@a f - - i ,, @i. ,@ @ -@@ 2 -, , i . i ii, = @i, .4.. @ 71 - --- ---------- Tr-.-nsci-ipt oi@ Ic'rocec('!@it"gs E L F ATt I)EPART,1-11,NT OF lii-@:AL'FH@, EDUCATION, AN,@,l@ n 5 A C: l@l' -1) 1, II,-kL IIEI)Olt'l@i@IIS, 415 Second Street, N. E. Telephone: Washington, D. C. 20002 (Code 202) 547-6222 NATION-WIDE COVERAGE CR 5884 5/5/7 2 ERC/Smith DEPARTMENT OF liEALTII, EDUCATION AND WELFARE 2 PUBLIC HEALTII SERVICE 3 HEALTII SERVICES AND MENTAL HEALTII ADMINISTRATION 4 REGIONAL MEDICAL PROGRAMS 5 - - - 6 REVIEW COMMITTEE 7 8 9 10 11 Conference Room G-H -laiqn Building Park 12 Rockville, Maryland Friday, May 5, 1972 I3 The meeting reconvened at 8:45 o'clock, a.m., 14 Dr. Alex M. Schmidt, presiding. 15 16 17 18 19 20 21 22 23 24 ce -oral Reportefs, Inc. 25 2 C 0 N T E N T S 2 ITEM PAGE 3 Anniversary Prior to Triennium: 4 Oklahoma . . . . . . . . . . . . . . . . . . . . . 3 5 Puerto Rico . . . . . . . . . . . . . 0 . . . . . . 37 6Anniversary Ilithin a Triennium: 7 Missouri . . . . . . . . ... . . . . 0 . . . . . . 63 8Planning - Continuation: 9 South Dakota . . . . . . . . . . . . . . . . . . . 105 10 General Discussion . . . . . . . . . . . . . . . . . . . 121 12 13 14 15 16 17 18 1 9 20 21 22 23 24 e-Fe4,1,al Reporters, Inc. 251 MU@ /tt harp de ea 00 3 P R 0 C E E D I N G S - - - - - - - - - - 21 DR. SCIIMIDT: Well, good morning. I think we might 3 get started. 4 If it is acceptable to the'review committee, I have 5 been asked to chair this one session this morning and have been 6 instructed to try to get the group through our last four pr.opo- 7 sals in time so that we might go on and discuss some of the gen- 8 eral issues that our former chairman ch arged us with last night. 9 So let's begin with Oklahoma. We .may have to re- 10 arrange the order slightly as we go on. If someone would pass 11 Dr. Scherlis the microphone down there,, we will @ee if Oklahoma 12 is okay. 13 DR. SCIFERLIS: I had the opportunity of chairing a 14 site visit to Oklahoma in July of 1971. There were many items 15 which were pointed out at the time'of the site visit, and these 16 included comments as far as what areas particularly needed 17 strengthening. 18 1 will refer to what the status is now as best I 19 know it in terms of the leadership. 20 Dr. Groom has been coordinator of the Oklahoma 21 Regional Medical Program. When we had visited him, an assista:,.:: director, extremely active and very productive individual, had 22 23 resigned. That was Mr. Hardin. The previous leadership, as far as the RAG was con- 24 eporters, Inc. cerned, was also subject to change. Dr. Johnson, who had been 25,1 4 I a particularly strong individual, was leaving to be replaced by 2 Dr. Strong, and there was some question as far as his ability 3 and his interests as far as RAG went. 4 - So there was a problem with the leadership from the 5 point of view of Dr. Groom's general attitudes and interests 6 from the point of view of staff which had been leaving and has 7 continued to leave, problems in terms of RAG. 8 So this was a strong point of our concer n and some- 9 thing which we did discuss at great length at that time. 10 We were also concerned about the strength of the 11 core. There was a problem as far as having adequate representa- 12 tion on RAG and we had pointed out that it should be-more in- 13 volved as far as monitoring the program. There was very little 14 indication, as far as its goals and objectives having to be in 15 line with what are the present directions of @IPS. 16 There was a problem at that time of subregionaliza- 17 tion, a problem of the Oklahoma Regional 14edical Program workinc 18 more closely with other Federal programs which were going on in 19 that area. There were significant strengths. Their coronary 20 project was one which spread pretty well throughout the State. 21 There were subnetworks,and subregionalization at least in that 22 particular program was really a very good one. 23 There was evidence of their working in a pretty good 24 way with the medical school of the university. We met with Ace#-Oede t a IReporters, Inc. 25 Dr. Kelly West who did an excellent survey as far as health 5 I needs in Oklahoma, but this had not been put into any discern- 2 ible use as far as the Oklahoma Regional Medical Program was 3 concerned. 4 Following the site visitcommunication was made 5 through the usual channels with Dr. Groom to indicate what some 6 of the strengths and weaknesses of this program were. This, 7 as I said, was through usual channels and followed by channel 8 communication. 9 I received a letter, having chaired the site visit, 10 from Dr. Groom, asking me if I shared the conclusions that Dr. 11 Margulies had expressed in the analysis of our site visit report--. ]2iI did not file a minority report at that time. .13 Following o.ur meeting, there were certain changes 14 which occurred which have been, I think, important as far as.be- ing of a constructive nature is concerned. One was that there 15 16 was a so-called Macer committee. This was a group from Colorado, 17 Wyoming and elsewhere, that went into the region apparently at 18 the invitation of the Oklahoma Regional Medical Program and went 19 over some of the aspects of the Oklahoma Regional Medical Progra-- 20 which had been pointed out to the region in the site visit. 21 There have been other changes which appear to be, I 22 think, helpful ones. First of all, as one looks at their present 23 application, it is in much better form than their previous ones 24 have been. At the present time, they are applying and it is kce - Federal Reporters, Inc. 25 a rather ambitious request, particularly in terms of what happen 6 I as far as the recommendation of the last visit was concerned -- 2 for their 04 year for a total of $1.5 million, out of which 3 $724,000 is for core, a continuation of some aspects of their 4 coronary programs in the fourth year of some $28,000, and the 5 rest is a series of some 14 or 15 individual projects, many of 6 which are related to,subregionalization, Ada, and elsewhere in 7 Oklahoma, $35,000, $40,.OOO to $50,000 each; rehabilitation pro- 8 gram in service education, a screening program, an educational 9 program centered around the VA, an application for emergency 10 medical service which will not be considered since that is beinc 11 looked at in a separate way, pediatric nurse associate, and so 12 on. 13 It is a large variety of programs which are not being 14 submitted. Unfortunately, in reviewing their application, it 15 is apparent that they have not really met the deficiencies whic-. 16 have been pointed out previously. This is apparent if anyone 1 7 had been,on the site visit. It is certainly well pointed out, 18 I think, as far as the staff review is concerned,which I think 19 is a very good document and really indicates what the strengths 20 and weaknesses are. 21 They have, as I have said -- and this is on the 22 positive side -- set up Tulsa as a subregion, and this had been 23 of some concern. When we were there, of course, Tulsa did not 24 seem to be adequately represented. Although the projects, they kce - Fedetal @eporters, Inc. 25 have shown ability to cut some off. They had originally had 11 7 I projects implemented when the regions became operations. Three 2 they terminated in two years, four at the end of three years, 3 and as I have said, continue the coronary care and one or two 4 core projects. 5 There has been some information which was just given 6 to me yesterday. There had been some indications that Dr. 7 Groom will probably resign, and it is my understanding he has 8 now sent such a letter to RAG. And there is already, I under- 9 stand, attempts being made to replace him and have a successor. 10 So I think in evaluating the region, we are in a 11 peculiar position of, first of all, not knowing who the coordi- 12 nator is. And recognizing the fact that while the godls and 13 objectives previously were not really in line with what usually 14 RMPS goals and objectives are, they have now drafted a comolete 15 series of new goals which have been approved and which I saw 16 yesterday and seem to have adequately expressed the direction. 17 However, there is the problem as to what sort of 18 leadership they will have from RAG because Dr. Strong has re- 19 placed Dr. Johnson who is the new strong individual. 20 In terms of the actual support that they requested, I 21 think one has to look at what should be done in Oklahoma which 22 is to take some time for actual operational efforts and try to 23 really reorganize their entire staff, and whoever replaces Dr. 24 Groom will not alone have some problems but ;%Till have some, I %ce-fe6erat R"tportets, Inc. 25 think,'strong points. Because in looking over their staff at 8 1 the present time there are several vacancies at a good profes- 2 sional level which can be filled. 3 I think Oklahoma has a lot to build on in the sense 4 that they do have a good record of an excellent coronary care 5 program, one of the better ones which has spread out, so there 6 is an active subregionalization evaluation. 7 Evaluation appears to be good. The methods of revie@ 8 ate good. They have been hampered by a change in leadership. 9 At the present time they are hampered by the loss of Mr. Hardin 10 who has been extremely active. 11 The problems, I think, in not having @oved into new 12 dire ctions Dr. Groom has very marked strengths in-the area od 13 continuing education but not in the outreach program that.the 14 Oklahoma Regional Medical Program really has required. I think 15 whatever recommendations are made -- and I would like to with- 16 hold those until there has been secondary review -- will have 17 to be in terms of what is a rather fluid condition in that 18 region at the present time. 1-9 So can I defer to the second reviewer before I make a 20 recommendation as far as level of funding. 21 DR. SCHMIDT: Fine, thank you. 22 Dr. Ellis. 23 DR. ELLIS: Dr. Scherlis has gon e over the program 24 extremely well and had the advantage of making the site visit, @ce -detal Reporters, Inc. 25 and I didn't. But I concur with what he has said. 9 1 much of the continuing education really is not educating the 2 physicians and other professionals about the goals and objectives 3 of the Regional Idedical Programs. And I was just wondering .4 there is going to be a great need to strengthen the leadership, 5 and I am wondering how, since a person who is not a physician 6 seemed to have been the person who carried the program on, and 7 we seem to be having such difficulty with these coordinators, if 8 another administrative mechanism could not be worked out utiliz;- 9 perhaps a physician as a consultant to could we not try -- an 10 administrator who would have the capability of really planning 4 11 things that would make the Regional Medical Program a meaningful 12 part of the health delivery system there. .13 I get the impression that this is still a great lot 14 of a university program that is not really moving, and I am not 15 sure the people have heard the message which -@IP has to give. 16 I really think that this program needs to have care- 17 ful guidance and complete reorganization. I can't see that we 18 can.keep going on with these kinds of coordinators who really 19 don't lend anything to the program, and I recognize that this is 20 a conservative area. It has been repeated over and over again 21 in the write-ups. But it seems to me with proper communication 22 a different administrative mechanism could be set up which wou a 0 23 be entirely acceptable to conservatives and also it would seem to me that part of the continuing education might be directed 24 %ce-Oedetal Reportets, Inc. 25 to the RAG. 10 I This has been done in a few places, and to see the 2 change in attitude when this type of thing goes on is good be- 3 cause unless we get the other disciplines, the allied profes- 4 sions, I can't feel that any real progress is going to be made. 5 Now, talking about the pediatric nurse practitioner 6 program is fine, and I certainly am for this, but I was distress( 7 to read that the nurse is not playing a really active role in 8 the discussion, and this is nursing service in the main and I 9 would wonder about that. 10 Also, I think that the core staff remains rather 11 narrow in a large number of the programs because4if real change 12 @is to be made in the lives of the individuals to be served 13 directly and indirectly, I think we have to connect with social 14 services in a way which is not clear to me here, and also it 15 might be good to really talk about the health education in a 16 little different way. And I think that this program could be 17 reconstructed. And since its major leadership has not been fron 18 a physician but rather this has been a confirming kind of 19 leadership, maybe the reorganization could be worked out along 20 these particular lines. 21 DR. SCIIERLIS: There has been a significant problem 22 in leadership. I think Dr. Margulies and others who are familia 23 lwith the area understand I have understated it because it is a 24 necessary thing to go into problems, particularly since Dr. kce-*deial Reporters, Inc. 25 Groom has just resigned. I am concerned about RAG. We met separately with Dr. 2 Johnson who is an extremely capable physician in Oklahoma who 3 had been chairman of RAG. And in every way that he could, he 4 both assured us and has assured the so-called Macer Comm3ttee 5 that he would be very active. 6 The Macer,Corimittee, I think, did an excellent job. 7 It is a good example of how a region near-by can be a help to 8 another one. They reviewed their problems and pretty much state 9 as you have, and as I have, what the problems are in that area. 10 Mr. Hardin,who has been extraordinarily strong and a 11 represented leadership that Dr. Groom didn't give, has accepted 12 a position of responsibility with the university, administrativeI 13 vice president or something of this sort, and is no longer 14 available. And I'think what this region has to find is a strong 1 5individual who will be active. 16 We did meet with the vice president of Health Science 17 on the campus or university who I think has a real understandin-- 18 of what the needs are of the Regional Medical Program, and I 19 think has been helpful in getting them through some of their 20 changing leadership at this time. 21 Looking at the core,personnel, there are eight or 22 nine vacancies, and there have been some resignations in additic 23 to this. So a new coordinator has an opportunity to really 24 restructure, as you pointed out, core and individual projects. Ace -@ederal '@'eporters, Inc. 25 if I can make a formal recommendation at this time, 12 1 I don't think it should be supported. The core has a great ma..t.., 2 empty slots in it, and'there is adequate room, by filling those 3 slots, by using funds available, I think through taking.a year 4 off from just individual projects and doing some planning. 5 The level which staff review recommended has a good 6 deal of logic behind it, but what they have suggested is they 7 be given the funds they should have gotten for 03 year before 8 they were cut, and this comes to something like $839,000. It 9 is significantly less than what they asked for, which is $1.3 '10 million. But with a new coordinator coming in I would think 11 the worst thing we could do would be to give the'm some of these 12 projects on an operational level and review them separately. I 13 don't think that's the way to go at this time. 14 I would therefore recommend a much reduced budget 15 in the order of $839,000 which would match -their 03 year, with 1.6 strong recommendations that they not only find a good coordi- 17 nator but they give him the necessary support to restructure 18 the Oklahoma program. 19 It has good strengths which can be utilized. But 20 one of the problems has been that Dr. Groom has not been, I 21 think, as involved as he should have been timewise, which has. 22 been a very significant problem and one of the reasons that 23 a strong individual like Mr. Hardin could be the force that he 24 was and, secondly, he came there at a time when P-%IP was basica'@' ,ce_o,ral Repottets, Inc. 25 interested in continuing education in that area. And this has 13 1 been the main thrust and that is where the thrust has remained. 2 Is there any staff comment on this? 3 DR. MARGULIES: I would like to comment just briefly. 4 We have met twice with the Vice Presi-dent for Medical Affairs, 5 Dr. Eliel. And he is a different kind of person who has 6 been very busy trying to do some things in the university, has 7 gone far enough so he understands the potentialities of Regional 8 Medical Programs. 9 Interestingly enough, Dr. Ellis, he i's thinking 10 about what kind of lead ership and organization that is needed 11 there is very close to what you were talking about. They are 12 on their research committee looking at competence which does 13 not require an ill.D. They are looking for someone who can give 14 it a different sort of leadership. 15 I think possibly the most hopeful thing about Okla- 16 home is thatDr. Eliel and the people in Oklahoma more and more 17 define the role of the University Health Science Center as an 18 institution to serve the State of Oklahoma, and he understands 19 that, and he feels, as.,do other people, that the Regional 20 Medical Program represents the kind of link they have to have 21 if they are going to be an institution of community service. 22 I think in the best university RMP arrangements tha@, 23 is the concept which dominates events. Dr. Eliel understands 24 He also wants to avoid having university dominance so that the kce-*,rat R'epotteis, Inc. 25 environment, if the selection of the coordinator is successful, I I 14 I is very promising. 2 This doesn't get around to the problem of the 3 Regional Advisory Group but.I think that when you get those two 4 forces working effectively the Regional Advisory Group may 5 function much more effectively. 6 DR. SCIIERLIS: I think the other strengths are Dr. 7 Kelly West who tends to maybe act.as a consultant. His report 8 on some of the health needs of Oklahoma is one of the best that 9 we have seen and, interestingly enough, was never referred to 10 in any of our formal meetings. We just happened to find out 11 about it casually and could be one of the strong' points of the .12 entire site visit. He really defines what a lot of.the health 1 3 needs of the State are. 14 Also,, another strong point is Dr. Johnson, and he 15 again tends to remain active, but he is no longer head of RAG, 16 but had assured us he would set up some form of advisory com- 17 mittee ongoing activity as far as the group is concerned. 18 So.there are significant areas that can be a real 19 credit to the Oklahoma program. This is one reason why I hate 20 to see a more drastic cut made. I think this cut is strong 21 enough. I think there are enough funds for restructuring and 22 replanning, yet at the same time giving them more would mean 23 saddling them with projects they have to support for a few 24 more years, and probably use good people. And they don't have -ce-laral Re- porters, Inc. 25 that many available. 15 DR. SCHMIDT: We have a motion, Dr. Ellis. Do you second that? 3 DR. ELLIS: Yes, I do. 4 DR. SCHMIDT: All right. We have a second to the 5 motion. Any discussion? 6 DR. KRALEWSKI: What is their organizational relatio!,- 7 ship to the medical school? Are they in a department or do their 8 report to the vice president? 9 DR. SCIIERLIS: You,see, earlier, when Dr. Groom came .10 there, he was essentially recruited by the medical school. This 11 is where his strength was, as a cardiologist, and very active 12. in teaching at the university, and he came essentially for that 13 reason. 14 DR. KRALEWSKI: Well, the basis of my question is in, 15 terms of their ability to get a good coordinator, if they are 16 going to have to get a guy who has certain academic qualifica- 17 tions or are they 18 DR. SCIIERLIS: It is through the University of Okla- 19 homa who is the grantee organization, but again I want to 20 emphasize what Dr. Margulies said, the relationship is an ex- 21 cellent one. 22 'This is not going to be, as far as we can see, 23 judging from Dr. Eliells statements. This isn't going tc be a 24 program I think completely dominated by the medical school. The @ce-Oderal "R'eporters, Inc. 25 point'you made, this is a very strong point as far as the vice 16 president of the university is concerned. I am not concerned 2 about this being a dominated program. 3 DR. SCH@IIDT: I remind everybody of the rating 4 sheets. If anybody turned their's in and needs a fresh rating 5 sheet, raise your hand. 6 Is there other discussion? 7 Joe. 8 DR. HESS: I would just like a little further 9 clarification on the recommendation for $839,000. If I under- '10 stood you c.orrectly, you were suggesting that there be relative% 11 little funding for projects, is that correct? 12 DR. SCIIERLIS: Yes. 1 3 DR. HESS: And as I look at the budget breakdown herc- 14 the 04 year request for Core is $677,000. Their current year 15 funding is $354,000. And then there is the request for $629,00@. 16 in operational activities,the past year spending $3 84,000. 17 Can you describe all these vacancies in the Core stage: 18 And what I am having trouble with is understanding why you 19 justify that much money.- 20 DR. SCIIERLIS: You say your feeling is that that mucd 21 is too high or too low. 22 DR. HESS: Too high. 23 DR. SCHERLIS: You think it's too high? 24 DR. HESS: Based on what you said before. -Oeral Repofters, Inc. 25 DR. SCHERLIS: I tried to use the following ground 17 I obviously too much. I think to strip them so they can be essen- 2 tially at the level where they were in the 03 year again is 3 too restrictive. I think they have to be at about that level 4 so they can restructure, and to have 'enough -- If we are going 5 to talk about subregionalization in getting this started as a 6 part of the reorganization, I think they have to put some mone@@ 7 into that. 8 The number was derived from what they had been 9 awarded before it was cut by, the council, an across-the-board 10 action. So what we did was restore the 03 year, knowing that 11 since they don't have that many projects continuing they can 12 hopefully support a couple of new ones in that, and.to give thE 13 new coordinator something to work on, frankly. 14 'I think if we begin by giving him very little, he 15 isn't going to have a program that is feasible, nor could we 16 attract a good coordinator to the area. 17 But I think there is enough in that so we could get 18 a couple of good projects going and restructure the core. The 19 number was derived from what they had in the 03 year prior to 20 the cut. 21 DR. HESS: Is that different from the $733,000 sho,.q 22 here on the-sheet? 23 DR. SCHERLIS: Yes. They had originally been given 24 $839,000, and it was cut to $738,000. It was cut at the counc, "-*ial Repottets, Inc. 25 level across the board, is that right? 18 I DR. SCIIERLIS: So they had been given $839,000, and 2 it was cut across the board. Logically giving them that just 3 indicates that's the level they had before and would continue 4 for another year until such time as they have shown by their 5 growth in program that they deserved or merited additional 6 monies. 7 DR. HESS: If I understand it correctly, Dr. Groom 8 has recently resigned. They don't have a new coordinator. 9 DR. SCIIEPLIS: Ile is going to stay on board, isn't 10 this correct, until there is a replacement? 11 MR. SAYS: Yes. It is my understanding Dr. Groom 12 has a contract with the university until the end of.June. The 13 have already interviewed at least two candidates, non-physicia4.. 14 at the doctoral level but I don't anticipate a replacement on 15 board until July 1. 16 I would like to throw out one comment that might 17 help you some in terms of the funding. 18 DR. SPELL!.IAN: Could you speak a little louder? 1 9 ,%iR. SAYS: As is indicated in the recommendation bv 20 the SARP, the action did not include consideration of Project 21 25, the emergency medical system, which will be taken up on 22 the 15th by an ad hoc group of the council, and that is 23 $140,000, which was their number one activity. They will also be submitting supplemental applica- 24 -e-oral Roporters, Inc. 25 tions-for several local health manpower systems, each for 19 $50,000 or less, June 1. So there are some other proposals 2 that will be in the hopper to be acted upon by the June council. 3 DR. SCII@IIDT: Sister Ann Josephine. 4 SISTER ANN JOSEPHINE: Dr. Scherlis, you have indi- 5 cated that you feel by putting the funding at the level of 6 $839,000 they'd have some money so that the new coordinator cou- 7 continue a few projects. 8 I am beginning to wonder, as I listen to these re- 9 views, wheth er we shouldn't feel that it is not only satisfac- 10 tory but probably in many cases advisable where programs in the 11 condition this program seems to be from the review, that a very 12@ worthwhile activity for a new coordinator is reorganization 13 without the distraction of projects. And I would like to make 14 a few points. 15 You know, you have to believe me, I love doctors, bu@- 16 I think that possibly in this program -- 17 DR. SCHERLIS: I'm afraid to listen to what is goin,- 18 to follow. 19 (Laughter.) 20 DR. SPELL@@N: You protest too much. 21 SISTER ANN JOSEPHINE: I really do. 22 (Laughter.) 23 I have been grappling with this for some time and trying to relate from my daily experience some of the problems 24 e-loal Reportets, Inc. 25 that I am seeing in this program. And I think that all of us, 20 I while we talk about health care, are disease-oriented. And as 2 we are disease-oriented, in the medical profession you are 3 diagnosis-oriented and make the diagnosis and then move on from 4 there. 