, we encounter in a general hos- 6 pital, you may.neea it in as much as a half or two-thirds. 7 And I've seen some other comments bv the panel to 8 re some deep prejudices in this.area, and I suggest there a 9 oh This have looked over this scheme and it's an excellent e 10 is one of the problems that falls through the cracks, and it'@ 11 like Any other technical achievement. You can't get research 12 echniqties on larger groups sup for utilizing these new t ,port 13 of people because it's not considered a nure research project 14 'and you can't get third-party payment because they doft't con- 15 sidet it absolutely proven practice, and it's precisely the 16 kind of thing that RMP ought to be addressing itself to, how 17 you move it from the'bench to the bedside. And to do@this in 18, any significant number of people, to find its place, you are 19 going to find three kinds of groups of@people, one, in ic 20 you do it to discover that it's not going to be useful -- in other wo of people can then be phased out rds, that group but 22 we really don't have that information now. You are going to 23 find that there are a group of people in which it does add 24 something and@you are going to find a group of People in 25 which it is Abs6lutely.necessarv for proper treatmIent. 149 1 And if it's not available and a medical school 2 simply can't do this because of the expense involved.,. then 3 there are some people that are going to be misdiagnosed and 4 there are going to be some people that ate going to be.@' mi s - 5 treated. It's like a lot of other technical things. You 6 don't need it very often, but when you do you need it a,htn- 7 dred percent. 8 I think it's a very well-thouqht-out program. It 9 has the strengths Dr. !@lillikan mentioned in that the material 10 can actually get around from the various community hospitals 11 to a center where it's going to be read because of the ihte-r- 12 change of personnel that they have, and I would disagree with 13 the Ad Hoc Renal Panel on that diagnostic one, and I would 14 'ticigm of the org agree with them on the cri an an s 15 transfer program 16 DR. PAHL: Dr. Merrill, do you have a comment?, 17 DR. MERRILL: Well, I certainly agree the organ an@! 18 tissue transfer program has very little merit. I don't think, 19 we ought to get into any technological discussion here, but 20 my own opinion is that the renal regional diagnostic.vrogrwn 21 that if I we're is a verv valuable one, but I must confess 22 running such a program myself and this is essentially what 23, we do oh almost all the patients we have; the yield in;..,,,terms 24 a ot,making adifference between curing Such i?atient.land not 25 curing such a patient is almost minuscule, which is very is 0 intin4 I think, to most of us. Perhaps Dr. Schreiner disappo 2 is an exception. So, for different reasons I would agree that 3 the application be deferred. I don't think the yield in terms 4 of number of@'peo-ple who might be helped, applying this gen- 5 erally, at the present timeiis going to be worthwhile. How" 6 ever, eventually, in A prospective study over a per od of f ve '7 or ten years, we are going to learn something from this. If 8 this can be interpreted as a function of rIAP then I would 9 agree with Dr. Schreiner, but it's my impression that this is 10 probably not the function of EU4P. 11 DR, PAHL: Is there further discussion before we 12 phrase a motion? 13 DR. OGDEN: I'd like to ask a question for purnoteE 14 of information. if the site visitors had recommended $2 15 million, I assume that that includes $34,640 for the oggan anc- 16 o-oi said you don't tissue transfer prograTqf which you have n 17 approve of. I.also assume that it includes the $133,533 for 18 am which you now tell us you the kinetic kidney disease progr 19 do approve of. 20 If we look at@the recommendation of our own review 21 committee of $1.7 million, andladd to it the $133,533 for the 22@ kinetic kidney d;pq@a"se pro 'ram we are up to $1,833,000. 9 to know fi ures are we deali 23 So I i#buld like what 9 24 ealincT he site with, if we are d,, with the $2 million from t 25 visitors committee, $1.7 million that has been recommended 1 ki e kidnev and then these other two dney programs. I assume th 2 programs are @;,iot in $1.7 million. 3 DR@'. PAHL: They are not in the $147 million4 4 COLBORN: Th6-strateqy for the $1.7 million was to not all@, for additional funding for the hew requested 6 activity and to keep,,the funding level of the regional faculty 7 at the present level and not at the requested increase. That 8 came to $1.7 million. That was the strategy of the committee. 9 MR. COLBURN: Ilhat you are really talking a u 10 here is $1.7 million, plus $133t533, if this regional kidney -2 11 disease proposal is approved. 12 MR. COLBURN: No. DR. EVERIST: No. 13 14 DR. MARGULIES: The thing is there is a difference, 15 -the issue that Clark is getting at, between at which is 16 site visitors recommended and what the review committee recom- 17 mended, and he is 'referrinq'the figure of the site visitors 18 which would come to what figure? 19 DR. CANNON: $2.25 million on the second year and 20 $2.50 on the third;vear. 21 OGDEN- He's talkin' about the $2 million. 9 22@ What l,'m talking about is the $1.7 million that our committee 23 proposes !Pius the@@,,,$133,533 for this kinetic kidney disease 24 pro am, which would,come to $1,833 533, gr E5 @@'@MRS. KYTTLE: Connecticut has an approved but 152 1 unfunded kidney activity which is the $133,000 that you see on 2 this chart. it's $97 000 that is the- proposed nlan that Dr. Schreiner mentioned. 4 OGDEN: I stand corrected. Then what we are MR. 5 talking about here is $1.7 million plus $97,006. MRS. XYTTLE: 6 Right. 7 DP,. MILLIKAN: 14hat I was really discussing was 8 without the inclusion of the kidney proposal, since those 9 were not really gone into by this site visit team. Since we 10 do have expert opinion about them here, did not in- 11 clqde them in my discus i n 12 MR. OGDEN. Dr. millikan suggested $2 million plus 13 $97JI000. 14 estion§ DR. MILLIKAN. I am not making any sugg 15 about the kidney proposals at all. think we should listen 16 to our experts on the subjedt. 17 DR. PAHL: May the chair hear a motion, pleAse. 18 DR. MILLIKAN: I move,that we go on record as 19 approving their application, the first year $2 million thi@@ 20 is not including funding of the kidney activity second 21 year, $2,250,000, the. third year $2,500,000. 22 MR. OGDEN: Do you then recommend on top of that 23 there would be 24@ DR. MILLIXAN: The way I'm phrasing,Tny mo on, @'.25 that would be a separate notion. 153 DR. PAHL: Is there a second to the motion? 2 A14NON: Second. DR. C 3 DR. PAHL: The notion hasi@been made and,,seconded 4 to accept the site visitors' recommended levels of suppotti 5 with the kidney consideration to be the suIbject of.a second 6 motion. 7 Is there further discussion oh this motion? 8 If not, all in -favor please say aye. 9 (Chorus of ayes.) 10 opposed? MR. OGDEN: No. 12 6 notion is carried. DR.,PAEL: Th 13 MRS. KYTTILE: Dr. l@4illikan, can I ask a staff 14 question right in'front of you' 15 DR. @1ILLiyAN: sure. MRS. KYTTLE: Spence, do you feel that you have 17 some material here that you could give committee feedback on 18 the specifics for the reasons that Council overturned their 19 recommendation? 1 don't feel I do, but if you feel you do, 20 then I will be comfortable with that. 21 DR4 14!LLIKAN: I can draft them. It may bea ten- 22 page document. 23 DR. MARGULIES: I think that would help. 24 DR. PAHL: The concern here is'@ that review com- mitte4 has, expressed an interest at.its last meeting in a 15 4 1 those instances where their recommendations are not accepted, 2 to have as clear- as possf ble an understanding of the basis on 3 which@the recommendations have been modified, and this is the 4 basis for@this reIquest that we as staff can convey the inf6r- 5 mation back to them. 6 DR. MILLI I think that's entirely fair. I'll 7 -be happy to draft it. 8 DR. MARGULIES: I wonder if I could just shed a 9 little light on this DeculiAr chain of events, because obviously 10 something did alter the view of this program, Clark, as you saw. It was a nost peculiar discussion by the review dom- mittee. Those who presented it, who had been on the site 13 visit did it extremely well and with considerable enthusiasm, 14 additf6nal su,,np and in this particular case there was.the, ort 15 of one of the site visitors, Dr. Hirs6hboedk, who i-s the co- 16 ordinator of the Wisconsin program and was equally enthtsi- 1;7 @astic. 18 Then the whole discussion sort of wound up in a 19 lot of other issues, some of which were related and some of zo which were not related, and there were some strong positions 21 of advocacy and,antagonism, 'and I'm not sure that by the time 22 we got ough.w'lth it the Connecticut Regional Medical Pro- 23 gram was what we were talkinq about. 24 DR. MILLIKAN-1.@ think that came through. 25 DR.,14ARGULIr@,S:' There was even a very strong motion 155 1 at one point, in a manner which surprised me, which would 2 suggest that what this program should do is conduct a plebi- 3 scite of all the doctors in this State to find out if they 4 liked what they were doing. Now, since this has hardly been 5 a custom in the Regional 14edical Program to have inhouse 6 plebiscites on how well they like what's happening, it gave 7 you some sense of the fact that the general review was not as 8 objective at all times as it needed to be. And I would add 9 exe6pting that I don't understand to the reasons for that 10 them. But there was somethit more afoot in that whol@ review process in looking at the Connecticut RMP, at least in MY 12 judgment. 13 illiSS SILSBEE: Dr. Margulies, nevertheless, the 14 review cortimittee's expression reflected the continuing concerns its that have been felt about the Connecticut program since 16 inception, and.they felt like the site team did.not come back 17 with an adequate appreciation of those continuing,concerns. @18 The amount of money that they were requester for the uni'vet- ,9 1 9 sity faculty which was rising over the three-year period with 20 no notion of how the universities were going to take over some 21 of this, if indeed the were these were questions that have y 22 been inherent in the Connecticut program since its beginning, 23 and I think that also was reflected in the committee discus- 24 Sion. 25 DR. MARGULIES: Yes. 156 14RS. IIYCKOFF: What do we do about the principle of 2 nnosed to phasing but orograns after three years? We are su,,,. recycle them. How do you get to that? 4 DR. 1.4ARGULItS: As I understand it, the basic plan, 5- so far as this additional staffing is concerned, is to have 6 this become the responsibility of the hospitals in which the 7 additional personnel are located, and they teem to have moved in that direction. There was some question about the:@validity 9 but that ap ed to be their purpose. of that, pear 10 And there was confusion although there was a dis- 11 6ussion, about the status of the faculty at the universities, 12 and I think valid discussion. There was also considerable confusion aboqt@what figu and the 14 review e kept bouncing back and forth between two levels of analysis, and it finally came down to a lower figure 16 that they had anticipated. I think the questions they raised were valid), but 18 the environment O'f:the@discussion became a little distorted. 