*EOO 143 Transcr ipt of Proceedings DEPARTMENT OF HEALTH, EDUCATION, AND WELFARE 14%'-@,S REVIEW CO@IMITTEE 14'0-ETING Rockville, Maryland Thursday, 21 Septeirber .19'72 ,kCE - FEDF@R:KL IIEPOIITERS, INC. Oificial Reporte7,s 415 Second Street, N.E. Washington, D. C. 20002 Telephone: (Code 202) 547-6222 NATIONWIDE COVERAGE t 7148 DEPARTMENT 'OF HEALTH, EDUCATIOX, AND WELFARE tAIG: paw 2 3 4 5 RMPS REVIEW COMMITTEE MEETING 6 7 8 9 Conference J"Ioom G@ 'LA' Parklawn Building Rockville, Maryland 121 Thur8day, 21 September 1972 13 14 15 16 17 18 19 20 21 A. X- 23 24 e - Federal Reporters, Inc. 25 2 C 0 N T E N T S R 7148 RAIG: paw .2 AREA: PAGE 43 3 Maine 4 Rochester 81 5 Central New York 134 6 Virginia 166 7 West Virginia 198 8 Albany 218 9@Hawaii 245 9 12 i3 1.4 15 16 17 18 19 20 21 22 23 24 e-Federal Reporters, Inc. 25 CR 7148 1 P R 0 C E E D I N G S 1 Reba 1 2 DR. SCHMIDT: Good morning. I missed my chance a i§Wles 3 minute ago, there was a little lull in conversation and ob- 4 viously it was time to begin. But someone said something and 5 I missed that opportunity. 6 I am used to a lot of feedback, from my Executive 7 Committee and its grouses that I work with, but it usually is 8 not as noisv as the feedback this morning. The room is turned 9 around and.there are some new audio equipment in here. We IO',-nay have a little more music than usual. in addition to the 11 new look of the table in the room there is a new look about the 12 table. 13 And first and most importantly we would like to 14 welcome some new members to the Review Committee and I would 15 introduce them to the other members of the Committee and to the 16 Staff and guests in the room. Immediately to my left, Mrs. 17 Maria E. Flood, no, I am sorry, down there. Hold your hand up 18 so everybody can see Mrs. Flood. Who is from the Texas @MP. 19 She is a staff person, a regional representative from El Paso. 20 And immediately to my left then Dr. Grace Jambs, who is a 21 pediatrician from Louisville, Kentucl@y. And on Dr. Brindley's 22,left is Dr. Bill Luainbuhl, Dean of the Division of Health 23 Services, University of Vermont from Burlington. Ile is on the Northern New England Regional Advisory 24 :e-Federal Reporters, Inc. Committee and is experienced in health care delivery systems 25 4 #1 and so on. So we welcome the new members to the Committee. I Reba 2 2 warn other committee members that the throe new members have 3 been working hard all yesterday afternoon. T hey have been 4 briefed and brought on board and made experts and I am a little bit concerned that they may be a little more expert in certain 5 6 areas right now than the rest of it. Is Henry here? Henry Lemon, our old friend, will 7 8 be with us for the site visit report to West Virginia. Henry 9 is.-@on vacation and he kindly agreed to come in for this session. And Dr. Simmons Patson, chairman of the North 0-arc!4@k-Aa Ti@4AP, will report on the site visit to Central New York. Dorothy Anderson is ill. Dr. Andrum is ill and won't be with us for 12 13 this session. Dr. Toomey is coming a little late. Dr. Brindley 14 unfortunately can be with us only today. Another announcement 15 is that Sister Ann Josephine is practically enroute to Rome for 16 a sabbatical year of study. She, this is her last meeting, there- 17 18 fore,, and I really need not express to the group the loss that 19 this committee will feel when she i.s no longer sitting there 20 holding down the fort. She has been in Salt Lake City for what did you say, 21 221 34 years? And this will really be a sabbatical for her. You 23 are really supposed to get one every seven years, not every 34. 24 But we thought this afte.rnoon that we would celebrate what I e-Federal Reporters, Inc. think is an exciting and happy event for her, and we will have 25 5 coffee and a little celebration this afternoon. Mr. Parks has Reba 3 resigned from the Review Committee, because of other pressing 2 3 priorities and time commitments and so on, and we will miss 4 Mr. Parks. And finally this is the last meeting for Warren Perry, 5 6 whose term expires in December. I would remind the committee Of the confidentiality of the meeting. The confidentiality 7 8 statement is printed in your material, the discussions of the Advisory Grouns are c onfidential except as disclosure is 9 authorized bv the ArITnini,.-,trator of the Administration. Dr. Margulies will review,the policy regarding 12.1 review of application meetings. 13 DR. @IARGULIES: There has been a new Executive Order 14 which was actually effective during the last meeting of the council but the date coincided with the time the Council was 15 16 actually in session and it has not yet been made official. It had not been then. It is now. This has to do with public 17 18 attendance, and it is meetings which are composed of advisory bodies affecting policy which are working with the Federal 19 20 Government agencies. And it has been further defined since the time of the Executive Order so that there is a reasonable level 21 of clarity now of what i-E means and how it is to be handled. 2 I^ The second, Secretary Richardson, has defined it 23 for our Council as applicable to those parts of Council meetings 24 e-Fedeial Reporters, Inc. which are discussions of policy and which lead to advice on poli y 25 to government, but has agreed that the review of applications 6 per se will remain closed, and that appears to be acceptable. Reba 4 2 That means that when the council meets, the agenda will be 3 carefully divided between those portions whi,ch deal with policy 4 review which in the case of the Council takes up certainly the majoritv of their time. 5 6 And those parts which represent review of applications. The Review Committee is not changed in its function. It still 7 8 remains a closed meeting according to current definitions. The Executive Order applies to all groups which act in an 9 advisory capac-'Ll--y and who represent non-governTtenta'L group 10 meetings. 12 It also means that there will have to be an appropira e 13 agenda available. It must-be announced in the Federal Register 14 at the time of the meeting to be held. It has to be in the Federal Register and there is a mechanism for members of the 15 16 public not only to attned but to have access to the written 17 materials, to the results of meetings and to the meeting,, it- 18 self. This applies to subcommittees, Executive Committees, 19 20 and applies for example to groups which we may pull together 21 to advise us on evaluation or on any specific phase of PMP activities. 22 23 It applies to all Federal activities and will among other things it seems to me keep a number of people extremely -- 24 L--Fedeta! Reporters, Inc. people managing all of the data which flows in, has to be 25 7 #1 I reviewed and put out again. It appears very likely that there Reba 5 2 will be at least some similar kind of requirements placed 3 On grantees. 4 This is likely to take place in the very near future. 5 It will not seriously affect the P2,IP function, excepting that 6 it appears highly likely that there will be a requirement for 7 the regional medical program when it is preparing or submitting 8 application to give public notice to that effect. The other 9 requirement such as the maintenance of materials, the continuation 10 of a library and an available information system for the public, 11 are already in existence in regional medical programs. 121 So also is the maintenance of verbatim records of 13 meetings which we have here, which we have at the Council. But 14 it will change the environment and will create some interesting entries. I expect that some programs will be more directly 15 16 affected by this than others. DR. SCIIIIIDT: Fine. Are there any questions or commen-s 17 18 for Dr. Margulies 19 If not, then I would remind the group of the con- 20 flict of interest policy which states that Review Committee A@l @embers should not participate in situations in which a violation 21 ' of the conflict of interest and re gulati-ons are likcly to '412 23 occur and I am sure that the new coranilttee members know that we 24 do not participate in discussions of applications and affairs L,-Federat Reporters, Inc. of regions in which we reside. 25 8 And so on. Also, a reminder of the future meeting Reba 6 2 dates which are on your agenda, January 17th and 18th, 1973. 3 And May 16th and 17th, 1973. We have a, as usual we have a 4 very full schedule for these two days. We will have to alter 5 the order of review somewhat to allow for Dr. Brindley's de- 6 parture today. 7 And also to conduct a couple of experiments and infor- 8 mation dissemination to the Committee, kind of experiments in 9 easing the.review process, and then we have obviously the '10 number of applications to get through, as well as the discus- 11 sions that are on-going about the function of the committee. 12 Probably a good part of the morning will be devoted 13 to report from Dr. Margulies about various things and other 14 staff members. Then moving on to one of the experiments in 15 information dissemination, and in the way that the Review 16 Committee fits into the total picture of the IU@IP Review process. 17 So that we will begin then with a report from,Dr. 18 Margulies about the recent council meeting and oth6r@matters 19 that he sees fit. 20 DR. @IARGULIES: Thank you. I think it probably would 21 be useful to talk in specific terms about the recent meeting f the Council with the kind of feedback that the Revi--w 0-om-- 22 0 23 mittee which I think you will find helpful, and after that 24 and whatever discussion.you may want to have on it, I would @-Fedefal Reporters, Inc. 25 like to talk with you about appropriations, legislation for I 9 regional medical programs and other programs, all of which is #1 2 of particular importance at this'time. 'p@a 7 3 You have in front of you a manilla folder which has 4 in its a status report to the Review Committee of the.actions 5 taken during the last cycle of the National Advisory Council. 6 This is primarily designed to give you the necessary infor- 7 mation. 8 It looks like this, (indicating), the necessary 9 information regarding the action which the Council took based 10 upon the review and recorcffctendaLions J':coitt this coi-aritittee. You 11 will find as you go through it that the actions of the Review 12 Committee in terms of funding w&re held up all the way through. 13 So also were all other actions with two exceptions. One of 14 them had to do with the rather uneasy recommendation on the 15 part of the Review Committee that tri-annual status for Missouri P 16 egional Medical Program be withdrawn. 17 Let me interrupt myself at this moment to say that 18 everyone has been welcomed here excepting the new Chairman, 19 Dr. Schmidt. lielcome, Dr. Schmidt, as Chairman of the Review 20 Committee. Ilhat made me think of this was the fact that I was 21 0 22 suddenly on Missouri and I realized that T had a new Chairman 23 next to me. There was a strong recommendation at the time the Review Committee met that there be a site visit to Missouri, 24 e- Federal Reporters, Inc. 2 and that this site visit be for -,rery specific purposes. I 0 A number of things have occurred since that time in- Reba 8 2 cluding the Site visit which will be reported on later during 3 this meeting and has just been completed. The other change 4 in the recommendations had to do with some action on a kidney 5 project which you can find evidence of in Ohio, as I recall. 6 otherwise the actions, the recommendations, the 7 criticisms of the Review Committee were those that were accepted 8 bv the Council and which were an official part of our subse- 9 quent action in'de&ling with the regional medical programs which ,o were r.eviewed iii that cycle. Now there may be some.further questions particularly 121aboulhe Missouri program because this occupied greatly the 13 review committee meetings. I think they would be dealt with 14 better as we get to that recent site visit which I think was 15 completed just this week, wasn't it, Mr. Chambliss? 16 MR. CIIAIIBLISS: Yes. 17 DR. MARGULIES: Now you may want to spend some 18 further time going over these figures and over the information 19 so we can come back if you wish. I will spend, I hope, a rela- 20 tively brief time trying to bring you up to date on such things 21 as appropriations for regional medical programs and new legis- 22 lation. 23 We live so close to it that we sometimes assume that 24 everybody has the same kind of vibrations that we have but e-Fedetal Reporters, Inc. 25 obviously that is not true because if I go across the hall I I #1 find thev don't get the same thing I do so let me at least Reba 9 2 tell you hwere it is from our point of view. 3 I think it is general knowledge that there was an 4 Appropriations bill passed by Congress, vetoed by the President, and the attempt to override the veto failed so that it has been 5 6 necessary for Congress to go back through the Appropriations 7 process once more. 8 That is now being done. The recommendation of the 9 President was that the Appropriations remain consistent with the recommendations which had been sent from the Adrqi-n4-s- tration to Congress so that there can be a orderly and accep- 12 table management of the national budget, and since he made that Irecommendation to Congress there has been action by the House 13 14 which represents a kind of middle position so far as I can 15 tell between what the Administration had recommended and 16 what was the final action of Congress in the bill that was 17 vetoed. What happened with RMP during that appropriation 18 19 process was approximately as follows: That the recommendation of the Administration which incidentally was the highest any 20 21 Administration has made for RMP was around $131 milliIon. That was raised to something like $150 million as I recall by the 2'-) 23 Ilouse. 24 It was raised by the Senate to $184.5 million and @e- Federal Reporters, Inc. then in the Conference Committee it was compromised around a 25 12 1 figure of $164.5. There has been in the action of the House Reba 10 2 a figure which is approximately as I recall around $149.5 3 million at the present time. 4 To my knowledge there has not been any Senate action 5 and certainly I have no knowledge about what might happen if 6 that iDassed and if the rest of the bill is at that level and 7 it again goes to the President. 8 That gets into some speculation which is'well beyond 9 me. If the Dresent bill does pass in whatever form it finally 10 emc@-gc-@ there will their be some further deiay as there is an 11 analysis of distribution of actual allocation of funds, and 121't takes .a certain amount of time for a program like our own 13 to know exactly what its funding will be. 14 It is very difficult to estimate that time with 15 minor skirmi§he@-like a national election coming up. But it 16 is not likely to be in the immediate future. That always poses 17 a problem. We are rather accustomed to it. it means that 18 in the interim this program like all programs in the Federal 19 Government operates on the basis of what is known as a continuing 20 Resolution. 21 A continuing Resolution restricts us to levels of 22 activity which are consistent with those th--t '.,&ad '@ur-L@-,g 23 the Preceding fiscal year. And it means that we cannot plan 24 on a large increase even though we think one is in the offing, e-Fedeial Reporters, Inc. we are free to reduce our funding, but in general we@are require 251 1 3 #1 I to stay around the same general level. We do not have any Reba 11 2 figure on the succeeding fiscal year. There will be a budget 3 submission. There will then be another round of reactions 4 between the Administration and Congress, and I think any 5 speculation on FY 1974 is pretty foolish. 6 On the other hand, we have to do a certain amount 7of speculating because we can't very well make decisions 8within this program or any other affecting levels of activity 9for one year and ignore the next year, so we will have the eV usual.kind of calculated guessing games going on as we did 11 in the past. 12 I don't anticipate, but I really can't rule out, 1.3 another kind of a problem like the one we had durin the last 9 14 Fiscal Year in which we had to deli)De rately plan around some 15 supplementary grant requests to make sure we could utilize 16 our funds effectively at the end of the'year. You will recall 17 that what we had to do was anticipate, well, really at the last 18 minute, the availability of funds during the second week of 19 June, funds which had to be expended effectively and usefully 20 by June 30th. 21 We did that by using a supplementary grant approach. 22 We have no intention of doing that again. We have never 23 desired to do it because it is totally inconsistent with the 24 WIP approach to things. In the current round of appropriations e- Federal Reportets, Inc. 25 recommendations which have been under discussion to the best 4 I of my knowledge there has been no earmarking of funds by Reba 12 2 Congress saying that there will be so much for this activity 3 and so much for that activity. There has been an earlier 4 decision which was based on the first appropriation process 5 to take some $15 million for emergency medical systems support. 6 Whether that will be sustained during the present 7 fiscal year, I do not know but I rather think it will be. There 8 is every indication that'that will be done. That is a budget- 9 ary decision within Health Services and Mental Health Adminis- I,,,, trat4-cn, pcr-@Occ4--ly acceptable to %Congress but iiot something 11 which was -,)art of their Appropriations Act. 121 Early in discussions on appropriations there were some 13 earmarkings, these were all dropped for one reason or another. 14 But they often reappear or come out in a different form after 15 the Senate takes action, so we simply have to wait to see 16 what will happen. 17 I don't know that I could respond to any question on 18 this subject but if anybody has some later information I would 19 be glad to hear it. Let me switch for a moment to an associated issue, on which I cannot add any further light, but perhaps 20 21 contribute to some speculation. We have talked about this during the last meeting of the Review Committee as well. This is the year in which 23 24 there has to be an extension of legislation for regional ;e- Federal Reporters, Inc.r 25 qcdical programs and for a number of others of the key programs 15 #1 in I!SI@IIIA which are dealing with the delivery of health services. Reba 13 2 Such joint programs as Comprehensive Health Planning, National 3 Standards for Pealth Services, R&D, Hill-Burton and so on. 4 This provides an opportunity for the Administration 5 to try to look at these many forms of legislation which ]-lave 6 varied histories in terms of their first passage, first intent, later intent, and so on, and try to pull them together in a 7 8 kind of pattern of legislative activities which could be admin- istratvely made rational and which could be used to subtend 9 I C) a consistent policy on the part of HEW. 11 The people who are thinking about it in the Department ite naturally and I don't say this for political 12 assume qu reasons, that they will remain in office for the next four 13 14 years. That is natural not because of the polls but because 15 there isn't much alternative when you are in the Department except to figure you are going to be in for another four years. 16 17 However, I think that it is their assumption t.hat 18 they will be in any case. Now if that is true and if their calculations are based on high probabilities, it means that 19 there is a better opportunity now than there has been in many 20 21 years with the growth and understanding of health problemsI for acdnsistent policy to be established. for this to be 23 based on a higher level of grants consolidations, on a higher degree of activities which reflect the concepts of health 24 a-Fedeial Reporters, Inc. revenue sharing, on the anticipation of National Health insuranc 25 16 and some of the other major issues which have been under dis- Reba 14 2 cussion for the last two or three years, and to design legis- 3 lation so that various kinds of programs relate with one another 4 in an effective fashion. That means that for regional medical programs an 5 6 isolated look at what R14P ought to do would belinacceptable. There has to be an analysis within the Department of what RYip 7 8 can or should do with some very careful reference to what then 9 this would mean with comprehensive health planning, with the development of manpower, with the development of insur-"ncc 10 systems, qualitv monitoring and so on, so that I am confident 12 that the basic recommendations which will finally come out and they have not iDeen completed, by the Department for Congres- 13 14 sional action will depend upon a total analysis of the related 15 legislative programs, and a better elucidation within the 16 Department of what its basic policies and intentions are. 17 There are certain currents which may be confusing; for-examdle, the development of stronger international heart 18 19 and lung institutes as a categorical activity, the National 20 Cancer Institute, as a categorical activity, and yet a simul- 21 taneously vigorous statement, restatement, constant statement by the Department that.it wants to avoid categorical activities 22 and to develop greater consolidation of programs. 23 I don't believe that there is the kind of inconsistence, 24 @e -Federal Reporters, Inc. in those kinds of comments that one might believe. There is 25 17 ffl I some level of inconsistency because sometimes actions are Reba 15 2 taken which are political and which are accepted despite the 3 fact that they may be inconsistent with other kinds of perform- 4 ances but I think that a good illustration of the kind of working 5 respect which can be established between a categorical approach and what we are attempting to do is expressed by the present 6 7 plans to develop a national hypertension control program. 8 Now I am not going to go into that in any great 9 detail because it has not been fully developed excepting that 10 the Secretary has p--rmittcd @.hc "",--partm,-n-L" ---@every Time -L mention the Department I get feedback. The Secretary has 12 committed a group of people for whom he is responsible to a prog an of hypertension control. But I think the differences in what 13 14 is being discussed probably as illustrative as anything that 15 I can find offhand of the ways in which one can deal with 16 categorical disease and not commit the errors of the past. If this were to be a hypertension program as we would 17 18 have done it four or five years ago it would lead very rapidly 19 to a number of grant requests to which we would have acceded 20 to build hypertension clinics and special investigative units 21 and other kinds of projects which allow people to pursue 22 their hobbies in various ways. And these would be designed around an elaboration 23 1 of the methods for identifying ren'al-hypertension, for doing 24 ,-Federal Reporters, Inc. various kinds of assays of blood levels which would associate 25 18 I clinical investigators with a better understanding of the Reba 16 2 specialized forms of hypertension which they currently don't 3 understand. 4 What is being talked about in the present Secretarial 5 initiative is not that at all. end 6 1 7 2 fls 8 9 10 12 13" 14 15 16 17 18 19 20 21 22 23 24 ;e- Federal Reporters, Inc. 25 t 2 swl I It is an approach to a problem with an epidemio.loic 2 basis which argues that one can move from a very miserable 3 level of hypertension diagnosis and management to a much better 4 level by using motification withing the existing delivery 5 system rather than setting up separate disjointed units to deal 6 with it in a separate kind of a way. 7 The figures are approximately like this: That there may be 23 million people in the country with hypertenstion; 9 that under the most generous estimates, 7 million of them have 10 a diagnosis --n-@4 ro-..nc of treatment. To go from 7 million to l@l something approaching 23 million cannot be achieved by setting 12 up a series of highly sophisticated hypertension centers,; 1.3 it can be done only by simplifying the system, by,-- 14 accepting the fact that what you are getting at is essential hypertension, that it is particularly a problem among blacks 16 where the frequency of hypertension is far greater than among 17 non-blacks. That it probably -- although that is not sure @8 has an accelerated rate among blacks, particularly among black 19 females. That it is the very major cause of disability and 20 premature death in many population groups including a large 21 number who have no access to reasonable medical care. 22 Under those circumstances, one caduld and I h---@ WI' 23 will in RMP as a part of this general-project, approach that 24 kind of a problem through the health delivery system and in the Reporters, Inc. rocess discover something more about how to approach similar 25 P 20 sw2 I kinds of problems by an elaboration of the system as it consists. 2 Quite clearly it will require not only better edu- 3 cation of the public, better education of the profession, but the utilization of the resoruces and particularly of providers -5 of medical care in ways that we currently are hot doing but with .6 which we have had some experience. On cannot expect the overloaded physicians in this 8 country to suddenly jump from the current level of hypertension I 9 control to.a high level of hypertension control entirely by io their own individualized efforts. No one seriously thinks that can be don. 12 So, I think it represents to us an opportunity to deaL with major disease entities in a way which is sensible and use- 14 ful and not in the patterns of the past. This will allow us to 1,5 work very intimately with the National Heart and Lung Institute 1 16 and there are plans to work out a long similar lines,a little 17 more difficulty, I believe, with the National Cancer Ins,itute 1 8 with some major cancer problems. - Back to the legislation. 19 ?Q At the present time I think that it ib..@reasonable to 21 assuem that when the new legislation for regional medical pro- grams is written that the de-art.-qent have soTc specific 22 23 recommendations to give it a higher level of definition than it 24 has had in the past. ,-Federal Reporters, Inc. Now, I can't really go beyond that because there is 25 21 sw3 I debate going on -.here and downtown as to what the definition of 2 RMP purposes should be. 3 I have argued as well as I can and some of my col.'. 4 leagues on the staff, that we have worked very hard in the last 5 two or two and a half years to develop a series of institutions, 6 regional medical programs, which are capable of functioning 7 effectively but which are currently not guided clearly enought .8 and in exactly what it is they are supposed to do; that they car- 9 not go on effectively doing as many different kinds of things as -hat they mus' have a clear l'o are b 4-n- asked of thcm and survivj4-ve-, 4@ 11 wbrking,relationship@'- with such major elements in HSMHA research 1'2 and development, comprehensive health planning, a better defi- s in KSMHA and in nition of relationships with manpower activite 14 NIH, but more than anything else an understanding of where they fit in what general HEW policy, a d6centralized approach to 16 improvement in health delivery systems and the other kind of 17 legislative programs. 18 1 don't believe that it is a matter of life or death 19 for us to have a stronger definition, but I think it would 20 serve 6verybody's prupose if that were the case. I have personally argued very strongly in favor of 21 f @- 1, keeping as a minimum a.stronq emphasis and an exuandina concern 22 in regional medical programs for quality assessment.and quality 23 24 assurance, which is a broad subject, one which must be approached ,e- Federal Reporters, Inc. vigorously and one where I think RMP consi.ders,,.;a very useful 25 22 sw4 purpose. 2 But, I doubt that we can continue to deal with every- 3 thing from review and comment which is being suggested as one of @4 our functions, to the development of regional centers, to cate- gorical approaches to cancer disease, to new forms of education, to new types)of manpower utilization, to the development of a 6 7 better world...health delivery system, et cetera, et cetera, and retaining effective and strongly functioning institutions. 8 I think most people accept that concept. What is not certAin is how the final definition of legislation will be proposed. Whether that has been done on the assumption that it will be, there is still the matter of Congres 12 r 13 to decide wha-@ it thin-Ks RMP and the other forms Of legislation should be so it should be an entertaining year. 14 At the present time there is a better understanding and a better appreciation of this program where there has been 6 very little-understanding than at any time in the past. 17 18 That is not surprising because the program is older, it has had better opportunity to be observed and more people hava .19 been involved in looking at it. 20 21 It is impossible-for me, also, to give you any kind lof idea of when legislation actions will start, but we do know 22 that the Congressional committees, staff's of the committees, 23 have begun their deliberation and some of the outside groups lik@- 24 e-Fedetal Repofters, Inc. one that Mac serves with, the Association of American Medical 25 sws I Colleges, have been carrying out their own deliberations and 2 reaching their own conclusions for what kinds oftestimony they @3 will make when'there is an opportunity for it. 4 Now, it may be there-are some questions.@about.-these 5 issues also. 6 What I have done more than anything else I think is 7 simply try to bring you up to date. Let me get down to a couple :8 of specifics for the moment then. We may want to come back to 9 this. 1 There are two issues which were not part of the review committee -- one that was not part of the reveiw commit- 12 Itee deliberations the last time and which was the subject of 13 extensive council discussion -- and that was the utilization of 14 R,P funds for support of health maintenance organizations. You will notice that one of the things I did not 15 16 speculate about was the passing of legislation for HMO's and I refuse-to-sp-eculate to that, you can pick up any newpaper 18 and the the latest speculation, but there has been,-,-forlthose who are not keenly interested, no legislation passed yet for health maintenance organizations. There has been, however, an 20 21 active program for the@,plannin.@gand development of HMO'S. There ..!as agrc--mcnt, after extensive debate within tha z council, that RMP funds could appropriately be used and should 23 be used for the support of health maintenance organizations for 24 ;e- Federal Reporters, Inc. planning and development purposes, with this to be limited to 25 sw6 I funds approved by the council during FY-72, that is in the 2 fiscal year which was just finished. 3 There was also an agreement that the review and -4 selection and general supervison of this-activity should be the '5 responsibility of the health maintenance organization service, 6@ which is a parallel service to regional medical programs in 7 HSMHA. 8 There was a reveiw carried out by the HMO process which goes all;...the way from the initial application to the 10 review in the regional offices to a central review here in. II, HSMHA, wiht participation on the part-of our staff and partici- 12 Ipation on the part of members of the National Advisory Council 13 prior to the official selection of HMO applicants for continu- 14 ation for planning and development. And out of that was made the selection of a number of HMO§:,, which were then given further support by cohtract4 That 17 was completed within the fiscal year. The activity is under way and will be continued in that manner only excepting by whatever individual action RMPs may elect to take as resource institutions, 20 until and whenever there is a further decision, either by legis- lative process or elsewhere for HMO development. n@"L-Sa@. -,icans L@ha'%-. the funds ai:e be-'Li-ig 'used for that 22 23 purpose., They are not being managed by the regional medical 24 programs. The regional medical programs remain available as,a e-Federai Reporters, Inc. lose resource and collaborator in it. 25 c #2 fol sw 25 mea-1 CR 6148 There was enough debate on that so we finally had 2 to end up with a mail ballot because there was real 3 dissension within the Council itself about the use of the 4 funds this way. 5 But I think they made the right decision because 6 the IIMO development does provide some opportunities for 7 things that RMPs ought to be dealing with that are very 8 striking, not the least of which is working on the whole 9 issue of quality assurance. ioi Then one final information item I would like to 11 bring to you which may get some further discussion. It will 12, certainly come up in a related way in one of the reviews. 13 v.ou indy cecall we have liad for aow,,- time 14 of discomfort with territorial overlaps in various regional 15 medical programs. 16 The most prominent one came up during the last 17 review sessions with the Intermountain Regional Medical Program which has its home base in Salt Lake City, mountain 18 19 states with a home base in Boise, and well, to the same 20 degree, the Colorado-Wyoming Program which has its home 21 base in Denver. 22 The difficulty there was that these programs very 23 sensibly are parts of several states. Each of them have 24 overlapping state areas which were designed around the Federal Reporters, Inc. natural flow of patient care, the referral centers and so on 25 There occurred over time more and more uncertainty 2 about whose turf belonged to whom and it was very 3 striking with their proposals for educational and service 4 activities in one case coming from two regional medical 5 programs for the same community. 6 That suggested that there was indeed some confusiOlL 7 over who it belonged to, although for some of those 8 communities it wasn't very exciting because they felt that 9 they would like to get funds from both regional programs, which is a reasonable community attitude. We were concerned for two reasons. One, because 12 there was adminstrative uncertainty on the part of those 13 programs, and two, because there are activities within states 14 like comprehensive health planning at the state level, and 15 other kinds of programs, Hillburton and so forth, which do 16 require a definition of state boundaries because of the 17 manner in which funds are managed. 18 So we felt that the programs should learn how to 19 deal flexibly, operate at the state'boundary level when 20 necessary but be perfectly free to move beyond those 21 boundaries when it made sense based upon the way the delivery 22 systerc, woj:'@-s. 23 In order to resolve that we asked that they meet 24 together which they did do on July 20 of this year, with e -Federal Repor tefs, Inc. 25 representatives of coordinators, of grantees, of regional mea-.5 advisory groups. Our role was to be there to provide any kind of 2 information necessary but not to make any decisions for 3 them. We felt that they were perfectly capable, better than 4 we, more capable than we of deciding how that should be 5 worked out. 6 They have reached a working understanding of how 7 this is to be done. And it includes some redefinition of the 8 territorial limits to be involved. It involves the creation 9 of a committee representing all of the programs, carfully 110 defined, to decide any uncertain types of project activities 11 where there appeared to be conflict or potential conflict. 12i They have devised an appeal process in case that 13 doesn't work very well and have agreed to work along that 14 line with some kind of reanalysis over a period of the next 15 six months to a year of how effectively it is working. 16 It seemed to us that they went about it very 17 sensibly, realized that they had to do something and have 18 provided both the geographic limits and the kind of 19 flexibility which is necessary for effective RMP function. 20 I do not believe that the solution they reached 21 or the way they went about it can automatically be applied 22 to another area because theirs was a special kind of 23 situation. And I think as we get to the review of some of 24 the other programs like those around Memphis and those e- Federal Reporters, Inc. 25 mea-4 28 I around Saint Louis that we will find that the issues may be 2 similar but the potentialities for a solution may not be the 3 same. They will have to be looked at in a,different way. 4 The reason I report on the one from mountain 5 states is because it belongs there and only there and it 6 has been a useful way of doing it. 7 But the others are other kinds of problems. I think 8 Mack, that that's as much as I need burden the Review 9 Committee.with at the present time. .0- DR. SCHMIDT: I welcome Dr. Patterson to the 11 session who just walked in. Happy to have you here, sir. 12i Are there any questions for Dr. Margulies at the 13 time? 14 DR. KRALEWSKI: On this funding for HMO projects 15 then essentially are we going to go down a path where some 16 of the RMP money is going to be devoted to the support of 17 the office of IR40 services and then some other RMP money be 18 funneled through this process to fund EN.10 applications? Is 19 that what you are telling us? 20 DR. MARGULIES: No, the agreement which was very 21 cle.arly in the record and which supported the statements the 22 Secretary made @-ihen he was testifying before the 23 Appropriations Committeewas that this is one-time money only. 24 In fact, it was released for P,114P by the Office of Management @e- Federal Reporters, Inc. 25 and Budget during that fiscal year with the understanding that mea-D I it would be used for that purpose or it wouldn't have been 2 released at all. 3 It happened to be in the RMP basket but it was money that had been not released during the preceding fiscal 4 5 year. 6 We are now on a one-year basis so that that kind of thing cannot occur but it is our understanding that this 7 8 is the one time that that kind of a process would be use 9 for FDAP money to be used by the HMO service for grant or 101 contract-for HMO development. 11 I cannot tell you, though, that there will be 12 during the coming year no additional effort at specific taps on RI@IP @Lunds beca'ase -@-hat may occuri TL have .,io c-,-i-lancc 13 14 it aside from the emergency medical activity which is pretty 15 close to our interest anyway as is the HMO. DR. SCHERLIS: Are you distinguishing in this 1 6 17 report between that given by RMPs and that given by local Pj4Ps becuuse a great many RMPs are obviously involved in 18 19 IL'40 activities? You are distinguishing between these two? 20 DR. I.IARGULIES: Yes, I am. The actions of the 21 HMOs locally have been defined in a memo of understanding 22, which we sent out early in the year, very carefully, which 23 was developed in common with the HMO service. This is to 24 keep the line of development of health maintenance organiza- '.e-Fedetal Reporters, Inc. tion consistent with the HMO organization. 25 mea-6 30 P,tiPs are encouraged to work as closely as they can and wish with applicants for health maintenance 2 organization to give them the kind of professional, technical support they may need but the actual development for funding, 4 further elaboration and so forth is to go through the HMO 5 channel. 6 That would mean that an RMP which is being 7 8 responsive in what it does would on learning of the interest of an applicant at an HMO, inform the regional office 9 -- people--so they would immediately begin working with the 10 applicant. The RMP could do whatever it felt advisable to assist them in their efforts but if there is to be further 12 @4un@-@'4@.-ig and at the present time @L believe, *-Coxdoa, 1 ai-a 13 right in saying that it is expended for the, at the present 14 time for new applicants. 15 Dr. McCloud is here. You are not currently 16 accepting new HMO applicants, are you, de novo? 17 MR. MC CLOUD: That is correct. The only way new 18 applicants could relate at the present time would be through 19 generator contracts. We have a number of contracts with 20 the American Association of Medical Colleges, American 21 22 Association of Medical Clinics, the National Medical Association Foundation, Health Association of America and 23 others. 24 e - Federal Reporters, Inc. And if a new applicant is looking for technical 25 mea-7 31 assistance he can apply to these organizations and actually 2 participate in getting started but this,is not the same 3 thing that we have been involved with in the past year 4 in providing money for planning and development activities. 5 DR. MARGULIES: Now, if there is available at any 6 time in the near or distant future more money for 1*10 7 development thereby it is the responsibility of RMPs to get 8 applicants in the pattern of that kind of funding and not to 9 try to supplant the HMO activity or take over HMO 10 responsibilities. 11 SISTER ANN JOSEPHINE: Dr. Margulies,, we talked 12 about-,HMO development and I may be wrong but my impression 13 at@the-present time is that we have developed just-one 14 component of the whole concept of the health maintenance 15 and,that is the prepared group practice component within the 16 HMO concept. 17 DR. MARGULIES: Well, of course most of the atten- 18 tion during the planning and development has been toward that 19 particular aspect of it because.in the absence of it you 20 don't have anything else to work with. 21 But there has been very extensive attention given to the manner in which the HMO wi),]. provide services, to the 2 4n 23 kinds of benefits which will be required, and there will be, 24 I would think, and perhaps Gordon would like to comment on Federal Reporters, Inc. this, a certain amount of investment by all of our programs, 25 mea-B when HMOs are well established in experimental approaches 2 toward altering the forms of health care delivery, in 3 increasing their prod uctivity, further defining what is meant 4 by health maintenance, altering patterns of medical care 5 in a favorable direction. -.6 one of the primary interests of RMP, and one of 7 the reasons I felt that the investment in this was reasonable 8 is because it does provide the kind of complete system in 9 which innovations can be considered and tested. @I %-I t a reasonable statement, Gordon? I u Is 4.,ja i- ll DR. MC CLOUD: I think this gives me an 12 opportunity to say at least some remarks about Dr. Margulies' 13 earlier comments about the lesiglative situation. @As of 14 yesterday the Senate, with 80 percent of those in attendance 15 voting for the H140 legislation,passed the bill . As of 16 yesterday the House Subcommittee reported it out 17 unanimously, which will go to the full committee. 18 There is a problem there with respect to getting 19 through Congress this late in the year. But the movement 20 has been in this direction. The problem that we face, 21 particularly at this time with respect to Harold's comments 2A) just now, is that we don't know which bill will be passed 23 and what definition of HMO we will be dealing with. 24 By that I am referring specifically to the item e- Federal Reporters, Inc. that was in the Washington Post this morning which points 2 5 mea-9 out that, "Established health maintenance organizations to provide mental-health and dental care as well as a wide range 3 of other types of medical services for persons preparing a 4 fixed annual fee on open enrollment plan." 5 Well, this has reversed the emphasis. We see a -6 basic program as being the comprehensive range of services 7 with an opportunity and wherever possible, mental health 8 benefits, dental health benefits and drug benefits being 9 included. I 0 LNow, -LA@ tiie Kennedy Bill is passed I think it is 11 fair to say that we probably would see this kind of all- 12 inclusive thing. 13 The Administration Bill, Congressmen Roy's Bill 14 in the House, works with a more limited but basically 15 comprehensive program and in every bill, the AdministrAtion's 16 Bill, the Democratic Bill in the House, the Democratic Bill 17 in the Senate, preventive health maintenance is mandated 18 in the definition, 19 I think the area has just really begun to open up 20 and I think we are going to see through the health 21 maintenance organization an opportunity to develop Preventive 22 programs. 23 The work is proceeding, and that's about where we 24 stand at the moment. ,e -Federal Repoftefs, Inci 25 DR. SCHMIDT: Warren? 34 mea-10 DR. PERRY: what is the current status of the area health education centers' work and R@IPS' relationship to it? DR. MARGULIES: I will give you a very brief 3 4 answer. You know some time or other I am going to discuss with this committee something that is all settled. But it 5 hasn't come yet. 6 7 Very, very briefly, the current status is that 8 what is called an area health education:center is -- has been very sharply defined. It is something which is -- 9 - operates through a university health science center through 10 11 a medical school on a contract basis funds available from 12 the Bureau of Health Manpower. it is a derivation from the legislation wlilci-i they 13 operate under, the health manpower legislation and is 14 15 operating without th.ere having been passed yet a specific bill for area health education centers. It represents that 16 part of their legislation which deals with what are called 17 18 health initiative health manpower initiatIive awards, AMEA, 19 they call them. 20 If there is new legislation passed dealing specifically with the area health education center it may 21 both alter the definition and responsibility. But right now 22 23 AHEC is a very specific, a little tighter than in the CR 7148 End #2 24 Carnegie definition r-eport operated by the Bureau. ,-Federal Reporters, Inc. 25 35 R7148 ake 3 1 DR. BRINDLEY:..Are the VA AHECs related? or -2- ..-.--.,DR. MARGULIES@. The VA activities will be related 3 if they are included in the application for contracts which 4 must be completed by the end of this month. 5 There have not been, to my knowledge, actual -6 contract releases from the Bureau. 7 Maybe tome of the others here, who have been 8 working with the Bureau could respond to that but they 9 must be completed by September 30. 10 -Lf the VA is included in an appiication,from the x 11 then it will be part of the AHEC. 12 on the other hand, if-the VA is included, it will. 13 The VA has also been working intimately with the RMP activities 14 which are not Area Health Education Centers by that 15 definition, but which are reflecting the. kinds of principles 16 which we develop during the general discussion over the 17 Area Health Education Centers. We have some very close affiliations with the VA 18 19 for that purpose. DR. SCHERLIS: Would you want to comment on 20 Emergency Medical Services,:in other words,.if a region comes 21 in for funds, i,s t--bis considered. as a total part of what they I-IL 23 will be getting or is it looked at separately? 