5 And at the same time, within the last year we have 6 been grappling with a total program evaluation, and I just don't 7 think we feel real comfortable or flexible or probably are as 8 able to handle this kind of concept as we can a task-oriented 9 concept where we are looking at one thing at a time and making 10 a decision, and moving on to the next. 11 And this may well be an inherent weakness in the 12 program that maybe is supported to an unrealistic degree by the 13 professional orientation of the leadership of the medical 14 profession. And I just throw it out as a possibility. 15 DR. SCHMIDT: The only comment I have about that 16 would be that in addition to the leadership of the Regional 17 Medical Program, obviously there are some troops out there in 18 the trenches that have been brought along by the coordinator. 19 And when one talks about stopping the projects, he is talking 20 about some of the people who have gotten up the projects in 21 good faith, and sometimes at some expense to their own thing 22 that they were doing. 23 So that there'might be some breakage kind of acci- 24 dently that would give-a new leadership a lot of problems with kce-teial Reporters, Inc. 25 loss Of confidence in the.people that he is going to have to 2 1 I turn around and work with. 2 So if you do stop projects prematurely, some of the 3 people who are the project types might suffer and may be less 4 willing to come along with a new and strong leadership. 5 I would rather favor phasing out and giving people 6 some time to fire their staff -- you know these sorts of things 7 have to happen. So I think we should be cautious about this. 8 I'was just thinking, with apologies to Mitch, I suppose that a 9 poor quality granting agency might be termed a sick provider. 10 SISTER ANN JOSEPHINE: Dr. Schmidt, as I say this I 11 don't mean to do it in any one step and do anything drastic, bu4h.- 12 I think it is something maybe we need to consider as.,a group. 13 maybe we don't give suf ficient recognition to the need for time 14 to stop and maybe reorganize while business does go on. 15 And I think that the health of the program isn't in 16 the number -- we all know this -- of projects and maybe sometim 17 even as we make the site visits, you know you have to plant the 18 seed and change attitudes. And I feel the same way about the 19 Federal Government. I think we rush from one program to another 20 And at the last meeting I was just forced to express again my 21 Iconcern that we destroy the possibility of continuity of pro- 22 grams by this kind of thing. I get the feeling we may be doing ?3 the same thing here. 24 DR. SCHMIDT: The point of discussion, really, I kce-*defal Fiepoitets, Inc. 25 think' is the level of funding. That is what we are on now. 22 1 DR. BESSO'.i: I would like to reiterate what is im- 2 plied in Sister Ann Josephine's comments by pointing out that 3 there are some questions even in the area as to whether it is 4 reasonable to support projects really because they represent 5 the hard work of some people who develop them. And while I am 6 sympathetic with the notion of providing some wherewithal for a 7 new coordinator and, let's say, a refurbished outfit to work, 8 with, I think we run a little bit of a hazard in perpetuating 9 mediocrity by providing funding for this kind of an organization- I would just like to re-ad to you some of the commen - .10 11 I noticed in SARP's comments, that they.referred4to a disparity 12 between the A and B agency approaches to some.of these projects. 13 And as I got the application to look at, what this 14 dis arity was, apparently, the Area Health and Hospital Plannin- p 15 Council had some question about viability of some of the pro- 16 jects and the approach of the IU@IP toward approving these pro3e -z 171 Yesterday I made the comment that there was abuilt 18 in bias to having RAG approve of the labors of their own people, 19 and I think that is so. We have seen constant evidence of it. 20 The A agency here apparently has that same bias. 21 They are hardly going to be in a position to turn away funds 22 if their approval would bring those funds into the area. So t'.. 23 are almost a pro forma review and common function. 24 But this particular group says in reviewing th&se al Repoiter.s, Inc. projects'they approve some and they approve others in principle 25 23 1. and reject others. And the comment here is in terms of the 2 projects rejected. And I am reading from the B agency comments 3 DR. SCHERIIS: B agency from %,iliere? 4 DR. BESSON: Tulsa. 5 "Projects Rejected. The Board felt the health bene- 6 fits likely to be accrued versus the expenditures anticipated 7 were not compatible... It was also felt that communications be- 8 tw'een the applicants and various interests within the region to 9 be served were minimal; that the projects were by and large 101 ill-defined in terms of methodology, and methods for evaluation 11 were not in evidence. 12 "Also a major concern to the board was the'failure to 13 have proposal adv ocates in attendance to answer questions. The 14 board recognized the imposition that would be placed on appli- 151 cants but also noted its own imposition in terms of performing 16 the review without sufficient information." 17 Then they go on to say that in the future they hope 18 P14P would consult with them to keep the projects a little bit 19 more relevant before they reach their decision. 20 That is the first time I have seen an honest comment 21 in any of these pro-forma approvals by any agency at the 22 peripheral level. I think it's very much in keeping with 23 the comments Sister just made, and I wonder whether the bolder 24 approach that we.had with Mr. Parks' comments about Northeast ,e eral Reportets, Inc. 25 Ohio yesterday of just phasing them out isn't the other point of 2 4 I view to the one that was presented by Dr. Scherlis. 2 DR. SCHERLIS: First, let me emphasize I have hardly 3 been considered an advocate of the Oklahoma Regional Medical 4 Program by the Oklahoma Regional Medical Program, so I am not 5 appearing here from the point of view of advocate. 6 There are certain things I think should be pointed 7 out. That is, that the Oklahoma Regional Medical Program has .8 not had the active participation.or cooperation of the Tulsa 9 group -- bear me out on this. The distance between Oklahoma 10 City and Tulsa has been a rather large one in terms of the Re- 11 gional Medical Program. 12 Their new plan includes subregionalizatio'n with 13 Tulsa being actively involved as part of the regional effort. 14 So this is recognized, was talked to as a point by our site 15 visit group. And looking at some of the projects that we are 16 talking now about eliminating,one of them relates to programs 17 for education in Tulsa. 18 I would not like to see the evidence t hat you have 19 given submitted as a failure of the Oklahoma Regional Medical 20 Program. I have to ask how many project directors appear bef--@ 21 B agencies to discuss their projects, and I think you come up 22 with a fraction of one percent. I think that would be a rather 23 accurate estimate. Maybe a little bit more. I may have to 24 move the decimal point over a bit,but I would hate to see that ,ce efal giepofters, Inc. 25 used,,and particularly since there is the Tulsa-Oklahoma City 25 1 situation. 2 I would again submit I am not an ad@locate of Oklahc-z 3 except trying to look at it from the point of view of the 4 strengths that they have and trying to build on them. I don't 5 think a sum of $800,000'is excessive in terms of core and in 6 terms of subregionalization and in terms of a couple of projectE 7 which appear to be viable ones. I don't think-this is a region 8 where we can now say, "You have done an awful job. Get rid of 9 your coordinator. Restructure and set up different relationship 10 with the medical schools," and so on. They are getting a new III coordinator. 12 Dr. Eliel, I think, is a real asset to the,group. I 13 think they have strengths that they can use. I think they are 14 beyond getting a warnin They have had warnings for the last 9. 15 two years, and it is obvious they @ave finally moved in a very 16 strong and positive direction. I don't think this is quite in 17 the order of going to a group and saying, "You have an awful co- 18 ordinator, you have poor structure, poor organization, and redo 19 it completely." They are. And I think they need some help to 20 accomplish it. 21 Do.you want to comment on the Tulsa situation? 22 @IR. SAYS: Yes. Since the site visit, the Tulsa 23 subregional office was staffed and got into full swing. That 24 office truly represents three CIIP areas, each having their own e-leal Repofters, Inc. 25 council with pretty good consumer input. There is a local RAG, 26 I a local advisory group to that @@IP subregional group. And in 2 looking at the analogy that we have done here of the ratings, 3 there are four projects that relate to the subregional, the 4 Tulsa area subregion, and they were all approved by the A and 5 the appropriate B agencies. 6 Now, since the submission of this application, there 7 has been a lot of work done out there, and mainly because of 8 the efforts of Dr. Cooper, a young planner who recently came on 9 board and is working out in the local level in Tulsa. 10 I have the minutes of a meeting that was held March 11 18. It was initiated by the Oklahoma IUIP. Without us calling 12 their attention to the disparity in coming to grips tiith project 13 activities to be supported by ORIIIPJI they recognized this them- 14 selves. And at least from the minutes that I received, I.,think 15 they are attacking this problem. And by the time we site 16 visited, it would be prior to the applications about a year-and- 17 a-half, I guess, I think they will have,solved many of these 18 problems. Staff will be monitoring this operation in the mean- 1 9time. 20 I think their relationships, while not the best, 21 have improved, and individuals on the core staff, I think, are 22 very sensitive to this. And with a new coordinator, I think 23 that much of it will be corrected. 24 DR. BESSON: I won't belabor this much. I know we Ace-Odeial Reporters, Inc. 25 are talking about a motion on funding level, but I think there 27 1 is a principle involved here I would like to explore a little 2 bit further. And that is Dr. Scherlis has mentioned we have 3 won them on more than one occasion. I think of the relationshi- :7 4 between IUIPS and the regions as being one of a limited leverage. 5 We do have a leverage of funds, and we do have a leverage of 6 education, and we are not going to make that core strength if 7 we provide the water unless they have the sam e perspective 8 about the problems that we do, let's say assuming that we are 9 the enlightened ones, and there is some question about that, toc '10 But I think we have to accept the limitations of our 11 leverage and say that unless there is a spontaneous generation 12 of interest and organizational implementation of principles 13 manifested in projects, we are just not going to be able to 14 exert enough of the.leverage from here on what is happening in 151 Oklahoma. ilnd I think we have to look at our methodologies for 16 how we do exert that leverage, and maybe we are over-using our 17 thinking about funding levels and what we can do by telling 18 them, "Well, here's some money,." or "We will withold that money 19 Maybe what we ought to do as an @IP is organization @i 20 relation to the regions so if there is a disparity in how they i 21 go about their business, if there is a disparity in the leader- 22 ship that is available, maybe we are not doing our job educa- 23 tionally rather than just from the point of view of funding. DR. SCHERLIS: I think what should be emphasized is 24 kce-Oeral Reporters, Inc. 25 that their relationship hasn't only been with a letter. Two, 2 8 I they had the Macer Committee which had a real impact on their 2 group. Their leaders, not just their coordinator, but Dr. 3 Eliel -- they have recognized, as attested to by their change 4 of coordinators, what one of the basic problems has been. But 5 he provided what has been referred to by many of the people 6 there as absentee leadership. And the whole feeling when you 7 dealt with the Regional Medical Program was a pessimistic one, 8 the whole aspect of this was a rather gloomy one. 9 This has been altered,as I have said. In that area 10 there has been utilization in terms of projects, in terms of 11 involving Tulsa, Ada and other health centers programs which 12 really give a great deal to build on, and they have g,otten the 13 message. I don't think we are in a position of saying they wil2 14 understand if we cut their money. It was cut at the site visit 15 drastically. They applied for a triennium. They were given a 16 one-year support at a very, very drastically reduced level. So 17 they have gotten the message, I think. Their change of leader- 18 ship is an indication. 19 DR. SCHMIDT:- Phil, do you have a comment? 20 DR. WHITE: I was going to ask how many dollars were 21 involved in the projects? 22 DR. SPELLMAN: And how many vacancies ate there in 231the core and how many projects will be phased out in this? 24 Maybe this will give you some idea of how much money there is kceseral Reportets, Inc. 25 -involved. DR. SCHERLIS: There is only one project that is 1 2 continuing, and that is-in the fourth year, and that is $27,000 3 for some aspects of coronary care, case records, and evaluation. 4 So after that, there are zero projects, isn't that correct? 5 Everyone they have applied for is beginning a fourth year. 6 MR. SAYS: No. 7 DR. HESS: On the sheet here there-are four continu- 8 ing projects. 9 DR. SCHERLIS: That's right. There are four. DR. HESS: And the amount is something like $103,000 11 continuing projects. 12 DR. SCIFERLIS: Right. There are two educational 13 ones, there's a rehab, aid to continuing education. There are 14 three or four continuing education programs in that. These are 15 subregionalization programs. 16 DR. HESS: But if you add that to their current 17 budget which includes eight vacancies, that adds up to $506,000, 18 if my arithmetic is correct. 19 DR. SCHMIDT:. They are looking at page 7 of the 20 salmon sheets. Just keep flipping your salmon sheets to page 7 21 and you will see the budget breakdown. 22 DR. HESS: The core request is $724,000. The current 23 year's expenditure of $354,000, if I understand you correctly, 24 includes eight vacancies which are not going to be filled kce -*rat neporters, Inc. 25 immediately July 1. i u I DR. HESS: They are funded at the level of $35.4,000, 2 and did you say they.have 3 oking at Form 6 in the applica- DR. SCHERLIS: I am lo 4 tion. 5 DR. HESS: I am looking at this previous 03 year 6 operational award which says $354,000. 7 DR. SCHERLIS: Which page are you on? 8 DR. HESS: Page 6 on the salmon sheets it says 9 "Previous Yrls Award 03 Operational Year," Core is $354,000, 10 and I assume that is what they are funded at. And within that 11 $354,000 there are eight vacancies. 12 DR. WHITE: That doesn't seem reasonable... 13 DR. SCIIER LIS: I am sorry I misquoted. Looking at 14 the vacancies, the turnover has been very rapid. Do you know 15 what the vacancy figure is? 16 MR. SAYS: No, I don't. I think the current profes- 17 sional staff number of posit ions is 15 or 16 or 17. Those are 18 the type people. 19 DR. HESS: Is this $354,000 what they are awarded fo2 20 the 03 year? 21 DR. SCHERLIS: Yes, that is the 03 year, that's 22 right. 23 DR. HESS: That is accurate. So what you are saying 24 is that the eight vacancies perhaps is not accurate but there Aceladeral Reporters, lric. 25 are some vacancies. 31 I DR. SCHERLIS: That's right. 2 DR. HESS: Within that $354,000. 3 DR. SCHMIDT: Dr. Ellis. 4 DR. ELLIS: I would like t6 say if we are going to 5 do a good job of reorganization and restart and possibly have 6 a non-medical coordinator, he should have the same opportunity 7 that the other people have had bef ore, or she,.as the case may 8 be, to try to be innovative and to get a staff which will 9 solidify. 10 In my mind, unless there is some money there for 4 11 this to have him look at the needs of the people,, he will be 12 so handicapped that he will not be able to even begin,to build 13 a permanent structure. 14 We have heard that the vice president is willing, 15 and is anxious, in fact, to try to go along with this, and I 16 suggested before that it is necessary to look at the kinds of 17 educational activity,continuing educational activity which is 18 going on. 19 I notice that in other connections, much of the co,-.- 20 tinuing education that is going on has been the same thing we 21 have been doing for 25 years, really, not involving anybody 22 except one discipline, not one cross-discipline at all, not 23 explaining concept at all. And I am just hopeful that as we -this it will have real meaning for the Regional Medical 24 do kcesetal Repoiters, Inc. 25 Programs and for their ability to really structure programs of I 32 I service to people. And I think if we reduce this to an extent 2 where they cannot get some guarantee of staff where people do 3 not feel that they are in a permanent situation that we will 4 defeat our purpose. 5 DR. SCHMIDT: I believe that the issues are-dra%%7n 6 fairly clearly here. There is a principle involved. There is 7 also the level of funding that'I think has been discussed enougi- 8 to' at least test the sense of the committee. 9 Joe, I would like to limit this to new issues, new 10 comments. we are beginning to circle a little bit. 11 DR. HESS: 1 just wanted to emphase that the funding 12 level which would permit continuation of core staff out of the 13 current level of funding, plus continuation of the projects, 14 is $506,000. I think we need that as background information to 15 any action on the recommendation. 16 DR. SCHMIDT: Fine. The motion on the floor is for 17 approval at reduced rate. They ask for 1.75 total. The moti 18 on the floor is confirmation of the SARP's recommendation of 19 $839,000. 20 Unless there is an objection, I will ask for a vote 21 on this motion. If you wish to reduce the level of funding, yoj 22 will vote no to the motion. A vote "yes" would mean a level of 23 $839,000. 24 MR. PARKS: Wait a minute. We may not be for it at Nce-deral @pofters, Inc. 25 all, so I think a negative vote should be presumed just to reduc 32 I service to people. And I think if we reduce this to an extent 2 where they cannot get some guarantee of staff where people do 3 not feel that they are in a permanent situation that we will 4 defeat our purpose. 5 DR. SCHMIDT: I believe that the issues are-drawn 6 fairly clearly here. There is a principle involved. There is 7 also the level of funding that I think has been discussed enoug'@- 8 to at least test the sense of the committee. 9 Joe, I would like to limit this to new issues, new 10 comments. we are beginning to circle a little bit. 11 DR. HESS: 1 just wanted to emphase that the funding 12 level which would permit continuation of core staff out of the 13 current level of funding, plus continuation of the projects, 14 is $506,000. I think we need that as background information to. 15 any action on the recommendation. 16 DR. SCHMIDT: Fine. The motion on the floor is for 17 approval at reduced rate. They ask for 1.75 total. The motior 18 on the floor is confirmation of the SARP's recommendation of I 9 $839,000. 20 Unless there is an objection, I will ask for a vote 21 on.this motion. If you wish to reduce the level of funding,, yo@ 22 will vote no to the motion. A vote "yes" would mean a level of@ 23 $839,000. 24 MR. PARKS: Wait a minute. We may not be for it at kce*ederal R'6porters, Inc. 25 all, so I think a negative vote should be presumed just to reduc 3 3 I DR. SCIIMIDT: A negative vote defeats the motion, 2 and we will need a new motion on the floor which could include 3 zero level funding. DR. BESSON: I know you are looking at the clock and 5 ready to vote on this motion, but I would like to just on this 6 motion again refer to the principle. And that is now, as I reac 7 the application further -- and I apologize to Dr. Scherlis be- 8 cause he has been on.the site visit and knows the -area very 9 well and I am just speed-reading now -- but in reading the 10 comments of the RAG chairman about the direction of O@IP, it 11 may be that the problems that they are having 12 DR. SCHERLIS: Which chairman is this? Dr.. Johnson 13 or Dr. Strong? It is very relevant. These are two totally 14 different individuals. 15 DR. BESSON: Dr. Johnson Is that good or bad? 1.6 DR. SCHERLIS: Dr. Johnson is one of the strongest 17 features of RAG. Of the whole program in the State, he is one of the strongest features. 18 DR. BESSON: Well, the question I am raising is 19 20 whether what we are seeing here in the difficulty that the Oklahoma region is having is not symptomatic of a national prob-- 21 22 lem, and that is the demand that we've made on the regions to 23 shift their emphasis out of category and continuing education 24 to,a whole new ball game. And maybe the anxiety that is being ce tal Reporteis, Inc. 25 produced in the regions is being manifest in the disorganization 3 4 I and lack of leadership. And in roadiiifj 'u-Iiis sun,@,iary by the RAG 2 chairman, apparently they have had a great deal of dispute in 3 their discussions about what direction Oklahoma Regional @ledica2 4 Program will take. 5 Dr. Groom is a cardiologist. He said, in your site 6 visit you reported he felt the function of the Oklahoma R.NIP 7 was continuing education and categorical, and' he just didn't 8 understand public health and didn't have anything to.do with it. 9 Now, this is reiterated apparently at-the conclusion '10 of their discussions where the RAG chairman says it all boils 11 down to the fact that Oklahoma Regional Medical @rogram has 12 elected to continue its relatively direct pursuits of-its origi- 1 3 nal purpose. 14 Now, that means that there is a paradox in what we 15 are asking them to do and faulting them for and what their per- 16 ceptions are and what their aims are. Or it may be, therefore, 17 that they really, in spite of the fact that we think that every- 18 body should have gotten the message by now, they really haven't 19 accepted this new role. @20 DR. SCHERLIS: When I began my introduction several 21 hours ago, I commented on the fact that they just recently 22 accepted completely reoriented goals and objectives and said 23 these were much more in direction as far as RMPS is concerned. 24 This just happened how long ago? kceleerat Reporters, Inc. 25 MR. SAYS: We just received them this week. DR. BESSON: So this is out of date. 2 DR. SCHERLIS: Yes, I said that since the time of 3 this submission, two important events have occurred. One, the 4 resignation of Dr. Groom; two, the drAfting of new goals and 5 objectives by the Oklahoma Regional Medical Program. 6 DR. TEIUPd4AN: A whole new issue. Could you clarify 7 for us one thing and that is how strong 8 DR. SCIIERLIS: I am having difficulty with anything. 9 I would like doctor's assistance. 10 DR. THUW4AN: I still refuse to step down. Can you I t 11 clarify for us how strong really Dr. Groom s resignation is -- 12 I'm looking beyond you, Len -- because he has resigned before. 13 (Laughter.) 14 Going back to what Dr. Besson said, I would be a 15 little more comfortable if I reall'y knew the day he was out 16 of the ball game. I don't mean to be ugly. I'm just asking 17 for information. 18 YiR. SAYS: Ithink his letter to the RAG, which we 19 have a copy of, carries no doubt he will be leaving. Dr. 20 Margulies may have more input. 21 DR. MARGULIES: I think there is no question that he 22 has resigned. We pursued that with some vigor and it is formal 23 and final. 24 I might just comment in terms of what kind of in- ice4*,ral Reporters, Inc. 25 Ifluence this type of review has on accepting new directions wi'@-hc),,,".- the necessary club of money, full review some time, or 2 we could do it for you. What has happened to a long list of 3 traditionally unacceptable coordinators in the last year-and-a- 4 half, especially those who reached prominence during the period 5 of earlier development of RMP which was categorical and project 6 dominated, and who were dealt with with regularity, you will 7 find that with the exception of one or two they have resigned. 8 DR. SCHMIDT: I know that I can't go into the State 9 of Indiana for a little while. I asked one of my department 10 chairmen for his resignation by letter. He gave it to me with 11 an effective date of 31 July 1978. 12 (Laughter.) 13 I am trying to figure out what to do with that. 14 Let's test the sense of the committee then. I think 15 everyone has an understanding of the motion. Unless there is 16 strenuous objection, I will call for a vote. 17 All in favor of the motion please say, flaye.11 18 (Chorus of "ayes.") 19 Opposed, "no." 20 (Chorus of "noes.") 21 All in favor, please raise your hand. 22 (Show of hands.) 23 I get seven. 24 Opposed? kce *eral Reporters, Inc. 25 (Show of hands.) 1 40 ob Six. 2 DR. SCHERLIS': The chairman has a right to vote. I 3 don't think you should be deprived of a vote because you're 4 really a member of the group. 5 DR. SCHMIDT: All right. The chairman in this in- 6 stance exercises his right to vote or not to vote. He votes 7 to create a tie, and thus defeats the motion,'and I will not 8 vote, so t@ motion is carried. 9 Are there other comments? 10 One thing I learned I had to do was memorize Robert's 11 Rules of Order. I'm assuming this committee operatesby Robert'-r 12 Rules of order, is that correct? 13 DR. MARGULIES: As long as you are in the chair, yes. 14 DR. SCHERLIS: As interpreted individually. 15 DR. SCHMIDT: There is a new edition of Robert's 16' Rules out that is a most excellent book in case anyone hasn't 17 seen it. 18 We will move on then.from Oklahoma to Puerto Rico. 19 Miss Anderson. 