19 if you look at the issue, for DR, MILLIKAN. 20@@ instance, of the full-time chief,, there is one hospital that has now opened@:up positions of surgery and T)svehiatry,and in 2 Pediatrics, rIelqIestinq zero funds from IU.IP,for those three new onvincod Via their ex- I full-time chief Tiny? They are so c ecruenting f the validity of the peri6nce from the s 0 25. concept that they are willing to fund it themselves. I think '157 ea nhenomenon. this is a fundamental id of the whole RMP 2 Now, if one were to ask the qu6stiot: Is the nor- ,3@ tion of this core staff, using the phrase in the large sense, 4 at the University Of Connecticut and at Yale, i's'it ever going 6 to be completel self-sup,,oorting, I would vent a guess on y ure 6 that that the answer is no. Now where the supoort Will come 7 from remains for time to determine, but I think that's the 8 problem of any core staff. 9 MR.@OGDEN: Iwould like to ask some questions And 10 also to make a comment. And I will preface this by saying 1 11, pm not a great believer in this body or any Regional Advisory 12 Group abdicating its responsibilities to its-staff, but at the same timell@think we owe it to the staff to answer the qu6s- 14 lions that they present to us. 15 Now we have adopted a budget here a moment ago 16 without actually addressing ourselves to some@associated ques- 17 tions which the staff has asked the Advisory Council@to answer, 18 and I think this is the first of the triennial aptili@cationsi 19 looking back through;them quickly that we have gone through 20 today on which specific questions have been asked by-,the 21 staff,, and I really feel we should address ourselves to,those. 22 this Ile also have left unanswered@in adopting 23 budget@the question of whether this'$2,2,561066 And 24 ion also includes.this kidney disease Proposal,, or whether 25 that will now be voted on as a separate almourit,to be aed. to 158 1 those which have already been authorized. 2 I should,like to ask Dr. Pahl to lead a discussion 3 about the three qu'e@s-Eions,that ap pear on the. blue sheet which 4 the staff has asked,' the first of these being that CRMP at 5 the end of its fourth year provide a statement on how Yale and 6 the University of Connectic'u";t intend to eventually absorb 7 the cost of,the university-based faculty; the second that CRMP 8 at the end of its fourth year provide a nrepite statement of 9 the relationship to organized medicine in the State and what @io has been accopiplished to 4rd their imptov w ement;@and third, 11 that the NAC render a policy guideline dev6ndin on the matter 9 12 of support@6f faculty physicians. 13 This is the reason I voted no a morqent ago because 14 these 0 I don't think and I d n't 1 5 feel that adopting the budget is appropriate until they have 16 been. 17 DR. PAHL: Thank you, Mr. Ogden. Let-,me open these 18 questions for discussion. Perhaps we night turn to Dr. 19 Millikan for initial response beyond his previous comments. 20 DR. MIT4 KAN: I think it's ntirely appropriate e 21 to ask any fundihg@group to.@tell us at a given point in tirqe 22 That's number one, what their in ent is as far as the future- 23 what and-Connedti@cut in the 04 year, what Are 24 absorbing these their plans for costs. I think it's entirely 25 legitimate to@-ask@@them that. 159 The second item had to do with the business of re- 2. lationship to organized medicine, and I tried, witho Ut 90 3 into a great deal of detail, to give the sumnated reaction 4 that the project site visitors had to this. 5 Now, nowhere in the yellow sheets or in the past 6 history of this thing did I see any details of a certain con- 7 sultation visit. It wasn't a project site visit4 It was 8 called a consultation visit to the Connecticut Regional Medi- 9 dal Program which was made a couple of years ago after this :Lo Council received a formal request from the Connecticut State 11 medical 8ocietv to disa ,p prove that abpli6 atioh. There was a 12 visit at that point in time where there was testimony from a 13 wide Variety of people about the Connecticut Regional r4edical 14 Program desi n, its impact on organized medicine, its impact 15 n individual ph sicians and on other health agencies in the 0 y 16 State, and it seemed apparent that there was A relatively 17 small group of individuals who were vehement in their opinion 18, that CCRMP was not a good thing. 19 Now, I was simply trying to identify at least a 20 s change in their willingnes to formallv express that bv Doint- 21 inns out that at this t nt from the, ime we do not have ta .eme 22 that we disapprove Co doticut State Medical Societv asking nn 23 rtinO the this application, nor do we have a statement suppo 9A inj to use that as evidence of some 25 modif icatic)-p of their position. 16 0 1 MR. OGDTN: May I interrupt you just for a moment 2 and say that I think perhaps asking CRMP at the end of its 04 3 year to provide a precise statement of the relationships with 4 organized medicine is perhaps asking them to do something that 5 nobody knows exactly what you want. What's a nrecise state- 6 ment? I don't know who'drafted that phrase,, but 1 find that 7 as A lawyer rather difficult to interpret. I think perhaps what we are looking for is some 9 better feeling@of relationship but I'm@not sure that's a very 10 good phrase for the staff to have used as a precise require- ment. I think what I'm getting At Clark, is really 13 numbers one and three, and I think here we do have an unusual 14 situation of'the support of faculty .physicians. And this is 15 something that T>ekhaps a policy guideline mghi,- to be@rendered 16 on. 17 DR* MILLIKAN:@ Well, it might be diffic-u t to write 18 a firm policy About this particular one. A good man of us y 19 have been convinced that it's 4 more effective mechanism to 20 get cooperative arrangements established to have part-time 21 supportifor a person who is a member of a university facultyr 22 presuming that he is really going to contribute to the M 23 activity, than it is to try to base a physician or a ,non- 24@, physician in A distant office and get him into effective 25 dail intercommunication inside the university. y 161 MR. OGDEN: Let me ask you a question here. Is 2 part of the lack of relationship with organized medicine in 3, Connecticut involved with the fact that there is some hos- 4 tility toward the medical school faculty members and the. 5 medical school itself? 6 DR. MILLIKAN: I don't ],,now the answer to that.'@, 7 MR. OGDEN: We have this from place to place. 8 DR. MARGULIES: I think that may be a factor. 9 There may alto be some tension over the differehc6 between 10 I those who are concerned with hospital function and those who 11 are concerned with non-ho§pital function. 12 gut let me just Dlace this in what kind of@ @@@light 13 we can. The problem in Connecticut has been to det6rmih6 who 14 it is that we are talking about and this was the review 15 committeels@languaqe, not the stafflt -- when we say to get 16 some interpretation of the attitude of organized medicine in 17 Connecticut. Because what has hap here has pened is that t 18 been an executive committee of the State Medical Society 19 which has had primarily one individual, and to some extent 20 another, who have spoken frequently and loudly abg their 21 relationships with:the RD4P, and nobodv has been able to de- 22 he what the rest of the executive committee:feels about termi 23 remainder of the it or what the organized segments of the 24 -C6hhedticut medical Society feel or the rest of the State. 25 Since we have one voice sT,)eaking loudly, and the@re.st of them 16 2 apparently going along in what apnears to be a ha,,o py arrange- 2 ment, it is difficult to know to'whom we address that kind of 3 a question. 4 DR. EVERIST4. it has been small in number;but large 5 in power, that have been@ the dissidents there. 6 Another thing about the Cbnnectidut Regional ?Iedica.. 7. Program, the first planning gkant that came along that we I 4- I-, IIII 8 thought was outstanding in this Council WAS from Conn6cticut, 9 and for e,first year or so of that olanniftg period we though,-. 10 it WAS outstanding So theik problems date not from the very ii-; begithing, as you may have thought from Mks. silsbee's comments, 12 but rather they developed after the State Medical Society be- 13 came upset about some of the things that were happening in 14 RMP. 15 DR. MILLIMW4 One more comment about this relation 16 Ship-to physicians, the most articulate and visible@of these 17 ihdividuals@is Dr. Granoff. Dr. Grahoff is a generalist Who 18 nts every practice ny patie day s in a private office seeing ma 19 He was asked in A@fkiendly fashion, how should RMP go about 20 hysic,ians in the maki 6kative arranqements,with the p ng coop 21 State? And he sai 'I@I-t should be dote at the level of the 22 dodtor's of f.ice 23 we 1, and everybody here,,, I haven't a en any 24 years that is getting il o the real successes down through the,@ ht 25 MD't bfftc p od. ilow, this i8ja fundamental difference e eti 163 cting coonerat of opinion about the way you go at constru ve ,2 arr angements, and this was the very reason I gave a bit of 3 history about why the community hospital -- and Connecticut 4, is a bit unique in regard to the fact that there are 33 sig- 5 tv hospitals, and only,33; in the entire State. nificent communi 6 MR, OGDEN: I would hope, though, that many of the 7 preceptorship programs around the nation are getting into the doctor's office. 9 DR. MILLIKAN: Well, there are so many things about @10 h't mention. For instance, I didn't mention this that I did anything about the affiliation a that Are being-con- qreementg 12 tet8 And a v tiety of these ttiV6d between the two medical cen a 13 2 hospitals, and these have been interesting steps. The first .14 one is a ve loose one, and ultimately i-t,be. s a much ry 15 closet, a much more commiting kind of affiliation agreement, 16 in which only eleven hospitals have signed up at this point 17 - in time. Now in those eleven hospitals, there is comp le te 18 i@hterchihqe of house staff, intern, resident, Atd including 19 Undergraduate students, between the center and the comm nit-V 20 hospital, and in three of those hospitals there is how a pro- 21 gram-for get ncr medical students into physician's offices. 