24 DR. MARGULIES: We are going to have a.separate ce - FedeFS1 Reporters, Inc. 25 discussion on that subject and I think it would be easier to -jor z 36 I to-it when we can go back over what we have been doing, but 2 we will get back to it. 3 DR. SCHMIDT: I would take the liberty of just 4 making one comment about what Harold said. That is that RMPs 5 in general, and certainly this review committee have been --,6 agonizing for several years about two things I think we will 'X 7 have to continue having noising about. He mentioned revenue sharing and there is a lot 8 9 of talk about health revenue sharing and if you think through -10 @he i,.mpli.rations c-f revenue sharing in regard to decenl--r.-A"@iza- 11 tion of programs, then the whole business of decentralization of authority is tied very closely to health revenue sharing. 12 13 Might be the health manpower dollar for example. That is :x 14 decentralized, implications for a lot of Federal programs 15 will change. 16, And we have talked about what the function of this review co@ittee is in regard to, or as opposed to local 17 18 review and I think that we will be discussing this more in @the next year because of the obvious major.-'-interest of the 19 present executive branch of the government in decentralization 20 and@revenue sharing. 21 22 The second thing really is what RMP is in its function, and you have to do with now CHPRMP, the national 23 denters and regional offices. 24 'e- Federal Reporters, Inc. These are sort of a cast of characters. 25 37 dor 3 1 A major question is when legislation is rewritten, -2 do you say, "Well, there are deficiencies in what these 3 programs are doing and we will either set them aside or let 4 them go on and build new programs." 5 This is a favorite technique of bureaucracies to 6 get a new program to do something that others aren't doing. 7 Or, do you take what you have got and change 8 them, strengthen them, make the regional offices better to 9 do certain things, make RMP do its things in addition, and to go with-wha-L you have got. 11 And these are the sorts of things that are-being 12 discussed and will have implications for RMPs and what they 13 do and how they fit in the future. 14 We will go on then, if there aren't further 15 comments or questions to reports on some specific items that 16 have already been raised in questions so that it is 17 appropriate that we have some review of the health service 18 educational activities and emergency medical services 19 activities. 20 And we do have some handouts and remarks on '21 these subjects. 22 Dr. Hinman? DR. HINMAN: Thank you, Dr. Schmidt. 23 24 As Dr. Margulies mentioned,during this past :e@ Federal Reporters, Inc. fiscal year, it became obvious that there would be a necessity 25 38 lor 4 I for acceptance of supplementary funding requests for several activities. --2 3 We are going to report to you on two very specific 4 activities that occurred subsequent to the last review 5 committee meeting prior to the National Advisory Council 6 meeting in June. 7 The Division of Professional and Technical 8 Development is organized around a series of task forces to 9 accomplish specific activities. These reports will be given b,, the manager-- of Z 10 11 these forces. 12 The first will deal with manpower activates, commonly known as the Health Services Educational Activities. 13 14 Dr. Conley is project manager of that task force. 15 DR. CONLEY: Dr. Schmidt, Dr. Margulies: The Review Subcommittee to consider applications 16 17 for supplemental funding of Health Services Education activities met on May 20 at Sun Valley, Idaho, just prior 18 to the RMP Third National Allied Health Conference. 19 The subcommittee consisted of representatives from 20 thb-National Advisory Council and from this committee, 21 n&2 the latter included .Dr. Warren Perry, who served as chairman 23 of the subcommittee, Ms. Dorothy Anderson, William Hilton, Elizabeth Kerr, and Dr. Hess. During the one day meeting 24 ce- Federal Reporters, Inc. a total of 79 projects submitted by 19 RMPs was reveiwed. 25 39 dor 5 1 The subcommittee was impressed with the number .-2 of RMPs who were able to respond in such a brief time with 3 well developed applications. 4 It was apparent that many RMPs had been moving in 5 the direction of Health Service Education activities for -6 some months previous, using existing funds in their initial 7 planning efforts. 8 The coordinators had earlier in the year given 9 their support to various concepts expressed in a position ,o paper h-d been prepared by staffs of RMPs and mipr 11 STAFF. 12 In this paper an approach was suggested by which 13 the RMPs might better systematize their ongoing manpower 14 efforts and by which they might bring about a better balance 15 bet ween the quantity and quality of manpower and identified 16 health services needs. 17 It was this position paper which largely shaped 18 the criteria used by the subcommittee in its review. And 19 copies of these criteria are available if anyone wishes to see them. 20 21 In addition to the more fully developed applications 22 reviewed by the subcommittee, the National Advisory Council had delegated authority to the Director of RMPS to fund a 23 limited number of planning grants, each of which was not to 24 'e-Federal Reportefs, Inc. exceed $50,000 in budget. 25 40 dor 6 This action brought the total number of funded health,service education activities up to 57 projects from 3 25 RMPS. 0 4 Now, we have distributed to you a three-page chart 5 entitled "RMPS Health Services Education Activities, May-June 1972." 6 7 In a sense this represents a profile of funded 8 activity in respect to how those projects conform to RMPS 9 concepts at the time of review. -lo The headings on the chart represent some critical 11 elements which the subcommittee emphasized during its 12 review. -Lt you will note on the chart, the RYiPs are listed 13 14 alphabetically, followed by the total award. 15 The next heading is RMPS Consortium Concept. 16 The subcommittee members were interest in t e 17 applicant's commitment to a consortium representative of education, health procedures, health care facilities, and 18 19 others, as appropriate for that community. The subcommittee was also interested in whether 20 that consortium would be moving toward independent status in 21 22 the future. 23 The next heading is"Documentation of Need." 24 The subcommittee was most interested in whether ce - Federal Reporters, Inc. the documentation was expressed in terms of health services 25 dor 7 4.L I needs, rather than exclusively in terms of numbers of -.2 personnel. 3 The basis for that is that identification of 4 Health Services needs logically precedes judgments on how 5 many personnel we need, what types, what type of training, -6 how they should be utilized, and how they should be 7 distributed. 8 It is also obvious,-'-as:. we move along the chart, 9 that only a few regions are in the operational phase of 10 the activity training 4-o being undertaken. 11 It is in this phase that a fully committed repre- 12 sentaiton consortium could provide the climate wherein more 13 effective manpower can be distributed and appropriate action 14 included. 15 The last column relates to belief that it is not 16 only good sense to involve the community in matters which 17 intimately respect it, but chronically resisted manpower 18 programs and problems may benefit subtly by the introduction 19 of different viewpoints and new forces for action. In conclusion, there is a plan for an ongoing 20 21 followup and consultation of this project by DPED staff. 22 Of most immediate interest is the oDportunitv for 23 cooperation which may arise.,.as AHECs are funde y Bureau activities, in areas where Health Services activities are 24 ;e-Federal Repofters, Inc. already developing, and as of last night, Miss Conrath 25 42 .or 8 1 reported from a meeting she attended that as of yet, nothing 2 has been reported on sites of AHECs or how many will be 3 funded, though probably it wouldn't exceed 12 or 13, but 4 such decisions as Dr. Margulies mentioned must be made by the 30th of September. 5 6 Finally, of course, RMPS staff is interested in the 7 further development of the 15 projects for Health Service 8 Education activities, which will be reviewed today and tomorrow as part of the applications in this cycle. 9 1V.',@,what do ' ant-icipat(z- from this RMPS experience we in supporting Health Education Service activities? 12 We expect, of course, there will be an exchange of ui., the reg,-ons 3.n findings of other reqj4.ons. 13 Specifically, we expect to learn more about the nature of 14 :xx 15 consortium, -their composition, organization and 16 operation. 17 We expect to see developed in the RMPs models 18 for the identification of. Health Services needs on which to 19 base sound manpower.judgments. 20 We expect to see more attention given to the 21 continuum between basic education, continuing education, and health services need. 221 23 Finally, the RMPS experience in the support of 24 these projects will help define more clearly the nature of :e-Federat Reportefs, Inc. community involvement in a productive partnership with-health 25 dor9 43 professionals and it will help us identify the educational needs of consumers so they can be fully developed as a --2 3 resource for improvements in the quality of care. 4 Thank you. 5 Do you have any questions? DR. THURMAN: Could you give us a little bit .@6 7 of a feel of what Maine had to say? MRS. SILSBEE: Well, it obviously has quite well- 8 9 conformed to the concepts which were promoted by RMPS. 10 DR. THURMAN: I agree with that. I guess what T 11 am really saying is for some of us, it is not quite clear 12 exactly what this program was designed to do in the absence of AHECS. 13 14 MRS. SILSBEE: Well, this program differs somewhat 15 from the AHEC concept that the Bureau of Manpower Education @x will be funded and emphasision the community, 1 6 17 community involvement, community commitment, community 18 willingness to make the kind of investments that are necessary to improve existing manpower problems. 19 DR. MARGULIES: -One of the things that is not 20 readily apparent from this paper is that the funds which have 21 been released in some instances cover 'three years of funding. ^42 We had to release them so that they could be all utilized 23 at the time of the grant award but they coul d be extended 24 ,e - Federal Reporters, Inc. over a period of time and kept separate from other kinds of 25 4 4 clor 3.0 I f unds. @.2 TheMaihe program is particularly exciting to the 3 review committee and interestingly enough, despite the large 4 amount of money which was involved, probably engendered the 5 least amount of controversy as to its worthiness. 6 It is unquestionably a very bold undertaking. 7 What they are trying to do in Maine, which incidentally is 8 probably somewhere near the bottom of the 50 states in its 9 manpower resources, is a total statewide mechanism for 10 developing manpower around service-@ needs with a collateral 11 development for which they will have other sources of 12 support of a medical school activity, which is a kind of 13 university without walls types of thing. 14 It will link together across Maine all of the 15 educational institutions, all of the treatment facilities 16 necessary to have an integrated education and health services 17 delivery system. It is unquestionably bold. 18 19 The primary question we had in reviewing it was 20 do they have the people on hand to take on this kind of 21 undertaking, can they come up to the heavy demands for skills, 22 organization, and so oni and the care @7ay con,.,4-nced 23 that they could in fact do so, that they had been working 24 toward this effort for at least five years. The whole state ,e-Fedeial Reporters, Inc. is committed to it, the governor, the nongovernmental people, 25 4 5 dor 11 the institutions, and it seemed like a very reasonable kind of an investment. 3 But it is unquestionably bigger, bolder and 4 potentially more meaningful than the average. it 5 DR. SCHMIDT: I want -- this probably doesn answer it -- I,would like to conduct an experiment. 7 Would everybody at the same time please reach 8 for those mikes and turn them all off? They are all on 9 and flick the switch toward the cord. I will ask the 10 committee members to reach for mikes, turn them on, so that 11 the staff in the back row can hear. 12 It is really not fair to pose questions. I 13 wonder if it wouldn't be ppssible for Dr. Thurman sometime 14 today to see the Maine application, then he can get the answers 15 to questions and we will come back, if he wishes to pose 16 questions based on the bold application after he gets it. 17 MR. HILTON: I was going to say, I suspect new 18 members might have difficulty getting a feel for what we are 19 talking about. They are not going to suggest examples 20 specifically but we could review the application and get the 21 same feeling. DR. SCHMIDT:Veronica will get an application to you. DR. KRALEWSKI: I have a couple questions on 23 24 this, bothered me probably because I don't understand the :e- Federal Reporters, Inc. funding and all that bit. 25 4 6 dor 12 Well, it seems to me that at a time when another agency is considering developing a similar kind of concept 3 that perhaps it wasn the wisest thing to do for us to 4 initiate this kind of action which might preempt the field, 5 and I suppose because you know now the development of two 6 centers and you know Podunk, Colorado, certainly because they 7 will both be fighting over the city again. 8 And the second thing is that by this approach, of 9 course, we are taking this, this area of concern out of the io general-tr,------r.,-,.Lm app!4---ations an--' we are fun'"ing, you know, 11 a separate set of activities that doesn't fit in with the 12 kind of thing we are attempting to get the regions to outline in terms of their program and education as part of that 13 14 program, and so forth, for the region. 15 And thirdly, I am wondering how much we are tying into here in terms of continuing funding because, you know, 16 17 particularly the one program that I keep site visiting, 18 we spent three years to try to get them out of a ma3or 19 commitment to one specific area of continuing education where 20 they were investing 90 percent of their dough over a long 21 period of time. '32 I wonder if it is the intent that wp arp. goi-'ng to help to set these up and someone else will take them over 23 24 and fund them or are we locked into this for a good many nd 3 :e -Federal Repofters, Inc years' support? 25 CR 7148 4 kar DR. SCHMIDT: I will take the liberty of commenting on won of your questions. America, United States is a pluralis- 3 tic society and the Bureau Health Manpower's effort and this 4 other.. effort are different. They are conceived of as being 5 complementary. -6 I think that they are two different approaches movinc 7 toward the same end goal and whether in rewrites of legislation 8 and so on these different efforts will be brought together or 9 not, I don.it know. In practical terms, we do have now two II0 different concept moving from different d4@rec@14-ons, and shor@ s 11 of alterations in the legislative process and so on, I am not 12 sure that anything can be done about that. -13 I suppose RMP could voluntarily withdraw from this 14 avenue, but it is not thought that this really would help RMP 15 at all or help the problem. In terms of the long-time fund commitment, who woul d comment on t at? 16 17 DR. MARGULIES: Well, the basic principles behind the funding is that this is the money required for a consortium 18 to be created which must then maintain its activities. This 19 20 money is for the limited period of time decided and there will 21 be further funds. In fact, when we provided this money, it was a separate kind -- on a budget basis. There is enough distinct di 23 between what we are talking about and what AIIEC is talking about'. 24 in the Bureau so that.oven though they may, well, if one argues ce- Federal Reporters, Inc. that they overlap, that still wouldn't 'Make me uncomfortable. 25 4 8 kar 2 I think you need a certain amount of that. But MIP operates through different kinds of community -.2 3 structure and through a different kind of constiuency, but if, 4 in fact, you read the definition of the AIIEC as it is currently 5 designed within the Bureau, it is primarily related toward the 6 expansion of numbers of individuals being trained, with a heavy 7 emphasis on reidents in family practice and others who are con- 8 cerned with primary care. It operates with a contract between 9 the University Health Science Center, the medical school and a community. And the contract is over a specific period of time lu 11 and most of the energy emminates from-the University. 12 They have also accepted in the Bureau the kind of 13 activity wliicii we are carying out under regional- medical pic)- grams, because they worked it out with us, but at.the present 14 15 time, they are not funding in the Bureau this type of consortiu 16 within the community developed on a community basis, which we 17 have described-'in-the B14P. But you are quite right, that there could be, with 18 new legislation, a definition of the area Health Education Centcr 19 which includes what RMP is now doing, and which would go, say, 20 to the Bureau for its development. I think nothing would be 21 nli lost in that because what we are doing has produced good result 23 and things of a different kind would have a different budgetary origin. 24 :e-Fedefal Reporters, Inc. DR. KRALEWSKI: I wish I could be at ease that that 25 kar 3 will occur, I hope it will, I know there has been concern over this over the past couple years, I know there has been a great 3 deal of conversation between HSMHA and, of course, Health Man- 4 power over the relationships of all these programs and that is 5 why, at the moment, you know, I hope that when we are going intc -6 the field with this kind of investment, that they are fully 7 aware of how it might articulate with their efforts. 8 DR. MARGULIES: -Let me sa y not only are they aware 9 with constant visits back and forth between members of the en a cursory exaininat stafjr,-but ev ion of the contract applica- 11 tions now under reviewi will demonstrate that most of them -- 12 and I can also add-; the best of them -- were written by the 13 regional medical programs. 14 Furthermore, there is a requirement even in existing 15 16gis lation that the RMPS, local RMPs coordinate with these 16 activities so that it will be required both at the local level 17 and at the federal level. But several were written almost 18 independently by the regional medical program, then adopted by 19 the applicant-and-utilized on that basis so the review and commEnl 20 which they failed to'get around to in any case was not terribly 21 important. 221 MISS KERR- T would 1-ike to -make a comment. I think 23 we are not at all incompatible, but rather compatible and from 24 the place where I sit wearing several different hats related to ce- Federal Reporters, Inc. 25 regional medical program, the area health centers concept has u kar 4 1 not been opposed by our particular University. It concerns the -2 community as community planners 'that are very active. 3 I see a great cooperative effort potentially possibl(! 4 and I further see the regional medical problem as the expedites 5 of this. So I don't feel threatened by this. I think if the 6 cooperation can exist, it can really work both ways with no con-- 7 flict. 8 DR. LUGINBUHL: What is the total amount that has 9 been awarded in these 57 projects over the three years? 10 DR. CONLEY: It is almost seven million direct cost. 11 DR. LUGINBUIIL: What is the total amount under con- 121 sideration by the Bureau of Health Manpower for their contracts 13 for area Health Education Centers? 14 DR. CONLEY: Yes, they have'a@total of 11 million. 15 DR. LUGINBUIIL: Are they going to be reviewing the 16 awards that were made last spring during the next two weeks wheii 17 they make decisions about the 12 contracts or so that they are 18 going to award? In other words, is there going to be an.actual 19 review of these existing awards and will that be a factor in 20 their reaching decisions about their awards, so that we don't 21 get'into the situation of duplication funding and hopfully we 2 mi@@* even ,--t the of --ompl@--.-Icn-@ary rcfunl,ing. 23 DR. CONLEY: The RMPS staff has met with the BIIMP 24 staff to discuss areas of mutual interest in the contracts. 'e- Federal Reporters, Inc. 25 However, PJAPS staff did not have the opportunity to look at the kar 5 1 contracts so there was some limitations on how productive that 2 meeting was. 3 DR. LUGINBUHL: What about the reverse, is there goii,g 4 to be opportunity for the Bureau Health Manpower staff to reviei, 5 these awards? 6 DR. MARGULIES: They already have. 7 DR. LUGINBUHL: They already have? 8 DR. SCHMIDT: Warren? 9 DR. PERRY: I had the privilege of serving as Chairm@n 10 of th4-s--@ubreview group, also presenting tells series of 11 awards to the council. I believe those of us that had the 12 opportunity to look at the goals and objectives of these specif.c 13 projects were indeed convinced with the outreach activities thal. 14 were involved in these. 15 That these were in many ways quite unique from the 16 AHEC Centers that are being developed in Health Sciences Center,;. 17 If you look indeed at the one in my own region,that I am famili@ir 18 with, it is those activities away from Buffalo, in the outreach 19 area of community concern, of the ways in which smaller education. 20 al programs are indeed tooling up to do the job in rural areas 21 and'such, indeed the ways in which the expertise and consulta- 22 tion of these people to help these others set involved that turike( 23 us on to many of these projects. 24 These are where the Health Sciences Center perhaps ce- Federal Reporters, Inc. 25 have not indeed one the job. They are bringing in other groups kar 6 of personnel in to doing the job out of these areas and particu-. larly the community support and involvement. I think it was 3 of this that did turn us on ih-this. Indeed the'council, al- 4 though I'will say it was partially the fact that we were 5 following when this was presented the HMO controversy and dis- -6 cussions this HGO, accepted this entire area which is not indeed 7 the usual practice without a lot of controversy. This was 8 something at home that they were interested in and accepted 9 the entire recommendation as such,, and I think you know, on behalf of the council, they were most impressed with this as an additional way in which RMP was developing manpower to do the job 121 within the areas of RMP objectives. 13 DR. THURMAN: One more, Mack, and 1 promise to shut 14 up. my concern about the Maine situation, g6ing'back,@to.what 15 both Bill and John have said, is that sitting on another review 16 committee reviewed the Maine program as-an AHEC. And that is 17 why I am really concerned. @I@go back to what Harold said,.@I 18 think it is a wonderful idea, I don't need to see the application 19 because I am sure 1 already read it. That leaves us in the 20 position- of just what John said, and the concern that Bill 21 is listing. I am sure that Maine did not ask for double money. A.A. This is L-ack t-- ,our 4--crm of pluralistic .Z 23 All of us are use to cross supplying. Without it we 24 would be dead. I sh are John's concern that if we are talking ,e-Federal Repotters, Inc.I 21 about what the role of a region should be related to education, 53 kar 71 and that is what this really says, then when we divorce those totally, my concern is that AHEC will not grow well with RMP 3 and therefore with community support. 4 Going back to what Harold said, the Maine program is 5 beautiful,, it is a:university without walls and it does have 6 every Tom, Dick and Harry in the health field participating in 7 continuing training in the need for the entire state, but it 8 strikes me as rather odd that at one time when we are talking 9 about it as being a good AHEC, we are also talking about it as 10 being another good something else. 11 And that is my only concern. 121 DR. MARGULIES: You picked a good one for us because 13 that happens to be a program which is probably as fully coordin- 14 ated between @IPS and the Bureau as anything we ever had. It 15 was.discussed most fully during a period of time when the 16 VA Bureau and the RMPS, had demonstrated their ability to work 17 together, had laid out very carefully for the people downtown 18 how we could do this in tandem. Something they have always 19 urged us to do. 20 Having done that, they reached the conclusion that 21 such'a thing was impossible, that we really couldn't do it at 22 all, and it was going fine. So they made a decision, in this 23 particular case being OMB, that something should go one place 24 and something else should go someplace else. Every element of ice-Federal Reporters, Inc. 25.@ the Maine program is fully undct2-stood, where it has to be kar 81 called an AHEC to get this kind of funding and where it has to --2 be called something else to get the other kind of funding and 3 the reason they come in in a different way is because it is the 4 only way we could provide them the kind of resources which were 5 available and which they needed, but the Bureau understood this 6 and we understood it. 7 DR. SCHMIDT: One question is still floating around 8 the room and that is the future of the review of these and the 9 integration of the review of these activities into the.usual jo process. Are Lhese going 'Lo be kep@L. separate or are they going 11 to be fed into the review committees 12 DR. MARGULIES: You will find during the course of 13 the review that they are a part of the regular review process. 14 We did this kind of separate review as I indicated earlier with 15 maximum reluctance. There was no desire on our part to do it 16 this way, but just the discussion which was carried out here 17 illustrates why we had to do it at the last moment and under 18 conditions of unusual pressure. 19 Furthermore, we are in high hopes that we can enlist the activity, the presence of members of the review committee 21 now in going to those which have already received some funding, n2 chart their proaress, become a part of what is aning on and 23 at the same time, to participate in Additional understanding 24 of these types of applications when they are part of a total -e- Federal Reporters, Inc. 25 kar 9 DR. SCHMIDT: Well, I think we will then move on to the next part of this presentation. 3 MR. HINMAN: The Secretary of Special Review and 4 Supplementary Refunding, since your last meeting was an Emergen(!y 5 Medica 1 Service Systems, Dr. Larr Rose Project Manager, our y Health Care Systems Task Force. 7 Larry? 8 DR. ROSE: We are passing out now an'a general 9 summary of what went on in the award which went through June 10 council. A very small introductory paragraph which goes with 11 that, most of you, I am surei- are well aware of the fact that 12 Emergency Medical Service has become very fashionable over the 13' last year and most fashionable over the last six, eighl--,.months. 14 We have had a lot of questions, a lot of comments 15 about what RMP is doing, what HSMIIA is doing, what the Departmeiit 16 of Transportation is doing, all of.these sorts of problems. Oul.-- 17 own history in this area pretty much began at the meeting of th(@ 18 RMP coordinators in St. Louis, last January, followed by some 19 writing of their general guidelines to the RMPS to submit appli 20 cations for supplemental funds, for emergency medical services 21 prog rams, these guidelines were written in.February. 29 A-pli---ati---.-.s ..,crc rcce,-vcd by a special r v--2Lew 23 committee, and the action -- which committee was Chaired by Dr. 24 Schleris; the actions of this special review committee@were@thei ,e -Federal Reporters, Inc. 25 presented to June council, and the results are what you have in ler 101 your hand. The major activity at the moment, other than the RMP 3 program which I think I should probably mention to you, is a 4 contract program run by a special project office within HSMHA, 5 headed by Mr. John Greardon, which has written contracts for 6 five model emergency systems around the country. These five 7 are in San Diego, Jacksonville, State of Illinois, State of 8 Arkansas and Southeast Ohio. 9 They will be writing other contracts for what are 10 termed model sub systems. They are in the process of wr4.,--ing 11 those now. There is reason to believe that within the next i2 six months,they w ill go on writing contracts for either total 13 systems or more likely, for other component systems, as well as 14 for evaluation of the Emergency Medical Services Systems. 15 Their time frame for writing these contracts could coincide witli 16 ours, naturally, and this coincidence has lead to some of the - 17 confusion. 18 Much more of it it turns out relates to the fact tha-: 19 the Department of Transportation has. been in what they consider 20 the emergency medical services business for a number of years. 21 And-their approach, contract approach and our approach, is not 22 the same. 23 I think what I should mention is one impression of 24 what is happening in some of the RMPS which we have been a ;e- Federal Reporters, Inc. 25 little concerned about and hope to begin working on very soon. 57 kar I' Some of the EMS projects which are listed to that summary sheet -2 are being run as pretty isolated, rather separate activities, 3 separate in the sense that they are, they seem to be in some 4 measure apart from the rest of what the RMP is doing or what 5 the rest.of'the RMP is interested in doing. I think this is -6 inevitable because highway safety has caught EMS for six or 7 seven years now. 8 The AMA, many committees, many organization have 9 explained what emergency medical services is, so it is inevitable that we would have fallen into the trap of allowing people to accept their understanding of emergency medical services. ]2i What I think is going to be emphasized.is the matter 13 of the problems common both to emergency medical services and t( 14 all other forms of medical services. What I am suggesting is 15 that one of the things that we will probably have to emphasize 16 a little more clearly over the next few months it the role of 17 emergency medical services activities in furthering the objective 18 of the RMP, helping the RMP to work in its areas of major inter(!sl 19 With this approach in mind, we are talking to a fair number of 20 the RMP coordinators. 21 We are planning to set up a series of probably rathe 2 I'- @Lnforiria'L v2Lsi'--Ls to t5oiitv- of tiie regions where the E14S programs 23 appear to be particularly splintered from the rest of the 24 activities. The other part of this EMS I mentioned is fashional)ll -ce-Federal Reporters, Inc. 25 is that a fair amount of new legislation is in the process of ]sr 121 coming out, some of it may be out.before the end of next week. 2 Much of it probably will not,-bu.t it is pretty well known to 3 most of the people who are interested in improved transportation, 4 in more radios,, better ambulances, these kinds of things, that 5 large sums of money are being discussed, hundred million, three -6 hunred million dollar type of programs and therefore, there 7 is a tremendous amoutn of pressure on many agencies, including 8 the RMPS to be sure everybody gets their slice of the action. 9 It is based on these kinds of pressures, but I think 10, we have a cerLain Sense of urgency about being sure that the 11 RMP knows why it is in this business. Plus the fact that the, 12 hopefully at least this separate isolated categorical type of 13 program will not since it is not the customary part of an 14 RMP activity, will not accur again and therefore the @IP will 15 have to be justifying their activities here based on their over- 16 all and primary problems. 17 We-Will be involved in some kinds of evaluation of 18 the activities to which are defined there. I say some kinds 19 because they vary in actual productivity. Some of hte RMPS are 201 involved primarily in setting up.local EMS councils and they 21 measure success or failure on whether a council has been set up 22 whereas. some others bave morp components and the other things 23 which can be evaluated. 24 Much of the evaluation,@.thouqh, will be carried out ,ce-Federal Reporters, Inc. 25 in the contract program by looking at the progress in t.@le model 59 kar li@ systems and a fair amount of that will be applicable to the RMPS. E 4 3 4 5 6 7 8 9 1 2 13 14 15 16 17 18 19 2 0 21 2 23 24 e -Federal Reporters, Inc. 25 60 7148 1 DR. SCHLERIS: Reactions that I think I could make aig#5 /21/72 2 to this but I would like to give you some of the points, for jr 3 instance the weaknesses of the program. 4 First of all the time-frame was one which did not 5 permit either the applications nor the review to have many of 6 the factors we would like. 7 I think at this point the staff should be compli- 8 mented on the fact that they did exhaustively review at least 9 the material given but at the same time all we had was with 10 the a-p!4--.at4-ons, no site visits were made. It was suggested that although the sum of money 12 saved looks large over that requested, some $24 million 13 which I would like a certain return I think that we won't 14 see all of that eight million spent either for some time. 15 There is nothing more difficult than working out 16 a system for emergency medical services. This is a total 17 community effort. It should end up in a categorization of 18 emergency rooms, hospital services, it has to involve the 19 major people involved with emergencies, not just transport, 20 emergency medical technicians but all the emergency rooms, 21 coronary care units, burn centers so on, a real stratification 22 of care, various echelons of services and as T sai(9 catector3,- 23 zations of various hospitals. 24 Almost every agency in the community that you can :e- Federal Reporters, Inc. think of working together. 25 jr 2 Don't think one could pick out more than one or two of these which really fit that. When you go to the areas 3 from which these applications arise you find many of the appli- 4 cations, I am sure, will prove to be nothing more than paper 5 applications. 6 They look good but really there wasn't the time to 7 have the necessary wide-spread community support. 8 When I review Hawaii later, I think it will become 9 apparent. This is one of the cases in point. This isn't 10 meant -Lo be a pessimistic view but really to indicate that 11 I am sure different standards would be used and should be 121 used looking at new applications as compared to these appli- 13 dations. 14 It is relatively simple to put in applications for 15 action, millions of dollars for hardware, but to make sure 16 the hardware, those people in communications can work with 17 each other will work with each other and should work with 18 each other is something else. 19 And I think we have gone in this with a degree 20 that will bear very careful watching. 21 I don't know how large your office is or how large the staff is but I think ,ou need a v@-y l@arge staff in the 22 23 field to look at these. I would assume everyone of these communities would 24 e- Federal Reporters, Inc. and should need a great deal of help in putting together not 21, 62 jr 3 1 just people and some equipment and hardware but if they're ,@2 going to have an emergency medical system for all types of 3 medical emergencies, the help they will need and the evaluation 4 and planning has to be extremely extensive. 5 I think that this is a dramatic area to look at 6 but one of the toughest to solve in a community because it 7 really gets at what the crux of the problem is in services 8 deciding who can best do what in the most reasonable and 9 in the best way. 10 S u c I't 'L.'i iii-ig6.ds deciding you can pass by the nearest 11 hospital which it gets to be a major point of contention 121 in the community and to decide why if you are going to another 13 hospital it is the better hospital to go to. 14 I think this raises the hackles of someone who 15 works in a hospital in the community. I am sorry you are 16 going Sister and, we could use you to work on this and you 17 could take your sabbatical right here. 18 SISTER ANN JOSEPHINE: I would have to agree with 19 the concerns you have raised and just to document one of 20 them I not too long ago, I sat in a meeting where this subject 21 was reviewed and the data that was used to support a project was data from a niibli t-.-qtioni state publication. 2 23 It was never accurate to begin with. And that was 24 the data that was used to support their application and I e-Fedeial Reporters, Inc. think that needs to be looked Into. 25 63 jr DR. ELLIS: I think,Mr. Chairman, that there is -- @@2 the interesting point that was raised here has to do with 3 the way regional medical programs can work, not only to 4 understand the best way to deliver emergency medical care, 5 but to look at what happens to the patients in the whole 6 process of care after the emergency care has been given. 7 And I really don't know of any other agency who 8 is in a position to do this. It really helps to get the 9 people to the care, but it certainly is important to look at 10 all of the things that have to happen to the patient after: 11 the emergency care is over because many of the sequela 12 which result hampers what the person can do with their lives 13 and I think this is a point we must not overlook as we look 14 at the planning for delivery which has been so beautifully 15 emphasized here, in my thinking, by the presentation we just 16 heard. DR. SCHMIDT: All rig@t, are there other comments 17 18 or questions? I will ask that you keep them brief if we can. Go ahead, John. 19 20 DR. KRALEWSKI: Just one question on the time- 21 frame here. Are these -- I notice most of them are one-year grants. Are these e.ssentially planning grants, thev'--re. Coming 22 back then for another application for implementation? 23 24 DR. SCHLERIS: Yes, there are several other con- e - Federal Reporters, Inc. cerns with this, one is is that if these are supported for 25 jr 5 1 only one or two years you are going to have a problem of the 2 maintenance of the system falling back on the State. 3 And I don't know if we have really looked that far. 4 I am sure that you have. 5 In our own state we have come up with a figure 6 which if we bounce it back to our state legislature is going 7 to be a large number just to maintain the system once you 8 put it into effect. 9 A lot of the single years are just planning, 4 10, =-c-su.T.,-ng that the major expense is hardware but then @-raining 11 gets ongoing and the assumption is -- inaudible -- you are 12, setting up communication's'networks which require staff, 13' personnel to be ongoing. 14 You can't set up a system for one year then drop 15 it when our evaluations for all our projects are what will 16 happen after the two or three years support by RMP. 17 We are setting up something here we assume pending 18 legislation will take care of, is that right? DR. ROSE: I think that is part of it. I think 19 20 the other real question that might be generated is whether 21 we know what an ideal EMS is for any community. 22 There are loqicallv real differences between the 23 amount of equipment, the amount of hardware, the numbers of 24 people, the levels of training between various communities e-Fedetat Reporters, Inc. relating to some extent to what the priorities for health care 25 65 jr 6 or in that area. -2 DR. MARGULIES: Until'we decided to move in this 3 direction during the past fiscal year I had resisted all blan- 4 dishments from all sources that have anything to do with 5 emergency medical systems. 6 They came up regularly, they came up in RMP before 7 I was here, they always appeared and disappeared. 8 -The surgeon-general would suddenly say this is the 9 most important thing to do, let's get plans and we will get 10 some money for it and six weeks later everyone had forgotten 11 about it. 12 We decided to move in this direction convinced 13 that this is now the time that people are really concerned 14 and something will happen as a consequence. 15 I think the evidence of the commitment to both 16 parties, the legislation which is developing, suggests that 17 there will be continuing support. 18 There is always a risk involved. And we also recog- 19 nized. not as well as you do but to some extent that we were 20 getting into something which was going to require an unusual 21 amount of attention and supervision. 22 I would net suggest at all that our --taff 23 adequate to do this. As a matter of fact our staff is being 24 pilloried and slinging at the present time. e- Federal Reporters, Inc. 25 We will, however, have access to many consultants 66 jr 7 1 and many people who can help us extensively in EMS activities. -2 I think we will have to use them more fully here 3 and in the education and service activities and as a matter 4 of fact all through RMP, than we have in the past. 5 I don't consider that undesirable. As a matter 6 of fact it will be of great advantage to us. We should 7 have done it, with the existence of adequate staff. Will 8 do it faster with a limited number of staff. 9 DR. HINMAN: A brief report on the pediatric pulmo- 10 nary issue. 11 During the process last year it was identified 121 that it was the will of Congress that the RMPs be active in 13 this area to the extent it had been previously. And I report 14 to you that we fulfilled this mandate. 15 One of our other major activities is in in stage 16 renal activities. 17 Mr. Spear is project manager for this and will 18 give us a report of exactly what is happening now and in the I #5 19 next few weeks. 20 21@ 22 23 24 e-Fed6ral Reporters, Inc. 25 CR7 14 t$ #6-ter-1 MR. SPEARS: Last year, for instance, according 2 to our count, as accurately as we could make it, we think it 3 is quite an accurate count, there were, at that time, in 1972, 4 29 regions which, together, received a total of 6.4 million 5 in funds from RMP to do essentially dialysis, transplantation, service capability expansion kind of things. 7 As these things were coming along, there was a call about last November for what was called a Health Initia- 8 tive Paper, from th e Administration. The Administration, at 9 that time, looking for areas in the health and other fields in which it could take a stronger, make a stronger thrust in science of technology -- kidney was one of those programs 12 13 permitted to respond to that call, and responded with a 14 document, which title frankly escapes me 'at the moment something to do with the ravages of kidney disease, but which 15 we call our life plan. 16 17 Taking the events as they transpired, taking those 18 things that we could identify as knowledge, facts we knew, 19 taking into consideration, the kinds of funds we had had, 20 and taking into consideration, the things we felt we could 21 do in a rational way with some focus, the last plan said, 221 we would like if it is your will, Administration, and with 23 $80 million to institute, a program nationally, that we believe 24 in, between five and eight years, will serve the provision of .e- Federal Reporters, Inc. care, renal dare to all people who can use such care. 25 b b ter-2 I Well, the plan was not adopted as one of the health @2 thrusts. But, it has done several other things. It was .3 attractive to the HSMHA Administrator, it has been attractive 4 to the Assistant Secretary for Health Assignment Affairs, it 5 has been known to be attractive to the Secretary. 6 There is a great interest in our undertaking this '@7 kind of a program. So, it was, whether we had these additional 8 funds or not, it has at least focused our thinking on the 9 needs, desirability of moving along the in-state track until 10 that pro'-Ulefft @Ls reasonably overcome to the degree we can do so 11 We stand at this moment, then with guidelines that 121 express our desire to fund as a part of a national RMPs 13 program in kidney in-state kind of projects and programs. 14 A contaminate document has come out also which is going to 15 have some impact on this program. 16' This refers to the requirements of Section 907F, 17 Title IX, which requires the Secretary to publish a list of 18 agencies. I know you have heard thisIbefore, and in connection 19 with the kidney aspects of the RMPs responsibility. There has been a document produced through a con- 20 21 tract with National Kidney Foundation, which gives an identi- 22 fication Or doe-c; 'dpntify through a -roup, @,,h,-,-,h the,, called 23 together to consider this problem; the various levels of 24 care which could be provided for in-gtate renal care,, and -e-Fedetal Repofters, Inc. the kinds of services that such levels of delivery would 25 69 ter-3 I surely encompass. Very simply, they identify those kinds of services 3 that are unique or characterize primary care in kidney disease 4 those that characterize secondary levels of care, and those 5 that characterize tertiary levels of care, and those that woul@ 6 define them. 7 The direct employment of this document is as yet, 8 unclear, although it is giving us a good statement to take 9 to people who wish to do kidney activities, to help their 10 thinking about the kind of facilities and services they should 11 be setting up, and what the relationships among them ought 12 to be. 13 The current kidney guidelines, the main body of 14 which were issued May 3i and addendum issued now on September 15 14, to clarify some questions about those, carried a require- 16 ment that we thought was critical to the Federal program; a@ 17 program with a Federally directed thrust to it, and that is 18 that we needed to have some review to be sure that the criteria 19 which we felt had to be met would, in fact, be a Part of the 20 program as they evolved. 21 The requirement is that, as a new-,.renal project ^2 comes into being, it be revi--,.@?cd by a minimum oL 23 party reviewers. In trying to implement this requirement, 24 we ran into, as usual, some snags. There are lots of people ce-Fedeial Repottets, Inc. out there who are quite qualified to do good review in so far 25 ter-4 as medical competence is concerned. One question was,,.who are they, and how do we reach them? 2 3 Another question was, would they consent to serve 4 in the kind of role we were going to ask them serve in? And thirdly, how did we -- how would we know that we were getting 5 the best people in the estimation of the parties in the field? 6 T6-resolVe this problem, we called together a 7 number of consultants who had sefved with kidney activities 8 9 for some years, and asked them to look at some rosters we 101 had, asked them to come up with some recommendations of their own, and proposed that they-join with us, having identified I 1 12 at least, a first crop, a first cadre of potential kidney 13 program re-@iewers; coming together with us in an c.-@,Lenta@t-";Oll session in which we would sit down with people selected and 14 who say yes, they will serve in this kind of a role, and 15 t 16 tell them some of the kinds of problems and this is what we 17 have to do in setting up a kidney activity. 18 Those kinds of problems are the things contained in the opening remarks of Title IX, the coordination required? 