20 MISS ANDERSON: I Will try and make this brief. T,-,'e 21 are talking about Puerto Rico now. 22 I have a problem, not being on a site visit, to talk, 23 to the RAG members and the coordinator and staff about the oro- 24 gram, so I was dependent upon the written reports of the staff ce-#ral Reportefs, Inc. 25 and the previous site visit in 1970 by Dr. Lemon. i 0 I didn't have a chance to talk to Jessie Salazar but 2 I did talk to George Hinkle and I appreciate his comments re- 3 gai7ding their recent visit there in December to assist the new 4 coordinator in developing his anniversary review application. 5 Apparently Dr. Fields and Jessie Salazar and George 6 Ilinkle and Robert Shaw did a very good job as the anniversary 7 review report is quite complete and up to date.. 8 Briefly, the profile of Puerto Rico is as you have 9 in your book. It's a small island with a heavy census of over 10 2.7 million, and the health statistics in regard to mortality 11 rates is a fairly healthy place to be in regard to heart diseaSE 12 cancer and stroke. 13 Fortunately, they seem to have some very good educa- 14 tional facilities and institutions. They have a school of 15 medicine. They have a school of public health that is accredit 16 They have ten schools of nursing, five at universities, one at 17 junior college and four at hospitals. 18 There are two schools of medical technology, and that 19 pretty well completes the educational aspects. They do have 20 18 nursing homes and the American Hospital Association reports 21 159 acute care and long-term hospitals in the area. 22 But in addition to this, they also have municipal 23 hospitals and district hospitals.. And there are 78 of those. 24 And as I understand, some of those are just one- and two-bed I Reporters, Inc. 25 affairs, but they are considered hospitals and they do give car I I r do not know the staffing patterns of these smaller places. 2 Incidentally, Puerto,Rico is made up of 75 municipalities, and 3 of the 75, 73 of them have hospitals of some sort. So there is 4 some type of public care. 5 The private hospitals are mainly in the cities and 6 they have 50 percent of the beds. And the public hospitals, as 7 I mentioned, are in the various municipalities also. 8 Now, in the coordinator's report he really spelled 9 out the new goals and objectives as clearly as possible and the,.4 10 do go into the direction of RMPS planning. The main thrust is 11 in regard to education and health manpower, health delivery ser 12 vices systems, and the collection of data and statistics. He 13. emphasized increasing availability of care and enhancing the 14 quality and moderating the cost of health care. 15 Now, some of the accomplishments they have done in 16 this short period of time are quite dramatic. And I would like- 17 to mention a few of them to you. They are all listed on page 5;. 18 of the salmon report. But they have been very much involved 19 with other official agencies, governmental and also nonprofit 20 organizations, in cooperating and developing proposals and pro- 2 1 jects. 22 They have expanded their services not only in San 23 Juan and the bigger cities but also in the rural areas and 24 villages. They have had active participation in their program. kce Oeral Reporters, Inc. from the Health Department, Department of Labor, labor unions, 25 I community and civic organizations, as well as related health 2 organizations. They are trying to obtain funds from various 3 resources in the community. -There is a problem. This area has 4 quite a bit of poverty, and they do not have the resources that 5 many other States of the Union have. So I think they are a 6 little slower in doing these things. 7 The region's continued -active involvement and 8 emphasis devoted to looking for other s@urces of support is on- 9 going. A point I was impressed with was the comprehensiveness 10 of the educational aspects of ongoing activities that include 11 education not only for the provider but also the community, the 121 patients and t.heir families. 13 Also anoth er plus is the fact that they are trying 14 to develop leadership roles for paramedical. type persons and 15 people. 16 The continued support, as was mentioned here, is 17 being established as part of their policy and is included in 18 all the proposals that they are planning. Actually, to date 19 there has just been one proposal that has been discontinued ana- 20 is being carried on by the health department. , 21 As far as minority concerns, I would like to state 22 the goals and objectives are directed to all the people in 23 Puerto Rico. Through intensive efforts toward regionalizati-on, 24 decentralization of treatment centers, continuation of health e-0 tal Reportets, Inc. 25 providers in isolated areas and educational programs directed a, both the patient and the patient's family, all are 2 considered to be served. 3 I was interested in and requested the interest of 4 minorities on the staff. All of the staff is made up of 5 Spanish surnames, and as Puerto Rico has a few other minority 6 groups which are the other side of the coin, such as black 7 people from the Virgin Islands and Caucasians'living in the 8 community. 9 Also they have other minority interests such as -10 allied health and nursing who are not recognized on their sta'L.'L 11 or their RAG. But I think this is the area that they are worki 12 ised this is the first review I have seen in on. I was surpr 13 which the females are not minorities on the core program staff. 14 On this program staff the females are a majority, 8 to 6.,. 15 The coordinator, as I mentioned, is a newly appointed, l@6 coordinator as of December 171, and he is a dentist and is 17 apparently very aggressive and very progressive. His special 18 interest is in education and he has had experience in health 19 manpower and is on some national committees with the National 20 Institutes of Health. So I think he has a feeling now of local 21 needs but also national trends and interests. 22 He has reorganized the program staff and and is more, 23 closely allying the staff's missions and responsibility to the 24 new direction. 0 kce *eial Repofters, Inc. 25 He has been involved in revising the RAG by-laws to 42 I increase the consumer representation at all socioeconomic 2 levels. lIe realizes that the RAG has been inadequate in the 3 past, and he is getting more involved in the activities of the 4 program. As the staff reports, he has gained the confidence of 5 the staff and'the community, and they feel that he is really 6 moving the program along very nicely. 7 The program staff is almost new. There are many 8 resignations due to reduced funding, and the demoralization in 9 regard to their feelings of not being so optimistic about IUIP's 10 future, but now they are developing their staff again. 11 And the staff is being focused on three main areas: 12 health, education and manpower; administration and health ,13 services, and planning and evaluation. We hope to have them 14 add more allied health people in nursing to their staff and 15 nursing. At the present time they have 32 positions budgeted 16 and only 21 filled. 17 A staff person is assigned to the RAG in order to 18 support their various task forces and also to help them in de- 19 veloping plans of action. 20 On the RAG-there are currently 28 members. There 21 are 4 vacancies. And of the RAG, 4 of the members are women, 22 and they are pretty well spaced, with 20 people from the north- 23 east, 2 from the south and 1 from the west, and they are plan- 24 ning now to add better geographic representation. @e-lefal Reporters, Inc, 25 And also in the new by-laws they are going to includf! the public and consumer categories which shall include at least 2 ten health services for consumers proporti onately representati%--, 3 of all socioeconomic levels of Puerto Rico. 4 The RAG used to have two meetings a year and atten- 5 dance was very, very poor. Now they are scheduled for four 6 meetings a year and the meetings are going to be rotated around 7 the island in order'to have better attendance and representa- 8 tion. 9 It,,is understood that the RAG has accepted their new '10 roles and responsibility and are willing to move ahead. 11 The RAG has twelve standing committees" and in re- 12 viewing the,literature I found that only three of these com- .13 mittees have met during the past year. The one comm,@ttee that 14 was most active is one on continuing education and has 15 member'@ 15 and met 10 times. 16 The project directors committee, which is a new com- 17 mittee, has 13 people who are involved as project directors, 18 and they have met nine times re-cently. And this is a new inno- 19 vative program that has been established by the coordinator to 20 help the project directors to understand more about RMP and the 21 goals of IUIP and lieloing these coordinators to work together 22 and possibly do more coordinating of their programs and projects 23 and in exchange of information, and that I thought was a very 24 big step forward. ,ce-eeral Reportefs, Inc. 25 I think also this adds to, in reviewing the literature I the enthusiasm and dedication that the various proposers see,,-, 21 to have toward IU4P and their projects. 3 There is another committee, the planning committee, 4 of 13 people, and that met 3 times recently in regard to short- 5 term and long-.term planning for the region. The remainder of 6 the committees were just on paper and were not active. 7i The grantee organization, according to the report, 8 is the University of Puerto Rico, and apparently the relation- 9 ships are very cordial and the university does not add any 10 pressure or direct guidance to the group. They are quite inde- 11 pendent. The participation of the @IP is that there is verv 13 active participation of the various health agencies on the RAG. 14 The program staff planning studies are planned in cooperation 15 with the State Department, prepaid health insurance organiza- 16 tion, the Puerto Rico Tiospital Association, the Department of 171 Health, and the San Juan Municipal Government and other munici- 18 pal governments. 19 The Veterans Administration there is active in doing 20 continuing education programs and other programs in the com- 21 munity, and they are working closely with the VA in regard to 22 this. They have joint activities with the Puerto Rico Medical 23 Association, and the coordinator is a member of the Committee f 24 Medical Education. :e -rat Reporters, Inc. Local planning they have regular meetings, as we 25 mentioned, i-iot onl-,,), the IU@G but of the Department of Health 2 ComirLunicatiori-,, Witlii the l@IIP' staff, to avoid duplication of 3 activities. Also C."-tP and IUIP are meeting together at regular 4 intervals. 5 RIIP has been appointed a member to the Municipal 6 Advisory Board of the planning office for the area of San Juan. 7 The Central Program Staff Planning and Evaluation 8 Section has served as a consultant and taken steps to provide 9 requested consultation services to the Planning Board and 10 Department of Health in Puerto Rico. 11 They are also planning to develop a consortium of 12 the various health agencies in the island, and to combine their 13 efforts in regard to data collection and interpretation. 14 And another recognition of their local planning is 15 a development of conferences and seminars with the various 16 health agencies and groups in the island. And what they are 17 trying to do now is to classify the various health service per- 18, sonnel and reorganize the educational system to meet t e new 19 types of health delivery. Also they are planning an Area 20 Community Health Education Center.- 21 The assessment of needs and resources is reflected i-, 22 the health professions human resources inventory that has been 23 completed and is transferred to the local Comprehensive Health 24 Planning for sharing with them and P14P and they plan for regulc_- @e Reportets, Inc. 25 up-dating of this material. I mentioned to you earlier that they are develc),i7),;l@@g a consortium of health educational agencies. 2 The core staff has planned activities and studies to 3 gather additional basic information for the development o f the 4 operational plan for the next trienniumm. Many of these studieE 5 are referred to and a direct result of the Program Master Plan 6 developed for the region. 7 Some of the things that they are planning to do in their studies are to survey the number of licensing, the proble7t 9 of licensing and health professions, the planning cost study 10 and outpatient clinics., They are planning a study on inventory 11 audio-visual resources in Puerto Rico and listing hospitals tha.@- 12 are accredited. And they have quite a list of things that they 13 are planning to do in this coming year. 14 Now, in regard to management, it appears to be pretti, 15 well organized, well managed. The staff is assigned to moni- 16 toring the various proposals and provide support to the project-- 17 They have monthly meetings of the project directors, as I men- 18 tioned to you earlier, with the coordinator and the staff. 19 Also progress reports and expenditure reports are 20 reviewed, mainly the expenditure reports are reviewed, by the 21 RAG annually and by-the staff quarterly, and project reports 22 are reviewed by the staff bimonthly. 23 As far as evaluation is concerned, evaluation pro- 24 cedures'are required for each project. And they are well writte- ce-oial Reporters, Inc. 25 into the project. All projects are evaluated by the program staff and consultants, and evaluation is of both a qual..itati,\7c, 2 and quantitative nature. 3 During the past year evaluation reports have been_ 4 completed on six projects. The program staff is actively work- 5 ing towards completion of the development and implementation of 6 the total program evaluation plan. And it is anticipated this 7 plan will be completed during the coming year. 8 Now, the action plan has been established and is 9 considered to be consonant with the national goals and the goal- 10 of the region. The region plans to continue currently on-going 11 categorical activities and has restated its goals.and objectives 12 in terminology agreeable.to the RMPs published missions. It 13 is noted the activities appear to be in complete agreement with 14 these goals. The new proposals are going in the new directions. 15 The on-going activities are most comprehensive with 16 respect to patient services, education of health providers, 17 patients and families and community health manpower utilization' 18 and establishment of new skills and new types of personnel. @19 Their dissemination of knowledge is being extended 20 into the community, and we mentioned this earlier about not 21 only the professionals but also the consumers and patients and 22 their families. And they are planning in the coming year to 23 have post-testing for all the continuing education programs, to 24 have pretesting and post-testing, in regard to the knowledge, ce rat Reporters, Inc. 25 attitudes and any change in practice that occurs. The utilization of manpower facilities seem to be 2 improving and they are-interested in developing health per- 3@ sonnel in new skills and training. The health assistants and 41 family health workers are being used in the community in rural 5 areas and are recognized as being valuable in increasing the 6 productivity of the physicians and other health manpower. 7 The improvement in care, I think, in reviewing some 8 of the proposals, you will find the pediatric cardiovascular 9 program, they have been testing children from prekindergarten .10 age to sixth grade, and have developed clinics and areas throug, 11 out the island. They usually star t out with one clinic or one 12 area, and then after that proves to be successful they multiply 1 3thcnselves in other areas. 14 The hematology and chemotherapy and blood banking 15 program has developed monthly clinics in various parts of the 16 island, and other parts, more inhabited parts, weekly visits 17 to areas for examination, teaching and treatment of these 18 children. Another example is pediatric pulmonary center has 19 20 developed continuing education for health professionals, 21 community people and family conferences. And you just go down 22 list of their other proposals, and these just naturally fall intc 23 the area of iraproving patient care. 24 Now, the short-term payoff, as far as activities are ,ce ral Reporters, Inc. 25 concerned, are the courses for the development of professional 4 9 and leaders in the- areas. I think it is one very 2 good example. Also the training of local health education coordinators in the rural areas and the training of health con- 4 sumer orientation. 5 The regionalization is with the staff located in 6 San Juan, and the new coordinator wants the staff there at the 7 present time. They are establishing subregional offices in 8 other towns. 9 The project activities are located in many other 10 areas throughout the island. The do consultation and give 11 help to the Virgin Islands in regard to their RMP program. 12 As we mentioned earlier, the other funding is being .13 included in their plans and at the present time only one propose. 14 has been funded by another agency. 15 I was wondering, maybe Dr. Spellman would like to 16 add some more. 17 DR. SPELLMA-N: Very little. I think Miss Anderson 18 has given a very compreliensive-report and I have very little 19 else to add. I think that the picture I get from reviewing thisi, 20 is that the ne w coordinator is a young, energetic, ambitious 21 man who is obviously committing full-time to his task. And I 22 think his report is an-excellent one and he projects optimism. 23 The supposition that essentially each of these 24 projects will be on-going and supported largely by the governmen kce oeral Repoftefs, Inc. 25 each enterprise he proposes will be sustained by.government support, and that projects h@,v,@ budgetary allocations, 2 1for example, to absorb the nc-,,,,; healt',i-i cz,.reers training. 3 Everyone of the projects, @,71ie-ther they are inven- 4 tories of health facilities or whether they are continuing edu- 5 cation for nurses or physicians or new health careers, are de- 6 signed to have a rapid, almost immediate impact on provision of 7 health services even if they aren't in the first instance 8 directly measurable. 9 There is the implication that subregionalization 10 will be effectively implemented through those district hospital--- 11 which are physically spread throughout the island, although he 12 doesn't specifically define this a s regionalization strategy. 13 I think that virtually all of this reflects the im- 14 pact of Dr. Fernandez, and I gather essentially the entire sta-Fr 15 is new because the old staff resigned with the cutting of the 16 RMP budget. So in a real sense it's a highly promising now 17 program which is going to be essentially dependent more than 18 most on his leadership. 19 The only other comment I'd like to make is the 20 composition of RAG. In his report he recognizes the inadequate 21 representation of consumers. The fact that all of them have 22 Spanish surnames throughout this is a kind of a nationalist 23 pride, I tl-iink,'and a certain degree of innocence in which it 24 expresses, I think, excessive optimism. But I think that this e-F&I Reporters, Inc. 1 25 under-represents, obviously, ethnic and population groups in tha island that have some interest besides their origins in the 2 Spanish culture. 3 I think he acknowledges this and has promised once 4 again that the expansion of this will'be truly representative 5 of the whole island. 6 I think all of this is consonant with the new goals 7 and objectives of P14P, an(2 I think the whole restructuring in .this rapid period of his on-coming is, I repeat, highly com- 9 mendable of what lie is likely to achieve. 10 I don't think I have anything else to add. 11 DR. SCIIL'4IDT: Do you have a recommendation 12 MISS ANDERSON: ;qell, the staff recommended a budget 13 of $1,496,631 as direct cost amount. It was recommended the' 14 funds be provided to support for the program staff at an in- 15 erational projects and two creased level for eight ongoing op 1 16 previously approved but 'unfunded projects and one new proposal. 17 . Also the increase of geographic scope of new activi-, 18 ties to be initiated is concentrated-in the south and west 19 health regions of the island. 20 Maybe some member of the staff may want to clarify 21 this some more. 22 DR. SPELL@@@i: I would like to make one other conmen4- 23 Maybe the staff could enlarge on this. 24 I sense that the hope for comprehensive accessible -ce rat Reporters, Inc. 25 health services in Puerto Rico are going to be dependent on governmental sponsorship. 2 You also get the impression the ownership of these 3 hospitals by private physicians create very littl,e contribution 4 from the private sector to a really enlightened kind of health 5 care system. 6 And taking up what Sister has just mentioned, my 7 guess is that much 'of the hope of this may be' the fact that 8 Fernandez is a dentist and young and not afflicted..witli much of 9 the preoccupations of the private sector in Puerto Rico, and in '10 this sense I would think that they have got a better chance tha- 11 they viould if the leadership were much more dependent on its 12 support from existing health components. 13 I have never been there; I have never site-visited; 14 so I don't know. 15 DR. SCHMIDT: Am I correct in assuming that the reco.-:k 16 mendation is for the level of funding requested? 17 MISS ANDERSON: Yes. 18 DR. SCHMIDT: All right. That would be an increase 19 in Core from $248,370 to $4417,597, and operations from $594,000, 20 to $1.04 million. Is there staff comment? 21 MR. III14KLE: The budget aspects of it -- I might 22 first speak to Dr. Spellman's concern about the private sector. 1 23 That is one of the concerns of past reviewers,and I think Dr. 24 Fernandez is pretty much aware of these. And as I read some of ice efal Reporters, Inc. 25 the on-going projects for the third year, they are planning to I move from the health center where they were initially set up 2 out into more isolated'areas, and some of the private hospitals 3 are also mentioned. And I feel as they move out into these 4 more isolated areas, they will bring in the private physicians. 5 Currently they start with the project in the health 6 centers, which are mostly government supported. Once they 7 get their base established, they move out 'into isolated rural 8 areas. 9 But Dr. Fernandez seems to be aware of all the 10 past criticisms, and in his brief term he has initiated some 11 proposed amendments to the by-laws, some of which were referred 12 to, and these were also taken into consideration in the past 13 criticism. He is aware that the RAG in his opinion hasn't been 14 as active as it should be. Ile has set up a liaison person on 15 his program staff to more actively work with the RAG and bring 16 them into daily operation.. 17 He has also set up his committee of project director 18 so that they can get a more overall view of the total Puerto 19 Rican MlP program instead of just their own. 20 I believe what I am trying to say here is that based 21 on his reaction to past criticism in the brief time he has been 22 on board, I,feel he would also move these things out more into 23 the private sector. 0 24 I have only been to Puerto Rico one time myself, and ,e - efal Reporters, Inc. just in December, and reading this application, most of the 25 comments reflected here came from the application at 2 face value. As I read it, as I'm sure some of you did, there 3 are many areas I would like to delve into much more deeply when 4 1 get an opportunity to go down there. 5 DR. SCH14IDT: I detect a very wistful note in all 6 of these plaintive statements that I am just reviewing this 7 from paper and I've not been down to Puerto Ri co. We maybe 8 should have the committee convene in San Juan in order to give 9 this program a good going over it obviously needs. 10 Is there a second to the motion that we had? I 11 didn't hear one. 12 DR. SPELL@IAN: I second it. 13 My only question about the level of funding is whel--hd-- 14 or not this rather striking increase of operation of activity is 15 warranted. I just don't know. There are a large number of 1 6projects. 1 7 DR.,SCHMIDT: The first sheet in this big black boo-,I 18 full of computer printouts that you were briefed on before, the 19 first quarter's sheet from Puerto Rico -- it's tabbed just 20 behind Puerto Rico '65 -- does give a nice breakdown of the 21 funds awarded in 01-02, and requested in 03, and onIe or two of 22 the projects do go up considerably. For example, Project No. 23 010, the request goes from $107,40.0 to $148,900, and I assume 24i that this'is because of expansion into other areas of the ce tal Reporters, Inc. 25 11 island. I So they are asl:ing :Liicreased funding of their 2 ongoing projects. I suppose the only thing that bothers me a 3 little bit is that they aren't a(jgressively moving these pro- 4 jects out into other sources of funding. But on the other hand, 5 there aren't any other sources of funding in the island for 6 these projects to go to, and I think there is somewhat 'of a 7 peculiar personality of the island that must be taken into 8 account here. I have visited it, not under RMP auspices but 9 under others, and would make that comment. 10 Sister Ann Josephine. 11 SISTER ANN JOSEPHINE: Dr. Schmidt, I wonder if some@ 121 one would talk to this proect tl iey are apparently asking to be 3 13@ funded, computerization of dose distribution. 14 DR. SCHMIDT: The question is the computerization of 15 dose project. 16 Bill. 17 DR. TIIURI@L: Sister, the major basis for this is 18 that Puerto Rico from the standpoint of cancer has been an un- 19 tapped resource for research and development. What they have 20 done, as indicated in the past, is they have had a cancer hos- 21 lpital and a university hospital and the two have never seen 22 eye to eye about the price of anything. And what they are tryi- 23 to do -- the project has always been in the cancer hospital -- 24 they are trying to bring it more into the university hospital, kce *eral Repoftefs, Inc. 25 and in so doing they are bringing on people who will be better able to establish a dose in the university hospital that can then be put into the periphery and delivered into OUtl@411(l 2 area units as well, primarily in radiation therapy but a!