2g So.Ith6re is a distant attempt in that regard. But s addressing myself to was the it" what I wa 24, ical educator and cooperative arrangemett, ability of the med -25 to get into offices of physicians across the nation. typ@ 164 1 DR. BRENNAN: I would like to res-oond to two of the 2 points that have been raised. First of all, I would much dis- 3 uidelines about pairing like to see us make anv general g L 4 salaries to people who are on university staffs. The relatior- 5 ship between the practicing profession, the hospitals, the 6 delivery of medical care oh the part of the university in 7 various parts of the country differs widely, and I don't thi@ 8 we could make a@Iv-alid-guideline on this. 9 The same thin I would say about this application 9 10 is that it seems to me that it's the review committee that 11 always has an explanation for the position it took. it is 12 very unusual to find the review committee recommendation go 13 this degree,contrary in a negative direction to a si e visit 14 recommendation, And I think that our oractide@has geherallv 15 been to figure that the site Visit brings b ck information for a 16 all of us that no amount of exariination Of documents can 17; not produce. I think that the inconsistency here lies in 18 Council voti@hg on Dr. Millikan s motion, but in the review .19 committee opposinct,the recommendation of the site visit itoup, 20 Ik A, bit DR. 14ARGULIE8: 1 do think we need to ta 21 they raised, although I iiould further about the point that 22 not be deep 6ne6rned about whether the Council reached any policy decision. 23 But I think all of you who have,had exten 24 sive expdriende with Regional 14edidal programs have a sense ol 25 the meaning of a policy statement which would say that no 165 part of RMP money can go to pay a part of the faculty of some- 2 one who is in a university health science center because- this 3 arrangement is pervasive in the Regional Medical Programs. It- 4 does produce problems, obviously. You have a divided loi7alty 5 and all the difficulties that are inherent in that kind'of 6 an arrangement, the question of how well one can control the 7 individual who is placed at some distance, et cetera. Yet, to 8 involve salaried time of university faculty people inla 9 Regional medical Program on a voluntary basis is most unlikely, 10 so this arrangement is commonly practiced, It requires care- 11 ful supervision. It has to be guarded very well. But I don't 12 know whether the Council has ever made any olicy statement p 13 covering that kind of an arrangement and whether it wishes to. 14 MR. HINES: I feel very ztrongl@ on one point. 15 Speaking as A laymah it's probably much easier to come to this 16 conclusion. @I do not think it's incumbent uoon this council 17 to pass judgment on approval of Reaional Medical be 18 cause the State Medical Association leadership r doe does o s 19 not ap does or does not relate Perfectly to the 20 Regional medical Program. 21 1 feel implicit in the question nc@ is some@co ,pt 22 that elements of organized medicine must a nrov6 befoe we; 23 approve, and I don IIt think that's the ourpose of-our work, 24 feel this very strongly. This ob@iousi ordi n@@@ program,, acc 25 to Dr. Millikan's 6 inioh I respect And whose presentation was p @l I @@ i@ 'I 166 most articulate, is extremely effectve. If there are element; 2 of the State iledical Association in Connecticut that are not 3 supportive of what is happening, that's too bad, but we should 4 go ahead and approve it anyhow. Oth6rwise we are going to 6 !5 find ourselves trapped by an inerti,,a that will mitigate again - 6 progress. Am I right, Dr. Millikan.> 7 DR. MILLIKAN- Yes, I think that's correct. I was 8 trying to point out the basic dichotomy here in the formal 9 past position of the Connecticut Medical Society, in contrast 10 to the behavior of its members. Now, I neglected to say, for 11 instance as far as this chief of service business is concerned, 12 has that been forced into any hospital:by P@,AP? Well,, the 13 that is no. A hospital staff must o answer to v te in favor of 14 a chief of service before the position can'be created. That's 15 an integral portion of the whole DlAn, and has@been right from 16 moment one. Those are practicing physicians, most of whom are 17 membersof the Connecticut State Med Cal Society, and so.fort 18 MR. OG well,, maybe I can wind it this way, DEN: UP 19: just with one comment. I think we.,have had two occasions this 20 afternoon, just with r6soect to one comment which w as made 21 down here, where we have approved budgets below those of the 22 site visitors,@ 23 Now, in connection with these three q,u6stibos that 24 are asked here-, unless Dr.@ Millikan.@l;wants to make some specific 25 t about it, maybe I ought to ust,@make a motion since I commen 167 lbkought them up. @2 Iwill start with the bottom, in which it would be 3 ,MY motion that this NationAl Advisory Council not tender a 41 olicy guideline on the n@attet of support of iang, p egidnal Medidal because Idoubt that there are very many R Programs around the country that don"t have some facu 7 physicians involved in them someplace. 8 , as far as CR14P providing a precise state- Secondly meht on relationships of Organized medicine, I just don't see 10 that this is possible. I think they have lot to come to some grips with the thing. I think asking them in a year to come 12 up with some precise statement is really asking for something 13 Olympian, which isn't likely to happen. It sounds to me as 14 if there are some neople up there who Are. bratty firm in their 15 opposition, and they are not going to change their minds in a 16 year. 17 So I would move that tie vote no on those two. 18 The first one maybe we ought to take up separately 19 because.that is the one I just don't have an opinion on- so 20 l@will move no on two and three. Can we take them u-o in that 21 "order? 22 DR. PAHL: Yes, sir. The motion hat been made to 23@ c jive an-answer of no to points two and three. Is there a 24 0 second td@'that moti n? DIRS. IIYCKOFF: I second it. 168 1 DR. PAHL: The n has been seconded. Is there 2 further discussion on the motion? 3 DP,. iMERRILI,: I think the ooint raised bv p6 nt 4 number three is a critically important one. I myself have 5 been given to understand that there was a policy already on th@ 6 matter of support of faculty physicians, And that it was no, 7 that we did not support then,. I disagree with this, but in 8 evaluating a grant and in looking at the evaluation by the 9 'ttee of the grant tha renal comru t I had to evaluate, I know 10 that they, top, felt that it was the policy not to support 11 faculty physicians. 12 DR. MARGULIES: John, I think the distinction here 13 i s partial s port of faculty for giving service t.Q,the Re 14 ional Medical Program versus partial support of faculty@to 15 carry out some kind of distantly IU4P-relAted activity. it's 16 really A question of adding RMP competence by the partial 17 support. 18 DR. MERRILL: Am I to understand then'that if one 19 adds RMP comnetencv by partial support this is justifiable? 20 DR 14ARGULIES: That's what Woody is saying, ye s 21 MR. OGDZN:: I will accept that 48 the motion. @2 DR. MERRILL: I second it very strong 23 DR. PAHL: Is there further discussion of the 24 moti on. 25 If not, all it favor of the motion please say aye. 169 I (Chorus of ayes.) 2 op 'posed? 3 (No response. 4 The motion is carried. 5 '4r. Ogden, would you like to discuss voint one now? 6 MR* OGDEN: Well, I would really have to defer to 7 Dr. Millikan on this. It seems to meo I don't know how re- 8 lated this is to item three. I really feel somewhat like the late Will Rogers, all I know is what I read in the.papers, and 10 this is the material that is in front of me, and I don't know 11 how Yale and the University of Connecticut currently to what 12 extent they are@Pa-vinct for university-based faculty and how 13@ CRMP is paying for@itl and whether Yale and the University of Connecticut can absorb these things. 15 DR. MILLIKMI: I think the question is a little 16 bit selective. I don't see the review committee, for instance, 17 Asking us to approach 56 Regional Medical Programs with the 18 request that@they@define for us how that Regional Medical 19 Program is going-to replace the funding of a given category of 20 personnel in each of the 56 Regional Medical Programs. Now,, 2]L what we Are talking about. These this is in essence peor)l 22 are doin .:Pj4P work g@ 23 MR. OGDEN: Let me ask you if you feel that it is@ 24 desirable tha the University of Connecticut eventually t Yale and 25 absorb the cost of the university-based faculty in s progrcim. I I I 170 1 DR. MILLIYAN: I think it depends on what these 2 people are doing. 3 DR. BRENIIAN: I think that probably the university- 4 based faculty here spoken about will become employees of the 5 hospitals concerned insofar as they ate acting as chiefs of 6 service in them. Now, I am happ these chiefs ,y to see that all 7 of service have a, speared in Connecticut, but I am not prepared 8 to believe that this is entirely the result of the CRMP effort. 9 That is a widespread tendency across the country, and it's 10 related to residency recruiting in a number of specialties 11, and 1 think there are strong motives for the hospitals to move 12 towards chiefs of service for er regions this@and oth and 13 that one could reasonably expect that if they were given a tim@ 14 ahead when support for this function was to be removed, that 15 ways would be found to compensate for it, not necessarily in 16 the university. DR.@MARGULIES: Now, there. is a distinction and 18 that caused :Some of the confusion during the review committee 19 between the support of re in the hospitals and the people who a 20 support of that portion of the program which is the- iesponsi- 21 I?ility of faculty people in the universities them6olves,'Ahd 22 its the latter that caused most of the on6o,thi because this 23- to bera@way, and it may be i n s@ 6 circumstances, of appears 24 Providing faculty for the university wh-ich the university 25 ink doesn't have to pay for. And l,th that's what concerns you 171 isn't it, Bob,? 2@ .MR. OGDEN: Yet, it does, because we have had this 3 up in Se,attle. 4 DR. MILLIKAN: There's a neat little item here 5 that the CCPJ@4P boys missed out on originally, if thev had 6 called these p Ole part-time. core staff, the question might, .po 7 never have been raised. 8 MR. OGDEN: I think it depends on what-they do. 9 DR. MILLIKAN: That's the poiAt. and incidentally 10 we inspected that by going to representatives of the hospitals, 11 the project site visitors actually they came to us@-- and 12 we querivdthem about the time devoted by the university-bated faculty to@@the activities identified in the application. we 13 14 way down the line. Ile got affirrnatives all@ the 16@ time 15 of these people. schedules on some 16 MR. OGDEN. I think nerhaps what we are talkin 17 about is something,that can't be resolved at the end of the 0 is connecti n,with year- the statement particularly, and in 0 a 19 ti comment that was made down heret perhaps what we are sugges rg 20 t the is that we would like CR*IP to make an ef fort to ge 21 university@-@based 'faculty, to get their costs absorbed by the 22 university 6'r @the hospitals, whenever 3.tls possible, as a 23 means of phasing out this kind of activity from CRMP support. 