19 what is the integration? What is the centralization unique 20 21 to the kidney, and how do you try to assure these kinds of things are being done to the best extent of the locality you 22 i 23 are looking at? 24 Are they really outreach, going out further from ,e -Federal Reporters, Inc. the centers than has been the case in the past? 25 ter-5 Is there outreach in fact? These kinds of things, 2 people who have not dealt with us directly, are not so familiar 3 with, and are critical in review programs, and the evaluations 4 we need to have placed on them. 5 The outcome of this has been that On September 30, -6 and October 1, in a very short session of what is in two 7 pieces, it will be not more than about eight or nine hours; 1 8 we will meet with some ninety people, representing a variety 9 of 6xpertise in the renal field, to discuss how to be a 10 consul---ant on regional RM-P kidney progL-a,-ns and those people for the forthcoming year will be the cadre from which we will 12 select consultants as the individual RMPS, when we are ready 13 to go with the kidney program, and we want somebody to look 14 at it and counsel with US. 15 Are there any qubstions? 16 DR. SCHMIDT: Questions, or comments? 17 Ed, do you have anything? 18 Thank you very much. 19 According to the schedule, we blocked out in advance of the meeting, we are now running about 45 minutes 20 21 behind, which is a little better than average. We do have a fairly heavy schedule of reviews, actual working tvve 22 23 business to get through today. 24 So that we.will take.a break right now, and I would ce -Federal Reporters, Inc. ask that it be, you know, aimed for 15, but we are going to 25 72 ter-6 I start in 20 minutes from now; even if nobody is here. 2 (Recess.) 3 DR. SCHMIDT: I believe we will begin. I would 4 like to warn the committee members that I think it would be 5 best if,we had long work-sessions today and plan to go, you know, perhaps beyond when the traffic congestion!is on the ,6 road. 7 8 We commissioned a study to show we waste time by leaving here at five, anyway, so that we will go until we 9 ;io do the necessary sorts of things, today. And, I will obvious'LN 11 have to try to move things along and hurrv people along, so I tvi@ll,,-@-from'time to'time, break into a discussion, and remind 12 13 whoever is talking, of the time that is going by and so on. 14 I will say, just once, that there is nothing perso- nal here, but I have always worried that at the end of the 15 16 second day, we give some regions, at times, short shrift; and 17 1 don't believe this is fair and I would rather be fair to the 18 regions than fair to the individuals on the committee, so that 19 I will take a perogative of moving the committee along, from 20 time to time, if that becomes necessary. 21 I have asked Mr. Chambliss to very quickly review '/-%21a few more informational items that will take fitTe to ten 23 minutes. 24 Then, we will move on to a case study. ce-Fedeial Reporters, Inc. Mt. Chambliss? 25 ter-7 MR. CHAMBLISS: Thank you, Dr. Schmidt. 2 I would like, first, to just simply present a 3 status report on some of the significant personnel changes 4 in the RMPs throughout the country. There are 13 regional 5 medical programs that have had rather key staff changes, and 6 I would just simply like to take those off for you. 7 First, the Central New York RMP has had changes 8 in its Directorship and now, Mr. John Murray has been appointe@ 9 Director there, as of July lst. In Delaware, one of our newer 10 regions, a coordinator has been appointed, Dr. Micl.,telil-.. Dr. 11 Michelin is formerly affiliated with the University of New 12 York -- New York University in Community Medicine; also with 13' Albert Einstein College of Medicine and also Yeshiva Universit3'. 14 He comes very highly recommends 15 There is an unofficial resignation of a coordinator 16 in the metropolitan Washington regional medical program. Dr. 17 Wentz, as I understand it, has tendered his resignation or 18 his intention to leave. At Rochester, Dr. Peter Mont has been appointed as the new Director. He has a background in 19 20 private practice and medical school teaching. He has headed 21 a Neighborhood Health Center in Tucson, Arizona. He will have 22 a new Assistant Director, shortly, in the person of Dr. Chuck 23 Adair, formerly associated with the Kansas Regional Medical 24 Program. ce-Fedeial Reporters, Inc. At Tri-State, Mr. Robert Murphy, has been appointed 25 ter-8 1 as a replacement for Dr. Leona Baumgardner, and Mr. Murphy .2 comes to that RMP with a background in hospital planning. He 3 has formerly also been the Deputy Regional Director for 4 Health and Scientific Affairs for HEW, Region I. 5 Also, At the Colorado-Wyoming RMP, Dr. Howard 6 Dome has resigned as of July 1, and his replacement is Dr. 7 Thomas A. Nicholas. Dr. Nicholas has had background in pri- 8 vate practice in a rural area of Buffalo, WYoming, and he 9 has also served as Chairman of the RAG for the Colorado- 10' Wyoming RMP. o-6/s-7 11 12 13 14 15 16 17 18 19 20 21 2 23 24 ce-Fedeial Repottets, Inc. 25 CR7148 Craig 7 75 jrb 1 1 At Intermountain, Dr. Robert M. Sadovick has 2 resigned as of August 1, and he has been replaced by Mr. 3 Richard Haglund, who was the Assistant Coordinator, and 4 Mr. Haglund is the interim coordinator until a permanent coordi- 5 nator is appointed. 6 In Oklahoma, the Oklahoma RMP coordinatoe'has 7 resigned, Dr. Dayle Groom. Dr. Kelly West is acting now as the 8 interim coordinator. 9 And in Iowa, and you probably have heard this one 10 before, that Dr. Harry Weinberg retired some -time ago and he 11 has been replaced by a coordinator pro tem, Mr. Charles Colwell. 121 There is a search committee at work now for a full time 13 coordinator for that region. 14 In North Dakota, Dr. Charles A. Arinson 15 has replaced Dr. Willard Wright as executive director there 16 as of August 1. 17 In Florida, a significant change: Mr. Robert Lawtont 18 who was formerly the deputy coordinator at the tristate RMP 19 has been made program developer for program development. 20 In Indiana, Dr. Steven Barry has been appointed as 21 Acting coordinator; he has also been serving as associate dean at the Universitv of Indiana Medical School. 23 And, finally, Dr. Laas Dorin has been appointed as 24 coordinator of the newly formed Ohio Regional Medical Program. .e-Fedefal Reporters, Inc. He has a background in private practice and that ends the 25 -b 2 76 significant changes in personnel in the RMP'S. MR. CHAMBLISS: We think the Committee would like to 3 know that the staff of RMP has been engaged in a wide range of 4 review certification visits to all of the RMP'S, or rather, 5 to most of them. Each of the RMP's will be reviewed in terms of 6 their review process, their review processes, and will be certi- 7 fied or partially certified or not certified before the end of 8 this year. 9 There will be, however, three RMP's that will be -10 carried over for review certification purposes and those regions are California, South Dakota and Delaware. These revieo 12 certification visits will be conducted before the end of March, 13 197@3. 14 And I might say that I think the Committee would like 15 to know that there has been a very high level of staff coopera- 16 tion in conducting these review certification visits, between 17 the DOD staff, that is the Division of Operations and Develop- 18 ment, and the Staff of the Division of Professional 19 and Technical Development, headed .by Dr. Henman, and equally 20 by the Staff of the Planning and Development Office, headed by 21 Mr. Peterson. 22 These visits are now in their final stages. 23 There have also been conducted a wide range of manage- mett survey visits to the various,RMP's, and that schedule 24 @e-Federat Reporters, Inc. of visits is moving along according to plan. 25 rD .5 77 And I am sure you will note some of the management 2 survey reports in the materials that you have. This activity 3 has been cited by HEW as being one of the a well performed 4 activity as far as management is 'concerned. 5 There may be some questions so far. If not -- if 6 there are, I will be glad to entertain them. 7 If not, may I just fastly shift to an item o 8 information for the Committee: 9 If you recall, at the last meeting of the Committee 10 the %Committee iiid.@Leated its interest in having for information 11 purposes the result of the staff anniversary review panel-s 121 activities. 13 This staff of an anniversary review panel is 14 comprised of 11 key members of the RMP staff, including the 15 Division Directors, the Division Directors of the various 16 offices attached to Dr. Marguliesloffice, and the Operations 17 Branch Chiefs. All 11 engage in the staff anniversary review 18 of those applications, those anniversary applications, within tle 19 triennium. 20 This panel this time looked at the anniversary 21 applications within the triennium of six RMP'S. If you will 0 22 notice this long shpet, and at the bottom of the page Linder 23 the line you will see the regions that were reviewed by the 24 staff: California, Colorado -Wyoming, Georgia, Maine, Michigan, @e- Federal Reporters, Inc. 25 and Wisconsin. j 78 I The staff review is done on a formal basis. The .2 applications to be reviewed are known in advance by the staff, 3 presented by a member of the operations division, and there 4 are three reviewers assigned to look at that application in 5 depth. 6 The significant things that came out of that 7 review, in addition to the ratings that the staff submits for 8 information -- for your information -- are the fact that in two 9 of the regions the council approved level is recommended for 10 an increase b-, t,@.c staff. That's in the case o'L I.Ilichigai-i, where .Z 11 the counsel approved level was 2.1 million, the funding level was 121 1.92456, and the staff or the SARP was an elevation of the 13.council approved level to 2,250,000. 14 You will see that on the spread sheet. You will 15 Probably be interested in the rationale for that increase in 16 Michigan. ,@ The staff considered it. There is a new coordinator 17 18 there, as I have mentioned. It was felt that there was funding 19 flexibility needed to further develop the program there. There 20 was a region with a very small staff and on that basis, staff 21 recommended an increase. Staff did not go along with the staff 22 panel -- the staff panel did not ao alone with the staff 23 recommendation there which was the region be funded at a level 24 of 2.9. ;e-Fedeial Reporters, Inc. The other region that has a significant point to be 25 jrb 5 79 1 brought to your attention is that of Wisconsin, the council 2 approved level being 1.779 million; the funding level being 3 1.779 million, and the SARP recommendation came out at 2.1 4 million. 5 The region requested 2.176 million, and you see 6 the SARP recommendation. And the rationale, I am sure you 7 would be interested in, again, the staff felt that was an 8 excellent review process being carried out at Wisconsim. It 9 was impressed by the fact that the RMP plays a significant role 10 -Ln the Gove.-no.-Is Commission on Quality of Care. There's a 11 functioning allied health council within the RMP. The EMS 12 proposal as reviewed by the special review group was approved 13 by council and committee. And the regional medical program there 14 had received an award of special merit, the Lambert Award 15 for "Innovations Designed to Improve Pa.tient Care and Reduce 16 costs". 17 This Lambert award, as I am given to understand, 18 is a national award which this RMP has woi4 in recognition for 19 what it is doing in the area of innovation. 20 That concludes my report, Mr. Chairman. 21 DR. SCHMIDT,-. All right. Thank you for making it so concise. 22 23 Are there comments or questions? 24 (No response.) 'e-Federal Reporters, Inc. If not, then, what vqe thought would be best at this 25 80 point would be to move on to a case study. 2 Now, you will be subjected from time to time to 3 "Schmidt's dicta about life". The first one I think I mentione@ 4 was that life is non-linear, and the second one is that you can 5 rarely get it both ways. And one of the things that the 6 committee has objected to in times past is the lack of time for 7 discussion of general topics of concern to the Committee. 8 Very many of us often spend time doing things that WE 9 absolutely have to do and neglecting the things that can be 10 put off, but turn out to be the most important in the long --angc. 11 And the Committee is engaged in times past about -- 12 in a discussion of what is the committee, what is its function, 13 and what is it now doing in terms of the total review process, 14 local review, national review. 15 The word "emasculation" has come up from time to 16 time, "rubberstamping" and things such'as this. And very 17 frequently at these meetings there simply has not been time 18 for a discussion, a good discussion, based on fact and so on 19 of how the committee has functioned, is functioning, and 20 probably should function in the future. 21 We can't have this sort of discussion without obviou ly 22 having to tighten up on the other side, and that has been verv 23 efficient,in our review of regions this afternoon and tomorrow. 24 But we thought it important enough to engage in 8L@discussion @e- Federal Reporters, Inc. 25 of the functions of the review committee, to make a special irb 7 81 effort this two-day meeting, to kind of integrate into the 2 discussion of regions the subject of the function of this 3 committee, so that we will begin with a case study that 4 is intended to demonstrate how a region develops, and how the 5 review committee is operated in the development of this region. 6 And this is a case study of the Rochester Region. 7 And we will move then, hopefully before lunch, from that discus- 8 sion into a review of the Rochester region -- Dr. Brindley -- 9 and we will alter the discussion somewhat in that way. 10 Then I mentioned before in the case of Albany, 11 Hawaii, and Mississippi, we will be trying different ways of 12i presenting information about the region to the review committed 13 in an attempt to find out, you know, which way the committee 14 looks at it, and how can we be more efficient and effective 15 in getting the necessary information to the Committee to allow it 16 to make a judgement as a Committee, rather than just listening t:) 17 what the principal reviewer says and in making a judgment perhaps 18 based on inadequate information. 19 So at this time we will begin presenting some 20 information that we hope will provide the basis of a better 21 discussion by the committee of its role in the total RMP 2n4 process, and Dr. Margulies and Elaine will lead this discussion. 24 And so who starts? 24 MS. FAATZ: The reason I am up here is because I am @e-Fedeial Reporters, Inc. 25 the onl@y person who has been bra-ve enough to go on three J.L.U 0 82 I successive site visits to Rochester. 2 (Slide 1.) 3 Dr. Margulies and Mr. Chambliss have asked me to 4 give you a brief historic overview of Rochester, because it 5 does represent a rather interesting case study. 6 It is a region for which everyone had originally had 7 tremendously high hopes. We watched it first with a little 8 bit of concern and then growing dismay as the region became 9 increasingly less attractive. 'IO - iii faQt, last year I think the review committee-, if it didn't assign its lowest rating of any RMP, it was as close 121 down there to the bottom -- 13 DR. SCHMIDT: Elaine, just stop a minute: Is there 14 any way to put that speaker up here? Will it extend? 15 MS. FAATZ: Would it be better if I sat at the 16 table? 17 DR. BRINDLEY: We can hear find. 18 DR. SCHMIDT: Well, they are having trouble; they 19 can't hear back there. 20 okay, go ahead. 21 MS. FAATZ: All right. I will fasten this thing 22 again. 7Craig 23 Okay, can you hear me now? 24 :e-Federat Reportefs, Inc. 25 83 CR 7148 MS. FAATZ: Although Rochester did take the down- 8 hill grade in the last year or so, somethings have been 3happening in Now York that make our hearts beat a little faster 4and that is what I am going to tell you about. All this is not 5to suggest that Rochester is the best of all possible RMP'S. 6Dr. Brindley in discussing the findings of the site visit 7team will tell you that although there have been tremendous 8accomplishments there is still a long road to hoe in Rochester. 9 But I am hoping that what we can show you is that 10 a region, given sufficient reason, can change the direction of 11 its program. First of all -- this is the first in our light an d 12 sound show. Let's look, see where Rochester is in respect to 13 the rest of New York IUAP'S. It is bounded on the west by the 14 lakes area RMP centered in Buffalo, on the east by the Central 15 New York T)rogram headquartered in Syracuse. 16 Tothenort of Rochester is Lake Ontario and to the 171south is the State of Pennsylvania; there are ten.counties 18 included in the Rochester area. These are the same ten counties 19 covered by the CHPB agency4 Rochester itself is the third 20 largest city in New York State. 21 The only other city in the ten counties of any 2'xl_ s-abs-LaiiLial size is Elmira (slide 2) down in the southeast 23 corner and that is in Chomung County. Because of these two 24 urban areas statistically the population of the Rochester e-Federal Reporters, Inc. 25 region is about 60 percent urban but that is really misleading 84 #8 because the other eight counties are primarily rural and Reba 2 2 small town. There is fruit growing, there are the vineyards, 3 there are the Finger Lakes over to the wast of the region which 4 are resort areas. 5 The population of the ten counties is about 1.2 6 million. Of that about 5 and 1/2 percent are non-white although 7 in the city of Rochester it is -- the figure goes up to about 8 18 oercent. There are 27 community hospitals in the region the 9 preponderance of them being in Monroe County up in the Rochester --an area, although each county in the region aoes I ri Mctro-oli4 L- 11 have a community hospital. 12 Maybe it would be well to go back to the beginning 13 and that was in 1966. When Rochester first applied for a 14 planning grant, everybody was delight ed, some were ecstatic 15 for a couple reasons. 16 First of all this ten county area was one which 17 in 1966 had already achieved an unprecedented degree of regional- 18 ization through the former efforts of the Rochester Regional 19 Ilos@ital Council. There were hospital linkages developed. And 20 many people thou ht that this was, if RI,.IP was going to succeed 9 21 anywhere, Rochester was the place. 0 In addition there was the- Rochester Health Planning 23 Council out of which grew an extremely strong CIIPB agency. 24 Dr. Ralph Parker, who was the former Director of the Hospital e-Federal Reporters, Inc. Council, was appointed coordinator in Rochester. 25 I 85 Mr. Frank Hamilton, an industrialist who was active Reba 3 2 in community affairs, and who was the past President of the 3 Hospital Council, was appointed regional advisory group 4 chairman and with the past history of the region and with these 5 two people in such key slots, everyone thought the situation 6 in Rochester was very auspicious. And things seemed to,90 7 along reasonably well for awhile. 8 There was little concern because Dr. Parker originally 9 had trouble recruiting full time staff, in fact for nine months he ;,,as only person on the Rochester staff. But in 1968 when the region applied for operational status, it seemed that they 12 had progressed to a point that it was reasonable to award 13 operational status to them. 14 Although we did say, we did not realize that we might 15 as well tape the message then and play it every year, the first 16 five projdcts that were funded in Rochester were in the area 17 Of heart. And we suggested that maybe it would be a good idea 18 if they try to develop a little more balance in the program. 19 Over the next couple years as applications from 20 Rochester were reviewed at practically every review committee 21 Deople began to worry. For a number of reasons. And first of 11 theke appeared to I-)e a -roiqing co- L L 22 ..con,-ration o' activities 23 Ln the city, metropolitan area of Rochester itself at the @xpe-nse of the other nine counties. 24 e-Fedefal Reporters, Inc. Secondly, the administrative practices of the 25 86 #8 1 coordinates could probably best be described as la issez faire. reba 4 2 Ile had no back-up administration and it was not a very tight 3 organization. Thirdly there had been a problem in getting 4 full time Professional staff. There were a number of pro- 5 fessional staff on the program. 6 Interestingly enough they were not full time, they 7 were project directors of @IP funded nrojects. Consequently 8 they had no practice in thinking of PJIP itself as an organization. 9 Their loyalties lay with their projects and with the 0 and to the @-.@.tent that @,m-P funded their pro4ects 11 it was great but in terms of doing anything else they just 12 1 were not thinking along those lines. And the fourth concern 13 was the level at the categorical and continuing education 14 oriented program. The region had developed and it was not 15 even a program that was categorical in continuing education 16 because the various activities were unrelated. 17 You did have, say, a cancer continuing education 18 program coming out of the university into each of the community 19 hospitals. You did have A hart continuation continuing education program coming out of the universities into each of the hos- 20 pitals and this went vou know bang, bang, bang for each 21 22 categorical area and there was no meshing between and among the 23 projects. 24 And at the same time the review committee was growing e-Federal Reporters, Inc.i 25 increasingly frustrated because every m.6eting which was at that 87 #8 1 time three and four times a year, they would be looking at Reba 5 2 supplemental applications from Rochester but they never did 3 get the whole picture. 4 All they would ever see was a project proposal and 5 they would say, yes, this is good or no, this is not good, but 6 they never crot a chance to look at the whole program and to 7 see how it fit together. 8 So out of this discontent, in April, 1970, grew the 9 first of a series of visits and contacts between us and between IO'Rochester. And that chart that was handed out at the beginning of this presentation shows the significant contacts between the 121review committee and the staff, and the Rochester program 13 starting in ADril, 1970, through the site visit we had just 14 last Month. 15 In the April 1970 site visit Dr. Richard Spellman 16 of the Review Committee was the Chairman. This site visit 17 was really a forerunner of the program site visit we have now 18 because if we looked at the projects, we spent just a very 19 little time doing that. Mostly we looked at the program, how it 20 was operating and you know, was there a program. 21 We found out that all the difficulties we had /'-2 suspected were confirmed and one that we had not noticed, it 23 had not come through in the application. And that was the 24 passive nature of the regional advi'sory grouo. In fact at one e -Federal Reporters, Inc. 25 oint t'ne regional advisory group had an 11 month hiatus between 8 8 #8 meetings. In fact the primary decision-making group at that P,eba 6 2 time was the planning committee which had'17 members, 13 of 3 whom were university people, three of whom were RAG members 4 and anything the nlanning committee disapproved was not sent 5 on to the regional advisory group. 6 The nlanning committee met monthly, the regional 7 group met as necessary and once as necessary was 11 months. 8 In addition, the technical review groups were almost all un- 9 dominated so it was 'pretty clear who was in charge, the coor- 10 dinates wasn't making decisions, the program staff were intet- 11 ested in their projects, the regional advisory group appeared 12 Ito be not interested in anything, and decision-making groups 13 were dominated by university people. 14 This was the first site I was on, may have been 15 the first one ever where there was a feedback session from 16 the site visitors to the nrogram. In fact we were so astounded 17 by what we found in Rochester that Dr. Spellman arranged for 18 two seoarate feedback sessions so he could be rather frank. 19 Ile spoke to the coordinates then spoke separately 20 with the RAG chairman to make sure the RAG chairman wou d get 21 the message as well and we thought we would be really brutal 22 and we thought maybe @l,!P nevcr bccn able @Lo go bac:'"- 23 to Rochester. 24 And after all.the frank advice we gave them we left Federal Reporters, Inc. 25 Rochester expected you know, in the next few months something 89 #8 1 really cataclysmic would happen. It didn't. For a long while Reba 7 2 you know Rochester went on with business as usual. In the 3 fall of 1970, there was a management assessment visit conducted 4 that was triggered by the concerns of the review committee that 5 confirmed the site visits findings. The management assessment 6 visit found precisely the same thing the site visitors had 7 found, prepared a written formal report that did not mince 8 words, that went back to the coordinates that went back to the 9 grantee, that made precisely the same recommendations that the 10 s, 4- .1 -1 @.Lsi-@rs had ma%Ae . Maybe something will happen. Next year in 1971, in 12 the spring of 1971, Rochester submitted at-riennium .applic. atio.n.' 13 This application showed the same chronic problem areas as 14 before. So another site visit was scheduled in June of 1971, an@ 15 Dr. Schmidt was the Chairman of that visit. 16 The only difference we could find in Rochester 17 was that the undominated planning committee had been abolished 18 and an executive committee of the RAG had been formed but aside 19 from that there were the same chronic problems and nothing 20 seemed to have changed, in fact it was almost a re-play of the 21 visit the year before which had had tapes of the feedback ses- sion. 2'-) 23 Still no.,program leadership from any quarters. 24 We could not identify any program direction. In fact the e-Federal Reporters, Inc. region didn't really know how to come up with program direction 25 9 0 #8 1 they would say things like "You know there is something we Reba 8 2 could do,-such and such an activity but the CHPB agency 3 has already done it so we don't know what we should do." 4 It was that sort of atmosphere in Rochester all they 5 could think of was continuing education and central regional 6 services, there still was no program staff that was not project 7 directors. And at that time, the site visit team and the review 8 committee really had to sit down and decide, okay, you know 9 what are we going to do now,this has gone on pretty long. 10 I think it was decided that you can't make a revol- 11 ution with silk gloves, and although we thought we had been 121tough the year before that must have been silk gloves so we 13 put on boxing gloves. And what the review committee finally 14 recommended was that the level of funding for the region should 15 be substantially reduced, that the region should be held to 16 one year approval only, with the warning that weare going to 17 come back next year and see what you have done. 18 Well these time and money limitations apparently 19 produced enough anxiety on the part of the Dean of the Medical 20 School that in September of 1971 Dr. Orbison, the Dean, and 21 Dr. Ernest Saward who is Associate Dean, for Intramural Affairs 22 -a,-,,c -@low,-i to T,oc'r@v-L'L'Le Lo i-iave frank discussions with Dr. 23 T4argulies about what was wrong with Rochester. 24 Then they went home. And we thought then maybe we e-Federal Reporters, Inc. 25 would really see some action. Just a word about Dr. Saward. 91 #8 1 He was brought to the University of Rochester in the Reba 9 2 I think it was the fall of 1970. fie had been associated with 3 K&iser-Permanente and the Washington Medical Program and one 4 of his main responsibilities at the University was going to 5 oversee the PJIP activities. 6 He has not been very much in evidence and we really 7 had no evidence whether he was interested in PL@IP or not. 1 8 think now we can see in retrospect that he was and he was 9 doing things behind the scenes but we were not aware of that 10 the time. As I say they went home and LI@Liiigs went on as 11 usual, so usual in fact that when Rochester received its 12 substantially reduced award it just stretched the award to 13 fund every single project that had been approved although at 14 a reduced level so at this time you had 17 projects that were 15 going on and I need not tell you what kind they were. 16 Some of them were actually kind of good but they 17 were all continuing education, central services and categorical. 18 Now maybe if we could take a look at this point at what 19 Rochester looked like for its first four years, (Slide 3). end 20 21 22 23 24 e -Federal Reporters, Inc. 25 CK #9 ty 1 Very briefly you can see that the allocation of 2 program dollars was pretty constant over the first four years, 3 about 36 percent program administration, which wasn't program 4 administration, about 26 percent in multi or noncategorical 5 and almost all that went for their early disease protection 6 unit which was a multiscreening thing which nobody had been 7 very well impressed with and looked like it might go on to the 8 end of the world and about 35 to 38 percent in categorical 9 activities which encompassed the litany that I have gone over 110 many @L..-fLmes, nursing, cont-LnuLiig education, coagulation 11 laboratories and so forth. 12 In the winter of 1971, though, we did receive word 13 that Dr. Parker had resigned. And then we didn't hear anything 14 more until around February 1972 at the request of the region 15 there was quite a large program staff contingent that went to 16 Rochester to consult with the people. In fact we really laid 17 on everything we had as Dr. Pahl, Mr. Simon from our Management 18 Assessment Branch, Mr. Peterson from Planning Evaluation and 19 a couple others of us and we thought we were going up there 20 because Rochester really had something to tell us about@how 21 they had changed. Well. we aot up th(-rp. 9.nrl we fo'Lind that exce-t for 22 C' 23 Dr. Parker's resignation, nothing had changed. The Executive 24 Committee still was talking about the things that needed to ,e-Federal Reporters, Inc. 25 be done but things they had not done. They still weren't ty 2 1 able to determine how they were going to find a role for 2 themselves. So we gave them the same old'advice that had been 3 given for the last two years. And came back to Washington 4 wondering, you know, why had we gone to begin with. 5 I think in retrospect we were mistaken or I was 6 mistaken at any rate. There was a lot more bubbling under- 7 neath the surface in Rochester than we could see. I think 8 people like Dr. Saward and others had been arranging their 9 pieces on the chess board but before they made that grand 10 swoop @@hcy wanted one fina'L reassurance that t'i.-lis was really 11 the way to go because after we left in February a number of 12 things started happening in very quick succession and I think 13 maybe the best way to explain those is to compare the program 14 that Rochester is proposing this year for its 05 year with 15 the program that they initiated in their'04 year. 16 one of the main areas of the change has been program 17 leadership.:. As I say Dr. Parker resigned. A new director was 18 brought on board in May of 172. His name is Dr. Peter Mont. 19 And Dr. Brindley when he discusses the site visit will tell 2d you more about Dr. Mont. 21 The RAG has changed. The program has instituted a system for the rotation of RAG members. Now that doL--sn't 22 23 sound all that swell until.you -realize that Rochester didn't 24 have a system like that before and so essentially the-RAG @-Federal Reporters, Inc. 25 that you saw at the end of 1971, the beginning of 1972, ty 3 94 except for deaths and resignations, was the same one that had 2 been appointed back in 1966. Thirteen new people have been 3 added to the Regional Advisory Group. The minority repre- 4 sentation has been increased from 2 to 5 of 36 members, and the 5 kind of consumer representation has taken on a different 6 character. 7 Mr. Frank Hamlin who had been RAG chairman since 196, 8 stepped down, his place was taken by Dr. Peter Warter who 9 is vice president of Research for Xerox in Rochester. As 10 i sai-d before the old Planning Committee is gone and there is 11 an Executive Committee of the RAG. 12 Another interesting thing to look at is the changed 131 relationship between the university, the grantee, and the 14 Rochester program. When we were on the site visit, Dr. 15 orbison, the dean of the medical school, assured the site 16 visitors that the university was content to have its input 17 to determination of program limited to that provided by the 18 six university members on the RAG, which seems reasonable. 19 Another interesting thing to look at is space. You 20 know the RMP had thought always it had to be housed with the 21 university, it was part of the university. The university uld spare en ou-h s-ace for the Roc.6,cs@Ic--' program. 2,) never r-,o 23 Consequently they were scattered in places, so the staff was 24 never put together you know. There would be a few over in this @e-Federal Reporteis, Inc. 25 building then you would have to walk across the street and I ty 4 95 I up some stairs to find the rest of the people. 2 Well, now with the support of the dean, the program 3 is moving into a building about a block up the road. It's 4 university off-campus space and you know they will be able to 5 hang out their shingle that says "Rochester RMP" and they will 6 be all in the same place. 7 Finally though this doesn't tell the whole story, all I:think@.-it is kind of interesting to look at project sponsor- 9 ship. 10 (Slide 4.) 11 This is determined by the allocation of dollars 12 by project sponsors. At the beginning of the 04 year every 13 single project, every single of the 17 projects that Rochester" 14 supported was sponsored by the University of Rochester,. 15 What the program is proposing for the fifth year, 16 you can see that 44 percent are sponsored by the university 17 but the others are divided, health and education associations, 18 like the education consortium, the Rochester Alliance and 19 Health Association of Rochester, 13 health care facilities, 20 a couple hospitals and a health center. Ten percent are spon- 21 sor6d by community organizations; the VA is sponsoring one, -her by @-he OEG Povert@y Agency in the central part of 2'11 ano4L- 23 Rochester. 24 I think another thing is program direction. If e- Federal Reporters, Inc. 25 we can go back to the chart we had before -- 96 ty 5 I (Slide 3.) 21 Now you can see the fifth year. You can see the '3 allocation of dollars by percentages remain pretty stable for 4 a program administration but this time it really is program 5 administration. They are going to have a program staff that 6 is more traditional in our terms. It will have program 7 specialists, that sort of thing. They will monitor projects; 8 they will be full time and not project directors. 9 The former program staff, the various members have IC) left to pursue their own interests whir-h apparently were not RMP and Dr. Mont-is assembling a new staff. At the bottom, see, only 3 percent of the dollars ar 13 going into categorical activities, that is a regional kidt-ley 14 program. That blue block got pretty big, 61 percent of the 15 money going into multi noncategorical. 16 of the 19 activities 16 that were going on in the 04 year have been terminated and 17 Rochester has been able to initiate new things. Now we can look at that 61 percent maybe in another 18 19 way. If we can break up 20 (Slide.) 21 the program into four thrusts that Rochester 22 has defined, health care services, education to improved 23 care for underserved, health care systems analysis and, finally, formal education of health professionals. 24 ;e- Federal Reporters, Inc. We can compre the fourth year and proposed fifth 25 9 7 ty 6 year. You can see where the two big changes have been In 2 the fourth year about 40 percent,went into health care services 3 now about 60 percent is going into health care services. 4 Actually that is more of a change than it looks like on the 5 chart even because the region's definition of what a health 6 care service is has changed. 7 Now what went into making up that 38 percent last 8 year in health care services @as-things like regional 9 coagulation laboratory, telephone EKG consultation, cancer 10 clearinghouse. The kinds of things being called health care 11 services this year are EMS activities, coordination of home 121 care services in rural counties, rural family medicine practices and that sort of thing. 14 The other big change is the decrease in the amount 15 of money that is being allocated for continuing education 16 activities. The red blocks. And-as I say, even the tenor 17 of continuing education has changed somewhat. That 37 percent 18 last year was physician@.s and nurse I s continuing education 19 programs,, many, many activities in the categorical things. 26 That 14 percent represents two activities, one, educational 21 alliance, the other is subsistence level combination of all the formal nursing continuing education programs. @22 23' The program is designed as it is, it will fund 24 through June 173 only, that is to give the school of nursing 'e-Fedetal Repottefs, Inc. 25 in Rochester an opportunity to decide do they want to pick this 9 8 ty 7 up in their priorities or do they want it to just go down the 2 drain? 3 Finally, I think another interesting concept, 4 back to the county map 5 (Slide.) 6 -- is how in Rochester the programs idea of what 7 regionalizations have changed. 8 Now last year 90-some percent of the activities 9 that the program undertook were designed to cover the entire 10 10-county area. In fact most of them were things that were L 11 emanating from Rochester and going out to do good in the other 12 counties like the continuing education and the laboratory ser- 13' vices. This year about a third of the activities they 14 propose are designed to take care of the 10 counties. But the region apparently has seen a need to design activities that 15 16 respond to the needs of particular areas of the region. 17 For instance, in the southern tier down there it 18 is Steuben,.Schuyler,' and Elmira Counties. There is an 19 effort in emergency medical systems. For instance the five counties there in the center,are the subject and 20 activity trying to coordinate home health care services? 21 Another example is bansville Hosp4@ll-al down in '-'L-le bQLLorct 2 part of Livingston County. There is a family practice program 23 24 coming out of Dansville to serve the rural areas of Steuben -Federal Repofters, Inc. and Livingston Counties. 2 5 9 9 ty 8 I There is a training program for bilingual allied 2 health aides to serve the Spanish speaking community of 3 Rochester itself and it is centered in the intercity there. 4 1 don't think I need to talk any more about program staff. re what it.is going to be 5 We know what it is. We are not su 6 but we think it will be better than what it was. They will be 7 doing things that program staffs ought to do. That -is 8 Rochester. 9 You know, I have a feeling you may be saying to 10 yourself vo@l know this is all' very interesting but why have 11 you taken up half an hour of our time? Well, I don't know. 12 I think it proves for one thing a program can change, we can 13 document this. We can look at the charts, look at last 14 yeari this year and see it is changed. What maybe isn't so 15 obvious is what is the impetus for change? 16 Well, I am not sure but I think what we have seen 17 in Rochester is a disapproval of the old adage th&t@.revolutions 18 are not made, they come. I think it is quite clear that if we 19 hadn't made the revolution in Rochester, it wouldn't have come. The program direction, the way it was being adminis- 20 21 tered was satisfactory to everybody in Rochester. It was 22 certainly satisfactory to the university. Satisfactory to the 23 coordinates. It was satisfactory to the program staff as long 24 as their projects kept getting funded and if the RAG ever e-Federal Reporters, Inc. 25 thought about it it was probably satisfactory to the RAG. 100 ty 9 I So what it took was dissatisfaction from some 2 quarter and that was down here. And I think the irritants that 3 were provided by the Review Committee in terms of you know, 4 you,got another site visit; we are going to come up and look at 5 you again and also finally the question in terms of the time 6 and money limitations are what brought about the revolution in 7 Rochester. If the Washington Redskins didn't, you know anyone End #9 8 can. 9 10 12 13 14 15 16 17 18 19 20 21 23 24 e- Federal Reporters, Inc. 25 101 CR 7148 10 eak 1 I MS. FAATZ: Dr. Schmidt knows what it is like and 2 Dr. Brindley knows what it is like to have questions. 3 DR. MARGULIE S: I think the presentation probably 4 is adequate to prove its point. I think it requires your 5 reflection to determine what it all means in terms of staff 6 function, Review Committee. Eileen is perhaps being modest 7 in not also pointing out the fact that one thing which should 8 be fairly clear from all this is that there is a level of 9 staff dedication involved in such an undertaking without which 10 it iii,.;t doesn't happen. But the Review Committee can get 11 a sense of what all this means only by occasionally stepping 12 back and seeing what the results have been. 13' Now, I could not tell you that this all happened 14 because of the Review Committee. I cotldn't tell you that 15 it all happened because of what we did here. For example, 16 the appearance of the -- of a remarkable man who first was 17 on the Executive Committee and then Chairman of the regional 18 advisory group in Rochester has a great deal to do with it. 19 You can't say this did it. But it is a combination of 20 activities in which the absence of any one of the elements 21 would have been ruinous, but consistently it was from the time 22 that the Review Committee and RMPS, with ito began to look at 23 it as a total program and the way in which it functioned that 24 it began to make some difference. c;e-Fedefal Reportefs, Inc. Now, I was talking wi.th Sister and about what I 25 102 eak 2 I personally believe is the primary merit of regional merit 2 programs and saying to her at the same time that there is no 3 way in which I can sell this to budgeteers, there is no 4 way which I can necessarily prove my point but it appears 5 to me that what we do most effectively when we are effective 6 produces a change in attitude which allows for some change 7 in behavior. That occurred in Rochester. 8 Now, -It could not occur if there were not the 9 potentials for it. It could not occur if-there were not 10 needs, @L.L' -Li-lejLe were iiot people who cared. But it is a change 11 in social perception'. It is a change in the way in which you 12 interpret the manner by which you apply your efforts to what 13 principles you hold. There was nothing unprincipled about 14 the old pattern. There is nothing profoundly different about 15 the principles in the new one but there is.a change in the atti- 16 tude toward how one preserves effort and moves to a specific 17 kind of a goal. 18 It also reflects a changing attitude within the 19 Review Committee not the least of which, which I think you all 20 know I strongly support, is a little tougher approach to 21 a program wl,ich is doing poorly. I can remember, Mac, that this is one of the several@ pro rams in which a su-gested remed,, 23 was associate coordinators,a deputy coordinatorsomething,of that kind. 24 ce-Federal Repoitets, Inc. Well, we went over that jump several times. When 25 I 10 3 eak 3 a coordihatoris inadequate, the best solution is another 2 coordinator. In fact@ it is the only solution. one of the 3 reasons we listed some of the changes which we listed to you 4 earlier during this meeting is to.demonstrate that that has 5 occurred in a number of other places and I think the changes 6 are meaningful to a number of members of this committee who 7 hav@-been onsite visits and who have reported here. 8 Now, I recognize that this has taken a considerable 9 amount of your time. It may not be a characteristic case 10 study. There is no characteristic case study but I think it 11 puts some of the dynamics of a program management in a conten- 12 tion which is worth your time. 13 DR. SCHMIDT: Before you comment,.I',would,-just 14 like to say that I have watched Harold and some of his staff 15 during the last year and have seen them really kind of be 16 surprised at the vehemence of some of the remarks of the Review@ 17 Committee members about the ineffectiveness of the committee 18 or the felt ineffectiveness of the committee in achieving 19 its purpose. And I think that, and Harold-and the staff have 20 been surprised by this because as they ate looking at the forest 21 they see the great impact that the committee has had and this 22 -e,-np@ to answer aL case report obv4-ous'-@, is an at4i I- .Z Least Solne 23 of the questions that have been posed around this table 24 about the impact of a committee. ce- Federal Reporters, Inc. Through site visits and through what the committee 25 104 eak 4 says it has recorded by staff, it is carried back to the regions 2 by staff that we kind of don't know-about, committe has 3 had voice and a st rong one and it has been influential. Our 4 trees have -very often been the projects and the details of 5@things as we get into the nitty-gritty, and this was an attempt 6 obviously to retreat back to a point where we could view the 7 forest. 8 Bill? 9 DR. LUGINBUHL: Under the recent clarification 10 of relationships between the grantee and the RAG, it spells 11 out the way in which the coordinator,,Sare appointed, They are 121nominated by the RAG and appointed by the grantee if I am not 13 mistaken. Who has the authority to fire a coordinator? 14 DR. MARGULIES: Grantee. 15 DR. LUGINBUHL: Thank you. 16 DR. SCHMIDT: Now, I would like to have any 17iiscussion right now before we move on to Dr. Brindley and 18Eurther discussion in a more treesy way of the Rochester 19-egion. I would like to stay with the forest just for a moment 20ind see if any committee member has any comments about the 21)resentation or interaction of this committee and the Rochester 22 c-.m,-r,--@@tee or any that has to do with the functioning of 23 this committee in the review process. 24 Now, it might be that ou will need overnight to y ce- Federal Reporters, Inc. 251think of a come back or something to say, so that we arenot 10 5 1 closing down on this issue but I would ask for comments right 2 now if there are any. Wellf if not, we will table this 3 until we get through some of the work of the,committee and then 4 we will come back to it. And it is the hope of staff 5 and Harold and so on that we will be able to use this as a 6 kind of a framework to hang comments and discussion on during 7 this two-day period about the Review Committee function. 8 And I would like to compliment Eileen on a 9 beautiful job of reviewing the region.. Having been up there, -10 I can.apprecidte how clearly she presented Llie picture. We wi-l'L 11 turn then to Dr. Brindley and our first really work part of 12 Ithis session then and we will take up an anniversary 13 review procedure to triennium of Rochester. 