-so 3 chemotherapy and related things. 4 it's over-priced for its effectiveness. I would 5'make that as a very critical judgment with no basis in fact. 6 But it is over-priced in its effectiveness, as are several othe-- 7 of these projects. And I think that basically their concern is 8 that they need to have the money in case they do get the job 9 done. I donI.t believe that they will have the money. I don't '10 believe they will get the job done. But this one is over- 11 priced. We have seen units like this in several institutions in 12 this country, and all of them have contributed. Puerto Rico 13 has been a real ideal spot for us in the field of cancer becaus -E 14 it has been so untouched in so many ways. 15 MR. HINKLE: May I make a comment, please. 16 Dr. Spellman, this dose distribution, one of their 17 previous., I believe, projects when we had project review. 18 When the region came in they asked for $89,000 for the first 19 year, $57,000 for the second, and $58,000 for the third. The 20 National Advisory Council increased their first request from 21 $89,000 to $160,00. The second year will drop down. They felt 22 they needed a little more money for equipment the first year. 23 DR. THUP14AN: I don't mean to stand in the face of 24 the National Advisory Council, but on the other hand, almost al' ce -*taf R6porters, Inc. 25 of these projects have been over-priced for what was necessary I to be done. Puerto Rico -- I have site visited this for the 2 National Cancer Institute. That is the only reason I am speaki.-- 3 with some degree of assurance. But the Puerto Rico idea is to 4 put it into this component of hospitals. Dr. Spellman has in- 5 dicated there's real concern about many of these private hospi- 6 tals. And if you go back to this specific project, there's a 7 request for a terminal in one of these private hospitals that 8 has three beds. I don't believe that's too rational, and I 9 think this is,why in general it's over-priced. '10 DR. SPELLMAN: That's my feeling. I think they shou'-;-, 11 be supported, and generously supported. I just wonder, really, 12 though, whether they are going to be able to spend that much and 13 money operationally, given the jump they are making, that 14 is why I was hoping staff would give us some idea. @e has only 15 beenthere a very short time. This is a substantial increase in 16 operational projects. 17 DR..KRALE'@ISKI: Ihave several concerns. I symda- 18 thize with the economy of the area, and I recognize that every- 19 one is backing this leadership, and the fact is that the guy 20 might do a really good job. 21 But what we are doing here is substantially increas- 22 ing the budget of this program at a time where they will be 23 coming in for a three-year application next year. So we are 24 giving them all this right now, and next year they will be @ce tal Repofters, Inc. coming in for a three-year program. And if they tie into all o-@ 25 I to be done. Puerto Rico -- I have site visited this for the 2 National Cancer Institute. That is the only reason I am speak4-,- 3 with some degree of assurance. But the Puerto Rico idea is to 4 put it into this component of hospitals. Dr. Spellman has in- 5 dicated therel-s real concern about many of these private hospi- 6 tals. And if you go back to this specific project, thdre's a 7 request for a terminal in one of these private hospitals that 8 has three beds. I don't believe that's too rational, and I 9 think this is.,why in general it's over-priced. '10 DR. SPELLMAN: That s my feeling. I think they shou'@@ 11 be supported, and generously supported. I just wonder, really, 12 though, whether they are going to.be able to spend that much 13 money operationally, given the jump they are making, and that 14 is why I was hoping staff would give us some idea. He has only 15 beenthere a very short time. This is a substantial increase in 16 operational projects. 17 DR. KRALEWSKI: I have several concerns. I symoa- 18 thize with the economy of the area, and I recognize that every- 19 one is backing this leadership, and the fact is that the guy 20 might do a really good job. 21 But what we are doing here is substantially increas- 22 ing the budget of this program at a time where they will be 23 coming in for a three-year application next year. So we are 24 giving them all this right now, and next year they will be @ce Oetal Repofters, Inc. 25 coming in for a three-year program. And if they tie into all o-f these projects, they are going to be tied into a I.ot o-IL-' ictiv;-t% 2 here at a time when they are supposed to be outlining a three- 3 year plan. 4 It seems to me that is going somewhat in the wrong 5 direction. 6 Secondly, these projects that they have outlined herc 7 don't appear to be terribly exciting. And when reviewed in the 8 context of their economy with a great deal of poverty, the fact 9 that they have many underserved areas that really need help. 10 'vlhat they are doing here is dealing with continuing education 11 similar to that, but really nothing terribly innovative. 12 And then thirdly, along the lines that have been 13 mentioned, I don't know if they will be able-to spend this kird 14 of money. You mentioned that they have some agencies in the co" 15 staff now and they are going to expand that tremendously. I 16 wonder if they are going to be able to handle this kind o in- 17 crease to be able to do justice with it at this time in their 18 development. 19 DR. SCHMIDT: Joe. 20 DR. HESS: I had a somewhat related concern. I was 21 trying to harmonize the project titles at least -- we don't 22 have descriptions of the projects available -- the project 23 titles and the budget, and the action, brief description of 24 their action plan. Some of the other things described here ce -oral Reporters, Inc. 25 is the direction in which they are going in the budget. And look at the essentially doia@'Dling oj' the operational activities L 2 and what that is going for. And I assume that much of these 3 new kinds of things that am talked about are subsumed under 4 the core budget which again is not clear. 5 But I have a similar kind of uneasiness about where 6 the program is going,as shown on these projects that they are 7 wanting to fund versus what it says in the descriptive material. 8 DR. SCHMIDT: Len. 9 DR. SCliERLIS: I guess there's such a-thing as a 10 halo effect. If you have a good coordinator everything takes 11 on a glow, and if you have no coordinator or changing coordina- 12 tor things don't look quite as well. I can comment on that 13' further, but that is apparent. 14 (Laughter.) 15 Strength of this committee, I will word it that way. 16 In looking at the new projects, if they reflect any- 17 thing they reflect committee retrenchment of what were the good 18 approaches of categorical grant requests three or four years 19 ago. As I add this.up, of the new funds requested, some 20 $339,000 go into the following: dose determination, for 21 malignancy, screening And early diagnosis. This is a public 22 education project to teach 300,000 men and women how to look for 23 cancer. That is project No. 17 which is $78,000. And Project 24 12 is prevention diagnosis and treatment. This is to establish a,ce eral Reportefs, Inc. 25 a cancer information center, and that comes to a sum of $100,000 L) U I I just ques4L-.ion if this new direction really reflectE 2@ any impact he has been able to have yet. It is too early to do 3 that. But I think $360,000 for such cancer-oriented activities 4 and what I think -- what little I know about Puerto Rico 5 would be a great area to do more imaginative things. 6 I wonder if you might just speak to the value of the 7 two programs, one in public education and the other one, not 8 just in terms of what.it would accomplish but mostly in terms 9 of the health dollar that could be best expended.in Puerto Rico. 10 I have a gut reaction that Puerto Rico looks good 11 RI/iP-wise, but at the same time it isn't such a warm glow in my 12 abdominal area. It is an occasional pang of consciousness. 13 As the chairman said yesterday, it's good and it's 14 bad. 15 DR. SPELLMM I agree. I think these new projects 16 are the least relevant. The ones that I was speaking about arc 17 really the ones which are ongoing, and I would agree they have 18 the leastapplicability to the goals and objectives of the progrz. 19 DR. TIIUIU,@'q: -Sister, let me go back and say all my 20 com,@,ents were predicated on I thought the computerized dose 21 was $89,000, and actually it's $160,000, and that therefore 22 makes my comments much worse, not better. 23 I think, Leon, in answer to your feeling about whv 24 they have gone so strong in cancer is that everyone in the Unit(,, ,e-l&al Reportefs, Inc. States has faced 25 the fact that Puerto Rico is our last untapped I frontier in mar@.7 of -the areas that we should have tapped before 2 in cancer detection and treatment. This is an improper term at 3 the Federal level, but they have a pipeline to the National 4 Cancer Institute, and I think that this in many ways is re- 5 flected in their interest in having R.14P money take on s o-P ome 6 these projects. I think that it is an overweight, yes,, and the@ 7 do have a considerable amount of money from other sources. 8 SISTER ANN JOSEPIIINE: You know, it's interesting 9 in the statistics of the area that the median age is 18.5, and '10 it would seem to me it would be an exciting area to develop 11 education programs so we could begin the intervention thrust be 12 fore we're treating disease. 13 DR. SCffMIDT: We have a seconded motion on the floor 0 14 for a level of $1,496,631. The chair would accept a substitute 15 motion. 16 DR. SPELLI,@N: I am trying to add up the sum of thes- 17 new ones, and the ones related to cancer, and I am going to just 18 produce one in a minute. 19 DR. SCH14IDT: We have a little bit of a time problem 20 here, and I think we do want to take about a very quick ten- 21 minute coffee break, so we will declare a recess and I will 22 appoint a committee of the primary and secondary reviewer over 23 coffee to come up with a level after the presentation of llissour 24 We will table this for the time being. ,ce efal F?eporters, Inc. 25 DR. SPELL@@N: I think we have or)e. $1.1 would, I think, do it. 2 DR. SCHMIDT: All right, $1.1., and this is general!,,, 3 acceptable. You know, it's marvelous. You mention coffee and 4 things move right along. 5 All right, then, the primary mover has amended the 6 motion to include approval at a level of $1.1. Are we ready fol' 7 a vote on the motion then? I see assent. 8 All in favor, please say liaye.it 9 (Chorus of "ayes. l') 10 Opposed, "no." I I (No response.) 12 DR. MARGULIES: I just wanted to make one quick 13 comment. We won't hold you up very long. It has nothing to do 14 with this particular application, but another activity of Puertc 15 Rico which I think you would all find interesting. 16 Some years ago they became particularly alarmed in 17 Puerto Rico with a number of physicians who could not pass local@' 18 examinations or the ECFMG. They have been educated primarily i 19 Latin America and Spain. This was three-and-a-half or four 20 years ago, and I suggested a plan of action which they then 21 followed through on and got a contract from the National Center 22 for Health Services R&D to involve the medical school in a pro-I 23 gram of supplementary education for these physicians who had 24 gone to great personal expense and a lot of deprivation to get -ofal Reportets, Inc. their MD's and couldn't practice. And the results have been 25 0 0 0 excellent. Tii-y been re'-,c--sted, with a special test set uo 2 by the Educa4,-ional Testing Service that has been cross-checked @3 against the ECFL@IG examination. And when I last heard, they had 4 salvaged about 64 physicians who are now available to practice 5 in Puerto lzico who otherwise would not have been. They are no,.,; 6 going to expand tliat,program which I think is a heartening kind 7 of an activity. 8 DR. SCIIIIIDT: We will reconvene for Missouri -- Dr. 9 Besson has to,,leave early -- sharply at 10:45. 10 (Whereupon, a short recess was taken.) 11 DR. SCH14IDT: Dr. Brindley is ready to begin with 12 Missouri, if we could take our seats and begin. 13 To relieve anybody's anxiety, I will be prepared to 14 do South Dakota in one minute 32 seconds. I timed my presenta- 15 tion. And South Dakota should be relatively easy to do, I thin'@ 16 DR. SPELLI.@4: Is that what you are going to do none? 17 DR. SCH@IIDT: No, we'll do Missouri. Dr. Besson has 18 a time constraint. 19 DR. BRIliDLEY-. Okay, Missouri. I will try to give 20 you a reduced summar y. 21 As you know, Missouri has been a complicated region. 22 It was started off with the expectation that the level of 23 funding would be higher than later proved to be realistic. The-. 24 did make commitments in large amounts to computer and bio- @ce -oral keportefs, Inc. 25 engineering projects. They have continued to support those. I They now have asked for some more monies. A site review has 2 been made to evaluate these programs and to see should these 3 monies be made available, should the level of funding be in- 4 creased,, and should the developmental component be added. 5 The current yeat's award is $1,947,417. They had 6 requested $5,061,962. Council had a recommended level of the 7 06 year of $2.5 million. The committed level is $1,825,417. 8 It is of interest that o f this committed level of $1.8 million, 9 the Missouri.@NIP did allocate $300,000 to the computer and bio- '10 engineering projects. 11 Three months after they received their funds, they 12 made the decision to continue to support the automated physician 13 assistant proposal In Dr. Bass' office rather than to phase it 14 out, even though the council had recommended that it should be 15 pleased out. 16 Missouri PDIP then requested a supplement of 17 $122,092 to permit the continued operation of the automated 18 physician's assistant project f-or the six-month period, Januaryl 19 1 through June 30, and council disapproved this request. 20 1I won't give you all those reasons right now. 21 They considered then the contract mechanism, as to 22 whether this might be a good way in order to support this. And 23 subsequently, a contract was let by R-NIPS for support of this 24 because they felt at that time that redeployment of Federal ckceoetal Reporters, Inc. resources allocated to aerospace and military technology would 25 soon initiate new programs in this field and that some monies I tified in this area. So a six months' contract was were ]us 2 made for approximately'$122,000. .3 Also they submitted the automated physician's assis- 4 tant project of the National Center for Health Services R&D and 5 subsequently a study section of this organization cons idered thE 6 request and disapproved the APA proposal. 7 I want to go over a few things quickly with you, if 8 1 may. 9 We. received from the study group letters from each '10 one of the reviewers in which they gave their opinions. And in 11 summary, they were all pretty much against it. As a matter of 12 fact, they recommended that funds not be allocated, and that a 13 developmental component not be allowed. 14 Now, to hastily review the things we are talking 15 about, a site visit was held on April 4 and 5 to review the 16 technical activities for the Missouri RMP. And these projects 17 included the automated ECG in the rural areas, the biomedical 18 information services, the automated physician's assistant, and 19 the development of these activities have been supported by the 20 @lissouri IU4P already for five years, an expenditure level of 21 approximately $7.,5 million. They are presently being supported 22 through grant and contract funds at a level of approximately 23 $422,000. 24 The reviewers were critical of the project progress @ce erat fieporte(s, Inc. 25 and recommended reduction of RMPS support. If you look at the automated ECG in the rural area, 2 this has been supported by R14PS for five years. It is focused 3 on making remote electrocardiographic interpretation available 4 to small hospitals located in rural a@eas of Missouri. 5 Now, they purchased 17 carts that would make the ECG'-C 6 transmit them to the University of,@lissouri who would interpret 7 them, and the reports be given back to these peoples. And now 8 they have reduced this to 9 carts, and they felt this was an 9 important thing to them. I talked to Bill Mayeri He feels tha 10 if this were supported for one more year, they could then become 11 self-supporting. 12 Now, the reviewers didn't share that conviction. 13 They were concerned, did not think it could become self-support@-- 14 The carts rent for approximately $300 a month which 15 is paid for out of Regional Medic'al Program grants. It is 16 presently supported by more than one source. They get $96,000 17 from R@IPS, $40,000 from the University of Missouri, and a con- 18 tract for translation of the program into Fortran from the 19 @tional Center for Health Services Research and Development. 20 Now, there are a lot of interesting things. When 21 they talked to the cardiologist, Dr. Sandberg, he admitted 22 there were errors in the interpretation in about half of the 23 cases, and then about 20 percent of these that the error would 24 be of clinical significance. lie thought they could achieve ce-Seial Repofters, InC. 25 economic viability if they added some other tests that could be I obtained at the same time. 2 So he talked about exercise ECG, phonocardiogram, 3 spirometry and pacemaker analysis. 4 The consultants had reviewed it, looked into this, 5 went over there and went over it. They felt that the spiro- 6 grams probably would add very little useful information in the 7 communities if this information' would be utilized, and that 8 actually a time vital. capacity test would probably be just abou-. 9 as good. 10 As a thoracic surgeon, I might add I don't think 11 that's always true, but those are probably not thoracic surgeon 12 that are interpreting the spirogra.-Lns. 13 Phonocardiogram, they thought it would be difficult 14 to record, and that the local physician would have some diffi- 15 culty interpreting it, and it probably wouldn't have a great 16 deal of clinical significance. 17 The exercise ECG that was used in preparation for 18 coronary artery surgery, and pacemaker analysis would not helo 19 the cost effectiveness, and they didn't feel there was very-muc.-.. 20 of a reasonable market for it. 21 Now, they intended to spread this responsibility out 22 and probably use some more cardiologists. There are three 23 cardiologists in the University of P-lissouri that interpret these 24 and one oroposal was maybe we should use some more cardiologists %ce etal Reporters, Inc. 25 throughout the State. They haven't really done much of that 6 8 I yet but that is one proposal' thi-i-I.- li@as been considered. 2 They felt it' was proL)Zl@)I.y not of much value in inter- 3 pretation of arrliytlimia.@, and @tlc: the time of the last visit 4 there was great doubt as to whether this ever would become 5 economically feasible. 6 They thought about chai-jing a fee of $5 for each one 7 of the ECG'S, and this $5 might or might not include the fee 8 for the cardiology interpretation. It wasn't very'clear in any 9 of the information we had. 10 In conclusion, they really thought probably this cou:-@ 11 be done better and for less money with some of the commercial 12 services that already are available where they could use analog .13 transmitter services through the telephone and have the cardi.- 14 ology interpretation, and if this was an excessive amount of 15 money that was being used, and they weren't getting their dollaz, 16 worth of value out of it. They concluded that the present mode 17 of computerized interpretation of ECG's is neither particularly 18 useful nor economically viable.. 19 Each one of the consultants that wrote back a letter 20 about this was really very critical and apparently unanimous in 21 their concept that this should not be supported. 22 They did make another suggestion that perhaps it 23 mig'ilt be well to consider an allocation of some monies possibly 24 around the $60,000 range to see if a less expensive method coul,"4 kce*erat Reportefs, Inc. 25 be devised where they could make available to the.smaller 1. communities ECG consultation and review of ECG'S. 2 A biomedical information service is a fact bank and .3 it's operated by the Missouri RMP in conjunction with the Uni- 4 versity of Missouri Medical School LiLrary and the Sch ool of 5 Engineering. It is designed to provide specific disease infor- 6 mation from recent journals and texts. It has continued in 7 operation for the past nine months. Also I think connected by 8 phone line with the University School of Pharmacy in Kansas 9 City as a resource on drug reaction and also with Mercy 10 Children's Hospital in Kansas City for poison control advice. 11 They estimate that it costs about $100,000 a year to 12 support this. At the present ti me, the University of Missouri 13 has been contributing around $2500 a month in support of the 14 fact bank-. They made a survey to try to find out how many folk3 15 were using this. -You might criticize the survey since they 16 only asked 59 physicians out of the 6,000 in the State, but 17 did use that as an index. And they concluded that 58 percent 18 of the physicians might accept it. Five hundred doctors have 19 used the service so far. 20 The supporters of the project have inferred they be-, it at 21 lieve this could be paid for by physicians subscribing to 22 the rate of $60 per physician per year. The reviewers felt tha, 23 Ithis was an optimistic conclusion and did have some difficulty 24 in obtaining this many people that would provide the $60. ce-*,ral @eporters, Inc. 25 It was interesting that most of the inquiries were received from physicians in Columbia, and vor@r from the 2 outlying areas of the State. 3 It was the consensus of the site visit team that 4 there was very little insight concerning the difficulties of 5 marketing a fact bank on a break-even basis and very little 6 comprehension of all of the technical difficulties of indexing 7 a large library. They concluded that it was too expensive for 8 the output, and the physicians of the State would be much bette-.- 9 served by using the national Library of medicine assets. 10 The also stated they felt that no P14P support was 11 justified by this activity. 12 The. automated physidian's assistant is something we 13 have talked about every time we have talked about Missouri. lqe 14 are up to bat one more time. And this is a five-year request 15 for $3 million for a one-year funding level of $538,000. And 16 this is to develop and use technological innovations to improve 17 medical care delivery in a rural area through the use of an 18 automated system of patient data handling. 19 This is in the office of a private practitioner by 20 the name of Dr. Bass in a relatively small community. Ile 21 apparently does have a large amount of very sophisticated equid- 22 ment. It is used primarily in evaluation of patients that are 23 seen for the first time. There's a lot of data here saying how 24 many patients that that consists, but it is actually not very e -leaf Re@ofters, Inc. 25 many,'probably not more than two a week. I Th e c i s qa,. c x c o E; @,3 i v eThere Is a great deal o'- 2 doubt about how much gocc'A it helps anybody, either the patient .3or the physician. 4 I won't go over again the things that are recorded 5 unless you wish to, but the major thrust involves automation of 6 collection of certain information components at the time of the 7 first visit. It includes an automated medical history, the 8 entry of physical examination findings from a structured check 9 list. The nurses actually record this data after Dr. Bass has 10 seen the patient The entry of clinical laboratory data which 11 consists primarily of an S-MA-12, and X-rays reports which are 12 sent back from the University of Missouri. Automated ECG. He 13. also has access to tile fact bank in helping him with diagnosis i 14 and recommendations of treatment. 15 It has been proposed that perhaps it might be well 16 to expand this program in'the University of Missouri in two 17 areas: One into a family practice type clinic, and the other 18 one into a thoracic surgery clinic. 19 The reviewers that saw it were not too impressed. 20 If you want to know the details of the technical parts I can 21 give them to you. They screen their patients for vision, 22 hearing, breathing function, blood pressure and electrocardiogra 23 The vision is evaluated by a Titmus vision tester, hearing with 24 a Traccraudiometer, breathing with a spirometer. All of them ,ce fal Reportefs, Inc. have been modified for digital recording. They do record the 25 72 I blood pressure by an air shield method and found it wasn't very 2 good, so now they take'the blood pressure manually. 3 The electrocardiograms are done with the Marquette 4 Electronics cart. They do use the S14A-12. There is very littlr- 5 method in there to record any subsequent visits. There is very 6 little effort about correction of any data. 7 I can give you the names of the investigators but 8 I don't think they would change your conclusions any. But they 9 see about two,patients a week. It's very rudimentary in nature. 10 To make a long story short 11 DR. BESSON: Did you say $3 million? 