24 Isn't that concept self de atin DR. SCHREINER 9 25 .,to what we are'tryinq to do? Let's just take A defined situatic 172 like the stroke situation. if you have a university that's 2 handling its service and requires one.neurosurgeon and vou now want to reach out into the community and support the backup of 4 the trainin in specialized care for a group of community g or 5 hospitals, the university's answer is, "We need one more neuro- 6 surgeon to do that," and simply because he's based in the uni- 7- vetsity hospital if'he's serving that purposei I don't think 8 expect that the university is going to absorb this, you can 9- because that's fine for a state university but it's not fine ab orb it for, a private university. What are they going to s -1 with? 12@ bR. 14!LLIKAN: Well, George, you',-7e just picked a real dandy. There has.beea no collusion here. The weak 14 part in the Connecticut Regional medical Program is the stroke o n na f it, and the i teresti 16 analysis of why it's so weak is reasonably simple. Yale has @17 a neurology department, for instance, that is not interested 18 in stroke, and there has been no ability@to go into Yale and 19 get 10 percent time or 12 percent time from somebody know- 20 ledgeable about stroke at that level. the University of 21 Connecticut emerging medical school has 6 vet developed any n t 22 kind of expertness in this particular area, so they have gone 23 a i ised, you see, about sup e sewhere. The question w s a _port, @they have gotten veryf very p 24-@ and oor talent but it's ail they 25 could get at this point in time, and your question is, 0 I 173 1 course, a dandy. 2 DR. Z4ARGULIES: We are dealing with an issue wh ch actually rises above the details of this particular discussion 4 but one 4hidh is of tremendous importance, and that is the @5y definition ibility of the medical@school of what is the respons 6 with relationship to the community? One would hope -- I w6ule 7 hope at least that it would become almost an "of course" 8. kind 'f thing the university would absorb this kind of 0 9 indi aIuse that's how it meets its community c it- vidu,al, bec OTIM 10 ments and I think hat institutions like Yale And the Uhiver 11 sity of Contecticut and many others are attempting to do so. 12 1 don't think thev are trying terribly hard, and I think they 13 are facing issues which they are allowing to defeat their 14 efforts more.readily than is absolutely necessary, on the 15 other hand, the do have some tough fiscal problems, They y 16 have the constant tensions of their Academic interests nd 17 their internal commitments of another kind.,, 18 @@so that'what we could well do, and I think what yoit L9 were saying@expresses that intent, is to push things in that 20 direction. My own feeling is and I have tried to propose this concept wherever possible that @IP may serve As@ one 22,-@ f that linkage between the medical schools o ;its best efforts, 23 whic,@ will make it more natural for it to be a part 0 t e 24 and-not find it a strange place but A rather COMM ty g5- rather natural place for it to teach, And for it to serve, I I 174 1 than defining it to the hospital. 2 DR. SCHREINER: The point I was making, though, wa 3 that the way to do that might be to put the man in the univer 4 sity. So if you take a doctor,and they understand you are not going to support a man within the unive rsity, you might 6 be defeating the best technique you may have for getting that 7 connection. 8 DR. MARGUL@S: The question always is, which 9 swallows which? -And,whAt we are hoping is that the medical 10 w'll be pulled out rather than the PJ4P being pulled in, chool i 11 but you can't govern that at all times. 12 DR. SCHREINER: You have to be realistic, that there are a couple of private schools th 13 at are on the verge 14 of bankruptcy because they've been involved in community 15 activities. So it's not really fair to say they are all 16 that negative. 17 DR. BRENNAN: I'd like to make a point relevant to 18@ the future of financing for this kind of thi:ng. I think when 19 RMP demonstrates.that a relationship with the university that 20 to update a hospital practice brings consultants@.and teachers 21 that there he RMP succeeds in showing the way to this, w n 22 exists resources for making various kinds of Arranqements to 23 allow this action@ to continue 24 For example, hospitals all over the country are 25 f Medicare and collecting substantial amounts o Medicaid 175 I monies that they didn't collect before and throwing these 2 funds,, insofar as the patients or staff cases, into what 3 they call educational funds or development and research funds. 4 Now, much of this money is noorly spent. You will 5 have the paradox that side by side with the university that is 6- pinched on being able to hire enough faculty to discharge its 7 responsibility, large-sized hospitals in the immediate area 8 will be building UP substantial bodies of money in reserve for 9 educational programs which may consist of lecture series and 10 other such or locally sponsored research projects, and so 11 forth. 12 So the funding is there. once the hospital staff 13 and the hospital administrator begins to realize that this 14 kind of a relationship with the university is,valuable, there 15 is nothing to stop an association of hospitals or a group of 16 ontractihg with the university to pay part or hospitals from c 17 Let him w rk from all of the faculty staff mo-mber's salary. 0 18 the university base and serve his function. 19 So I don't think we have to fall back from the 20@ ic- id4 that we want our monies to turn over, that we Are.bas a 2, @y @b sin@ss of starting thin S, and we should '.t be 1 in the 22 frightened about the lack of resources. The resourceslare 23 th ly not being Put to these urpos s', ere. They@are simp p 24 I think the Connecticut program will teach@, e 2.5 Connecticut people the value of this, and if it"is re 11 176 1 worthwhile and it's having a genuine impact in the community, 2 they will see to it that it goes on. 3 r4R. IIINES: I'd@.like to speak to the funding asoec@ 4 of the problem, not out of,iny personal Attachment to Yale but 5 as a matter of principle. 6 It seems to me that as amatter of principle we' 7 should not look to universities to absorb these costs, but as 8 a matter of principle we should be very sensitive to the 9 economic difficulties of the universities, and try to supnort 10 them whenever we can, because they are so bereft of funds, 11 and the work that we are trying to stimulate is so much re- 12 @!Ated to patient care. It's impossible to separate the func- 13 I see it of medic ion from medical care, that tioh as al educat 14 I feel strongly as a matter of principle that we ought to take 15: a position that we want to try to support these programs 16 whenever we can and not ask them to absorb the costs. I don'l 17 know whether there is general agreement on that point of view 18 but I feel quite strongly about it. 19 DR. t4ERRILL: I would certainly acTree4with that 201, statement. think the point is'; we have already pa$$(d 21, a resolution 'which affirmed@-partial support for faculty @2 h gicians when it's@@ ustified if it adds to RMP competence. p y 23 I think the roblem is what@happens to a mant let's say, who 24 is funded for three years as an assistant Professor, and@theh 25 the university cannot,pick up the@tab, And I can tell you roii 177 experience as the chairman of the committee on resources for 2 the Harvard Medical School, there are many, many instances, 3 in s-oite of.,Medicaid and Medicare, in which the hospital or 4 the medical school cannot pick up the tab. However, I still 5 affirm the principle which you have stated, because at least 6 it gives'them three years to look around and do something els4 7 in that time, and it seems to me he can be of tremendous 8 assistance to the spread of medical care or to the facil ta- 9 tion of medical care. And, of course, in my own specific are@. 10 of competence, of course this includes the transplantation 11 and dialysis area. Ile can be there to train people and to @12 take care of sick@ people and to help outside physicians accom- 13 plish this same end. 14 So I'would agree that support is nedessarv but I 15@ can't see that the university is able or willing,to pick up 16 the tab after that-*- and that this support should depend on 17, their b6ifi able to do it. 9 DR. t'VERIST: This statement says that all they are 19 t fr these two universities at the asking for is a@@statemen Om 20@ ar to say when thev Ate eventually croincr e e 21 @t It mean that they want it done at t at 22 @@@@-@itne. As@ a' matter of;fact, they have funds to go three years @23 @@.s6 that 4ventuall might be twenty years henceil and they are y 24 not con"ce ned about,time at all here. It says eventually. 25 DRI. BRENNM They are not even asking the 178 1 university necessarily to do it. All thev are asking is that 2 it be phased out of ILMP. 3 DR. EVEAIST: No, they are asking to make A state- 4 meht of whether they intend eventually to do it. 5 DR* MARGULIES: if I get the sense of the Council 6 uo to the present time, it is that this particular arrange- 7 ment, if well-'handledican work for the benefit of the univer- 8 sity and the benefit of the Regional Medical Program, and I 9 think we can express that concept. 10 On the other hand, it can be mishandled and be used 11 as a cheap method of getting help that the university is not 12 contributing to community resources 13 I think we can transmit to the Connecticut RMP 14 in generally that sense. 15 MR. OGDEN: I think we are dealing with a subje6ti@6 16 'In a sub3 as well as an objective discussion here. 'ective 17 sense 1 think this item one makes sense, within a year let's 18 see what they can do. From an objective standpoint I agree 19 with Dr. Merrill. 20 DP,. MARGULIES: I'd like to add just in passing 21 that I think@this is another one of the areas of general 22 Is around the Country which we must continue to concern in RMP 23 evaluate, because the issue has not come up before. It's a 24 little more striking here. We have begun to 661lect some data 25 @this kind of arrangement and we will continue to do so and on 179 keep you current on how much this kind of process is being 2 pursued and what it seems to mean. MR. OGDTN: Ile haven't completed the kidney por- 4 tion. 5 DR. PAHL: If it's the pleasure of the Council, I 6 would suggest that we break for a few minutes for coffee be- 7 f o cold and I lose my secretary who has been ore it.gets to 8 frowning at me for fifteen minutes, and that we then proceed 9, on with Dr. Roth's application so we do justice to those 10 regions,@unless you feel we can come to a very quick resolution 11 t of the Connecticut nroposal, nd perha of the kidney aspec a Ps 12 over coffee Dr,. Schreiner And Dr. Merrill can chat with me to know how to proceed after coffee. 13 14 (Whereupon, a short recess was taken.) 15 DR. PAHL-. May we get started again, 'pl6ase. 16 I'd like to take one minute more at the request 17 of Dr. Brennan to call on him for a specific statement rela" 18 tive to the discussion which we just completed, and then we 19 W-ill@move on to@the-kidney proposal with Dr. Schreiner and 20 Dr. Merrill. 