14' DR. BRINDLEY: Thank you. I also would like to 15 compliment Eileen on a very fine job. I wish she had 16 taken about four more:minutes then I could have just given 17 you a proposal regarding funding. They have made a complete change in almost everything. The goals and objectives have been 18 changed, they now are much more compatible with national 19 20 goals. They seem reasonable, possible of attainment. There are three major intermediate goals that they 21 2z^- list, are the establishment of Tne.tbods of restructuring of primary health services in rural areas with particular 23 24 emphasis on hospital outpatients facilities, emergency @e-Fedetal Reporters, Inc. rooms. Can you hear me all right? Is this on? 25 10 6 eak 6 I The joint assessment of new health care systems 2 in the region and improving the care of the chronicly 3 ill including those in the rural areas. Right off hand 4 as soon as we saw those, the question wa s, well what are you 5 doing about the city. Looks as though practically most 6 of the emphasis was being placed upon the rural areas and perhap3 7 they were forgetting that a large part of the people were 8 in the Rochester area and that there were some problems 9 related to the urban poor. We discussed this with them and iv Lliey ha,u' two good answers. 11 One, that there already is a system of neighborhood 12 centers that were initially proposed by the medical school 13 faculties and by the comprehensive health agencies, And that they 14.thbught,that -those centers would be capable of caring for the 15 urban poor health problems. 16 One of the proposals as you can see a little bit 17-@ater is oiIng to be evaluation of systems of health care deliver 9 18 And it was interesting in our and I will digress there a 19 minute. They have a Monroe plan which is the foundation 20 for medical care, Tennessee Valley Group Health 21 Association, which is the Blue Cross sponsored program, AOEO 22 neighborhood health centers net@7ork and family practice 23 program at a Highland hospital".,, They are proposing 24 that these four programs be evaluated as to effectiveness ,e - Federal Reporters, Inc. 25 and that the RMP is going to have its input perhaps into the 10 7 eak 7 I efficiency of health care delivery by evaluating the systems 2 of health care. An interesting problem came up there. How do 3 you evaluate quality? And who is going to do the evaluation? 4 And we never did receive a very good reply to that. Dr. Berg 5 is Chairman of a committee that will be evaluating quality. And 6 I am sure that is a hard thing to determine, what is quality 7 of care. But they propose that this would be an ongoing 8 assessment and that perhaps the rules and modifications will 9 continue to develop as progress ensues. As we look down to io accomplishments and implementation, of course they haven't 11 accomplished very much because this is a whole new ballgame 12 with them. They have proposed 19 projects and of these there 13 we.L,e only three t@-ha-@ were there before and those three are 14 the Family Counselor Program, the primary care analysis 15 and the kidney program, which already had earmarked funds. They do have a continuing nursing education program 16 17 which will require some funding until-the middle of next 18 year, and they are hopeful that by that time, other sources 19 of funding for the nursing education program will be 20 available. We did feel that there were some deficits in their 21 establishment of intermediate goals and objectives. 22 They had not clearly pointed out how you were going to evaluate progress, what were the milestones going to be that 23 24 you would look at as you went along with the program. And they ce -Federal Reporters, Inc. also have not established a definite way of determining 25 108 eak 8 I priorities. They said they had'themselves listed with 2 priorities but there is no clear-cut way of how priorities 3 will be assessed or determined or evaluated We thought 4 it was very important that they write those out so everyone 5 would know how you are going to determine priorities. That had 6 not been done at the time that we were there. 7 However, the new goals do seem like good ones 8 and they do seem to be consistent with their needs. They 9 showed us a number of studies in which it would imply that t4 110 annually the rural@ corununl @es are the ones that need mosjL-. 11 action at this time by the Rochester Regional Medical Programs. 12 Some accomplishments have developed. Eileen has 13 already related to most of these. Of.course, they have a new 14 coordinator. He is an impressive young man. He is obviously 15 intelligent. He is charming, has a lot of charisma. I did 16 have two reservations. 17 Dt..Warter, who is the Chairman of both the RkG 18 and Executive Committee is a very agressive domineering 19 finite individual that is accustomed to really running the show 20 and he is going to -- Dr. Mott is going to have to get up 21 early and assess himself pretty clearly to be sure he gets 22 his vote in because Dr. Warter is accustomed to runnina the 23 whole picture. 24 otherwise, though Dr. Mott has many attractions, a-Federal Reporters, Inc. he has a lot-of good ideas. HE,. has a nice tactful way of being 25 eak 9 109 1 a good liste.er and I think that he will have many possibilities 2 of accomplishing his goals. But he perhaps will need to be a 3 little bit more agressive. The continued support -- oh, they 4 have changed the composition of RAG. They have elected 5 13 new members and they do seem to be more representative 6 of the committee. They have done a better job of having the 7 minorities represented on the RAG. They are trying to get 8 some more true consumers. That will be represented on the RAG. 9 They have some deficits there. They do not really have allied 10 health professions real3v represented and need to add more 11 in that area. They have established new goals, terminated 12 old programs. They have a closer relationship with the 13 CHP. They have a superb CHP. 14 In fairness to the regional medical people, the CHP 15 were there earlier and they have the whole ten counties 16 well organized, good committees in each,county that have ,-oned, they have 17 evaluated needs. As I have ment, 18 already organized the neighborhood health centers.in the city. 19 They have outlined priorities of their programs of development. 20 They are overlapping directorships of RMP and CHP. They seem 21 to get well together and that will be a good person to have on our team. 22 y 23 The CHP is strong in the area. Minority interests, 24 well they have some deficits there but they seem to be trying ,e-Federal Reporters, Inc. to improve that in all sincerity. This is a new ball club. The 25 110 eak 10 have no one on there in the program staff that represents 2 the minority interest buy they say.they are trying to obtain 3 those and of the three, they were seeking at the time we 4 were there, one of them was a black person. They are hopeful 5 RAG will be more represented by the minority interest and 6 certainly programs are being related to the minotiry needs over 7 the regional medical programs. 8 Dr. Mott tells a good story to us about how anxious 9 and eager he is to really see that this is fulfilled. Now, 10 in fairness, the executive committee is all male and all white. 11 They are trying to reducer though, the responsibilities 12 iof the executive committee and really have RAG take over more 13 of those responsibilities. If I am leaving out some things 14 about that, do you want to comment more about that, Eileen? 15 MS. FAATZ: No, I don't believe so. 16 DR. BRINDLEY: We did ask them to go to the black 17 committee and ask them if there could be someone there that 18 would be hopeful and they took the pledge and said they would 19 try it. The program staff, they have some nice boxes written 20 down and it looks good on paper and you almost have to vote 21 for them as to what they intend to do. 2/^. Nuw, tilere are some glaring errors on what they 23 presently have because they don't have many. They have got 24 about three batters and then they are out of hitters but they @e- Federal Reporters, Inc. 25 propose to get this new assistant director and I heard you say eak 11 I a while ago, Mr. Chambliss, that they now have one so it will be 2 good to have him. They seriously need to have a person in 3 charge of program development. They have a temporary, we 4 think he is temporary, evaluator, Czechoslovakian. He doesn't 5 seem to be wholly adequate for such a big problem to me and 6 perhaps he will need to have someone else there. Then there 7 is no one who has been selected for a lot of these other 8 hearings they have on their program. But if they fill all t ose 9 slots, they will be able to do it very well. They say that 10Ithese will all be full-LiitLe people and they no longer will be 11 directors of projects and that the technical consultant will 12 @come from truly people that are experts in their field. 13 They have made a number of feasibility studies 14 and they have cooperated with the CHP in these feasibility 15 studies and actually have put on the board for us areas 16 of responsibility pretty much over the entire regioni about what CHP is going to do and what RMP is going to do and how 17 they will relate with each other. 18 19 Some areas the major response would be RMP and 20 other areas the responsibility would be CHP and how they 21 might dovetail the program. I am a great believer in that so I hope- that wi-.Il he able to work out. The regional advi-sorxr 22 23 group says now that they are going to take on more of the 24 responsibilities. .e- Federal Reporters, Inc. Dr. Warter is a great believer in taking his regiona 25 112 eak 12 advisory group and dividing it up into a number of committees, 2 and these committees would consist of two,or three members 3 of the regional advisory group and one man from staff. And 4 that these committees would be given responsibilities 5 of reviewing pro3ects and looking at programs and evaluating 6 funding and evaluating progress and that they would then 7 relate it back to the entire RAG for consideration and approval. 8 There was some fear that maybe Dr. Warter was 9 dominating this to a degree but he says not. I talked to him 10 about it privately and he doesn't think that that really 11 is a serious problem. Their review process consisted of 12 sending out about 600 letters inviting proposals and then they 13 'got about 4-@ of -It-.hose that they thought '@ooked pretty goo"'.. @@hc,,, 14 had a special review committee that would look at each one of 15 these and the CHP reviewed it before. The parent review 16 committee chairman reported it back to the regional advisory 17 group for final approval. The grantee organization, 18 I think, deserves a lot of credit because they were pretty much the whole show u before right now. 19 p And their part has been greatly reduced, their 20 21 proportion of the projects has been largely diminished. They @2' will have six representatives now on RAG where they were most 23 of them before. But they seemed very interested. They think this is a good way to go about it. They indicate a 24 :e-Federal Reporters, Inc. desire to help the program. And the people we talked to all were 25 113 eak 13 1 unanimous in their commendation of the University of 2 Rochester and its present approach to the change that had 3 been made. 4 Participation, it was good. I'talked to the 5 doctors and also talked to a lot of the hospital administrators 6 and they are enthusiastic. One real good thing that they are 7 doing is the medical school is relating to each one of these 8 community hospitals in their training programs, and particularly 9 in their family practice training programs, also, in the e 10 allied health trainina vrograms. 1 2 14 15 16 17 18 19 20 21 22 23 24 :e -Federal Reporters, Inc. 25 114 arl I They are sending these boys out, or women, out to 2 the communities to actually serve as primary health care 3 providers under the direction of the staff community 4 hospitals and they are even going so far as to say after you 5 have been out there a while, you find somebody you think will 6 make a good secretary and bring her back to the community 7 hospital and we will train her, too. 8 By doing this, they have been able to get a 9 number of these boys and girls that have stayed in these smaller rural C-, .p- to prac-ice, wh-ch .,Uftit4cs and have gone in 10 11 was refreshing, and it looked as though they actually were 121 providing a better quality of health care to the region by the sharing of facilities. 13 14 Their assessment of need has been done, as I 15 mentioned before, largely through the CHP and their ten-county 16 committee programs which seems to have(bne-a good job. Really 17 I wouldn't know how effective the new programs are until we 18 have had a little time to see experience, but on paper it 19 looks pretty well. We spent a lot of time on evaluation, 20 and they have kind of an unusual way of evaluating things. 21 Two members of RAG and one member from staff, along with a program director, will evaluate a program or proie(!t 22 1 23 and then this project committee will report quarterly through 24 an assistant director to the RAG and then on the recommendation .e-Federal Reporteis, Inc. of thelxoject committee the assistant director may change the 25 ar2 115 I budget up or down up to 20 percent; unless an appeal is made 2 to the project director, and then to the full RAG. 3 And talk to Dr. Warter about that, he says I need 4 to get the RAG involved, I need to have these people know 5 what is going on, they are the ones that ought to have some 6 active interest. I think this should be a management function. 7 Well, you kind of wonder, you know, where does the coordinates c ome in and assistant director come in, and 8 9 when does he get to vote so he asked Dr. Mott about this and Dr. Rudolf, was it, and they said, well, now, All of 10 11 these proposals and recommendations come through them and that they have the right of changing some things or improving 12 them ';-_Iefoxe i:he,, actually get to the RAG for full approval. 13 z 14 They seem satisfied with this recommendation. 15 We suggested to them that we thought the burden of 16 proof was upon them. If they showed that this system was a 17 good one aid can make it work, why, then, that was fine.. If 18 this didn't work, why, maybe they needed to look at another 19 method because it is a little unusual plan that they have 20 proposed, and they have three levels of funding that they 21 suggested to us. One was what they thought was just rock bottom. 22 23 One was one they thought was -- would do a better job; and 24 three, I sure would be thankful if they gave that to us. ce-Fedefal Reportefs, Inc. We looked those over and we will talk about that 25 ar3 116 at the last minute. Dissemination of knowledge, they 2 haven't disseminated yet because they haven't gotten to work 3 yet, but if they do, the things they are saying, it should be 4 very purposeful and I think succeed. 5 Utilization of manpower and facilities on paper again looks really good. They have made some good suggestions, 6 7 improvement of care, it should be significant because they 8 are really going to get out with the community, particularly 9 in these rural areas and make a lot of changes that should be 10 I helpful. And I have all those projects down, which ones 11 they will be doing, if you want to look at them, but I don't 12i think you need to look 11 at them right now. If you go ac to 13 the level of fund2Lng, Last year, as you remember on the 14 picture up there, they got $858,000. They have a kidney 15 program that is, has been funding out of separate funds for, 16 I believe, $35,000. We felt it would probably be well to suggest the 17 18 $900,000 level of funding, plus the $35,000 for kidney, that 19 this would do several things. It would permit them to increase 20 their program staff, to add the men and women they need to 21 have for this; it would show some optimism in the development 22 of their program. 23 And if the program they had last year was worth 24 800,000, this is sure worth a heck of a lot more. o -Federal Reporters, Inc. We are ready for questions. 25 ar4 117 Eileen, did I leave out some footnotes? 2 MS. FAATZ: The only thing is'I have talked to 3 the region recently. In the box was one of the two main -divisions, program development, Shawkadeary is coming 4 5 in as assistant director for program development. There are 6 four slots for program development specialists under him. 7 You will recall Miss Clark was one of them. They have three 8 new people who have accepted offers for those slots, so that part, they are getting on with bringing on the staff. 9 DR. BRINDLEY: One other th 4ng didn't mention I 0 L 11 that is very important, they did not have any bylaws while 12 we were there. We thought it was extremely important for 13 lines of authority not to be talked about, but to be down on 14 paper. So we asked them about that and so the day that we 15 left, why, they said we just got through writing it last 16 night. But nobody had @reviewed it, their RAG had not 17 approved iti so we said we are going to recommend a level of 18 funding contingent upon the bylaws being sent and being read 19 and approved by staff. 20 But it was very important for them to have some bylaws because everything was just kind of coming off the top 21 of your head. He is responsible. Well, he is. You ought to 23 go this way. But nothing was written down. 24 DR. SCHMIDT: . All right, then, your recommendation, ;e-Fedetal Repoitefs, Inc. would you repeat the recommendation, please? 25 118 ar5 11 I DR. BRINDLEY: We are recommending a level of 2 funding of $900,000 exclusive of the 35,000 of the kidney 3 program. This is a one-year level of funding. 4 DR. SCHMIDT: Is it contingent upon acceptance 5 of the bylaws and -- 6 DR. BRINDLEY: Yes. 7 DR. SCHMIDT: One-year funding with then another 8 application due in a year, is that right? 9 DR. BRINDLEY: They said they hoped that after this 10 kl,ear of kind of r--roup4-ng and getting going that next year 11 their program would be mature enough where they could apply 12 for biannual status, but they were not ready to be considered 13 for that now. 14 DR. SCHMIDT: I'd like, before comments, to remind 15 the committee of the RMP review criteria and the score sheets 16 that you are to be filling out. Are there any comments before 17 we go on to the second reviewer, or let's say Are there any 18 questions directly to Dr. Brindley? 19 DR. SCHLERIS: I was interested in the emergency 20 service award of $141,000 to Rochester. I was wondering 21 if you were able to get any on-site impression of how they 22 are moving with that in terms of their planning or in terms of 23 how it relates to RMP in that area? 24 DR. BRINDLEY: I asked Eileen a while ago about that :e -Federal Reporters, Inc. 25 so she could tell me how much had been funded out of the 119 ar6 I funds you were looking at and that is for which programs, 2 Eileen? 3 MS. FAATZ: Well, they have about four separate 0 4 AMS components, some two of which I believe were funded 5 from the special supplemental funds, two of which are funded 6 from the regular program, Rochester MIP funds. 7 one of the components is for overall planning and development of EMS and two of the people responsible for 8 9 that are coming next week to meet with Dr. Rose. -lo I We didn't get any on-site experience, no, they had the money for such a short time there wouldn't be much to say. 12 DR. BRINDLEY: Leonard, there was one other pretty 13 glaring weakness in it, that was who is going to provide 14 the continuity of care. I @ked Dr. Berg that because it is 15 important for the patient to come in the emergency room and 16 say he had diabetes. Who takes the ball from there? He said that is an interesting problem and we are sure going to work 17 18 on it. 19 DR. LEWIS: I won't take up very much of the 20 committee's time. I won't take up very much of the committees time because I think that this region 21 22 has been reviewed by as thoroughly as any other since I have 23 been here. 24 I think in reviewing the site visits, reports 'e- Federal Reporters, Inc. and present application, one gets the impression that you 25 120 ar7 I are reading a psychopathologic conference complete with 2 autopsy. I don't know where we are with-this union insofar 3 as not having participated in the site visit, the application 4 is essentially an application for a new region, and in the 5 application it is perfect, I really enjoyed reading it, which was surprising. 6 7 Dr. Brindley, I think, describes for us exactly 8 what I needed to know. I think that some of the things that 9 are in the grant here that are questionable. For example, 10 they discuss the issue of active recruitment and. redistribution 11 of physicians and the possible role that RMP can play in this 12 which I think would be a rather sensitive area, and I am not sure they are ready for that, but it reads very well. 13 The way in which they are going to distribute their 14 15 funds certainly appears to be more in concert with what 16 RMPs should be doing. The only questions that I have in reading the application, is with regard to how much the award 17 18 should be. It is very difficult to know what their budget 19 has actually been because of the -- the figures we get for their previous f iscal period is 9-71 to 12!-72 and I suppose that 20 21 if you assume a constant distribution of expenses over 15 months, then you could just divide it out and get a 12-month ,-2 23 figure, but at any rate, the suggestion of $900,000 budget 24 for this coming fiscal.period based on the fact that it is a :e -Federal Reporters, Inc. much better program, if the previous programs were $800,000 25 121 ar8 I don't think is irrational judgment because I don't think 2 the previous program was worth $800,000. 3 In fact, $4-1/2 million has been poured into this 4 region in the last four years which I think is a shame. 5 The core budget was $326,000 from September, 171 to 12-72, 6 which might break down to 280,000 for the previous year, 7 and the present core program staff budget would go up to 8 $415,000. 9 I just wo ndered whether this was not a rather large 10 @,steP up considering -- I 'share everybody Is hope that what is 11 down on paper is going to work out, but the past history of 12 this region has been bad, and I just wonder whether that is 4 13 not a very significant increase considering the amount of 14 activity that is going on there. 15 So that I would like to hear a little more discus- 16 sion with regard to the amount of step up in the core staff 17 program cost and also what they really need to get started 18 in expanding the program with 13 new projects. 19 I think certainly the money they asked for was 20 far in excess of what they should be getting. I think the 21 $900,000 may be in excess also. 22 DR. SCHMIDT: Dr. Bri.ndley, would you like to. 23 comment on the rationale or background of the arrival at the 24 $900,000 figure? e-Fedefal Reporters, Inc. DR. BRINDLEY: The core staff expenditures in our 25 ar9 11 I opinion were important primarily as related to the program 2 staff and program staff development, evaluator, and 3 perhaps improvement in their financial accounting. is 4 They did have a rather large staff before, but it was not a very effective one, and it was accomplishing 5 6 mostly the administration of projects from the medical 7 school and medical school faculty. 8 Maybe this was an erroneous judgment, but it did 9 seem to us to be one of the major things they needed to do, 10 was to have a good program staff, and that the core was a 11 pretty important part of their program. 12 Frank, do you want to comment on that? MR. Nl T.11 .i@o, thin'- c-ne Of -Lhe other reclsur,:s 14 the site visit team recommended the 900,000 was to show this 15 region that they have made progress and to reward them for 16 accepting recommendations and making changes that they have. ell 17 18 19 20 21 22 23 24 @e-Fedeial Reportefs, Inc. 25 CR7148 #12-ter-1 1 DR. SCHMIDT: I think that it is certainly the 2 feeling of the site-visitors and staff that substantive change! 3 have, indeed, occurred. 4 The Coordinator and Project Site or the Project 5 Directors, not being staffed, the building of the staff and 6 so on. And that the region has done now, for sure, absolutely 7 at least, some Of the things that it was told to do. 8 So, then, do you now pat them on the head and say, "Good boy," and give them some money; or do you then, say, 101 "Bad dog," again? I am trying to train a puppy, so you know, and 12 where does that get you? 13 DR. THURMAN: Gets you a wet rug, sometimes. 14 DR. SCHMIDT: Well, Bill, you are bothered. 15 DR. THURMAN: I guess I have had too many wet 16 rugs. I would share Dr. Lewis's concern about adding a 17 hundred thousand more to what amounts to a cesspool. Ind, 18 too, I doubt seriously that if we think constructively, about 19 what this region can accomplish before they come back in with another year's application, that they are going to be 20 21 able to meaningfully attract people that they need, particular y 22 in the area of evaluation. to really 'Use this money. 23 I think that Dr. Brindley has brought out some 24 very important points; who is running the program? It has a ce -Federal Reporteis, Inc. long history of nobody running the program, now we have either 25 ter-2 124 I a RAG Chairmaror Coordinator and we don't know. And, I would 2 just, I think, if Dr. Lewis were making a substitute recommend- 3 ation for Dr. Brindley's idea of tag along with it because 4 granted anything would be better. 5 The $800 thousand we already spent; let us make 6 sure the $800 thousand we plan to spend this year are worth 7 at least 800 thousand because last year's 800 thousand was 8 not; so I am a wet rug. '9 DR. SCHMIDT: All right. Dr. Lewis? I 0 I'aR. 'UEW'L-0: Well, I don't Yea-'Lly feel competent 11 to make a substitute recommendation on the basis of having 121 read the documents but not participating in the sitb-visit, 13 but I would like Dr. Brihdley and the people who participated 14 in the site-visit at this point, to reconsider the possibility 15 of keeping the funding at the previous level, and what its 16 impact would be, because I feel that the recommendation of 17 $900 thousand is in excessi but I don't feel competent to 18 DR. SCHMIDT: I mean, what specifically was the 19 previous level? 20 MS. FAATZ: Annualized.'--. it was $800 thousand plus 58 thousand earmarked for kidney. What the recommenda- 22 tion is, is an increase of 900,000, We Are talking about an 23 approved level, too, not necessarily a funding level. 24 They sometimes differ. Nine hundred thousand, ce- Federal Reporters, Inc. plus $35 thousand for kidney. 251 ter-3 DR. SCHMIDT: Okay, we are not, the Committee in 2 its pasti has often spent the most time over the smallest 3 amounts of money. 4 This is, that is proper if principles are involved. 5 So the, what I am hearing now is, do we keep them at the same 6 level as sort of a, you know, okay, we are satisfied, but, 7 you have still got to show us, or do we give them a little 8 more as a pat on the head? 9 Other Committee members have comment? ol DR. ""r-,@@j@qD@UEYz In fairness, this is really kind of 11 a promissory note, they have not done these things, but they 12;1 are trying to do all the things we asked them to do; or at 13 least, most of them, and we felt perhaps, it was worth saying, with some encouragement. This, we think this is a good step and we do like 15 16 to see you try it. Eight hundred would-be fine for me. -They 17 haven't proven they can use that 800 well. They have not gone up to bat yet, and have not filled those slots but, I 18 don't want them to say, "We could not fill them because we did 20 not have the green stops. 21 DR. KRALEWSKI: Has this been increasing in the previous years. Brancl? DR. BRINDLEY: It has. 23 24 DR. SCHMIDT: In your loosepleaf books, these ce-Fedeial Reporters, Inc. illustrations, I think, are'indluded. 25 12 6 ter-4 I MS. FAATZ: There was.an increase going into the 2 second operational area and it has decreased steadily, since 3 then. 4 DR. BRINDLEY: A million, eight. 5 DR. SCMIDT: I sense that the site-visitors and e6 so on, feel some resistance to dropping this -- (Slide.) 8 -- although then, you kind of say that the 800 9 thousand would be fine. Let me try to move this along by io saying, there is a motion on the floor, it was not seconded, 11 so I will revert to Robert's Rules, by which I hope we will 121 operate. 13 There was a motion on the floor for approval that 14 a one-year level of 900,000 exclusive,of"'the.35 thousand for 15 kidney, is there a second to that motion? 16 DR. KRALEWSKI: I will second it. 17 DR. SCHMIDT: All right, it is seconded. 18 I will ask Dr. Lewis or Thurmond if they wish to 19 move a substitute motion, or amendment to the motion on the 20 floor? 21 Dr. Lewis? 22 DR 6 T.@Wl S: I -,ould move sul@-s@,J-uL@e motor @'-at 23 they be approved at the level of funding, exactly as the 24 previous year. ce - Federal Reporters, Inc. DR. SCHMIDT: Okay. 25 ter-5 That is 858. We will test, then. Send them to 2 the Committee, there is a substitute motion, is there a 3 second? 4 Lldqinbuhl?, 5 DR. LUGINBUHL: Second. DR. SCHMIDT: All right, It is seconded. We t7 will discuss the substitute motion. 8 DR. KRALEWSKI: What you are recommending, then, 9 is a sliglht increase, it would be 858 and actual need for the ,so I kidney project is going to be less this year than last? 11 DR. LEWIS: I think that It I think that the 12 kidney project should be considered outside of their budget, 13 since in their proposal, they consider it outside of their l@4 budget, and I meant for this proposal to be $800 thousand, 15 plus whatever their kidney project is going to be. 16 DR. SCHMIDT: Eight hundred thousand, plus the 17 kidney? I presume your substitute motion includes the other 18 parts of this? 19 DR. LEWIS: Yes. 20 DR. SCHMIDT: Continued on bylaws for one year and 21 so on? DR. HESS: Just like to v,,ave us go over the budget 23 sheet, the next to the last sheet, page 23. 24 Seems to me that this pinpoints the difference ,e -Federal Reporters, Inc. 25 at least as they see it, between the $800 thousand program and 12 8 ter-6 I the 900 thousand, is that correct, Doctor? Doctor Brindlel@'.) 2 So this would cut back 25 thousand for staff, people on the 3 right hand side, in the lower column. It would not enable 4 them to increase -- or to do as much with the delivery systems 5 evaluation and it would -- it would eliminate the enrichment 6 program and place some limitations on the program. That is 7 what we voted for the substitute motion? 8 DR. BRINDLEY: All right, are there any ot er 9 comments but Dr. Bridley, or staff? Is there any kind of In damage tL'Lat this substitute motion might possibly -- are there any concerns about the level of 800 thousand? 121 MS. FAATZ; I think one thing we have to consider 13 is that one of the strongest recommendations that came out 14 of the site-visit team was that the region might well want 15 to increase its program staff abaove what they projected in 16 the application, because the site-visit team frankly, did 17 not think that was adequate. They thought that was a bare- 18 bones approach to program staff. So, we, you know, you might 19 want to think about some words to relate to the region if 20 you are willing to recommend the 800 thousand, and at the same 21 time, recommend they increase the program staff, over what @1) thev have nroiectp6- 23 DR. SCHMIDT: Thank you. 24 Are there any other comments? ce-Federal Repoftets, Inc. 25 MRS. SITSBEE: I would like, Betty I would like, 12 9 ter-7 I Betty, to consider the site-visit recommendations, and also 2 we have talked about the $800 thousand, not accomplishing 3 anything this year and yet it was, this year that this change 4 was occurring and I am thinking of it from the standpoint of the Division of Operations for Development and not for the 6 individual-region, but when an attempt is made to try to 7 follow the Committee's recommendation of last year, and staff 8 assistance developed; the region responds and they, and the @9 Committee comes back with the same level of funding; I think 10 this '-s a message that Tay undermine staff attempts in the 11 future. 121 DR. SCHMIDT: I would think that if the Committee 13 goes with the 800 level, it would be obligated to state why,, 14 so there would be a specific message perceived and received, 15 and they would not be left with the idea that what they had 16 done was wrong; which would be one interpretation, or the 17 staff had misled them, or the site-vi8itors had misled 18 them, which would be another bad message to be received by a 19 cut. 20 I think we would want to be specific as to why the 21 level was chosen. John.> ')2 23 DR. KRALEWSKI: I don't want to take too much time, 24 but one question, and one comment. ce- Federal Reporters, Inc. Are they going to have a fair amount of surplus 25 130 ter-8 funds this year? 2 DR. BRINDLEY: Will they have any? 3 MS. FAATZ: No. I think there no I don't think 4 they are expecting surplus funds. 5 DR. KRALEWSKI: they will be able to expend out 6 that eight hundred thousand? 7 MS. FAATZ; Not having to be very much left over. 8 DR, KRALEWSKI: They are then up to expending the 9 eight hundred thousand, and if they have made the changes, you have indicated, I would speak in favor of giving t'nem 11 some increase in funding to recognize those changes and to 121 allow them to progress in their pattern, over the next year. 13 DR. SCHMIDT: I think the Committee is ready to 14 test the motion. 15 I will call the question, unless someone wishes 16 the floor? 17 Dr. Ellis? 18 DR. ELLIS: I would like to see them have some 19 increased funding if they are expending the 800 thousand, 20 because otherwise, they will have absolutely no flexibility 21 for growth. 22 DR. SCHMTDT: romnent from staff? 23 VOICE: Cannot hear. 24 DR. SCHMIDT: We will then vote on the substitute ce-Federal Reporters, Inc. 25 motion. ter-9 I MS. FAATZ: I think people count here, Dr. Ellis. 2 DR. ELLIS: I thought we were voting on motion, I 3 was just speaking. 4 DR. SCHMIDT: Speaking against the substitute 5 motion? 6 DR. ELLIS: Yes, I was speaking against the sub@ 7 stitute motion and supporting -- had said and that was that 8 they should -- if they are expendinq up to 800 thousand dollar 9 and have no surplus, it would be impossible for them to have 10 the -flexib,-'_;-+-y for growth, which they need. 11 And, therefore, I would think that some higher 121 funding should belmade available -- increase in funding, should 13 be made available to them. 14 SISTER ANN JOSEPHINE: I would like to say one 15 more thing in support of funding by way of encouragement. I 16 think the report indicated the great mobility of these people and it may well be that in a program of this type, which is 17 18 on the -- seems to be going in the right direction, now, 19 shows promise, if there were no increase in funding, they 20 might well lose some of the people who could make the program go. 21 22 DR. SCHM IDT: Thank you. 23 I think we are ready for the question then, on the 24 substitute,.motion. All in favor of the substitute motion, Reporters, Inc. which is voting for the reduced level, please say "aye." 25 ter-10 (A show of hands.).,@ 2 DR. SCHMIDT: You don't follow instructions very @3 well. 4 DR. SCHMIDT: Opposed, please raise your voice. 5 All right the substitute motion is defeated. '6 The motion then to be considered, is the original "7 motion. 8 All in favor of the original motion, please say, 9 flaye.11 Opposed, "nay." All right, it is not unanimous. "Nays" are recorde 12 DR. SCHLERIS: I think the illustration is of 13 value in showing the Rochester program has followed the smoke 14 signals from Washington, as they have interpreted them as 15 far as reduction in categorical areas are concerned. 16 Whether or not the smoke signals will be different 17 in the future, I don't know, but at least, they harkened to 18 the message. DR. SCHMIDT: Bill is going 19 DR. LUGINBUHL One more negative comment that 20 21 is-going back to what Mr. Scherlis said. 22 The grant shows how well we fRrtil.i7.p(3 thp-ir program, and how much we got from them by giving them an 23 increase, we 3ust voted to give them in.'the years past. 24 e -Federal Reporters, Inc. They didn't do anything for that increase of 25 ter-11 1 200,000. They didn't take a message from a decrease or anothe2 2 decrease, so I am not opposed, except for the principle of 3 money. 4 DR. SCHMIDT: I think the staff does have enough 5 from these comments to be able to warn the region that the 6' Committee was aware of the changes, we will be watching very 7 carefully. It is now 12 minutes to one. '9 I think we should take a lunch break at this point, 10, and I believe that 45 minutes will be adequate for ltinch. 11 So, we will reconvene in 45 minutes. (Whereupon the meeting was recessed for lunch, at 12 13 p.-,,n., to reconvene at i:30, p.m., this same day.) -12/s-13 14 15 16 17 18 19 20 21 22 23 24 ,e -Federal Reporters, Inc. 25 134 7148 1 AFTERNOON SESSION aig#13 /21 2 (1:33 p.m.) jr 3 DR. SCHMIDT: If the Committee could please be 4 seated I think our 45 minutes are up. And we are arranging 5 the sequence this afternoon as follows: 6 We will lead off with Central New York. And follow 7 up then with Virginia, West Virginia, Alabama, Hawaii and 8 Mississippi. 9 And Albany and Hawaii and Mississippi have kind of 10 different sorts of prcocnl--a-@ioA-,s and I'd if possiA'Jlia to 11 get through with those today so the maximum number of reviews 121 committee members will be here and will be able to comment on 13 the variations of presentation of material to the review 14 committee. 15 Also like to remind committee members that the 16 scoring sheets can be filled out with any number between 1.0 17 and 5.0, but the system won't take anything below the unit 18 number 1 or above 5. 19 You can use one decimal place between 1 and 5 if 20 you have problems with just the four categories. I'd like to 21 recognize Henry Lemon and welcome him back to the group. 0 22 He interriavted his vacation and as'l said'earli6r 23 and came down from the North Country to be with us. 24 So at this point we will begin with Central New e- Federal Reporters, Inc. York and I believe that we will begin with Dr. Patterson. 25 135 jr 2 1 DR. PATTERSON: Thank you very much. I believe 2 Dr. Ellis wanted to say a word before I begin. 3 DR. ELLIS: I don't, Mr. Chairman, have anything 4 new to say. I was assigned to review, that is why I looked 5 at you and I was simply going to take the opportunity to say 6 that we had Dr. Simmons Patterson with us who had the good 7 fortune to make two of the review visits and was in a better 8 position perhaps to speak on the more current information 9 than I. 10, DR. SCHMIDT: Let me interrupt right now and say 11 you were primary reviewer and that was understood. 121 My instructions, by somebody who I can't name right 13 now, were that he would lead off then we would turn to you. 14 DR. ELLIS: I see, well fine. 15 DR4 SCHMIDT: But however you want to do it. 16 DR. ELLIS: Would this then'be all right if he 17 just went on and gave what was seen on the -- okay. 18 DR. PATTERSON: I was fortunate enough to one-year 19 ago attend as a member of the site visit team to Central 20 New York and was pleased to be able to@go back the,second time. 21 Regret very much Mrs. Anderson is not able to be here today. 22 Mrs, Anderson was Chairman of the Site N74-s4-t Team 23 and was going to make the report which I will make today and 24 she asked me if I would speak on her behalf. !-Federal Reporters, Inc. 25 I thought probably since you had most of the 13b I information sent around to you as I understand concerning jr 3 2 the comments or different points'made by Dr. Brindley con- 3 cerning those priorities so forth, probably I'd give an over- 4 all picture of my impression of this site visit and then 5 could come back to the review sheet and possibly go through 6 it quickly or answer any questions that might arise. 7 In many respects it was hard for me to believe 8 when I went back this year that it was the same regional 9 medical program that I had visited the previous year. 10, The former director, Dr. Lyon-,,and many of his 11 staff departed this past year, through resignation. It was ]2i very obvious from the beginning that the program in recent 13 months since the time of the departure of these individuals, 14 that the program was vastly understaffe 15 Both John Murray who was elected unanimously by the 16 regional advisory group as coordinator and Mr. Walt Curry 17 who was his more or less deputy, in my opinion, ought to be 18 commended greatly for the heavy load that they have carried 19 in the recent months. 20 In fact when we were present at the site visit 21 Mr.-Murray had just recovered from an illness due to over- 22 work. He had Just gone beyond the point of human endurance 23 and we quickly made him aware that this was not the right 24 way to go at this job. It's clear that they can't continue -Federal Reporters, Inc. 25 in an understaffed manner in the future. 137 jr 4 1 Unquestionably in my opinion and in the opinion of 2 most of the staff of the Site Visit Team, the top priority 3 probably of this program at this time is the recruitment of 4 additional qualified individuals. 5 At the present time the staff is really in reality 6 so small in number that they cannot adequately handle the 7 duties and responsibility concerning the projects they now 8 have. 9 Doing my homework before this meeting I went over iO the recommendations and -- that we made last year as to what 11 we found they should do. And I believe sincerely that efforts had been made 13 to meet the requests of the previous site team. It was recom- 14 mended at the time tha t a physician associate director be 15 appointed, a man that had administrative capabilities, that 16 had rapport with the medical profession, and as yet such an 17 individual has not been recruited. 18 They do have a physician by the name of Dr. Carhart 19 who had been recruited to be more or less of a coordinator of 20 what is known as North Ridge. 21 This region is ddvided into four areas and they 2 v cparticular problems in L-L'il-Ls northern area beu-ause of Lhe 23. isolation due to weather, et cetera. 24 Dr. Carhart-is doing a magnificent job in a liaison e- Federal Reporters, Inc. 25 capacity in arranging for medical students and so forth to go jr 5 1 out to the hospitals. 2 But still, Mr. Murray in my opinion needs a physician 3 associate director and we advised him so very emphatically. 4 We have told him that he shouldn't rush into this, that he 5 should be very careful in his selection. 6 Another thing that is most essential is to have 7 an organized staff. From an instructural standpoint. They 8 need people in key positions such as assistant directors of 9 operations and administration, evaluation. lol One of the staff is carrying a dual hat, which is 11 bad. I they have several staff members that are -- they're 12 on the staff,- the program staff, as being in the capacity of 13. project directors. 14 We recommended to them that these people should 15 be made in reality full-time project staff members and not 16 capacity of project directors. 17 This holds true as well to an individual who is 18 coordinating the education. A year ago they had 11 position 19 evaluators. Part-time men. No one knew what they were doing. 20 In no uncertain terms we recommended this be done 21 away with. They heeded our advice and they do have an evaluator 221 now. There is some question as to whether he is the man 23 for the job because he is attempting to get a Ph D degree and 24 I feel probably he is not able to spend the time with the -Fedefat Reportefs, inc. 25 program that he should. 13 9 jr 6 1 And Mr. Murray is cognizant of this fact. 2 Mr. Murray is a very dedicated man, hard working, has the 3 respect of his entire staff, and it is hard to believe that 4 he is becoming engaged in as many activities as he can. 5 Questions have been asked me as to my opinion-as to.his ability 6 to administer this program. It is difficult to say. But my 7 feeling at the present is that he can do the job if he learns 8 to delegate authority and if he gets a well-organized 9 structural staff. -c delegate authority. We talked .0 He r,,,us@ carn '-- J. L. 11 very frankly to him and I think that he got the message and 12 I think that this is the most important aspect in as far as 13 the future of the program is concerned. 14 Last year recommendations were made concerning 15 improving representation on the regional advisory group. 16 This advice has been heeded. Participation by members of 17 this group is excellent. 18 They have a very dedicated physician, Dr. Case, 19 who is the Chairman of the Regional Advisory Group. Dr. Case 20 spends much time with this program. He works closely with 21 Mr.,Murray. 22 There is no question of competition, Dr. Case 23 advises and he is not trying to run the program. He is a 24 very clear-thinking individual. 3-Federal Repofters, Inc. 25 He wants to do what is best for the program, and I I 14 0 jr 7 think they're indeed fortunate to have such a man as Chairman 2 of the Regional Advisory Group. 3 I was particularly impressed and gratified by the 4 many and varied health activities that the staff members were 5 participating in. 6 Particularly gratifying was the relationship with 7 the -- "B" agencies. "B" agencies have procured emergency 8 medical service, coordinator is from the areas and regional 9 funding program is funding their salaries. 10, The representation by the regional medical program 11 staff is on all the "B" agencies. The "B" agencies have 121 representation of course on the regional advisory group and 1'3 the relationship between these two bodies is very very 14 commendable. 15 Dr. Scheiner, who I understand is not here today, 16 gave an excellent evaluation of the kidney program. The Kidney 17 Program has been sorely lacking in planning and help from the 18 program staff. 19 They have underestimated the needs of the area 20 and there has got to be more cooperation not only with the 21 program staff but with other groups, agencies and so forth, 22 in this reaion. 23 Dr. Schneider gave a very excel ent report at our 24 session at the end of the site visit and I think ge got his 8-Federal Reporters, Inc. 25 point across very clearly. 14 1 ir 8 1 1 got also the impression that possibly the program 2 needs some assistance in their fiscal management but I think 3 this is being taken care of through the State University of 4 New York, upstate medical centers through their business 5 affairs and also through the research foundation of New York 6 who has a branch office in Albany. 7 And I think with@help from these two groups that, 8 and Mr. Murray realizes that because of his undermanned 9 staff that.he needs this fiscal support and he is taking ]'V' steps.ir, that direction as an overall picture and inclusion 11 it is my opinion that this program needs help and not dis- 12 couragement. 13 And I emphasize this. And I enjoyed very much 14 hearing Dr. Brindley's presentation previous to this one, 15 and the remarks that several people made. 16 I think that this group really felt like they were, 17 had received a blow last year when they were funded, at quite 18 a low level. 