12 DR. BRINDLEY: They estimated it cost $60,000 a year 13 just for the computer time, and that the total technological cos 14 might be as much as five times that. And the cost of the patien 15 would be somewhere between $165 and $175 per patient. You could 16 do a pretty good examination for that. 17 They suggested maybe there might be two others thing 18 that might be tried, neither one of which sounded very good. 19 The might make a satellite station similar to Dr. Bass' clinic 20 in another area without a physician. And it wasn't very good 21 in Dr. Bass' clinic, and it is hard to see how it would be any 22 good anywhere else. 23 They also suggested that you might develop a modular 24 system for $180,000 and use an IBM System 7. But the revie@.ie,, %ce-eetal Repofteis, Inc. 25 never did get a very clear answer about what the goals were, ho,., 7 3 I you were trying to go about it, how you might achieve these 2 goals, and how it would actually improve health care. It would 3 cost at least $2,000 a month to keep it up. 4 So the conclusions of the reviewers was that these 5 were not good-proposals. Technologically they were not well 6 conceived. The medical super vision was not good, that it 7 had not been as useful as it would need to be to justify this 8 cost, and they did not recommend that we give any funds for 9 Project 72 wh,ich is the automated physician's assistant, or to '10 75 which is biomedical information service. 11 There was a differenceof opinion as to whether any 12 money should be given for the automated ECG in the rural area. 13 There has been a suggestion that we might consider the $60,000 141to see if a less expensive method could be devised to provide 15 this assistance to the rural communities. 16 And as you know, a second request was for an in- 17 creased level of funding from the $1,904,417 to $4,460,852. 18 When we made a site visit to Missouri, we found their 19 goals to be very broad and vague, poorly defined, that they 20 largely were related to projects rather than to programs, that 21 they largely depended upon interested physicians, mostly 22 physicians,@ in communities to submit plans for projects, and i@L 23 they proved to be good ones and the idea to obtain regionali- 24 zation was to use a similar thought and see if you could set it cel*efal Repofters, Inc. 25 in another area. 7 4 That program consists primarily of accumulation of 2 projects. Evaluation was largely evaluationof projects, and 3 they had a great deal of difficulty in phasing our or modifying 4 poor projects. Sometimes it would take them three or four or 5 more years to do this, and they were very reluctant to change 6 them once they had accepted them. 7 Th e coordinator seemed to be a fine,man, but actuall-. 8 his administrative ability was not as good as it might be. He 9 is not a very strong administrator. 10 The staff is large, maybe too large, for what they 11 should be doing. It largely is related to projects that have 12 been developed in the past for which they felt some commitment. 13 The staff review when they saw them did not feel that they had 14 improved this enough to where they would be justified in the 15 greatly increased level of funding nor did they think we were 16 Justified in recommending a developmental component. 17 I did speak to Bill Mayer -- off the record. 18 (Discussion off the record.) 19 DR. SCHMIDT: Dr. Brindley, I will apologize to you, 20 and I will also apologize to Jerry because he does have a time 21 constraint. 22 DR. BESSON: Let's leave that flexible. I think thi-i 23 is much more important. 24 DR. SCHMIDT: was trying to read where you were ice *Ira[ Reporters, Inc. 25 approaching you might make a recommendation. Are you approachi;-, 75 I that point? 2 DR. BRINDLEY: Yes. 3 DR. SCH14IDT: Would you object if I turned to Dr. 4 Besson who does have a time constraint, and let's get his 5 overview on this and then we'll come back to you. 6 DR. BRINDLEY: Right. 7 DR. BESSON: Getting out of Missouri is like getting 8 out of Vietnam except that we can make the decision right here. 11 9 DR. SCHMIDT: Can we make an assumption of what is 10 coming from that? 11 (Laughter.) 12 DR. BESSON: There are two parts to this request. 13 One is.the bioengineering and the other is continued support 14 in the deveopmental component. 15 The bioengineering is very simple. The technical si---14 16 visit said no, and the only disagreement is whether they should 17 get $60,.OOO or not for the automated ECG. And as I went throu!z':- 18 a careful analysis to try to justify the $60,000, I must agree 19 with SARP and say that that's not justified either. 20 So my general impression is that as much as we could 21 phase out of the ridiculous.,kinds of requests that we keep 22 getting from Missouri, the more we should. 23 As far as committed support is concerned, they prese7 24 two plans, Plan A and Plan' B. Plan A is $1.8 million, and Plan ce*eral Reporters, Inc. 25 B is for $4.4 million. They ask for a developmental component 76 I as well, and part of our decision 'as to which plan to support 21 wards whether they are ready for a de- involves our approach to 3 volopmental component. And as I went over the individual pro- 4 jects to assess that, I came up with a very negative opinion as 5' to their readiness to have a developmental component. I could 6 bore you with the details, but I think just their approach to 7 the bioengineering phase itself should be sufficient indication 8 of their lack of maturity, at least so far as not only the new 9 direction of M4P but even the old one. And with all due respect, 10 to our recently eulogized chairman, I must disagree with him an4f 11 perhaps his paranoia is only because he is so deeply involved 12 in the program. 13' But I would then not be in favor of awarding the 14 developmental component, and of the two plans that they offer, 15 under Plan A there is a commitment of $1.825 million that has 16 already been made. Plan B, the $4.46 million, I think should 17 be outrightly rejected. If we accept Plan A, that gives them 18 and we also reject the bioengineering -- there is an additional 19 million under Plan A that would not be funded therefore. That 20 would give them an additional $1 million to use for other nro- 21 jects. 22 14ISS liOUSEAL: That's inaccurate. There would be 23 approximately $200,000 to $300,000 under Plan A that would be 24 freed up. The $1 million is out of Plan B, and that was the kce eral Repottefs, Inc. 25 plan presented to the site visitor s. 77 I DR. BESSON: That's right, Donna. The $1 million 2 would be v7hat they were requesting under Plan B of the $4.4 3 million, but if we accept their Plan A but deny them their bio- 4 engineering, those three plans, 69, 72 and 75, come to a sum 5 total of $200,000. 6 We cannot deny them that $200,000, though, because 7 that is already committed. Therefore, they would have the 8 ojects. But never- option of using that $200,000 for other pr 9 theless, in keeping their funding at $1.8 million instead of 10 the $4.4 million that they request, we are in effect cutting 11 them down about an additional 40 percent from the request from 12 the $4.4 million to the $1.8 million by keeping them at a level 1 3 funding. 14 So in effect, the suggestion would be to reject the 15 bioengineering request,to reject the developmental component 16 request, and by keeping them at a level funding, indicate the 17 displeasure of this committee and our hope that they might 18 terminate the bioengineering activity. 19 DR. SCHMIDT:- Thank you. 20 Are there any staff comments on that? 21 MISS HOUSEAL: There are a couple of corrections to 22 the record. The $3 million request for five years of computer 23 activities was what was presented to the National Center for 24 R&D. The request to P14P was for one year only at this point. ,@e-I&ral Reporters, Inc. 25 So that the R&D, what they reviewed at their study section 7 8 I about a month ago was the $3 million, five year request. 2 With regard'to the EKG, the site visitors felt that 3 on the basis of what the region was charging Inow and the number 4 of subscribers they had, that they could not reach a level wherE 5 they would become self-supporting in another year. The site 6 visitors felt that the most valuable thing they could provide 7 would be an overread or a consultation service to the rural 8 physicians. And they thought if the project were totally re- 9 directed that,this would be worthwhile or worthy of support. '10 They felt that the region had the resources to do this, and it 11 would be something that would be worthwhile. 12 DR. SCHMIDT: Thank you. Dr. Brindley then. 13 DR. BRI14DLEY: Yes, sir, I was going to get around 14 to that and I think that's good. I would move that we recommend 15 $1,825,417 as our funding, that we deny the developmental com- 16 ponent. 1 7 DR. SCHMIDT: All right. This is consistent thenwith 18 what Dr. Besson outlined, is that correct? So that you second, 19 Jerry? 20 DR. BESSON: Yes. 21 DR.. JOSLYN: May I ask, does that motion include a 22 denial of the three pro3ects that are now within the $1.8 23 budget? In other words, the computer projects, that $200,000 24 could not be used for the compu@rprojects but could be used kce-oeral Repoitefs, Inc. 25 elsewhere. That was stated in what you were saying but not in 79 I what Dr. Brindley was saying. 2 DR. SPELLI\IAN: I think the implication is there but 3 I don't think you could deny them. 4 DR. BESSON: I think we could disapprove of those 5 projects which is what I think the question was. 6 DR. JOSLYN: I think the site visit committee felt 7 that a disapproval of those specific projects was needed in 8 0 rder to change the direction of those pro3ects. In other 9 words, just allowing the funding that even remains in the A 10 budget would allow a continuation of the projects in the direc- 11 tion they are going. 12 DR. SCHMIDT: Then the specific question would be 13@ the disapproval of which projects then? 14 DR. BESSOI@: Projects 69, 72 and 75. 15 DR. JOSLYN: Those projects are the automated EKG, 16 the biomedical information system, and the automated physician' 1 7assistant. 18 DR. SCHMIDT: Dr. Brindley is primary mover. What 19 is the intent of the motion? 20 DR. BRINDLEY: I would like to include that in the 21 motion. 22 DR. SCHMIDT: That is included in the motion. Is 23 that acceptable to the seconder? 24 DR. BESSON: Yes. %ceeetal Reporters, Inc. 25 DR. SCHMIDT: Is there further discussion then? so I MR. PARKS: My unreadiiiess goes to'the whole project 2 I guess , because I have' some questions about what it is that 31 we are doing here and what is it that apparently RMP is dOMMittE-- 4 to. 5 I happened to run a scan of the full application herE 6 and it raises some very real questions. First of all, I find 7 the so-called minority participation to be so small as to be I 8 totally nonexistent. With respect to that I would say directly 9 and frankly it is a shame, and a shambles. 10 On the other hand, the participation of the grantee 11 in the operation of this with respect to the staff listing of 12 positions, which is on Form 6 which lists the core peIrsonnel, I. .13 would daresay with a scan like this that the personnel is close 14 to the 90th percentile from the University of Missouri. This 15 is highly suspect. Yet, when I look at the report of the RAG, 16 the very first thing that they outline with respect to their 17 programmatic relevance is the fact that they have addressed 18 themselves with a high blood pressure program, which is a 19 serious problem primarily among the black population of Kansas 20 City. And then the rest of it goes off into a number of other 2 1 projects. 22 -Again I find in the opening page of the application 23 an announcement that this is the Missouri Regional Medical Proc-' 24 heart disease, cancer and stroke. Going back into the programs ce -oral Reporters, Inc. 25 @that they intend to continue, I am not sure that I find that 81 I there is a shift in emphasis that corresponds to the so-called 2 change or new national emphasis. 3 So with respect to this, I understand that we are 4 committed to them at this point on some kind of a continuing 5 or triennial commitment. But I raise some very serious ques- 6 tion as to whether there is minimal compliance with those basic 7 conditions that are necessary not only to obtain but to sustain 8 the eligibility as a grantee or regional medical program operate-, 9 as this one is. 10 DR. SCHMIDT: I think it would be appropriate for 11 staff to note these particular comments very, very strongly, in 12 that they be conveyed and the concern of this committee in this 13 area be conveyed very strongly to the region. 14 Jerry. 15 DR. BESSO@L: I would like to respond to Mr. Parks' 16 comments because I think again they raise a principle that 17 disturbs me personally greatly in our relationship with a totaled 18 untenable region such as Nlissouri is. And that is how we have 19 managed to remove ourselves from the decision-making process. 20 Three years is a long time, and if change is occurring as ex- 21 ponentially as it is currently to have committed ourselves a 22 year ago when we may have just felt in a more salubrious mood 23 and maybe a little more generous to this level of funding, and 24 now coming back to see the intemperance of the region and @ce*erat Reporters, Inc. 25 funding the program in the face of council disapproval, and 82 I their cheek in presenting a budget like.this with obvious 2 changes in national mood, yet we are left powerless to do any- 3 thing about it. We have to fund them at a level of $1.8 millior 4 because that was committed a year ago. 5 Our only action on this application, Mr. Parks, can 6 be to disapprove the request for these three projects, disapprove. 7 the developmental coiupent, period. We can't 'do anything more, 8 but you raise the fundamental question, I think, of the in- 9 approidriate s.tance that this review committee and therefore 10 council has now placed itself in relation to a rapidly changina 11 prograi by fixing itself to a three-year conmitment with periph- 12 eral decision and no decision-making power left at this level. 1 3 DR. SCIFMIDT: Sister Ann. 14 SISTER ANN JOSEPHINE: I wou.U like, in conjunction 15 with Mr. Parks' question, to raise a question that probably 16 we are going to be facing maybe we won't be on the committee 17 any more., but we will be facing it somewhere down the pike. Anr-' 18 that is the total funding of medical education as it relates 19 to the faculty. 201 Mr. Parks points out that 90 percent of the personne-@' 21 on the program, on the @IP program, are from the university- 22 I think that it would behoove all of us to read the recent 0 23 Nlillis report on irrational public policy for medical educati- 24 and its financing, or somewhere down the line vie are going kce-*eral Reporters, Inc. 25 to be sorry we permitted this type of investment in underwriting 83 I faculty salaries, and the unrealistic development of faculties 2 beyond the financial capability of funding them when the 3 Regional Medical Program is phased out into another type of 4 program. And as we know historically what Federal programs do, 5 this is going to happen, and I think it is terribly important 6 that we realize we are contributing now to a stance that has to 7 be taken on medical education. It has to be adequately funded 8 but from the right sources so we are going to have a continued-, 9 of funding. I 0 DR. SCII,',IIDT: Staff? 11 DR. JOSLYN: I have been with M-IPS for less than a 12 year, and I am not knowledgeable of all the politics and con- 13 straints and all, but I would hope that this review committee 14 or National Advisory Council or some board would have the power 15 to have some eff ct in Missouri, and I think this is what I hea--r .16 people saying, particularly Dr. Besson, at the table. And I 17 think that something needs to be said besides a letter of 18 recommendation which has gone out the last four years. I don't 19 know whether this takes this committee having its next meeting 20 in Missouri with national television coverage, or what, but I 21 guess I'm just asking: Is there any way this committee -- and 22 Dr. Margulies and I have talked about it, and I don't want to 23 lbate it-if it's not appropriate, but I would hope that the 24 committee can move this region. It has some positive aspects. ce-I&ral Reporters, Inc. 25 ISome of these have not been brought out. But it do es have some 84 I positive aspects, but it is misguided in other areas, and I 2 think those have been brought out and they have not been moved 3 in the past. I would like some innovative way to move them, an@ 4 hopefully this committee might do that. 5 DR. SCIIMIDT: I'm sorry we can't. Here committed 6 to meet next in Puerto RICO. 7 (Laughter.) 8 Joe. 9 DR. liESS: I would just like to say that I share the 10 concerns being expressed around the table. One of my early 11 site visits was to the Missouri region, and I see that many of 12 the things we identified then were matters of concern are matter 13' of continuing concern and nothing much has happened. 14 And in connection with this discussion, I wonder if 15 it is possible under current policy,or if a new policy should 16 be created to make it possible, to put a very large red flag on 17 this anniversary approval and say that if certain actions are 18 not taken by next year, that in spite of the triennial status 19 that there will be funding cut-backs. 20 Now, that may or may not be a new policy, but if it 21 requires new policy, I think perhaps this is an issue we ought 22 to raise for discussion here and pass on to council. 0 23 DR. MARGULIES: I'm in full sympathy with your con- 24 cern, but I just have.a trace of the historical perspective in kce-*deial Repotters, Inc. 25 this, too. I would like to point out to you that this program 85 I reached zenith of its categorical activities under the old 2 processes under which -this review committee operated, and it 3 this committee that put them at the extraordinary level of 4 hardware activity which has generally dominated it. And it is 5 only now, under these circumstances, that you first begin to 6 look at the program. It is only now that you begin to raise questions about minority representation. It is only now that yc-- 8 begin to look at the grantee structure. It is only now that 9 you look at the question of university domination and of the '10 presence of PL@IP paid people on the faculty. It's now that you 11 can begin to deal with it as a total structure. And what you're 12 hesitating about I don't understand. In the past all you did %,.a3 13 go from project to project, and under those circumstances it 14 reached a total hardware level of something in the range of wha-l- 15 $4.5 million, $5 million, $6 million? 16 DR. JOSLYN: Yes. 17 DR. MARGULIES: And it was recently -that you began to, 18 look at it as a progr atic structure. You are in a much better 19 position to act on this as altotal program than you have been/a-("- 20 any time in the past. 21 DR. BESSON: Except that we are constrained totally 22 by the triennial review process and the fact that we can say 23 nothing about this program except within the limits of denying 24 developmental component and denying these bioengineering processc ce -*Ial Repotters, Inc. 25 nd I say that's not enough. I think the program is changing 86 I too rapidly for us to be tied in to a three-year anniversary 2 review. And I thin)-, that policy must be reexamined in the ligh-, 3 of rapidly changing events. It's inappropriate. It's unre- 4 sponsive. It leaves the change lag t6o great. If you are 5 chastising this group for reaping the fruits of some action it 6 took a year or two ago, I'm making the bid for making this 7 organization much more responsive, and immediately so. 8 DR. MARGULIES: And I'm asking you why you don't 9 just take the action you keep talking about. What are you 10 hesitating about? There is nothing special about a triennial 11 review. You have this program to look at now. Why are you 12 leaning back? 13 DR. BESSON: Well, maybe we should have some more 14 information. Could you outline for us what we can do about 15 Missouri other than the motion? 16 DR. 14ARGULIES: You have a full range of reconaenaa-, 17 tions. You can do what you think is best. 18 DR. BESSON: Are we not enjoined from interfering 19 with the committed support? 20 DR. MARGULIES: The support is committed on a vear- 21 by-year basis. The triennial review anticipates a continuing 22 level of commitment if the program meets its responsibilities. 23 If it does not, then it does not get the level. It's merely a 24 matter of continuing it under those circumstances. kce*detal Reportets, Inc. 25 DR. BESSON: Okay. 87 DR. SCli@IIDT: Len. 2 DR. SCIIERLIS: Several things. One.is that-several 3 of us have over the past several years been very concerned abou-, 4 the involvement of the Regional Medical Program in computer 5 activities which appeared to be looking for programs so that onz,: 6 could use tools rather than trying to meet health needs and 7 finding that computers were of assistance in this regard. 8 Several years ago -- I g.ucss it was several, when 9 we had categorical review by a heart committee that looked at 10 all the heart programs and cancer committee -- at that time I 11 was a member of a committee chaired by Paul Hugh, and subse- 12 quently I chaired a committee'. And on each occasion we wrote a 13 letter to the council -- I don't think you have a review com- 14 mittee at that time -- saying we wished to have the council have 15 EKG! an ad hoc committee formed to draft a statement on computer l@6 because we felt frankly this was very much at that time being 17@ misused. The committee finally met a few months ago. And this' 18 was an action we had requested because we were very concerned 19 about the involvement of @IP in hardware at that time. 20 We also sent a statement asking for mobile ambulance 21 units in coronary disease, and that one I guess never quite got 22 help. But the feeling we had in the area of cardiology was 23 there was a gross misuse as far as computer equipment was con- 24 cerned. ce I Reporters, Inc. 25 I completely share the recommendations as far as EKG 88 I here is concerned. They could do the same thing as far as 2 helping some rural physicians by having a telephone at one end 3 and sending the EKG directly to a physician or Xeroxing it and 4 sending it over. The use of a computer here is a Cadillac to 5 do the work that somebody could on foot. And I think it's an 6 expensive examole. 7 So I think as far as' the excessive hardware in 8 1-11'ssouri, we all bear responsibility for it, but all of us had 9 seen this coining and had tried to get some directions about ho,@.;. 1 0 much hardware was going t o be purchased. 11 I would hope the committee at this point '-- and I 12 would lean back to the original recommendations and think in 13 terms of cutting that recommendation financially, significantly 14 even beyond the limit that was suggested. 15 DR. SCHMIDT: Dr. Thurman. 1 6 DR. TliUP-,MA'.i: In view of the discussion, I would likb 17 to offer.a substitute motion, and that is that we disapprove 18 this application with the intent that there be a site visit 19 within the very near future, disapprove it with the understand- 20 ing that Dr. Margulies would agree to continue to fund it at t-@- 21 present level until'such time as that site visit could be car- 22 rie6 off, and many of the apprehensions that have been listed 23 here today be specifically charged to that site visit group. 24 DR. SCHMIDT: And the site visit would be ch arged Fede ta I Repor te i s, Inc. 2 5 with making recommendation then for funding level, and so on? 89 I DR. TliU@N: It's my understanding it is within 2 Dr. 14argulies'power to continue funding this at the present 3 level to let them go on until such time as the site visit could 4 be organized to address many of tliese'problems. And t herefore 5 we would not be jeopardizing the eventual future of the Missour-., 6 Regional Medical Program should it adhere to many of the things 7 we night suggest at that time. 8 DR. SCHMIDT: Ile have a substitute motion on the 9 floor, then, for disapproval with funding maintained adminis- 10 tratively. 11 DR. THURIIAN: Excuse me one second. Miss Anderson 12 had an addition to my substitute motion. 13 DR. SCHMIDT: I'm sorry, that is out of order. 14 DR. SCHERLIS: Point of information. My reading o 15 that would be that you would be including ongoing support for 16 the very projects we suggested they not fund, if you make it 17 at the same level. Ilould it be feasible to drop that level dow-4 18 excluding the support of the automated EKG processes? 19 DR. THUPI@N: As a discipline of Robert, I can also 20 say I can accept that in my substitute motion, and would expand 21 my substitute motion to include the recommendations previously 22 listed. And that is thatnone of these three projects be 23 permitted continuing operating money at Dr. Margulies' discre- 24 tion. ce - Federa IRepottefs, Inc. 25 DR. SCHMIDT: Is there a second to that motion then? 9 0 MISS 7LNDERSO,,N: I will second it. 2 DR. SCHMIDT: The motion is seconded, and I presume 3 understood. Would you like to modify it further? 4 MISS ANDERSON: No. 5 DR. SCHMIDT: That incorporates it. 6 MISS ANDERSON: Yes. 7 DR. BESSON: Perhaps we can have a clarification tha, 8 this is an action that cannot be,, because of Catch 22, rejected 9 by council. 10 DR. SCHMIDT: Was that a question? 11 DR. BESSOZ4: No, I would like to have a comment by 12 Dr. Margulies that what we are doing is not going to be hung 13 up on a technicality. 14 DR. SCHMIDT: I presume this could be rejected by 15 council. 16 DR. MARGULIES: Of course. 17 DR. BESSON: Barring that, is there any reason why 18 what we propose is going to be rejected by council for some 19 technicality. If they reject it on principle, then that's 20 debatable, but if it's rejected on a technicality that we can',@- 21 do this 22 DR. MARGULIES: The only technicality which might 23 arise would be the need, because I cannot do exactly what you 24 said. cannot continue the program beyond its fiscal year @ce-Federal Reportefs, Inc. 25 without the council giving approval of an award level. So that 9 1 I they would have to set some level at which they would operate. 