21 Dr. Brennan. 22 DR* BRENNAN: In inspecting the yellow sheets here 23 that qive the projected budget, I am led to a feeling of 24 caution with respect to the bottom of page 3 in the yellow P. 5 nnecticut application; which shows the cost sheets on the CO 180 1 for university-based Regional medical faculty growing from 2 $180,000 in the first year of that program to $819,000 in the 3 sixth year of the program.. 4 It seems to me-that in the motion that we have just, 5 passed the approval of the grant we have given, that we have 6 laid before our staff, which will have.the problem of looking 7 at the second and third ear of this application, a difficult y 8 job if we don't give them some guidelines. 9@ Therefore, I should like to move that the CIU4 P be 10 notified that it is the desire of the Council that ways of 11 reducing the RMP share of these expenditures, these projected 12 expenditures, be found. 13 e university to pay these I am not calling f or th 14 expenditures. It's All right with me if they get it,frorq 15 tford Tr omething like that; but simply that the Har ust, or s 16 they explore ways in conjunction with the hospitals and other 17@ funding sources, for seeing to it that this exemplary program 18 is,continued without quite so large a rate of growth as is 19 is page. projected at the bottom of th 20, @DR.'EVr@,RIST: Do you want@to,give that same admoni- 21 ti6n for the community base?.' 22, Dli.@BRENNAN: No, because I understand the commun I,.y- 23 based orocfram is one whi6 I all r*4@t, I will give it for 24 the commuhity-bised program, e whol6.works as A matt6r'6f 25 is it, little more difficult to fact. The only problem I i 4 @ - I handle this one. 2 DR. PAHL: Is there a second? 3 DR: SCHREINER: Second. 4, DR-@* PAHL: The motion has been made and seconded. 5 Is@,there further discussion bv the Council? 6 Mr. Colburn. 7 MR. COLBURN: This could be confusing about the 8, community based because the commuhity-based physicians do 9 have a built-in phase-out mechanism, and it provides for only 10 three years to a maximum of $15,000 per year. 11 DR. SCHREIN ER: The numbers still keep going up. 12 MR. COLBURN: If you want to make some. type of 13 -judgment of what the saturation noint is on the number.6f 14 full-time chiefs in the State of Connecticut. 15 DR. BRENNAII: All I want to do is put a shot across 16 i their bow, that's all. I don't intend to knock them down. 17 DR* PAHL: The motion, however, includes a state- 18 ment as to the expectations of of the program 19 which would relate therefore to the community-based activity, P-0 I would assume. Is there further discussion? 21 Al in favor of the motion please say aye. 22 es.) (@Ch6tus of ay 23 Opposed? 24 onse.) (-No resp 25 ti6n is carried. 182 DR. PAHL: Now, if we may turn to Dr. Schreiner or 2 Dr. Merrill for a mot ive to the kidney aspects of the 3 Connecticut triennial application. 4 DR* MERRILL: Dr. Schreiner and I have had a little discussion during the coffee break, and I think we are essen- 6 tially of the same opinion, although I think the implementation 7 of that opinion is probably a matter for the board to decide. 8 First of all, we both aqr6e that the organ and 9 tissue transfer program is probably not worth funding. We lo: agree also that one should do renal biopsies, and that 66r- tainly more than 10 percent of these do require EM or FM 12 biopsies. 13 Where we perhaps disagree slightly is in whether 14 or not this is critically important to the medical t-rIeatment 15 of a large'number of patients4 I do hot feel so from our own 16 experience., If, however, diagnosis as an end to itself is 17 son@ething,the Regional Medical Program should fundf then I think we are in total agreement that this is a good procedure. 19 i;i that a fair statement qdokge? 20 DR. SCHREINER: Yes. I think part of o r d fer- 21 encesof opinion as we chatted were that we see a little dif- ferent kindof material. John's conclusions on glomerulo- 23 nephritis, for ekample, are completely valid as far as our 24 experience goes, but our material apparently is a little bit 25 different. I think it has a little more utility than he does, 183 but I also think that we did cardiac catheterizations long 2 before there was cardiac surgery, and I think about three- 3 quarters of what we do in medicine to establish diagnoses is 4 done without necessarily assuming that we are going to@follow 5 immediately with successful treatment. There is always A poirt 6 in making an accurate diagnosis even if successful treatment 7 doesn't exist, and T think this is a valid thing. After alllf 8 what's the success ful treatment for cancer if@you want to 9 get down to it. Ile Can do all kinds of diagnostic procedures 10 and rightly so, in order to characterize so that when the de- velbpments come along we will be able to put them in the righl- 12 slots at the right time. 13 DR. 14ARGULIES: Really, the issue is not-so much 14 a technical one@at this point as whether this represents the 15 kind of an activity which PI.IP should reasonably support and 16 which it isa segment of a health delivery system which at 1 7 the present time ends at the point of diagnosis with no 18 definitive treatment following, and I think we probably had L 9 enough experience that we could probably get a mo ion one 20 way or another on whether this is worth supporting with P14P funds. 22 DR. SCHREINER-. Ilell, I would move that it be supported for a three-year period, and I think it has@some 24 @interestifio 16si6na to be learned from applying this. There 25 aren't very many communities in which you can adtu ,get 184 1 t,4e tissue is being this material moved from the places where 2 taken to the place where it can be adequately studied, and I 3 think a sma 11 State with a big community hospital is a unique 4 kind of situation. 5 DR. PAHL: Mrs. Kyttl6 reminds me that this is a 6 two-year proposal in which $97,037 is required for the first 7 year, and $82,820 for the second year. 8 I haven't critically gone over all DR. SCHREINER 9 aspects of the budget. If the staff feels t,hat this project 10 can be done with a little bit less., I think that would be satisfactory as far as I am concerned, but I would 1 ke to, 12 move that the two-year project be approved. 13 DR. PAHL: The motion has been made. Is there a 14 second! 15 DR. BRENNAN: Second. 16 d seconded DR. PAHL: The motion has been made an 17 :fo approval of the two-year period of project:3!)., Is there r 18 further di4cugsioh? 19 DR. MERRILL: Could we have just a comment, per- 20 haps,@from staff, those two gentlemen at the head tablet as 211 to whether there is any policy w@ith regard to funding this 22 kind of approach? 23 DR 14ARCULIES: well"so far at' kidney activities 24 are concerned and we are now talkinq-in categorical terms 25 @@o@ this.Council has been to as you knowl the -previous policy@, 5 1 concentrate the expenditure of funds in the development of 2 complete centers for the management of patients with terminal 3 kidney disease, and since-this is a separate kind of activ3ty, 4 my interpretation would be that it falls outside of that pre- -5 viously established policy, and it will, of course, if passed, 6 be in competition for other funds which we would elect to 7 grant as a part of our general kidney effort. So one of the 8 issues is: What else might be done with the same funds as a 9 the total dialysis transplant facility? part of 10 Now, I don't think we have any previous pol cy re- 11 garding th s kind of expiration of diagnostic skills, but I 12 do not believe that it has been a regular part of RMOS, or for 13 @have tried to concentrate on practice ready the most part we 14 activities which are part of a continuum of diagnosis and 15 treatment. 16 DR* BRENNAN.- Is this practice ready from that 17 standpoint? 18 DR. $CIIRE-INER-. Yes, but it falls between the 19 cracks and@this is the problem; at least in most areas you 20 t fund it with Blue cAn't fund it with NIH funds and you can' 21 Cross or Blue Shield. One of them says it's research and the 22 other one says it's care. 23 DR@. BRENNAN: So this,,is developmental rather than 24 research. There's a nice distinction but I think it's real. 25 DR. PAHL: Is there further discussion by the 136 1 Council or staff? 2 If n on please say aye. ot, 411 in f aVor of the rqoti 3 (Chorus of ayes.) 4 Opposed?@ 5 (No response.) 6 The motion is carried. 7 In the interest of time and since we have an 8 executive session which we,perhaps might schedule at 4:30 or 9 a quarter to 5:00, I think it would be well if we would turn 10 to the It Ohio Valley @IP; It with Dr. Roth as principal reviewer, 11 Mr. Ogden as backup reviewer and Miss Parks as staff resourc 12 person. 13 DR. ROTII-. Thank you very much. I'm sorry to throw :14 the -time schedule but of kilter. I ap ciate this. pre 15 Th is is a triennial request, triennial review. I 16 had the privilege of,participating in the site Visit, the 17 report of which I believe is available to you at least in 18 draft form. 19 The site visit team and the review committee 20 recommendations are in Virtually comlolete agreement,-so I am, 21 spared dealing with any dichotomy on that score. 22 It might be entirely appropriate, since this Is 23 tr to h6iteii the procedure by simply movin the redommen- ue, s 24 dati-ons that have been agreed upon by the two bodies. Iloweve3, 25, I very briefly want to comment on two philoso hical matters, p 1 8 7 1 two problems that are of concern to the Council, that were 2 manifest in this area. They are discussed at.least briefly 3 in the site visit report, and one relates to a -problem which 4 I suspect will be cropping up in oth6r,,regions in respect to 5 the subject of Health Maintenance Organizations. 6 It was interesting to have recenti r ad Dr ,y e 7 Hinman's recapitulation of the 11@40 definitionvexy much as Mr. 8 Riso repeated it for us this morning, and find th at when we 9 got to Kentucky that there had been evidence of exer6ise of 10 supreme grantsmanship in constructing the material which they 11 forward on to Rockville, with a substantial emphasis on I-imols 12 in support of IIMO'S. 13 s a little bit surprising in testi It wa ng@out t e 14 sentiments about H140's from individual physicians, ropresen- 15 tatives of State MediIcal Society and so on, to find that,they 16 took a much more free-wheeling view of@what an H.MO might be 17 even to the point of including within the definition things 18 that were not prepaid,or financed on a capitation basis. 