19 They for some reason w6ren't too satisfied with the 20 site visit. That came out lotd and clear this time. We tried 21 to give them the impression and it is an honest impression 22 that we wanted to help them but I than,',, this program is at 23 the brink now where they, and I am trying not to let emotionalism 24 take over but I think that this group is honestly trying to ,-Fedeial Repofters, Inc. 25 do what we recommended last year.. I 142 jr 9 I think that when Dr. Lyons left it put an added 2 burden on the staff. I think the staff did some things that 3 weren't too wise. 4 One was these mini-contracts. Had the opportunity 5 to read about the mini-contracts, they share my opinion. 6 When you think about these mini-contracts it is an effort 7 on the part of program staff to get people in this region 8 involved and they went out and requested projects for up to 9 six months period with a maximum sum of $5,000. 10 And they received requests from over 300 individuals. 11 And in reality, what the program has been doing is dispensing 121 funds for these contracts as if the program had the authority 13 to use developmental component funds. 14 And since this program has not been approved it is 15 not justified in use this way. Furthermore I do not think 16 these mini-contracts related to the overall program goals 17 and objectives. 18 Many manpower hours were required to supervise 19 these feasibility studies and an undermanned staff is incapable 20 of doing this. 2@l It would be much wiser to have coordinators, I mean four i-.-.d,-viduals th-- 4-- are L-hiiiii ng of p'Lacing one 23 in each region, each area of the region. To have coordinators 24 determine the needs rather than let people come in with varied e-Federal Reporters, Inc. 25 ideas. 14 3 jr 10 on this basis money could much more wisely be 2 spent in completing these, carrying out these needs than would 3 be involved in a hit and miss mini-contract idea. 4 Another think I think in the program is that there 5 needs to be additional minority members on the program staff. 6 We discussed this thoroughly with Mr. Murray and Dr. Case. 7 They do have one minority member that is working 8 with the Spanish speaking individuals in the area. But the, 9 they need minority members on the program staff, they need 10 minority members on the regional advisory group. 11 We found out there was some, I am just not satisfied 12 with their priority system. We discussed this thoroughly with 13 them. I was not too impressed by their appeal mechanism. 14 I think this should be clarified. I mention al 15 these things not in a negative fashion but just things that 16 I think need to be improved. But the program staff does need 17 help and not discouragement. 18 I emphasize that again. You have a dedicated group, 19 the program staff, although inadequate in number to have done 20 a yeoman's job. All the lines of authority have'.le to 21 Mr. Murray and he has been as I said before overworked. 22 It is absolutely essential that he fill the 23 vacancies in this new structure with well-qualified capable 24 individuals as soon as possible. Well-qualified staff, :e-Federal Reporters, Inc. 25 adequate number, if it is carefully recruited I feel that 14 4 jr 11 Central New York Region probably will be ready to submit a 2 Triennial application a year from now. 3 It is important, however, to carefully review 4 the projects submitted in this present application and to 5 approve only a sufficient number that the program staff can 6 adequately develop, supervise and evaluate. 7 To overburden the staff in the next year with too 8 many new activities would revert the program in my opinion 9 to the same status that has existed in the past six to nine 10 months. 11 It is the feeling of the site visit team that we 12 would recommend $429,000 for staff and, let's see, a total 13 of $889,000, with $429,000 of this to be for the program 14 staff and direct cost to January 1, 1973. 15 We feel this amount would accommodate an adequate 16 staff and would not overburden them with unreasonable program 17 activities. 18 Also, this amount should give them a vote of confi- 19 dence that would improve their morale which is most important 20 and deserving at the present time. 21 Now that I have tried to use as an overall picture. 22 We have comments that we will) be aJad. to make on the review 23 sheet that we have concerning goals, objectives and so forth 24 and I'd be glad, I know, I think this was sent to you and e-Federal Reporters, Inc. 25 therefore I hesitate to go through step by step unless you so 1 4!) jr 12 1 desire. 2 DR. SCHMIDT: I think'that it would be probably best 3 in view of all things to hold off just.a bit and use that in 4 response to questions that might be, might develop. 5 So if you would remain there I will turn to 6 Dr. Ellis for any comments she might have then I'd like a 7 motion. 8 DR. ELLIS: Thank you Mr. Chairman. He has dis- 9 cussed this very well. 10 I would like to ask one question. How did you find 11 Dr. Patterson, how did you find the neighborhood health 12i center which was one of the problems that we talked about when 13 we were there on the first visit? 14 I notice it has been transferred but -- 15 DR. PATTERSON: I am going to be very honest it 16 didn't come up in our discussions at all, doctor,. 17 DR. ELLIS: Well you see the neighborhood health 18 center was one of the things that we talked about because 19 this was a way to provide services to many of the poor people 20 who lived in the community and also the way to use new kinds 21 of personnel in order to get the services to them. 22 But perha'-s -@- was --ro,-,nd th4-s discussion and 23 Dr. Lemon was there too, and made the visit to the neighborhood 24 center, that Dr. Lyons had some feeling of insecurity. I don't e-Fedeial Reporters, Inc. 25 know. Was this your impression? 1 14 t) jr 13 1 DR. PATTERSON: Well at the time Dr. Lyons, frankly, 2 didn't know much about what was going on'in the neighborhood 3 health center, that was our impression. 4 And then unfortunately several members of the site 5 visit team during the visit went and visited the neighborhood 6 health center and this invoked much criticism from the people that we visited. I feel like I am answering this just from my 9 -thoughts-. It occurred that the region was not involved 10 in the neighborhood health center at all a@L. the and 11 because they were so undermanned and so overworked I feel 12@ like probably their activities with the neighborhood health 13 center, Dr. Ellis, have been practically nil lately. 14 DR. 14ARGULIES: I could add a little bit to that, 15 just purely by coincidence I was in Syracuse in the last two II& days. And not particularly, not on a site visit activity 17 but some other purposes with the RMP. 18 Met with the staff and with the director of the 19 neighborhood health center who was Very intimately a part of 20 the regional medical program. 21 Wherever I went he was. And it was quite obvious 22 that the working relationship between the two at least as T 23 observed them casually were very intimate. 24 Of course, Murray was in that kind of an activity e-Federal Repoftets, Inc. 25 very deeply before he became the current director of the 147 jr 14 1 program up there so it's becoming-a natural part of their 2 interest. 3 DR. SCHMIDT: Miss Kerr? 4 MISS KERR: My response is strictly from the written 5 word not having been there as a site visitor and I do have 6 as a result of my reading and study some major questions, 7 some of which I think Dr. Patterson has answered quite well. 8 I still have some questions in mind. And I will 9 express them and if he or one of the review people will help 10 me, I a-prec4-a4.-c th4- o 11 I think there is no question but what Mr. Murray 121 as a new coordinator has improved working relationships with 13 agencies throughout the region. 14 My question about the leadership of the coordinator 15 is not one of public relations and not one of motivation 16 necessarily. All through the report it seemed to come to me 17 that there was an indication that he was a person apparently 18 unable to delegate responsibilities. 19 And that in several instances said he feels he must 20 do everything himself, and I am wondering, and basic to the 21 weaknesses which have potential for strengthening, if with 22 the enlargement of staff, and this Permeates the whole report, 23 the need to enlarge staff and expertise and competency needed 24 to carry out the vision they have, but if the staff is enlarged Federal Reporters, Inc. he point needed, is the coordinator going to be able to 25 to t .L li 0 jr 15 develop the ability to delegate responsibilities and the .2 authority that goes with it? 3 This is a major concern that I have. 4 Secondly, the region has been advised about the 5 addition of minority representation on the RAG and while there 6 has been some it seems to me it is in the nature of tokenism 7 and I think we need to stress this again. 8 There are many other areas. More specifically there 9 are two proposed projects here having to do with nursing homes, 10 improvement of personnel in nursing,homes in the areas of 11 medication administration and, something of this effect. 12i I am wondering how aware leadership is in this 13 region as to the vast amount of funds now available through 14 other sources for nursing home personnel. 15 And I question the amount of money that they are 16 requesting in those two particular projects for this reason. 17 DR. PATTERSON: I will try to answer the first 18 question. Maybe Dr. Margulies knows more about this than I do. 19 Of course the only two times I have seen Mr. Murray are the 20 times on the two site visits and it is impossible for me to 21 answer some of the questions you asked. F.--.m a persona'L T 'Uoi-i'L was 23 any better off than John Murray as far as ability for desire 24 to delegate authority. I thought I had to do everything and e-Federal Reporters, Inc. 25 I soon learned that that was an utter falsehood. -16 1 We had a very very frank talk with him about this. 2 And I don't think it was too frank.but very forthright 3 and just told him what happened to him from a, from physical 4 exhaustion was a good example. 5 And I told him that of my experiences and so forth. 6 And all I can say is I think he got the message. He is the 7 type that will carry these things out,.I don't know but I 8 think so. That is a personal impression. 9@ .0 Dr. Margulies, maybe you could answer that. 1 just 11 can,@.!t go any further than that. If I had to say yes or no '12 I'd say yes I think he can do it. 13 Second question you asked about concerning allied 14 health. When we first had our first site visit great emphasis 15 in this region was on nursing. 16 There are health services, education activities and 17 so forth involved in nursing more than anything else. The 18 site visit team a year ago recommended involvement of more 19 than just nurses and did not recommend the funds they wanted. 20 Whether this led to the resignation of the nurse 21 coordinator, I forget her name, Miss Soebia, I don't know. 1) T knoii she is tryi---g to doctorate degree 23 Whether this led her to resign, I don't know whether 24 she was upset about the decision or the recommendation of e- Federal Reporters, Inc. 25 the site team, decision of the review committee I don't know. 150 jr 17 1 But I think when she left they lost a very excellent 2 person in the field of nursing and allied health. I think 3 that condition still exists. 4 I think they have to make strides forward in involve- 5 ment of allied health. People not only in their proposals, 6 their programs, but also in their regional advisory group 7 and so forth. 8 Here again we had very very heart-to-heart talks 9 about this matter. It sounded like this was the sole site io visit business but -Lt-- in reality was one and I think they 11 were satisfied and took our recommendations very well. 12 Now concerning these two proposals I am going to 13 ask Gary. 14 MR. STOLOV: This was done as a core staff activity 15 and there is no requested project directed. It was -- 16 they were working fairly close with the New York State 17 Department of Health in reference to the nursing home business. 18 DR. PATTERSON: Do you think they realize they have 19 20 DR. SCHMIDT: You all are giving the reporter fits 21 here. Speak within about an inch of the mike, would you please. MISS KPPR: Tn summarN7 noiq that toy questi-----=- -have 2'zl .4 23 been responded to I would support Dr. Patterson's recommenda- 24 tion that this region be given encouragement rather than Federal Repoftefs, Inc. discouragement through the funding level. 25 jr 18 DR. SCHMIDT: Would you make that in the form of a 2 motion then to support the recommendations as outlined by 3 Dr. Patterson? 4 MISS KERR: I would so do, yes. 5 DR. ELLIS: I will second that. 6 DR. SCHMIDT: Oh, good doctor. our primary reviewer 7 then goes along with that. As a second. So we do have a 8 motion on the floor. Remind you it is for a one year 9 approval at the rate of $889,000 with $429,000 for support of St-"ff. MR. STOLOV: Dr. Roberts reminded me to say that 121 the site visitors included in the $889,000 is $1.6,000 to 13 11 continue their home hemodialysis program one more year so I 14 was unclear as to whether the $889,000 included kidney but I 15 wanted to make that for the record that this includes a $16,000 16 earmark. 17 DR. SCHMIDT: The record will show it does include 18 kidney then. 19 DR. SCHLERIS: The present core budget is -- 20 DR. SCHMIDT: Should be on that big long sheet you 21 have there. DR. SCHLERTS: T,ooking at the core 'erc:onnel. p 23 MR. STOLOV: Could you repeat the question please DR. SCHLERIS: Yes, the question I asked was 24 a-Federal Reporters, Inc. is the present support of core personnel as,of 6-30-791, 25 jr 19 1 I read that as being 309,000 and if I@add correctly 2 there are 18 vacancies on that, that leaves 29. 3 DR. SCHMIDT: The correct figure given down here 4 is $341,745. According to the yellow sheets, the fourth, 5 back of the fourth yellow sheet. 6 DR. SCHLERIS: I pulled this out of the original grant requests and there was an insert in it that was apparently, 7 8 an update from the old one. 9 Am I correct on that? I guess the question, what? MR. STOLO'%7: Yes. DR. SCHLERIS: In other words they have 18 vacancies 121 now and you are increasing their core by a significant amount 13 ;, of money. They already have 18 to fill. 14 Is this part of the source of their mini-contract 15 funds, unexpended course. 16 DR. PATTERSON: That's right, from resignations of 17 last year, that is where they got their assessed money, from 18 mini-contracts. But some of these people are being paid as 19 project directors and we are recommending that these people 20 that are project directors be brought on the staff and paid 21 as full staff. DR. SCHLERIS: The question I have reallv has to 23 be answered by your judgment. Do you think that they can 24 fill not only some of these positions but additional positions @-Federal Reporters, Inc. as recommended because that seems to be a healthy increment 25 153 jr 20 1 to existing core not to a planned core. 2 DR. PATTERSON: I personally do. 3 MR. STOLOV: However, grants management officer 4 asked me to call to the review committee's attention that 5 there is a large unexpended balance that was made available 6 to us. And we have as a site visit team recommended a manage- 7 ment survey go over this but we feel this is quite significant, 8 this unexplained balance. 9 DR. SCHLERIS: I would think so with the number of 10 18 vacancies in 29. 11 DR. PATTERSON: I am sorry I neglected to mention we have recommended very emphatically that the management 13 assessment team visit inthe early part of this coming year. 14 DR. LUGINBUHL: As a new member I'd like to ask, 15 when we approve this level, that is a maximum level that we @16 are recommending is that not correct? 17 And that the actual level of funding will be deter- 18 mined by decision of Dr. Margulies and staff, that our recom- 19 mendation is a ceiling, is that correct? 20 DR. SCHMIDT: Yes, our recommendation goes to 21 Council who then approves a figure that is in fact generally 1) nrce-+-ed as a ceiling, tl.-.cn 4.cpanl@ing on rLionles ava Lalii-e, 2z. -- DI - 23 principally, staff can award money or Dr. Margulies, or surgeon- 24 general or now the secretary or President Nixon can award ce-Fedefal Repottets, Inc. 25 actual amounts. jr 21 1 Based on dollars available and so on. Generally, 2 staff does not unilaterally make a decision more or less 3 arbitrarily on the basi s of disagreeing with the review com- 4 mittee or Council and give them less than we recommend. 5 If they do give less it is usually because funds 6 aren't available or budget cut. 7 DR. SCHLERIS: I think the reassurance is if they 8 get the money theywill spend it. The mini-contracts bother 9 me because they shouldn't have been core expenditure. DR. 1,4ARGULIES: Again by coincidence I discussed 11 this with them when I was there yesterday, indicated to:them 12i that the use of funds this way either in the endeavor to spend 13 it because you have it or to initiate contracts because you 14 think you have a chance to do it is not looked on very 15 favorably. 16 If they came back to us and'said we miscalculated 17 and we have not spent as much money as we thought we would 18 that that would get a much more favorable hearing. 19 In answer to you question, Bill, what we would 20 normally do if this committee takes action and Council confirms 21 it, would be to make the grant available to them based on 22 of course our available funds, but also on -an assessment 23 following a management survey and the state of progress in 24 that program so if it l.ooked indeed like the point being Federal Reporters, Inc. 21@ raised is an important one, that they cannot utilize the funds jr 22 1 as they had anticipated then the grant award would actually be 2 adjusted around the facts. 3 It is so difficult to be sure of these things at 4 the time of review. 5 MR. TOOMEY: I believe you said RMP funds a number o:' 6 CUP was that correct? 7 DR. PATTERSON: No, sir, what I said, and Jerry, I'd 8 like for you to correct me if I am wrong btit@it was my under- 9 standing that a coordinator for emergency services was re- 10 c@u4-4----,-' for each area by the CUP agency and then was paid 11 through RMP funds, is that correct? 12 MR. STOLOV: Dr. Rose just had a technical consul- 13 tation and before I answer I just wondered if he discussed that 14 Mr. Murray is using the CHPS as a recruiting arm and then 15 these personnel now become part of RMP personnel and may be 16 housed at the CUP office. 17 DR. JAMES: As a point of information I would like 18 to know in circumstances where the region may have quite a 19 few problems, has it been a policy of the review committee 20 to make a recomendation for the total years allocation based 21, upon possibly the fact that many of the problems be resolved 22 within a Deriod of months, for instance; contingent upon three 23 months improvement, then one may be assured as to the steps 24 that the program is going to take. e- Federal Reporters, Inc. 25 or is it usually the policy that the total year 156 jr 23 I award be made and then go back again a year later perhaps and 2 find that the program has either stood still as we heard this 3 morning, or has even regressed. 4 I wonder has there ever been consideration in giving 5 three months, six months approval. 6 DR. SCHMIDT: That is sort of tough because regions 7 have to plan, recruit and so on and breaking the year down .8 has not generally been done. 9 But what has been done is that awards have been 10 maae contingent on something that could happen fairly quickly, 11 such as the set of bylaws being approved and so on. 12i, But you have just about got to make an award and 13 let people go ahead and perform or not perform. What we do do 14 is send back very strongly worded messages that you must do 16 this and this and this. 16 And you know the year goes by very quickly and in 17 this particular instance they will be back in a year. But 18 everybody from the OMB on down has to plan their budget'and 19 so on more or less on the basis of the year. 20 We have not made three monthly awards or six 21 monthly awards. 2 DR. %--an -L jus'L add Lo Llia-L Coi:, a Moment 23 DR. JAMES: Yes, because I think you missed my point 24 a little bit. What I really was saying, that the total year @-Federat Reporters, Inc. 25 allocation would be available. jr 24 However, the approval of the project or the region 2 would be based upon a three-month period'of time dependent 3 upon -- this is not to dissipate their funds or to piecemeal 4 funds.going into the region. 5 In other words the total allocation of money would 6 be there. However, at the end of six months or whatever 7 arbitrary period of time depending upon how quickly they came -8 together with improving the deficiencies, the money would be 9 totally awarded for the whole year. I don't know whether that clears it or muddles it. 11 But I am aware of some agencies, not necessarily in this 12, particular group, however, being on a three-month watchdog 13 basis. And if they haven't come up to standards, then their 14 annual budget is cut and withdrawn. 15 DR. MARGULIES: The closest I could come to a 16 response to that is to tell you that when programs receive a 17 grant award and the funds are made available to them, we do 18 follow the rate of development and rate of expenditure, if 19 they get, well say $800,000 and it appears that those funds 20 are hot going to be utilized during the course of the year 21 those funds do not remain available to them. @-2 There was a in past years --f I-ett4-,-L-j There, 23 carry over funds from one year to the next. That's not the 24 case. Unexpended funds are a part of RMPS general funds and e -Federal Reportefs, Inc. 25 are then placed somewhere else. 158 jrl;t I If it's apparent that they may expend it at a rate 2 of half what they anticipated then we make an adjustment in 3 our budgets according to the rate of expenditure. 4 DR. SCHMIDT: That, still doesn't get to I think 5 what you are looking for. If I understand what you are looking 6 for we haven't done that. In the past. And particularly 7 with an established region with the sorts of activities that 8 are going on here, cooperative arrangements and these sorts 9 of things, three months, and recruiting and so on, three or Six -,,onths, an aw'Lu'L'Ly short t-LrcLe. v 11 A year is a block of time for RMP that might be 121 equivalent to three months with some action program with more 13 discreet and finite objectsives. DR. JAMES: The comment I would like there was based 15 upon the experience we had this morning and the review of the, 16 first program I believe, Rochester, in terms of three or four 17 or five, six years going on with a total expenditure of 18 money which does in the long run amount to a great deal. 19 And I had understood that strong worded messages 20 had been sent back but they did not result in change. And I wonder would the review committee want to consider going on 21 ,),) and on and on for a numbp-r of .9(,3r]i.ti-on al years withoi-it some 23 assurances that important changes in program would not be 24 forthcoming and not having to wait anot her year for the change., Federal Reporters, Inc. to come back. 25 jr 2 1 DR. MARGULIES: There is one exception to what we 2 have said to you. The only time that we have felt that a pro- 3 gram was in such desperate straights that it needed to have 4 shorter-term funding, we have acted that way. 5 I think we might have done it in the past in the 6 program that was presented this morning. But I think those 7 who were on review committee before recall that we in fact 8 in the State of Ohio put three programs simultaneously on 9 six month funding, at the end of which time they had to show 1.0 evidence of progress toward what we had outlined for them, 11 went on from there. 12-- it did have a good result. But when there is a good potential within a program and it is moving, it is a 14 terrible hindrance to tell them you can't be sure of this 15 money unless you meet such and such a mark, and it is a kind 16 of character role with the regional medical programs that 17 we have tried to avoid as much as possible. 18 DR. LUGINBUHL: I think the concern we have is 19 that there are vacant positions and if they indeed were 20 funded at this higher level we might end up with either those 21 funds used for other purposes as they were in the past or 22 that they would simply be carried over and I feel I have 23 gotten the assurance that it is possible through administrative 24 control to make sure that doesn't happen. -Federal Reporters, Inc. 25 So I feel that it is perfectly,acceptable from my 16 0 ir 3 1 point of view to approve this level with the understanding 2 that it can be managed through the administrative role. 3 DR. SCHMIDT: I think that and Ilthink once again 4 the record will show the committees concern that the staff 5 be built up and the monies provided for the core staff be 6 utilized for such. 7 John? 8 DR. KRALEWSKI: One final comment in that regard. 9 To read through this the recommendation was that you higher iO a deputy coordinator with talents and public relations 11 indicating you feel they need something to reach out and balanc( 12i of administration which means you know you think you need 13 some administrative talent within which really doesn't leave 14 much left for the coordinator and doesn't leave me with a 15 great deal you know leave me very comfortable with him. 16 Then coupling that with the fact we have got 18 17 vacancies and we are giving them another $150,000 on top 18 of those, for core, you know it just doesn't seem to follow 19 in terms of recommendations. 20 I wonder if the -- if this whole surplus bit 21 really did come up during the site visit or maybe that is a n e, 4-ece of information for your group and woui'.%'A perL'LC-L-&-@ 23 influence your recommendations and amounts o money? 24 DR. PATTERSON: Maybe I misrepresented my feelings Federal Reporters, Inc. 25 about the position of the site visitors impression about this. I 161 ,jr 4 1 I think that what I should have said they need a 2 man that does have some administrative ability. I think 3 that anybody in the position of associate director or deputy 4 director does have some administrative ability but I think 5 they need someone that can become more closely associated with 6 the county medical society, the state medical society, so if 7 you have got a man, administrator who is not in the position 8 I think that is a moot point whether it's wise or not. 9 But accept the fact that this administrator is 10 4- that pos4@t4j-on. Lhink it's wise to have a physician in 11 this position, if something should happen to Mr. Murray from 121 illness or if he is away this man would be the one who would 13 be in charge of the program and therefore I think he should 14 have some administrative ability. 15 That is my concern, it's hard to find a person 16 like that but I think they need closer relationship throughout 17 the region with other groups, allied health, physicians, and 18 so forth that such a man could give them. 19 DR. SCHMIDT: Seems part of your answer to the 20 question would be that management visit was strongly recom- 21 mended and if the committee would wish the motion could include 22 something effect-- %that penu'.-Lng the results of the iiianage- 23 ment assessment visit, somebody, staff or Dr. Margulies, 24 could reduce the award by some amount of funds that they @e- Federal Reporters, Inc. 25 obviously weren't going to be able to spend or some such@ J-b 2 jr 5 1 We are lacking some information I feel. I feel it i,, 2 necessary to answer some of the questions about the surplus 3 and what they will be able to spend and so on. 4 Presumably that is the reason for the management 5 visit. Like to be sure that all the issues are clear. 6 We are spending a little bit too much time on the 7 same issue here that I think is before the committee. Are 8 there other issues to be brought up. 9 DR. ELLIS: DR. HESS: One of the things that'-- concerned me 10 is the combination of staff and expanding project activity. 12 And the question as to whether or not some priority ought to be given to building program staff before project activities, 13 14 is in a better position to manage it. 15 And a related question is about the quality of 16 some of the new projects, if in your opinion they were good 17 quality projects. And then the second question is, what are 18 the decision-making mechanisms and guidelines which they will use in deciding which of those they have to select from will 19 20 in fact be funded if they get reduced funding. 21 How they go about picking the ones they think will 22 give the most mileage given their resources. 23 DR. PATTERSON: Well in reality we'are recommending 24 just that, sir, this they do not undertake har y any new e- Federal Reporters, Inc. activities. Continue what they are. 25 jr 6 1 They have gotten into the field of emergency 2 medical services which is going to take quite a great deal of 3 time. What we want the m to do is try to continue what they 0 4 are presently doing with only a few additions which would 5 keep them from being overburdened. 6 I think you are absolutely exactly right. That is 7 the word that was passed along. 8 MR. STOLOV: They have ranked each one of their 9 projects on a basis. And the site visit team felt that the -- 10 because of ranking situation we feit that no new activities 11 should be carried on through this period but built on the PMS 121 and also education until activity is that do demand a lot of 13 staff time. 14 DR. HESS: If I am reading these figures right, I 15 am looking at -- at, on the yellow summary. And the new 16 projects appear to the right of this double standard dividing 17 line sort of comes down through the middle of the page. Those new projects come to substantially more.than 18 19 $200,000, and that's the difference. If you turn to Page 4, 20 about $200,000, current'level of operation projects, you are recommending 460, so it's about 260,$270,000 difference and 21 22 it seems to me that there is more new ones there on the, on Page 5 than can be accounted for here so it looks to me as 23 24 though they are getting.into some new things. Federal Reporters, Inc. MR. STOLOV: The region has merged some projects 25 .L b 4 jr 7 1 that were originally started and put a new number on it. 2 So that accounts for project 44 and project 46. 3 And projects 23 to 31 have been merged into health systems 4 Northwest 45. 5 1 Because we got no report of phasing this out this 6 is the way it turned out to read. 7 DR. SCHMIDT: Dr. Ellis, did you have a comment? 8 DR. ELLIS: Thank you, Mr. Chairman, I just wanted 9 to say that Ihad the opportunity to see Mr. Murray once and I 10 was extremely impressed with his administrative capability. 11 I felt he really related to all aspects of the 121 community and had the, -- he could work very well with all 13 of the disciplines within-@the framework of mutual respect. 14 I could not see anything wrong with having a person 15 who is a nonmedical person in an administrative position. 16 I felt he had a much better understanding. I 17 thought it would be interesting to know that he did not have 18 the opportunity to make final decision on many of the things 19 when he was not in the director,'s role. 20 DR. SCHMIDT: We have a motion on the floor and 21 the points brought out by discussion. I think we must come 22 to a decision Doint. If we continue -qt this rate we @-7i-ll be 23 here until nine o'clock tonight before we get done with what 24 we ought to today. Are there any issues that haven't come up e- Federal Reporters, Inc. 25 that anyone wants to discuss before we do test the matter. jr 8 We have a second motion for the one year approval 2 at the level of $889,000. We had a management assessment 3 visit coming up which would provide staff with some information 4 We have the obvious sentiment of the committee 5 that building staff is there first priority. Warn them against 6 utilizing their energies in other areas until they have staff 7 competencies built up. 8 Are you ready for a vote on the motion? All right, 9 all in favor, please say aye. opposed, no. I ask for a show ISO of hands, all 'Ln favor, please raise your hand. 11 Seven is. And opposed? Five Nols. 12 So the motion is carried. Thank you very much, i 13 13 Dr. Patterson. 14 15 16 17 18 19 20 21 2 23 24 e- Federal Reporters, Inc. 25@ 16 6 Take 14 @R 7148 DR. SCHMIDT: We will move on to Virginia. Again, I remind everyone to fill out your sheets, ,or 1 2 3 using number 1 through 5, nothing lower tha n 1, nothing 4 higher than 5. 5 You can use decimal points between 1 and 5. 6 The order we want to get through this afternoon 7 is Central New York, Virginia, West Virginia, Albany, Hawaiit 8 and Mississippi. 9 So we are on number 2, Virginia. 10 There was a site visit. Sister-@@ Ann Josephine. xxxxxx 11 SISTER.' JOSEPHINE: Thank you. 12 The site visit was made to the Virginia Regional Medical Program on August 3rd and 4th of this year, and I had 13 14 the opportunity to chair the program and Dr. Benjamin Watkins 15 was a member, as were Dr. Morton C. Creditor and Dr. Vaun. 16 We had hoped they could be here to also review the program with me, but it wasn't possible for them to 17 18 arrange their schedule in this way. 19 The members of the staff were Mr. Frank Nash, 20 Clyde Couchman, George Hinkle, Marjorie L. Morrill, and 21 Joan Ensor, and they were most helpful to the Staff. I had an opportunity to %ri-sit the pro-rarr. last 22 23 year as a site visit team. At this time it was apparent that 24 there were a number of. problems related to magnitude as well e-Fedefat Reporters, Inc. as a number of problems related to the program itself. 25 16 do r 2 1 There was little opportunity for us to make any 2 significant changes in the arrangement of the schedule 3 planned for the site visit. We asked for a number of changes, 4 hoping it would give us an opportunity to evaluate the 5 program a little more effectively. 6 However, it became very apparent that members of 7 the program were defensive and were somewhat hostile. 8 Doctor, that is true. I had to check on this 9 because is changed and I don't want you to do to me what you 10 wanted to do to Albany. You know, I keep being afraid of time because, 12 as I look at Dr. Schmidt, I see somewhat my own Bishop who 13 recently stood up and said the prayer in the middle of a 14 sentence I was making, so I want to hurry up. 15 (Discussion off the record.) 16 SISTER JOSEPHONE:, The program when we reviewed 17 it in 1971 had categorical thrust to the program and I say 18 these things because it is kind of interesting in mind of 19 what was said about Albany and in mind of our own experience 20 and probably experiences other programs are going to have. x 21 I think some programs have coordinators who have attracted staff, who have more quickly moved along --nd 23 felt comfortable in programs that do change its smoke signals 24 frequently. :e-Federat Repoiters, Inc. 25 Also, I think some programs have probably been I 16 8 dor 3 able to attract to them staff, people who have developed 2 expertise in grantsmanship and I think all this does make 3 a difference in the climate of the programs and I think this has to be taken into,consideration and this program is a slow 4 5 learner. 6 These kinds of things did not exist a year ago, but 7 during -- also, this program is unusual in that there is a 8 minimum amount of domination from the two existing medical 9 colleges. 10 In fact, there was very little interest in this program. 12 Also, the RAG was very weak because all the decision m-ak4-ng ---oc3ss reall@- existed in the Board, of -the coypurat,-ori 131 r, .1 14 that was the grantee agency. 15 This year it became apparent that a number of 16 things had changed. Betieen the time of the site visit in '71 and our 17 18 site visit in August of 1972, staff has worked very hard 19 with the members of the core staff and with the coordinator. And they simply are to be complimented on the 20 21 success of their efforts. 22 Their efforts, however, were successful because core staff and coordinators responded to their efforts,.and 23 I think all this exists in Virginia Regional Medical Progre,,Li 24 e -Federal Reporters, Inc. 25 at the present time. 16 9 dor 4 I The goals and objectives which this program has 2 developed during the past year reflect the goals and objectives 3 of the program nationally and reflect a much better under- 4 standing of the latest mission statement of the Regional Medical Programs. 5 6 It was our impression that they reflect regional 7 needs and problems, although the site visit team felt 8 that the core staff need -- the core staff under,@the@...dit6ction 9 of the coordinator, need to develop ways and means to better identifv the local needs. .0 11 This, however, the difficulty of identifying local 12 needs,however, is bound up with the fact that they have at the 13 present time a rather -'inadequate data base in Virginia, and so they don't have this type of information to draw on. 14 But on the Regional Medical Program, it is going 15 16 to participate in the accumulation of this type of data and 17 will have it available as time goes on.. 18 The triannual application which they presented, 19 we felt, was not as well written as we had hoped. In fact, 20 there is so much duplication in it and repetition, and it 21 is presented in a way that might be confusing to the reader. 22 It is interesting in the first evening we met 23 for discussion, I think all of us felt that the program had not made the advances that we had anticipated--they wc)uld'in response 24 ce-Fedetal Reportets, Inc. to the directives and help given from staff. 25 dor 5 170 I But as time went on, we realized that the triennium 2 application was probably written by someone who did not 3 have the expertise that may exist in other programs where 4 better applications are written. 5 However, as we took time to sit down and talk 6 with the people involved, we found that their program was a 7 much better program than was reflected in the written 8 document. 9 The region has endeavored to prioritize the goals 10 and objectives as well as proposed activities. And this has 11 not been to their advantage. 12 So the site visitors felt that they would do better not to try to prioritize objectives as well as 13 14 programs, but rather to show how the programs were related 15 to objectives. 16 The evaluation process as it exists in the 17 Virginia program has many things to be desired. 18 The young man who is in charge of the evaluation has some of the limitations that were indicated existed in 19 20 the Albany program. 21 And in discussion with members of the sit evisit team and hearinq ir reviewed here today, that my recommendation 2) 23 and the recommendation of the group was that if at all 24 possible, the Regional Medical Program Services be given to -- ;e- Federal Reporters, Inc. 25 through their staff capabilities, be given to develop 171 I evaluation criteria and evaluation programs that can be 2 turned over to the different regional medical programs, 3 maybe even as a canned program or as a model, that they 4 could use for evaluation to -- for their own process, and cxx 5 they could modify it in their own process. 6 It was our impression, it continues to be my 7 impression, that we have too much energy that is being put 8 into developing techniques and skills almost in a competitive 9 atmosphere that should be shared between the programs and io -probablv we could move further ahead, and T think that 11 Virginia R etional Medical Program, the young man who is 12 doing the evaluation could profit by this kind of help. 13 Evidence of significant program staff activities 14 was manifested by involvement toward imporved care for stroke 15 patients in underserved areas, development of skills in 16 utili zing medical audit as an educational instrument to 0 17 improve quality of patient care, and activities related t 18 rehabilitation consulting teams for nursing homesi educational 19 programs in sickle cell anemia were beginning to be pahsed 20 out of Virginia Regional Medical Program into Public Health. 21 In the past, one of the problems that existed 22 in the relationship between the Department of Public Health 23 and the Virginia Regional Medical Program was that the head 24 of the Department of Health was also chairman of the RAG, of :e -Federal Reporters, Inc. Regional Medical Program. 25 172 dor 7 I And I think that with his resignation from that 2 position, I think a better relationship,'more effective 3 working relationship will be developed with the Department 4 of Public Health. 5 The program staff activities have stimulated 6 or directly resulted in greater involvement of dentists, 7 pharmacists, and allied health personnel. 8 There is a measure of accomplishment in the 9 building of relationships in five subregional districts io staffed by community liaisc)i-, officers and eventually 1-hey 11 hope there will be representatives from Regional Medical 121 Program in each of these subregional offices. And this is 4 13 envisioned by the coordinator as one of the functions of 14 liaison officers in coordinating activities in the state. In some areas the activities of comprehensive 15 16 health planning and activities of the'Regional Medical 17 Program are all intertwined but as I listened to them 18 talking, as I thought about them, the things that were 19 said later at this point in time, this may not be all bad. 20 There is one thing that is very evident in this program and it may exist in other programs, but may not be 21 so evident, and I would li.ke to comment on this and that 2'11- 23 is that as we sat and listened to their explanation of the 24 program, we sensed that there might be some hidden agenda e- Federal Reporters, Inc. that v,,asn't on the table. 25 173 dor 8 And as we continued to pursue with questioning, 2 we found that there really wasn't a hidden agenday in the sense 3 that they didn't want to share it but the planning that they 4 were doing was long-range planning, and while they were 5 describing the projects they had at the present time, they 6 already had their plans laid for the future, but weren't sure 7 that you disclose this. 8 And I think that it was not in an effort to be 9 secretive in any way. 10, And then 1 thought a'-so aboul- the climate in this 11 particular state. I think this is a very conservative culture in this state and I was reminded of the time when I 12 1 13 was working with kittens as experimental animals. The 14 pharmacist said to me, "If you keep moving the hand so fast 15 to get at the kittens, you are going to be clawed to death," 16 and I think this is the same here, and I think Dr. Perez is 17 very sensitive to the people in the area, he moves slowly 18 and he moves consciously and as a result, he is able to plan 19 ahead and then when he sees it is the right time, he implements his plans. 20 21 I would not have realized all these things had I not 21-) returned for a site visit within a vear and saw what had 23 happened, and he felt much more comfortable with me, it was 24 much easier to begin to see this. ;e-Federal Reporters, Inc. This may be true in other programs and if it is 25 dor 9 174 I just a one-shot deal, maybe I get the wrong impression. I 2 don't know. 3 They have currently ten projects ongoing. They 4 are still in the initial year of support and there is no 5 positive indication of future sources of funding. 6 And one of the criticisms that could be made of 7 this program in the past is that as they have developed 8 projects, they have not built into the project design 9 possibilities for phase out funding. However, this will be 10 -rue in the new projects, the 15 new projects, -that they are 11 recommending. 12 Like the Albany program, the 15 projects for the 13 most part show -- indicate an anticipated activity rather than 14 ongoing activity. 15 And in support of these projects, I would say 16 that the change in attitude, the change in climate,, the 17 change in attitude, the new members of the core staff 18 who have been brought on board, indicated to us on the site 19 visit they were capable, they wore knowledgeable about what 20 was going on in the area, and their willingness and under- 21 standing, the new direction in which the Federal government 22 anticipates that we shall, make- i-he programs go, as well as 23 their success in identifying phase-out funding, will 24 probably be supportive of the 15 projects they are ce-Federal Reporters, Inc. suggesting although there is no evidence of past success, 25 175 dor 10 there is no, little evidence of past success in all of the 2 areas. 3 We talked to Dr. Perez about the need for a deputy 4 coordinator. 5 We used that term because this had been suggested 6 on several previous visits and it became apparent as we were 7 talking that probably we were really saying, it is necessary 8 that you delegate more authority and -- or I suppose you 9 delegate responsibility and give people authority to carry 10 it out. 11 I think the concern we were expressing is that 121 if anything happened to Dr. Perez, there is really no one 13 to take over the rein, and this is a program that has 14 come as far as it has because of the leadership and strong 15 control that he has exerted over the program. 16 He was a little resistant, initially, to the idea 17 of a deputy coordinator, but was receptive to the idea,of 18 another member on the staff who would, to whom he would delegate responsibility. 19 20 It is -- I think maybe in the past semantics 21 1 were the kind of thing that stood in his way, but I think this is very important in this pro-ram because if anythin- 23 were to happen to him, it just isn't going to move without him. And this recommendation came through again from 24 L,-Federat Reporters, Inc. the site visit team. 25 1 77 dor 12 1 for better communication with the chairmen, the chairman 2 of the RAG who, in turn, will be able to do a better job 3 with RAG, but I feel he may well be one of the very good 4 chairmen that we have of the !'.Regional Medical Program RAGS. 5 The Virginia -.-Regional Medical Program is an 6 incorporated entity governed by a 12-member board of 7 direcors and since their incorporation, three of thecriginal 8 board of directors have once again accepted membership on RAG 9 @and this has been good because it is assured knowledge and 101 understanding of the senarate functions of each of the +--"."'o 11 groups. 12 And it may be as time goes on that one or two 13 others will rotate onto RAG. However, in discussing tnis 14 with Dr. Perez, the site visit team pointed out that too 15 heavy a concentration of this group on RAG would destroy 16 the benefits of a more diversified representation. 17 The Virginia Regional Medical Program has 18 established closer interrelationships with the major 19 health oriented organizations within the state and Mr. Hinkle will comment on some of the meetings that have taken place 20 since we were there on the site visit, which would indicate 21 22 that they are pursuing closer relationslyps with different agencies, so that they canbe more effective in providing 23 24 their, or in functioning in their role of catalysts. :e -Federal Reporters, Inc. I think they do not have the problem of see4-ng 25 178 dor 13 I themselves as broker although they have been sensitive to areas 2 in which they can provide seed money for'some of the projects 3 that would be supported by Comprehensive Health Planning-..' 