2 I don't have the authority to continue to award a grant unless 3 the council has approved, but that would be the only technicali- 4 As a matter of principle, they can endorse this action, or 5 reject it, of course, because that's their legislative preroga- 6 tive. 7 DR. BESSON: So we have a level of $1,625,417, is 8 that correct, Donna? 9 MISS IIOUSEAL: Yes. 10 DR. SPELLMAN: But I think the rejection and the 11 prospects of rejection in principle would be diminished to the 12@ extent that the report to the council clearly states all of 13 the considerations which have gone about. The only one I would 14 add to that, I think this kind of unreal commitment, to Kansas 16 City on the one hand, and clearly 'a system of program that has 16 throughout responded to an essentially rural constituency, 17 using urban methods, hardware, extraordinarily expensive pro- 18 grams where an individual physician almost operates a multi- 19 phasic screening operation at an enormous cost. 20 DR. SCIIMIDT: A brief staff comment? 21 DR. JOSLYN: In light of the many past site vis3ts 22 and the data you have, I would just like to question what data 23 you expect to gain from a site visit that will alter your 24 position. And secondly, I would like to ask whether or not ce-Federal Spotters, Inc. 25 behind the recommendation for the site visit is a hope to move 9 2 I the region, which is what I was addressing before. And I think 2 merely requesting a site visit is another long chain of site 3 visits. 4 DR. SCHMIDT: There are site visits and site visits, 5 and I believe that some of the site visits we have made have 6 not really been so much to gather data as to provide data. And 7 we go back to what we were talking about before, that there 8 have been a number of site visits, and my most recent one, I 9 suppose, being an example that resulted in quite@an upheaval 10 and change of direction in the region and so on. I believe it 11 is this sort of site visit that was recommended. 12 Joe. 13' DR. HESS: I would just like to get some clarifica- 14 t@ion on when that site visit was projected and what it was de- 15 signed to accomplish. 16 DR. TIIUPI,@i: I think it's projected as soon as the 17 staff can arrange it, Joe, because I think basically by not 18 approving continuation of the triennium, I share Jerry's concert 19 about what the council is going to say about that, but in not 20 approving that v7e are creating a little bit of an administrat4L,.r- 21 morass, and therefore the site visit would have to come as 22 quickly as staff could arrange it. And specifically the site 23 visit would be as Mac has indicated, to approach the problems @24 of why they weren't approved. And I think that in that light ce-Federal Reporters, Inc. 25 the site visit will be a fairly critical site visit. 9 3 I DR. IIESS: My question, then, is this a better way 2 of trying to accomplish our goal than cutting back the funding 3 having the advice letter and staff contact and so on, the messa: 4 carried that way, with the provision that there be a site visit 5 a year from now after the message was carried back and they hav-. 6 had some time to reorient. And then a site visit team would 7 go in with the purpose of seeing what they've done about the 8 advice that they were given. 9 ,m wondering if that wouldn't be a better use of '10 the site visit m echanism@ 11 DR. BESSON: When you made the motion, Bill, I 12 deferred to you, but I had a different approach to this other 13 than a site visit, which would accomplish what Joe has now 14 raised. And I thought, well, a site visit may act as our 15 way of telling them directly face to face just what @,IP is 16 concerned with. But it may be that if we let them know by the 17 funding mechanism, and my motion was to have been to cut them 18 down not from $1.8, minus the $200,000, which was the bio- 19 engineering, but down to an arbitrary lower figure, $1.5 millici 20 let's say, which would have given them a message that we are 21 objecting not only to their bioengineering, and therefore 22 cutting down $200,000, but we are objecting over and above that, 23 Now, if that can be done with an advice letter, and 24 then tell them this region would be reevaluated by a site visl- @ce-Fedetal Reporters, Inc. 25 after you have had time to reassess the impact of.this change 9 4 I in RMPS policy about the triennium review, then that might give 2 the council an opportunity to establish an entirely new approac.- 3 to triennial review which we haven't taken yet. But deferring 4 it to a site visit, it almost implies we are not meeting the 5 problem in a head-on fashion; we are not doing anything. Well, 6 I guess in cutting down the $200,000 in funding level 7 DR. SCIIMIDT: Jerry, we are also disapproving the 8 application. 9 DR. BESSON: No, we are disapproving the application 10 entirel y I I DR. TIIU@@N: That was implicit in the motion, and 121 Dr. Ellis and I were raised to use the term, I think if we did 13 an advice letter we would be patting them on the fanny, and 14 that's all we would be doing. 15 DR. SCHIIIDT: The motion is for disapproval of the 16 application, with just funding being sufficient to keep them 17 from going down the tube completely. 18 DR. BESSON: But the application is what? For 19 developmental component and these three projects. Is that 20 right? That's all that the application is. And an increased 21 funding level. 22 Well, we are denying the increased funding level; 23 we are denying the developmental component; we are denying the 24 bioengineering. But we are saying more than that. Disapproval kce - Federa IReporters, Inc. 25 1of this application doesn't get to the heart of what's wrong 9 5 I with Missouri. 2 DR. THURYIAN: I think if the site visitors had the 3 courage of their convictions, and the wisdom of this review 4 committee behind them, they would get'to the heart of M issouri. 5 DR. BESSON: But you reassured me by disapproving 6 this application that we are'changing policy, and we are tellin@ 7 them that we disapprove of Missourils general program. But we 8 are not doing that by disapproval of this application because 9 this is an interim application that only asks for three addi- 10 tional bioengineering projects, plus a developmental component. 11 Is that correct? 12i MISS HOUSEAL: When you say interim, I'm not sure 13 what you mean. This is an application for the next year's sup@@ 14 that includes funding for core and their projects, including t-@- 15 support for the three computer activities and the developmental 1.6 component. It's for one additional year, the second year of 17 their triennium. 18 DR. BESSO!I: It's a different impact, though, in 19 keeping them at a level funding, and in concomitantly disapprove 20 ing this application, than in disapproving what they are 21@ doing which doesn't appear on this. 22 MISS HOUSBAL: Do you want an application before the 23 site visit goes out, or do you just want the site visit team to go out and get further information and then carry a message to ,ce -Federal Repotters, Inc. 25 the region? 9 6 .1 DR. MARGULIES: I think what you're doing in effect, 2 if I may say so, is saying that you are withdrawing the previou; 3 approval of a triennial award, and that what you want to do is 4 send some people out there who know what they are talking about 5 to give them an understanding of why. And the site visit is 6 sort of broad term, and what you are really advising is that 7 they be given straight information on what they are going to ha,'-,: 8 to do to have a Regional Medical Program. 9 DR. BESSON: If those words are included in the sub- iO stitute motion, disaooroval of the previously approved tri- 11 ennial award, then tl-iere's no problem, I think. 12 DR. TliU@IAN: Them I'm perfectly willing to accept 13 it as Dr. Margulies has phrased it, because that was my intent. 14 DR. SCIIMIDT: Do you have a comment? 15 MR. GARDELL: If you disapprove the application, re- 16 gardless of what council does, we cannot make an award without 17 an approved application. So we would have to get something .@rc:- 18 them between now and September 1 to make an official award. 19 DR. BESSON: I like the most recent wording better. 20 DR'. SCH:,IIDT: All right, the most recent wording is 21 adopted by the mover and the seconder as part of the motion. 22 ilow, the funding level we are talking about is 23 $1,625,000. 24 I think we are in a sense moving toward testing the @-Fedetal Repotteis, Inc. 25 question. 9 7 John. 2 DR. KRALEIISKI: Let me see if I understand this. We 3 are suggesting now $1.6 million, a site visit, a new application 4 which we possibly will deal with before September. 5 DR. 14ARGULIES: No. 6 DR. KRALE@ISKI: And that funding level is going to 7 be $1.6 regardless of the site visit, or would you clarify that 8 for me? 9 DR. MARGULIES: The point is good, because you ar e 10 going to have to decide at what point you want to reconsider. 11 if you withdraw triennial approval, and if you say there must 121 a site visit and a new application, then you may want to set a 13' time for a subsequent meeting which is out of phase, if neco_ssa 14 to see if they can come back with some reconciliation in it and 15 new directions. Otherwise, it is pretty infeasible to ask the-. 16 to come in with a totally new application with about two to thr-4 17 months to do it. It wouldn't be realistic. You wouldn't get 18 anything good out of it.. 19 DR. THUR.NIAN: May I ask the question for information' 20 What good would a new application do at this point in time? 21 intent was that we would visit to do what you said in your last 22 statement. A lot more information on paper that is garbage is 23 still more garbage. So it would do us no good to have another 24 application, and if nothing else would raise their frustration kce-Federal Reporters, Inc. 25i level'almost beyond acceptance. 9 8 So my intent in the motion, which obviously has 2 never been clear, was that we would have a site visit reasonabl- 3 soon, and that in that interim there would not be a new applica-. 4 tion, but that instead, within the power of your office and 5 the council, that funding at the previously approved level, 6 1.6, not the 1.8, would continue until that site visit could be 7 again reviewed by this comittee which would then be in Septe:,nbei 8 DR. SCHERLIS: That is my understanding. 9 DR. 14ARGULIES: If you don't include an application, 10 then it could be done. DR. THURMAN: I am perfectly willing to have the 121 motion voted on on whether everybody wants another application, 13 but to commit more words to paper doesn't change the course of 14 the program. 15 DR. BESSON: I think as far as John's comment is 16 concerned, I think the words Harold used "as soon as feasible,"' 17 is the only reasonable approach;staff should arrange it at the 18 earliest opportunity, and we should visit, and then give the.-i 19 an opportunity to resubmit a new application after that 20 message is clearly verbally given. 21 DR. SCHMIDT: We could withdraw triennial status, 22 and then set a lower level for the second year, 1.6. And 23 that's what we're doing. 24 DR. BESSON: When is their anniversary? @ce - Federa IRepor ters, Inc. 251 MISS HOUSEAL: Their year starts September 1, 1972. 9 9 They would then be coming in with another application, a year 2 from now. 3 DR. SCHMIDT: That's reasonable, then. 4 DR. BESSON: So the new level of 1.6 would begin 5 September 1972. The site visit can be held at any time. They 6 would have ample time then for a new application. 7 DR. SCHMIDT: That's correct. 8 DR. SPELL,',W4: A year hence. 9 DR. SCHMIDT: Joe. 11 DR. HESS: I would again like to raise the question, and perhaps direct this to Dr. Margulies. Do you feel that it 12 takes a site visit to get the message across-to.Missouri, or 13 are there other established administrative mechanisms that can 14 be just as effective in getting the message to Missouri without 15 a site visit? 16 DR. l@RGULIES: I think it takes at least a site 17 visit, and a very carefully selected one. Yes, I think that 18 could be helpful, particularly if it is in the framework of re- 19 form. And it has worked in the past. There are unusually 20 resistant factors that we are dealing with here, but we will 21 deal with them as best we can. 22 DR. SCHMIDT: All right. It's getting on. I believe 23 we are ready to test the substitute motion then. Unless there 24 is strenuous objection, I will put the question. %ce-Federal Reporters, Inc. 251 All in favor of the motion please say "aye-if 10 0 (Chorus of "ayes.") 2 Opposed, "no." 3 (No response.) 4 All in favor of Sister Ann chairing the site visit 5 say aye. 6 (Laughter..) 7 MRS. KYTTLE: Donna, are we thinking alike on what 8 we have written here, withdrawal of the triennial status, 9 funding level for the upcoming year of $1,625 million, an earl, 10 site visit, rejection of developmental component, and rejec- tion of the bioengineering proposal. 12 DR. MARGULIES: Could I make one comment. This is 1 a very convenient time for me to do it -- we should have d@iiu L 14 the very first -- which is to let you all know what I hope you 15 do know, and that is the newly appointed Deputy Director of the 16 Operations Division is Judy Silsbee. This is a notable achieve- 17 ment. I, bring it up at the present time, not because I just 18 thought of it, but because it seems to me that one of the thing@, 19 she could do to really contribute and show how wise we were'in 20 choosing her is to lead us out of the Missouri wilderness. 21 That's combined with the announcement of the fact 22 that we're awfully happy to have her in this job. 23 MISS ANDERS014: Mr. Chairman, I hope that in this 241 next site team the members would be selected to reflect the new %ce - Federa IRepo r tefs, Inc. 25 @ direction of JUIP 101 I DR. SCHIIIDT: I think there is a lot hidden in that 2 remark. I'm not sure I understand the full flavor of it. 3 DR. BESSON: Mr. Chairman, one other thing. Now 4 that we are through with Missouri, I wonder whether this would 5 not be an appropriate time, since we obviously have been opera4k--- 6 ing under inadequate information as to what our responsibili- 7 ties as a review committee could entail, to ask whether we 8 coulcin't have a staff clarification by @iemo to review committee 9 perhaps council, outlining exactly what your prerogatives are 10 currently. We've got kidney, emergency medical services, anni- 11 versary review, our relationships with SARP and staff, the 12 regions. I think that would be very helpful to delineate our 13 areas of responsibility. 14 DR. @IARGULIES: I think that is a very good point 15 because these have accumulated, and to put then all together in- 16 one document would be very appropriate. 17 DR. SCIIERLIS: lie have a manual of operations. 18 DR. WHITE: I would think it terrible if we had to 19 have guidelines as to what we can do and can't do. What we.can 20 influence or not influence may be a different thing. But 21 council has to abide by whatever its decisions are going to be 22 and they must adhere, presumably, to whatever policy it estab- 23 lishes to guide its function. But I would hope this committee 24 could remain totally independent and recommend to council :e-F*al Reporters, In'5' anything it pleased to recommend. Whether they accept it 2 or 102 I not is a different proposition. We may be speaking in an in- 2 creasingly higher-pitched voice, but we've got to be heard. 3 DR. SCII14IDT: I think I can read Harold better than 4 I can from previous doctor associations, and so on, but I think 5 that was the message he was giving us earlier today, and was 6 sort of behind my comment yesterday, that you are what you do. 7 And I think Harold is saying that this committee really should 8 not hold back from doing what it feels is right and proper in 9 flexing its muscle. I don't think anybody has taken our muscle 10 away legally. If the thrust of Jerry's request is to get a clari- 12 fication of the charge to this committee, rather than guideline 13 or constraints or whatever, I believe that that would be a fair 14 request. I occasionally get requests from conlmittees to re@ 15 charge them or clarify their charge. 16 Len. 17 DR..SCIIERLIS: Two brief points. The reason I was 18 agreeing with what Jerry said was more in line with a definitio.- 19 of terms, particularly with new members, and what it means to 20 a region to be told they have a triennium. I am not talking 21 about proscribing the limitations of activities of this commtitt-- 22 but just getting down the jargon on what this means in terms o-' 23 whether these are contracts or not. 24 The other point I wanted to raise was that while thi-c ce-Federal Reporters, Inc. 25 is valuable, I find it less value to me than would be another, 10 3 I either substitutive or additional form of information. When 2 you are constricted to a certain number of letters to describe 3 a project, even the title doesn't come through completely. 4 While we don't look at individual projects, the flavor to me 5 of whether a region has certain directions lies in a little 6 paragraph discussing each individual project. l@ow, this doesn't 7 mean the entire project or anything else. 8 But the forme r yellow sheets I found to be invaluabl- 9 and frankly I got lost in a lot of material which I find less '10 clear and more obfuscating than helpful in terms of the follow- I 1 ing. 12 I would like to see, for example, as far as Missouri 13 is concerned, a paragraph about each one of the projects that 14 tliey have which I find difficult to obtain even from the total 15 application from the terms of their descriptions. What I am 16 asking for is what is present in only a few of these regions 17 at this time, a small paragraph describing the individual pro- 18 ject. 19 1 wish there could be some staff comment on this be- 20 cause I find the flavor of a'region lies in what it is doing, s me it's going to do. Its goals and ob' 21 not what it tell 3ec- 22 tives, they all read alike now, they've got this clearly, but 23 as far as the projects, this is how they translate it. 24 Is this a fair statement? 6ce-Federal Reporters, Inc. 25 DR. SCHMIDT: There are many heads nodding in assent 10 4 I around the table. 2 Bill, do you have a comment? 3 MR. IIILTON: Yes, I have a concern closely related 4 to that one. I was interested in background information, and I 5 know that going through the various briefing documents provided 6 on each of the regions, they vary somewhat in quality, and 7 while there appears to be a move to uniformize at least certain 8 of the material in accord with our criteria for evaluation, I 9 find it helpful to be able to refer to background, demographic, 10 geographical information. I find that is not consistently reo- 11 resented and not always presented with equal thoroughness. 12 Missourils happens to be one of the better ones I 13 have seen. It provides me with some information. It helps me 14 assess how well the region has made its plans in light of the 15 regional needs. 16 And I would like to make a bid for staff making a 17i more standard approach in that area, too, everybody provide 18 certain background data on each of the regions, in addition to 19 this additional information about progress. 201 DR. SC!IMIDT: I would agree in many respects the 21 old yellow sheets were a little more helpful to evaluate the 22 summary of the projects rather than to be one more time removed 23 in evaluating the evaluation of a.summary of the project. 24 Before we move to South Dakota, then, there is this ce.-Federal Spotters, Inc. issue,we have surfaced. Is there any other comment on this 25 - --I I @ Vs a lw r Vt do 0 to 105 I particular one? 2 All in favor of the motion, say "aye" again. 3 (Chorus of "ayes.") 4 Opposed, "no." 5 (No response.) 6 The motion is carried. 7 We will move on then to South Dakota. 8 I said that I did have a 1 minute, 33 second versio 9 of a review, and was sort of planning on this a week ago, and 10 thci McGovern started to win more, and I thought better of this and will give a 5 minute, 21 second version. 12 This region is not ratable on your sheets this time 13 because what we are reviewing is an application for a planning 14 grant, and the review criteria et cetera, are so much oriented. 15 toward operational that I agree with the staff it's essentiaii,,rl 16 unratable. 17 South Dakota used to be married to Nebraska, as was 18 brought out yesterday, and early on it was a happy marriage wi-.. 19 good otential and most people agreed that the couple should p 20 produce marvelous projects together. 21 But South Dakota became a little unhappy. She began 22 to feel that the marriage was an unfair partnership. She did a 23 lot of drudgery without getting too much glory, had a lot of' 24 ideas. The good ideas seemed to be implemented in Nebraska and kte-Federal Repottefs, Inc. 25 not in South Dakota. She felt neglected,and suffered from lack 10 6 I of affection and attention. Core staff seemed to be developed 2 more in l@lestern Nebraska. All the meetings are Eastern Nebras- 3 ka. All the meetings were held there and not in South Dakota 4 which forced South Dakota to come always to Nebraska. Only a 5 few projects got going in South Dakota, and she just felt she 6 wasn't fulfilling her potential as an individual program. 7 She asked to change the marriage vows more to a. 8 partnership contract, and there was some attempt to work this 9 out but it didn't really come to any good end. She did not 10 feel liberated and filed for divorce. There was a site visit mounted in October of 170 iDy 12 council to South Dakota to look at this. And the site visit .13 recognized that the RAG for the combined region was too large, 14 was not functioning well, particularly for South Dakota. The re 15 were problems with the dean of the two-year school of medicine 16 in South Dakota. There was no full-time coordinator for that 17 subregion, and very little staff expertise in a relatively 18 have-not state. The State had-become disenchanted and,save f ri 0 19 a coronary care unit training projects, which they are very 20 enthusiastic about, have lost enthusiasm for the activities 21 there. 22 The recommendation of council was a new region be 23 established, that they be given planning funds, that the corona-- 24 care training projects which were considered valuable by both 4kce - Fedefal Reportefs, Inc. 25 site visitors and the region be continued. 10 7 I So that on 1 January 1971 South Dakota was officiall- 2 designated a region. However, they were not funded independenl--- 3 ly until 1 July 171, and a new and very good coordinator did 4 not come on board until 1 September 1971, and within six months 5 they were charged with coming in with their application. 6 This planning application, which is asking for very 7 modest levels of support, they seemingly have a good start wit'-. 8 some good people. And my recommendation will be the same as 9 the staff's, and that is that the application be approved at 10 the funding level requested. The coordinators mentioned is good. They have 12 structured a Regional Advisory Group that is interesting. It 1 bei ng consumers,and serves as the governing 13 is.41 members, 2 14 body for both CHPA in the State, as well as the Regional 15 Advisory Group. They have worked out a sort of a common cause 16 in which the CHP will be dealing with conceptual planning ana i@ 17 general strategical affairs, and the @4P will @e implementing 18 and more concerned with tactical aspects. The two directors, the directors of CliP and @.IAP are 20 different individuals and they work well together and are cor.- 21 municating well. 22 The core staff is small but dedicated and competent, 23 and they are building a good staff. South Dakota needs more o-- 24 less one of everything, and they are trying to bring in co,.- @ce-Federat R@pottets, Inc. 25 petencies needed in the State. 10 8 I They are somewhat weak now as an organization. They 2- have very little bench strength, as I have intimated. There is 3 no evaluation competence on board right now and an inadequate 4 field staff, but they have plans to obtain these. 5 The Chairman of the RAG is an excellent person about 6 whom this committee will learn much more in the future. 7 They have accepted a problem or ientation way of plan- 8 ning and have established some early-on goals and priorities 9 listing emergency health service as number one, and this seems 101 appropriate for .South Dakota; chronic care, number two; acute 11 care, three; preventive care, four; subacute care, five; and' 12 custodial services, six. 13 They aren't quite sure why they chose these. Some 14 of it obviously is guessing at what the Federal Government want<,: 15 and yet they have done some good thought in these areas, and 16 again under the planning grant will be refining these and 171 coming up with a program. 18 Dr. Lowe has an evaluation letter in the application, 19 and one is impressed reading the letter. He mbLkes cases well. 20 fie has gotten around the State. Just for one example, he has 21 visited every hospital in the State at least twice already. 22 lie has been an aggressive, active person, and I think has great ?3 promise for becoming a leader in that area of the country. 24 The reconstituted Regional Advisory Group is quite ,ce-Fedefal Reporters, Inc. 25 engaged in the program. They have more than 80 percent attendii 10 9 I their meetings. And interestingly enough, the divorced partner!@ 2 are seeing each other frequently. They are still dating on 3 occasion and are talking about cooperative efforts between Sou@@' 4 Dakota and Ilebraska where these are appropriate. They are 5 having development meetings for the Regional Advisory Grouo, 6 even giving them training sessions in management, and this sort 7 of thing that is interesting and kind of acute. 8 They have'some problems" and I have a few questions 9 about what they are doing, but I really don't fear that they 10 will recognize their problems and move to correct them. I believe that their request for funds to support 12 planning studies and feasibility studies is very reasonable. 