19 I don't@think that I want to base any Council action 20 on this exdt t to alert the Council to this peculiar problem p 21 which we are going to have to face Iup too And it's probably ni>t 22 at all surprising at this stage in the'devel-op@ent of the 23 concept, but I think we have to recognize that sometime when 24 we get grant applications involving' support of IIMO that the 25 people at the other end of that application aren't really 1 talking about HMO's,as they may be defined in our language, 2 and on the other,hand, there is the very real, not only possi 3 bil@ty bu-E'fact, that in some areas illustrated by part of 4 this regi9n,,,whek6 making a great deal of fuss and furor about 5 supporting Hmols turns off some of the groups of providers in- 6 volved, and this I'think is unfortunate because it represents 7 a lack of communication. I think the people who understand 8 HMO'sl as 14r. Riso presented them to us today and as we can 9 hopefully educate the provider public to understand them, 10 will not automatically assume that this is some kind of c6m- pulsory governmental intervention with their business,, that 12 it is a developmental, experimental innovative and flexible 13 approach. 14 I want to make no more of An issue of it than to 15 point out that in this peculiar area that parts of three 16 States parts of four States - West Virginia, practically allIof Kentucky., a southern part of bhi6, and some of Indiana that you are,involving medical societies And county medical 19 societies of broad diversity of opinion from some pockets of 20 ultraconservati@sm to some fairly liberal groups. These are 2i in mind, simply considerations that I think we need to bear 22 and it ma""be worth substantial thought here at RMPS to try y 23 to make the communications crystal clear and forceful when 24 we are dealing with' a confusing matter, at least confusing 25 in the publ'ic':s rii-nd and many of the physicians' minds with 189 1 this HMO subject. 2 The only other thing that I would like to point 3 out is that in this area when the committees, the site visit 4 committee and the review committee, speak of minority@group 5 representation, in this area, certainly, and in probably 16 others, the truly unders6rv0d of the area are not encorkpaIssed 7 in the ordinary,definition of minority groups, by which I 8 imply that the real need for provision of medical service in 9 this particular area extends to a group not normally con- 10 sidered among the minorities-.. because most of them are white 11 Anglo-Saxon Protestants without sho6s on back in the hills, and 12 therefore,, when we are concerned for minority representation, 13 I think we need to think of it in a different context in@t-his 14 particular area. 15 Having said those things, I would 16 approval of the recommended ding e@ ent of recrueoed 17 levels, which includes well, perhaps I'd better isolate this 18 renal project again. 19 DR.,@PAliL: Yes. ROTH: I 20 will move approval of all except the DR# 21 renal project which includes a ,=Ltiphasic conti 22 health screening rdject, and this has been run through staff p 23 here recogniz g,that it is a Council position that we have 24 a freeze on new multiphasic health screening projects, but 25 since this@is acontinuing request it is apparently,,in the 190 1 opinion of staff$, at any rate, with which I would concur, 2 that it would be inapt to cut them off now, that if they are 3 running a good program, and since this is a continuation 4 project, I would:interpret for the Council, unless it wishes; 5 to object, that this falls outside the Proscription of funding 6 of multiphasi6 health screening, and it includes a normal 7 developmental component. I move approval with the 6xception of the renal 9 segment. 10 DR. PAHL: Thank you, Dr. Roth. 11 Mr. Ogden, would you care to comment before we ask 12 for a second? 13 MR. OGDEN: The only comment I would make is,that 14 i was impressed with this project, with this Regional Medical 15 Program,, with the way that it's been written up. I think 16 they have met their problems in a Very imaginative an a very 17 straicjhtforward.way. It seems to me that they are moving 18 @rapidly to the kind of a way.from the categorical areas into the kinds of changes in health care delivery which the area obviously needs. 21 I have one question and that is, Doctor, I believe 22 that the 90 percent that is'recommended includes the renal 23 project. 24 DR. ROTIII. Yes, this is correct. 25 DP,. PAHL;-.' The motion is excluding that. 191 DR. ROTH-.@ It's hard to sort out but if it creates 2 a fiscal problem that will be a staff problem, not@ours. 3 DR. PAHL: The motion as made is for acceptance of 4 the review committees recommendations, exclusive of th@se 5 sums which can;be related to the kidnev project. 6 MR. OGDEN:@"@lSo the figures that appear here are -not 7 those that we are approving. 8 DR. PAHL: That's correct. 14ay 1 have a second fox 9 the motion? 10 DP,. 14ERRILL: Second. t 11 DR. PAHL: The motion has been moved and seconded. 12 is there further discussion? 13 if not, All in favor of the motion please say aye. 14 (chorus of ayes.) 15 opposed? 16 (No response.) 17 TIhe motion is carried. if we may now turn back of the velloii tab to the 19 Tti-State anniversary application, again br,. Roth is princi- 20 pal reviewer, Dr. Ochsner is backup reviewer, 4nd'Mr. Colburn 21 is the staff person.. 22 DR. ROTH.-,,- It's been a pleasure to go over this 23 because'althoti'gh I have not been there currently, I was in- 24 volvedlin the site visit for the triennial review of this 25 area and it'@s 'very encouragin to see that things are workin 19 2 1 out as well as the site visit team at that time expected they 2 might. 3 This is a very sophisticated RMP with an@excellent 4 core staff. I can't help but point out that'Ithe reports of 5 the staff anniversary review panel make a couple@6f@@enter- rO taining comments, which I'm sure are completely true as evi- 7 dence of grantsmanship out of Tri-State RMP, where they say 8 in one place that it was the conclusion of the staff re ew 9 that Tri-State PJAP is trying to present itself as being a pro- 10 gram that is all things to all peoples and in Another place it 11 s that this:is probabl-,7 ingenuity at its greatest. comment 12 It's 'an excellent presentation and those of us 13 who have been there know that it is based on factual opera- 14 tions. 15 The matter before you obviously now,,under the 16 new system, is really essentially the recommendations of the 17 staff anniversary review panel, and they have been crystalized 18 into two sets of items. I don't know whether everyone has the 19 white sheet, the anniversary application within the triennium 20 f or Tri-State. 21 DR. PAIIL: Yes, they do. 22 DR. ROTII: I think we should briefly take these 23 in reverse order the items submitted for Council's.info rma- 24. tion. Propo for,@-vhich fuhain4 is recruested, 193 1 appear to be,within the scope of the recrion's three-vear nlan. 2 However, staff has specific concerns regarding projects 4, 11 3 and 17. The region has been notified of these, and the- 4 recommended reductions in funding are really reflections of 5 what might in the old days have been denials of these projects 6 since it seems obvious that-the region will be persuaded to 7 adjust itself to the budcretarv circumscriptions if this 8 Council approves the recommendations by shorting those three 9 projects, and there is mention of the region's extensive use 10 of the contract mechanism. This was examined with the 11 resultant recommendation that RMPS consider the need for de- 12 vel6ping policies to govern this method of funding. This is probably a more practical recommendation than that made by 14 the site visit team a year ago where we suggested that since 15 they practically invented this business, they might come UP 16 with some proposed Guidelines. In any event, there is a need 17 for some ground rules on how you run these little contracts 18 of relatively small amounts, recognizing that they can be 19 immensely productive, that it's a mechanism that -probably' 20 ought to be used by other RMP'S, but that there needs to be 21 some definition of limits beyond which you cannot use in- 22 dividual inno ation@and ingenuity. 23 Having given those items'for the Councills inf6rma- 24- tion, I would then proceed to the items requiting Council P-5 action which are listed first, and I would move approval of 19 4 the intent of these two items, recognizing that thez@xegion 2 has requested $3.5 million for its fourth operational year, OJAI 3 that the staff anniversary review panel has,recommended.,that 4 the approved level of $2.3 million be.raised to $2 .5.@million 5 for each of the 04 and 05 years, and that there be,lan@'increase 6 in the developmental level which would be included, in@,the $2.5 7 million. 8 DR. PAHL: Thanlc you, Dr. Roth. 9 Dr. Ochsner, do you have any comments? 10 DR. OCHSNER: I have nothing more. I was tremen- dously impressed by the presentation here, I haven't had tho 12 Pottunity of visiting the area so 1 can't speak to that. OP- 13 DR. PAHL: All right. A motion has been made. 14 DR. OCHSNER: I'll second it. 15 u u cil? DR. PAHL: Is there further disc ssion by Co n 16 MRS. 14ARS: In the raising of the sum, where will this money specific lly ap y a pl in taking it@from the $2.3 18 Million to the $2.5 million. 19 DR. PAHL-. Mr. colburn, could v6u perhaps answer? 20 MR. COLBU-RN: I'm not sure,I understood e ques- 21 tion. 22 Welli it was recommended that e MRS. MARS. 23 the sum of fundinq from what the approved Council level of 24 $2,323,591 is, to raise it to $2,500,000. tqhere will this 25 difference of monIey, from the $2,323,591 to@$2,50'a:0000, be 195 1 applied? 2 MR. COLBURN: 'That would be the decision of the 3 Regional 14edical'Progran as determined through their own 4 decision-mak.ing processed but it would have to be applied to 5 MRS. MARS: So there was no specific project that 6 you were thinking of in raising the sum. 7 MR. COLBURN: That's correct. 8 DR. EVERIST: That $2.5 million does include the 9 developmental component. 10 MR. COLBURN: Yes, it does. You have limits on 11 the developmental component. 12 DR. PAIIL: Dr. Roth, did you have a further con@ment? 13 DR. ROTH: No, if Mrs. Mats I§,gAtisfied with that 14 answer, the1$2.5 million is mathematically arrived at by@ 15 taking the $2.3 million and the increase in a kidney co oneftt 16 which is hot really under debate at this time; it was a grant 17 request which was submitted and apokoved subsequent to the 18 triennial appropriation that created the $2.3 million.. 19 DR. PAHL@: Is there further discussion by Counci@l? 20 If not, all-th6se in favor of the motion p ease 21 say aye. 0 22 (Chorus f ayes.) 23 24 (No response B5@ he motion is carried. 196 1. DR. PAIIL: I should like at this moment to take 2 care of one or two housekeeping chores. 3 First, I think the record should show that Mr. 4 Milliken was absent when the Council discussed and voted on 5 the Ohio Valley application, and Dr. Koriaroff and Dr. @4errill 6 were absent during the discussion of the Tri-State application. 7 AlSo,.I would like to make a statement to the 8 Council. I'm afraid we left you in a bit of confusion, or 9 at least some of bu, earlier today y when we distributed@to 10 t form. This is for information you the revised rating shee 11 s only, and we Are not asking you in any sense to use purpose 12 it for the-applidations under discussion. It was mer6lv to ez u what our present system is,and how it has changed show yo 14 from the earlier one. 15, We will be distributing to you at the end of this 16, meeting a sheet which will display the review contmittee's 1 @7 rankin of the regions and the priority ranges, as we did at@ 9 18 the last Council meeting, and Ask you before you disband to .19 either endorse or modify those ratings as a group. 