4 It would appear that the region's political and 5 economic power complex is actively involved with the 6 participation of all three medical schools, CHP (a) and (b) 7 agencies, the State and Local Health Departments, both the 8 Medical Society of Virginia and the old Dominion Medical 9 Society, Virginia Academy of General Practice, and others, 10 were present each of the two days of si4@-c visit an 11 it was possible for Dr. Watkins to become aware of how he 12 could possibly provide better services for the Black people 13 in Virginia than he was providing at the present time. 14 The doctors who are working with this group 15 of people in Virginia are overworked and are unable to do all 16 that they really want to do, but in the past, they have not 17 seen other organizations as providing the capacilities for 18 them to expand their services. They have simply concentrated 19 on doing it themselves. 20 This is one of the things that came out of the 21 meeting and it might be interesting next time the program 22 1 is evaluated to see how successful they have been in this area. 23 24 The Region.has established mechanisms for e -Federal Reporters, Inc. obtaining comprehensive health planning and review and 25 179 dor 14 comment but as is true in many other programs, the projects 2 are sent through on too short notice and the Comprehensive 3 Health Planning doesn't really have an opportunity to review 4 the programs adequately. 5 At the present time there is no systematic, 6 continuing method of identifying needs, problems, and 7 resources, and as I indicated earlier, this may be related 8 in some way to the fact that there is a very important data 9 base available in Virginia. And this is one area where the program needs 11 help, and needs to continually be monitored. The management blueprint followed by the 12 13 Virginia Retional Medical Program appears to be conceptually 14 adequate. The fiscal management review that was made in 171 15 found the program adequate in this area and we called earlier 16 17 today and found out that at the present time that there are, 18 I think it was May or June reporting, the program is $10,000 in excess of its budget, which isn't all that bad. 19 20 It was the consensus of the team that the workload 2 1 and-responsibilities of the review and evaluation committee 22 should be delegated to a larger base of people who had more technical expertise and maybe some of their money should be 23 24 invested in consultation. @e -Federal Reporters, Inc. Since the last site visit, Virginia R6gional 25 180 dor 15 I Medical Program has established a RAG program committee 2 whose responsibility is to review and update goals, 3 objectives, strategies and concepts for the Virgizia Regional 4 Medical Program, along with providing guidance to the 5 executive director for program activity and project 6 development. 7 And they are beginning to move along in this 8 direction. I think that there is quite a gap that exists 9 betw een the knowledge of core staf f and coordinator and 10 knowledge of RAG. 11 But this gap will, if they continue going in the 12 direction they are going, should gradually be decreased. .1 They are utilizing their manpower and facilities 13' 14 in an efficient manner so far as we could see and their programs by the testimony of some of the people who came 15 have led to a better utilization of personnel, to better 16 17 dissem'Lniation of knowledge, better quality of patient.care 18 and in some instances, a containment of costs. 19 They are moving along with regionalization, 20 and are beginning to develop better cooperative agreements in various regions and they are also beginning to be able to 21 22 identify funds that can be used as matching funds for Regional Medical Program funds. 23 24 Before I comment on the recommendation of the e-Federal Reporters, Inc. site visit team for funding, probably the second reviewer- 25 1 81 d.or 16 would have some comments to make. DR. BRINDLEY: I have not had the opportunity 2 3 of having a site:@visit. I know the area, know many of the people there, 4 5 and Sister, perhaps I read the wrong things while you were speaking, but it sounds as though you made many apologies 6 for the program as you were going through it and indicated 7 8 some hopes for improvement in a lot of areas. 9 My only point of difference really was in your funding level in which I just wondered and I want to ask some 10 questions about that when we get to this. 11 12 If I may, I have nothing else pertinent or 1 that would be helpful tc 4--hc discussion but -t see@-i-@s to 13 that there are many areas that are weak and we hope will get 14 getter and in the program that you have indicated are 15 probably going to be improved but have not yet. 16 DR. SCHMIDT: All right, let's go on then, to 17 the recommendations of the team. 18 SISTER JOSEPHINE: The site visit team spent 19 some time in discussing the funding level and I think that 20 had we made the decision on the first day,, our decision would 21 have been somewhat different than it was after we had an opportunity to visit it with the group the second day and to 23 find out that there were more things that were going on 24 e - Federal Reporters, Inc. than were really reflected effectively in their application. 25 182 dor 17 1 That is a very poorly written application. 2 Accordingly, the site visit team recommends that the Virginia 3 Regional Medical Program be approved for triennium status 4 at $1,800,000 direct cost level for each of the three years, 5 and the,developmental component, which was requested at 6 $80,000 level to be funded within this total $1.8 million. 7 DR. BRINDLEY: May I ask questions about that? 8 DR. SCHMIDT: You put this in the form of a 9 motion, I presume? 901 SISTER JOSEPHINE: Yest the site visit team recommends that the Virginia Region Medical Program 12 be approved for triennium status at $1,800,000 direct cost level for each of three years:@,and approval for a developmental 13 il 14 component in the requested amount, which was $80,000, to be funded within the total $1.8 million level. 15 16 DR. SCHMIDT: Is there a second for this motion? 17 DR. SCHLERIS: Second. 18 DR. BRINDLEY: About core personnel and in their 19 budget, I know the current year has listed $501,000, in their 20 request for the first year, it is a'@-million sixteen. I can't see where that million sixteen is coming from but maybe I 21 don't have all the information. 2z. 23 Here is core personnel over on form 6 where they 24 presently have budgeted $351,000 and they have 12 more people :e- Federal Reporters, Inc. that they hope to employ and if they include their salaries, 25 184 or 19 I about two hours. 2 Then finally we ended up ten'of us in about 3 three or four different groups and we came up -- we tried 4 going through project by project and we couldn't get anywhere 5 on that basis, because th el asked for almost three million 6 dollars and we knew they were only around a million now, 7 and I guess that made it not feasible to take that approach, 8 so we got into our separate groups and first of all, I 9 personally came up with about 1.6, someone came up about 2.2, 10 and,",c thought we would have to work some more and wc did, 11 and then finally, someone else came up with 1.6 and the 12 first evening, after about two hours, that was the support 13 level we thought we would recommend. 14 Now, this is after the first day. The second day, we met with the program staff 15 16 and then following the session after that, but during the 17 programistaff, as the site visitors, consultants, primarilyf 18 had opportunity to quiz the program staff, what they were -19 doing, what they were planning on doing, how they were 20 going to do things, things that weren't in the application 21 or at least, we couldn't derive it from the application. '4%2 As soon as we got through, about an hour and a 23 half session with them, one of the consultants again, as soon as we broke, said that one point six isn't enough, let's make 24 Federal Reporters, Inc. it one point eight, so that is how we arrived at it. 25 dor 20 DR. LUGINBUHL: I am sorry, but I am lost. 'I don't have the application. 2 3 What I have got is the yellow sheet. 4 Well, the yellow sheet shows $500,000 for program staff in the current year. 5 6 $536 for operational projects. 7 A total of about a million dollars. 8 And then in the request for the triennium, their 9 request is almost $3 million for the first year. lo That is three times as much and they are doubling 11 the amount for program staff and they are increasing fourfold the amount for operational projects. 12 SISTER JOSEPHINE: Actually, "Cheir@current 13 14 funding now is $1,037,000. 15 They are asking for $2,989,000 and we are 16 recommending $1,800,000. 17 Unfortunately, the recommended amount isn't in 18 here for the first, second and third year, but this is their request, which on this seet, oh, yes, is for $2,989, $80,000 19 developmental. 20 21 We are recommending one eight. 22 DR. BRINDLEY: Can you see one.eight, you think 23 they can use one eight effectively? 24 SISTER JOSEPHINE: Yes, we felt they could. ce- Federal Reporters, Inc. There is a certain element of risk, but we felt they did it. 25 I?J b dor 21 DR. SCHMIDT: Let's give it back to Bill and 2 let him finish because he isn't done yet, I can tell. 3 DR. LUGINBUHL: My problem is they are going to double their core staff between this year and next year, 4 5 and they are going to increase then their operational 6 @,-,,!prO3ects also. 7 They are going to double those. That seems to be 8 a very rapid buildup in a program in which there seemed to be 9 some reservations and without looking at the projects, I 10 obviously have no way of knowing how thi,s money is goin- to 11 be spent but it just seems to be an awfully rapid increase 12 in a program budget._ 13' SISTER JOSEPHINE: As we go to those 15 projects, 14 there are a number ol them which could well be incorporated 15 and they could probably be stronger projects, so that I think 16 the 15 is a larger number than they will finally come up 17 with. 18 Insofar as the cor e staff goes, I think that they 19 realize that it will not be possible to fill all of those vacancies but they have as an alternati@e-the possibility 20 of purchasing services with some of these funds in the 21 22 absence of being able to fill these positions which would 23 be an alternative way to go. 24 DR. SCHMIDT: First Joe, then John, then ,e- Federal Reporters, Inc. DR. HESS: I had a question related to the 25 187 dor 22 previous one asked. That is, does the site visit team have 2 any recommendations as to how that one point eight might be 3 split between two program staff and operational projects? 4 Togehter the contracts are all contracts for core staff support services of one sort or another. 5 6 SISTER JOSEPHINE: Yes. 7 DR. HESS: Some of what he said sounded 8 like developmental component, feasibility studies, that kind 9 of thing. I just wonder if they are nettina the tl,70 m4-xed io 11 up- 121 SISTER JOSEPHINE: No, I don't believe so. 13' DR. HINKLE: Dr. Hess, the contract, 379,000, 14 I did a little analysis on that and what they are asking 15 for, 342 thousand of it I could identify, that is 16 for central type regional services which they want to continue. 17 One of them happens to be their stroke project for 18 rural stroke rehabilitation, which was a project. They 19 don't want to review the project. They think they should 20 continue a little vig. 21 Another consumer project, at a reduced amount into 22 their core until they can get the state health department to take it over, they think they have a firm commitment. 23 24 Feasibility study done in the prior year, the year they are in e -Federal Reporters, Inc. 25 now, they anticipate two of those will be completed, two .L 0 0 dor 23 of them are, have evolved in program proposals, and six 2 of those are ongoing now, again, moved over into the 3 central regional activity. 4 I have A'list of them. It is staff library 5 health data, survey of continuing education needs, career en- 6 hancement for allied health. 7 one of thel.big one is -- well, I punched a hole 8 right where it is, but it is health care and -- the last 9 three of them. 10 And another one, thev have a physician and 11 residents activity which they claim to put six thousand 12 in that, to their core, those are big items plus a few that run Lwo I-W -f've hundred, and up to ab i3 thousand, - en L.Y 1 our_ 14 342 thousand. 15 We feel that the.'funding level or the site team 16 did recommend that they will have to cut back on some of 17 these. 18 If some of these are marginal since they have 19 prior year experience on them, they may just decide not to continue them at all but we don't feel they can come anywhere 20 21 hear a million dollars into their core based on a million 22 eight hundred thousand funding recommendation. 23 DR. HESS: Well, I would just like to comment on 24 what this kind of think suggests to me or at least, the e- Federal Repottefs, Inc. question ir raises, that has to do with their readiness for 25 189 dor 24 triennium status. 2 It seems to me if we accept the sit e visit 3 team's judgment as a k ind of measuring stick, objective 4 measuring stick, it is very disparaging judgment between 5 the region judgment and site team judgment as to what capa- 6 bilities in the region are. 7 I just wonder perhaps the funding level is all 8 right, but I am not wondering about their assurety in terms 9 of managing capacility, whether or not they are eligible ,o for trienni_,_lm -ctatus. SISTER JOSEPHINE: Did I hear you say that the site 0 12 visit team feel they are but the region doesn't, is that; 13 tYle impression I have. 14 DR. HESS: No, you recommended triennium status. end 14 15 SISTER JOSEPHINE: Yes, sir. 16 17 18 19 20 21 0 @- 2 2 3 24 -ce -Federal Reporters, Inc. 25 I!) u 14-A kar 1 DR. HESS: Obviously, the region believes they are 2 ready. But I am questioning the readiness in view of the 3 rather substantial disparity between your estimate of what they 4 are ready to do and their estimate of what they are ready to do 5 Seems to me there is a very substantial weakness 6 there in terms of if we accept your judgment as correct, what 7 they are really able to do and I just wonder if there isn't som(! 8 more maturation desirable before they go triennial status*- 9 So I am questioning that particular part of your recommendation 10, SISTER ANN JOSEPHINE: Well, you know, it just may b(! 11 that I didn't -- I am really very sorry that Dr. Creditor or 12@ Dr. Vaun, one or the other, aren't here because it may well be 13 that I just didn't reflect this very well. I think what I 14 I sm sure that they, you know, do need more maturation. I 15 think the question-is not whether they made more maturation, 16 but are they at a point' where over the next three years they caii 17 handle triennial status. And I think that is somewhat differen-:. 18 And I would say that that is true. That they do, 19 they have indicated at this point. You see, they have within 20 the course of a year really changed from a totally categorical 21 focus to a service focus within the framework of the categorical. 22 I real-'Lst4L c a IL ly , they have done as much as anyone car, 23 do, but the way they have done it and the way they talked about 24 it as we were there, indicated to the site visit team,.and I e-Federal Repotters, Inc. 25 am usre I am reflecting accurately when I say this, the site 19 1 kar 2 visit team felt that they would develop considerable maturity 2 during the coming years, but that they had attained a maturity 3 of judgment and a demonstration of competency in the way they 4 had moved this far and in the way they anticipated they were 5 going to move with their programs, that 'they could handle 6 triennial status at this point in time. 7 DR. SCHMIDT: I would like to move us along because 8 Dr. Lemon is going to have to leave about four. And that means 9 that we will have to have our little party and give Dr. Lemon 10 time, ,,and Mrs. Flood" 11 So that I will. ask John to be brief 12 but we will want to cover the points. -.3 DR. KRALhvt'SKI: -L will indeed-', it is still not clear 14 what kind of increases we are offering. I wonder if we might 15 go back to Joe's question again, that budget, how much are we 16 offering them for staff, how much for core-staff activities, 17 and how much for projects. And that will give us an idea of 18 what the increases are. 19 Maybe they are not as substantial as maybe they look 20 on the surface. 21 DR. SCHMIDT: George, can't you do that quickly? 22 MR. HINKLE: Yes, sir, we anticipated that type of 23 question, but unfortunately at the time we were there, we would 24 say well, suppose you get a million and a half or two million, ;e- Federal Reporters, Inc. how would you allocate it? That is the only way WE-, could get 25 19 2 kar 3 a feel of whether they would take a cut in program staff or 2 whether in their projects. 3 DR. KRALEWSKI: Where did you think they should take 4 it? 5 MR. HINKLE: I think a little out of both. They jusi 6 about doubled both. We asked them what procedure they had 7 set up, you know, what plans they had made and they said they 8 were waiting. Now, at that time, they said they were waiting 9 to get their funding level, then they would have to meet and 10 almost start and retrench again. That is the reason we mention 11 our concern about prior advertising their projects and their 12 goals with no indication how they were going to use them, but 13.1 I was on the phone with them the other day and they indicated 14 to me that they-are ready, since we were down there, and I thin@. 15 this indicates their receptiveness. 16 They have come up with four alternative plans for 17 funding. A, B, C, and D,is the,way they identified them. And 18 whichever funding level they hit is the way they intend to go, 19 and I didn't have the nerve to ask them what range they were 20 looking for. I thought about it, but I was afraid to ask, but 21 they are working on it. 221 DR. SCHMIDT: I think in this particular area, it 0 23 would be safe to say that the information you are after we really 24 couldn't get until after they know how much they are going to 'e-Fedeial Reporters, Inc. 25 get, then they will make a decision so that way we are back to 19 3 kar 4 Joe's question. It is a matter of our judgment as to their 2 judgment and it is clear that the site visit team did feel that 3 they had the porcess for making the wisest'judgment, given 4 Virginia and so on, but I don't think we will know how they will 5 spend the money because they don't know how much money they will 6 have to spend, and their decisions will, obviously, be made in 7 part depending on how much money they get. 8 Mrs. Plood? 9 preciate the opportunity to MRS. FLOOD: Well, I ap 10 address the point that I was going to make, but it h as been well 11 covered now because it was the same question, the same concern 121 for recommendations from the survey-team as to which level 13 for what. Thank you. 14 DR. SCHMIDT:, Are there 15 DR. LUGINBUHL: I see in their first year request 16 that there is $376,000 which is labeled as post-contract money 17 which is an alternative with expenditure as core staff. Would 18 it be possible since we don't have a very clear understanding 19 of how they would react to a cut in budget to make that item in 20 some way a contingency item? 21 DR. SCHMIDT: To make the contract money a-:contingency 22 4-@@cm? 23 DR. LUGINBUHL: On clarification on how they would 24 spend that money or built to spend it at core staff, getting @e- Federal Reporters, Inc. 25 back to the flexibility that seems to exist for staff decision kar 5 after we have approved an upper level funding. 2 DR. SCHMIDT: It is my understanding that area was 3 fairly well blocked out, that the contractual money was to be 4 used for fairly definite and specified feasibility studies and 5 so on. 6 George? 7 MR. HINKLE: Within the application, those funds are 8 explained even with the narrative, a little porposal narrative 9 of what they area going to do on form number 12 in the applica- 10 tion. There -2Ls 11,000 on the form 11 at the feasibility study, 11 but they are both covered under central regional activities 12 under form 12. I have the complete list and balance if you 13 would like to run down 14 DR. SCIILE@IS: I think we can discuss any application 15 before this review committee on an item-by-item basis. I think 16 a great deal of the decisions that go on really relate to the 17 advantage of a site visit group having spent a considerable 18 amount of time getting to what really amounts to certain levels 19 of confidence and how well a region can really handle the funds 20 which it requests. 21 I don't think it is a reflection of immaturity for a region to ask for three mil.li,on and you ---ay sorry, we ;-ire on!,, --)2 giving you one point eight. That is the name of the game. 23 24 So I don't question the fact that there is disparity Federal Reporters, Inc. in the judgment of the-@ite Visit group as opposed to the amount 25 19 5 kar 61 requested. I think all of us on the site visit find that before 2 we, when we read the document before meeting the group, we come up with conclusions that prove to be totally falliciousjafter 4 you have met with the group and had an opportunity to sample 5 the opinion there. 6 I suggest we have a vote. I have serious questions, 7 but I think most of those have been resolved by the nature of 8 the responses that have been given and they really result in 9 the fact that after you have visited with a group, you have 10 confidence if they have answered the questions that have been I I raised. 12 DR. SCHMIDT: All right. The vote has been called 13 for then. We-will do so,.unles§ someone urgently requires the 14 floor. If not, then the motion is for approval, again, at the 15 level of 1.8 direct cost for three years with the developmental 16 component to be founded within this. All.lin favor please say 17 1. And opposed, no. 18 And the motion carries with dissent. 19 It is 3:23 or 3:24 And we will, within this room 20 right now,, have a little celebration in tribute to Sister 21 Josephine who is leaving for Rome. The occasion is dedicated to 22 her, 23 Coffee is dedicated to Warren Perry. This is his line 24 we wrote on the cake and tried to write on the surface of the ce- Federal Reporters, Inc. coffee and the sugar stuff melted, so there is no message on the 25 11 19 6 kar 7 coffee. But we won't have any speeches or anything, but over 2 in the far corner of the table is our coffee and cake and befor( 3 we do get up, Dr. Margulies will say a word. 4 Before I relinquish the microphone, in order for 5 Henry to make his plane, we will reconvene in ten minutes after 6 we stand up. 7 Harold? 8 DR. IIARGULIES: I actually had prepared a very long 9 speech about Sister Ann, but sitting next to Mack, I can't.do 10 it. I would like to say just a couple of things. One of them 11 is that this decision for her to go to Rome was at no time 12 cleared through us. I was a little startled by that. I suppos(! 13 the Vatican recognizes itself as a higher authority than this 14 one,, but we haven't always felt that way about it. 15 Sister Ann, for those of you who are unacquainted 16 with our experience with her, has always, for some reason, 17 inherited some of the toughest programs to review that anybody 18 ever has to take on. She has a great capacity to cut through 19 the mirk. She looks extremely gentle, but the main reaction 20 of the staff which told them that she was going to Rome was, 211 well, is Rome ready for her? 22 I don't know wi-icL slie is going to do there. I do 23 know that she requested that the review criteria be translated 24 into Latin. And so we expect to see some kind of reasonable Fedeial Repoitefs, Inc 25 change by the time she returns. 19 7 kar 8 1 We also had a po pularity vote on her as a member of 2 the review committee. And we did a control study, she turned. 3 out to be one of the most popular members of the review committee 4- we ever had, and we took this for nonsecretarian purposes as 5 a vote both on and after Yom Kipper, and it came out the same. 6 You can't say better than that. 7 And so I do want to wish you God's speed, but before 8 I do so, I would like to attempt that if anybody Attempts to 9 hijack.your plane, he is in trouble. IV SISTER ANN JOSEPHINE: Well,, you know, to respond to 11 your question about, well, wondering why I am going there, when 0 12 I heard about this, I said to myself, you know, life is not a 13 series of problems to be solved, but mysteries to be lived. B 14-A 14 (Break.) 15 16 17 18 19 20 21 22 23 24 e- Federal Reporters, Inc. 25 CR 7148 19 8 jean 1 I (Recess.) 2 DR. SCILIIIDT: Can we bring the coffee to the table 3 and reconvene, please? 4 DR. SCIIIIIDT: Ilove on now to the Ilest Virginia area. 5 DR. Ll',I%1011: Thank you. 14ow that everybody's relaxed 6 over coffee, this should go very quickly, I hope. i till try tc 7 be very brief; otherwise, I will miss my plane. I wish to s,-)end a little bit of time on the background wliici 8 1 I think is quite Pertinent, since this particular area has been 9 'IO somewhat neglected bv bring Under site visited; nevertlicl-cos, it has, in the opinion of the site visitors, done very well with very limited resources. The problems in this area are geography, 121 13i v7e have the first slide (slide) ; it is 61 percent rural. 14 There's been a massive exodus of physicians from the area. 15 They have lost 30 percent of their physicians in the last decade 16 The economv is in rough shape, between,40 to 50 percent of the 17 natients in the rural counties fire no pay indigent. The medical 18 resources have only recently been organized and the medical center which is T)e-ripherally located at the top of the geograph- 19 ical man a@,iay from the major centers of patient care. Further- 20 21 more, the graduates that are now coming into practice in the state, 65 percent of them are FLIG'S, and they have over 400 22 23 non-licensed IlDs practicing in some of their coal mining clinics 24 That is 400 out of a to.tal, in addition to a total licensed 'e-Fedetal Reporters, Inc. no,)ulation of somewhere around 1,000 or 1,200, 1 forget the 25 jean 2 19 9 exact figure. The area assets, however, are considerable. These peonle are quite independent. They like to work out 2 3 their own nrol3lems and there's been a very excellent working 4 relationshin established between the state medical association leadership and the medical center, the medical center which 5 has been a tremendous asset to PIIP. This is centered on Dr. 6 7 Andrews, whols been sort of the moving force, and much of this -8 has gone without detailed organizational lines or committees done on a first name basis, and this is one of the 'things that 9 -I^i we were initially nlistified bvi how so man,, things -ot done IV I .1 t) with so few people and we were soon informed. Next slide will 12 show (slide) well along in sub-regionalization. This slide sno,,vs comprehensive health planning regions that have been 13 14 developed. Some eleven of them in the state and the PIIP has 15 now gotten I think five or six. Next slide shows the TU,IP sub- 16 regional offices which are congruent for the most part with the CIIP offices and throughout CIIP the "B" activities have been 17 flushed out and firmly established through th e very excellent 18 19 Peripheral regional activities of lll.IP. Furthermore, they have 20 local foundation!-,, the IIY(,EIA Foundation, Ephraim @IcDowell 21 Foundation, that have come across with matching funds to supply their health delivery programs which have been initiated under 23 I-'!iP, and this is on an eight to one matching basis, in other words, @'IP has invested over $12,000 and they have over $1 million 24 e-Federal Reporters, Inc. returned. 25 jean 3 Now, the high priority basic medical needs here are develor- 2 ment of residency training programs. They have none outside 3 of the medical centers at I-lorgantown, which is way at the top 4 of the map. These are in the v@orks and the state legislature 5 has aT)T)ro,)riatecl $300,000 to help (levelol)e these in Iluntington, 6 Morganto@in and Parl:ersburg, located in this area and down there. @7 They have done little, however, in getting their unlicensed 8 l@IDS. This is one of the criticisms we would lay before you on the nroaram thus far. 9 Next slide nlease (slide). This just reviews the state- 10 11 wide nrograms that are underway. You can-It possibly read all 12 those, but there are quite a wide ranging number. For the 13 most ,Dar@-, thcsc '-nvo'Lvc -.hG of 'JietLer Lli delivery services in snecific areas in cooperation with local 14 15 lay people-and professional peopl6., 16 Next slide (slide). This shows the proposed projects and 17 how they are centered around it, some of the major regions and 18 you see these are all peripheral for 14organtown, so we have here a verv concrete demonstration, this was the thing I thought 19 20 would be very help@ul to the committee, to see that indeed this medical orogram is not the creature of the medical centers but 21 it has gone out. It's acutely aware of the medical needs, 22 their priorities are well established in terms -- their object- 23 24 ives I mean -- and they have gone out and done a very capable, e -Federal Reporters, Inc. thorough job of sub-regionalizdtion. 25 jean 4 201 Is that the last slide? (new slide). This shows the, 2 this is emergency medical services. Two subregions, this is 3 one of their three major Priorities. These are two of the 4 projects in emergency medical services. (Slide) The next one shows another group of their projects. I can't read that 5 here. It ,3hows different distribution. I'll point out 6 from 7 that they do(not try to do much at the present time in the very 8 southernmost tip of the state, which has the majority of their non-iqhite population, because this already is covered by very 9 1 larqe Appalacian rograTns, witli which there has been some, I won't say conflict but they have been rather slow in getting 12 involved down there, because this is part of another regional Program. i thin,,@ tnat -,s the last slid(--, is it not.> 13 Thanlz you verv much. Lights please. 14 !,le interviewed a total of some 41 people, and it was amply 15 16 demostrated that they have -- that the objectives are quite congruent with service objectives of IU-,IP, and they revolve 17 I8around health care delivery, emergency medical service and 19 health manpower. Every one of their proposed new programs, of which they have a considerable number, relates s pacifically to 20 21 these objectives. I,Iow, when the area had the disastrous combination of 42 23 circumstances of losing its initial original coordinator by death then getting a site visit, I guess from the last site 24 :e- Federal Reporters, Inc. visit three years ago, the -- tli(!y chose I-Ir. Holland as the 25 j ean 5 202 I acting coordinator and they have been very effectively led 2 by ?,Ir. Holland, iihom we rated.very high for his administrative 3 ability, his energy. fle had been the assistant coordinator - prior to that, and lie has gotten in a good group of assistants. 4 It's a rather simplified organizational structure which he has 5 developed, but he has been able to develop the six subregional 6 7 offices staffed bv regional liaison officers who report directll 8 to him, and they coordinate their activities very closely with 9 the "B" agencies and the university county extension programs. 0 The state university has its own county P,@t(,n-,ion program in various areas. ".)ou have not only the "B" level programs, but the other programs of the state university. 12 Tle 13 I felt tlia@t tile ,I(--cif;4-on riak-Li-ig objectives, dc-c.'Lsion 14 making and reviev7 processe@;,@.7ere quit(-- adequate for tri-annual 15 support, and we felt that they had performed really quite ex- centionally in their planning process and in the flexibility 16 witl-i i-7hich they continued to redefine their objectives and goals. 17 I18 The institutions, as I said, are the backbone of this and this war readily apparent from testimony of the dean of the 19 medical school and Dr. Andreiqs who is now provost of the uni- 20 211versity, which is sort of a flexible i,ir. fixit job. And lie continues to keep a very close eye on IUIP, so that Ilr. Ilollaiid 1) 2/- has quite adequate high level professional assistance in the 23 T)olitical power area from the president of the state medical 24 'e- Federal Reporters,inc. association, Dr. Ileek e and from the dean of the m dical school, 25 jean 6 2 0 3 and the provost of the university. 2 The program staff activities,,with a'rather small budget, 3 has been very effective,since there is a,30 year background 4 really in the development of community efforts to increase and retain nosition coverage for some of the small towns, and since 5 6 there has been this background of community action in terms of medical care, R-TIP has been able to move in, I think, more 7 8 rapidly in this area in sub-regionalization of medical care 9 access than in many other parts of the country and they have ,No done verv wel.l. an(I this is where the major emphasis of %--he approximate five-fold-expansion in non-core staff funds. They are not asking for expansion of their core staff funds, but they 12 are aS.4ncj for -nore 4unds to in't'ate the development of many 13 L more local grou,-) practicing centers. 14 15 In addition to the United 14ine IVorkers initiated group 16 practice activities from which they're basing their present 17 model for extension of medical care, the individual solo practic@ 18 of medicine by the members of the medical society is due for a change. There is a large group practice now being organized in 19 20 CharlesITown, and I would like to have you remember that the conventional medical practitioners in this area have never been 21 sympathetic with the Ul,l'@l clinics, but these two are croina to 22 23 come together, we hope, and we think IT?-IP in the next three years will have a tremendous opportunity not only to improve medical 24 'e- Federal Reporters, Inc. access and general medical care in the outlying rural areas, but 25 jean 7 204 I to d(-,velo-) liaison and backup with specialized high quality 2 medical care from the major medical centers of Charleston, 3 Huntington, and Parkersburg through the development of residence 4 programs. 5 ,-low, if they know they only retain 40 percent of the 6 physicians they train at the medical school who largely go out 7 of state for internship, if they can get them into residencies 8 in the state, and there are none outside of the medical centers, 9 about 70 nercent of them will elect to stay in the state. l@ The,/ have done vc-r well in getting continued support. I L-1144@nlz y this is one area that they have demonstrated very well that they 112get continued.support for l@,IP initiated programs. - - bome of the criticisms that relate to this regional 14 advisory group, they have not really been able to answer the 15 earlier criticisms of previous site visitors that the regional advisory cjrouz) was not sufficiently made up of minority groups. 16 - In their area they think the most urgent problem is with the 17 18 medically indigent. They don't have adequate representation of the medically indigent consumer on their regional advisory group 19 but with 50 percent of their Dopulation either without or unable 20 21 to pay for medical care this is a problem that they'lre very much 22 concerned about. This is not adequately represented on regional 23 advisory group. The coordinator has done all he could. Ile went 24 into this in considerable detail to recruit minotiry employees :e -Federal Reporters, Inc. for the program staff, -)ut there was only one minority 25 lean zi 205 representative on the core staff, so we felt that this should 2 be certainly something that should be remedied in the future. As I said, we rate d the coordinator very high. Ile knows 3 how to delegate responsibility, and we felt also that somewhat 4 5 he was in a rather advantageous position being,a non-physician, 6 because he could relate equally diplomatically to the university and to the leadership of the state medical association. Ile 7 8 works well with both of these major resources. Program staff 9 was all high quality, well trained. 10 Ile did feel that the,i needed more input from physicians, physicians time on the staff and a nursing physician, particu- 12 larly in terms of evaluation. This is one area where we don't I-ave problems in evaluation. You can actually count the 13 " 14 additional number of people who will have access to physicians where there weren't physicians before. I mean this is an area 15 16 which one should be able to evaluate what they are doing very 17 well. t,,7e felt that the )@egional Advisory Group bylaws were 18 restrictive, they thev shouldn't -- again the previous site I19visitors had come into this were very health prior oriented and this should be opened up, 20 21 It isnot that the people on the Regional Advisory Qroup 22 are not cognizant of what they should do. For instance, IIYGEIA, 23 a foundation, is putting many hun.dreds of thousands of dollars 24 in supporting these programs, but there isn't a representation @e- Federal Reporters, Inc. of the IIYGEIA foundation on their regional advisory group. 25 20 6 jean 9 This is a matter of ordinary diplomacy. You would think 2 they would get representatives from the major foundations who 3 are hel-,3ing their work, the grantee organization, There's been 4 some oroblems vjith this. There's been assessment recently, and 5 these problems are -3robal@)ly pretty well worked out. There is 6 a long delay between the presentation of vouchers for payment 7 and payment, as long as there months. This is because it's a 8 state university, it's the grantee agent,and this has to go 9 through all the checks and balances and delays of'a state uni- system. Again, this has been an educational business both ways, 12 The university has become educated and the IU4P in what it can do 13 and trirough the checks and balances there is little chance for 14 any real mismanagement of the funds by this organization. our 'oyv,7er structure of the state, political and medical, is well 15 16 represented. The nurses, however, are not represented. There's been a 30 nercent increase in nurses in the state in the last tei 17 18 years, and, of course, in areas where they can't put physicians 19 in, pediatric nurse practitioners, that type of program is in 20the works, and they should I-lave much more nurse representation, 21 both in their core staff --tnd on the Regional Advisory Group. 1,7e feel that the@,, have not recognized the p-@blerris ade,,-uatoly,, 2@ 23 as yet,of the 400 foreign trained physicians or U.S. trained 24 physicians who have been unable to get licenses, but they made @e -Federal Reporters, Inc. the decision verv early in the course of IUIP that they had to 25 jean 10 207 concentrate on first things first, and they were going to leave continuing education to the medical centers, and they did not make it a Dart of their regional medical program. 3 '4 I-lanagei-.ient xias well done; we felt that the office of 5 prograra and research and evaluation, this is staffed by a single 6 program evaluator, data analysis and a research assistant. 7 Ilow this is in the process of cl-iange. Ile felt that their quarterly progress reports and recording were quite adequate, 8 9 but we didn't think that the feedback was getting back to 10 the regional advisory g.L-oupl was getting back to the coordinator IIIand his staff, but it's not getting back to the tegional 12 advisory groun in terms of the regional advisory group really being l@e-)t thoroughly informed as to tl-ie relationship between 13 pronosed programs and lioi,7 well they are meeting their objectives. 14 4. 15 The executive coi--mitiLee of the regional advisory group, 16 for instance, meets on a monthly basis. That just shows how 17 much responsibility the coordinator and the staff have been given in terms of running this program. 18 lie had no real question as to the programs which they had 19 20 carried out. There was one rather extensive program which is producing few physicians, but this orogram was probably very 2 1 . I Iimportant in the early of thi-- rie(ii-cal pr,,Dgra.Tp, 22 23 educating the r)hl,,sicians in what MIP was all about. If they 24 want some money to continue this, this is one of the things we -e- Federal Reporters, Inc. felt could be cut in the future, riot put another 1-iundred thousand 25 jean 20 8 I dollars in it, and we have information that that can probably -2 be funded by others, from other sources in the future. 3 Finally, on page 17 our recommendations, I think I have 4 covered most of the lesser points. On the funding level the 5 one big item, most of the new projects represent just sort of 6 seed monev for the organization for new clinic activities or feasibility studies or health planning activities which are 7 well tied into CIIP. They did ask for $250,000 for the first 9 year for total staffing of the new clinic, Camden on Galle. fc"t that was a little bit high. flaybe @IVIP should only 11 buy 50 nercent of that, and since that was a precedent, all ,the other things that tlicv'd be able to start, they'd started 12 ii with a much lesser proportional funding. So that if we knock 13 14 out half of the Camden on Galle support which they requested 15 and we did not allocate another $100,000 for the physician and 16 medical self audit program which is now in its fourth year,, that 17 knocked out about $175,000, then with the usual startup problems in new -)rograms @7e felt that a reasonable figure for their 18 .11 19Onerational year would be one-and a-half million dollars, then 20 one-sixth for the fifth operational year and 1.7 for the sixth operational -,7ear. 'tle had no real concern in view of the, of 2 1 their 4G national i.nr-rea-L-e, there arc nraC-4cally rio physicians 22 t-@ L i in the rural communities an,r more and people don't have really 23 .2 the transportation to get to a physician. '@,le had really no 24 @e-Federal Reportets, Inc. feeling "-hat they i7ould not be a.)le to do great things with thei 25 jean 12 20 9 develor)rqental component. Ile did hope they would put part of this into development of their residency programs, that this 2 3 would be within IUIP guidelines, and also do some kind of pilot 4 study to see how they could bring their unlicensed physicians 5 into the medical community. 6 DP,. SCII.IIIDT: We have a most excellent and strong 7 secondary reviewer which relieves some of the pressures we are 8 Under, and I'd like to ask Leonard first if he has any questions 9 of ilenrv, because he is going to have to phase out in about 10 ten Tni nutos. So, the mo-- 4-- important t'iliri@ @Ls to be sure that 11 the secondary reviewer gets what information he needs. 12 DR. SCIILERIS: I want to ask one or two questions. in looking at tile approximately 15 or 16 projects that are to 13 14 be supported, do you feel that they have the necessary strength in West Virginia and the core to make sure that these are 15 16 productive ventures? In looking at numbers, oli, 21 on down? 17 lqot just that one but all 16 projects listed. Do you think they 18 can adequately evaluate those? 19 DR. LE1,10T.4: 1,7ell, we did, the second afternoon we 20 went out to look at one of the clinics that's been developed by the community, without any benefit of l@?,IP assistance. These eoT)le have the I:no@.7 lio@.7 to develoTD c--ni--irt- pnlitical.ccm,-rchensi,.@c 22 23 health nrograms cove-ring the whole community, including everybod@ in the co,@,iunit@7 and if they can to this in the town of Fairmont, 24 -e-Federat Reporteis, Inc. lest Virginia including a bus system for the patients so they 25 Z.L V ican 13 can get to the clinic, as I say, you have to know them, and I have a professional associate @qhols from West Virginia and 2 3 one of the reasons they half a deficit of physicians, these 4 -people are great do-it-yourselfers, if you give them half a chance. I'@le felt very sure that they would be able to do these 5 things and this is backed up by the people at the medical center:; 6 7 and the state medical association. They're not without the 8 best help they can get in the state. DR. SCIILETZIS: Are they going to do anything about 9 the core itself? I note that essentially $577,000 for core the current year, asking only for $584,000. 12 DR. LE14ON: They did not ask for -- we felt the core -h@ulrl he -- needed so.-ic strengthening in particularly Lile- e-val- uation. We felt that what they were doing was so valuable there 14 and there are some other activities like these other organized 15 clinic activities that now have such a large amount of expertise 16 and experience that we were hoping they could beef up their 17 evaluation and got more of this out in the printed word in the 18 form of reports that would filter to other areas and be helpful 19 to other areas. 20 DR. SCIILERIS: Are you suggesting any strenglitening 21 iof cor@-? 22 DR. Lr,',10"1: 6,7e felt the core program was slightly 23 under staffed, but not inordinately under staffed, and they do 24 ce-FederaiReporteis,inc. have hel-) from the medical centers @7est Virginia medical center@ 25 211 jean 14 and university. DR. SCIILERIS: How strong are'your recommendations 2 for reorganizing T7pSt Virginia 3 4 DR. LI@1,1017: I think here you have to walk the path 5 of di-,31omacy. They have done a very good job. I would like to 6 put it in strong language, but I would not make the award con- 7 tingent on that. 8 DR. SCIIIIIDT: All rig]-it. 9 DR. LF,,'11014: I put this in the form of the motion. DR. SCITI,T7,RTS: Dr. Schieris: Second. 10 - DR. SCIIIIIDT: Dr. Schleris puts it in the form of amotion. i2I 13 SIST),@R JOSEPHINE: Second. 14 DR. SCIII.LIDT: Dr. Schleris, we will turn to you as a secondary reviewer. 15 16 DR. SCJILJ,RIS: I have gone through the document. It's ver,7 brief. The anectodal part of it is extremely brief 17 and the site report is more lengthy than:tlie.anecdotal comments, 18 so the review is very important in this instance. The individual 19 projects aren't described, This is whv I asked whether or not 20 vou felt this could be self running. You have a great deal of 21 confidence that this is indeed so. 22 DR. Ll,'ZIO@ll: I think their performance is extremely 23 good in that out of $120,000 RPIP has put into development they ii)w 24 ,e- Federal Reporters, Inc. generate a million dollars of support from IIYGEIA. How much 25 jean 15 212 longer the Galle foundation can add to the support is -- 2 DR. SCIILERIS: I have-indicated my concern about core remaining the same in the face of 15 or 16 new projects 3 4 scattered throughout the state, many of which will I-lave to 5 recruit additional physicians and personnel who, as I read it, 6 may not be available. So, I think it's probably wise in terms 7 of startup, there will be undoubtedly delay in many of these organizational and staffing problems. 8 9 DR. LETION: 1,@7e went into rather thoroughly how flexible thev were and thev have been rather auick to phase out programs they felt were unproductive or where they couldn't 12 get adequate assistance in the local area, but there is in 13 Liost of are-as, as far a.,; @@,,c could determine t--Illey'L@Ai; see their sub-regionalization with these sul)regional directors, 14 the@7're out in the boon docks 80 percent of their time. This 15 is where their time is going, making sure these resources are 16 there. 