13 They seem to have structured a good review system of activities 14 less than $1,000. The coordinator will be free to make commit- 15 ments of funds. The executive committee of the RAG must be in- 16 volvea- in projects between $1000 and $2500, and anything costi.-4$ 17 more than $2500 will be evaluated by the whole Regional Adv,-sor-., 18 Group. 19 They.need to develop a program. I think they can. 20 The coordinator comes through, on paper at least -- I have not 21 visited there -- he'seems so potentially attractive that I hop- 22 that he is used in site visits and brought in here to head- 23 quarters and oriented well and supported by staff. I believe 24 they need help from good regions in setting up their processes, ice - Fedeta I R6por te f s, Inc. 25 but I'am kind of excited about what they have the potential for 110 doing. 2 My recommendation, therefore, is strongly for 3 approval of this planning application at the level requested, 4 with continuation of the one tripartite project for the remain-. 5 ing year of this project, the coronary care unit, nurse training 6 and other training activities. 7 The secondary reviewer, Dr. Ancrum. 8 DR. ANCRU14: Well, only having the same material than. 9 Dr. Schmidt reported on, there isn't too much that I can add to '10 it. By and large I concur with all the things that he said about the program. 12 Looking at the time'that they have had to plan and 13 develop potential programs, they have done a fairly good job 14 on it, and I think with realistic approaches. When I first read 15 it, I had questions about the small feasibility studies for 16 developing the programs, but then after reconsidering the man- 17 power available and the population characteristics and density, 18 that this probably was the best way to go about it. 19 In terms of their minority structure, they seem to be 20 moving toward this direction. They have a small staff now 21 both for theirRAG and for their core staff, and they do have 22 tv:o Indians, I believe, on the core staff. And they are making@ 23 an attempt to get other minorities involved in the program. 24 DR. SCHMIDT: Thank you. Would you second the motic.- kce-Federal Spotters, Inc. 25 that was made? I S, I'll second it. DR. ANCRUM: Ye 2 DR. SCHMIDT:' The motion is seconded'. Are there 3 questions, comments? 4 Bill. 5 MR.- HILTON: I don't see any mortality data on this region, but I assume with the emphasis on coronary care, that 7 would be the major concern of this region? There are no other 8 area focuses that 9 DR. SCHMIDT: I don't believe that's entirely accura; '10 This project is a hang-over in a way from the early days a couple of years ago when these were the things to do. It was 12 really the one attractive type of regionalization type of getti: .13 across the State type of project that was mounted in South 14 Dakota, and was considered to be a very good thing to do. And 15 it has been supplying a great need for the hospitals in South 1.6 Dakota to at least get nurses in that know what to do in certai 17 emergency situations. But this is really not their top need or 18 their top priority, which they-have given, at least initially, 19 as emergency health services'. You see, this is a planning 20 application, and they will be coming in with the sorts of data 21 that will back up their program in a year when they apply for ai 22 operational program. So this is not even in an operational 23 status as yet. 24 SISTER ANN JOSEPHINE: Dr. Schmidt, I wonder if -ce-Federat Repofters, Inc. 25 Harold might want to comment from staff. 112 I DR. SCHMIDT: Harold made a most recent visit Out 2 there. Harold? 3 MR. OIFLAIIERTY: I would only echo the sentiments 4 that have been expressed here, particularly with respect to the 5 'coronary care unit nurse training project. This was the rem- 6 nant left over from the bi-State region, and it has been the 7 major entree into South Dakota at this juncture in giving them 8 some continuing visibility. The program has put together what 9 appears to be a good staff. They have set direction. They ha%- 10 set a somewhat unique approach to planning which you may find interesting in that they have established what they call the 12 problems in delivering health care. And related to these 13 problems is the resources that will be necessary to augment 14 present facilities and resources in order that the present 15 delivery system may be enhanced. And it may be more canable 16 of providing better health care. 17 So they are extremely sensitive to the needs o'L the 18 health care system. They are working consistently with them. 19 Given the-fact that Dr. Lowe came on board September 1, they 20 are moving systematically, albeit deliberately, to develop a 21 three-year plan that is reflective of the needs of the region 22 with a couple of major programmatic thrusts that have been 23 reduced to time phase objectives which would include the 24 terminal points for evaluation. This is the kind of consulta- e -Federal Reoorters, Inc. 25 tion and guidance we have been providing them. This is the 113 I type of thing they see to be their need to develop real pro- 2 grams instead of a conglomerate of disparate projects. 3 DR. SCHIIIDT: Thank you. 4 Mr. Parks. 5 MR. PARKS: I wanted to get some clarification on a 6 few things. Dr. Ancrum, I think, according to the report I 7 have here, there are two Indians on the Regional Advisory Grou@ 8 and none on either core or project staff, unless there has been 9 some change. 10 I think well, let me ask a question. Is there some reason why the university medical school is the total 12 source of personnel for this particular project? 1 3 MR. O'FLAHERTY: Do you mean, sir, the program sta-'4r unit project? 14 or coronary care 15 MR. PARKS: The program staff for personnel. 16 MR. O'FLAIIERTY: In fact, they have not really been 17 the total support. They have brought on some iDeople that have 18 heretofore not been associated with the university. The 19 director principally was the assistant commissioner of health. 20 Ile have addressed this issue with them, of the 2 1 minority group interests, and you may find this interesting, t4-1;-: 22 Mr. Abel Redfish, who is a member of their Regional Advisory 23 Group, of the Sioux tribe, has been recently appointed as the 24 chief executive officer in the Governor's cabinet for Indian -e-Federat Repofters, Inc. @ affairs. I had the occasion to spend some time with him 25 114 I personally two or three weeks ago in South Dakota, and he feels 2 that the region is somewhat sensitive to the needs of the 3 Indians. But he is preparing for me his own independent assess- 4 ment of the health care status and sensitivity of this program 5 and other related programs to the needs of Indians. 6 MR. PARKS: That's sort of like the black that they 7 appoint to a government position who is in charge of the black 8 problem. He certainly should address i t in a way that is going 9 to be salutary for whatever is going on. 10 But my question is: You tell me, for example, that 11 Dr. Lowe is connected wit4 what was it? 1 2 MR. OIFLAIIERTY: State Department of Health. 13 MR. PARKS: He is listed her as being affiliated 14 with the University of South Dakota. 15 MR. 0"FLAHERTY: They're the grantee. 1 6 DR. SCII)'.,IIDT: There's a chance for confusion here. 17 This is a two-year medical school. They do not have clinical 18 departments. The people that get engaged in the projects,be- 19 cause the medical school is the grantee, and pays them, get. 20 listed -- and I believe the problem is that these are listed 21 as being associated or affiliated or something with the school, 22 but there reall isn't a clinical school, and I believe that y 23 the impression that's being given these are all from the schoci 24 is incorrect by the table that you're looking at. ,-Feqe,al Reporters, Inc. 25 MR. PARKS: Is that right? Then this is inaccurate. 115 I MR. O'FLAHERTY: Yes. 2 MRS. KYTTLE: Mr. Parks, it's that the university 3 is the grantee, and when these people join this program they 4 become the employee in that light of the university, because 5 the university receives the funds and pays them, and therefore 6 in that sense they become an employee of the university. 7 1 think Jerry Gardell could probably give you,-- 8 MR. PARKS: Is it that the program, is not a body 9 corporate politic. Is that what you're saying? -And the uni- 10 versitv is and handles it for payroll purposes? 11 MRS. KYTTLE: Yes. And that's why that column 12 comes up listing them as affiliated with the university, becaus- 13 indeed they are for payroll purposes. 14 MR. PARKS: Okay. Then your form should be modifiec-, 15 I think, to reflect that kind of thing. 16 DR. SCHERLIS: Look at the front. You will see that. 17 MRS. KYTTLE: That is not to say, Mr. Parks, in som@- 18 programs there are people who are giving x percent of their 1 9 time to RIIP. 20 MR. PARKS: Well, my question has been answered. 21 And that is that there is a reason why the core staff is 22 listed as university personnel, which was my question. 23 The next question that I would want to address goes 24 to a comment that Dr. Spellman mentioned yesterday, and that ,al Reportefs, Inc. 25 1 was the fact that a sick physician was a sick provider. And in 116 the report of the principal reviewer, the suggestion was that 2 there was an adequate and substantial consumer participation on 3 the RAG. And I would like to know just how that's determined. 4 DR. SCHMIDT: I am not sure I understand the ques- 5 tion. 6 MR. PARKS: I believe you gave a figure -- 7 DR. SCHMIDT: Yes, 21 of 41 people on this body that 8 serves both CliP and PJIP are listed as consumers. 9 MR. PARKS: I was wondering how you determined that 10 they were consumers. When I see categories of representation, 11 I am not able to just gather how that is determined.' For 12 example, we have the sales manager for the Blac)@ Hills Clay .1,3 Products, and I-le is listed as a public member. Is that a con- 14 sumer? And the retired banker who is a public member. And 15 then the retired Indian agent. I take it these are consumers. 16 DR. SCHD-IIDT: The CIIP has rules about determining 17 and guidelines for determine ng consumers or public members, and 18 we accepted their review and designation of this. 19 MR. PARKS: The reason why I asked was because in 20@ scanning this, there is an almost direct connection with what. 21 1 in an urban area would be called a board of trade. For example, 22 the retired farmer, it turns out, is listed as the public removed 23 but he is the President of FE14 Electric Association, Director 24 and Past President of the Rural Electric Association, and so on. :e-Federal Reporters, Inc. 25 It goes down in here. For example, there's a farmer here who 117 I is listed as a public member. He's the chairman of the Miner 2 County Board of Commissioners. 3 I am just looking in terms of so-called programmatic 4 direction with respect to attention u@on under-served people 5 and populations, whether in fact you have a "consumer" that is 6 representative of that group. 7 DR. SCEIMIDT: I looked through this, and my answer 8 to this, being quite familiar with South Dakota, is that the 9 answer that I accepted was to look at where these people are from. And he is chairman of the Miner County Board of Co,-,u-,iis- sioners, and in Miner County the Chairman of the Board of 12 Commissioners is someone who can read and write and has some 13 free time, and so on, from his farm. He's in Carthage. And 14 if you look at the geographic distribution of these people, 15 they are from Bell Fourche and Mission and Carthage and Raaid 16 City and Brookings and Phillip and Mitchell. They are well- 17 distributed people across the State. 18 MR. PARKS: The reason I raise the question is that 19 a program in this stage of development which is planning need 20 not get into'an operational or formalized state by a body 21 like this condoning the development of the processes which we 22 find in older and more sophisticated programs, to be now in a 23 state of rigor mortis concretized.- For example, the question 24 about your minority involvement ought to be raised, and it e-Federal Re@orteis, Inc. 25 ought-to be monitored very carefully while this is in the I planning stage. 2 With respect to the composition of the RAG, it ough@, 3 to be examined very carefully as to the genuineness of the 4 interests that are supposedly represented there. 5 I think we would be doing, I would say, great 6 honor to the purpose for which we are serving here if, in this 7 planning stage, we did work with them to prevent error rather 8 than a year or so hence, looking at them with a microscope 9 saying that they have 10 DR. SCIII'4IDT: I certainly agree with you and would 11 accept your statements as something that should be conveyed 12 back to the region. I can't probably put my finger right now 13 on why I was led by the reading material to believe that they 14 are very aware of the minority representation problem that the% 15 have. There are positive statements that they will involve 16 minority groups in the workings of the program. I think it's 17 in the coordinator's letter. 18 DR. AINCRUII: It was in some of the material I re- 19 ceivea, and I don't have it right now, that this was something 20 that had been discussed and there were efforts being made to 21 correct this. 22 Also, some of the things you brought out about the 23 participation, I was going to point out about the large rural 24 population and the inability of some of these peoule to par- :e-Federal Reporters, Inc. 25 ticipate because of this. I don't know very much about South 119 I Dakota. 2 DR. SCHMIDT: I hesitate to say why I know a lot 3 about South Dakota because I am ashamed of it. Why I know a 4 lot about it, I spent many years hunting pheasants there, and 5 now there aren't any pheasants left, and I left lead scattered 6 all over the State. 7 DR. KRALE;ISKI: Do ou have a lead poisoning proble:7. y 8 there? 9 MR. O'FLAIIERTY: Dr. Schmidt, at their recent 10 April 13 meeting of the Regional Advisory Group they revamped 11 the by-laws governing the program. They have specifically 12 delineated groups from which consumers would come. They have 13 established a nominating committee which would be comprised of 14 a majority of consumers. The same nominating committee will 15 now appoint providers or recommend to the Regional Advisory 1.6 Group that providers be appointed in that manner. They were 17 sensitive to our recommendation that this be taken out of the 18 realm of the speculative and put in the realm of performance to 19 meet these kinds of specifications. 20 DR. SCHMIDT: All right, are there any other com- 2 1 ments, questions? 22 MR. HILTO!I: This is not with respect to the 23 motion, but I wanted to mention, before I forget: Lorraine, 24 do we have any guidelines, or anything asked for in any of the .e-Fedefat Repoftefs, Inc. 25 forms, to give us any idea what percentage of time is given to 120 I RYIP? I know on some of the sheets, in the kind of situation 2 that was discussed earlier, the possibility of there being some 3 confusion of the affiliations of the granting organization. 4 DR. SCIIMIDT: Yes, the budget sheets list the people 5and their percent of time. 6 MR. HILTON: And the other concern I just want to 7kind of amplify -- and I notice it has come up with other 8regions -- the definition of.consumer. I think what many of us 9feel a real need for is to have representative consumership, -10 that is economic cross-section of each area, and a tendency to 11 lelect as chairman of the board -- and in not all instance is it 121just the guy who can read and .write. In the larger urban set- 13 tings it becomes a guy who is very far removed from the po.Qula- 14 tions that are supposedly being served in some indirect way 15 through all this. And I wondered if there were any guidelines, 16 through Ci!P or Ri'vIPS, that spe cifically designates -- I don't kno-. 171how you would go about it, by annual income or what have you 181that there be alcross-section in the consumer body. 19 DR. SCfl,4IDT: There have been guidelines promul- 20 gated for choosing RAG members. I think probably historically 21 people who were chosen were non-physicians with clout. And we 22 have been moving away from that in many of the programs. But 23 the criticism is a very valid one. It's the same thing that'- is 24 eing faced all over the country by hospital boards of trus- -Fedeial Repotters, Inc. 25 1ees that generally have corporation presidents on them and 121 nobody from the community on them. This is changing, and I 2 think this will change, too. 3 All right. Are there other comments? 4 I would interpret most of the things that have been 5 said as being advisory to the region and concerns. I would 6 ask before putting the question to the vote whether anyone was 7 concerned with the level of funding or giving them this amount 8 of money. It's a moderate amount. 9@ Unless there's strenuous objection, I'll call the io question. All in favor please say "aye." 12 (Chorus of "ayes.") 13 opposed, "no." 14 (No response.) 15 That concludes the formal part of the actions of 16 this committee. It is now 12:30, and I think we should decide 17 what we want to do at this point. There are two or three things 18 that we ought to do, I think. Bill Mayer left us with a list 19 of two or three things. One we have talked about during the 20 morning. It's the emasculation issue that I think probably may 21 not be as vital an issue as before. There were questions that 22 ',Ir. Parks had relating to council feedback, and there was the 23 issue of a chairman for this committee. 24 If the committee wished, Mr. Dick Clanton could make -Federal R60ortefs, Inc. 25 a report to us concerning civil rights. This could be left to 122 I the next meeting. So we could go for a little while and then 2 break up. We could have lunch and come back for a little while. 3 We could stop now. 4 What is the desire of the committee 5 DR. SCIIERLIS: I would suggest we remain here and 6 finish. I don't think that there is that prolonged a discussion 7 required unless it is the view of the chairman otherwise. 8 Is Dr. Margulies free? 9 DR. PAHL: I think he had to leave for an NIH 10 meeting. DR. SCHMIDT: Harold told me earlier he would be herE! 12 until about noon, and tj'ien I missed him when he got up and le'Lt. 13 So that I can't answer that. 14 DR. PAHL: Let's call upstairs and find out. 15 DR. SCHERLIS: I would suggest maybe we could stay 16 and finish. Is this an ope n session or executive session or 17 what? 18 DR. HESS: Before staff leaves, there is an issue, 19 a question I would like to raise, apart from these three issues. 20 DR. SCHMIDT: The floor is yours. Would you talk 21 into the mike, please. 22 DR. HESS: We have for a number of years now been 23 placing emphasis on the gathering of evaluative data that would 24 assist in decision making. And one of the problems which I fin--' .e- Federal Reporters, Inc. 25 in looking at the applications and progress reports, and so on, 123 I is that that data is almost uniformly missing. lie see des- 2 criptions of the process, and summary-statements that evalua-, 3 tion is being carried out, but very little of the results of 4 that evaluation. And I am wondering 'if staff might give some 5 attention to seeing that that data appears in the applications 6 and that selected parts of it might appear i n the summaries we 7 get so we can begin to get a little better feel of some of the 8 outcomes of the results of all the money we areputting in. I 9 realize I am asking a difficult question. It's a difficult 10 request. But I think that all the years we have been talking 11 about, we ought to begin to see some results surfacing here. 12 DR. SCHMIDT: Dr. Margulies is coming down and will 13 be available until 1:10,.is the answer to that question. 14 Does the staff or anyone have a comment, or is there 15 supplementary comment to what Joe said? 16 Pete. 17 MR. PETERSON: I think staff has been concerned with 18 this same problem. It is a long-standing problem. It doesn't 19 even get around to what I think you're talking about in the war 20 of evaluation. So for example, recently we have been looking, 21 just as an activity which is an intermediate step, and we find 22 that these are often lacking in and of themselves. 23 It is a concern at the regional level, too -- at 24 least in some of the regions they feel that some of the evalua- .e- Federal Reporters, Inc. 25 tion activities that have been undertaken don't allow themselves 124 I to be reflected adequately in the present application. On the 2 other hand, a number of regions have begun as a course of sub- 3 iaitting some of that as a supplemental to the application. 4 I think from looking at it, Dr. Iless, some of it, at 5least some of the more recent ones, I think it's a problem that 6has to be worked at and is one and I know you and I have 7talked about this a little that particularly in relation to 8triennial review in connection with site visits -- and I go back 9to, for example, the site visit you and I participated in, the 10 Greater Delaware Valley if you really highlight it in those 11 instances, I think often we are faced with a lack rather than 12 the presence of it. 13 DR. IIESS: My point is that if we continue to be 14 content to just having the process described and not seeing the 15 results, that it means that we continue to have shoddy evalua- 16 tions. On the other hand, I think perhaps there is some data 17@wiiic.-I is available which may be worth seeing, but we never 18 asked for it. It is not required. And I am just suggesting we 19 begin to require the inclusion of outcome type evaluation in' 20 fact on health care in the applications. 21 MR. PETERS014: One of the things we have discussed 22 in connection with the present application form is the possi- 23 bility for some other additional information. One specific, 24 and it is only one of several things, is perhaps the desirability :e-Federat Reporteis, Inc. 25 of seeing, on activities that have been constantly completed, at 125 least with the @IP supported and placed out, something in the 2 nature of a termination report some time after the activity 3 has really been completed that would provide some of the infor- 4 mation I think you are talking about, as well as information 5 which I think is critical in terms of the sustaining of an 6 activity once P14P support has been phased out. 7 That is one of the few areas in which I think we can 8 present some fairly hard data. That doesn't tell you anything 9 about the impact of the activity, but at least it begins to 10 speak to the success, whether it is a categorical activity or 11 something quite comprehensive, success with which a region can 12 initiate efforts and can see them carried on within the 13- regular health care planning. 14 So I think there are points with which we can begin 15 to present some valid data, and I think this has been an area 16 in which the committee has begun to make gross judgments, the 17 inability to get out from underneath activities. It doesn't 18 say anything about how meritorious they are. 1 9 DR.IIESS: ;Iell, I just feel we don't -- 20 DR. SCIIMIDT: Joe, the stenotypist simoly cannot 21 hear you. I-lould you speak into a mike, please? 22 DR.IIESS: I just want to reemphasize that if we 23 don't start insisting on seeing it, I don't think we are ever 24 going to get it. I just feel that we've got to take a much e- Federal Reporters, Inc. 25 firmer stand on this than we have in the past. 12 6 I DR. SCHMIDT: All right. other comments? 2 I would guess that the committee would agree with 3 you in those comments. 4 All right. Does anyone wi'sh to pursue the issue of 5 the charge to the committee or the actions of the committee, 6 the constraints on them? Are we agreed, Harold, that there will- 7 be some clarification of these issues coming from your office 8 or staff? 9 DR. I.IARGULIES: Yes. 10 DR. SCHMIDT: Mr. Parks, you had some queries. 11 MR. PARKS: I had a request for answers. At the las-- 12 meeting of the committee, we formulated several questions which 13 were supposed to have been put to the council. And I have.not 14 been informed that the council either entertained them or acted 15 on them. I do not have the specific articulation of them, but 16 the one that I'm particularly concerned about did have to do 171 with civil rights. 18 And my questions are, first of all, did the council 19 receive it,.did they act on it and, if so, what action? What 20 was the result. 21 DR. SPELLI@I: I wasn't at the last meeting. What 22 was the question, more specifically? 23 MR. PARKS: There should be a stenotype report of the 24 last proceedings, and it might be well and helpful, I would e -Federal R@porters, Inc. 25 think- if the proposition was stated as it was put to council. 12 7 I DR. SCIII,IIDT: I'm afraid I can't be- helpful because 2 I was not at the last meeting myself. 3 DR. MARGULIES: We had intended to bring this up on 4 the agenda yesterday, but Mr. Clantoh couldn't be here. We 5 have asked him to be here today, and I think he can be respon- 6 sive. 7 MR. CLANTON: Let me just say at the outset that 8 since assuming the position of EEO officer for PIIPS, I share 9 the concerns that I've heard in the past few minutes of some @10 of the committee members. As I look at the ethnic profile of 11 many of our Ri@P's across the country, as I look at the profile 12 of our program staffs, of our Regional Advisory Groups, and of 13 our local advisory groups as well as committees, I certainly, 14 share the concerns that I've heard in the past few minutes. 15 Since you last met, thd RMPS EEO office has been 1.6 reorganized. We have broadened the scope of activities to in- 17 clude addressing the issue of civil rights in the @IP's. Ile 18 are still in the process of recruiting staff, and we are 19 hoping thatin the not too far distant future we will have our 20 full complement of staff. 