20 un6il meeting and with the Subsequent to this Co 2,1 formalization of:the rating procedure, we will be bringing to 22@ you bft the review committee and staff Anniversary review 23 panel sheets, the ratings given by those bodies, so that at 2@4 the time of Council review, presumably starting with the next 25 Council, you will see the ratings that have been given And 19 7 1 will have an opportunity to comment on then, at your leisure. 2 Perhaps we might go on to another ap ,placation, and 3 so that we won't,shorten Mr. Hines' time tomorrow, since he 4 does have to leave early, perhaps we might take up the North 5 Dakota application, which is under the anniversary tab. Mr. 6 Ogden is the principal reviewer, Mr. Hines the backun reviewex, 7 and Mr. Ashby our staff person on this application. 8 MR. OGDEN: In reviewing this application I felt 9 myself at a disadvantage in not having had the opportunity to 10 visit this Regional Medical Program and to experience 8-omewhai 11 first-hand the problems that they so obviously seem to have, 12 and I think I should like to preface my entire comments with the thought that I think we need to be careful not to -kill a@ 14 Regional medical Program by action that perhaps is unintendo 15 in the hope that we are being helpful. 16 That is a rather mixed statement, ut 1 th nk you 17 will see what I-mean as we get into this. 18 This is a Regional Medical Program which admittedly 19 has good -provider supporti but as I understand it, the North 20 Dal,,ota situation once upon a time it was hoped that this would 21 be A part of the Northlands PJIP; the North Dakota people 22 elected to go it on their own. They have a group of 23 reldtively,uhimprdssive projects, most of them related to 24 nurse$ and to types of hospital inservice training. 25 I think I thoroughly agree that this is not a 19 8 1 al application. Funding for on trienni e year is all that.is 2 warranted, and that a developmental component.is not@in order, 31 I thought the staff anniversarilrev'xew's critical 4 comments were well summarized. It seems to me thxt more.@'stress 5 needed to be laid throughout the entire proposal on the evalu- 6 ation of what is being done and what has been accomplished., ard 7 considerably better coordination with CHP in North Dakota is 8 necessary. 9 Under Tab 3 you will find that they are indicating-- 10 I think page 17 under that hopefully that they are going tc 11 be working -- it's under Tab 3. 12 DR. PAHL: Mt. Ogden, only you have that? the two 13 ptihcipal reviewers. 14 MR. OGDEN: All right. In any event, they have indic ted an intent to work more closely with CHP but this a 16 strikes me as something that perhaps has been included for 17 rposes of an application, and nobody@has thought thtougli the pu 18 precisely how that should be done. 19 This Regional Medical Program has a dire tor who 20 is not full time. I .t obviously needs Some additional staff3'.n@T, 21 - and it's my thought here that if this is approved at the@@ 22' figure of $293,301, that perhaps to tha @@.should,.be added 23 sufficient monies to hire a full-t d r 6tor, and a 24 full-time -program development and evaluation Lhi and 25 I'm not certain and would like to ask staff wheth@r@;the, feel 19 9 1 that the $293,301 should include those two new people. 2 I also felt that Project No. 10, which is mentioned 3 on your summary sheet for the items requiring Council action,, 4 was worth supporting. There is another project of about 5 $8,600, which I gather I anparently am the only one who has 6 dinq through their material an ealed to me. I it, that in reA 7 don't know whether it would be numbered Project 44 or Drecis6ly 8 what it is. This is a very difficult document to go through. 9 I agree with somebody's comment that the grantsmanship could 10 stand some improvement. But it's called Community Health CarE 11 Aid Demonstration Project that involves a nurse Providing 12 health care services insome rather remote areas in the State, 13 a sum of $8,600 involved in that. 14 It would be my suggestion that on,the items re- 15 4u'lring Council action, first of all; that this be treated, t 16 a one-year Application onlvi that the fuhdin4 of $293,301i ifl 17 it does hot ihdlude.the full-time denuty dir 66tor and a pro- 18 gram development and evaluation man, that the cost of those 19 1 would like to have staff two people be added to this, and 20 advise me as to whether they feel their recommendation on 21@ item No. 4 on this Educational Center for @6sDiratory. Cate is 29 included in the $293,301, because I am simplv not ableIto 23 tell whether it is or not, and I agree that the developmental t c rtainly is hot appronkiate for this. 24 componen e 25 This Educational Center for Respiratory Care 200 1 strikes me as being one mechanism on a regional basis toward 2 changes in health care delivery in the State of North Dakota, 3 and I think it's'well worth sup u in it .porting beca se it has 4 that seed of something very necessary for this Regional 5 Medical Program. 6 DR. PAHL: Thank you, Mr. Ogden. 7 Let me also understand, you do agree wit@ the 8 recommendation that the developmental component be dis- 9 approved? 10 MR. OGDE14: Yes, I do. I don't believe that the develop-mental component would be spent in a useful fashion in ci 12 this Regional Medical Program at this time. 13 DR. PAHL: All right. Now, before we move on to 14 the comments from Mr. hinesi perhans we could ask Mr. Ashby 15 and Mr. Webster to comment on the points raised by.Mr."Ogden. 16 resting MR* WEBBER: This is a very inte RMP and 17 it's sort of At the crossroads. As you may not know, last 1 8 week, because of the fact that the written page does not 19 A decision Always carry all the information which is vital to 20 made a site visit from here, and Mr. Ashby and Mr. O'Flaherty 21 gs about which I%neii some, not com- they uncovered some thin 22 completely;. Fok example,.the situation at the moment is that 23 th6@deah of the medical school snends 30 percent of his time 24 and receives 30 percent of his salary as the coordinator. 25 There is a full-time and very capable director, Dr. Wright, @2 01 1 somewhat of a conservative, I would say, but he let,me know 2 last week that he now plans to retire, or he hinted to this 3 extent that he plans to retire this coming year. 4 Meanwhile, there is a very capable@phys'ician who,is 5 heading up the 14edex program at the university, b eing paid 6 100 percent by the university, and spending 10 percent of his 7 time in the m4P program, part of whose arrangements for 8 coming to the university were that he would take over the 9 directorship of the Pd4P upon Dr. Wright's retirement. 10 The one fallacy or shortcoming in this ap proach is 11 that in view of the apparent intent of Dr. Wright to retire,- 12@ it will be well to get a deputy director on board without any 13 more delay than possible so that this transition can be made 14, smoothly, and that there might be some young new blood put 15 into that program. 16 Nowi the pt o ram is not completely conservative. 9 17 They are doing some innovative things. Some things are@'ki-rid 18 of tied down and I am going to ask Mr. Ashby to comment on 19 these. For example, they have an interest in fostering and 20 helping in the development of an HMO. Well, you can do this in 21 North Dakota; thi@s is pretty good. We have the application in@ 22 the regional.6ffic6. It has been approved,,,,ind we aIuspe 23 it wi 1 be funded. So they are changing some dire ons 24 I will just turn it over to Mr. Ashby at @this,@ poin., 25 but we think thelmain thing is we need to get,new"le@aderihip 202 in there. First let me,just mentio@,I-;h@ the $293,000 would 2 not be adequate to do these things, to put on these two addi- 3 tional personnel full-time, which are badly needed, and to 4 include any acti projects which will not be @yity in,these hew 5 able to be covered as'far as we@@cat see in the $293,000. 6 MR. ASHBY: The last site visit was made in Decem- 7 ber 1970 which was almost A year ago, and during this visit -- 8@ Actually it was a get-acquainted visit for me because I had 9 never been in the State of North Dakota at all. They do have 10 :a system now set up, and it's the same as Inter-Mountain, for 11 evaluation and planning, and are utilizing it forevaluation, 12 as far as I know now no planning. They have excellent visibil- 13 ouohout the State. They work closely with four B ageh- ity thr 14 cies in the State., They have full cooperation of the medical 15@ community. 16 ;In each one of the records that I have read there 17 has been concern that this program was oriented towards coh- 18 tinued education for nurses, and to a certain extent this is 19 true, but I found out one thin while I was there any hospi- 20 tA! in the State of North Dakota has to have a coronary care 21 d or 28 bed or wh t, unit, and it doesn't matter-j,,f it's 20 be a 22 And a lot of this had been incoronary care, a lot of the 23 nursing train ncj, nd'I think@.this included about 00 hospital-I. a 24 I think after talking to each member of the staff, 25 they have a competence and thby;have a dedication. I think 41 203 that they are certainly doing something towards upgrading 2 the quality of care in North Dakota, and I'm sure tb,L-y are 3 doing some towards accessibility. 4 This doctor that he was referring to that heads ;5 the t4edex program is a Dr. Bassett, and this class I think 6 graduates in January, and we talked with this fellow for I 7 guess two hours. He's a young physician, very innovative, 8 and I think would probably fit in well, but anybody that taker 9 somebody over for Dr. Wright up there is going to have to be 10 that supported Dr. Wright. He is a powerhouse in North, 11 Dakota. Ther6ls no two ways about it, this guy has the 12 power, and when Dr. Basset came 'in on the Medex Drogram he 13 was promised Dr. Wriqht's job when 14edex was over. 14 I don't know most of the projects are poor pro- 15 jects. They have no problem whatsoever getting volunteer 16 people to,work, and they put on their seminars and so forth, 17 and I just think with the $293,000 we're just killing them. 18 That's all there is to it. I think there s more there. I 19 think the foundation is there for a good RMP, and I think we 20 have to have a deputy director for that, and T think we 21@ definitely have to have a full-time director for planning and 22- tually, Council had approved to go on the 03 evaluation. Ac 23 year $371,3 DR. PAHL: Thank you. Let me ask Mr. HInes to @25, comment, and then we could come back to possibly what 204 1 additional sums are required for those salaries and the 2 projects that Mr. Ogden referred to. 3 MR. HINES: I have nothing to add to Mr. Ogden's 4 comments except the hope that Dr. Wright keeps the faith. 5 (Laughter.) 