17 DR. SCII',IIDT: Are there questions or comments from 18 committee members? 19 MR. .IIILTO'I: Two questions. You mention the soutlierr- 20 most nortion of 'qest Virginia and 30IRe problems there. Is tlierc 21 interface? 22 DR. LEIIO'4: There is a $5,000,000 Anpalachia,healtli 23 project that includes i@IcDo@7ell. County, which is 25 percent 24 of T :e - Federal Reporters, Inc. b 1 ack The rest @7est Virginia is only about 4 percent,, but 25 jean 16 2 1 3 I that one county, which is one of the most depressed and re- 2 tarted counties, is included in another $@ million Appalachia 3 program. 4 DR. LEI,10@Ll": !lo, this is under Ap ,palachian Regional 5 Commission. 6 IIP. IIILrl"ON: Are you satisfied, are there opportun- 7 ities for cooperation or not? 8 DR. LE1,10il: I thin],, they are hust now beginning to 9 develop their contacts there. I think the other projects had 10 -some nroblem in persuading the l@iE-,alth providers of that region 11 to get involved and so fourth so that we were told that they -- 12 there-is a good liaison now, but this is onl-,7 a recent develop- 13 ment. 14 DR. TLI\RGULII-7,S: If I can comment on,tliis, we are currently exploring the relationship between regional medical 15 16 programs through all the 13 states ori-the Appalachian commission 17 and the commission. It's an extremely complex kind of thing 18 with traditional nolitics involved. It varies tremendously from state to state. The commission is designed around governor, 19 20 gubernatorial control with a chairman set up by the governors 21 and a federal co-cliairrian appointed by the president. Then, the funding goes throuali loc@l political Processes and X- A. I:, unendural:)ly comiolex. I have asked we explore it only if it 23 looks like it's worth exploring, because it may be the kind of 24 'e- Federal Reporters, Inc. thing on which you can expend an extroardinarv amount of time an 25 jean 17 IG J. -2 come out with a trickle on the other end. In IVest Virginia it's Particularly troublesome. I think we have had something 2 3 like five million a year for nine years or something like that and, in that area. And, its pretty well controlled by the 4 group that's dozen there and it's probably just as well they 5 6 don't try to compete with them. 7 IIR. IIILTON: One other comment, the question was raised about representation of poor consumers from the i@lest 8 Virginia area, and while we were all, I think, suitably im@,oressel 9 with the accomplishments of this T)artici3lar program areas, I thin]: it's important not to under estimate the role 12 of great development on the part of poor folks in llest Virginia 4- program 13 . I thing @,ic are prepared to, I get the feeling 14 we might be nrepared to let that kind of slide, because other 15 aspects appear to be quite good. Statement was, question was 16 raised earlier as to whether or not our feelings about this particular matter were strong enough to make reform a cortingencl, 17 on funding. Indicated it would be, should have a very strongly worded suggestion. I would like to raise the possibility that we 19 do in fact make a contingency. 20 DP,. TIA',IGULIES: I'd like to comment for a moment on 21 that and nicl-,up on something lienry was already identifying. The people who xiorl: in the subregions around the state 23 work also with the e;@tension service, and their involvement with 24 -e-Federal Repoiters, Inc. total community is,in mN7 knowledge and. JUIP's,unique. 't7hen 25 215 jean 18 1 they go in some place everybody knows them; they deal at every 2 level and they function in a different way. That doesn't deny 3 the importance of presence on the regional advisory group, but 4 it would be a disservice to the lqest Virginia Regional @ledical 5 Program, to suggest that they are not dealing directly as they 6 are .,@ith the poor in the state. But, they are doing it through 7 a different kind of a process. @8 !Nevertheless, I think your point is well taken. If they 9 are not represented on the regional advisory group it certainly 10 isn't because that i-s ir, concern of tiia-L i-U-IP-; it is its first concern. IIR. IIILTOIJ: I-Ihat you are saying is it really 12 13 should be easy for the recruitment. 14 DR. SCTILERIS: I was going to second that. There are five members of the public, one of whom is a professor in 15 16 civil engineering, one an extension agent, one an executive 17 director of the planning com@nission, a state director of United Transnortation, and a housewife. I would think they could be 18 19 urged to have a more broad representation. 20 DR. They have some very dedicated people with long e.-Inerience in the health field, and the consumer end 21 of this, but thev have had troubles rpal.lv in these 22 1 T)eo,,-)lc. Ile got that testimony from some of their community 23 - , health neonle. People in that area, you ],:now they don't go 24 ce -Federal Reporters, Inc. I)e,iond their front yards. They're verl,-,,very insular i-i their 25 jean 19 216 1 approach. It's very hard to get people out of- their front 2 yard. 3 DR. SCII:IIDT: All right. Are there other questions 4 or comments? If not, are you ready for the question? 5 Seeing heads nod I think I will call the question. All in 6 @@aver oil the motion then for approval of the rates designated 7 please sav ave. opposed, no. I hear no dissent. 8 Ifenry, thank you very much. Been fun having you back. 9 I think you will make your plane. IY'l'aile the cast of characters is changing and there are still this nurrlber of committee members here, I would like to 12 call attention to a document that you have; it is entitled .1@ "Chapter 4, Application and Review." Paragraph 4, three review ),,4 group structure functions and authority. This pertains to, 15 again, the functions of the review committee, Council and 16 Staff Anniversarv Review Panel, and again it's something that 17 was developed in good part in response to the previous discussions 18 by the review committee on its function and what it's doing and 19 what it is for. And without attempt@being made at overkill, 20 this again is something else that is prepar ed in large measure 21 for the committee, and I would hope that committee members would look at tbis t6ni-lit --,-n-d be -re,--ared t- comment on a 4 k- - @ler 23 to,-iorro@,7 or by letter or by phone call in regard to any response 24 that the document evokes. It will be part of the, of sort of ce- Federal Reporters, Inc. 25 jean 20 217 1 the official litany or liturgy, whichever is the right word, 2 of Pllp' 3 SISTER A!117 JOSEPIII14L;': Ritual, maybe. 4 DR. SCJJIIIDT: Ritual. Moving on then to Albany, if I am counting correctly. 5 Right. end 4!15 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 2 23 24 :e- Federal f?epoftets, Inc. 25 2 1 8 CR 7 14 8 I DR. KPAT,F,'@,TSKI': This consists of 24 counties 2 maC@e up of 21 counties of northeastern @4c@w York, two counties 16 a 1 3 in Ve)-mont, one in I-,Iassachusettr,. @@e have a slide here that 146 4 shows that block of counties. 5 It interfaces @,,,itla four other regional medical 6 programs, northern 1,4e@,; England, Tri--@State-s, metropolitan New 7 York and the central New Yor-l-, that we reviewed, today. xxxx 8 They have a committee put together that attempts 9 to iron out the interface problems between these different 10 programs and in general it seems they do not have a lot of 11 difficulties in relating the programs to their needs. Now 12 this group of bounties in the Albany PT,gion;il P'ledi-cal. Program 13 is made up of rural and urban centers. The compilation is 14 generally pretty much split. It is about 53 percent urban, 15 46 nercent rural. In the rural areas we have gene-rally the 16 problems of rural health care across the nation. 17 T@Te have a number of small towns. Some of them have 18 lost their physicians and have not been able to attract new 19 physicians. Some of them have'physicians but they are'.aging 20 and'they are overworked and they have not been able to bring a 21 lot of additional talent. 22 That is the headquarters of the program is located 2@ in Albany. The program is one of the older.ones formed under 24 Pt@,P guidelines. B-Fedeial Reporters, Inc. 25 It was formed by the I-Sedical College back in 1966. 2 19 I( They had an initial grant for planning in 1.906, and in 1967 Reba 2 2 got Fin operational grant. And at that time the Dean of the 3 Medical School at Albany became the Chai.-ri-nan of the P,,C-.-Cfiona 4 Advisory Group, and it was largely through his initiative and 5 the Chairman of the continuing education program or department 6 at the university, a fellow by the name of Woolsey, that the 7 program got off the ground and Dr. Woolsey then became the 8 coordinator of the program (Si.,i.@le) 9 That essentially is the background of the program. 10 It covers a population area of about two million people and 11 it has about a six or a seven percent of minority groups. 12 And the population area. Now the history of the program is 13 mixed. As I mentioned it was started in 1966. It was spawned 14 by the Medical School, had a strong orientation toward con- 15 tinuing education, and as a result a great deal of their 16 initial effort and our money went into education continuation 17 programs dominated by the university. 18 This was of great concern to several site team 19 reviews through the history of the program. And they gave of 20 course advice to the program to broaden their program input. 21 Many times it did not result in any substantial 22 changes. Now this past year in 1971 we site visited the program. 23 Then at that time they were applying for triennium. 24 Again we looked at their projects, the very narrow program they e-Federal Reporters, Inc. 25 had, some other points we looked at in the program, and we 22 0 at ",,at time @-jc,. should fund -them for one more 3 2 y E. rand then should cc)iT-t(-- in for- triennium after they have 31 to irt-tpl-e,,'t(-@nt E7ori@, of the cl-ianc jc.,s we believed were 0 4 rie--@csF@a:rv ).n,,a tlat -L-hcy s@.@ii(i they wanted implemented in order 5 to strengthen tl,,cj.r program. 6 These -Lnc.'iuded pliasing out of some of their very 7 narro%@,) projects, par-LL-icularly a two-way radio communications 8 program IL-licy had for continuing education that they had not 9 1.)Iiased out, was just'an on-going project funded by 1-U4P. 10 Ile thought they should fund that out before we looked 11 at tiie triennium application. Ile thought they needed to straighten 12 out their rapport with the medical school because the program 13 was quite dominated by the medical school. The Dean of the 14 Medical School is Chairman Brag. They had a weak regional I5 advisory group, a weak executive committee, they met only once 16 or twice a year. 17 Attendance was fairly low at those meetings and it 18 clearly was a question as to who was runn ing the program. We 19 thought they needed strengthening on their program staff. They 20 lacked a Deputy Director, the Administration was mixed to 21 say it in its kindest way, and the program staff generally 22 were acting on their own volition, taking other kinds of 23 tasks they wanted to do with very little overall direction. 24 There was question over the location of staff. They e-Federat Reporters, Inc. 25 were located in several different buildings so they never were 2 2 1 @16 1 able to be pulled together, there was question over some o. 4 2 the talent on the staf-l'. They regionalized their area into 3 six different r(--ciions in order to be able to reach out to the 4 Population a little better and they developed a program where 5 they @,,oul-d have neoplc@ on their staff who most of them, who 6 were formerly drug salesmen, detail men, that would act in the 7 capacity to handle these regions and interface P-J-IP with the 8 different agencies in those regions. 9 Always there will he some question as to the 10 effectiveness of that program and the relationship of t e 11 people they had in that capacity to the individuals assigned 12 to program management and program projects. Again that was 13 a question we raised a year ago, one we thought they had to 14 face. 15 They had 28 people on their staff. They had many 16 capable individuals we thought, they would pull them together. 17 They had a great deal of potential the way it looked. They had 18 support from the Medical School and it seemed to us that Dean 19 Witgers was willing to consider Fubstanti.al changes in order 20 to make the program viable. 21 Yet this was all on the paper as proposed changes 22 and we as I mentioned thought we would be best to give them 23 a substantial amount of advice in writing regarding the kinds 24 of things I just mentioned, to carry on another site visit e- Federal Reporters, Inc. 25 this year, and then to decide on triennium application form lat this time. 2 2 2 1. 6 1 As a result v7c-@ gave thcT,,i essentially level. funding 1) a 5 2@la.,;t year, c3 s-@-tall j-ncrca5c so that they could undertake some 3@ ne,@7 activities and reorginizalti. on and then when more money be-- 4 copies a,vailal.-)l(-- this -cast vear gave them a little more 5 money to iminlernent sortie o'f the, projects that they liaet in mind. 6 All right. So in front of us then we have an appli- 7 cation that resulted from that .-,- those deliberations and this 8 year's application then asks for money to fund new projects 9 essentially. 23 nrojects. Seven of those -nrojects were ii-(tple-- 10 meritecl with funds P.MPS gave them in the middle part of the 11 year as excesses occurred and the rest of them are new projects. 12 They phased out all their old projectsi the ones we 13 were concerned about. They are asking for developmental com- 14 ooneiits $90 000 a year and asking for staff support of nearly 15 $800,000, per year. And so asking for about 2.3.lner year support for the triennium. So this is the application then that 16 17 is in front of us. Well, we carried out the site visit this past summer 18 then, and some of the site teams members were the same people 191 20 who were there the year before so we-had an opportunity to 21 look, at their progress and see how they were doing. Now when vyc read their application it seemed to us that they had made 22 substantial orogress. 23 24 Yet.we were skeptical for a couple of reasons. ,e-Fedeial Reporters, Inc. One, we were really wondering how much they could turn an 25 2 2 3 1,116 1 organization aro-ctnd in that length of time, and number two, P,eba 6 2 you know, @,ihotilier n 4- Iiat tire,, !-@aiyie site team members were I coming back, whether they knc, v7 the right words to use and could 4 therefore give us a little better presentation. 5 In part I think that probably did occur. On the other 6 hand, we were fairlv 7:)I-c-E,,Lsed,,.quit(,- pleased as a matter of 7 fact, with the t)rogrc,.ss that they had made. All right. Our 8 finding, on an I might i-nc-ntion we did not as far as the 9 roconi-rlendations, recommend that x!7c go back next year. I was 'te n 10 qu,- _leased to find that because on the trip in 1971 coming 11 out of Chicago we lost an engine and the trip this past summer 12,we were coming out of Philadelpl-iia and we lost an engine; So 13 I am not about to try a third one under any circumstances. 14 All right. I!@7ell, their findings then, number 1, 15 they have tried to restructure their corporation. They have 16 taken a look at their relationships with the university and 17 tired to develop a different corporate structure t at wou d 18 give them more autonomy and would strengthen the RAG. 19 They have expanded the P\.AG to include different members on it and give different orie ntation away from univer- 20 21 sity-control. '(Slide). This shows you the transformation that has taken nlace. From the domination, fair amount of people 22 23 on the PAG from the '-Iedical School, you, can see going from the 24 blue to the red, 1970 to 1972, that they have do-creased, the e- Federal Reporters, Inc. Providers have decreased,cchsumerf, have increased, and you can 25 22 4 C) I the T,,icTtY)(:@:r-s of T?-2@G that came from a 7 2 P..lbFnv area and increased it from the outlying areas. So 3 they have really done a. remarkable job in being able to re- 4 JE,@tructure their regional advisory group. 5 Part of their ability to do this resulted from the fact that thev expanded it from 27 to 37 members. That gave ther.-. 6 7 running room and qave them a chance,to add some different 8 Pec-@Ple- In terms of minority representation tlie@ are still 9 They have a couple of members from minority groups. 10 11 They recognize that they have not been as successful as they hoped, in that area, but they really, in terms of the projects 12 13 they hope now to carry out, we feel that they need to make some more progress in terms of minority representation on their 14 regional advisory group. 15 Secondly, after revi@,ing'the group 16 itself, they, 17 Dean l@liggers from the '4edical School stepped down as Chairman 18 and they then recruited a new chairman for the group, a man 19 formerly who was administrator., also an MD, a very capable 20 guy, he devotes one full day a week to the program and comes in and works on their bylaws and things such as that. 21 22 He is devoting a lot of effort and it is largely 23 because of his efforts they have been able to restructure the nrogram as much as they have during the past year. They have 24 e-Fedeial Reportefs, Inc. restructured their executive committee and working executive 25 226 i'f. 1 6 1 coililtitt-co-. Tl,,.ey ;ire r,.iecting Their regic)l).al advisory 2 groUT-), they ar6 trying to get together as much as nine time.-, 3 a year. 4 I don't thin]-, thev will ever really put it off, but 5 th.c!y thi.nle-I they need that much 4n,@ut. They are breaking them 6 into @,,,orkj-nc .j subcommittees so when they come together they 7 work as subgroups on different T)roblein areas and it is really 8 an active, involved group and we are really impressed with it. 9 The executive committee knov7s what is going on, they 10 look at themselves as policy makers in terms of the program and 11 they are obviously enjoying the role. Medical school as far as 12 '-le can determine are quite pleased to see all this liaDTDcn. 13 They don't appear to be feeling at least that they liav@ 14 lost anything over the whole shift and it seems to be working 15 Out fairly well. They have been able as I mentioned to get 16 more community involvement through regional advisory groups and 17 of course that has helped them restructure their program again. 18 As a result then of reorganizing the RAG, they have ig been able to reorganize their bylaws and then reorganize 20 their goals and objectives so again we have seen restructuring 21 in both of those areas. We feel the bylaws are still a little eak in that they do not explicitly state who has the hiring 22 w 23 and firing power for the coordinator and they leave some areas silent in terms of relationship with the university. 24 -Federal Reporters, Inc. And we feel they should spell out sonic working documen 25 2 2 7 the @,oiic@ of these fringe issues to do that. As they went through T@(-,I)a 9 2 -)oy 'ie re I ort a -he cori equation 3 n-'@.-atior-i o' the regional. advisory 4@ @l rou,-,.@c c@-@era, they then a deputy director to their 5 core stai'l'-, a man i-)y the name of Dr. Krc-,ft. Ile has a great 6 deal of i.i-i group practice. And he is well versed 7 in organizational matters and. we feel lic, is realJ.y a strong 8 guy. 9 iTe added a great deal to the program in terms of 10 the. administrative a,oility and he started reorganizing their 11 staff, he started phasing out some of the regional coordinates, 12 the drug detail men they had on their staff. Ile phased out 13 two Of then'' and now is reconsidering you know, @,jhetlier he shoul@ 14 kc-,eT,, the other two or reallocate their talents in some other 15 way. 16 Ile has also streamlined !many of the other relationshir-s 17 in their6 corporation internally, because they had at one time as high as ten or tx.,,elve people reporting to one person. He 18 19 is now vou I-,no,,q restructuring.tliat so they can handle the d3f- 20 fc!r-ent staff members, he has been a real strength to their 21 staff. 22 As a result of that, of course, the staff has built into a unit and are now pursuing tasks the program wants them 23 to -pursue rather than what interest them that comes across 24 'e- Federal Reporters, Inc. their des]-. and we )DOlieve their administrative hierarchy s-Lill 25 2 2 8 r) I !,as a to go, anc,' while we believe they probably need to p c@ l') a I- 02 of their directives a little more in terms of 3 operating, )olicies, i,,c- no)-ic-,tlacless feel that they have gone 4 long in the las- -\,-car and that that staff is really cap-- L- 5 i-io,,@7 of handling amature program. 6 They have, still, many vacancies on their staff 7 an,,'. they are attempting to recruit for those although they are 6 riot anxious to fill them until they decide exactlv what they 9 want to do in terms of reorganizing the talent they have on 10 board nw@i. 11 That seems like an honest approach to us and one that 12 Imade a lot of sense. Wc- did note, however, that since they 13 were embarking on a number of new programs it would be well 14 for them perhaps to add some new staff members, particularly tose with monitoring talents, and with fiscal talents, and to 15 16 be able to monitor those projects as they develop. Otherwise 17 they will get out of hand. 18 As a result of these changes I have mentioned they hav2 19 been able to turn the program-arotind, they have phased out their projects and to their credit they have been able to find 20 21 other agencies to come up with the funds to carry almost all 22 of those projects so they have not terminated. 23 New projects, they have submitted to us, they were 24 able to obtain nearly 1-3rd of the money for those projects I-Federal Reporters, Inc. so the money from P.'IP is essentially the two-tl-iirds of it. 251 22 9 Thev have )-)(:,en able to take. it out of university l@c@))a ],.I 2 domination and spr(@ad it more judiciously throughout the region. 3 1-7c have a slide here that rcp r(-@s(,,@nts the results of thos 4 atter,,,z-@ts, (Slidc,.) and you can see the first diagram to the left 5 is our visit in 1971. and the one to the right is 6 our visit this r)ast summer. 7 You can see how the projects have changed to a broader 8 representative group in terms of sponsoring agencies. In other 9 i@7ords, reorganization of RAG, bringing in more community 10 representation they have really been able to reach out and to 11 bring that large number of sponsoring agencies to put in project 12 IT)ronosals. 13 Through this process they glean some 45 new projects 14 and then through their review mechanisms they brought these 15 down to 23. We feel that review mecha'nism.still needs refii,4emen- 16 and there is an assessment to be carried out later, it was going 17 to be carried out after our review but after,we got through 18 our review they were ready for a rest, and had decided to delay 19 it a bit. 20 rDut that will be carried ou t a bit later. age feel 21 however, that they have the basic mechanism pretty well outlined They have the mechanisms to review projects in terms of their 22 23 minority. They have the technical review process outlined and 24 we feel they are capable of handling projects, and to realign -Federal Reporters, Inc. Ithem into the orogram as they go along. We have one more slide 25i 2 30 '@16 licrc,- that Purt 11 T)ut o-2i that (Ic@sc-cibE@s Et l,ittl.e more their lzc-@ l@) a 1 2 2 re@,rionalizatiori of -the i-),--ojc-@cts (S.I-.idc-,) 3 DP-, . S C J'I'I. IDT: l@71iile he is doing that lot me inter- 4 ject here -that this is one of the kinds of test presentations 5 -to the committee. And we will isk sTDc.--cificall.y your opinion of these %Tisuals, this mc@thod- of principles presentation by 6 7 the review committee member. The other two presentations were 8 a combination of staff and review committee, also with light 9 and sound. 10 But I will ask specifically about the visual. so I woul@, like you to be thinking about how helpful they are or not I-ielp-- 11 12 ful, because they are work that we don't want to put peop e 13 to unless they are helpful. DR. R-@LEWSJ'\I: I am afraid -- okay, fine. This 14 15 represents, A, the little triangles there, the main, some of the 16 main projects thev are submitting for funds, this represents 17 where they would be based and represents the fact that they 18 will be you know, out, some of them at least out of the Albany area based in some of these other areas. 19 Burt,Tnaybe you would like to explain that. 20 21 IAR. KLINE- Yes, possibly, these are the headquarters 22 sites for activities which are city-i@7ide in nature. The next 23 overlay will show the activities which are county-wide in nature and the triangles represent the geographical locations of the 24 e-Fedeial Reporters, Inc. TDroject site licadquart ers. The next overlay shows the multi- 25 -ir-4--ivi-tie@- of -- and the triangles again represent 2 31 6 I again th..,@ rrojec,,t :7,it-c hea,,'Iqlial@tcrs T@ic.., fourtl-j (slide-) Reba 13 2 is the region-4,ij-,Ic activitic@@, and the project site lieldquzirters. 3 "Ilc-ntall-y adding -t--h(-- triangles you get the feel, I hope, at 4 least fox- the regi.onalization or the outreach of the All-)arly 5 program during the past year. 6 DR. KPPLL"I,,'@ISKI: '@'@c)t only the outreach but the fact that 7 thev have been able to I)rii-i(i logical. groups tog-ether in the 8 count,-.es for regionalized kinds of efforts which @%7c thought 9 v7e@-c-- quite useful, helping put together grant applications for 10 Irl'O, feasibility studies. They have been working very hard 11 to initiate health programs, working with hospitals, working 12 with universities working with -- well, there are no doctors 13 in towns in the rural areas, trying to devel.op programs for 14 them. 15 And develop projects that would train nurses for 16 these roles after they get the program set. This is essentially 17 what we found. W(-- believe this. We think we have seen a program 18 here really turn around in the past year and we feel we should 19 g've them sup 'port. 20 Thev are asking for a lot of money. We felt we 21 could not give them quite as much as they are asking. We 22 L'c-1t, however, we should give them some additional advice in ter@-'s 23 of the strength and weaknesses of their program. 24 Ile note that evervone of the pieces of advice we @e-Fedefal Reporters, Inc. 25 had furnished to them last year thev have accomplished. They had 2 32 1 6 addressed the clij(@cti,r)n. T,-ic-,y ))rc)ucTI)t in an outf@,i.(I(@ consultant 14 2 from another regional and asl,-.ed him -Lo study their 3 organization and give 'L-1-ic--m i-c commendations of how they should 4 reorganize their relationship with -the university,. 5 They addressed ev(--ryoic of the suggestions we gave 61 them last year and have ma(a,--.@ in correcting every one 7 of the deficits. At our session this year they asl@Ed 8 us to comment on several of ti-ic areas @@liere, they were strong 9 or %Break and we did and we have a. letter from them already 10 indicating the progress they have made on some of the areas 11 we thought they were weak in. 12 ,;o it is really i heads up organization that is 13 attempting to strengthen the things they are doing and that 14 impressed us. In some though we feel they -- they get these 15 projects together rapidly and as a result there are a group 16 of projects but they don't probably represent a programjust yet, 17 also -,ome projects in there that don't fall within the PD,,IP 18 guidlines and we had to recommend those projects be deleted. 19 We noted nerhaps as mentioned before then that the 20 core staff needed some strengthening in terms of being able 21 to handle these many projects and. therefore we would recommend 22 they add some additional talents and fiscal management. The 23 letter thev wrote us said they already had been able to attract 24 a man of that caliber and so they are tal@ing that position to e-Federal Reporters, Inc. 25 Strengthen core staff. 2 3 3 1 6 I To continued to rc-firi,-! core @3-taff and -to T?.r-,@)a 15 2 reallocate some of the talents and we feel Dr. Kraft will do 3 ju@t tl-iot ]Dccauf,-e he is a goc)r3. gu@r. II(-, has some real a@imi.nis-- 4 tra.tive al-,i.lity. @,To Question about that and I he has 5 the willingness to 1,.ial-e the hard decision we have, to make. 6 In terms of hirihg.and firing- to be able to re- 7 allocate those talents, so vie feel he i,7ill. do it and has done 8 some of it already. We feel that they ha--,r(,@, to clarify a fe.@,,, 9 more issues with the university. Many of their staff members 10 have faculty appointments and there reall.y is some qu6stion 11 about how much time they should spend teaching or how much time 12 at the university, et cetera. 13 We feel they should outline that in a working document 14 with the university so they spell out those factors, let their 15 faculty know about it so they can operate within those guidelines. 16 1,@7e feel they should go back to these projects and put them in ard 17 take a package and put it into a program and we feel they have 18 the mechanisms to do that and we feel the regional. advisory 19 group will be anxious to assume that responsibility to do it. 20 They should also bring their staff together, as I 21 mentioned, they were housed in different spots. Acjain all @vo 22 have from Dr. Woolsey indicated they have already done that. 23 We recommend to them also the university provide space instead 24 of it being in our budget because they are charging 52 percent e-Federal Repofters, Inc. overhead, the university has responded to that bay qiving 25 2 3 4 1 6 n,,i. vr s i. t y ta'i,) fo-@- u TIC@l-)a 16 !)eye since? our va.sii-- an..-I @lb.c-@-@7 ),,iav(2 furni@,lied ei-iouc h sl)ac(,- 2 t 3 to I,-)ri.ng tlicir staff S:Lrice our ve they 4 These are inCiicati,,)ij@, to u@- of ho%,,, r(,-sponsi are. Tn vi-e-,j of that revi-(-@@.; 1 ',-tavr@ sor-tc-, suggestions for funding 5 6 )Dut I Nqill@ I @,ii]-l offer thc),3c after our secoi-idary rc,,v.Lewc,,r T@) c rh an 7 end 16 8 ARf ls 9 I 0 1 1 12 1 1 4 1 5 1 6 1 7 1 8 1 9 20 21 22 23 24 @-Federal Reportefs, Inc. 25 2 35 16-a P.rl MR. TOOMEY: Not having 12z-,d the opportunity to 2 visit the Albany program, but knowing some of the people who 3 were involved in it, I frankly was more interested in the 4 people, the organizations]., structure and their achievements 5 over the past year rather than in specifically looking at 6 their projects. 7 I am impressed with the fact that they have a 8 practically new leadership both in their organization and in 9 their RAG. I knew Dr. Woolsey from years past, and his 10 interest in continuing education, and frankly I am not 11 surprised that this two-way radio system was their primary 121 thrust for the first period of years with the organization 13 I also know that he is a very, very smart, very. 14. capable and very fine person, very dedicated to this whole idea of dissemination of knowledge for the benefit of the 15 people who will receive that knowledge and use it for the 16 17 benefit of patients. I am a little bit surprised tha t there is so much 18 19 emphasis on his deputy or assistant coordinator because . I 20 would have felt that once Dr. Woolsey was off on his 21 particular kick that he would have been able to accomplish 22 this pretty much with his own capabilities. 23 I am also impressed that you were able to get 24 Dr. Bordley, and I am not at all surprised, I know him most 'e-Federat Repottefs, Inc. by reputation and what he's done with the Mary Imogene Baptist 25 36 ar2 I Hospital- in Krugerstowri wlij..ch is perhaps a model for hospitals 2 in this country in terms of the relationships with general 3 practitioners, the relationship of private practicing 4 physicians and yet with a full-time staff in a hospital 5 and a great educational program in that institution. 6 So that I was, in-reading the material., quite 7 impressed with these changes because from these changes, 8 of course, can flow all of the other good things that have 9 happened to the Albany program. I think that Dr. Bordley's 10 leadership in the meeting times and turn around in the RAG, 11 the numbers of times that they met, the use of task forces, 12 the preparation of proposals, seemed to me was a was 131 quite impressed with it. I think perhaps unlike you, Dr. Kral.ewski, I 14 15 1felt that their establishment of goals and objectives was 16 quite adequate, quite appropriate. 17 I similarly felt that the establishment of 1 8 priorities in terms of the pro3ects that they were to under- 19 take were quite sensible. 20 For instance, they had seven projects that they rated as very high priority and using almost 50 percent of 21 the funds for the allocation to those very high priority 22 23 projects. Another 35 percent of the funds allocated to those 24 that there listed as high priority. And this represents some- ,e- Federal Reporters, Inc. where in the neighborhood of 80 percent of their money going 25 ar3 2 3 7 I into pro-ects for which they themselves in terms of their 2 goals and objectives had established the highest kind of 3 priority. 41 I thin]-, that they also should be coimended for 5 the regioiia3.izati.on. It v?as -- it was, and as far as RYIPS history is concerned, understandable that an organ.izc-i- 6 7 tion in RMP would be captured, if you will, by the university 8 in the initial categorical kind of structure of the regional 9 medical program. 10i And I think it is a tribute to the leadership in 11 Albany-i, including the Albany medical college, that when the 12 thrust of the regional medical program changed, that they 13 were capable, once it was called to their attention, that it 14 actually was something that seriously needed change, that 1 15 they were able to make the turn around in as short a time as 16 they did. And with the same, I think, effectiveness. 17 All in all, I was quite impressed with what they 18 had done. And I know Dr. Kralewski is going to recommend 19 the financing for this, and 1 will turn it back to him. 20 DR. SCEIMIDT: I think I would agree with most of 21 the-comments, but just add that once Frank Woolsey's attention 22 was captured, some things happened rather quickly, so on. 21 But it took a long time to get his attention. 24@ John? @e- Federal Reporters, Inc. DR. KRALWESKI: It is somewhere to it, couldn't 25 2 3 8 ar4 1 qtij.tc-, get the mule to work and promised if he bought the 2 mu!(:, from him, lie would alway!7, be kind to him, so he called 3 tl),e original,. owner over. @IL- rai-d, "What should.I be doing?" 41 He said, "You hit 1-iim over the head.with a two 5 by four." 6 He said, "I thought you said be kind." 7 lie said, "YLs, but you have to get his attention." 8 I have outlined some of the funding of the program 9 since I started. We are going tip here, doing pretty well, 10 and we cut them in here, and during this period, and then this got to be a 15-month figure, so really it came down to 900,000 11 12 total. Part of this 900,000 was money that was given by 13 14 RMPs to the program in the midpart of the year.after they had shown they really were turning the place around. So we came 15 16 into last year with them for funding, was like $700,000. 17 They were really going straight down and they were very concerned over it, then, of course, they r eally decided they 18 should do something. 19 All right, so totally, then, during this last year 20 21 they had, after the PMPS supplementary funding, $900,000 22 broken out as 631,000 for staff, 269,000 for projects, and 23 no developmental funds. 24 What they are requesting now is this, triennium, e-Fedeial Reportefs, Inc. but for the next budget year, they're requesting 768,000 for 25 2 39 ar5 I staff, million five for projects, 90,000 for developmental, 2 tune of 2.4. 3 Overal.1 for the triennium their request would be 41 $8 million. That is what they would like to have. After 5 reviewing this whole thing along the lines I just mentioned, 6 and breaking this down to some categories to see if we I-lave 7 come to grips with what we think they could handle, we are 8 recommending they go in with a staff of 638,000 which gives 9 them a 5 percent salary increase from last year. They have 10 got staff vacancies in theret so they can add one or two people 11 within that figure and that will force them, we believe, to 12 reshuffle some of their talent which they have really got to 13 do, and fire a couple people. Craft knows that, and he is 14 willing to do it. And that will give him a couple openings to hire some people. 15 16 So coming in at 680,000 -- we are recommending 17 this million five they are asking for projects be reduced to 950,000 dollars. 18 We think that first of all, there was about three 19 20 projects in there that did not fall within RMP guidelines, 21 so we told them about that, and the projects got thrown out 22 and reduced the budget. 23 Then we went through the rest of the projects to see 24 exactly what they were doing and where we might cut money, ce-Federal Reporteis, Inc. and came up with this kind of figure for them. We believe 25 2 4 0 ar6 I they are capable of handling a triennium application and 2 capable of handling developmental funds, but we think 3 $90,000 would be hefty, so we are recommending $30,000 for 4 the first year in developmental. 5 The remaining years we are recommending the staff goes up by one position is all, then the remainder is 6 7 increases for cost of living. ;le recommend these projects 8 essentially increase by the percentage proportion that they 9 had originally asked for based on our base. 10 So they would go up to the third year to a million 11 one. We recommend that the developmental funding from the 12 30,000 we are recommending for the first year, to 45 for the 13 next year, 60,000 for the final year for their developmental 14 component. 15 So totally, then, we are recommending a $5 million budget for them for three years as opposed to their $8 million 16 17 request, developed along the lines right here of those three figures added up to make up that 5 million' with. this figure 18 19 right in here (indicating) being the figure we are recommending 20 for the first year of the million six as opposed to their 21 2.4..that they were asking for. 22 DR. SCHMIDT: We will accept this, then, as a 23 motion on the floor and seconded by Mr. Toomey. So the floor 24 is now open for discussion. :e - Fedetal Reportets, Inc. Mrs. Clark Flood? 25 1 MRS. FLOOD: Do you really feel in light of 1 2 1their new thrust in regionalization with the operational 3 base of these projects being shifted from a strong university 4 center with all the skills and management, that reducing the 5 @poten tial. for hiring the skills they need in their personnel 6 is fair to them, to as],, them then to adjust to a regional 7 concept with small institutions, small educational institul-I 8 tions, health delivery people, assuming the responsibilities 9 for project information without being able to buy the in-housb 10 skills for supervision, project management, evaluation? 11 DR. KRALEWSKI: That is.a good question4 First, 12 their shift from the university does not mean they lose any 13 of the university support services. They maintain all of 14 those. They need no additional people. 15 What they have,really done is gotten it taken out 16 of the picture in terms of running RAG and a new guide in 17 and new corporate structure. The university is still the 18 grantee organization. Still furnishes them financial back-up, 19 does their auditing. In terms of monitoring the projects, you are right, 20 21 they need the staff to do that, but we believe that they 22 should just take a hard look at that staff and reorganize 23 it and they will have spots. Plus the fact they did have two vacancies, two, was it, Burt? I believe two vacancies, so 24 ,e-Feder,ql Reportefs, Inc. they have those two positions they can fill., and we think 25 2 4 2 ar8 they can do it within that context. Plus, of course, as I mentioned, the second year 2 3 we are g.i-ving them then an additiona man. 41 DR. SCHMIDT: Burt, do you have any comments? 5 MR. KLINE: Only if I understand your question, Mrs. Flood. They have a monstrous task, I think, facing 6 7 them in terms of surveillance and fiscal management. In 8 light of this, what they have done as reported in this recent 9 letter is they have hired a fiscal man which they did not have 10 before because they are very aware of this problem. Secondly, I believe if I am not mistaken, and I 12 could stand corrected on this, but they had two 50 percent 13 men from the medical college assigned to work with the 14 financial aspects of the Albany regional medical program. 15 What they have done is they have traded those two 50 percent 16 men in and gotten one 100 percent. This gives them a firmer 17 grip on financial aspects as they relate to the co ege.system. 18 DR. SCHMIDT: Other comments or'questions? 19 DR. @'THU@zN:, Burt said they had 21 professional 20 people on their staff and this represents even for a large region, I think, a sufficient number of people. I think they 21 22 are worried about it. This is the picture I got, is that they are worried about the fact they have so much area to 23 24 cover, but they also, I think, are willing to do with it. ;e-Federal Reporters, Inc. With 21 professional people, I think they have a pretty good 251 2 4 3 ar9 chance. DR. LUGINBUHI,: On the yellow sheet it lists 3 $75,000 in the current year for operational projects. And 4 your recommendation is increasing that to 950,000 dollars. That is not in accord with the figures up there. There is 5 some discrepancy, and on your figures, the projects are 6 7 269,000 in the current year, going to $950,000 next year, which is a threefold increase, but nevertheless not of the 8 9 magnitude suggested by the yellow sheet. DR. KRALEWSKI: Right. The $75,000 represents 10 11 the old projects that they had and they have phased them all 12 out. The difference between the 75 and 269 is the additional money tnat fqvips gave them in the middle of the year, and 13 14 they started seven new projects with it. Projects with it. So that is what they are going into this year with. 15 16 Since they did restructure your whole program and 17 you are exactly right, that is a big jump in projects, but 18 since they really phased out essentially everything they had 19 and started those seven, we felt that, you know, that they 20 had now an opportunity to add the ones around that made 21 sense and that they could handle, you know, that amount of 22 money to do it. 23 DR. LUGINBUHL: I also get the impression there's 24 been a reshaping of the core staff which will give them the e - Fedetal Reportifs, Inc. capability for handling increased project commitments, 25 24 4 arlo I management projects, evaluations. 2 DR. KRALEWSKI: Right. A beginning, at least. 3 And we feel. that it will continue. 4 DR. SCHMIDT: All right, are there any other 5 questions? 6 If not, then we w@ll vote on the. motion for approval 7 of the amounts on the board. All in favor, please say aye 8 9 opposed, no. 10 I hear no dissent. We have done five. There are eight together. 1 1 12 We could move on, or work hard tomorrow. I will ask you if there is any strong sentiment. 13 14 Do you want to take one more? 15 DR. LUGINBUHL: One more, at least. 16 DR. SCHMIDT: Okay, let's move on to -- we -- we thought we would go on to Hawaii next. So. Leonard, you are 17 on. 18 L6-a 19 20 21 22 23 24 :e-Federal Reporters, Inc. 25i 2 4 5 CK l@17 ty 1 xxxx 1 MR. RUSSELI,: First of all., I would like to call 21 to your attention at the request of the staff and representc-itiv(@-a 3 that we are reviewing the Regional Medical Program of Hawaii, 41 American Samoa, Guam, and the Trust Territory of the Pacific 5 Islands. 6 In doing this, we will look at the two programs, 7 the State of Hawaii and that of the Pacific Basin separately. 81 They are closely related but they are in a way separate 9 programs. 10 This is what we refer to as a Pacific Basin, 11 however, American Samoa is not shown on this map. These number" 12,i in the circles are not pertinent to this presentation. 13 The Basin covers a geographical area of over 3 14 million square miles. It is populated by 220,000 people who I5 live on 105 islands. Ten different languages are spoken. 16 And the islands, here is Guam with about a hundred thousand 17 population, American Samoa somewhere off of the screen, 18 around 28,000, which gives us approximately a hundred thousand 19 people spread out over 103 islands. 20 The Regional Medical Program in Hawaii has moved 21 into the Trust Territory, into the Basin. They have two pro- 22 jects based in Guam. They have another one based down here 28 in the Palau Truk and another one in the Truk district, Guam; 24 American Samoa and Guam are different. More-than 50 percent e- Federal Reporters, Inc. 25 of the population have no ready access to health care. So to 2 4 6 ty 2 I give yoti an idea of where this is located, Saipan, which 2 si.ts here, is 3900 miles 'Lr--om Honolulu. So that is really 3 regionalj.zation when you reFtc'il out that far. 4 Then if we could have the next slide. (Slide.) Now we are 10 oking at the map of the State of 6 7 Hawaii. The total population here is around 750,000. By 8 counties you can see the County of Honolulu has the largest 9 population of 623,000. The next largest is Hawaii County, 10 62,000 population. Then we move to Maui County with 11 approximately 38,000. Then Kauai with approximately 28 000. 1 121 By air, Honolulu is approximately 5000 miles from Washington, D. C. It is 2400 miles from the Mainland. 14 The chain of islands, if you draw a straight line from this island on down to the other side of Hawaii Island, would be 16 approximately 400 miles. From Maui to Hawaii, here, is approximately -- I am sorry, Maui- to Hawaii is about 40 miles 17 18 I believe. Hawaii to Oahu is 170 miles. Oahu to this island is 80 miles. And then Oahu to Molokai is approximately 30 miles 19 of course the main means of transportation here is 20 21 by air. 22 The headquarters is located here in Honolulu. This, of course, is a large blowup of the main island Oahu, 23 not to be confused with the largest island in the state, the, 24 :f,,-Federal Reporters, Inc. 25 Island of Hawaii. 2 4 7 ty 3 1 There are no CHP "B" agencies. However, the 2 CHP "A" agency does have committees on all but two of these 3 islands. The location of R@,IPI-I activity, as reflected in the 4 review you will be doing, covers most of the state. There@. 5 are 18 projects in the application. Four of those we have 61 already mentioned are in the Pacific Basin. Fourteen of the 7 projects are within the State of Hawaii. There is one here on 8 the Island of Hawaii, the bedside nursing care project. There 9 is one on the Island of Molol-,ai., which is a home health service 10 There are eight projects which are statewide in 11 nature, cancer chemotherapy, physiological data monitoring, 12 manpower utilization and hospital cost, medical care 13 utilization project, renal program, continuing education for 14. nurse practitioners. Medical library and continuing education 151 project for nurse practitioners also reaches out into the 16 Pacific Basin. So there are actually six projects which o 17 have an impact on the Basin. 