21 We did get involved -- I got involved -- at the 22 point when I was asked to make a presentation to the National 23 Advisorv Council to reflect the committee recommendation at 24 your last meeting. I talked to the council in terms of civil e-Federat Reporters, Inc. 25 rights compliance of grantee institutions, the requirement to 12 8 complete the Form 441, which guarantees in so many words that 2 a grantee will bein.compliance with the Civil Rights Act of 3 1964. 4 In addition, I pointed out to them some of the 5 activities which we would be proposing in the coming year. 6 I also presented them with your recommendations, ana 7 I now read that to you. "The review committee recommends to council that 9 council establish a policy in which they instruct those par- 10 ticipating in the review process,, whether that be site visit or 11 this review activity, that a special interest be given to and 12 attention to the issue of compliance of the individual regions 13 with the Civil Rights Act. And that as a part of the review, -14 that documentation occur in each and every instance that has in 15 fact occurred in the review process. And if in fact the re- 16 viewers felt that there was some question of compliance,'that 17 they would have the right and responsibility to request that 18 appropriate review of thztissue occur." 19 This was presented to the National Advisory Council. 20 A@lie council endorsed this recommendation and approved it, which 21 I feel gives us the leverage that we need to go about the 22 business at hand. 23 In addition, I would call to your attention the 24 PIIP5 affirmative action-plan which, incidentally, is considered e -Federal Repo(ters, inc. 25 in many circles' as the best affirmative action plan in this 12 9 I agency. And incidentally, I will be mailing copies of the plan 1 2 to each of you. I call to your attention Dage 40 of the plan 3 which deals and addresses the issue of civil rights in the 4 Regional Medical Programs, and I read to you some of the action 5 steps: 6 111. The Director, RMPS, will appoint a study grouo 7 composed of, but not limited to, representatives from the 8 Operations Division, the Youth Advisor@ Council, RMPS Minority 9 Caucus, R:,IPS Women's Group, Office of Communications and Public .10 Information, the EEO Council, and resource people from outside 11 of @,IPS, to define the responsibilities for implementing and 12 monitoring an EEO program in the 56 @IP's." 13 This is one of the activities which we will be about 14 in the very near future. 15 "2. Site visit teams will be constructed in such a 16 manner that the objectives listed above are dealt with on all 17 1 site visits. 18, "3. Site visit reports will include a comprehensiv 19 section regarding progress toward effective implementation o@4 20 RI.IPS EEO goals and objectives. 21 "4. The Director, Operations Division, will review 22 the EEO Section of the site visit report, and quarterly renort 23 to the Council on the EEO progress in the 56 PjIP's." Again, I say the Director, Operations Division. 24 Reporters, Inc. 25 "5. After the completion of the study group's 130 report, an abridged version of the RMPS affirmative action 2 plan will be distributed to the @%IP's. 3 "6. The Office of Communication and Public Informa- 4 tion will regularly distribute EEO information to the RMP's." 5 Now, this plan has the endorsement of top management 6 at the agency level, and has been endorsed by the program 7 director. And we feel this, in addition to the council approva.-l- 8 of your recommendation, gives us the leverage that we need to 9 go about the-b usiness of EEO within the RMP'S. io I would close by saying that we soli'cit your support, we solicit your suggestions and your recommendations in improv- 12 ing our efforts here in helping us in these efforts. We will 13 need your help, certainly. We are in room llAl6. If you want 14 to write to us individually, feel free to do so. Call us. We 15 need your help in the effort. @16 DR. SCII14IDT: I would like to request that copies c-@ 17 the plan be sent to review committee members. I think it i,7oul@@ 18 be imperative we be familiar with this. 19 MR. HILTON: May,I ask what is the expected size of 20 your staff? 21 MR. CLANTON: The staff will be three people, as it 22 currently stands. Of course, we are hoping for more. 23 DR. SCHMIDT: All right. Are there questions? 24 Mr. Parks. e - Fedetal Reportets, Inc. 25 MR. PARKS: Mr. Clanton, you have just-announced 131 I something to us. It would be helpful to me if you could get 2 the exact wording of the action of the council. That would be 3 very helpful to me. 4 The other thing that I would ask, beyond the announc2. 5 ment you have-just made here today, has this been brought to 6 the attention of the staff that is involved with these particul@- 7 programs? That is the first question. 8 Secondly, will it be in the immediate future com- 9 municated to-the various RMP's so they would be on notice. -10 Third, could you provide us with the information 11 pertaining to the various civil rights acts and the provisions 12 which HEW has published in the Federal Register with respect 13 to programs funded by HEW which are found not to be in compli- 14 ance with the several civil rights acts and regulations. 15 MR. CLA!ITON: Gladly. 16 MR. PARKS: Thank you, sir. 17 MR. CLAINTON: In answer to your second question, 18 which had to do with communication to the staffs of RMP'S, we 19 have begun to interact with several of the @@IP's, not all, to 20 date, several who have indicated an interest in recruiting in- 21 dividuals for their program staffs. We did distribute to 22 the council members, as well as a number of consultants to the 23 program, copies of the affirmative action plan. A number of 24 the @@'s now have the affirmative action plan. As a matter e-Federal Reportefs, Inc. 25 of fact,, as the representatives from the program staffs come 132 I in to visit us, we provide them on the spot with a copy of the 2@ plan. So there has been some communication to some of the 3 p,4p,s, not all. 4 DR. SCHMIDT: Bill. 5 MR. HILTON: I was simply going to suggest, Mr. 6 Chairman, that as a national'conmiitmentl and as the opportunity 7@ now presents itself with the unfortunate departure of four of 8 our members, we possibly ought to consider those areas that 9 are served by RIAP where we have large Spanish-speaking popula- 10 tions in the country that are served by RMP'S, I would hope 11 whoever it is that replaces those of us who retire or pass on 12 or something would consider having Spanish-speaking representa- 13. tion on the review committee in the future. 14 MR. CL@@TON: It might be interesting for you to knc.@ 15 your request has gone forward for -Spanish-speaking representa- 1.6 tion on this committee at this point. I believe for some 17 reason or another it has been tabled. But the request has 18 come from the program to include Spanish-speaking representa- 19 tion on this committee. 20 It would seem to me a statement from the committee 21 would certainly help us in this effort, some kind of a state- 22 ment to the agency. 23 DR. SPELLI%IAN: I submitted a name this morning of a 24 Spanish-speaking representative from the University of Puerto e- Federal Reporters, Inc. 25 Rico who I think wou ld make an excellent addition. 13 3 I DR. IIARGULIES: I think the word "tabled" is 2 probably a little misleading, Dick. What we havedone is to 3 provide names of people who vie thought would very well serve 4 the interests of Span ish-speaking people, which is not just a 5 single interest. If you have someone from the Southwest United 6 States, that's not the same as a Puerto Rican from New York, 7 or not the same as a @lexican-American from Cdlifornia. 8 We have run into a conflict of priorities for the 9 time being which @,ie simply have to sort out, because we also @-10 have to meet geographic needs, we have to meet the legitimate 11 and very pressing needs of representation by women, and there 12 is a requirement we have representation by people under the 13 age of 30. We also have a requirement to try to find some 14 people who have certain,kinds of professional skills and educa- 15 tional skills and educational interest to balance the whole 16 committee structure. 17 So it's a matter'of trying to maneuver through that 18 and still come up with what we.need. I recently had a rather 19 acid discussion on a related sub ect coming out of a Chicano 20 conference -- and incidentally, we are in the process of 21 sponsoring another one -- in which there was an insistence 22 that people dealing with Chicano affairs on committees be c'om- 23 petent to deal with them, and that there should be representa- 24 tion from the Chicanos on all their councils. ce - Federal Reporters, Inc. 21@ Some bright person in HSIAHA said that's fine but we 13 4 I must have evidence of competence. 2 And I said, "Well, that's all right, we'll have the 3 same evidence of competence we require for all of our cbm- 4 mittees, and what is that?" 5 Well, there wasn't any answer because we don't re- 6 quire that kind of thing in migrant health councils, and so 7 forth. 8 1 suggested that one of the better qualifications 9 for sitting on a committee to deal with Chicanos was to be a 10 Cliicano, and I continue to believe that's a pretty good idea. 11 Interestingly enough, I met an argument on that one as well. 121 I really did. I had a very severe argument over that. .13 But that's. what we are trying to get done. I think 14 we will succeed in getting that kind of representation on the 15 committee. I cannot speak for the council. That gets into 16 another area. 171 DR. SCliERLIS: How are you progressing as far as 18 replacements of this coi-nmittee-are concerned 19 DR. 14ARGULIES: That's a part of the whole thing. 201 What we'd like to do, of course, is maintain the high level of 21 competence that the committee has. And when you have people 22 like 13ill @layer leaving, you would like to have a replacement 23 somewhere near his qualifications. And then when you try at 24 the same time to meet the other requirements, the choices get :e-Federal Re@orters, Inc. 25 constricted and it becomes a matter of priorities.. So far as 135 1 I am concerned, representation of women and of Spanish-speaking 2 or Spanish surname people is the top priority, regardless of 3 other factors, but we have to deal with all of them. I think 4 we can manage all of them, but it requires a very careful kind 5 of analysis. 6 MR. HILTON: Is it-your judgment, Harold, that we 7 need to make a motion officially on this matter, or could it 8 be left at a suggestion? 9 DR. YIARGULIES: I think we understand the comiitteels 10 desires in this. As a matter of fact, it is a part of the 11 official policy of IIEW, and as I'm sure Mr. Parks can tell you, 12 it also represents civil rights legislation, so that I think 13 we can pursue it along those lines. It is really more a matter 14 of sticky process than anything else. 15 On this subject, if you would like any further 116 comment, Joe de la Puente -- I don't know whether Jessie is her2 17 or not but the two of them have been dealing with this par- 18 ticular issue, and we have set up a number of activities outside 19 of review committee and outside of R@IP to foster our involveme-- 20 with the Spanish surname group. 21 MR. DE LA PUENTE: I must say our activity has been 22 very intense since the recent Southwest conference for Chic'ancs 23 in San Antonio, which was sponsored by Dr. Du Val's office and 24 paid by @,,IP, partly. e-Fedeial Reporters, Inc. 25 As a result of this conference and a positive resons@- 136 for this conference, several activities took place. 2 First and foremost, we are going to have a conferenc@- north of Albuquerque run by the Cultural Awareness Center of 4 the University of New Mexico. In thi ,s conference we will have 5 all the coordinators of the seven Southwest States, the nine 6 coordinators of the different areas in California and appro- 7 priate staff, and pertinent staff here in RMP. We arelooking 8 forward to this conference. I think it's very timely. 9 Froia then on, there will be several activities that 10 will take place concerning the effective participation of 11 Chicano consumers in the decision-making and program planning 12 throughout those regions. We are looking forward to this 13 activity, and we are working very closely with Mr. Chambliss 14 in these efforts, because th at division concerns itself not 15 only with the minorities in the Southwest, the Spanish-speakinc- 16 people in the Southwest but also the Spanish-speaking people 17 throughout. And we are also working very closely with an urban 18 group that we will have some urban health conferences in whic- 19 these issues are going to be arranged. As a matter of fact, 20 1.1r. Wood fror.@ the New Jersey RI@IP is going to be at the confer- 21 ence in New Mexico as the liaison with the urban group. So 22 things are starting to percolate and we are looking forward 23 to it. 24 DR. SCHMIDT: Thank you'. @-Federal Reporters, Inc. 25 Jerry, did you have a comment? 137 I DR. BESSON: Yes, and I hope my comments are mis- 2 understood. I've been a critic so often of the way things are 3 done, it is delightful to see the alacrity with which there is 4 a response to this comment made at the last meeting, and I 5 must say, since I'm not going to be here again, that although a,- 6 this end of the table I have appeared to be critical of R14PS 7 and its seeming lack of responsiveness, I would like to say tha., 8 that is certainly more than balanced by the sense of responsive- 9 ness that I have felt emerging at this meeting. And it was 10 probably there right along. 11 DR. SCIIMIDT: All right. Thank you. Are there 12 other questions or reports? I have an uneasy feeling that 1 3 this was one of a number of questions that were posed, Mr. 14 Parks,, is that correct? 15 MR. PARKS: I don't recall specifically i-ilial@- they 16 were, but as I recall, there may have been another question. 17 wasn't on this particular issue, but as I recall there was at 18 least one other question that I think was referred to. I 1 9 don't recall what it was. 20 DR. SCII.'4IDT: Can staff help here? The discussion 21 at the last meeting. 22 DR. 14ARGULES: I think what happened is there was 23 a very good discussionabout it, and unless I am confused in mv 24 memory, Mr. Parks, there was a movbment in one direction which -e- Federal Repofters, Inc. 25 was then altered to produce the statement which went from here 13 8 to council, and you may be thinking about both. But I am 2 really not sure, but that is what our record shows. .3 Maybe I should comment to you about what our hopes 4 are for continuation of chairmanship @and of vice chairmanship 5 of this committee. What I wouldlike to do, as long as we are 6 able to keep him active on the council, is have Mack Schmidt 7 continue as chairman, and John Kralewski as the vice chairman 8 with the understanding he will assume the role at the time Dr. 9 Schmidt finds he also succumbs to time in the rules and regu- iol latioiis of the committee membership. DR. KRALEWSKI: That calls for comment. 'In keeping 12 with our institution here, I would say that in that statement 13 there is some good news and bad news. 14 (Laughter.) 15 I'm not sure which is which. 16 DR. SCilMIDT: All right. My leading instinct is 17 that we are coming to closure here. 18 John. 19 DR. KRALEWSKI: If we are off of that topic, I have 20 one other qu'estion I wanted to raise. "4aybe you talked about 21 this yesterday morning when I wasn't here, and if you did, 22 please forgive me. But since you are going to be reviewing 23 some substantial applications senarate from this review commit- 24 tee, such as the emergency health service programs, et cetera, e -Federal Reporters, Inc. 25 what mechanisms have you developed so that this committee will I 1 3 9 .1 be on top of the results of those reviews when we look at 2 regions and look at their total program and try to come to 3 grips with a total funding package. 4 DR. MARGULIES: Very briefly, we did discuss this 5 at length yesterday. lihat I explained was that v7e had to set 6 up a special review mechanism for both of these activities. 7 In other to meet that requirement, we established a review 8 committee for each of them made up of a combination of members 91 of this committee and members of council, and these will be 101 processed in time to go through the council. The results will 11 immediately come back to you so you know what action took place 12 and it will become part of the record of what is going on in 1 3 each Regional I-ledical Program. 14 DR. SCH14IDT: All right. Sister Ann. 15 SISTER A!iN JOSEPIIINE: I'would like to follow throug-. 16 on a comment that Dr. liess made earlier, and that is on the 17 material that is provided us for review. 18 The reason I feel that if we could develop a more 19 meaningful format of information we would possibly be able to 20 make better judgments and ask more correct questions is because 21 recently at the hospital I am affiliated with we developed a 22 patient drug profile, and it is interesting now that the 23 doctors look at the drug profile. It is making an imnact on 24 the-ordering of drugs for the patient. e- Federal Reporters, Inc. So I feel if we could develop -- and maybe staff 25 1 40 .1 needs to brainstorm this, and we have capable people on the 2 staff who have expertise in this area-- the kinds of profiles that will be meaningless at this point in time when we are not 4 only identifying the programs as A, B @nd C level, but we are 5 having an interesting opportunity where South Dakota, of course, 6 doesn't have the problem of large programs, where there are 7 conflicts between universities and schools of medicine, such 8 as we find, for instance, in Ohio where the conflict is between 9 lqe@tern and Ohio State. But we have a program that is still 10 in the planning stage that has some of these obscuring areas re- 11 moved from the picture, and whereas Mr. Parks indicated we can 121begin to concentrate and not keep on repeating the problems that 13 we see are emerging in other programs and have caused problems. 14 And I think we are fortunate to have a staff, Harold, who has 15 expertise in evaluation, and with this expertise will be able to 16 give them the kinds of help that a program in a planning stage 17 in moving toward an operational stage needs. 18 So I think that we are coming into a time when 19 there are many very basic things we can begin to identify, maybe 20 regroup and p@ovide a kind of new viability to programs as we 21 begin to look at a new direction, which is to insure the via- 22 bility of the total program. 23 DR. IAARGULIES: I would -just like to make one com- -but which also carries with 24 ment about that which is in support @-Federal Reportefs, Inc. 25 it some very frank expressions of concern for our present 14 1 .1 problems and problems that will persist. And these are in 2 violation of my basic principle which is that there is no point 3 in sharing my problems with you if you can't do anything about 4 it; they're my problems. 5 Nevertheless, the pillaging of staff in all of the 6 programs in liSIIIIA has been tremendous. We just put together 7 a list of people who have been taken away from us. of course, 8 when someone takes someone away to do something else, he always 9 wants the best possible person. So we have lost people on 10 detail after detail. We have tried to remodel the system of 11 review for the Operations Division so that their time is not 12 totally consumed with the review process because the other 13 thing we most want them to do is to serve as technical assis- .14 tants and deal with the kinds of issues particularly which we 15 just discussed, those which have to do with the interests of, 16 minorities, and those who are deprived. 171 So there is an extremely heavy demand on staff, and 18 at some points in the game, as a management principle, we have 19 to do some things better and some things less well. 20 I would be misleading you if I were to suggest that 21 we are going to amplify very rapidly or in great depth some of 22 the kinds of information which we would like to have i-n everyone 23 of the programs. Instead, what we will have to do is manage 24 this so we can concentrate as mucli-as feasible on problem areas @e- Federal Rpporters, Inc. 25 in the Regional Medical Programs with all the risks that that 14 2 entails, and I don't see any alternative. To suggest that 2 we can do it all is to send this staff, which is sitting around 3 here and some who aren't here, into a state of collapse because 4 they work extremely hard. 5 1 have to go over and negotiate with the,N@tional 6 Heart and Lung Institute right now, and I see my companion is 7 waiting for me to go, but before I do I would like to say again, 8 without overstating it in any sense, that the people who are 9 leaving this committee are leaving the committee with some 10 holes that just can't be filled no matter how well we do. 11 They are remarkably good contributors. It is going to change 12 things permanently. I know that you have said things to them 13 already, but whatever was said that was nice I support, and i 14 you thought anything bad I don't support it. They go with my 15 very deep thanks and with my blessings. And again my affirma- 16 tion of what I said yesterday, we aren't really going to let 171 them get away entirely. 18 DR. SClil'.IIDT: Thank you very much, Harold. We 19 appreciate your time that you've spent with us these last two 20 days. 21 Any closing comments? Jerry. 22 DR. BESSON: I'm sorry Harold left, and I really 23 should not usurp his last word, but I did want to follow up 24 on the' comment Sister made and he-responded to, because this is ce-Federal Reporters, Inc. 25 one subject that we have skirted around but haven't really 143 discussed, and I don't think it's appropriate at this time to 2 get into a long discussion of it, but I would like to raise it 3 for the review conimittee's consideration at a future time. 4 The sense of what I gathered that Sister has said on 5 more than one-occasion at this.meeting is that we are some- 6 times not asking the right questions, and that sometimes we 7 become so involved in the trees that we are not looking at the 8 forest. And this is something that has disturbed me a great 9 deal about the way the PL@IPS seems to be operating currently. 1 0 About a year ago the National Center asked me if I 11 would serve on a committee to evaluate the Center. And I was 12 privileged to do so and it was an outside look by people who 13 are not involved at all with the National Center. I know that 14 the Arthur D. Little Corporation did such a study for IUAPS 15 about a year-and-a-half or two ago, and that was a remarkable 16 document in nany ways and probably formed some of the basis for 17 the shift in direction of @@IPS. It served a useful function bu 18 in many_ways it was too ponderous to be helpful to the rank and 19 file. The summary was very helpful. But I think that that 20 kind of ongoing outside evaluation of IU,IPS is probably going to 21 be continually necessary if RMPS can maintain its viable and 22 responsive posture. I sense in many of the applications that 23 we've discussed over the past two days, Northeast Ohio, Okla- 24 homa, and I knowleven though we haven't talked about California -e-Fedetal Repofters, Inc. 25 that a recent action in the California Committee for Regional 1 4 4 1 Medical programs has for the first time created a breach be- 2 tween the practicing physician, as represented by California 3 Medical Assoc iation, and the entire Regional Medical Programs, 4 -n that California Medical Association Council, reaffirmed by 5 House of Delegates, indicated to California Regional Medical 6 Programs that they would only continue to cooperate with 7 Regional Medical Programs if Regional Medical Programs stuck tc 8 its original charge, which was continuing education and cate- 9 gorical interests, and did not begin to meddle in delivery. 10 Now, that may be symptomatic of what we're seeing in 11 the statements of Dale Groom,, p d in the statements erhaps, an 12 of Charlie If udson in Northeast Ohio and various places, which 13 may not be quite articulated. But I think that it does repre- 14 sent a potential problem for M4P and should be surfaced, this 15 committee should be aware of its extent and the extent of the 16 breach that may be developing, or maybe there was never really 17 close communication with the practicing physician, as I some- 18 ti,,:ies s-uspect, and this kind of information should be brought 19 back to review committee solthat in dealing with the individual 20 regions and in dealing with the individual decisions that we 21 have to make about the nitty-gritty, we can do it in the con- 22 text of viewing the entire program as serving a national pur- 23 pose. Is it on target? And if not, what are the impediments? 24 Unless we can do that, I think we can very often @e-Fedefal Re@orters, Inc. 25 be wide of the mark and spend much of our time fruitlessly in 145 .1 discussing details that may be totally irrelevant. 2 So I would suggest that this review committee, per- 3 haps at later deliberatioiis somewhere along the line, or perhaps 4 they might consider presenting to council the notion of doing this on an ongoing basis for review committee and council's 6 advice, to have an outside group -- maybe not as ponderous as 7 Arthur D. Little -- but to liave'some outside group put itself 8 in'a position of continually evaluating philosophy, purpose, 9 meeting of goals of the program nationally, rather than any 10 individual area. 11 DR. SCliMIDTt I suppose this is akin to a lot o'L the 12 universities that have vis4-Lors' committees, the same type of 13 function. 14 All righ@. Ot.1-i--r comments 15 (No response.) 16 Are we ready to -idjourn then? 17 All right. With great thanks, ;.7e will stand 18 adjourned. 19 (Whereupon, at 1:15 p.m., the meeting was adjourned.) 20 21 22 23 24 ,e-Fedeial Repoiters, Inc. 25