6 MRS. ITYCKOFF: Can you get someone to take a job 7 on a one-year basis? Don't you have to have A little more base than that. 9 DR. MRIST: Keep the faith. @io MRS. KYTTLE: In arriving at the $293,000, the staff anniversary review panel thought it would force the 12. region to make certain funding decisions that we thought must 13 be made a t this point. Approximat6ly $90,000 of.the dollars 14 conti ue b6yond,their be.,riod in this program are earmarked to n 15- of 8 port programs that we were rather hoping would,be UP turned off. Another $971,000 were to activate, previously 17 @approved projects which we rather w r no onger as thought e e 1 L8 relevant to national priority as they are now, and moving 19 back from those points, we felt that $253,000 would be close 20 but it would require funding decisions and still provide 21 enough room to add the two full-time positions that we felt 22@ were more critical than keeping programs onooing that we wore 23 rather hoping would be turned off and not initiating these 24 new programs that he proposes. 25 DR. PAIIL: Mr. Ogden, would you like to specify 205 the notion with respect to Project 10 and the other project 21 whose number I don't recall, so that we could have it.., 3 MR. OGDEN:, I'm not sure I've got a hIumber,for it. 4 It turned up in my book -- it's under Tab 13 on page 101. It's called Communitv Ilealth Care Aide Demonstration@Project, 44-5-M 0. 7 DR. BREN14AN: I've got a little question about one 8 of the projects here. They've got a cancer registry going 91 for a substantial amount of money here. They can't add more 10 than about 1200 or @1500 cancer patients in the whole State a year. The reality and value of a cancer registry..ih a,popu- 12 lation of half a million people -- a little m6ke-than that,, 13 e 600,000 -- can be qu stioned. It seems to me that this nro- 14 gram is a twisting of the things which medical societies 15 group will probably find acceptable, helpful in one way or 16 another, but that the program isn't probably moving things 17 very substantially there, and won't. 18 MR. WEBSTER: Could I make a brief comment? WhAt- i9 ever the funding level is agreed upon bv the Council, the 20 most important aspect is the personnel, leadership changeover 21 And I would hope that this is appropriate, that the condition 22 Of the award provide that the first thing thAt'@ust, P- done,, 2 rovided,this new leadershio,@ with@whatever money is -P and 24 direction be brought in as a condition of funding. 25 MR. OGDEN- Mrs. Kyttle, I understand your comment II @ 206 to include that the $293,301 was to include Project No. 10 2 also? 3 MRS. KYTTLE: That is a demonstration-@feasi@ility 4 study type thing which was to be undertaken as,a vart,of core, 5 was not? 6 MR. WEBSTER: Yes. 7 MRS4 KYTTLE: That's a core activity. 8 MR. OGDEN: So it would be in the $293,301z. 9 MRS. KYTTLE: Yes. 10 MR. OGDEN: Well, I think on that basis, since T did not understand that, I am going to recommend that this 12 project be Approved for just the $2931,301, with no additions. 13 DR. SCHREINER4. Does your motion specify@the 14 salary of the people to be brought on? 15 MR. OGDEN: Yes, And that included afull-time 16 deputy director and a full-time development and evaluation 17 man. 18 MR. ASUBY: The money is not there. It cAh't 19 include it. 20 DR. 14ARGULIES: Well, you kho%.I, that depends upon 21 what tic d cisions they make. Ithink the ooint Mrs programme e 22 KY h If you Ate talkincT, as ttle was ralsinq was exactly t at 23 d this motion to e about@, she was suggesting,, as understan 24 dd in a s6cific fashion, and a sum of mone which is to be us p E5 are going to develbo new leadership and if you are if you 207 1 going to,bting the new leadership int a Program which is 0 2 given'enough money to initiate some activities they should 3 have initiated in the first place, you're going to saddle that, 4 new leadership with some things they never should have been saddled with. This program actually is at the point where 6 to go back to some- with the right kind of people that it has I 7 thing like a planning level and decide what it needs to be, and if it continues what it's been doing and adds more of the 9 same, the leadership that comes in is going to be stuck with 10 what they have already started, and it's going to take another year or two to undo it, at which point that leadership might 12 decide they'd like to go somewhere else. 13 DR. BRENNAN: For example, they could hire, at 14 assistant project director for $25,000 just by dropping that 15 cancer register. 16 MR. OGDEN: I agree with that and I think on their 17 Project No. 2 for training nurses and rehabilitatiot of 18 @nurs3.nq techniques, this again is a project that perhaps coule 19 be phased out, and some effort could be made to find sunnort 20 for this with hospitals and with nursing homes, an6,1 would 21 frankly say.,-that this kind of project is one which I think 22 needs"evaluation because in so many cases the people who 23,. -Attend these are people from nursing homes and they go back 24, to where they come from, and for budgetary and other reasons 25 simply ate not Able to carry out what they have learned, and 20 3 1 I think that project may very well when it's evaluated prove 2 to be less worthy of support than it appears. 3 DR. P@IL: The motion has been made to accept the 4 taff anniversary-review panel, recommendations of the s 5 specificall including the salary of a deputy program director y 6 and an assistant director for management planning and ovalua- 7 ti6n in the recommended level of support for the one year. 8 Is there a second to that motion? @9 DR. NNAN: Second. 10 DR PAHL: The motion has been made and seconded, 11 Dr. Roth. 12 DR, ROTH: I think it's important for the Council 13 to recogfti2e that here you are dealing with a rather peculiar :14 infant region. For dxample, North Dakota has the lowest 15 MO ion, if this i the thing rtality of any State in the un s 16 that everybody sort of judges medical care efficiency by. 17 I don't know the precise figure, but they are about 41 to 47 18 percent below the national average in terms of ratio of 19 physicians to population I'm not equatitq these two things 20 (Laughter.) 21 one of the first studies that North Dakota RMP 92 did was an extraordinaril interesting study of physicia y n 23 movement,from "their small towns;fifty years ago tiere were physician in all these little towns scattered throughout 25 North Dakota. Some of them would have three or four physicia s 209 1 ne now have none. The ones that, 'had The ones that had only o 2 three and four are lucky if they are holding on to one. 3 Their problems in meaningful projects for North Dakota a're,,,i 4 think, a very different sort of problem than most of the, 51 regions we have to deal with. Perhaps the site visit teams 6 and the review teams sitting here are taking all of these 7 factors into consideration. Their problem, for exarple, is not 8 a matter of getting distribution or delivery of care to people 9 in any ordinary sense of the term. It's a geographic problem 10 that will probably never be solved, except by the development improved transportation, perhaps even air of ttade-offst 12 transportation, the use of two-way television, the development 13 of new kinds of allied health personnel. I think we need to 14 be ve careful not to downgrade a program in an area like ry 15 this because it hasn't shown performance like other areas that 16 are more stereotyped in their demands. 17 I have not been in North Dakota to look At the RMP 18 program. I know a number of physicians out there and have 19 discussed what RMP is doing and, as has been said here, there 20 is no problem with the fact that the program has established 21 good rapport with the providers of service, not only the P4.D.S 22 but the other areas. ly 23 But I think to summari cut them down@'to the 24 bone becaus4,they haven't got some kind of a dramatic program 25 may be short sighted, because this is an area withl:,eficienci?s 210 1 that are shared by some other areas, perhaps Alaska has got 2 them worse, but not too many other places have them, and what 3 is innovative and constructive in North Dakota I think 4 wouldn't be given a second thought in any of our TietroDol tan 5 lareas or any of our more populous r64ions.,.This is all gratui- 6 tous information. I haven't studied the program. I mostly:@ 7 know about it from the fact that the first grant application 8 I had to present when I came on the Council happened to be 9 North Dakota, And I have continued an interested in their 10 problems. 11 DRo PAHL: Thank you, Dr. Roth. 12 MR ASHBY: Their two major industries, believe 13 it or not, are farming, and the second is hospitals. 14 DR. ROTH: The Air Force base. 15 DR. BRENNAN: They've got very good bird shooting 16 there, too. 17 I would say that one of the thihcrs that troubles me about this program, thought is drawn exactly from what Dr. 19 Roth has talked about, namely,, that thelor6blem up there is a 20 radical problem in medical care, just as it is in northern P-1 Michigan, and the extension of funding and efforts along what 22 I would call the stereotyped lines rdptes6hted by this appli- 23 c no hope of making aft impa t on that problem. ation has c 24 Now, one doesn't want to destroy the morale'of 25 these peoplerutterly, but oh the other hand, he has to face 211 1 up to it. An P"',,IP in a region like that with those -problems 2 comes up with this list of projects, he really does need some more core staff, a lot better than it's got at the present 4 time, and it's going to have to do the things you're talking 5 about, and it hasn't begun to think about doing them. 6 So I don't think they are going to be injured in 7 their fundamental interest by the withdrawal of some of the 8 support for some of these projects and the requirement to put 9 it into staff effort, Although I'm sure that they@may be dis- 10 couraged, and it will be a hard bump for them to take, and I regret thati but I have no hope that the Diirsuit of this kind 12 of thing or the encouragement of this kind of thing is going 13 to gain anything for them. 14 DR. EVERIST-. If George Nloore were here he would 15 note that they are getting 50 cents -per person in this area, 16 so it's not A small amount of monev relative to population. 17 'DR. PAHL: Are there further comments or discussion 18 by Council? 19 if not, all in favor of the motion Dlease say aye. 20 (Chorus of ayes.) 21 Opposed? 22 (No response.) 23 The motion is carried. 24 Since it's now 20 of 5:00, I think, we will conclude 5, tiohs for today and 46 into ekecutivf p the review of the applica 212 the 1 session, and starting tomorrow we would like to have 2 Virginia application first, since Mr. Hines will have to de- 3 part, and then we will take.up the other applications and the 4 kidney proposals which we,@Oid not on those applications which 5 were reviewed today- 6 Let's just take A three or four-minutd break And 7 then we will reconvene in executive session. 8 1,7hereu on at 4:45 p.m., a short recess was p 9 taken, and the meetina- was continued in executive session.) 10 12 13 14 15 16 17 18 19 20 21 22 23 24 25