18 In addition to what you have in your application there, there is an emergency medical service project which 19 20 has already been funded and does also cover the entire state. 21 There are four projects that have the operational base in Oahu. There is a patient origin study. There is a dietary counseling 22 project which serves a rural area of @Kdolauloa which is on this 23 side of the island. Also there is a health screen for@,the 24 e -Federal Reporters, Inc. elderly project which covers two urban areas and the Honolulu 25 2 4 8 ty 4 I area. And then two rural areas. One of them is in -- I 2 can't pronounce it but it is over here and the other is 3 Frank, could we have the Waianae overlay? This is 4 known as the Waianae Coast, up the coast from Pearl 5 Harbor, about two-hour trip by bus to Honolulu. This 6 community here has the lowest health profile within the State 7 of Hawaii and this is a particular matter of interest because 8 this is where the Regional Medical Program of Hawaii is putting 9 one of their proper priorities@- and has had an impact. 10 With that as a background, I will turn it over to 11 Dr. Schleris now. 12 DR. SCHLERIS: Are there any questions on the 13 geography of the area? I think it might be of interest to 14 know that the Territory, Samoa, Guam, so on, many of the 15 People find it more convenient if they are going to one of thos,; 16.1 islands to another to fly back to Honolulu and then go back down. So the transportation problems are immense. 18 We went to Hawaii. The visitin g participants, I 19 want to list some of these because it really was a group 20 with which all of us enjoyed working. Mr. Hiroto, a member 21 of the National Advisory Council. Kenneth Barrows, Banker 22 Life Company. Dr. Holcomb, Eugene, Oregon. Mr. Russell, Mr. 23 Sullivan, Mr.,Currie, and Dr. Hinman. 2@ It was a valuable visit. I had opportunity to traveL :e-Fedeial Reporters, Inc. 25 over with Dick Russell. On that flight we had opportunity to 2 4 9 ty 5 I rev:i.(-@w every docu.ment that has ever passed between Hawaii 2 and iuips. 3 We informally the evening we got there, trying 4i to outline what we viewed as areas we particularly wanted to 5@ explore. And I think this is a particularly useful device, 6i to try to underline what areas appear to be most important. 7@ Several things I learned in Hawaii. You don't 8 tell people in Honolulu what it is like in the United States. 91 You can tell them what it is like in the Mainland, but not ioi in the United States because you will quickly get reminded that they are also part of the Union. 12 Secondly, the background of many of the people 13@ on Hawaii are totally different from that of the Mainland and 14 these sensitivies have to be part, I think, of the reaction 15 of the group. 16 We had been particularly forewarned as far as 17 Hasegawa was concerned and documents related to him as far 18 as the coordinator of the Hawaii Regional Medical,Program. 19 So we were alerted to@.some potentially important areas. 20 First of all, as far as the history of the area 21 goes, their grant was divided very nicely into three different 22 approaches; where@they had been, where they are now, where 23 they would like to go, which is a very logical approach. And 24 they had originally started back in 1966 with the organization -Federal Reporters, Inc. 25 being University of Hawaii. 2 5 0 ty 6 At the present time the University of Hawaii is a 2 tv7o-year school but its present freshman class went through 3 four years, so they have made that decision in the legislature. 4 Actively as far as getting faculty and gearing up for this, 5 and I would think that both the RMPs and medical, school 6 benefit from this. Although.I didn't see anything of Hawaii 7 on this trip, I had had the opportunity to be there a year 8 ago, had gotten to five major islands and had been to most of 9 the major island hospitals at that time. So I had some 10 background to apply. After they had planned for about 26 months, they I 1 12 put into -- requested three operational grants received in 1968. And part of the original problem of Hawaii stems from 13 14 the fact that they do include American Samoa, Guam and the Trust Territory. 15 This is not exactly a homogeneous type of request 16 17 from one small geographical area. Albany thinks it has problems in geography. It only has to think of coordinating the varied 18 activities in this area with. its Varied wings. To cover first 19 20 1971 they received a one year grant which they used to go from 21 their transition from what had been a purely categorical 22 app roach to assist the improvement of health care delivery system. They have nicely summarized in their brochure exactly 23 24 what they presented the public at the present time-as being e-Fede@al Reportefs, Inc. what they have accomplished in their transition. 25 2 5 1 ty 7 1 I will come back to that in a moment. 2 This one year grant was extended to December 31, 3 1972 and at the present time they are applying for a second 41 tr-i.e@nnual, beginning January 1, 1973, with the request also 5 for developmental component. I think the site visit group 6 I shared made a rather thal-i-usual recommendation as far as 71 when to start developmental component, roughly one year after 8 we left the island but I think you will see why we did that. 9 They define Regional Medical Program of Hawaii as folllows 10 which is the present statement, as a consortium of providers 11 in linkage with consumers which assists in the advancement 12 of health care delivery system of Hawaii by improving 13 equity and access, maintaining quality and influencing 14 moderation in the cost of health care. 15 They have a Regional Advisory Group chaired by one 16 of the I was going to say better. I would have to say one 17 of the best chairmen whom I have had the opportunity of 18 meeting. He is Mr. Bryan, serves as chairman of their group. 19 He devotes a good deal of his,time to the effort. He has some 20 physical disability which not only doesn't immobilize him but 21 I think is part of his contribution to the program. He is a 22 strong individual. He is-well aware of the program, of t e 23 area, of the directions it has had in the pasti where it is 24 going- e -Federal Reporters, Inc. 25 I think he is one of the strongest people as far as 2 5 2 ty 8 t'ilu- E)rOcj)@- M is coi-iccrned. Mertibers of his RAG whc@n we met 2 are capable people very much involved with the programs. And I 3 refer, will, a little later, to various documents of the past t) 4i Hawaii- indicating specific problems in their area and how they think they have met each one of these, because they have 6 really tried specifically to meet each and every one of the 7@ problems. 8 Functions are described, RAG functions, in the usual 9 way, additional functions on various committees. They have an 10 Executive Committee. They have a committee which they call 11 PIE which is for planning, implementation, and evaluation. 12 This committee poses some problems if you attempt to look at 13 the structure of the group because in reality so many things 14 pass through PIE that it gets to be a group which in many 1 51 ways presents overlapping and conflicting routes as far as 16 administration is concerned. 17 They have some categorical committees but Actually 18 these are now, the advisory committee, continuing education, 19 allied health committee, Pacific Basin Council. So this is 20 show they define the categorical committees. Not in terms of 21 heart disease, cancer or stroke but in terms of their actual 22 delivering quality of health care. 23 I mentioned they include the Basin. The program 24 staff has been added to in the past few years. Many of the e- Federal Reporters, Inc. 25 people who have been at it are indeed very strong. Perhaps I ty 25 3 I cou'l.@,. F@pen(i a. mo,,aent discussing Dr. Hasegawa, a great deal of 2 our evaluation in that area is depei-)('Ient upon views of Dr.. 3 Hasecj,-J@,'@,@-L, his pot c@ntial strengths and weaknesses. He is still 41 a par t4-ally pra.Ctj.C4r,g pediatrician in Honolulu, and sometimes., 5 I guess a little later for meetings. He was about 10 or 15 0 minutes late for our meeting-. 7 As chairman, stimulated by members of the group, 8 I decided to start without him which I think he could 9 pardon. Having come so far we thought it might be nice if he 101 had been there at the scheduled time. We waited 10 or 15 11 minutes, then decided to proceed. I don't think we phased him. 12 He indicated he was busy.with some other problems at the time 13 and this was an impression which,@my sensitivity is such that it 14 took a little time for it to wear off. But I think t e rest 15 of the group took it in stride. 16 And as time went on I gather that Dr. Hasegawa -- 17 he posed problems to me in evaluation and it is a problem 18 that as I read in one of Mrs. Silsbee's letters in 1970, it 19 went on page after page. Also presented problems in your group 20 of evaluating, both in performance, personality and so on. It 21 became apparent as the days went on, he operates very much 22 in the total community. He belongs I think to every committee 23 of any importance on Oahu. 2@. He is.,@respected by all of the organized groups in th(! e- Federal Reporters, Inc. 25, island. He has been a tremendous impetus to the acceptance of 2 5 4 ty 10 1 l@,/iP at c.,-vcry le@7ei. we can discern as far as consumers, providers, 2 And maybe it is his many facet c-d personality that permits this. 3 And I would say that in terms of what he has done for the 4 group, recognizing the fact that he has been reluctant to give 5 up many of the powers of director that he has now managed to 6 get-. the deputy director, Mr. Omar Tuiiks, who is functioning 71 very effectively with one problem, that is that -the 8 control3-er-wbuld prefer to communicate everything to,Dr. 9 Hasegawa, would rather not discuss much of the economic 10 aspects of the group-with Mr. Tunks, but that too seems to hope- 11 fully be on the road to being modified somewhat. 12 But Dr. Haseg awa functions very effectively I 13 guess as Mr. Outside, and spends a good deal of his time as I 14 have indicated gettin P accepted ,g RM It is one of the more I5 important committees of the local medical society and 16 acceptance of RMP into the medical society, Dr. Hasegawa is beiag 17 accepted by the medical society. So I would say however a comple x individual he is, a-i 18 19 complexity is only minimally.hit by my discussion, apparently has been part of what has been viewed as being good leadership. 20 21 And-this is something that we will try to get out.in many ways, whereever we looked. at it this became apparent. 22 After being essentially categorical for a -period of 23 three years and its categorical emphasis was on rehabilitation, 24 Federal Reporters, Inc. catastrophic diseases, education to nurses, home care prograr,.i. 25 2 5 5 ty 11 I some of tire, hospitals and so on. Then eiitc-@@e-d a period of transition. The program osmosis I was familiar with was 3 the CPR program, what impressed. me was how all- the islands 4@ reizt ed beautifully with RMP, Honolulu, that program. That 5@ has been phased out, is being partially supported and apparently 61 a-, a fairly adequate level by the Heart Association. This was 7 good to see that it was ongoing. They then entered a period of 8 transition where they stated the goal was to improve the total 9 health care delivery system t.o the region while not restricting with the categorical disease field. 10 In reality they did restrict that. They entered into 11 12 priorities I gave, better health services, trying to develop 13 health manpower, better utilization of health facilities and so on. One of the first things they became involved with was 14 attacked as a catalyst.i-s-where the Waianae Coast@Comprehensive 15 16 Health Center which is in an area of real need. And we met staff who had been involved with this from the point of 17 18 view more of time than funds and this had proved to be a very important contribution. We met people who had been involve 19 @o with this from that area. They spoke of the contribution RMPH made of this venture. 21 What they are requesting is a much greater movement 22 23 toward their goals as they see it now in terms of projects so they are interested in a greater contribution. They are 241 ,,e - Federal Reporters, Inc.Iinterested in taking over and modifying somewhatEMCRO 251 2 5 6 1. 2 I which is the lia.wa-Li E>-pe-rimei-itE,,.l Mental. Care Review 2 Or(tatiizatj-c,--q undc-@,, Dr. Anderson. Thi,r:, is now be' i.ng supported 3 through the Hawaii Medic@il. Association but apparently througho-u'- 4 side developmental funds, and throucTh Dr. Ariderson's 5i involvement with this they are looking with care at peer 6 review and other methods for evaluation, delivery I health services. 7i Dick, you correct me if I am wrong.. I think some 9 54 percent of all the physicians in Honolulu are involved 10 with this, isn't this true, as far as their EMCRO is 11' concerned at this time? 12! MR. RUSSELL: I don't remember the exact figure but a substantial umber are. 13 n 14 DR. SCHLERIS: Yes, and their feeling is thatthey 15 would like to support this through the Hawaii Regional Medical Program for many reasons, first of all it gets them 171 into quality health care services, also into physician practice in the area and there is wide support for this. And they have I9listed certain strategies for improving health care and have indicated how they will approach it. 20 First strategy is to improve your system of care. 2 1 MR. RUSSELL: Just since we have been back I 22 talked to Omar Tunks, the deputy. And I said, "Did the 23 @Hawaii Medical Association get the message?" And he sa:'Ld, 24 :e-Fedefal Reportets, Inc. 25 I"Dick, I don't think they heard a word that was said." So I 25@- ty 2, 3 I they are still. working that Problem out. 2 DR. SC'I'LERIS: I guess they got the message but 3 don't know how to interpret it. 4 The second major priority is designing system 5 measure providing health care servi.ces.";This is part of what I 6 referred to under the heading of EMCRO with Dr. Anderson. 7 The third priority is better health manpower develop- 8 r(Lent. This involves upgrading and trianing of many of the 9 nurses on the Island of Hawaii. Better utilization of health 10 facilities and again this involves training in the allied 11 health field. Emergency medical services I have referred to. 12 Let me discuss some of the unique problems presented 13 by the Basin area. As you can imagine there are very few 14 physicians there. We met.the individual of their staff who 15 was assigned to that area and he was one of the more 16 impressive individuals of their staff. He spends a good third 17 of his time out of the main island on the coast of Guam and Samoa 18 and the other areas. 19 Projects for which-he has asked for support, and 20 I will refer to thosein a little more detail later on, really 21 referred to the need for something like physician's assistance 0 22 or health assistance. They aren't tal.king about the very 2 13 sophisticated training that is being given in many areas of the 2'4 Mainland. They are talking in many instances of taking e - Federal Reporters, Inc. 25 natives who now function at the minimum level, upgrading ty 14 25 8 11 1 their tr@,j.ni.ng by uFii.iig very I)asic audiovisual techniques so 0. S 4 2 that they can either treat some of the iTior @mpl.e illnesses 3 they found or be able to communicate by radio with physicians 4@ on some of the islard.s. They have very basic problems there 5 in terms of needs. Youngsters have hearing loss, they want 6 to screen these for help. There are problems as far as 7 some of the more basic health needs in that area and some of '8 the funds requested for specific basin are specifically earmark(.' for a specific basin. 10 That means in terms of our figures we will be 11 specifically suggesting that "X" funds, k be specifically for 12 core or for specific programs in a certain basin area. I know 13 this has been done somewhat previously and we feel this 14 should be done at the present time as well. 15 With reference to the specific site visit report, 16 you all have that. Perhaps you have been scanning it as 1 171 have been presenting the report. Perhaps I can mention 18 some of our concerns and then some of the assets of the program 19 We were concerned@about some of the key projects. 20 This was related to the feedback-sessions with Dr. Hasegawa.- 21 Emergency medical systems troubles us because it should be a trouble system which it doesn't appear to be. I mentioned 22 23 to Dr. Sl,oane since they do not refer very much to corenary 2 14needs or other emergency problems I asked Dr. Hasegawa whether ce-Federal Reporters, Inc. 25 they had utilized the ICHD reports in arriving at any of their 2 5 9 ty I I 1 r(---(@omnenda..tiox).s fo:@- the einergen@7 medical system and there was z 2 which ran for 30 seconds while I deliberately waited to 3 see if there was a response and I had still been waiting 4 because I have a feeling that ICHD is not known to the RMP 5 group in Hawaii. In fact afterwards it was apparent they 6 had not utilized these reports, not only haven't utlized them 7- but haven't been aware of them. To this extent, many of their 8 staff. And I Wbtild,@,suggest that,:tome.6ffort be made to make 9 sure that various RMP programs indicate at least an 10 inaudible. 11 Dr. Anderson's position in core is not yet fully 12 understood..either by @s@or,,by him. Very often questions were 13 asked which could have been answered by him. They more often 14 were answered by Dr. Hasegawa and he is aware of this as well. 15 Waianae has a great deal of promise but yet there is also a 16 considerable area of risk. If they promise certain services 17 and they don't work out in that area I would be concerned about 18 potential reaction. 19 Pacific Basin area, this is a group of individuals 20 who obviously have chauvinism, possibly to their own island, 21 their own area. As far as it was away we have three or four .0 22 individuals who were there and were extremely interested and 23 involved and know what is.going on in Samoa and Guam and the 24 Trust Territory. This is an area that bears@watching, I know ce-Federat Reporters, Inc. 25 there are little pressures which are of extreme importance in ty 16 26 0 that area. And I think a word should go to Dr. Izutsti, 2 who is the associate director for Ameri-can Samoa, Guam and Trust Terri.tory on behalf of the Hawaii. staff. He is 4 excellent and I think one of the strongest people they have. I 5 think if he were to leave that whole project would fail 6 abysmally but lie is obviously married to it in many ways. 7 Mentioned problem providing continuity by early planning for 8 other sources of funding rather than at -the last minute looking 9 for alternate funding$. We are very concerned about their 10 evaluation system. They do have PIE. But when we try to get a 11 clear understanding or.evaluati-on the man in charge of the 12 evaluation gave it one way, Dr. Hasegawa tried to give it 13 another way. I think he used the term that heads will fall 14 because there was confusion on this point. 15 Request had been made about RMPS, caftlt give 16 developmental component without bylaws and at the moment it 17 requires revision. one can't have developmental component 18 without having more formal bylaws than they do now although again 19 as I said they are giving this a very, very high priority. 20 We were-,concerned about the relationship of PIE to the 21 Executive Committee, to RAG, seemed to be a duplication of the way documents would move. They never really stop anything once 2@ 231 it enters the system. They do invite the person who submitted 24 the project to be available and to come to each one of the kce-Fedefal Reporters, Inc. 25 review mechanisms so you can be a categorical one then a RAG 2 6 1 ty 17 1 then executive IL--h(:,,n PIE and it c,@,n go on -and on so this was 2 discussed and-they didn't think duplication was the problem 3! but obviously PIE is somewhat in concept with them. 4 We thought communication within the organization should 5 be improved because again as I have said Mr. Tiinks should@. 6 have great access to the comptroller and funding. It is hard to run a --how without knowing where the money is. 8 We were concerned they should have inore--a@llied'he@lt@, 9 representation. This was conveyed to them. We were favorably 10 impressed with the leadership as far as the head of RAG. I 11 told you the complexity of Dr. Hasegawa and it is apparent 12 that now that he has appointed Mr. Tunks as deputy director 13 that there are changes and the changes are real. 14 Mr. Tunks at the site visit took a very, very active 15 role and obviously knows what is going on and those like 16 Russell who knows the problems-of Hawaii this is a very refresh- 17 ing change. He has a good staff, a lot of bright,-young people 18 aboard and they are interested, they are dedicated, and I think 19 a good group to move with. 20 There are little problems that take place. The 21 head of CHP agency, use to be the secretary to Dr. Hasegawa. 22 So this gets to be a little difficult in terms of having 23 your former secretary head of another large agency but apparently 24 this hopefully will work out.@l: A lot of the projects are very ce- Federal Reporters, Inc.' 25 innovative. Had to be impressed with the tremendous change in 2 6 2 ty 1. 8 I direction. We are impressed with the Pacific Basin Council. 2@ They have set up a separate council -to hell.) review the problems 31 of that area and the other thing was we asked them suppose they 4 only.go4@- half the money they asked for, what would they do in 5 terms of which projects -they would support and they had a list 6 there already of priorities.for each and every one of their 7 items which demonstrates a certain level of responsibility. 8 The university has a research corporation which 9 serves as a fiscal agent and very fank discussions, this has 10 worked out extremely well.. They have had no problems with this. 11 It has been.a good source of support, fiscal-wise to RDIP. 12 It should also be mentioned that the funds of.;Hawaii RMP 13 re resent the greatest source of funds for that research p 14 corporation, so the university is obviously very interested 15 in this, dean of the medical school was there and gave very, 16 very strong support of RMP. He obviously knows what they are 17 doing but like Hasegawa, really runs a separate show. 18 I will go thorugh the details as far as the rest 19 of our meeting was concerned. We obviously had questions in 20 terms of their byl aws, in terms of evaluation. It is thorough 21 but confusing. This is really what it amounts to. An w at 22 I would like to do at this poin t is to have the secondary - 23 reviewer comment. Then give our recommended levels for funding 24 MR. HILTON: I promise to be very quick, not only :e- Federal Reporters, Inc. 251 out of altruism to fellow committee members but at this point 2 6 3 ty 19 I the call of nat.lure is very emphatic on my part. I appreciate 2 the comments with regard to Pacific Basin. Some concern and 3 some que,,Lic,,ri., about that. 41 I do need some direction here with regard to the 5 yellow sheet. I see the figure of about -- is that currently 6@ available for a two-year period? That threw@me off a little 7 bit, maybe ought to discuss that when we talk about 8 projects but I didn't quite know what that meant. You.find 91 it on the -- on the very bottom, No. 2. 10 MR. RUSSELL: The money there that is shown there, 11 the $1.4 million, has has been awarded for the emergency 12 medical services project. Actually that is two years' worth 13 of money. However, it has been awarded for fiscal purposes 14 in a one year period. They will be able to use it for two 15 years. 16 MR. HILTON: I was concerned about the Hciv,7.-Lii 17 Community Clinic. Am I under the impression that'.the-st&te 18 and model cities will pick that up or is the -- apparently 19 they are going to pha se..it@,lout and a number of other projects 20 as well at the end of next year I believe. 21 Are these'things being picked up for continued rt or what is happening to them? 22 suPPO 23 DR. SCHLERIS: Well., they are very actively involved 24 in Waianae groups in getting all the support they can. .ce- Federal Reporters, Inc. 25 So far the Hawaii RMP Has acted as really one of the 26 4 ty 20 1 best friends the,; have had towards being accepted in respectably 2 society as a group that could come in for funding and their 3 acceptance now by.thc-- medical. society, even though it is whole- 4 hearted, enthusiastic one, whatevei- has been achieved has 5 been through RMP. 6 They are looking at all other sources of support and 7 right now most of their support is from outside RMP. Remember 8 I mentioned that some of the strengths are potential weaknesses 9 If Waianae doesn't get support after RMP this could really 10 react unfavorably for RMP. They appeared to be very aware of 11 this and are doing everything they can to assure support. 12 Do you want to comment further on that? 13 MR. RUSSELL: lust to point out that Mr. David 14 Pollick, the gentleman we heard from at the site visit, is a key 15 man. Mr. Pollick,, is really one of the leaders in the minorities 16, of Hawaii. The minorities there being the Hawaiians, IPuerto Ricans, Portuguese who were brought over as -- in the 17 18 plantation days. Mr. Pollick is extremely active politically 19 and if there is anyone in Hawaii who can shake loose state 20 dollars which he has been effectively doing I think we can 21 have- a ring of confidence that there will be social support 22 coming as long as IPH is there to guide Hawa.-'Lian representative. 2@ MR. HILTON: I am concerned with that. I am glad to. 24 hear there is another possibility of support. Actually, well, ce- Federal Reporters, Inc. maybe -- will your recommendation include some kind of 25 2 6 5 ty 21 I c6ntin en-,y? 2 DR.' SCIJILERIS: Yes., 3 MR. IIILTO"17- Also, you are recommending a fi.crure 4 that.is a hundred thousand dollars higher than they are 51 requesting and I was interested in that. You are reconunending 61 1.8 and they are requesting 1.7. 7@ DR. SCHLERIS: I will come to -that. 8 MR. HILTON: Well, that concludes mine. 9 DR. SCHLERIS: Mr. Chairman, do you want me to 10 comment and make our recommendations at this point? 11 Each of you has been given a comparison and these 121 are listed at the top part of the page in terms of Pacific.--, 13 Basin, I am sorry, the top part combines them both and the 14 bottom is the Pacific Basin. Perhaps I can go to the Pacific 15 Basin area first which is the last series of blocks on the 16 page. 17 The Pacific Basin only, the program staff now is 18 $50,000. They requested $107,000 and we, column fourt are 19 recommending they be granted that amount. 20 The reason is the staff now is very limited. The area 21 to be covered is large and in'terms of what we think are programs that will go, they appear to have projects in those 22 23 programs which are indeed viable. They now have $142,000 for 24 projects in the Pacific Ba.sin. They requested $192,000. We Federal Reporters, Inc. 25 have recommended this amount be granted and what we would 2 6 6 ty 22 I like to have in oLi-@ final recommendation would be that these 2@ be specifically stated as being for the Pacific Basin. 3 I have ric) doubt these funds will be utilized. As 4 I mentioned, Dr. Izutsu operates alone in this entire area and 5 the cost-- of transportation alone as you can appreciate is 6 tremendous just going back and forth between these areas. 7@ This is one reason why many of the members of these islands 8 don't come too often to RAG or as I said they were there 9 for the RAG, as I said they were there at the time. This is 10 one recommendation as far as the staff of Hawaii only -- if 11 these names are confusing while we were there the sucfqestioii 12 was made by one of their legislators and I forwarded ;@.this note 13 to RMPS, that a name be changed because now it is RMP Hawaii, 14 American Samoa, Guam, Trust Territory of Pacific. It comes 15 out as Hawaii RMP. 16 They suggested we just call it Regional Medical 17 Program, period. But it was pointed out this conflicted with 18 all the other regional rpogram in the United States. They are 19 currently being funded at $467,000 and had requested $584,000. 20 And we didn't specifically make a recommendation as far as 21 staff is concerned. But in terms of their total projects; they 22 have requested, they now have 395,000,,had requested 1.092 28 million. 24 Now if you refer to the upper blocks across in ce- Federal Reporters, Inc. 25 terms of combining these, program staff and projects, currently I I ty 2 -@,I 26 7 1 $1,079,000. Requested $2,254,000, which for them would be 21 an increase of 109 percent. W(- recoraiaendcd $1,820,000, 3 which in terms of wli.---t they arc getting now is a 68 percent 4 increase which reflects a high degree of confidence in their 5 change in direction and in the leadership and staff-6f core, 0 and in the specific projects that we reviewed. 71 . It is obvious that we are cutting out several. We 8 are not recommending developmental. We think they could handl.E 9 it if they only had bylaws which were accepted and if they 10 only had, I think, a few days work@going over the evaluation 11 procedures. But what we suggested instead was that they be 12 considered for developmental components the second year of the 13 triennium, and that there be not a formal site visit but almost 14 can be a staff site visit to assure us that they indeed have 15 evaluation procedure and bylaws. 16 I think they can handle it. I think that the 17 combination of Dr. Hasegawa and Mr. Bryan, the deputy director, 18 the. staff that he has, and their ability to get involved with 19 programs that are starting, to me, is a good indication that 20 they are all moving in the right direction, and are mature 21 enough to handle it. 22 They try to answer every specific, oh -- in the past 23 they have had many letters back and forth indicating weaknesses. 24 They have tried to answer every one of these and they have 2-Federat Reporters, Inc. 25 very effectively accepted the ones I have outlined. 2 6 8 ty 24 I I recommend v@liat we have here. 2 DR. JAYIES: I am not sure I understood the reference 3 in your material relating to the inability of some members to 4 get information "from the comptroller." 5 Could you speak to that point? 6 DR. SCHLERIS: Dr. Hasegawa has always run the 7 Hawaii Regional Medical Program very tightly. He has been 8 the source of all information and I guess one way of doing 9 this is to have the comptroller respond only to him. 10 One very strong recommendation was made that the 11 deputy director, who now has, who has taken over a great dea 12 of the internal control but as far as the comptroller is 13 concerned that has concerned us, anything that goes out, you, ii: 14 you have a deputy director he should know what is going on. 15 Do you want to comment on that? 16 MR. RUSSELL: Yes. I would like to point out that 17 inthe past Dr. Hasegawa has been very reluctant to confide 18 in any of his staff members except the comptroller. In 19 fact for a long time it was very difficult to tell what was 20 actually the deputy. As a result of site visit recommendations 21 in the past, about a year ago I believe it was, Dr. Hasegawa 22 did appoint Mr. Tunks deputy. However, up until this past 231 site visit, after a few traumatics to Hawaii, only -- was 24 Mr. Tunks allowed in fact to operate as a deputy. He is, as ce- Federal Repirters, iric. 25 we saw it, tremendous change was being looked to as deputy I ty 25 269 1 but all of the staff except the comptroller. 2 Now,-I know for a fact there is a personality clash 3 between the comptroller and the dputy. This may not, however, 4 be the primary problem. 5 We know the withholding of fiscal information 6 policies of the Pd4PH not only to the comptroller but to the 7 association. They had a great deal of difficulty 8 (inaudible) --,this may'well be and this is condoned by Dr. 9 Hasegawa. This may well be Dr. Hasegawals way of controlling 10 which information he wants to go to whom and w en. 11 However, we do plan as a result of.the review process to 12 hit very hard to this issue of making the deputy a real 13 deputy. 14 And we think that when the word goes back to the 15 RAG, which now is definitely taking over control which in 16 the past belonged to the coordinator and to the Executive 17 Committee, I feel confident that the RAG will be given more 18 direction to Dr. Hasegawa and as a result, we will see some 19 changes. 20 Does this help? 21 DR. JAMES: Yes, the way that it was written in the 22 report here, gave me some concern. If in fact no one else 23 was sharing fiscal except the director and the comptroller, thell 24 how could the RAG or others be apprised or know what was going @ce -Federal Reporters, Inc. 25 on in the development of the program? Just seemed kind of od.d ty 26 270 1 or strange that those -- that was a tremendous amount of 2 responsibility for one or two people. I don't know. 3 I didn't understand in the narrative as to who was 4 the, rrLoni-k--oring the f iscal 5 MR. RUSSELL: It indeed has been strange in the past 6 I think it is on the way out. I think a year from now we may 7 well have a case history as we did on Rochester. We are now 8 getting down to, if you will pardon, the real gut issue which 9 have been ferreted out and now we can deal with them from the 10 advice of this Committee. 11 DR. SCHMIDT: As far as fiscal sresponsibilities 12 go there is no question about the handling of the money or 13 anything like that. It is more a personality and power issue 14 than it is anything having to do with counting. 15 MR. RUSSELL: Last night I received a call from 16 Hawaii and they wanted me to be sure and report to the 17 Committee that their bylaws they say are finalized. They have 18 gone through five drafts since we have been there. 19 I asked them if they had incorporated the recent 20 REMPS policy on the grantee'RAC-:relati.onships and they said 21 "oh,, yes, we have modified it substantially." So I said, !'Wb@will have to see that. Right away." 22 23 So to go on with what Dr. Schleris has been saying, 24 they have not had an opportunity to test the review process and kce- Federal Repotters, Inc. 25 their bylaws. The review process by the way they tell me has I ty 27 2 7 1 1 been rewritten since we have been there and it is complete 2 but here again hasn't been tested. 3 DR. KRALEWSKI: Two questions: one, did they call 41 collect? The second one, as I recalls the last time we reviewed 51 this'program we attempted to earmark some money for the Pacific Basin project. Did that work out? Did they use the money for 7 that? 8 And so your similar recommendation here you feel 9 will be 10 DR. SCHMIDT: I think it is safe to say that the coordinateor feels very greatly the responsibility, this vast 11 12 territory. And I think he used to be certainl y anxious to 13 put money into it. 14 DR. SCHLERIS: There is no question I think as far 15 as RAG is concerned. They have a great deal of sensitivity 16 about that area and are willing and anxious to do everything 17 they can. They support the Pacific Basin Council. They support. Dr. Izutsu. I am sure they will accept this recommendation. If any of you appear confounded by our statements 19 20 about Dr. Hasegawa and his relationship to the comptroller 21 and-deputy you share that, we were there for a few days and I am sure that RMPS has shared that for many years; is that a 22 23 fair statement? 24 MR. CHAMBLISS: Doctor, I don't intend to respond @ce- Federal Reporters, Inc. to your question. I wanted to add 'additional information if 25 ty 28 2'@ 2 I I may 2 It was out of the concerns of this Committee that 3 the earmarking was done for'-LliE,, Trust Territory. Just last 4 week-the HSI@IHA raised questions as to the kinds of commitments 5 that RMP. was making in-to the Trust Territory and it is 6 Out Of Your actions that we.wer(-- able to make what we considered 7 to be a very substantive response to show that -there is 8 definite commitment from RMPS, and that things are happening 9 with our dollars in that area. 10 I thought you would like to know. 11 MR. RUSSELL: In answer'to Dr. Kralewskils question, 12 yes, that earmarking was extremely effective. As the people 13 on the Basin said we are damn tired of planning. 14 Now RMPS is one of the first organization that has come in and funded operation in the projects and they are 15 16 very, very successful. 17 DR. SCHMIDT: Never forget the. first time I met the ,8 coordinator he came in my office and I had a lot of stuff on 19 my desk and he was trying to make a point of how big the 20 Territory was and in describing he swept everything o my 21 desk. Now we have a motion on the floor but no second. 22 23 DR. KRALEWSKI: I will second it. 24 DR. SCHMIDT: Are there further comments or questions @ce -Federal Repofters, Inc. 25 directed to the reviewers? Or just to me? -Ly 2 9 .1 2 7 3 If not, is the motion understood? 2 DR. J'l@ES: I would like to make a comment. If I 3 do understand, that this is a fairly new area for the RI@IPS.- 4 to engage in and because obviously it is primarily an area 5 that w'L],]. be considered minority I would certainly want to say 0 that it is tremendous and if the man wants to keep his mouth 7 shut about his money I don't blame him because it may be 8 part of growing pains and it may be a good thing that the comp- 9 troller and director share such information for any new program 10 as valuable as this. 11 I am sure there must be some distrust somewhere 12 lurking either in the Mainland or on the Islands. 131 DR. SCHLERIS: I will make a comment but after the 14 vote if I may in response to that statement. Time is XXI5 DR. SCHMIDT: Anyone else? 6 p.m. when this 16 MR. RUSSELL: We have another kidney problem, portion was taken. 17 Mr. Hilton. 18 In terms of the proj6ct and the applicatior,, maybe 19 Dr. Miller, would you like to comment on that, pleas6? 20 DR. MILLER: Actually there are probably two problems 21 related to the kidney proposal with Hawaii. 22 The first one, the main one is the fact that there 23 is a competing hospital on the main island and that is Kuwakini 24 Hospital. And the grant was originally set up so that St. @ce - Federa I Reportefs, Inc. 25 Francis Hospital would be the primary tertiary tenter for the I I ty 30 2@14 I slarids of Hawaii. 2 It is my understanding -that there has been no 3 resolution of the problem of competition betwe@e-n these two 4 hospitals, and it would seem -r--ather fc)(,)lish to put one's 5 money in orie bag and have competition in the same area. It 6 would defeat the purpose of the kidney idea of establishing 7 just one tertiary center in one area to serve the population. 8 DR. SCHMIDT: Dr. Iiiiiinan? 9 DR. HIN@IAN: I attended the site visit and discussed 10 this issue with the RAG chairman and staff there. Part of 11 the problem revolves around the issue that one of the 12 hospitals is predominantly oriented toward the Chinese 13 population so there are some ethnic background issues that 14 have to be addressed involving this problem. 15 RAG has taken the position -- according to the 16 verbal statement given to me -- that they will support St. 17 Francis Hospital activity and that will be the only place they 18 will put their money because this is where the primary 19 competency is. 20 It is anticipated that the Kuwakini Hospital will 21 either eventually begin to share with or work with the St. 22 Francis group or it may be difficult for lack of support. 23 DR. SCHMIDT: Leonard, you were going to make your 24 comment. :e-Federa! Reporters, Inc. 25 DR. SCHLERIS: No, that was what I was going to say. ty 31 2'7 5 DR. SCHMIDT: I am not sure I should pursue this. 2 Is there any -need to pursue this furtl-ier? 3 DR. SCHLERIS: I don't believe so. 4 Dr. Hinman who attended our sit visit as you know 5 is charged with the responsiblity in this area and I am 6 sure that the funds would not be expended until such time as 7 there is a coordinated effort. It has been our assumption 8 and our goal that there only be one program and that dupli- 9 cation be avoided and I think Dr. Hinman will find duplication 10 in his own way in this or his group would. 11 DR. HIN14AN: Of course the problem is that we 12 could never tell when.we were to ston providing care of any 13 type. The only controls we have is to not fund their 14 activity or not support them. I believe the Comprehensive Heall:h 15 Planning Agency is aware of some of the problems here. 16 There are several other things that lie somewhat 17 behind this in the number of different ethnic groups in Hawaii 18 that have to participate and work together. They have some 19 unresolved problems here. It is a very complex thing. I 20 think they are working toward what is the best possible 211 solution for the patients in the area. 22 DR. SCHMIDT: thank you. 2.3 Any other comments or questions? 24 DR. MILLER: One other point I wanted to make. ,ce-Federal Reportets, Inc. 25.1 That was in the proposal there was an item of equipment called ty 32 2 76 1 a liquid scintillation spectrometer which deals with testing 2@ compatible kidneys. You mostly really in retrospect and mostly really dealing with related donor population. The proposal 4 does suggest that they purchase this machine which I assume 5 from reading this, they don't state it but it is about another 6 $15,000, in the actual monies, and according to the technical @ reviewers of the project, two7of the technical reviewers felt 8 that this item of equipment was not necessary. The RAG, itself, did not address itself to this 10 problem and I think that something should be mentioned about this. Again I am going to re-fer to Dr. Hinman on this who 121 represented the renal.gtoup@as well as the staff. Do you want to comment? 14 MR. RUSSELL: What we need here, I don't think the I15lack of a Regional Advisory Group-, not to consider this, I 16 don't think it was deliberates I just don't think it was 17 clear to them that they were supposed to decide between the two. I am serious. You have to have been out there to understand 19 it. DR. SCHMIDT: Strikes me as being a rather technical 20 decision and I am not sure it is one the advisory group should ? 2@ make. 23 MR. RUSSELL: Well, they have the recommendations of what it boils down to, three people. Tow of them say no, 24 ,ce -Federal Reporters, Inc. one of them say yes. I think what we at staff need.is say 25 ty 3 2 77 led to do I will- you make that decision for them since they fai it or will you delegate this responsibility to Dr. Hi.nman's 3i staff? DR. SCHMIDT: Once again concern is registered and 5 you are aware of this. I thank you. Other comments or questions? 7 If not, we will call. the question. 8 DR. KRALEWSKI: Just quickly, are we voting on 9 some money for that kidney project now then, or are we not? 10 DR. SCHMIDT: Yes, it includes the kidney project. DR. SCHLERIS: I think it should be a matter of 1 have the final word on 12 record that Dr. Hinman's group wil 13 that. We have not looked to them in detail. We have always 14 looked to the rdnal,grolap. 15 DR. HESS: Does it meet that criteria of the 161 region having developed a regional plan when there is another 4ospital developing activities? 17 DR. HINMAN: The region has a plan and the plan is 18 19 to support the St. Francis Hospital activity. 20 DR. HESS: For that activity? 21 DR. HINt4AN: Yes, sir. DR. SCHMIDT: I don't think Dave can be faulted 22 23 because there may be a dissenting group that wants to go on their own. That would be asking I think too much. 24 -ce-Fedetal Reporters, Inc. DR. HINMAN: I think the same phone call last night 25 ty 34 278 I Mr. Russell received there v,,Ets another approach that they 2 are trying to work out in th.at--.area which may involve that 31 actually some of -the surgery is done at Kuwakini Hospital 4 by a-team at St. Francis which is a possible solution which ,5 would get aound some of the considerations-so they are @6 actively working oi) the issue. 7 I think that it is complex. enough looking at the 8 entire history of Hawaii and the socioeconomic conditions 9 that I think for us to recommend anything more stringent than 10 what we have already done would be a little unfair to the regiOlL. 11 DR. JAME.S: Right, I agree. 121 Would that not constitute an.internal affair of 13 the region which possibly would not be, well, could be 14 resolved at that level? 15 DR. HINMAN: That is what we have asked them to 16 do. 17 DR. SCHMIDT: Questions? 18 If no one wishes the floor, that is really not in 19 order. We can vote. We can't call the question. That is 20 really not a legal parliamentary procedure. 21 We will call the question then. 22 All in favor, please say aye. 23 Opposed, no? 24 Once again I hear no dissent. Reportefs, Inc. 25 Leonard? ty 35 2 79 DR. SCI-IL,El@,IS: The c@oi-m-,,ic@nt I wanted to mak(, was that 2 thc@ whites on Hawaii arc- .39 nonwhites are 61 percent. 3 Arid if You ]Drea.]-. up all the groups there all minorities, you 4 know, no oric- has total Y,,t,3.jori-Ly there. So it is hard to inorities. 5 def rie rl 61 Dr. Hasegawa represents a different issue in a 7 way because he was one of the unfortunate Japanese who lived in apparently California at the time of Pearl Harbor, was 9 one of those who was confined in a concentration camp at the 10 time. And a great deal I am sure of,-- of his reactions and 11 operations are rightfully bas ed on that experience and I 12 assume that part of-the problems might relate to that experienc 13 Hadn't brought that up before but I think it is 14@ pertinent in his being coordinated. He has not,onl,,7 been 15 accepted but has done an exemplary job as coordinator, despite 16 the tremendous limitations. He is a tremendous asset to the 17 regional.organization of Hawaii. 18 DR. SCHMIDT: Before we break up, I would remind the Committee of several thin s. First:, now we have had the 19 9 26 Rochester presentation by Eileen this -morning, then we had 21 the,presentation by John,with the aid of some visuals and in t .-s last presentation we had a short overview by Dick of the 2@ 23 region provider to the presentation by the Committee member. @4' Now these are all variations on the theme. There wi I ce- Federal Reporters, Inc. 251 be one more in the morning after which we will stop and discuss I11 ty 2 80 for 15 oi@ 20 minutes various foryi@@,,@7 of presentation and see 2 wh.e,',,-h(-@r the-, visu;F@.is which are included in your review book 3 by the w@,y are helpful in this sort of setting the region in 41 plac(-,, and -Ls v,@,lu;-,ble enough to continue. 5@ I would remind you the document is Chapter 4 that 61 we would like you to look over tonight-. We will discuss it a 7 little more. 8 The function of the Review Committee, it is your 9 reading assignment and we will have an oral quiZ-on this at 10 8:30 in the morning when we start. Your rating sheets you may keep but they should 12 be kept more or less confidential.. Do you want to pick these up today? 14 All right, keep them but put them away and continue l@5 to use the same sheet then tomorrow. With thanks to the group for their good work today, 17@ we will adjourn and reconvene at 8:30 in the morning. ,@18 (Whereupon, at 6:10 p.m., the, meeting was adjourned, End #17 19 to reconvene at 8:30 a.m., Friday, 22 September 1972.) 20' 21 22 23 241 ,C'e-Federal Reportefs, Inc. 25